Cardiology

Packer, M. (2018). “The epicardial adipose inflammatory triad: coronary atherosclerosis, atrial fibrillation, and heart failure with a preserved ejection fraction.” Eur J Heart Fail Sep 17. [Epub ahead of print].

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Effect of epicardial adipose inflammation on coronary arteries: Classically, coronary atherosclerosis has been viewed as an inflammatory response to the transit of lipoproteins from the bloodstream across the endothelium and into the vessel wall. However, accelerated coronary atherosclerosis is also a prominent feature of many systemic inflammatory disorders, in a manner that is independent of circulating lipoproteins. How can systemic inflammation promote the development of obstructive coronary artery disease? Systemic inflammation leads to the accumulation and deranged biology of epicardial adipocytes. The resulting transmission of pro‐inflammatory cytokines and mesenchymal cells from the perivascular adipose tissue across the vascular adventitia can lead to plaque formation within the coronary vessels. In chronic inflammatory states, the accumulation of epicardial adipose tissue is closely associated with the presence, severity and progression of coronary artery disease, in a manner that is independent of circulating lipids or adiposity. Focal obstructive lesions reside in the coronary arterial segments that are immediately adjacent to areas of epicardial fat with the greatest thickness, and experimental resection of the epicardium ameliorates coronary atherosclerosis. These observations support the hypothesis that the accumulation of epicardial adipose tissue (and inflammation of perivascular fat) can act in a paracrine manner to adversely influence the structure and function of the coronary arteries. (Excerpt from text, p. 2; no abstract available.)

Bouabdallaoui, N., B. Claggett, M. R. Zile, J. J. V. McMurray, E. O’Meara, M. Packer, M. F. Prescott, K. Swedberg, S. D. Solomon and J. L. Rouleau (2018). “Growth differentiation factor-15 is not modified by sacubitril/valsartan and is an independent marker of risk in patients with heart failure and reduced ejection fraction: the PARADIGM-HF trial.” Eur J Heart Fail Sep 11. [Epub ahead of print].

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AIMS: Growth differentiation factor-15 (GDF-15) is associated with adverse prognosis in cardiovascular (CV) and non-CV diseases. We evaluated the association of GDF-15 with CV and non-CV outcomes in the PARADIGM-HF trial. METHODS AND RESULTS: In 1935 patients with heart failure and reduced ejection fraction (HFrEF) in PARADIGM-HF, median GDF-15 values were elevated and similar in sacubitril/valsartan and enalapril patients (1626 ng/L and 1690 ng/L, respectively). Diabetes, age, creatinine, high-sensitive troponin T, N-terminal pro-B-type natriuretic peptide, and New York Heart Association class III/IV were most strongly associated with elevated GDF-15 values (all P < 0.001) (adjusted R(2) = 0.3857). Baseline GDF-15 and changes in GDF-15 at both 1 month and 8 months (log-transformed) were associated with subsequent mortality and CV events. Each 20% increment in baseline GDF-15 value was associated with a higher risk of mortality [adjusted hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.08-1.18, P < 0.001], the combined endpoint of CV death or hospitalization for heart failure (adjusted HR 1.09, 95% CI 1.05-1.14, P < 0.001) and heart failure death (adjusted HR 1.16, 95% CI 1.05-1.28, P < 0.001). Changes in GDF-15 were not influenced by assigned therapy (all P-values >/= 0.1). CONCLUSION: In patients with ambulatory HFrEF, GDF-15 is not modified by sacubitril/valsartan and is strongly associated with mortality and CV outcomes, suggesting that GDF-15 is a marker of poor outcomes in these patients. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01035255.

Annamalai, S. K., M. L. Esposito, L. Jorde, T. Schreiber, S. Hall, W. W. O’Neill and N. K. Kapur (2018). “The Impella Micro-Axial Flow Catheter is Safe and Effective for Treatment of Myocarditis Complicated by Cardiogenic Shock: An Analysis from the Global cVAD Registry.” J Card Fail Sep 20. [Epub ahead of print].

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BACKGROUND: Myocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella trans-valvular micro-axial flow catheters in the setting of myocarditis with cardiogenic shock. METHODS AND RESULTS: We retrospectively analyzed data from 21 sites within the cVAD registry, an ongoing multicenter voluntary registry at sites in North America and Europe that have used Impella in patients with myocarditis. Myocarditis was defined by endomyocardial biopsy in 34% (n=11) or by clinical history without angiographic evidence of coronary disease (n=23). A total of 34 patients received Impella 2.5, CP, 5.0, or RP device for cardiogenic shock complicating myocarditis. Baseline characteristics included age 42+/-17 years, left ventricular ejection fraction (LVEF) 18+/-10%, cardiac index 1.82+/-0.46 L/min/m2, pulmonary capillary wedge pressure 25+/-7 mmHg, and lactate 27+/-31 mg/dL. Prior to Impella placement, 32% (n=11) of patients required intra-aortic balloon pump. Mean duration of Impella support was 91+/-74 hours. 21 of 34 (62%) patients survived the index hospitalization and were discharged with an improved mean LVEF of 37.32 +/- 20.31% (p=0.001). 15 patients recovered with successful support, 5 patients were transferred to another hospital on initial Impella support, 1 patient underwent orthotopic heart transplant. Ten patients required transition to another mechanical circulatory support device, Conclusions: This is the largest analysis of Impella-supported myocarditis cases to date. The use of the Impella appears to be safe and effective in the settings of myocarditis complicated by cardiogenic shock.

Tisminetzky, M., H. L. Nguyen, J. H. Gurwitz, D. McManus, J. Gore, S. Singh, J. Yarzebski and R. J. Goldberg (2018). “Magnitude and impact of multiple chronic conditions with advancing age in older adults hospitalized with acute myocardial infarction.” Int J Cardiol Aug 22. [Epub ahead of print].

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BACKGROUND: To examine age-specific differences in the frequency and impact of cardiac and non-cardiac conditions among patients aged 65years and older hospitalized with acute myocardial infarction (AMI). METHODS: Study population consisted of 3863 adults hospitalized with AMI at 11 medical centers in central Massachusetts on a biennial basis between 2001 and 2011. The presence of 11 chronic conditions (five cardiac and six non-cardiac) was based on the review of hospital medical records. RESULTS: Participants’ median age was 79years, 49% were men, and had an average of three chronic conditions (average of cardiac conditions: 2.6 and average of non-cardiac conditions: 1.0). Approximately one in every two patients presented with two or more cardiac related conditions whereas one in every three patients presented with two or more non-cardiac related conditions. The most prevalent chronic conditions in our study population were hypertension, diabetes, heart failure, chronic kidney disease, and peripheral vascular disease. Patients across all age groups with a greater number of previously diagnosed cardiac or non-cardiac conditions were at higher risk for developing important clinical complications or dying during hospitalization as compared to those with 0-1 condition. CONCLUSIONS: The prevalence of multimorbidity among older adults hospitalized with AMI is high and associated with worse outcomes that should be considered in the management of this vulnerable population.

Still, S., A. F. Shaikh, H. Qin, J. Felius, A. K. Jamil, G. Saracino, T. Chamogeorgakis, A. E. Rafael, J. C. MacHannaford, S. M. Joseph, S. A. Hall, G. V. Gonzalez-Stawinski and B. Lima (2018). “Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation.” Interact Cardiovasc Thorac Surg 27(3): 343-349.

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OBJECTIVES: Prior sternotomy is associated with increased morbidity and mortality following heart transplantation. However, its effect on primary graft dysfunction (PGD), a major contributor to early mortality, is unknown. Herein, this effect is studied using the International Society for Heart and Lung Transplantation consensus definition for PGD. METHODS: Medical records of consecutive adult cardiac transplants between 2012 and 2016 were reviewed. Baseline characteristics, postoperative findings and 1-year survival were compared between patients with and without prior sternotomy. RESULTS: Among 255 total patients included, 139 (55%) had undergone prior sternotomy; these recipients were older, more often male, had higher body mass index, higher frequencies of united network for organ sharing (UNOS) 1A status and ischaemic cardiomyopathy and experienced longer waitlist times when compared with those without prior sternotomy (all P < 0.018). Postoperatively, the prior sternotomy group exhibited higher rates of mild to severe PGD (32% vs 18%; P = 0.015) and higher short-term mortality (P = 0.017) and 1-year mortality (P = 0.047). They required more blood transfusions, had more postoperative pneumonia, wound infection and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of PGD (odds ratio 2.7). Multiple prior sternotomies was associated with even more UNOS 1A status, ischaemic cardiomyopathy and pneumonia. However, logistic modelling did not show a difference in the rate of PGD between those with 1 or >/=2 prior sternotomies. CONCLUSIONS: Our data suggest that prior sternotomy is a risk factor for PGD. Consistent with previous reports, prior sternotomy is associated with increased morbidity, blood product utilization and 1-year mortality following cardiac transplantation.