Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.4
Steven Tsui
Whilst there has recently been unprecedented growth in heart transplants (HTx) in North America, the number has been static or falling in most European countries. These have resulted in significant increases in the waiting times. In the UK, an Urgent Heart Allocation Scheme has been in existence since 2001. With a growing number of heart failure patients on temporary mechanical circulatory support (MCS) devices, a Super Urgent category was introduced in 2016. So far, ∼15% of HTx in the UK are performed under this new category and the median waiting time has been ≈7 days. Post-transplant 30 day survival has been reassuring. However, ongoing monitoring will be required to ensure effectiveness. The other major development has been donation after circulatory death (DCD) HTx. To date, ∼100 DCD HTx have been performed worldwide, with 70 of these being in the UK. Growing waiting lists have led to increased implantation of bridge-to-transplant left ventricular assist devices (LVAD). However, the extended waiting times for donor hearts in stable patients mean that patients being bridged are effectively having destination therapy by default. Whilst destination therapy is approved in some countries, the available evidence has not been accepted by other countries. The Swedish Evaluation of LVAD as Permanent Treatment in End-stage Heart Failure (SweVAD) is a prospective randomised study comparing LVAD therapy with optimal medical therapy. Recruitment commenced in 2016 with the aim of randomising 74 patients. Outcomes and adverse events associated with implantable MCS will further improve as new devices using novel pumping mechanisms with lower shear stress are in development to address inherent limitations of current devices.
{"title":"4 Updates on cardiac transplant and LVAD implants across the UK and europe","authors":"Steven Tsui","doi":"10.1136/heartasia-2019-apahff.4","DOIUrl":"https://doi.org/10.1136/heartasia-2019-apahff.4","url":null,"abstract":"Whilst there has recently been unprecedented growth in heart transplants (HTx) in North America, the number has been static or falling in most European countries. These have resulted in significant increases in the waiting times. In the UK, an Urgent Heart Allocation Scheme has been in existence since 2001. With a growing number of heart failure patients on temporary mechanical circulatory support (MCS) devices, a Super Urgent category was introduced in 2016. So far, ∼15% of HTx in the UK are performed under this new category and the median waiting time has been ≈7 days. Post-transplant 30 day survival has been reassuring. However, ongoing monitoring will be required to ensure effectiveness. The other major development has been donation after circulatory death (DCD) HTx. To date, ∼100 DCD HTx have been performed worldwide, with 70 of these being in the UK. Growing waiting lists have led to increased implantation of bridge-to-transplant left ventricular assist devices (LVAD). However, the extended waiting times for donor hearts in stable patients mean that patients being bridged are effectively having destination therapy by default. Whilst destination therapy is approved in some countries, the available evidence has not been accepted by other countries. The Swedish Evaluation of LVAD as Permanent Treatment in End-stage Heart Failure (SweVAD) is a prospective randomised study comparing LVAD therapy with optimal medical therapy. Recruitment commenced in 2016 with the aim of randomising 74 patients. Outcomes and adverse events associated with implantable MCS will further improve as new devices using novel pumping mechanisms with lower shear stress are in development to address inherent limitations of current devices.","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A2 - A2"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/heartasia-2019-apahff.4","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45775953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.1
M. Mehra
The advent of left ventricular assist systems to support patients with advanced-stage heart failure has been a 50 year odyssey, now available broadly to such patients.1 Engineering advances have ushered in an era of small, durable devices that can be fully implanted within the chest. Yet, haemocompatibility related adverse events, which emanate from the interaction between the device and the patient they support are manifest principally in increased stroke rates, de novo device thrombosis requiring replacement and in gastrointestinal bleeding (a peculiar adverse event resulting from the unnatural physiology of continuous flow with low systemic pulse pressure).2 A novel fully „magnetically levitated pump, the HeartMate 3 pump has now been introduced which is engineered with wide blood flow pathways (to decrease shear stress and haemolysis) and programmed with an artificial intrinsic pulse. A large study has demonstrated its superiority in ameliorating pump thrombosis, reducing stroke rates and improving medical resource use and cost of care when compared with other devices such as the HeartMate II pump with a mechanical bearing and axial flow pathway.3 However, much needs to be learned, especially within the Asia Pacific region. Questions of genetic diversity in response to anticoagulation targets, predilection towards haemocompatibility complications and outcomes within this distinct population remain less well understood. Estimates of patient need in this region suggest that over 50 000 eligible patients with advanced heart failure may qualify for such mechanical support but access, cost and regulatory barriers as well as the optimal medical management of these pumps remain poorly understood. In the Asia Pacific realm, >100 centres currently implant such pumps with most performing <10 pumps annually and the top 20% of centres performing the majority of these surgical implants. Japan, Australia, India, Singapore and Taiwan lead the region in experience with durable implantable pumps. As experience ensues, there will be more widespread use and the field continues to await newer pumps that are not only forgiving on end points of adverse events but also forgettable by virtue of eliminating the need to be externally powered through a driveline that exits the body and connects to a power source.1 Myocardial recovery using haemodynamic support and facilitation of intensified pharmacotherapy is being studied in an effort to improve outcomes and restore patients to a better stage of less severe symptoms but this aspect remains poorly developed.4 The future is in smaller pumps that can provide partial support, mimic the physiological; flow pathways and maintain pulsatility. These devices will usher in earlier use and may provide the impetus to facilitate recovery in patients who are not too far advanced. References Mehra MR. Evolving disruption in left ventricular assist systems: Forgiving but not yet forgettable. Eur J Heart Fail 2018 December 3. doi:10.
{"title":"1 Ventricular assist devices: developments in asia and global outlook for the next 10 years","authors":"M. Mehra","doi":"10.1136/heartasia-2019-apahff.1","DOIUrl":"https://doi.org/10.1136/heartasia-2019-apahff.1","url":null,"abstract":"The advent of left ventricular assist systems to support patients with advanced-stage heart failure has been a 50 year odyssey, now available broadly to such patients.1 Engineering advances have ushered in an era of small, durable devices that can be fully implanted within the chest. Yet, haemocompatibility related adverse events, which emanate from the interaction between the device and the patient they support are manifest principally in increased stroke rates, de novo device thrombosis requiring replacement and in gastrointestinal bleeding (a peculiar adverse event resulting from the unnatural physiology of continuous flow with low systemic pulse pressure).2 A novel fully „magnetically levitated pump, the HeartMate 3 pump has now been introduced which is engineered with wide blood flow pathways (to decrease shear stress and haemolysis) and programmed with an artificial intrinsic pulse. A large study has demonstrated its superiority in ameliorating pump thrombosis, reducing stroke rates and improving medical resource use and cost of care when compared with other devices such as the HeartMate II pump with a mechanical bearing and axial flow pathway.3 However, much needs to be learned, especially within the Asia Pacific region. Questions of genetic diversity in response to anticoagulation targets, predilection towards haemocompatibility complications and outcomes within this distinct population remain less well understood. Estimates of patient need in this region suggest that over 50 000 eligible patients with advanced heart failure may qualify for such mechanical support but access, cost and regulatory barriers as well as the optimal medical management of these pumps remain poorly understood. In the Asia Pacific realm, >100 centres currently implant such pumps with most performing <10 pumps annually and the top 20% of centres performing the majority of these surgical implants. Japan, Australia, India, Singapore and Taiwan lead the region in experience with durable implantable pumps. As experience ensues, there will be more widespread use and the field continues to await newer pumps that are not only forgiving on end points of adverse events but also forgettable by virtue of eliminating the need to be externally powered through a driveline that exits the body and connects to a power source.1 Myocardial recovery using haemodynamic support and facilitation of intensified pharmacotherapy is being studied in an effort to improve outcomes and restore patients to a better stage of less severe symptoms but this aspect remains poorly developed.4 The future is in smaller pumps that can provide partial support, mimic the physiological; flow pathways and maintain pulsatility. These devices will usher in earlier use and may provide the impetus to facilitate recovery in patients who are not too far advanced. References Mehra MR. Evolving disruption in left ventricular assist systems: Forgiving but not yet forgettable. Eur J Heart Fail 2018 December 3. doi:10.","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A1 - A1"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/heartasia-2019-apahff.1","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42750728","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/HEARTASIA-2019-APAHFF.28
G. Karthikeyan
Digoxin is often used in the management of patients with heart failure (HF) with or without atrial fibrillation (AF). There is sound biological rationale for the use of digoxin, but the data on clinical outcomes with digoxin use in this patient population are conflicting. There is a single adequately powered randomised trial of digoxin in patients with HF in sinus rhythm.1 This trial showed a small but significant reduction in the rate of hospitalisation due to HF with the use of digoxin, when compared to placebo, among patients treated with ACE inhibitors and diuretics. There was no effect on mortality.1 On the contrary, there are numerous secondary analyses of observational data from randomised trials which suggest that there may be an increased risk of death from using digoxin, both in patients with HF, those in AF, or both.2 However, observational data on digoxin use suffer from treatment bias (confounding by indication), as the sickest patients are the ones who are prescribed digoxin. Propensity matched analyses have been attempted to overcome the effect of this bias with conflicting results.2 3 However, it is likely that because the magnitude of this bias is large, no amount of statistical adjustment can yield reliable effect estimates. This highlights the need for large, randomised trials of digoxin.3 References Digitalis Investigation G. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997;336:525–533. Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GY, Steeds RP, Townend J, Kotecha D. Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data. BMJ 2015;351:h4451. Karthikeyan G, Devasenapathy N, Zühlke L, Engel ME, Rangarajan S, Teo KK, Mayosi BM, Yusuf S; Global Rheumatic Heart Disease Registry (REMEDY) Investigators. Digoxin and clinical outcomes in the Global Rheumatic Heart Disease Registry. Heart 2018 Sep 12. pii: heartjnl-2018-313614.
地高辛常用于伴有或不伴有心房颤动(AF)的心力衰竭(HF)患者的治疗。使用地高辛有良好的生物学基础，但在该患者群体中使用地高辛的临床结果数据是相互矛盾的。有一项单独的充分有力的随机试验，地高辛治疗伴有窦性心律失常的HF患者该试验显示，与安慰剂相比，在接受ACE抑制剂和利尿剂治疗的患者中，使用地高辛治疗HF的住院率虽小但显著降低。对死亡率没有影响相反，对随机试验观察性数据的大量二次分析表明，使用地高辛可能会增加心衰患者、房颤患者或两者的死亡风险然而，关于地高辛使用的观察性数据存在治疗偏倚(指征混淆)，因为病情最严重的患者是服用地高辛的患者。倾向匹配分析已经试图克服这种偏差的影响与矛盾的结果。然而，由于这种偏差的幅度很大，很可能再多的统计调整也无法产生可靠的效果估计。这凸显了对地高辛进行大规模随机试验的必要性G.地高辛对心力衰竭患者死亡率和发病率的影响。中华医学杂志(英文版)1997;33:525 - 533。Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GY, Steeds RP, Townend J, Kotecha D.地高辛的安全性和有效性:系统评价和观察性和对照试验数据的meta分析。BMJ 2015; 351: h4451。Karthikeyan G, Devasenapathy N, z hlke L, Engel ME, Rangarajan S, Teo KK, Mayosi BM, Yusuf S;全球风湿性心脏病登记(REMEDY)调查人员。地高辛和全球风湿性心脏病登记的临床结果。心脏2018年9月12日。pii: heartjnl - 2018 - 313614。
{"title":"28 Should we be using digoxin in 2018?","authors":"G. Karthikeyan","doi":"10.1136/HEARTASIA-2019-APAHFF.28","DOIUrl":"https://doi.org/10.1136/HEARTASIA-2019-APAHFF.28","url":null,"abstract":"Digoxin is often used in the management of patients with heart failure (HF) with or without atrial fibrillation (AF). There is sound biological rationale for the use of digoxin, but the data on clinical outcomes with digoxin use in this patient population are conflicting. There is a single adequately powered randomised trial of digoxin in patients with HF in sinus rhythm.1 This trial showed a small but significant reduction in the rate of hospitalisation due to HF with the use of digoxin, when compared to placebo, among patients treated with ACE inhibitors and diuretics. There was no effect on mortality.1 On the contrary, there are numerous secondary analyses of observational data from randomised trials which suggest that there may be an increased risk of death from using digoxin, both in patients with HF, those in AF, or both.2 However, observational data on digoxin use suffer from treatment bias (confounding by indication), as the sickest patients are the ones who are prescribed digoxin. Propensity matched analyses have been attempted to overcome the effect of this bias with conflicting results.2 3 However, it is likely that because the magnitude of this bias is large, no amount of statistical adjustment can yield reliable effect estimates. This highlights the need for large, randomised trials of digoxin.3 References Digitalis Investigation G. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997;336:525–533. Ziff OJ, Lane DA, Samra M, Griffith M, Kirchhof P, Lip GY, Steeds RP, Townend J, Kotecha D. Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data. BMJ 2015;351:h4451. Karthikeyan G, Devasenapathy N, Zühlke L, Engel ME, Rangarajan S, Teo KK, Mayosi BM, Yusuf S; Global Rheumatic Heart Disease Registry (REMEDY) Investigators. Digoxin and clinical outcomes in the Global Rheumatic Heart Disease Registry. Heart 2018 Sep 12. pii: heartjnl-2018-313614.","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A12 - A12"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/HEARTASIA-2019-APAHFF.28","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"64288507","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.10
L. Cheung
It is well documented that implantable cardioverter defibrillator (ICD) saves lives in populations at risk for sudden death. However, mortality in advanced heart failure remains high despite advances in therapy.1 Twenty per cent of ICD patients receiving shocks in the final weeks of their lives experience pain and decreased quality of life, causing distress to patients and their families.2 Ethically and legally, there are no differences between refusing ICD therapy and requesting withdrawal of ICD therapy. Carrying out a request to withdraw life-sustaining treatment is neither physician-assisted suicide nor euthanasia.3 Decisions about deactivation of ICD are complicated. Proactive communication by clinicians before implant and during device follow-up are important in order to minimise suffering as the end of life nears for patients with ICDs. Clear discussion about the benefits and burdens of the device should be made. Advance care planning addressing device deactivation should be encouraged for all patients with ICD.4 References Goldberger Z, Lampert R. Implantable Cardioverter-defibrillators: expanding indications and technologies. JAMA 2006;295;809–818 Goldstein NE, Lampert R, Bradley E, Lynn J, Krumholz HM. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med2004;141:835–838. Lampert R, Hayes DL, Annas GJ, Farley MA, Goldstein NE, Hamilton RM, Kay GN, Kramer DB, Mueller PS, Padeletti L, Pozuelo L, Schoenfeld MH, Vardas PE, Wiegand DL, Zellner R; American College of Cardiology; American Geriatrics Society; American Academy of Hospice and Palliative Medicine; American Heart Association; European Heart Rhythm Association; Hospice and Palliative Nurses Association. HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm2010;7:1008–1026. BHF. ICD deactivation at the end of life: Principles and practice. 2013. https://www.bhf.org.uk/-/media/files/publications/hcps/icd-deactivation.pdf
有充分的证据表明，植入式心律转复除颤器(ICD)可以挽救处于猝死风险人群的生命。然而，尽管治疗取得了进步，晚期心力衰竭的死亡率仍然很高20%的ICD患者在生命的最后几周受到电击，经历疼痛和生活质量下降，给患者及其家属造成痛苦在伦理和法律上，拒绝ICD治疗和要求退出ICD治疗没有区别。执行撤销维持生命治疗的请求既不是医生协助的自杀，也不是安乐死关于停用ICD的决定是复杂的。临床医生在植入前和设备随访期间的积极沟通对于减少icd患者生命末期的痛苦非常重要。应该明确讨论该设备的好处和负担。应鼓励所有icd患者提前制定护理计划，解决设备停用问题。参考文献Goldberger Z, Lampert R.植入式心律转复除颤器:扩大适应症和技术。张建军，张建军，张建军，等。中国医学杂志2006;29;809-818。临终关怀中植入式心律转复除颤器的管理。Ann Intern Med2004; 141:835-838。Lampert R, Hayes DL, Annas GJ, Farley MA, Goldstein NE, Hamilton RM, Kay GN, Kramer DB, Mueller PS, Padeletti L, Pozuelo L, Schoenfeld MH, Vardas PE, Wiegand DL, Zellner R;美国心脏病学会;美国老年医学会;美国临终关怀与缓和医学学会;美国心脏协会;欧洲心律协会;安宁疗护及缓和护理协会。HRS专家共识声明:心血管植入式电子设备(CIEDs)在接近生命末期或要求停止治疗的患者中的管理。心Rhythm2010; 7:1008 - 1026。BHF银行。ICD在生命末期停用:原则和实践。2013. https://www.bhf.org.uk/-/media/files/publications/hcps/icd-deactivation.pdf
{"title":"10 When is it time to switch the ICD off in a heart failure patient?","authors":"L. Cheung","doi":"10.1136/heartasia-2019-apahff.10","DOIUrl":"https://doi.org/10.1136/heartasia-2019-apahff.10","url":null,"abstract":"It is well documented that implantable cardioverter defibrillator (ICD) saves lives in populations at risk for sudden death. However, mortality in advanced heart failure remains high despite advances in therapy.1 Twenty per cent of ICD patients receiving shocks in the final weeks of their lives experience pain and decreased quality of life, causing distress to patients and their families.2 Ethically and legally, there are no differences between refusing ICD therapy and requesting withdrawal of ICD therapy. Carrying out a request to withdraw life-sustaining treatment is neither physician-assisted suicide nor euthanasia.3 Decisions about deactivation of ICD are complicated. Proactive communication by clinicians before implant and during device follow-up are important in order to minimise suffering as the end of life nears for patients with ICDs. Clear discussion about the benefits and burdens of the device should be made. Advance care planning addressing device deactivation should be encouraged for all patients with ICD.4 References Goldberger Z, Lampert R. Implantable Cardioverter-defibrillators: expanding indications and technologies. JAMA 2006;295;809–818 Goldstein NE, Lampert R, Bradley E, Lynn J, Krumholz HM. Management of implantable cardioverter defibrillators in end-of-life care. Ann Intern Med2004;141:835–838. Lampert R, Hayes DL, Annas GJ, Farley MA, Goldstein NE, Hamilton RM, Kay GN, Kramer DB, Mueller PS, Padeletti L, Pozuelo L, Schoenfeld MH, Vardas PE, Wiegand DL, Zellner R; American College of Cardiology; American Geriatrics Society; American Academy of Hospice and Palliative Medicine; American Heart Association; European Heart Rhythm Association; Hospice and Palliative Nurses Association. HRS Expert Consensus Statement on the Management of Cardiovascular Implantable Electronic Devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm2010;7:1008–1026. BHF. ICD deactivation at the end of life: Principles and practice. 2013. https://www.bhf.org.uk/-/media/files/publications/hcps/icd-deactivation.pdf","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A5 - A5"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/heartasia-2019-apahff.10","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45264720","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.13
M. Kiernan
Cardiogenic shock (CS) is defined as a state of ineffective cardiac output caused by a cardiac disorder that results in both clinical and biochemical manifestations of inadequate tissue perfusion.1 Among patients presenting with CS, there is a spectrum of disease whereby some patients can be stabilised with pharmacologic interventions alone, while others require escalation to mechanical circulatory support (MCS).2 As patients and treatment options both become increasingly complex, comprehensive critical care may be best delivered in disease-specific service line ICUs.2 The model of the cardiac ICU has transitioned over time from one focused on electrocardiographic monitoring for early identification and termination of peri-infarct arrhythmias, to units experienced with invasive haemodynamic monitoring and management of percutaneous/surgically placed MCS devices for the treatment of CS. Early recognition of shock is vital to improving outcomes, and in-hospital survival for CS has been observed to be reduced in patients who are more rapidly supported with MCS.3 Integrating dedicated intensivists into ICU teams has therefore not surprisingly been demonstrated to improve survival in critically-ill patients.4 Furthermore, survival for CS may be better when treated at specialised centres with greater experience compared to centres with lower annual volume of shock cases.5 Contemporary, comprehensive cardiac critical care includes multidisciplinary teams with expertise in MCS, pharmacotherapy, mechanical ventilation, renal replacement therapies, and palliative care. Shock teams have necessarily expanded beyond a given institution to incorporate networks of centres, such that highly specialised care is centralised at quaternary referral centres with resources and expertise to manage this complex condition. References van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017;136:e232–e268. Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL 2nd, Parrillo JE, Peterson PN, Winkelman C; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation 2012;126:1408–1428. Basir MB, Schreiber TL, Grines CL, Dixon SR, Moses JW, Ma
{"title":"13 The shock team approach: the rationale and evidence","authors":"M. Kiernan","doi":"10.1136/heartasia-2019-apahff.13","DOIUrl":"https://doi.org/10.1136/heartasia-2019-apahff.13","url":null,"abstract":"Cardiogenic shock (CS) is defined as a state of ineffective cardiac output caused by a cardiac disorder that results in both clinical and biochemical manifestations of inadequate tissue perfusion.1 Among patients presenting with CS, there is a spectrum of disease whereby some patients can be stabilised with pharmacologic interventions alone, while others require escalation to mechanical circulatory support (MCS).2 As patients and treatment options both become increasingly complex, comprehensive critical care may be best delivered in disease-specific service line ICUs.2 The model of the cardiac ICU has transitioned over time from one focused on electrocardiographic monitoring for early identification and termination of peri-infarct arrhythmias, to units experienced with invasive haemodynamic monitoring and management of percutaneous/surgically placed MCS devices for the treatment of CS. Early recognition of shock is vital to improving outcomes, and in-hospital survival for CS has been observed to be reduced in patients who are more rapidly supported with MCS.3 Integrating dedicated intensivists into ICU teams has therefore not surprisingly been demonstrated to improve survival in critically-ill patients.4 Furthermore, survival for CS may be better when treated at specialised centres with greater experience compared to centres with lower annual volume of shock cases.5 Contemporary, comprehensive cardiac critical care includes multidisciplinary teams with expertise in MCS, pharmacotherapy, mechanical ventilation, renal replacement therapies, and palliative care. Shock teams have necessarily expanded beyond a given institution to incorporate networks of centres, such that highly specialised care is centralised at quaternary referral centres with resources and expertise to manage this complex condition. References van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017;136:e232–e268. Morrow DA, Fang JC, Fintel DJ, Granger CB, Katz JN, Kushner FG, Kuvin JT, Lopez-Sendon J, McAreavey D, Nallamothu B, Page RL 2nd, Parrillo JE, Peterson PN, Winkelman C; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation 2012;126:1408–1428. Basir MB, Schreiber TL, Grines CL, Dixon SR, Moses JW, Ma","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A6 - A7"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/heartasia-2019-apahff.13","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45606325","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.32
A. Roy
South Asia has seen rapid epidemiological transition in the last two decades with a rapid rise in cardiovascular diseases, which have emerged as the leading cause of mortality in this region. In India the leading cause of disability adjusted life years is ischaemic heart disease which has seen a 104% increase between 1990 and 2016.1 Similarly the burden of obesity, hypertension and diabetes mellitus has increased markedly over this time and with poor control rates for these risk factors leading to a fertile soil for rise in incidence of heart failure.2 In the absence of active surveillance mechanisms reliable estimates of heart failure burden is missing. However, one study estimates it to the tune of 4.6 million which is probably a severe under-estimate given the risk factor burden.3 The study of the heart failure patients in two large registries, INTER-CHF and Trivandrum Heart Failure Registry,4 5 revealed disturbingly high mortality rates of 23% and 31%, respectively. This was much higher than that of patients from other low and middle income countries.4 The chief driver of this mortality seems to be suboptimal medical management of these patients with a large percentage not receiving beta-blockers and renin-angiotensin aldosterone inhibitors; drugs known to improve survival. Thus, quality improvement program using guideline-directed medical therapy will go a long way in improving survival of these patients. References India State-Level Disease Burden Initiative Collaborators. (2017). Nations within a nation: variations in epidemiological transition across the states of India, 1990–2016 in the Global Burden of Disease Study. Lancet 2017;390: 2437–2460. Prabhakaran D, Roy A, Praveen PA, Ramakrishnan L, Gupta R, Amarchand R, Kondal D, Singh K, Sharma M, Shukla DK, Tandon N, Reddy KS, Krishnan A. 20-year trend of CVD risk factors: urban and rural national capital region of India. Glob Heart 2017;12:209–217. Huffman MD, Prabhakaran D. Heart failure: epidemiology and prevention in India. Natl Med J India 2010;23:283–288. Dokainish H, Teo K, Zhu J, Roy A, AlHabib KF, ElSayed A, Palileo-Villaneuva L,Lopez-Jaramillo P, Karaye K, Yusoff K, Orlandini A, Sliwa K, Mondo C, Lanas F, Prabhakaran D, Badr A, Elmaghawry M, Damasceno A, Tibazarwa K, Belley-Cote E, Balasubramanian K, Islam S, Yacoub MH, Huffman MD, Harkness K, Grinvalds A, McKelvie R, Bangdiwala SI, Yusuf S; INTER-CHF Investigators. Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study. Lancet Glob Health 2017;5:e665–e672. Harikrishnan S, Sanjay G, Agarwal A, Kumar NP, Kumar KK, Bahuleyan CG, Vijayaraghavan G, Viswanathan S, Sreedharan M, Biju R, Rajalekshmi N, Nair T, Suresh K, Jeemon P. One-year mortality outcomes and hospital readmissions of patients admitted with acute heart failure: Data from the Trivandrum Heart Failure Registry in Kerala, India. Am Heart J 2017;189:193–199.
{"title":"32 Epidemiology of heart failure in south asia","authors":"A. Roy","doi":"10.1136/heartasia-2019-apahff.32","DOIUrl":"https://doi.org/10.1136/heartasia-2019-apahff.32","url":null,"abstract":"South Asia has seen rapid epidemiological transition in the last two decades with a rapid rise in cardiovascular diseases, which have emerged as the leading cause of mortality in this region. In India the leading cause of disability adjusted life years is ischaemic heart disease which has seen a 104% increase between 1990 and 2016.1 Similarly the burden of obesity, hypertension and diabetes mellitus has increased markedly over this time and with poor control rates for these risk factors leading to a fertile soil for rise in incidence of heart failure.2 In the absence of active surveillance mechanisms reliable estimates of heart failure burden is missing. However, one study estimates it to the tune of 4.6 million which is probably a severe under-estimate given the risk factor burden.3 The study of the heart failure patients in two large registries, INTER-CHF and Trivandrum Heart Failure Registry,4 5 revealed disturbingly high mortality rates of 23% and 31%, respectively. This was much higher than that of patients from other low and middle income countries.4 The chief driver of this mortality seems to be suboptimal medical management of these patients with a large percentage not receiving beta-blockers and renin-angiotensin aldosterone inhibitors; drugs known to improve survival. Thus, quality improvement program using guideline-directed medical therapy will go a long way in improving survival of these patients. References India State-Level Disease Burden Initiative Collaborators. (2017). Nations within a nation: variations in epidemiological transition across the states of India, 1990–2016 in the Global Burden of Disease Study. Lancet 2017;390: 2437–2460. Prabhakaran D, Roy A, Praveen PA, Ramakrishnan L, Gupta R, Amarchand R, Kondal D, Singh K, Sharma M, Shukla DK, Tandon N, Reddy KS, Krishnan A. 20-year trend of CVD risk factors: urban and rural national capital region of India. Glob Heart 2017;12:209–217. Huffman MD, Prabhakaran D. Heart failure: epidemiology and prevention in India. Natl Med J India 2010;23:283–288. Dokainish H, Teo K, Zhu J, Roy A, AlHabib KF, ElSayed A, Palileo-Villaneuva L,Lopez-Jaramillo P, Karaye K, Yusoff K, Orlandini A, Sliwa K, Mondo C, Lanas F, Prabhakaran D, Badr A, Elmaghawry M, Damasceno A, Tibazarwa K, Belley-Cote E, Balasubramanian K, Islam S, Yacoub MH, Huffman MD, Harkness K, Grinvalds A, McKelvie R, Bangdiwala SI, Yusuf S; INTER-CHF Investigators. Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study. Lancet Glob Health 2017;5:e665–e672. Harikrishnan S, Sanjay G, Agarwal A, Kumar NP, Kumar KK, Bahuleyan CG, Vijayaraghavan G, Viswanathan S, Sreedharan M, Biju R, Rajalekshmi N, Nair T, Suresh K, Jeemon P. One-year mortality outcomes and hospital readmissions of patients admitted with acute heart failure: Data from the Trivandrum Heart Failure Registry in Kerala, India. Am Heart J 2017;189:193–199.","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A13 - A14"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/heartasia-2019-apahff.32","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45740546","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.27
K. Chan
The incidence of lower limb ischaemia ranges from 11%–52% in patients receiving VA ECMO. The reported rate of amputation ranges from 2%–10%. Patients with vascular complications related to lower limb ischaemia carries a higher risk of death. Antegrade perfusion of superficial femoral artery via a distal perfusion catheter (DPC) has been shown to be an effective therapy to reduce the incidence of lower limb ischaemia. However, the clinical indications remain largely unclear with various reported strategies. While the benefits remain largely unknown, there is increasing experience on the use of near-infrared reflectance spectroscopy, or NIRS, in the monitoring of lower limb perfusion during ECMO therapies. Strategies alternative to DPC include end-to-side graft, posterior tibial artery retrograde perfusion, axillary cannulation and central sports mode. Novel bidirectional perfusion cannula may appear as a future promising option. References Cheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, Esmailian F, Azarbal B. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg 2014;97:610–616. Tanaka D, Hirose H, Cavarocchi N, Entwistle JW. The impact of vascular complications on survival of patients on venoarterial extracorporeal membrane oxygenation. Ann Thorac Surg 2016;101:1729–1734. Juo YY, Skancke M, Sanaiha Y, Mantha A, Jimenez JC, Benharash P. Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs 2017;41:E263–E273. Wong JK, Smith TN, Pitcher HT, Hirose H, Cavarocchi NC. Cerebral and lower limb near-infrared spectroscopy in adults on extracorporeal membrane oxygenation. Artif Organs 2012;36:659–667. Spurlock DJ, Toomasian JM, Romano MA, Cooley E, Bartlett RH, Haft JW. A simple technique to prevent limb ischemia during veno-arterial ECMO using the femoral artery: the posterior tibial approach. Perfusion 2012;27:141–145. Marasco SF, Tutungi E, Vallance SA, Udy AA, Negri JC, Zimmet AD, McGiffin DC, Pellegrino VA, Moshinsky RA. A Phase 1 study of a novel bidirectional perfusion cannula in patients undergoing femoral cannulation for cardiac surgery. Innovations (Phila) 2018;13:97–103.
在接受VA ECMO的患者中，下肢缺血的发生率为11%-52%。报道的截肢率在2%-10%之间。下肢缺血相关血管并发症患者的死亡风险较高。经远端灌注导管(DPC)顺行灌注股浅动脉已被证明是一种有效的治疗方法，以减少下肢缺血的发生率。然而，临床适应症仍然很大程度上不清楚各种报道的策略。虽然其益处在很大程度上仍然未知，但在ECMO治疗期间使用近红外反射光谱(NIRS)监测下肢灌注方面的经验越来越多。替代DPC的策略包括端侧移植、胫骨后动脉逆行灌注、腋窝插管和中央运动模式。新型双向灌注插管可能是未来有希望的选择。Cheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, Esmailian F, Azarbal B.体外膜氧合治疗心源性休克和心脏骤停的并发症:1866例成人患者的meta分析。安胸外科，2014;97:610-616。田中D, Hirose H, Cavarocchi N, Entwistle JW。血管并发症对静脉-动脉体外膜氧合患者生存的影响。安氏胸外科杂志，2016;01:1729 - 1734。Juo YY, Skancke M, Sanaiha Y, Mantha A, Jimenez JC, Benharash P.远端灌注插管预防体外膜氧合肢体缺血的疗效:系统回顾和meta分析。人工器官2017;41:E263-E273。Wong JK, Smith TN, Pitcher HT, Hirose H, Cavarocchi NC。成人体外膜氧合的大脑和下肢近红外光谱研究。人工器官2012;36:659-667。Spurlock DJ, Toomasian JM, Romano MA, Cooley E, Bartlett RH, Haft JW。在股动脉静脉-动脉ECMO中预防肢体缺血的简单技术:胫骨后入路。灌注2012;27:141 - 145。Marasco SF, Tutungi E, valance SA, Udy AA, Negri JC, Zimmet AD, McGiffin DC, Pellegrino VA, Moshinsky RA。一种新型双向灌注套管在心脏手术股骨插管患者中的一期研究。创新(费城)2018;13:97-103。
{"title":"27 Lower limb ischaemia in patients undergoing VA ECMO","authors":"K. Chan","doi":"10.1136/heartasia-2019-apahff.27","DOIUrl":"https://doi.org/10.1136/heartasia-2019-apahff.27","url":null,"abstract":"The incidence of lower limb ischaemia ranges from 11%–52% in patients receiving VA ECMO. The reported rate of amputation ranges from 2%–10%. Patients with vascular complications related to lower limb ischaemia carries a higher risk of death. Antegrade perfusion of superficial femoral artery via a distal perfusion catheter (DPC) has been shown to be an effective therapy to reduce the incidence of lower limb ischaemia. However, the clinical indications remain largely unclear with various reported strategies. While the benefits remain largely unknown, there is increasing experience on the use of near-infrared reflectance spectroscopy, or NIRS, in the monitoring of lower limb perfusion during ECMO therapies. Strategies alternative to DPC include end-to-side graft, posterior tibial artery retrograde perfusion, axillary cannulation and central sports mode. Novel bidirectional perfusion cannula may appear as a future promising option. References Cheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, Esmailian F, Azarbal B. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg 2014;97:610–616. Tanaka D, Hirose H, Cavarocchi N, Entwistle JW. The impact of vascular complications on survival of patients on venoarterial extracorporeal membrane oxygenation. Ann Thorac Surg 2016;101:1729–1734. Juo YY, Skancke M, Sanaiha Y, Mantha A, Jimenez JC, Benharash P. Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs 2017;41:E263–E273. Wong JK, Smith TN, Pitcher HT, Hirose H, Cavarocchi NC. Cerebral and lower limb near-infrared spectroscopy in adults on extracorporeal membrane oxygenation. Artif Organs 2012;36:659–667. Spurlock DJ, Toomasian JM, Romano MA, Cooley E, Bartlett RH, Haft JW. A simple technique to prevent limb ischemia during veno-arterial ECMO using the femoral artery: the posterior tibial approach. Perfusion 2012;27:141–145. Marasco SF, Tutungi E, Vallance SA, Udy AA, Negri JC, Zimmet AD, McGiffin DC, Pellegrino VA, Moshinsky RA. A Phase 1 study of a novel bidirectional perfusion cannula in patients undergoing femoral cannulation for cardiac surgery. Innovations (Phila) 2018;13:97–103.","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A11 - A12"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/heartasia-2019-apahff.27","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46458676","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.11
Raymond SK Lo
Advanced cardiac diseases are common non-cancer conditions that require good palliative care. Palliative Care should embrace both cancer and non-cancer conditions, and is applicable early in the course of illness, in conjunction with other therapies. There is a high prevalence of symptoms and distress in heat failure (HF) necessitating palliative care, which include not just dyspnoea and oedema but also a range of other symptoms that are all sub-optimally controlled at the end of life.1 For patients with HF, palliative care attends to physical, psychological, social and spiritual distress, caring for both patients and families with optimisation of quality of life.2 Palliative care also facilitates communication and complex decision-making with advance care planning. Palliative support should be offered once there is a need. Prognostic indicators are also available in alerting clinicians to timing and need for palliative care, especially in older patients.3 Evidence for benefit of early palliative care is emerging for structured palliative care services for HF. The PAL-HF randomised controlled trial shows that an interdisciplinary palliative care can yield greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with usual care alone.4 Challenges in withholding or withdrawing care options like with non-invasive ventilation, implantable defibrillators, left ventricular assistive devices will need to be further addressed. Serious illness conversation guide from Harvard University is available also in local Hong Kong Chinese setting to facilitate discussion.5 Good HF care necessitates an integrated care programme, with palliative team working hand in hand with cardiologists. References Gibbs LME, Addington-Hall J, Gibbs JSR. Dying from Heart Failure: lessons from Palliative Care. BMJ 1998;317:961–962. Braun LT, Grady KL, Kutner JS, et al. Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement from the American Heart Association/American Stroke Association. Circulation 2016;134:e198–e225. Coventry PA, Grande GE, Richards TA, Todd CJ. Prediction of appropriate timing of palliative care for older adults with non –malignant life-threatening disease. A systematic review. Age Ageing 2005;34:218–27. Rogers JG, Patel CB, Mentz RJ, et al. Palliative Care in Heart Failure: The PAL-HF Randomised, Controlled Clinical Trial. J Am Coll Cardiol 2017;70:331–341. Jockey Club End-of-Life Community Care Project. Serious illness communication guide in Hong Kong, 2018. (accessible at https://youtu.be/_5RxXYHWCPg).
{"title":"11 Hospice and palliative care for advanced cardiac diseases in hong kong","authors":"Raymond SK Lo","doi":"10.1136/heartasia-2019-apahff.11","DOIUrl":"https://doi.org/10.1136/heartasia-2019-apahff.11","url":null,"abstract":"Advanced cardiac diseases are common non-cancer conditions that require good palliative care. Palliative Care should embrace both cancer and non-cancer conditions, and is applicable early in the course of illness, in conjunction with other therapies. There is a high prevalence of symptoms and distress in heat failure (HF) necessitating palliative care, which include not just dyspnoea and oedema but also a range of other symptoms that are all sub-optimally controlled at the end of life.1 For patients with HF, palliative care attends to physical, psychological, social and spiritual distress, caring for both patients and families with optimisation of quality of life.2 Palliative care also facilitates communication and complex decision-making with advance care planning. Palliative support should be offered once there is a need. Prognostic indicators are also available in alerting clinicians to timing and need for palliative care, especially in older patients.3 Evidence for benefit of early palliative care is emerging for structured palliative care services for HF. The PAL-HF randomised controlled trial shows that an interdisciplinary palliative care can yield greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with usual care alone.4 Challenges in withholding or withdrawing care options like with non-invasive ventilation, implantable defibrillators, left ventricular assistive devices will need to be further addressed. Serious illness conversation guide from Harvard University is available also in local Hong Kong Chinese setting to facilitate discussion.5 Good HF care necessitates an integrated care programme, with palliative team working hand in hand with cardiologists. References Gibbs LME, Addington-Hall J, Gibbs JSR. Dying from Heart Failure: lessons from Palliative Care. BMJ 1998;317:961–962. Braun LT, Grady KL, Kutner JS, et al. Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement from the American Heart Association/American Stroke Association. Circulation 2016;134:e198–e225. Coventry PA, Grande GE, Richards TA, Todd CJ. Prediction of appropriate timing of palliative care for older adults with non –malignant life-threatening disease. A systematic review. Age Ageing 2005;34:218–27. Rogers JG, Patel CB, Mentz RJ, et al. Palliative Care in Heart Failure: The PAL-HF Randomised, Controlled Clinical Trial. J Am Coll Cardiol 2017;70:331–341. Jockey Club End-of-Life Community Care Project. Serious illness communication guide in Hong Kong, 2018. (accessible at https://youtu.be/_5RxXYHWCPg).","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A5 - A6"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/heartasia-2019-apahff.11","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42112948","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/HEARTASIA-2019-APAHFF.8
P. Macdonald
Frailty is a condition that is characterised by reduced physiological reserve. Multiple instruments have been developed to measure frailty mainly in community-dwelling elderly people.1 We have adapted one of these instruments, the Fried frailty phenotype, to assess frailty in patients with advanced heart failure (AHF) referred for consideration of ventricular assist device (VAD) implantation and/or heart transplantation (HTx). Since 2013, when possible all AHF patients referred to our centre have been assessed for frailty. Fried’s five physical domains – exhaustion, grip-strength, mobility, appetite and physical inactivity (frail ≥3/5), as well as cognitive impairment (MoCA ≤26) and depression (DMI >9) were assessed. We have demonstrated that frailty is associated with increased mortality in patients with AHF2 3 and increased morbidity and mortality after VAD implantation and after heart transplantation.4 Despite the increased morbidity and mortality post-intervention, physical frailty is reversible in the majority of patients undergoing bridge-to-transplant VAD implantation and HTx. Of the individual frailty domains, change in handgrip strength is the least sensitive indicator of improved frailty status. Future goals or challenges in frailty research in the setting of AHF include the development of a universally accepted frailty measurement, the development of measures that distinguish reversible from irreversible frailty, and the role of pre-habilitation in reducing frailty-associated morbidity and mortality after VAD or HTx. References McDonagh J, Martin L, Ferguson C, et al. Frailty assessment instruments in heart failure: A systematic review. Eur J Cardiovasc Nursing 2017 May 1:1474515117708888. Jha S, Carter D, Hannu MK, et al. Frailty as a predictor of outcomes in transplant eligible patients with advanced heart failure. Transplantation 2016;100:429–436. Jha S, Carter D, Hannu MK, et al. Cognitive impairment improves the predictive validity of physical frailty for mortality in patients with advanced heart failure referred for heart transplantation. J Heart Lung Transplant 2016;35:1092–1100. Jha S, Hannu MK, Newton P, et al. Reversibility of frailty after bridge-to-transplant ventricular assist device implantation or heart transplantation. Transplantation Direct 2017;3:e167.
{"title":"8 Reversibility of frailty in LVAD and heart transplant patients","authors":"P. Macdonald","doi":"10.1136/HEARTASIA-2019-APAHFF.8","DOIUrl":"https://doi.org/10.1136/HEARTASIA-2019-APAHFF.8","url":null,"abstract":"Frailty is a condition that is characterised by reduced physiological reserve. Multiple instruments have been developed to measure frailty mainly in community-dwelling elderly people.1 We have adapted one of these instruments, the Fried frailty phenotype, to assess frailty in patients with advanced heart failure (AHF) referred for consideration of ventricular assist device (VAD) implantation and/or heart transplantation (HTx). Since 2013, when possible all AHF patients referred to our centre have been assessed for frailty. Fried’s five physical domains – exhaustion, grip-strength, mobility, appetite and physical inactivity (frail ≥3/5), as well as cognitive impairment (MoCA ≤26) and depression (DMI >9) were assessed. We have demonstrated that frailty is associated with increased mortality in patients with AHF2 3 and increased morbidity and mortality after VAD implantation and after heart transplantation.4 Despite the increased morbidity and mortality post-intervention, physical frailty is reversible in the majority of patients undergoing bridge-to-transplant VAD implantation and HTx. Of the individual frailty domains, change in handgrip strength is the least sensitive indicator of improved frailty status. Future goals or challenges in frailty research in the setting of AHF include the development of a universally accepted frailty measurement, the development of measures that distinguish reversible from irreversible frailty, and the role of pre-habilitation in reducing frailty-associated morbidity and mortality after VAD or HTx. References McDonagh J, Martin L, Ferguson C, et al. Frailty assessment instruments in heart failure: A systematic review. Eur J Cardiovasc Nursing 2017 May 1:1474515117708888. Jha S, Carter D, Hannu MK, et al. Frailty as a predictor of outcomes in transplant eligible patients with advanced heart failure. Transplantation 2016;100:429–436. Jha S, Carter D, Hannu MK, et al. Cognitive impairment improves the predictive validity of physical frailty for mortality in patients with advanced heart failure referred for heart transplantation. J Heart Lung Transplant 2016;35:1092–1100. Jha S, Hannu MK, Newton P, et al. Reversibility of frailty after bridge-to-transplant ventricular assist device implantation or heart transplantation. Transplantation Direct 2017;3:e167.","PeriodicalId":12858,"journal":{"name":"Heart Asia","volume":"11 1","pages":"A4 - A5"},"PeriodicalIF":0.0,"publicationDate":"2019-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/HEARTASIA-2019-APAHFF.8","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49138308","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-04-01DOI: 10.1136/heartasia-2019-apahff.31
Alex P. W. Lee, Kevin Kh Kam, E. Fung, Josie T Y Chow, Yiting Fan, P. Teekakirikul, K. Wong, J. Y. Chan, David K. H. Chan, B. Sheng
Fabry disease (FD) is an X-linked inherited lysosomal storage disorder that results from mutations in the α-galactosidase A gene (GLA), leading to deficient alpha-galactosidase A (α-GalA) activity and subsequent accumulation of globotriaosylceramide (Gb3) in a variety of tissues.1 The estimated prevalence of classic FD in males ranges from 1:8000 to 1:117,000,2 likely an underestimation given its non-specific manifestations. The mutation IVS4 +919G>A (c.936+919G>A) associated with founder effect in East Asia was first described in Taiwan.3Left ventricular hypertrophy (LVH) is a hallmark of the later-onset cardiac variant of FD. The prevalence of FD among adult patients with LVH is unknown. In an ongoing FD screening programme from August 2017 through 2018, we measured plasma α-GalA activity using dried blood spot testing in 143 consecutive male patients with LVH (defined as maximal LV wall thickness ≥13 mm on echocardiography). Patients with low α-GalA activity underwent GLA gene sequencing analysis and endomyocardial biopsy. Four of 143 patients with LVH (2.8%) had low plasma α-GalA activity (0.4±0.2 μmol/L wb/hr; 3%–15% of the mean in normal controls). All 4 unrelated patients (aged 53–74 years) shared the same IVS4 +919G>A mutation with maximal LV wall thickness ranging from 14–29 mm. None had extracardiac manifestations but presented with hypertrophic cardiomyopathy, hypertension, heart failure, or aortic stenosis. Endomyocardial biopsy performed in one patient showed hypertrophic cardiomyocytes with sarcoplasmic vacuolisation. Our results suggest that FD should be considered as a cause of LVH in adult men even when other more usual causes of LVH are present. References Germain DP. Fabry disease. Orphanet J Rare Dis 2010;5:30. Meikle PJ, Hopwood JJ, Clague AE, Carey WF. Prevalence of lysosomal storage disorders. JAMA 1999;281:249. Lin HY, Chong KW, Hsu JH, Yu HC, Shih CC, Huang CH, Lin SJ, Chen CH, Chiang CC, Ho HJ, Lee PC, Kao CH, Cheng KH, Hsueh C, Niu DM. High incidence of the cardiac variant of Fabry disease revealed by newborn screening in the Taiwan Chinese population. Circ Cardiovasc Genet 2009;2:450.
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