International Journal of Heart Failure最新文献

Background and objectives: Renal dysfunction is a common comorbidity in patients with advanced heart failure who may benefit from left ventricular assist device (LVAD) therapy. The effect of preoperative renal dysfunction on clinical outcomes after LVAD implantation remains uncertain. We conducted a systematic review and meta-analysis to compare outcomes post-LVAD in patients with and without renal dysfunction.

Methods: PubMed, MEDLINE, and Embase databases were searched for studies comparing outcomes in patients with and without renal dysfunction who underwent LVAD implantation for advanced heart failure. The primary outcome of all-cause mortality was reported as random effects risk ratio (RR) with 95% confidence interval (CI).

Results: Our search yielded 5,229 potentially eligible studies. We included 7 studies reporting on 26,652 patients. Patients with renal dysfunction (glomerular filtration rate [GFR] <60 mL/min/1.73 m²) (n=4,630) had increased risk of all-cause mortality (RR, 2.21; 95% CI, 1.39-3.51; p<0.01) compared to patients with normal renal function (GFR >60 mL/min/1.73 m²) (n=22,019).

Conclusions: Patients with renal dysfunction have increased mortality after LVAD implantation when compared to patients with normal renal function. GFR can be used to risk stratify patients and guide decision making prior to LVAD therapy.

Background and objectives: During the coronavirus disease 2019 (COVID-19) pandemic, virtual visits (VVs) were recommended as an innovative and necessary alternative for patients with heart failure (HF). To assess the feasibility and acceptability of VVs in patients with HF, pulmonary hypertension (PH), and heart transplant (HT).

Methods: We designed a single-centre cohort study. Consecutive VVs performed in our HF unit were analysed. The period comprehended between January 1st and March 19th (before COVID-19) and March 20th and June 30th (during COVID-19) was compared. We assessed acceptability, feasibility and the need for diagnostic studies, in-person medical evaluation, and hospitalization at 30 days.

Results: HF unit medical doctors conducted 22 VVs in the pre-COVID period and 416 VVs during the COVID period. The VV was able to be performed in all patients scheduled for it and 44% answered the survey. Ninety percent of the patients who answered the survey strongly agreed that VVs were easy to be carried out. All the patients "strongly agreed" or "agreed" that their health problem could be resolved. Most patients (95%) rated the global experience as very good or excellent, with an overall average rate of 9.76±0.5 out of 10. We found no differences regarding the requirement of diagnostic studies, in-person medical evaluation and hospitalization during the first month after VVs between the 2 periods.

Conclusions: VVs were feasible, presented high acceptability, and the overall experience was positive in patients with HF, PH, and HT, being this modality a valuable tool that complements in-person care.

Heart transplant is the optimal treatment for selected patients with end-stage heart failure. Immunosuppression after heart transplantation has significantly reduced the incidence of rejection and improved patient outcomes with the routine use of calcineurin inhibitors. Antimetabolites and proliferation signal inhibitors add to the improvement in patient outcomes as well. The goal of induction therapy is to provide intense immunosuppression when the risk of allograft rejection is highest. Most maintenance immunosuppressive protocols employ a 3-drug regimen consisting of a calcineurin inhibitor, an antimetabolite agent and glucocorticoids. The management of rejection proceeds in a stepwise fashion based on the severity of rejection detected on biopsy and the patient's clinical presentation. This review will cover induction, maintenance, rejection therapy and some special considerations including sensitization, renal sparing protocol, and corticosteroid weaning. It will end in consideration of potential future directions in immunosuppressive strategies to promote patient and graft survival.

Whereas traditional understanding of left ventricular afterload was focused on a steady-state circulation model with continuous pressures and flow, a more realistic concept is emerging, taking the pulsatile nature of the heart and the arterial system into account. The most simple measure of pulsatility is brachial pulse pressure, representing the pulsatility fluctuating around the mean blood pressure level. Brachial pulse pressure is widely available, fundamentally associated with the development and treatment of heart failure (HF), but its analysis is often confounded in patients with established HF. The next step of analysis consists of arterial stiffness, central (rather than brachial) pressures, and of wave reflections. The latter are closely related to left ventricular late systolic afterload, ventricular remodeling, diastolic dysfunction, exercise capacity, and, in the long term, the risk of new-onset HF. Wave reflection may also evolve as a suitable therapeutic target for HF with preserved and reduced ejection fraction. A full understanding of ventricular-arterial coupling, however, requires dedicated analysis of time-resolved pressure and flow signals. This review provides a summary of current understanding of pulsatile hemodynamics in HF.

Heart failure (HF) is a complex clinical syndrome caused by a structural and/or functional cardiac abnormality, resulting in reduced organ perfusion. The goals of treatment in patients with HF are to improve functional capacity and quality of life, and to reduce mortality. Cardiac rehabilitation (CR) including exercise training is one of the treatment options, and current guidelines recommend CR as safe and effective for patients with HF. CR has been known to improve exercise capacity and quality of life, minimize HF progression, and lower mortality in patients with HF. Improvement of vascular endothelial function, activation of the neurohormonal system, increase of mitochondrial oxygen utilization in peripheral muscles, and increase of chronotropic responses are possible mechanisms of the beneficial effects of exercise-based CR in HF. Although CR has been shown to decrease morbidity and mortality, it is underutilized in clinical practice. Despite the existence of concrete evidence of clinical benefits, the CR participation rates of patients with HF range from only 14% to 43% worldwide, with high dropout rates after enrollment. These low participation rates have been attributed to several barriers, including patient factors, professional factors, and service factors. The motivation for participating in CR and for overcoming the patients' barriers for CR before discharge should be provided to each patient. Current guidelines strongly recommend applying a CR program to all eligible patients with HF.

Cardiac amyloidosis (CA) is a highly underdiagnosed cause of heart failure. Amyloid light-chain (AL) and amyloid transthyretin (ATTR) cardiomyopathy are two major subtypes of cardiac amyloid. Amyloid fibril deposits cause cardiac dysfunction by mechanically infiltrating the myocardium or by direct cardiotoxicity. Achieving a timely diagnosis is important to initiate disease-modifying therapies and improve the survival of patients with CA. Therefore, physicians must be aware of "red flag symptoms" that increase suspicions for CA when assessing heart failure patients. Although endomyocardial biopsy is a definitive diagnostic tool, with recent advances in non-invasive imaging, non-biopsy diagnosis is feasible in ATTR CA. There have been major advances in treatments for both AL and ATTR CA, and survival of CA has improved. In addition to general management of heart failure, numerous treatment options are increasing for both AL and ATTR CA. Given the systemic nature of amyloids, multi-disciplined team approaches are crucial to management of CA. With recent development of diagnosis and treatment options for both AL and ATTR amyloidosis, it is no longer considered a non-treatable disease.