Journal of cardiology最新文献

Background

We hypothesized that the beneficial effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors on diastolic function might depend on baseline left ventricular (LV) systolic function.

Methods

To investigate the effects of SGLT2 inhibitors on LV diastolic function in patients with type 2 diabetes mellitus (T2DM), we conducted a post-hoc sub-study of the PROTECT trial, stratifying the data according to LV ejection fraction (LVEF) at baseline. After excluding patients without echocardiographic data at baseline or 24 months into the PROTECT trial, 31 and 38 patients with T2DM from the full analysis dataset of the PROTECT trial who received ipragliflozin or no SGLT2 inhibitor (control), respectively, were included. The primary endpoint was a comparison of the changes in echocardiographic parameters and N-terminal pro-brain natriuretic peptide levels from baseline to 24 months between the two groups stratified according to baseline LVEF.

Results

Differences in diastolic functional parameters (e' and E/e') were noted between the two groups. Among the subgroups defined according to median LVEF values, those with higher LVEF (≥60 %) who received ipragliflozin appeared to have a higher e' and lower E/e' than did those who received the standard of care with no SGLT2 inhibitor, indicating longitudinal improvements between baseline and follow up (p = 0.001 and 0.016, respectively).

Conclusions

Ipragliflozin generally improved LV diastolic function in patients with type 2 diabetes, the extent of this improvement might appear to vary with LV systolic function.

A hallmark of heart failure (HF), whether it presents itself during rest or periods of physical exertion, is the excessive elevation of intracardiac filling pressures at rest or with exercise. Many mechanisms contribute to the elevated intracardiac filling pressures, and notably, the concept of volume redistribution has gained attention as a cause of the elevated intracardiac filling pressures in patients with HF, particularly HF with preserved ejection fraction, who often present without symptoms at rest, with shortness of breath and fatigue appearing only during exertion. This phenomenon suggests cardiopulmonary system non-compliance and inappropriate volume distribution between the stressed and unstressed blood volume components. A substantial proportion of the intravascular blood volume is in the splanchnic vascular compartment in the abdomen. Preclinical and clinical investigations support the critical role of the sympathetic nervous system in modulating the capacitance and compliance of the splanchnic vascular bed via modulation of the greater splanchnic nerve (GSN). The GSN activation by stressors such as exercise causes excessive splanchnic vasoconstriction, which may contribute to the decompensation of chronic HF via volume redistribution from the splanchnic vascular bed to the central compartment. Accordingly, for example, GSN ablation for volume management has been proposed as a potential therapeutic intervention to increase unstressed blood volume. Here we provide a comprehensive review of the role of splanchnic circulation in the pathogenesis of HF and potential novel treatment options for redistributing blood volume to improve symptoms and prognosis in patients with HF.

Background

Primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) may reduce the risk of subsequent cardiovascular events but remains challenging. The study aim was to evaluate the clinical characteristics and long-term outcomes of patients undergoing primary PCI for STEMI with CS.

Methods

We conducted an observational cohort study of patients with STEMI who underwent primary PCI between April 2004 and December 2017 at Juntendo University Shizuoka Hospital. The primary outcome was cardiovascular death (CVD) during the median 3-year follow-up. We performed a landmark analysis for the incidence of CVD from 0 day to 1 year and from 1 to 10 years.

Results

Among the 1758 STEMI patients in the cohort, 212 (12.1 %) patients with CS showed significantly higher 30-day CVD rate on admission than those without (26.4 % vs 2.9 %). Landmark Kaplan–Meier analysis showed that CVD from day 0 to year 1 was significantly higher in the patients with CS (log-rank p < 0.0001). Multivariate Cox regression analysis showed that CS was significantly associated with higher cardiovascular mortality (adjusted hazard ratio, 11.8; 95%confidence intervals, 7.78–18.1; p < 0.0001), but the mortality rates from 1 to 10 years were comparable (log-rank p = 0.68).

Conclusion

The cardiovascular 1-year mortality rate for patients with STEMI was higher for those with CS on admission than without, but the mortality rates of >1 year were comparable. Surviving the early phase is essential for patients with STEMI and CS to improve long-term outcomes.

Background

Racial disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are controversial among African Americans (AA). This study investigated racial disparities comparing AA and Caucasians undergoing aortic valve replacement.

Methods

Patients who underwent SAVR and TAVR for aortic stenosis were identified in National Inpatient Sample from Q4 2015–2020. In-hospital perioperative outcomes, length of stay, days from admission to operation, and total hospital charge, were compared between AA and Caucasians using multivariable analysis, adjusting for sex, age, socioeconomic status, comorbidity, and hospital characteristics.

Results

In TAVR, 51,394 (84.41 %) were Caucasians and 2433 (4.00 %) were AA. In SAVR, there were 50,080 (78.52 %) Caucasians and 3565 (5.59 %) AA. Compared to Caucasians, AA underwent TAVR had a higher risk of complications such as major adverse cardiovascular events (MACE) [adjusted odds ratio (aOR) = 1.335, p = 0.02)], respiratory complications (aOR = 1.363, p = 0.01), acute kidney injury (AKI) (aOR = 1.468, p < 0.01), pulmonary embolism (aOR = 4.65, p = 0.05), hemorrhage/hematoma (aOR = 1.202, p < 0.01), or superficial wound complication (aOR = 1.414, p = 0.04). AA who underwent SAVR had higher risks of morality (aOR = 1.184, p < 0.05) and surgical complications including MACE (aOR = 1.263, p < 0.01), pericardial complications (aOR = 1.563, p < 0.01), cardiogenic shock (aOR = 1.578, p < 0.01), respiratory complications (aOR = 1.261, p < 0.01), AKI (aOR = 1.642, p < 0.01), venous thromboembolism (aOR = 1.613, p < 0.01), hemorrhage/hematoma (aOR = 1.129, p < 0.01), infection (aOR = 1.234, p < 0.01), superficial wound complications (aOR = 1.756, p < 0.01), vascular complications (aOR = 1.592, p < 0.01), and diaphragmatic paralysis (aOR = 2.181, p = 0.02). In both TAVR and SAVR, AA had longer waiting times from admission to operation (p < 0.01), longer hospital stays (p < 0.01), and higher hospital charges (p < 0.01).

Conclusion

AA were underrepresented, especially in TAVR. AA experienced higher in-hospital mortality post-SAVR, but not after TAVR. Furthermore, AA had more complications for both TAVR and SAVR. These findings underscore the pronounced disparities among AA in aortic valve replacement.

Background

Hyperlactatemia (HL) is a common phenomenon after cardiac surgery which is related to tissue hypoperfusion and hypoxia and associated with poor outcomes. It is also often seen in the postoperative period after orthotopic heart transplantation (OHTx), but the association between HL and outcomes after OHTx is not well known. We evaluated the incidence and outcome of HL after OHTx.

Methods

This was a retrospective study of 209 patients who underwent OHTx between January 2011 and December 2020. Patients were classified into 3 groups according to their peak lactate levels within the first 72 h postoperatively: group 1, normal to mild hyperlactatemia (<5 mmol/L, n = 42); group 2, moderate hyperlactatemia (5–10 mmol/L, n = 110); and group 3, severe hyperlactatemia (>10 mmol/L, n = 57). The primary composite endpoint was all-cause mortality or postoperative initiation of veno-arterial extracorporeal membrane oxygenation (VA ECMO) within 30 days. Secondary endpoints included duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay.

Results

Patients with higher postoperative peak lactate levels were more commonly transplanted from left ventricular assist device support (33.3 % vs 50.9 % vs 64.9, p < 0.01) and had longer cardiopulmonary bypass time [127 min (109–148) vs 141 min (116–186) vs 153 min (127–182), p = 0.02]. Composite primary endpoint was met in 18 patients (8.6 %) and was significantly more common in patients with higher postoperative peak lactate levels (0.0 % vs 6.4 % vs 19.3 %, p < 0.01).

Conclusions

Severe hyperlactatemia following orthotopic heart transplant was associated with an increased risk of post-transplant VA ECMO initiation and mortality at 30 days.

The coronary circulation plays a crucial role in balancing myocardial perfusion and oxygen demand to prevent myocardial ischemia. Extravascular compressive forces, coronary perfusion pressure, and microvascular resistance are involved to regulate coronary blood flow throughout the cardiac cycle. Autoregulation of the coronary blood flow through dynamic adjustment of microvascular resistance is maintained by complex interactions among mechanical, endothelial, metabolic, neural, and hormonal mechanisms. This review focuses on the neural mechanism. Anatomy and physiology of the coronary arterial innervation have been extensively investigated using animal models. However, findings in the animal heart have limited applicability to the human heart as cardiac innervation is generally highly variable among species. So far, limited data are available on the human coronary artery innervation, rendering multiple questions unresolved. Recently, the clinical entity of ischemia with non-obstructive coronary arteries has been proposed, characterized by microvascular dysfunction involving abnormal vasoconstriction and impaired vasodilation. Thus, measurement of microvascular resistance has become a standard diagnostic for patients without significant stenosis in the epicardial coronary arteries. Neural mechanism is likely to play a pivotal role, supported by the efficacy of cardiac sympathetic denervation to control symptoms in patients with angina. Therefore, understanding the coronary artery innervation and control of microvascular resistance of the human heart is increasingly important for cardiologists for diagnosis and to select appropriate therapeutic options. Advancement in this field can lead to innovations in diagnostic and therapeutic approaches for coronary artery diseases.

Background

There is a concern that the coronavirus disease 2019 (COVID-19) pandemic has led to underutilization of non-invasive positive pressure ventilation (NPPV) in patients with acute heart failure (HF). We investigated the alterations in clinical management of acute HF during the COVID-19 pandemic.

Methods and results

This study was an observational study of patients treated in emergency care with acute HF, using a Japanese Administrative database for a period before and during the COVID-19 pandemic. Of the 9081 overall eligible patients, the ratio of patients receiving NPPV and tracheal intubation during to before the COVID-19 pandemic were 0.88 [95 % confidence interval (CI): 0.80, 0.96] and 1.38 (95 % CI: 1.11, 1.71), respectively. Propensity score matching in patients treated in COVID-19 receiving facilities and emergency declaration response areas showed that ratio of NPPV and tracheal intubation during to before the COVID-19 pandemic were 0.88 (95 % CI: 0.76, 1.03), and 1.65 (95 % CI: 1.19, 2.28), respectively.

Conclusions

The implementation rate of NPPV decreased significantly in eligible patients, with a decreasing trend observed in patient populations in COVID-19 receiving facilities and emergency declaration response areas. Tracheal intubation increased in all populations.

Background

In transcatheter aortic valve replacement (TAVR), complications may force the need for a surgical bailout, but knowledge is rare about outcomes in Germany.

Methods

Using national health records, we investigated all TAVR in German hospitals between 2007 and 2020, focusing on 2018–2020. We extracted data on those interventions with need for a surgical bailout.

Results

A total of 159,643 TAVR were analyzed, with an overall rate of surgical bailout of 2.30 %, an overall in-hospital mortality of 3.85 %, and in-hospital mortality in case of bailout of 16.51 %. The number of all annual TAVR procedures increased substantially (202 to 22,972), with the rate of surgical bailout declining from 27.23 to 0.61 % and overall mortality from 11.39 to 2.29 %. However, in-hospital mortality after bailout was still high (28.37 % in 2020). The standardized rates of overall mortality and surgical bailout between 2018 and 2020 were significantly lower for balloon-expandable and self-expanding transfemoral TAVR than for transapical TAVR after risk adjustment [transapical/transfemoral balloon-expandable/transfemoral self-expanding TAVR: in-hospital mortality: 5.66 % (95 % CI 4.81 %; 6.52 %)/2.30 % (2.03 %; 2.57 %)/2.32 % (2.07 %; 2.57 %); surgical bailout: 2.33 % (1.68 %; 2.97 %)/0.79 % (0.60 %; 0.98 %)/0.42 % (0.31 %; 0.53 %)]. Coronary artery disease [risk-adjusted OR = 1.50 (1.21; 1.85), p < 0.001] and atrial fibrillation [OR = 1.29 (1.07; 1.57), p = 0.009] were found to be the main risk factors for bailout.

Conclusions

Rates of TAVR with need for a surgical bailout and overall in-hospital mortality have declined noticeably over the years in Germany. However, the outcomes are still unfavorable after surgical bailout, as in-hospital mortality is continuously high. We present risk factors for surgical bailout to improve preparation of subsequent measures. It must be a major goal to further reduce the rate of surgical bailouts in the future.

The heart utilizes glucose and its metabolites as both energy sources and building blocks for cardiac growth and survival under both physiological and pathophysiological conditions. YAP/TAZ, transcriptional co-activators of the Hippo pathway, are key regulators of cell proliferation, survival, and metabolism in many cell types. Increasing lines of evidence suggest that the Hippo-YAP/TAZ signaling pathway is involved in the regulation of both physiological and pathophysiological processes in the heart. In particular, YAP/TAZ play a critical role in mediating aerobic glycolysis, the Warburg effect, in cardiomyocytes. Here, we summarize what is currently known about YAP/TAZ signaling in the heart by focusing on the regulation of glucose metabolism and its functional significance.