Abstract The highest-risk patients with heart failure with reduced ejection fraction are those with ischemic cardiomyopathy and severe left ventricular systolic dysfunction (ejection fraction ≤35%). ...The cornerstone of treatment is guideline-driven medical therapy for all patients and implantable device therapy for appropriately selected patients. Surgical revascularization offers the potential for improved survival and quality of life, particularly in patients with more extensive multivessel disease and the greatest degree of left ventricular systolic dysfunction and remodeling. These are also the patients at greatest short-term risk of mortality with coronary artery bypass graft surgery. The short-term risks of surgery need to be balanced against the potential for long-term benefit. This review discusses the evolving data on the role of surgical revascularization, surgical ventricular reconstruction, and mitral valve surgery in this high-risk patient population.
Abstract Two guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and collaborating societies address the risk of aortic dissection in patients with ...bicuspid aortic valves and severe aortic enlargement: the “2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease” (J Am Coll Cardiol 2010;55:e27–130) and the “2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease” (J Am Coll Cardiol 2014;63:e57–185). However, the 2 guidelines differ with regard to the recommended threshold of aortic root or ascending aortic dilatation that would justify surgical intervention in patients with bicuspid aortic valves. The ACC and AHA therefore convened a subcommittee representing members of the 2 guideline writing committees to review the evidence, reach consensus, and draft a statement of clarification for both guidelines. This statement of clarification uses the ACC/AHA revised structure for delineating the Class of Recommendation and Level of Evidence to provide recommendations that replace those contained in Section 9.2.2.1 of the thoracic aortic disease guideline and Section 5.1.3 of the valvular heart disease guideline.
Objectives The rationale and design of the Surgical Treatment for Ischemic Heart Failure trial is described. Before the Surgical Treatment for Ischemic Heart Failure trial, less than 1000 patients ...with ischemic cardiomyopathy had been studied in randomized comparisons of medical therapy versus coronary artery bypass grafting. Trial data reflect how these therapies were delivered more than 20 years ago and do not indicate the relative benefits of medical therapy versus coronary artery bypass grafting in contemporary practice. Methods Randomization of consenting patients with heart failure, left ventricular ejection fraction of 0.35 or less, and coronary artery disease is based on whether patients are judged by attending physicians to be candidates only for coronary artery bypass grafting or can be treated with medical therapy without coronary artery bypass grafting. Patients eligible for surgical ventricular reconstruction because of significant anterior wall akinesis or dyskinesis but ineligible for medical therapy are randomly assigned to coronary artery bypass grafting with or without surgical ventricular reconstruction. Patients eligible for medical therapy are randomly assigned between medical therapy only and medical therapy with coronary artery bypass grafting. Patients eligible for all 3 are randomly assigned evenly to medical therapy only, medical therapy and coronary artery bypass grafting, or medical therapy and coronary artery bypass grafting and surgical ventricular reconstruction. Major substudies will examine quality of life, cost-effectiveness, changes in left ventricular volumes, effect of myocardial viability, selected biomarkers, and selected polymorphisms on treatment differences. Results Enrollment is now complete in both STICH hypotheses. Follow-up will continue until sufficient end points are available to address both hypotheses with at least 90% power. The primary outcome of hypothesis 2 is expected to be reported in 2009. The primary outcome of hypothesis 1 is expected to be reported in 2011. Conclusions The Surgical Treatment for Ischemic Heart Failure trial is a National Heart, Lung, and Blood Institute–funded multicenter international randomized trial addressing 2 specific primary hypotheses: (1) coronary artery bypass grafting with intensive medical therapy improves long-term survival compared with survival with medical therapy alone, and (2) in patients with anterior left ventricular dysfunction, surgical ventricular reconstruction to a more normal left ventricular size plus coronary artery bypass grafting improves survival free of subsequent hospitalization for cardiac cause when compared with that with coronary artery bypass grafting alone.
The Society of Thoracic Surgeons Clinical Practice Guidelines are intended to assist physicians and other health care providers in clinical decision making by describing a range of generally ...acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.
Lower cholesterol levels are associated with worse outcomes in patients with chronic heart failure (HF) and have been shown to predict in-hospital mortality. The relation between lipid profile and ...postdischarge outcomes in patients hospitalized for worsening HF is less clear. In this post hoc analysis of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST), 3,957 patients hospitalized for worsening HF with ejection fractions ≤40% were examined. Baseline total cholesterol and triglyceride levels were measured <48 hours after admission and evaluated as continuous variables. The primary end points of all-cause mortality and cardiovascular mortality or hospitalization for HF were compared using Cox regression models. Patient characteristics at randomization were also compared among quartiles of total cholesterol. Patients with lower total cholesterol tended to have lower blood pressure, ejection fractions, serum sodium, and albumin, and were more likely to have worse HF functional class, to have higher natriuretic peptide levels, and to have histories of diabetes mellitus, renal insufficiency, and coronary revascularization (all p values <0.001). After adjustment for baseline clinical risk factors, total cholesterol was predictive of all-cause mortality (hazard ratio 0.73, 95% confidence interval 0.63 to 0.85, p <0.001) and cardiovascular mortality or hospitalization for HF (hazard ratio 0.73, 95% confidence interval 0.66 to 0.82, p <0.001) at median follow-up of 9.9 months. Lower baseline triglyceride level was also associated with worse outcomes. In conclusion, lower baseline total cholesterol is correlated with a high-risk patient profile and is a marker of disease severity in patients hospitalized for worsening HF with reduced ejection fraction. Baseline total cholesterol and triglyceride levels are predictive of mortality and HF rehospitalization beyond traditional risk factors.
Advances in medical therapies leading to improved patient outcomes are in large part related to successful conduct of clinical trials that offer critical information regarding the efficacy and safety ...of novel interventions. The conduct of clinical trials in the United States, however, continues to face increasing challenges with recruitment and retention. These trends are paralleled by an increasing shift toward more multinational trials where most participants are enrolled in countries outside the United States, bringing into question the generalizability of the results to the American population. This manuscript presents the perspectives and recommendations from clinicians, researchers, sponsors, and regulators who attended a meeting facilitated by the Food and Drug Administration to improve upon the current clinical trial trends in the United States.
Gender disparities in short- and long-term outcomes have been documented in cardiac and valvular heart surgery. However, there is a paucity of data regarding these differences in the bicuspid aortic ...valve (BAV) population. The aim of this study was to examine gender-specific differences in short- and long-term outcomes after surgical aortic valve (AV) replacement in patients with BAV. A retrospective analysis was performed in 628 consecutive patients with BAV who underwent AV surgery from April 2004 to December 2013. To reduce bias when comparing outcomes by gender, propensity score matching obtained on the basis of potential confounders was used. Women with BAV who underwent AV surgery presented with more advanced age (mean 60.7 ± 13.8 vs 56.3 ± 13.6 years, p <0.001) and less aortic regurgitation (29% vs 44%, p <0.001) and had a higher risk for in-hospital mortality (mean Ambler score 3.4 ± 4.4 vs 2.5 ± 4.0, p = 0.015). After propensity score matching, women received more blood products postoperatively (48% vs 34%, p = 0.028) and had more prolonged postoperative lengths of stay (median 5 days interquartile range 5 to 7 vs 5 days interquartile range 4 to 6, p = 0.027). Operative, discharge, and 30-day mortality and overall survival were not significantly different. In conclusion, women with BAV who underwent AV surgery were older, presented with less aortic regurgitation, and had increased co-morbidities, lending higher operative risk. Although women received more blood products and had significantly longer lengths of stay, short- and long-term outcomes were similar.
...of its activities, the committee has reduced the documentation burden on clinicians and hospitals in the hope that this will thereby allow them to focus on more critical areas of quality ...measurement and improvement. ...the performance measures were extended to assess functional outcomes. Valid, reliable, disease-specific patient-reported questionnaires include the Kansas City Cardiomyopathy Questionnaire (KCCQ); Minnesota Living with Heart Failure Questionnaire (MLHFQ); and Chronic Heart Failure Questionnaire (CHFQ).2Patient symptoms have demonstrated clinically important deterioration since last assessment.3A documented plan of care may include >=1 of the following: reevaluation of medical therapy, including uptitration of doses, consideration of electrical device therapy, recommended lifestyle modifications (e.g., salt restriction, exercise training), initiation of palliative care, referral for more advanced therapies (e.g., transplant, ventricular assist device), or referral to disease management programs.4Counseling should be specific to each individual patient and include documentation of a discussion regarding the risk of sudden and nonsudden death AND the efficacy, safety, and risks of an ICD.
Integrated Imaging in Hypertrophic Cardiomyopathy Choudhury, Lubna, MD; Rigolin, Vera H., MD; Bonow, Robert O., MD, MS
The American journal of cardiology,
01/2017, Letnik:
119, Številka:
2
Journal Article
Recenzirano
Abstract Hypertrophic cardiomyopathy (HC) has a very heterogeneous clinical spectrum and lends itself to multimodality imaging for evaluation and management. This review addresses clinical ...applications of cardiac imaging in patients with HC. Integrating various modalities of echocardiography and cardiac magnetic resonance (CMR) are discussed in the clinical context such as diagnosis, evaluation, management, risk stratification and family screening of HC patients. The utility of peri-procedure imaging techniques are highlighted for guiding surgical and transcatheter septal reduction procedures. More limited roles of invasive or computed tomography (CT) coronary angiography are discussed for HC patients with chest pain and risk factors for coronary artery disease. Nuclear techniques though available for decades, play a more limited role in contemporary routine management, but may assist in risk assessment. Newer CMR and echo imaging techniques are discussed in their emerging roles for further characterization of HC patients and family members with prospects of preclinical diagnosis. The strengths of the different imaging modalities are presented as well as a flow diagram summarizing integrated imaging in this disease. In conclusion, integrated imaging using the various imaging modalities predominantly echocardiography and CMR based on the clinical picture, plays an essential role in the management of HC patients.
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