Chagas Disease: Chronic Chagas Cardiomyopathy Echavarría, Natalia Giraldo; Echeverría, Luis E.; Stewart, Merrill ...
Current problems in cardiology,
March 2021, 2021-Mar, 2021-03-00, 20210301, Letnik:
46, Številka:
3
Journal Article
Recenzirano
Chagas disease (CD) is a tropical vector-borne infection caused by the protozoan parasite Trypanosoma cruzi (T. cruzi), also known as American Trypanosomiasis. It is considered endemic in all South ...and Central America and in this past decades its becoming a burden particularly in the United States and Europe due to human migration. The vast majority of patients during the acute phase are asymptomatic, while chronic symptomatic phase appears years later, with around 30% progressing toward detectable organ damage affecting mainly the cardiovascular and digestive systems. Chagas cardiomyopathy is the leading cause of nonischemic cardiomyopathy (NICM) in Latin America and affects around 30% of infected patients. The foremost characteristics are a diffuse myocarditis with focal fibrosis, mainly located in the apex and basal segments of the posterior and inferior wall, leading to a highly arrhythmogenic disease. Treatment can be etiologic during the parasitic infection, without and established efficacy during the advanced chronic symptomatic phase. Chronic Chagas cardiomyopathy treatment consists in guided medical therapy for non-ischemic cardiomyopathy, but more studies are imperative to improve clinical outcomes, some of them already in progress, and hopefully soon refine treatment and recommendations.
Background There is a paucity of outcome data on patients who are morbidly obese (MO) undergoing transcatheter aortic valve replacement. We aimed to determine their periprocedural and midterm ...outcomes and investigate the impact of obesity phenotype. Methods and Results Consecutive patients who are MO (body mass index, ≥40 kg/m 2 , or ≥35 kg/m 2 with obesity‐related comorbidities; n=910) with severe aortic stenosis who underwent transcatheter aortic valve replacement in 18 tertiary hospitals were compared with a nonobese cohort (body mass index, 18.5–29.9 kg/m 2 , n=2264). Propensity‐score matching resulted in 770 pairs. Pre–transcatheter aortic valve replacement computed tomography scans were centrally analyzed to assess adipose tissue distribution; epicardial, abdominal visceral and subcutaneous fat. Major vascular complications were more common (6.6% versus 4.3%; P =0.043) and device success was less frequent (84.4% versus 88.1%; P =0.038) in the MO group. Freedom from all‐cause and cardiovascular mortality were similar at 2 years (79.4 versus 80.6%, P =0.731; and 88.7 versus 87.4%, P =0.699; MO and nonobese, respectively). Multivariable analysis identified baseline glomerular filtration rate and nontransfemoral access as independent predictors of 2‐year mortality in the MO group. An adverse MO phenotype with an abdominal visceral adipose tissue:subcutaneous adipose tissue ratio ≥1 (VAT:SAT) was associated with increased 2‐year all‐cause (hazard ratio HR, 3.06; 95% CI, 1.20–7.77; P =0.019) and cardiovascular (hazard ratio, 4.11; 95% CI, 1.06–15.90; P =0.041) mortality, and readmissions (HR, 1.81; 95% CI, 1.07–3.07; P =0.027). After multivariable analysis, a (VAT:SAT) ratio ≥1 remained a strong predictor of 2‐year mortality (hazard ratio, 2.78; P =0.035). Conclusions Transcatheter aortic valve replacement in patients who are MO has similar short‐ and midterm outcomes to nonobese patients, despite higher major vascular complications and lower device success. An abdominal VAT:SAT ratio ≥1 identifies an obesity phenotype at higher risk of adverse clinical outcomes.
Obesity may increase the risk of vascular complications in transfemoral (TF) transcatheter aortic valve replacement (TAVR) procedures. The transcarotid (TC) approach has recently emerged as an ...alternative access in TAVR. We sought to compare vascular complications and early clinical outcomes in obese patients undergoing TAVR either by TF or TC vascular access.
Multicentre registry including obese patients undergoing TF- or TC-TAVR in 15 tertiary centres. All patients received newer-generation transcatheter heart valves. For patients exhibiting unfavourable ileo-femoral anatomic characteristics, the TC approach was favoured in 3 centres with experience with it. A propensity score analysis was performed for overcoming unbalanced baseline covariates. The primary end point was the occurrence of in-hospital vascular complications (Valve Academic Research Consortium-2 criteria).
A total of 539 patients were included, 454 (84.2%) and 85 (15.8%) had a TF and TC access, respectively. In the propensity-adjusted cohort (TF: 442 patients; TC: 85 patients), both baseline and procedural valve-related characteristics were well-balanced between groups. A significant decrease in vascular complications was observed in the TC group (3.5% vs 12% in the TF group, odds ratio: 0.26, 95% CI: 0.07-0.95, P = 0.037). There were no statistically significant differences between groups regarding in-hospital mortality (TC: 2.8%, TF: 1.5%), stroke (TC: 1.2%, TF: 0.4%) and life-threatening/major bleeding events (TC: 2.8%, TF: 3.8%).
In patients with obesity undergoing TAVR with newer-generation devices, the TC access was associated with a lower rate of vascular complications. Larger randomized studies are warranted to further assess the better approach for TAVR in obese patients.
Introducción: la malnutrición al ingreso hospitalario y una ingesta calórica inferior a las necesidades durante la hospitalización se han relacionado directamente con peores desenlaces clínicos. El ...objetivo del estudio fue describir a los pacientes en la unidad de cuidados intensivos de un hospital de alta complejidad en el nutritionDay 2020. Métodos: se realizó un estudio observacional en pacientes adultos admitidos en unidades de cuidados intensivos (UCI) en noviembre de 2020. Se analizaron los resultados del instrumento de recolección del nutritionDay, y se incluyeron adicionalmente datos de la escala de severidad, duración de la terapia nutricional y el tipo de fórmula administrada. Se presentan medidas descriptivas. Resultados: se incluyeron 50 pacientes, el 42 % (21/50) fue admitido en la UCI por causa pulmonar, el 64 % (32/50) requirió sedación y el 80 % (30/50) requirió algún soporte ventilatorio. El 66 % (33/50) presentó sobrepeso/obesidad. La terapia médico-nutricional por sonda se administró en el 70 % (35/50) con una mediana de duración a la evaluación de 9 días (rango intercuartílico RIC: 4-18) y al 46 % (16/35) se le interrumpió la terapia; el 63 % (22/35) recibió fórmula hipercalórica e hiperproteica; la mediana de calorías programadas en las 24 horas previas a la evaluación fue de 1413 (RIC: 1120-1548). La terapia nutricional convencional se administró en el 32% (16/50). Ningún paciente se alimentó con nutrición parenteral. Conclusiones: la información obtenida en este tipo de actividades de auditoría internacional permite conocer las debilidades y oportunidades de mejora en el proceso de atención nutricional del paciente que garantice mejor desenlace clínico y calidad de vida del paciente teniendo en cuenta la tipificación del paciente crítico. Palabras clave: nutrición enteral, ingesta, malnutrición, suplementación, dieta.
PDF
