Publications by authors named "Shane Nanayakkara"

52 Publications

Association Between Urine Output and Mortality in Critically Ill Patients: A Machine Learning Approach.

Crit Care Med 2021 Sep 22. Epub 2021 Sep 22.

School of Medicine, Griffith University, Southport, QLD, Australia. Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia. Centre for Transformative Innovation, Faculty of Business and Law, Swinburne University of Technology, Hawthorn, VIC, Australia. Department of Data Science and AI, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia. School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia. Department of Cardiology, Alfred Hospital, Melbourne, VIC, Australia. Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia. Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.

Objectives: Current definitions of acute kidney injury use a urine output threshold of less than 0.5 mL/kg/hr, which have not been validated in the modern era. We aimed to determine the prognostic importance of urine output within the first 24 hours of admission to the ICU and to evaluate for variance between different admission diagnoses.

Design: Retrospective cohort study.

Setting: One-hundred eighty-three ICUs throughout Australia and New Zealand from 2006 to 2016.

Patients: Patients greater than or equal to 16 years old who were admitted with curative intent who did not regularly receive dialysis. ICU readmissions during the same hospital admission and patients transferred from an external ICU were excluded.

Measurements And Main Results: One hundred and sixty-one thousand nine hundred forty patients were included with a mean urine output of 1.05 mL/kg/hr and an overall in-hospital mortality of 7.8%. A urine output less than 0.47 mL/kg/hr was associated with increased unadjusted in-hospital mortality, which varied with admission diagnosis. A machine learning model (extreme gradient boosting) was trained to predict in-hospital mortality and examine interactions between urine output and survival. Low urine output was most strongly associated with mortality in postoperative cardiovascular patients, nonoperative gastrointestinal admissions, nonoperative renal/genitourinary admissions, and patients with sepsis.

Conclusions: Consistent with current definitions of acute kidney injury, a urine output threshold of less than 0.5 mL/kg/hr is modestly predictive of mortality in patients admitted to the ICU. The relative importance of urine output for predicting survival varies with admission diagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000005310DOI Listing
September 2021

Comprehensive Physiological Modeling Provides Novel Insights Into Heart Failure With Preserved Ejection Fraction Physiology.

J Am Heart Assoc 2021 Oct 25;10(19):e021584. Epub 2021 Sep 25.

Department of Medicine Columbia University Medical School New York NY.

Background Although a rapid rise in left atrial pressure during exertion is considered pathognomonic of heart failure with preserved ejection fraction (HFpEF), the fundamental circulatory determinants of this response are not clear, impacting upon the development of more effective therapies. We aimed to comprehensively describe the circulatory mechanics of patients with HFpEF at rest and during exercise in comparison with controls. Methods and Results We performed simultaneous right-heart catheterization and echocardiography at rest and during exercise in 22 healthy control volunteers and 60 patients with confirmed HFpEF. Using detailed individual patient-level hemodynamic and left ventricular ejection fraction data we performed computer simulations to evaluate the circulatory parameters including the estimated stressed blood volumethat contribute to the resting and exercise pulmonary capillary pressure. At rest and during exercise, left ventricular stiffness (V, the end-diastolic pressure-volume relationship at a filling pressure of 30 mm Hg), left ventricular elastance, and arterial elastance were all significantly greater in HFpEF than in controls. Stressed blood volume was significantly greater in HFpEF (26.9±5.4 versus 20.2±4.7 mL/kg, <0.001), becoming even more pronounced during exercise (40.9±3.7 versus 27.5±7.0 mL per 70 kg, <0.001). During exercise, the magnitude of the change in stressed blood volume (=0.67, <0.001) and left ventricular stiffness (=-0.44, <0.001) were key determinants of the rise in pulmonary capillary wedge pressure. Further detailed modeling studies showed that the hemodynamic response to exercise results from a complex non-linear interaction between circulatory parameters. Conclusions The circulatory determinants of HFpEF physiology are complex. We identified stressed blood volume at rest and during exercise is a novel, key factor, therebyrepresenting an important potential therapeutic target.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.121.021584DOI Listing
October 2021

Short- and Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Public and Private Hospital Settings: A Propensity-Matched Analysis.

Heart Lung Circ 2021 Jul 6. Epub 2021 Jul 6.

Heart Centre, The Alfred Hospital, Melbourne, Vic, Australia; Department of Cardiology, Epworth Healthcare, Melbourne, Vic, Australia.

Objectives: To compare short- and long-term outcomes after transcatheter aortic valve implantation (TAVI) in the public and private hospital setting.

Design: Propensity-matched, retrospective analysis of a prospective registry.

Setting And Participants: Patients with severe aortic stenosis who underwent TAVI at a tertiary public hospital (n=507) and an experienced private hospital (n=436).

Main Outcome Measures: The primary endpoint was all-cause mortality.

Results: Patients that underwent TAVI in the public hospital were younger than patients in the private hospital (82±8 years vs 84±6 years, p<0.001), with lower estimated short-term mortality risk (Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] score >4.0%: 43% vs 56%, p<0.001). There was no difference between public and private hospitals in 30-day mortality (1.5% vs 1.2%, p=1.0), and the rate of complications was similar. Long-term survival was similar in propensity-matched public (n=344) and private (n=344) patient cohorts. The 1-year, 2-year, 5-year and 7-year survival rates were 95%, 90%, 67% and 47% in public patients, and 92%, 86%, 67% and 51% in private patients (p=0.94). In multivariable analysis, the hospital setting was not a predictor of mortality.

Conclusion: Despite increased age and predicted mortality in private hospital patients, short- and long-term outcomes after TAVI were comparable between public and private hospital settings. This study demonstrates the feasibility of performing TAVI in a private hospital with a dedicated and experienced team and questions the current restricted access to TAVI in the private sector.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hlc.2021.05.083DOI Listing
July 2021

The Gut Microbiome of Heart Failure With Preserved Ejection Fraction.

J Am Heart Assoc 2021 07 2;10(13):e020654. Epub 2021 Jul 2.

Heart Failure Research Group Baker Heart and Diabetes Institute Melbourne Australia.

Background Risk factors for heart failure with preserved ejection fraction (HFpEF) include hypertension, age, sex, and obesity. Emerging evidence suggests that the gut microbiota independently contributes to each one of these risk factors, potentially mediated via gut microbial-derived metabolites such as short-chain fatty acids. In this study, we determined whether the gut microbiota were associated with HFpEF and its risk factors. Methods and Results We recruited 26 patients with HFpEF and 67 control participants from 2 independent communities. Patients with HFpEF were diagnosed by exercise right heart catheterization. We assessed the gut microbiome by bacterial 16S rRNA sequencing and food intake by the food frequency questionnaire. There was a significant difference in α-diversity (eg, number of microbes) and β-diversity (eg, type and abundance of microbes) between both cohorts of controls and patients with HFpEF (=0.001). We did not find an association between β-diversity and specific demographic or hemodynamic parameters or risk factors for HFpEF. The Firmicutes to Bacteroidetes ratio, a commonly used marker of gut dysbiosis, was lower, but not significantly so (=0.093), in the patients with HFpEF. Compared with controls, the gut microbiome of patients with HFpEF was depleted of bacteria that are short-chain fatty acid producers. Consistent with this, participants with HFpEF consumed less dietary fiber (17.6±7.7 versus 23.2±8.8 g/day; =0.016). Conclusions We demonstrate key changes in the gut microbiota in patients with HFpEF, including the depletion of bacteria that generate metabolites known to be important for cardiovascular homeostasis. Further studies are required to validate the role of these gut microbiota and metabolites in the pathophysiology of HFpEF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.120.020654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403331PMC
July 2021

A prospective STudy using invAsive haemodynamic measurements foLLowing catheter ablation for AF and early HFpEF: STALL AF-HFpEF.

Eur J Heart Fail 2021 05 8;23(5):785-796. Epub 2021 Mar 8.

Baker Heart & Diabetes Institute, Melbourne, Australia.

Aims: The impact of atrial fibrillation (AF) ablation in early heart failure with preserved ejection fraction (HFpEF) is unknown. Our aim was to determine the impact of AF ablation on symptoms and exercise haemodynamic parameters of early HFpEF.

Methods And Results: Symptomatic AF patients referred for index AF ablation with ejection fraction ≥50% underwent baseline quality of life questionnaires, echocardiography, cardiac magnetic resonance imaging, exercise right heart catheterisation (exRHC), and brain natriuretic peptide (BNP) testing. HFpEF was defined by resting pulmonary capillary wedge pressure (PCWP) ≥15 mmHg or peak exercise PCWP ≥25 mmHg. Patients with HFpEF were offered AF ablation and follow-up exRHC ≥6 months post-ablation. Of 54 patients undergoing baseline evaluation, 35 (65%) had HFpEF identified by exRHC. HFpEF patients were older (64 ± 10 vs. 54 ± 13 years, P < 0.01), and more frequently female (54% vs. 16%, P < 0.01), hypertensive (63% vs. 16%, P < 0.001), and suffering persistent AF (66% vs. 11%, P < 0.001), compared to those without HFpEF. Twenty HFpEF patients underwent AF ablation and follow-up exRHC 12 ± 6 months post-ablation. Nine (45%) patients no longer fulfilled exRHC criteria for HFpEF at follow-up. Patients remaining arrhythmia free (n = 9, 45%) showed significant improvements in peak exercise PCWP (29 ± 4 to 23 ± 2 mmHg, P < 0.01) and Minnesota Living with Heart Failure (MLHF) score (55 ± 30 to 22 ± 30, P < 0.01) while the remainder did not (PCWP 31 ± 5 to 30.0 ± 4 mmHg, P = NS; MLHF score 55 ± 23 to 25 ± 20, P = NS).

Conclusion: Heart failure with preserved ejection fraction frequently coexists in patients with symptomatic AF and preserved ejection fraction. Restoration and maintenance of sinus rhythm in patients with comorbid AF and HFpEF improves haemodynamic parameters, BNP and symptoms associated with HFpEF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ejhf.2122DOI Listing
May 2021

Long-Term Outcomes Stratified by Body Mass Index in Patients Undergoing Transcatheter Aortic Valve Implantation.

Am J Cardiol 2020 12 2;137:77-82. Epub 2020 Oct 2.

Department of Cardiology, Alfred Health, Melbourne, Australia; Department of Cardiology, Epworth Hospital, Melbourne, Australia. Electronic address:

Transcatheter aortic valve implantation (TAVI) is emerging as the default strategy for older patients with severe, symptomatic, and trileaflet aortic stenosis. Increased body-mass index (BMI) is associated with a protective effect in patients undergoing percutaneous coronary intervention. We assessed whether elevated BMI was associated with a similar association in TAVI. We evaluated prospectively collected data from 634 patients who underwent TAVI at 2 centers from August 2008 to April 2019. Patients were stratified as normal weight (BMI 18.5 to 24.9 kg/m, n = 214), overweight (25 to 29.9 kg/m, n = 234), and obese (>30 kg/m, n = 185). Outcomes were reported according to VARC-2 criteria. Mortality was assessed using Cox proportional hazards regression analysis (median follow-up 2 years). Kaplan-Meier analysis was used to estimate cumulative mortality. Baseline differences were seen in age (85 vs 84 vs 82, p <0.001), STS-PROM score (4.3 vs 3.4 vs 3.6, p <0.001), sex (50% vs 36% vs 55% female, p <0.001), clinical frailty score (p = 0.02), diabetes (21% vs 29% vs 40%, p <0.001), and presence of chronic obstructive pulmonary disease (COPD) (13% vs 13% vs 23%, p = 0.009). On multivariable analysis there was no mortality difference between normal and obese patients (hazard ratio [HR] 0.70, confidence interval [CI] 0.46 to 1.1 p = 0.11), however overweight patients had significantly lower mortality (HR 0.56 CI 0.38 to 0.85, p = 0.006). Variables independently associated with increased mortality were increasing age, male sex, COPD, previous balloon valvuloplasty, and higher STS-PROM. In conclusion, overweight patients have lower long-term mortality when compared with normal weight and obese patients undergoing TAVI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjcard.2020.09.039DOI Listing
December 2020

Identification of physiologic treatment targets with favourable haemodynamic consequences in heart failure with preserved ejection fraction.

ESC Heart Fail 2020 Sep 9. Epub 2020 Sep 9.

Columbia University Medical School, New York, NY, USA.

Aims: Heart failure with preserved ejection fraction (HFpEF) is characterized by complex pathophysiology including an impaired diastolic reserve. We recently showed that milrinone favourably modifies filling pressures at rest and during exertion in HFpEF patients; however, the responsible mechanism is uncertain. The objective of this study was to develop a clearer understanding of the acutely modifiable physiologic parameters that may be targeted in HFpEF.

Methods And Results: We conducted computer modelling simulations based on invasive haemodynamic assessments, by right heart catheterization, in HFpEF patients at baseline and in response to milrinone. Our aim was to develop a detailed understanding of the physiologic mechanisms, which accounted for the observed actions. The resultant circulatory model of HFpEF encompassed the left ventricular (LV) end-systolic and end-diastolic pressure-volume relations, together with stressed blood volume, heart rate, and arterial mechanics. To support the modelled action of milrinone, we conducted complementary LV conductance catheter and echocardiography studies in sheep to evaluate LV end-systolic and end-diastolic pressure-volume relations. In HFpEF patients, the acute haemodynamic effects of intravenous milrinone (n = 10) administration compared with placebo (n = 10) included significant reductions in right atrial pressure (7 ± 1 to 3 ± 1 mmHg, P < 0.001) and pulmonary capillary wedge pressure (13 ± 1 to 8 ± 1 mmHg, P < 0.001), while cardiac index increased (2.77 ± 0.19 to 3.15 ± 0.14 L/min/m , P < 0.05), and mean arterial pressure remained unchanged (95 ± 2 to 93 ± 3 mmHg, P = not significant). Computer simulations showed that these haemodynamic effects were explained by a concomitant 31% reduction in stressed blood volume together with 44% increase in LV end-systolic elastance (LV E ). Individually, changes in these parameters were not sufficient to explain the haemodynamic effects of milrinone. In vivo studies conducted in sheep (n = 5) showed that milrinone reduced LV filling pressure (8.0 ± 0.8 to 2.7 ± 0.6 mmHg, P < 0.01) and increased LV E (0.96 ± 0.07 to 2.07 ± 0.49, P < 0.05), while no significant effect on LV stiffness was observed (0.038 ± 0.003 to 0.034 ± 0.008, P = not significant).

Conclusions: These data demonstrate that stressed blood volume in HFpEF represents a relevant physiologic target in HFpEF; however, concomitant modulation of other cardiovascular parameters including LV contractility may be required to achieve desirable haemodynamic effects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ehf2.12908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754909PMC
September 2020

Impact of Gender on Transcatheter Aortic Valve Implantation Outcomes.

Am J Cardiol 2020 10 30;133:98-104. Epub 2020 Jul 30.

Department of Cardiology, Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. Electronic address:

Previous studies indicate that women who underwentwho underwent transcatheter aortic valve implantation (TAVI) have poorer 30-day outcomes compared with men. However, the effect of gender as a prognostic factor for long-term outcomes following TAVI remains unclear. Between 2008 and 2018, all patients (n = 683) who underwent TAVI in 2 centres in Melbourne, Australia were prospectively included in a registry. The primary end-point was long-term mortality. The secondary end points were Valve Academic Research Consortium-2 (VARC-2) in-hospital complications and mortality at 30-days and 1-year. Of 683 patients, 328 (48%) were women. Women had a higher mean STS-PROM score (5.2 ± 3.1 vs 4.6 ± 3.5, p < 0.001) but less co-morbidities than men. Women had a significantly higher in-hospital bleeding rates (3.3% vs 1.0%, Odds Ratio 4.21, 95% confidence interval [CI] 1.16 to15.25, p = 0.027) and higher 30-day mortality (2.4% vs 0.3%, hazard ratio [HR] 8.75, 95% CI 1.09 to 69.6, p = 0.040) than men. Other VARC-2 outcomes were similar between genders. Overall mortality rate was 36% (246) over a median follow up of 2.7 (interquartile rang [IQR] 1.7 to 4.2) years. Median time to death was 5.3 (95% CI 4.7 to 5.7) years. One-year mortality was similar between genders (8.3% vs 7.8%), as was long-term mortality (HR = 0.91, 95% CI 0.71 to 1.17, p = 0.38). On multivariable analysis, female gender was an independent predictor for 1-year mortality (HR = 2.33, 95% CI 1.11 to 4.92, p = 0.026), but not long-term mortality (HR = 0.78, 95% CI 0.54 to 1.14, p = 0.20). In the women only cohort, STS-PROM was the only independent predictor of long-term mortality (HR 1.88, 95% CI 1.42 to 2.48, p < 0.001). In conclusion, women had higher rates of peri-procedural major bleeding and 30-day mortality following TAVI. However, long-term outcomes were similar between genders.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjcard.2020.07.052DOI Listing
October 2020

Presentations of stroke and acute myocardial infarction in the first 28 days following the introduction of State of Emergency restrictions for COVID-19.

Emerg Med Australas 2020 12 12;32(6):1040-1045. Epub 2020 Sep 12.

Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.

Objectives: To determine if Victorian State of Emergency (SOE) measures to combat COVID-19 were associated with delayed presentations or management of acute stroke and acute myocardial infarction (AMI).

Methods: This was a retrospective, pre- and post-implementation study using data from an adult, tertiary cardiology and neurosciences centre with 24-h capacity for endovascular procedures. All primary presentations with acute stroke or AMI during the first 28 days of stage 2 and stage 3 SOE restrictions (26 March to 23 April 2020) were compared to an equivalent period without restrictions (26 March to 23 April 2019). The primary outcome variable was time from onset of symptoms to ED presentation.

Results: There were 52 (1.6% of all ED presentations) patients who met inclusion criteria during the SOE period and 57 (1.0%) patients in the comparator period. Patients were equally matched for demographics, disease severity and prior history of stroke or AMI. Median time from symptom onset to presentation was 227 (93-1183) min during the SOE period and 342 (119-1220) min during the comparator period (P = 0.24). Among eligible patients with ischaemic stroke or ST-elevation AMI, median time to primary reperfusion intervention was 65 (37-78) min during SOE and 44 (39-60) min in the comparator period (P = 0.54). There were no differences in mortality at hospital discharge (9.6% vs 10.5%) and hospital length of stay (5.4 vs 4.3 days).

Conclusions: In the first 28 days, SOE measures to combat COVID-19 were not associated with delays in presentation or life-saving interventions for patients with acute stroke and AMI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/1742-6723.13621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461453PMC
December 2020

Changes in the Preterm Heart From Birth to Young Adulthood: A Meta-analysis.

Pediatrics 2020 08 7;146(2). Epub 2020 Jul 7.

Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom;

Context: Preterm birth is associated with incident heart failure in children and young adults.

Objective: To determine the effect size of preterm birth on cardiac remodeling from birth to young adulthood.

Data Sources: Data sources include Medline, Embase, Scopus, Cochrane databases, and clinical trial registries (inception to March 25, 2020).

Study Selection: Studies in which cardiac phenotype was compared between preterm individuals born at <37 weeks' gestation and age-matched term controls were included.

Data Extraction: Random-effects models were used to calculate weighted mean differences with corresponding 95% confidence intervals.

Results: Thirty-two observational studies were included (preterm = 1471; term = 1665). All measures of left ventricular (LV) and right ventricular (RV) systolic function were lower in preterm neonates, including LV ejection fraction ( = .01). Preterm LV ejection fraction was similar from infancy, although LV stroke volume index was lower in young adulthood. Preterm LV peak early diastolic tissue velocity was lower throughout development, although preterm diastolic function worsened with higher estimated filling pressures from infancy. RV longitudinal strain was lower in preterm-born individuals of all ages, proportional to the degree of prematurity ( = 0.64; = .002). Preterm-born individuals had persistently smaller LV internal dimensions, lower indexed LV end-diastolic volume in young adulthood, and an increase in indexed LV mass, compared with controls, of 0.71 g/m per year from childhood ( = .007).

Limitations: The influence of preterm-related complications on cardiac phenotype could not be fully explored.

Conclusions: Preterm-born individuals have morphologic and functional cardiac impairments across developmental stages. These changes may make the preterm heart more vulnerable to secondary insults, potentially underlying their increased risk of early heart failure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/peds.2020-0146DOI Listing
August 2020

Extended-Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction.

J Am Heart Assoc 2020 07 18;9(13):e015026. Epub 2020 Jun 18.

Department of Cardiology Alfred Hospital Melbourne Australia.

Background Heart failure with preserved ejection fraction (HFpEF) is an increasingly prevalent form of heart failure, representing half of the total burden of heart failure. We hypothesised that modulation of the phosphodiesterase type 3/cyclic AMP using a novel oral formulation of milrinone might exert favorable effects HFpEF via pulmonary and systemic vasodilation and enhancement of ventricular relaxation. We assessed the safety and efficacy of oral milrinone on quality of life and functional outcomes in patients with HFpEF. Methods and Results The MilHFPEF (Extended Release Oral Milrinone for the Treatment of Heart Failure With Preserved Ejection Fraction) study was a randomized, double-blind, placebo-controlled pilot study in 23 patients with symptomatic HFpEF. Efficacy end points included changes from baseline in Kansas City Cardiomyopathy Questionnaire summary score and 6-minute walk distance. The primary safety end point was the development of clinically significant arrhythmia. The Kansas City Cardiomyopathy Questionnaire score improved significantly in milrinone-treated patients compared with placebo (+10±13 versus -3±15; =0.046). Six-minute walk distance also tended to improve in the treatment group compared with placebo (+22 [-8 to 49] versus -47 [-97 to 12]; =0.092). Heart rate (-1±5 versus -2±9 bpm; =0.9) and systolic blood pressure (-3±18 versus +1±12 mm Hg; =0.57) were unchanged. Early filling velocity/early mitral annular velocity (-0.3±3.0 versus -1.9±4.8; =0.38) was unchanged. One patient in the placebo arm was hospitalized for heart failure. Holter monitoring did not demonstrate evidence of a proarrhythmic effect of milrinone. Conclusions In this novel pilot study, extended release oral milrinone was well tolerated and associated with improved quality of life in patients with HFpEF. Further longer-term studies are warranted to establish the role of this therapeutic approach in HFpEF. Registration URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12616000619448.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.119.015026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670502PMC
July 2020

Device Based Approaches to the Prevention of Contrast-Induced Acute Kidney Injury.

Interv Cardiol Clin 2020 07 7;9(3):395-401. Epub 2020 May 7.

Department of Cardiology, Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Wellington Road, Clayton, Melbourne, VIC 3168, Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia. Electronic address:

Contrast-induced acute kidney injury is not uncommon after percutaneous coronary intervention, particularly in high-risk patients. Pharmacologic approaches have not demonstrated significant benefit, and numerous device-based approaches exist targeting a variety of pathways. In this review, we summarize the most recent interventions and the evidence behind them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.iccl.2020.02.005DOI Listing
July 2020

Optimal Mechanical Unloading in Left Ventricular Assist Device Recipients Relates to Progressive Up-Titration in Pump Speed.

J Am Soc Echocardiogr 2020 05 12;33(5):583-593. Epub 2020 Mar 12.

Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia. Electronic address:

Background: Left ventricular (LV) assist devices (LVADs) are known to elicit reverse remodeling by mechanically unloading the left ventricle. Current guidelines target a reduction in LV end-diastolic diameter (LVEDD) of 15% compared with pre-LVAD dimensions; however, there is significant heterogeneity in the degree of unloading achieved. We sought to investigate factors associated with mechanical unloading at 6 months of LVAD support.

Methods: Data were retrospectively collected for 75 LVAD recipients at five time points: pre-LVAD, within 14 days post-LVAD, and at 1, 3, and 6 months post-LVAD. The percentage change in LVEDD between the pre-LVAD and 6 months post-LVAD time points was termed ΔLVEDD. Optimal LV unloading was defined as ΔLVEDD of ≥15% at 6 months. Patients who achieved optimal unloading (group A, n = 30) were compared with patients who did not (group B, n = 45).

Results: At 6 months, optimally unloaded patients (group A) demonstrated higher fractional shortening (15% ± 10% vs 10% ± 7%, P = .007), lower rates of moderate or severe mitral regurgitation (10% vs 33%, P = .02), and lower pulmonary capillary wedge pressure (9 ± 4 vs 16 ± 7 mm Hg, P = .02). Right ventricular dysfunction was more prevalent at 6 months in poorly unloaded (group B) patients (73% vs 43%, P = .008). Between hospital discharge and 6 months, the percentage increase in pump speed (Δ revolutions per minute) was higher in group A patients (4.4% ± 3.7% vs 0.1% ± 2.6%, P < .001). In a multivariate analysis, Δ revolutions per minute and tricuspid annular systolic velocity (S') at 6 months were independently associated with 6-month ΔLVEDD.

Conclusions: Recipients of LVADs who undergo progressive pump speed up-titration during outpatient follow-up are more likely to sustain optimal LV unloading. Progressive LVAD-related right ventricular failure is prevalent in suboptimally unloaded patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.echo.2020.01.002DOI Listing
May 2020

Management of heart failure with preserved ejection fraction.

Aust Prescr 2020 02 3;43(1):12-17. Epub 2020 Feb 3.

Monash University, Clayton, Vic.

Heart failure with preserved ejection fraction is a highly heterogenous disease. There is emerging evidence that treatment should be tailored to the individual’s associated comorbidities No current algorithms exist for the management of heart failure with preserved ejection fraction. Conventional therapies used in heart failure with reduced ejection fraction are yet to show a mortality benefit Key treatment objectives include control of hypertension and fluid balance Common comorbidities include coronary artery disease, atrial fibrillation, obesity, diabetes, renal impairment and pulmonary hypertension. These comorbidities should be considered in all patients and treatment optimised
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.18773/austprescr.2020.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026917PMC
February 2020

The effect of parity on exercise physiology in women with heart failure with preserved ejection fraction.

ESC Heart Fail 2020 02 20;7(1):213-222. Epub 2020 Jan 20.

Department of Cardiology, Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia.

Aims: Women are overrepresented amongst patients with heart failure with preserved ejection fraction (HFpEF); however, the underpinning mechanism for this asymmetric distribution is unclear. Pregnancy represents a potential gender-specific risk factor for HFpEF. It leads to significant physiological adaption, and increasing parity has been associated with some cardiovascular risk. We sought to examine the relationship between prior parity with the rest and exercise haemodynamic and echocardiographic profile of women with HFpEF.

Methods And Results: Patients referred for assessment of exertional dyspnoea and confirmed to have a haemodynamic and clinical profile consistent with HFpEF were included. Detailed evaluation consisted of rest and exercise right heart catheterization and echocardiography. A socio-economic and obstetric history was also documented. Fifty-eight women were assessed and categorized as having either 0-2 births or ≥3 births, dividing the cohort equally. Women with ≥3 births achieved a lower symptom-limited workload than those with 0-2 births [38 (24-51) vs. 46 (31-68) W, P = 0.04]. Women with ≥3 births had a greater rise in pulmonary capillary wedge pressure indexed to workload with exercise [0.5 (0.3-0.8) vs. 0.3 (0.2-0.5) mmHg/W, P = 0.03], paralleled by a greater rise in right atrial pressure [10 (8-12) vs. 7 (3-11), P = 0.01]. Pulmonary vascular resistance was also higher in women with ≥3 births [1.9 (1.6-2.4) vs. 1.6 (1.4-1.9) mmHg/L/min rest, P = 0.046, and 1.9 (2.4-2.4) vs. 1.4 (1-1.8) mmHg/L/min exercise, P = 0.024]. Left ventricular ejection fraction was lower at rest [60 (57-61) vs. 63 (60-66), P = 0.008] and during exercise [65 (62-67) vs. 68 (66-70), P = 0.038] in women with higher parity.

Conclusions: Higher parity is associated with greater impairments in multiple physiologic parameters of HFpEF severity in women, including diastolic reserve, pulmonary vascular resistance, and systolic dysfunction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ehf2.12557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083419PMC
February 2020

Alcohol Abstinence in Drinkers with Atrial Fibrillation.

N Engl J Med 2020 01;382(1):20-28

From the Heart Center, Alfred Hospital (A.V., T.N., B.C., S.N., S.P., D.S., S.A., D.V., H.S., D.K., A.J.T., P.M.K.), the Baker Heart and Diabetes Institute (A.V., B.C., S.P., D.S., H.S., A.J.T., P.M.K.), the Department of Cardiology, Royal Melbourne Hospital (A.V., J.M.K., S.P., G.W., C.N., H.S.), the Department of Medicine (A.V., J.M.K., P.M.K.) and the Centre for Epidemiology and Biostatistics (A.D.S.), University of Melbourne, the Department of Cardiology, Cabrini Hospital (P.M.K.), the Department of Cardiology, Western Health (D.S., M.W.), Monash Heart, Monash Medical Centre (E.K.), and the Department of Epidemiology and Preventive Medicine (D.S.) and Medicine (A.J.T.), Monash University - all in Melbourne, VIC, Australia.

Background: Excessive alcohol consumption is associated with incident atrial fibrillation and adverse atrial remodeling; however, the effect of abstinence from alcohol on secondary prevention of atrial fibrillation is unclear.

Methods: We conducted a multicenter, prospective, open-label, randomized, controlled trial at six hospitals in Australia. Adults who consumed 10 or more standard drinks (with 1 standard drink containing approximately 12 g of pure alcohol) per week and who had paroxysmal or persistent atrial fibrillation in sinus rhythm at baseline were randomly assigned in a 1:1 ratio to either abstain from alcohol or continue their usual alcohol consumption. The two primary end points were freedom from recurrence of atrial fibrillation (after a 2-week "blanking period") and total atrial fibrillation burden (proportion of time in atrial fibrillation) during 6 months of follow-up.

Results: Of 140 patients who underwent randomization (85% men; mean [±SD] age, 62±9 years), 70 were assigned to the abstinence group and 70 to the control group. Patients in the abstinence group reduced their alcohol intake from 16.8±7.7 to 2.1±3.7 standard drinks per week (a reduction of 87.5%), and patients in the control group reduced their alcohol intake from 16.4±6.9 to 13.2±6.5 drinks per week (a reduction of 19.5%). After a 2-week blanking period, atrial fibrillation recurred in 37 of 70 patients (53%) in the abstinence group and in 51 of 70 patients (73%) in the control group. The abstinence group had a longer period before recurrence of atrial fibrillation than the control group (hazard ratio, 0.55; 95% confidence interval, 0.36 to 0.84; P = 0.005). The atrial fibrillation burden over 6 months of follow-up was significantly lower in the abstinence group than in the control group (median percentage of time in atrial fibrillation, 0.5% [interquartile range, 0.0 to 3.0] vs. 1.2% [interquartile range, 0.0 to 10.3]; P = 0.01).

Conclusions: Abstinence from alcohol reduced arrhythmia recurrences in regular drinkers with atrial fibrillation. (Funded by the Government of Victoria Operational Infrastructure Support Program and others; Australian New Zealand Clinical Trials Registry number, ACTRN12616000256471.).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMoa1817591DOI Listing
January 2020

Arrhythmia recurrence is more common in females undergoing multiple catheter ablation procedures for persistent atrial fibrillation: Time to close the gender gap.

Heart Rhythm 2020 05 19;17(5 Pt A):692-698. Epub 2019 Dec 19.

The Baker Heart & Diabetes Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Monash University, Melbourne, Australia. Electronic address:

Background: Female gender is associated with an increased recurrence of atrial fibrillation (AF) after catheter ablation (CA). Although AF is more common in men, women constitute a significant proportion with persistent atrial fibrillation (PsAF).

Objective: The purpose of this study was to determine whether multiple ablation procedures improves arrhythmia outcomes in females with PsAF compared to men.

Methods: We performed a multicenter observational study to determine long-term arrhythmia outcomes in patients undergoing >1 CA for PsAF. CA involved pulmonary vein (PV) isolation with additional ablation including linear, posterior wall isolation, electrogram-guided, or a combination of these.

Results: A total of 281 patients had >1 ablation procedure for PsAF and were included in this analysis (mean age 58.7 ± 9.3 years; 86 [30.6%] female; left atrial [LA] area 27.0 ± 5.3 cm; PsAF duration 1.7 ± 1.7 years). At mean follow-up of 45.5 ± 31.8 months, freedom from recurrent AF was present in 148 patients(52.7%) after 2.2 ± 0.5 procedures. After multivariate analysis, female gender (hazard ratio [HR] 2.10; P <.001) and enduring PV isolation (HR 1.64; P = .01) were independently associated with AF recurrence. Enduring PV isolation was significantly higher in women than in men (33.7% vs 19.5%; P = .01).

Conclusion: Female gender was independently and strongly associated with arrhythmia recurrence in patients undergoing multiple procedures for PsAF. PV reconnection was less likely, and fewer reconnected PVs occurred in women. Further studies are required to better understand the mechanisms responsible for AF in females to assist in closing the gender gap in the success of CA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2019.12.013DOI Listing
May 2020

Trends of Use and Outcomes Associated With Glycoprotein-IIb/IIIa Inhibitors in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention.

Ann Pharmacother 2020 05 25;54(5):414-422. Epub 2019 Nov 25.

Alfred Hospital, Melbourne, Victoria, Australia.

Glycoprotein IIb/IIIa inhibitors (GPIs) are a treatment option in the management of acute coronary syndromes (ACSs). Evidence supporting the use of GPIs predates trials establishing the benefits of P2Y12 inhibitors, routine early invasive therapy, and thrombectomy devices in patients with ACS. The aim of this study was to determine trends in GPI use and their associated outcomes in contemporary practice. We assessed GPI use in patients with ACS undergoing percutaneous coronary intervention (PCI) from the Melbourne Interventional Group registry (2005-2013). The primary endpoint was the 30-day incidence of major adverse cardiovascular events (MACE). The safety endpoint was in-hospital major bleeding. GPIs were used in 40.5% of 12 357 patients with ACS undergoing PCI. GPI use decreased over the study period ( for trend <0.0001). Patients were more likely to receive GPIs if they were younger, presented with a ST-elevation myocardial infarction (STEMI), had more complex (B2/C-type) lesions, and when thrombectomy devices were used (all < 0.0001). MACE were higher in patients receiving GPI (4.9% vs 4.1%, = 0.03). Propensity score matching revealed no difference in 30-day mortality and 30-day MACE (odds ratio [OR] = 1.00; 95% CI = 0.99-1.004 and OR = 1.01; 95% CI = 0.99-1.02, respectively). GPI use was associated with more bleeding complications (3.6% vs 1.8%, < 0.0001). GPI use in ACS patients undergoing PCI has declined, and use appears to be dictated by ACS type and lesion complexity, as opposed to high-risk comorbidities. GPI use was associated with a doubling in bleeding complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1060028019889550DOI Listing
May 2020

Interatrial Shunt Device for Heart Failure With Preserved Ejection Fraction.

Front Cardiovasc Med 2019 18;6:143. Epub 2019 Sep 18.

Heart Failure Research Group, Department of Cardiology, Baker Heart and Diabetes Institute, Alfred Hospital, Melbourne, VIC, Australia.

Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of the current burden of HF, and the prevalence is continuing to rise. In contrast to HF with reduced ejection fraction (HFrEF) there are no clinically effective evidence based therapies for HFpEF. The principal pathophysiologic disorder is an elevation of left atrial pressure, most notable during physical activity, which results from impaired left ventricular diastolic reserve, and increased left atrial stiffness. This review outlines the clinical development of a potential device based therapy for HFpEF, the interatrial shunt device (IASD).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fcvm.2019.00143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759808PMC
September 2019

The Baker Biobank: Understanding Cardiovascular Outcomes.

Heart Lung Circ 2020 Jul 9;29(7):1071-1077. Epub 2019 Sep 9.

The Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia.

Background: Cardiovascular diseases (CVDs) and diabetes are two of the most important public health problems. Outcomes for patients with these disorders vary considerably, likely due to the added influence of a range of interacting clinical, metabolic, environmental, lifestyle, genetic and psychosocial risk factors associated with these diseases. The Baker Biobank study was designed to characterise these factors to inform better risk prediction, earlier diagnosis and better treatment of CVDs and diabetes.

Methods: This paper describes the detailed methods for the establishment of the Baker Biobank. The study collected extensive phenotypic detail about the participants recruited from Victoria, Australia. Data and samples were collected at the Departments of Cardiology and Respiratory Medicine at the Alfred Hospital and Healthy Hearts Program at the Baker Institute.

Results: A total of 6,530 adults with age 18-69 years were recruited into the Biobank. The majority of these participants (63%) were male. The mean (standard deviation [SD]) age of the Biobank Cohort at the time of data collection was 57(15) years. The study collected data on socio-demographic characteristics, behavioural and lifestyle factors, anthropometric measurements, medical and medication history, and blood levels of various biomarkers. The study also collected and stored Guthrie cards, serum, plasma, buffy coat, whole blood collected in Tempus tubes (for RNA extraction). For some samples extracted DNA and RNA is stored. The Biobank data is also linked to echocardiogram, hospital admission, pathology and mortality datasets. The Baker Biobank data and samples are available for health researchers with approval of Biobank Steering Group and Human Research Ethics Committee.

Conclusion: The Baker Biobank provides valuable data and samples into the study of the interplay among cardiovascular diseases risk factors and their impact on morbidity and mortality in Australia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hlc.2019.08.014DOI Listing
July 2020

Impact of Sex on Ventricular-Vascular Stiffness and Long-Term Outcomes in Heart Failure With Preserved Ejection Fraction: TOPCAT Trial Substudy.

J Am Heart Assoc 2019 07 22;8(13):e012190. Epub 2019 Jun 22.

1 Department of Cardiology Alfred Hospital Melbourne Australia.

Background Women have higher vascular stiffness with aging. The aim of this study was to characterize sex differences in vascular and ventricular structure and function, and to investigate the impact on the primary outcome in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial). Methods and Results Data from the Americas cohort of the TOPCAT trial were analyzed. Patients with echocardiography (n=654) were compared according to sex, and achievement of the primary end point (a composite of death from cardiovascular causes and heart failure hospitalization) assessed. Echocardiography revealed higher arterial, systolic, and diastolic ventricular elastance and worse ventricular-vascular coupling in women. Women had better overall survival and heart failure hospitalization outcomes (hazard ratio 0.74, 95% CI 0.57-0.98, P=0.034), however, determinants of achievement of the primary outcome differed between the sexes. Pulse pressure was a key determinant of outcome in women (hazard ratio 1.04, 95% CI 1-1.09, P=0.034) whereas in men heart rate (hazard ratio 1.61, 95% CI 1.02-2.52 per 10 mm Hg increase, P=0.04) and B-type natriuretic peptide (hazard ratio 1.01, 95% CI 1-1.02 per 10 ng/mL increase P=0.02) were associated with poorer outcome. Conclusions Outcomes in patients with heart failure with preserved ejection fraction appear to be differentially influenced by key physiological factors that vary according to sex. In women, ventricular-vascular stiffening was the most significant determinant of outcome, whereas in men overall survival was influenced by heart rate and B-type natriuretic peptide; this highlights key sex differences in the pathophysiology and outcomes of heart failure with preserved ejection fraction and warrants further exploration. Clinical Trial Registration URL: https://clinicaltrials.gov . Unique identifier: NCT00094302.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.119.012190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6662372PMC
July 2019

Impact of Pre-Procedural Blood Pressure on Long-Term Outcomes Following Percutaneous Coronary Intervention.

J Am Coll Cardiol 2019 06;73(22):2846-2855

Alfred Hospital, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia. Electronic address:

Background: High systolic blood pressure (SBP) increases cardiac afterload, whereas low diastolic blood pressure (DBP) may lead to impaired coronary perfusion. Thus, wide pulse pressure (high systolic, low diastolic [HSLD]) may contribute to myocardial ischemia and also be a predictor of adverse cardiovascular events.

Objectives: The purpose of this study was to determine the relationship between pre-procedural blood pressure and long-term outcome following percutaneous coronary intervention (PCI).

Methods: The study included 10,876 consecutive patients between August 2009 and December 2016 from the Melbourne Interventional Group registry undergoing PCI with pre-procedural blood pressure recorded. Patients with ST-segment elevation myocardial infarction, cardiogenic shock, and out-of-hospital cardiac arrest were excluded. Patients were divided into 4 groups according to SBP (high ≥120 mm Hg, low <120 mm Hg) and DBP (high >70 mm Hg, low ≤70 mm Hg).

Results: Mean pulse pressure was 60 ± 21 mm Hg. Patients with HSLD were older and more frequently women, with higher rates of hypercholesterolemia, renal impairment, diabetes, and multivessel and left main disease (all p ≤ 0.0001). There was no difference in 30-day major adverse cardiac events, but at 12 months the HSLD group had a greater incidence of myocardial infarction (p = 0.018) and stroke (p = 0.013). Long-term mortality was highest for HSLD (7.9%) and lowest for low systolic, high diastolic (narrow pulse pressure) at 2.1% (p = 0.0002). Cox regression analysis demonstrated significantly lower long-term mortality in the low systolic, high diastolic cohort (hazard ratio: 0.50; 99% confidence interval: 0.25 to 0.98; p = 0.04).

Conclusions: Pulse pressure at the time of index PCI is associated with long-term outcomes following PCI. A wide pulse pressure may serve as a surrogate marker for risk following PCI and represents a potential target for future therapies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2019.03.493DOI Listing
June 2019

HDL Phospholipids, but Not Cholesterol Distinguish Acute Coronary Syndrome From Stable Coronary Artery Disease.

J Am Heart Assoc 2019 06;8(11):e011792

1 Baker Heart and Diabetes Institute Melbourne Australia.

Background Although acute coronary syndromes (ACS) are a major cause of morbidity and mortality, relationships with biologically active lipid species potentially associated with plaque disruption/erosion in the context of their lipoprotein carriers are indeterminate. The aim was to characterize lipid species within lipoprotein particles which differentiate ACS from stable coronary artery disease. Methods and Results Venous blood was obtained from 130 individuals with de novo presentation of an ACS (n=47) or stable coronary artery disease (n=83) before coronary catheterization. Lipidomic measurements (533 lipid species; liquid chromatography electrospray ionization/tandem mass spectrometry) were performed on whole plasma as well as 2 lipoprotein subfractions: apolipoprotein A1 (apolipoprotein A, high-density lipoprotein) and apolipoprotein B. Compared with stable coronary artery disease, ACS plasma was lower in phospholipids including lyso species and plasmalogens, with the majority of lipid species differing in abundance located within high-density lipoprotein (high-density lipoprotein, 113 lipids; plasma, 73 lipids). Models including plasma lipid species alone improved discrimination between the stable and ACS groups by 0.16 (C-statistic) compared with conventional risk factors. Models utilizing lipid species either in plasma or within lipoprotein fractions had a similar ability to discriminate groups, though the C-statistic was highest for plasma lipid species (0.80; 95% CI, 0.75-0.86). Conclusions Multiple lysophospholipids, but not cholesterol, featured among the lipids which were present at low concentration within high-density lipoprotein of those presenting with ACS. Lipidomics, when applied to either whole plasma or lipoprotein fractions, was superior to conventional risk factors in discriminating ACS from stable coronary artery disease. These associative mechanistic insights elucidate potential new preventive, prognostic, and therapeutic avenues for ACS which require investigation in prospective analyses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.118.011792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585356PMC
June 2019

Pathophysiology of Atrial Fibrillation and Heart Failure: Dangerous Interactions.

Cardiol Clin 2019 May 20;37(2):131-138. Epub 2019 Feb 20.

Department of clinical research, The Baker Heart and Diabetes Institute, 75 Commercial road, Melbourne, Victoria, 3004 Australia; Department of Cardiology, The Alfred Hospital, 55 Commercial road, Melbourne, Victoria, 3004, Australia; Department of Medicine, University of Melbourne, Grattan Street, Parkville, Victoria, 3010, Australia. Electronic address:

Atrial fibrillation and heart failure (HF) frequently coexist and are associated with a significant increase in morbidity and mortality. Despite the shared common risk factors atrial fibrillation and HF subtypes exacerbate each other. This review provides an overview of the pathophysiologic relationship between atrial fibrillation and the two most common types of heart failure syndromes: HF with reduced ejection fraction and HF with preserved ejection fraction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ccl.2019.01.002DOI Listing
May 2019

Resting and Exercise Doppler Hemodynamics: How and Why?

Heart Fail Clin 2019 Apr 2;15(2):229-239. Epub 2019 Feb 2.

Department of Cardiology, The Alfred, 55 Commercial Road, Melbourne, Victoria 3004, Australia; Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Victoria 3004, Australia.

Exercise intolerance is the clinical hallmark of the failing heart. Evidence of hemodynamic derangement is not always present at rest, often necessitating dynamic challenges to accentuate abnormalities. Although cardiac catheterization, particularly with exercise, remains the gold standard method for hemodynamic assessment, it is limited by practicality, access, risk, and its invasive nature; consequently, there is a need to better understand noninvasive measures. Echocardiography and cardiac MRI offer promising modalities to quantify ventriculo-vascular interactions. Significant heterogeneity exists around exercise protocols, and there is a need to develop consensus methodology and to validate these noninvasive measures in all forms of heart failure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hfc.2018.12.003DOI Listing
April 2019

Sex Differences in Heart Failure With Preserved Ejection Fraction Pathophysiology: A Detailed Invasive Hemodynamic and Echocardiographic Analysis.

JACC Heart Fail 2019 03;7(3):239-249

Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia; Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Clayton, Victoria, Australia. Electronic address:

Objectives: This study sought to identify sex differences in central and peripheral factors that contribute to the pathophysiology of heart failure with preserved ejection fraction (HFpEF) by using complementary invasive hemodynamic and echocardiographic approaches.

Background: Women are overrepresented among patients with HFpEF, and there are established sex differences in myocardial structure and function. Exercise intolerance is a fundamental feature of HFpEF; however, sex differences in the physiological determinants of exercise capacity in HFpEF are yet to be established.

Methods: Patients with exertional intolerance with confirmed HFpEF were included in this study. Evaluation of the subjects included resting and exercise hemodynamics, echocardiography, and mixed venous blood gas sampling.

Results: A total of 161 subjects included 114 females (71%). Compared to males, females had a higher pulmonary capillary wedge pressure (PCWP) indexed to peak exercise workload (0.8 [0.5 to 1.2] mm Hg/W vs. 0.6 [0.4 to 1] mm Hg/W, respectively; p = 0.001) and lower systemic (1.1 [0.9 to 1.5] ml/mm Hg vs. 1 [0.7 to 1.2] ml/mm Hg, respectively; p = 0.019) and pulmonary (2.9 [2.2 to 4.2] ml/mm Hg vs. 2.4 [1.9 to 3] ml/mm Hg, respectively; p = 0.032) arterial compliance at exercise. Mixed venous blood gas analysis demonstrated a greater rise in lactate indexed to peak workload (0.05 [0.04 to 0.09] mmol/l/W vs. 0.04 [0.03 to 0.06] mmol/l/W, respectively; p = 0.007) in women compared to men. Women had higher mitral inflow velocity to diastolic mitral annular velocity at early filling (E/e') ratios at rest and peak exercise, along with a higher ejection fraction and smaller ventricular dimensions.

Conclusions: Women with HFpEF demonstrate poorer diastolic reserve with higher echocardiographic and invasive measurements of left ventricular filling pressures at exercise, accompanied by lower systemic and pulmonary arterial compliance and poorer peripheral oxygen kinetics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jchf.2019.01.004DOI Listing
March 2019

Impaired left atrial strain predicts abnormal exercise haemodynamics in heart failure with preserved ejection fraction.

Eur J Heart Fail 2019 04 16;21(4):495-505. Epub 2019 Jan 16.

Baker Heart and Diabetes Institute, Melbourne, Australia.

Background: Elevated left atrial (LA) pressure, particularly during exercise, is associated with symptomatic status and survival in patients with heart failure with preserved ejection fraction (HFpEF). We aimed to characterize the contribution of abnormal LA mechanical properties to exercise haemodynamics in HFpEF.

Methods And Results: Simultaneous echocardiography and right heart catheterization were performed in 71 subjects with left ventricular ejection fraction ≥ 50% referred for assessment of exertional dyspnoea. According to haemodynamic evaluation, 49 patients were diagnosed with HFpEF [pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg at rest and/or ≥ 25 mmHg at maximal exertion] and 22 as non-cardiac dyspnoea. Apical two- and four-chamber views were used for blinded two-dimensional LA speckle tracking analysis. HFpEF was characterized by impaired LA reservoir (24.3 ± 9.6 vs. 36.7 ± 8.4%, P < 0.001) and pump strain (-11.5 ± 3.2 vs. -17.0 ± 3.4%, P < 0.001); and increased stiffness (0.8 ± 0.7 vs. 0.2 ± 0.1 mmHg/%, P < 0.001). Reservoir and pump strain correlated with exercise PCWP (r = -0.64 and r = 0.72, P < 0.001), and remained independent predictors after adjusting for left ventricular mass index, LA volume index, mean E/e' and systolic blood pressure (B = -0.66 and B = 1.41, respectively, P < 0.001). LA stiffness was strongly related to B-type natriuretic peptide levels (r = 0.73, P < 0.001; B = 173.0, P < 0.001). Reservoir strain at cut-off of ≤ 33% predicted invasively verified HFpEF diagnosis with 88% sensitivity and 77% specificity, providing a net reclassification improvement of 12% in comparison to the 2016 European Society of Cardiology criteria for non-invasive diagnosis of HFpEF.

Conclusions: Impaired LA reservoir and pump function and increased stiffness are associated with abnormal exercise haemodynamics in HFpEF. These markers provide significant HFpEF diagnostic utility in elderly ambulatory patients with dyspnoea.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ejhf.1399DOI Listing
April 2019
-->