Update on Mitral Repair in Dilated Cardiomyopathy

Heart failure is one of the leading causes of hospitalization worldwide. Mitral regurgitation (MR) is a known complication of end-stage cardiomyopathy and is associated with a poor prognosis due to progressive mitral annular dilation. A vicious cycle of continuing volume overload, ventricular dilation, progression of annular dilation, increased LV wall tension, and worsening of MR and CHF occur. Commonly, these patients were managed medically with diuretics and afterload reduction, and frequently with mitral valve replacement, both of which have poor long term survival in patients with CHF and MR. Over a 10-year period we prospectively studied over 200 patients with cardiomyopathy and severe MR who underwent mitral valve repair utilizing an undersizing overcorrecting annuloplasty ring. The mortality was low with one intraoperative death and eight 30-day mortalities. There were 26 late deaths; 2 of these patients had progression of heart failure and underwent transplantation. The 1-, 2-, and 5-year actuarial survivals have been 82%, 71%, and 52%, respectively. The NYHA class has improved for all patients from a preoperative mean of 3.2 ± 0.2 to 1.8 ± 0.4 postoperatively. All patients demonstrated improvement in ejection fraction, cardiac output, and end diastolic volumes with a reduction in sphericity index and regurgitant volume at 2 years post operation. All of the observed changes contribute to reverse remodeling and restoration of the normal left ventricular geometry. Mitral valve repair is a safe and effective operative intervention that corrects MR and offers a new strategy for patients with MR and end-stage cardiomyopathy. (J Card Surg 2004;19:396-400)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72871/1/j.0886-0440.2004.04079.x.pd

Mini-Reoperative Mitral Valve Surgery

Background: Reoperative surgery involving the atrioventricular valves places the patient at risk for cardiac or bypass graft injury upon reoperative sternotomy. Standard right thoracotomy can avoid these problems but is associated with a large incision and possibly more pulmonary complications. Methods and Results : An alternative, minimally invasive approach for reoperative atrioventricular valve surgery was studied in 22 patients. Patient age was 66 ± 10 years. Postoperative mitral regurgitation was 3.4 ± 0.3 and New York Heart Association (NYHA) Class was III/IV, despite a mean ejection fraction of 44 ± 14%. These patients had 1–4 prior procedures a mean of 5 years previously. An anterior 5th interspace incision of 5- to 10-cm was performed. A 1-cm segment of 5th rib was removed to facilitate exposure. Cardiopulmonary bypass was performed via ascending aorta or femoral artery cannula and bicaval venous cannulae. Systemic cooling (25°) and fibrillatory arrest was used. Operations performed included mitral valve repair (12). mitral valve replacement (5), prosthetic mitral valve rereplacement (4). repair of perivalvular leak (3), tricuspid valve repair (5), and atrial septal defect closures (7). Mean bypass time was 109 ± 21 minutes with a mean fibrillatory time of 62 ± 12 minutes. There was no intraoperative or 30-day mortality. Patients were weaned from ventilation at a mean of 5 hours postoperatively and received 1.3 ± 1 unit of blood. There were no wound complications or re-explorations for bleeding. At a mean follow-up of 15 ± 8 months, survivors are NYHA Class I-II. When interviewed, all patients felt their recovery was more rapid and less painful than their original sternotomy. Conclusion : This minimally invasive approach to reoperative atrioventricular valve surgery is safe and technically feasible. It has become our preferred approach to the atrioventricular valves in patients with a previous sternotomy.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73273/1/j.1540-8191.1998.tb01084.x.pd

Psychological Recovery from Coronary Artery Bypass Graft Surgery: The Use of Complementary Therapies

This study explored the use of complementary therapies that patients pursued after coronary artery bypass graft (CABG) surgery and its relation to psychological recovery, particularly postoperative distress. Information about post-CABG surgery depression and general distress, health-care practice thereafter, perceived social support, and chronic conditions other than cardiac disease was gathered from a sample of 151 patients through two questionnaires. Additional cardiac, surgical, and demographic data were obtained from medical records. Structural equation modeling (LISREL 8) was used to test the hypothesis that patients' health-care practices improved psychological adjustment after CABG. Of the sample, 85% practiced complementary approaches, especially prayer, exercise, and lifestyle-diet modification. The number of other chronic illnesses strongly predicted post-CABG depression and general distress. CABG patients who pursued complementary approaches, particularly exercise and prayer, had better psychological recovery.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63178/1/acm.1997.3.343.pd

Mitral valve repair in heart failure

Mitral regurgitation (MR) is a frequent complication of end‐stage heart failure. Historically, these patients were either managed medically or with mitral valve replacement, both associated with poor outcomes. Mitral valve repair via an ‘undersized’ annuloplasty repair is safe and effectively corrects MR in heart‐failure patients. All of the observed changes contribute to reverse remodeling and restoration of the normal left‐ventricular geometric relationship. Mitral valve repair offers a new strategy for patients with MR and end‐stage heart failure.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102643/1/ejhf00125-2.pd

Dichloroacetate enhances myocardial functional and metabolic recovery following global ischemia

This study was undertaken to determine the effect of dichloroacetate (DCA) on myocardial functional and metabolic recovery following global ischemia. Sixteen isolated rabbit hearts were subjected to 120 minutes of mildly hypothermic (34[deg]C) cardioplegic arrest with multi-dose, modified St. Thomas' cardioplegia. Following ischemia, hearts were reperfused with either a physiologic salt solution (PSS) as controls, (CON, N = 10), or PSS containing DCA (DCA, N = 6) at a concentration of 1 mmol/L. Functional and metabolic indices were determined at baseline and at 15, 30, and 45 minutes of reperfusion. Results were analyzed using analysis of variance (ANOVA, Sheffe F test) and significance was defined as P 2) was increased in the DCA versus CON hearts (71 +/- 10% of baseline, v 51 +/- 19%). Diastolic compliance during reperfusion was improved in those hearts receiving DCA, as was myocardial mechanical use efficiency (DP/MVO2). Correction of myocardial tissue pH to baseline values was similar in both groups, indicating that the beneficial effect on functional recovery seen with DCA was not solely related to amelioration of acidosis. The enhanced myocardial function and improved metabolic status noted with DCA may result from increased oxidative phosphorylation due to altered pyruvate dehydrogenase (PDH) activity.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/31660/1/0000594.pd

The role of amrinone in potential heart transplant patients with pulmonary hypertension

Orthotopic heart transplantation is contraindicated in patients with pulmonary hypertension and an elevated pulmonary vascular resistance. In an attempt to make otherwise unacceptable patients possible candidates for heart transplantation, amrinone was administered intravenously to 27 individuals with a transpulmonary gradient and pulmonary vascular resistance in the abnormal range. Twenty-four of 27 patients (89%) responded positively. Twenty-one of 27 (78%) went on to transplantation and 20 of 21 (95%) survived the procedure. A second study compared amrinone therapy with conventional therapy in 38 potential transplant candidates with pulmonary hypertension. Amrinone was more effective in reducing pulmonary hypertension than conventional therapy with high-dose diuretics, digitalis, and captopril (86% v 63%). Survival rate of those awaiting transplantation was also significantly higher in the amrinone group (91% v 63%). Although the protocol for comparing the two regimens does not allow for extrapolation of the results (amrinone was administered in-hospital under close monitoring, whereas conventional therapy was self-administered at home), the findings confirm the clinical impression that amrinone seems more effective and safer than conventional therapy in the treatment of potential heart transplant patients with pulmonary hypertension.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/27644/1/0000025.pd

ATP precursor depletion and postischemic myocardial recovery

Although cardioplegia reduces myocardial metabolism during ischemia, adenosine triphosphate (ATP) depletion occurs, which may contribute to poor functional recovery after reperfusion. Augmenting myocardial adenosine during ischemia is successful in improving ATP repletion and myocardial recovery following ischemia. If adenosine is an important determinant of ischemic tolerance, then depletion or elimination of myocardial adenosine should lead to poor functional and metabolic recovery after ischemia. To test this hypothesis, isolated, perfused rabbit hearts were subjected to 120 min of 34[deg]C ischemia. Hearts received St. Thomas cardioplegia alone or cardioplegia containing 200 [mu]M adenosine, or cardioplegia containing 15, 5, 2.5, or 0.025 [mu]g/ml adenosine deaminase (ADA), which catalyzes the breakdown of adenosine to inosine, making adenosine unavailable as an ATP precursor. Functional recovery was determined and myocardial nucleotide levels were measured before, during, and after ischemia. Following ischemia and reperfusion, control hearts recovered to 51 +/- 3% of preischemic developed pressure (DP). There was significantly better recovery in adenosine-augmented hearts (68 +/- 7%), while ADA hearts had significantly worse recovery. Hearts treated with 0.025 [mu]g/ml ADA recovered to only 29 +/- 5% of DP and higher dose ADA hearts failed to demonstrate any recovery of systolic function. Furthermore, adenosine enhanced metabolic recovery, whereas ADA resulted in greatly depleted ATP and precursor reserves. Postischemic developed pressure closely paralleled the availability of myocardial adenosine, consistent with the hypothesis that myocardial adenosine levels at end ischemia and early reperfusion are important determinants of functional recovery after global ischemia.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29313/1/0000378.pd

Biotic elicitation as a tool to improve strawberry and raspberry extract potential on metabolic syndromeâ related enzymes in vitro

BackgroundRaspberry and strawberry are high valueâ added food products that can contribute to human health due to the abundance of polyphenols that they contain. Polyphenols are secondary metabolites and therefore devoted to improve plant adaptation, these polyphenol profile can be induced applying different stimuli, such as certain bacteria. The aim of this study was twofold: (i) to evaluate the ability of two bacterial strains to modulate secondary metabolisms in strawberry and raspberry, and (ii) to explore the ability of plant extracts to modify enzyme activities related to metabolic syndrome.ResultsTotal phenolic and anthocyanin content was higher in strawberries than in raspberries, despite similar antioxidant capacities. Strawberry extracts performed better on the tested enzymes, except on αâ glucosidase inhibition capacity. Bacillus amyloliquefaciens stabilized the effects of extracts at different points in time, and Pseudomonas fluorescens modified plant metabolism after more inoculations (spring) in both species, improving the effects of raspberry extracts on αâ glucosidase, COX1, and COX2, and of strawberry on αâ amylase and COX1.ConclusionIt is good to include these two fruits in the diet because they improve the activity of metabolic syndromeâ related enzymes. Applying either strain during plant growth modifies the bioactive profile of the plants, improving the effects of the fruit extracts on human health. © 2018 Society of Chemical IndustryPeer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/148422/1/jsfa9507_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/148422/2/jsfa9507.pd

Altered Hyperlipidemia, Hepatic Steatosis, and Hepatic Peroxisome Proliferator-Activated Receptors in Rats with Intake of Tart Cherry

ABSTRACT Elevated plasma lipids, glucose, insulin, and fatty liver are among components of metabolic syndrome, a phenotypic pattern that typically precedes the development of Type 2 diabetes. Animal studies show that intake of anthocyanins reduces hyperlipidemia, obesity, and atherosclerosis and that anthocyanin-rich extracts may exert these effects in association with altered activity of tissue peroxisome proliferator-activated receptors (PPARs). However, studies are lacking to test this correlation using physiologically relevant, whole food sources of anthocyanins. Tart cherries are a rich source of anthocyanins, and whole cherry fruit intake may also affect hyperlipidemia and/or affect tissue PPARs. This hypothesis was tested in the Dahl Salt-Sensitive rat having insulin resistance and hyperlipidemia. For 90 days, Dahl rats were pair-fed AIN-76a-based diets supplemented with either 1% (wt:wt) freeze-dried whole tart cherry or with 0.85% additional carbohydrate to match macronutrient and calorie provision. After 90 days, the cherry-enriched diet was associated with reduced fasting blood glucose, hyperlipidemia, hyperinsulinemia, and reduced fatty liver. The cherry diet was also associated with significantly enhanced hepatic PPAR-α mRNA, enhanced hepatic PPAR-α target acyl-coenzyme A oxidase mRNA and activity, and increased plasma antioxidant capacity. In conclusion, physiologically relevant tart cherry consumption reduced several phenotypic risk factors that are associated with risk for metabolic syndrome and Type 2 diabetes. Tart cherries may represent a whole food research model of the health effects of anthocyanin-rich foods and may possess nutraceutical value against risk factors for metabolic syndrome and its clinical sequelae.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63187/1/jmf.2007.658.pd

Regular Tart Cherry Intake Alters Abdominal Adiposity, Adipose Gene Transcription, and Inflammation in Obesity-Prone Rats Fed a High Fat Diet

Abstract Obesity, systemic inflammation, and hyperlipidemia are among the components of metabolic syndrome, a spectrum of phenotypes that can precede the development of type 2 diabetes and cardiovascular disease. Animal studies show that intake of anthocyanin-rich extracts can affect these phenotypes. Anthocyanins can alter the activity of tissue peroxisome proliferator-activated receptors (PPARs), which affect energy substrate metabolism and inflammation. However, it is unknown if physiologically relevant, anthocyanin-containing whole foods confer similar effects to concentrated, anthocyanin extracts. The effect of anthocyanin-rich tart cherries was tested in the Zucker fatty rat model of obesity and metabolic syndrome. For 90 days, rats were pair-fed a higher fat diet supplemented with either 1% (wt/wt) freeze-dried, whole tart cherry powder or with a calorie- and macronutrient-matched control diet. Tart cherry intake was associated with reduced hyperlipidemia, percentage fat mass, abdominal fat (retroperitoneal) weight, retroperitoneal interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) expression, and plasma IL-6 and TNF-α. Tart cherry diet also increased retroperitoneal fat PPAR-α and PPAR-γ mRNA (P=.12), decreased IL-6 and TNF-α mRNA, and decreased nuclear factor κB activity. In conclusion, in at-risk obese rats fed a high fat diet, physiologically relevant tart cherry consumption reduced several phenotypes of metabolic syndrome and reduced both systemic and local inflammation. Tart cherries may reduce the degree or trajectory of metabolic syndrome, thereby reducing risk for the development of type 2 diabetes and heart disease.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78120/1/jmf.2008.0270.pd