Is cystatin C useful for the detection and the estimation of low glomerular filtration rate in heart transplant patients?

Although previously studied in patients with chronic kidney disease, there is less data for the use of cystatin C and cystatin C-based formulas in heart transplant recipients. The ability of creatinine and cystatin C to detect renal failure (glomerular filtration rate [GFR] below 60 mL/min/1.73 m(2)) in heart transplant patients has been compared. The accuracy and precision of a creatinine-based formula (Modification of Diet in Renal Disease [MDRD]) versus a cystatin C-based formula (Rule's formula) to estimate GFR have also been studied. GFR was measured using the (51)Crethylenediamine tetraacetic acid tracer in 27 patients. There was no significant difference between GFR and the reciprocal of creatinine or cystatin C. Receiver operating characteristic curves for cystatin C and creatinine were similar. Both formulas were well correlated with the GFR. The bias of the cystatin C-based was significantly better than one of the MDRD formula, but the standard deviation appeared better for the MDRD formula (bias of +3.9 mL/min/1.73 m(2) versus +12 mL/min/1.73 m(2) and SD of 8.5 versus 11.6, respectively). Plasma cystatin C has no clear advantage over serum creatinine to detect renal failure in heart transplanted patients

Impact of contractile reserve on acute response to cardiac resynchronization therapy

Background: Cardiac resynchronization therapy (CRT) provides benefit for congestive heart failure, but still 30% of patients failed to respond to such therapy. This lack of response may be due to the presence of significant amount of scar or fibrotic tissue at myocardial level. This study sought to investigate the potential impact of myocardial contractile reserve as assessed during exercise echocardiography on acute response following CRT implantation. Methods: Fifty-one consecutive patients with heart failure (LV ejection fraction 27% ± 5%, 67% ischemic cardiomyopathy) underwent exercise Doppler echocardiography before CRT implantation to assess global contractile reserve (improvement in LV ejection fraction) and local contractile reserve in the region of the LV pacing lead (assessed by radial strain using speckle tracking analysis). Responders were defined by an increase in stroke volume ≥15% after CRT. Results: Compared with nonresponders, responders (25 patients) showed a greater exercise-induced increase in LV ejection fraction, a higher degree of mitral regurgitation and a significant extent of LV dyssynchrony. The presence of contractile reserve was directly related to the acute increase in stroke volume (r = 0.48, p<0.001). Baseline myocardial deformation as well as contractile reserve in the LV pacing lead region was greater in responders during exercise than in nonresponders (p<0.0001). Conclusions: Heart failure patients referred to CRT have less chance of improving under therapy if they have no significant mitral regurgitation, no LV dyssynchrony and no contractile myocardial recruitment at exercise

Anemia and Heart Failure

peer reviewedThe prevalence of heart failure is increasing. Anemia is often present, particularly in severe cases. The Fick equation illustrates the relationship between anemia and heart failure. The concepts of cardiorenal syndrome and erythropoietin resistance are parts of the physiopathology. Anemia is associated with a bad prognosis in heart failure. Nevertheless, it is too early to know precisely whether anemia represents a simple marker of severity or if specific treatment, especially with erythropoietin, is useful in terms of morbidity and mortality. Current guidelines recommend the correction of secondary causes when anemia is present in a heart failure patient

How I explore...a patient with chronic heart failure

peer reviewedUne insuffisance cardiaque est définie par des critères précis associant signes cliniques et anomalies cardiaques. La recherche de signes et de symptômes doit être associée à la réalisation systématique d’un électrocardiogramme, d’une radiographie thoracique et d’un échocardiogramme afin de ne pas retarder le diagnostic et d’orienter le patient vers une mise au point adaptée. De nombreux tests complémentaires existent (cathétérisme, imagerie isotopique,…). Le but est de pouvoir asseoir précisément le diagnostic, l’étiologie et de repérer les facteurs de mauvais pronostic.Heart failure is defined by precise criteria associating clinical signs and cardiac abnormalities. The exploration for signs and symptoms must be associated with the systematic realization of an electrocardiogram, a chest X-ray and an echocardiogram to rapidly obtain the diagnosis and direct the patient to an adapted complementary clarification. Other additional tests are available (catheterization, nuclear cardiology imaging,...). The purpose is to confirm the diagnosis, to determine the aetiology and to identify factors of poor prognosis

Myocardial reinnervation after heart transplantation

peer reviewedDespite many studies, cardiac reinnervation after heart transplantation is not yet fully understood. This article reviews the physiology of the transplanted heart and briefly describes the imaging techniques and functional tests which allow demonstration of cardiac reinnervation. The data reported on this subject in the literature are summarized and the remainin uncertainties are underlined

BNP et NT-proBNP: valeurs de référence et seuils décisionnels

peer reviewedLes peptides natriurétiques, en particulier BNP et NT-proBNP, sont de plus en plus utilisés comme tests de screening chez les patients avec suspicion d’insuffisance cardiaque (IC), afin d’éviter de recourir d’emblée à des examens spécialisés coûteux tels que l’échocardiographie. Très performants pour la valeur prédictive élevée d’un résultat négatif, permettant ainsi d’exclure l’IC chronique avec une forte probabilité, ces biomarqueurs sont également reconnus pour leur intérêt diagnostique dans cette pathologie. Des taux élevés de peptides natriurétiques sont corrélés avec un risque accru d’hospitalisation pour cause cardiovasculaire et de décès. La stratification du risque chez les patients présentant une insuffisance cardiaque est facilitée par l’utilisation de seuils décisionnels «bas» et «élevé», pour lesquels différentes valeurs ont été proposées dans la littérature. Le présent article a pour objet de faire le point sur le positionnement des seuils décisionnels eu égard aux valeurs de référence de NT-proBNP déterminées dans la population résidant en Province de Liège (Belgique). Les données ont été analysées en fonction de l’âge et du sexe des sujets, deux des facteurs majeurs de variation des concentrations plasmatiques des peptides natriurétiques

Comparative Analysis of Indications and Results of Percutaneous Coronary Angioplasties According to Age

peer reviewe

The ideal valvular prosthesis still does not exist. Which factors come into consideration to guide the choices between mechanical and biologic valves ?

peer reviewedLa prévalence des valvulopathies atteint 2,5% dans la population générale. Le remplacement valvulaire aortique est l’une des procédures chirurgicales les plus courantes. Nous rapportons l’histoire d’une patiente dont la valve aortique mécanique, mise en place à l’âge de 54 ans lors d’une intervention de réparation mitrale, a dû être remplacée 14 ans plus tard en raison de la formation d’un pannus sous-valvulaire rétrécissant l’orifice valvulaire. Nous profitons de cette histoire clinique pour comparer les avantages et inconvénients respectifs de la plastie, du remplacement par valve biologique et du remplacement par valve mécanique, et donner les arguments les plus récents pour le choix de la prothèse la plus adaptée à un profil de patient particulier.The prevalence of valvular heart diseases reaches 2.5% in the overall population. Aortic valve replacement is one of the most common surgical procedures. We report the story of a female patient whose aortic mechanical valve, implanted at the age of 54 years at the time of a mitral valve repair surgery, had to be replaced 14 years later, due to the development of a subvalvular pannus narrowing the valvular orifice. We use this clinical story to compare the advantages and disadvantages of repair surgery and valve replacement with a biological or mechanical prosthesis, and summarize the latest evidence for the choice of the most adequate prosthesis for a particular patient’s profile

Heart Transplantation: Secondary Prevention

peer reviewedCardiac transplantation is the treatment of choice for refractory heart failure. An immunosuppressive therapy must be given in the perioperative course to avoid graft rejection. In this article, we review the main classes of immunosuppressive agents (calcineurin inhibitors, anti-metabolities, corticoids) and their side effects. The general preventive measures and the different kinds of rejection (hyperacute, acute vascular, acute cellular and chronical) are discussed. The current bacterial, protozoarian, mycotic and viral infections are described. We finish with the risk of cancer, mainly skin tumours and non-Hodgkinian lymphomas