The prognostic role of different renal function phenotypes in patients with acute heart failure

Objective: Worsening renal function (WRF) is common in patients treated for acute heart failure (AHF) and might be associated with a significant increase in blood nitrogen urea (BUN). Although many patients develop WRF during hospitalisation, its prognostic role is still unclear. Thus, we aimed to evaluate the prognostic relevance of WRF according to BUN changes during hospitalization. Methods: We studied patients with AHF screened for Diur-HF Trial (NCT01441245). WRF was defined as an in-hospital rise in serum creatinine ≥0.3 mg/dl or estimated glomerular filtration rate (GFR) reduction ≥20%. BUN increase was defined as a rise in BUN ≥20% during admission. Effective decongestion was defined as complete resolution of two, or more, signs of HF, or absence of clinical signs of congestion at discharge. Results: Of 247 patients enrolled, 59 (23%) patients experienced WRF, 107 (43%) had a BUN increase ≥20%, and 111 (45%) were effectively decongested during hospitalization. During 180 days of follow-up, 136 patients died or were re-hospitalised for AHF. An increase in BUN was an independent predictor of adverse outcome, regardless of WRF (HR = 2.19 [1.35–3.54], p = 0.002 and 1.71 [1.14–2.59], p = 0.010; with and without WRF, respectively) or congestion at discharge. WRF was not an independent predictor of outcome if BUN did not increase or when congestion was effectively relieved. Conclusions: an increase in BUN≥20% during hospitalization for AHF predicts a poor outcome independently from renal function deterioration and decongestion. WRF predicts adverse outcome only if BUN increases substantially or clinical congestion persists

Increased left atrial size is associated with reduced atrial stiffness and preserved reservoir function in athlete's heart

Left atrial (LA) fibrosis with increased stiffness has been assumed to be the substrates for occurrence of atrial arrhythmias in athletes. However, this hypothesis has not yet been confirmed in humans. Aim of this study was, therefore, to assess LA remodeling and stiffness in competitive athletes. 150 competitive athletes and 90 age and sex-matched sedentary subjects were analyzed by speckle-tracking echocardiography to measure peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS). LA stiffness was determined using E/e' ratio in conjunction with PALS. Left ventricular (LV) stiffness was also calculated. LA volume index was greater in athletes as compared with controls (24.6 ± 7.3 vs. 18.4 ± 7.8 mL/m(2), p < .0001). LA PALS, LA PACS, and E/e' ratio were lower in athletes in comparison with controls (p < .05, p ≤ .001, and p < .0001, respectively). Despite greater LA size, competitive athletes had lower LA stiffness as compared with controls (0.13 ± 0.04 vs. 0.16 ± 0.06, p ≤ .001). In addition, LV stiffness was lower in athletes (0.84 ± 0.27 vs. 1.07 ± 0.46, p ≤ .001). The only independent predictor of LA stiffness was LV stiffness (β = 0.46, p < .0001), while the only independent predictor of LA volume index was LV end-systolic volume index (β = 0.25, p = .002). Competitive athletes showed greater LA size associated with lower stiffness as compared with controls. Thus, LA remodeling in the context of the athlete's heart is not associated with increased LA stiffness. These findings support the benign nature of LA remodeling in athletes, occurring as a physiological adaptation to exercise conditioning

First Evidence of Cardiac Stem Cells from the Left Ventricular Apical Tip in Patients with Left Ventricular Assist Device Implantation

Background Recent studies have challenged the dogma that the adult heart is a postmitotic organ and raise the possibility of the existence of resident cardiac stem cells (CSCs). Our study aimed to explore if these CSCs are present in the "ventricular tip" obtained during left ventricular assist device (LVAD) implantation from patients with end-stage heart failure (HF) and the relationship with LV dysfunctional area extent. Methods Four consecutive patients with ischemic cardiomyopathy and end-stage HF submitted to LVAD implantation were studied. The explanted "ventricular tip" was used as a sample of apical myocardial tissue for the pathological examination. Patients underwent clinical and echocardiographic examination, both standard transthoracic echocardiography (TTE) and speckle tracking echocardiography (STE), before LVAD implantation. Results All patients presented severe apical dysfunction, with apical akinesis/diskinesis and very low levels of apical longitudinal strain (-3.5 ± 2.9%). Despite this, the presence of CSCs was demonstrated in pathological myocardial samples of "ventricular tip" in all 4 of the patients. It was found to be a mean of 6 c-kit cells in 10 fields magnification 40×. Conclusions Cardiac stem cells can be identified in the LV apical segment of patients who have undergone LVAD implantation despite LV apical fibrosis