Diagnostic and Therapeutic Challenges in Patients With Coexistent Chronic Obstructive Pulmonary Disease and Chronic Heart Failure

Chronic obstructive pulmonary disease (COPD) and heart failure (CHF) are common conditions. The prevalence of COPD ranges from 20% to 30% in patients with CHF. The diagnosis of CHF can remain unsuspected in patients with COPD, because shortness of breath is attributed to COPD. Measurement of plasma B-type natriuretic peptide (BNP) levels helps to uncover unsuspected CHF in patients with COPD and clinical deterioration. Noninvasive assessment of cardiac function may be preferable to BNP to uncover unsuspected left ventricular (LV) systolic dysfunction in patients with stable COPD. Patients with COPD or CHF develop skeletal muscle alterations that are strikingly similar. Functional intolerance correlates with severity of skeletal muscle alterations but not with severity of pulmonary or cardiac impairment in COPD and CHF, respectively. Improvement of pulmonary or cardiac function does not translate into relief of functional intolerance in patients with COPD or CHF unless skeletal muscle alterations concomitantly regress. The mechanisms responsible for skeletal muscle alterations are incompletely understood in COPD and in CHF. Disuse and low-level systemic inflammation leading to protein synthesis/degradation imbalance are likely to contribute. The presence of COPD impacts on the treatment of CHF, as COPD is still viewed as a contraindication to beta-blockade. Therefore, COPD often deprives patients with CHF due to LV systolic dysfunction of the most beneficial pharmacologic intervention. A large body of data indicates that patients with COPD tolerate well selective beta-blockade that should not be denied to CHF patients with concomitant COPD

Experience with dedicated geriatric surgical consult services: Meeting the need for surgery in the frail elderly

Rosemarie E Hardin1, Thierry Le Jemtel2, Michael E Zenilman11Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA; 2Department of Medicine, Tulane Medical Center, New Orleans, LA, USABackground: Surgeons are increasingly faced with consultation for intervention in residents of geriatric centers or in patients who suffer from end stage medical disease. We review our experience with consult services dedicated to the needs of these frail patients.Study design: Patients were prospectively followed after being evaluated by three different geriatric surgical consult services: Group 1 was based at a geriatric center associated with a tertiary medical center, Group 2 was based at a community geriatric center, and Group 3 was based with an hospital-based service for ambulatory patients with end stage congestive heart failure.Results: A total of 256 frail elderly patients underwent of 311 general surgical procedures ranging from major abdominal and vascular procedures to minor procedures such as debridement of decubitus ulcers, long-term intravenous access, enterostomy and enteral tube placement. Almost half of the surgical volume in Group 1 and 3 were ‘maintenance’ (decubitus debridement, long term intravenous or stomal or tube care); all of Group 2 were for treatment of decubiti. There was minimal morbidity and mortality from surgery itself, and overall one year survival for Groups 1, 2, and 3 was 46%, 60%, and 79%, respectively. Multivariate analysis showed that each group had its own unique indicators of decreased survival: Group 1 dementia and coronary artery disease, in Group 2 gender and coronary artery disease, and Group 3, gender alone. Age, number of comorbid illnesses, and type of surgery (major vs minor) were not significant indicators.Conclusions: This is the first review of the role of dedicated surgical consult services which focused on residents of geriatric centers and frail elderly. Conditions routinely encountered in this population such as dementia, end stage disease, multiple comorbidities, polypharmacy, decreased functional and nutritional status are not frequently encountered by general surgeons. But the surgery is safe, and survival data is comparable to those in geriatric centers who did not undergo surgery. A multidisciplinary team approach gives the most effective care, with a primary goal of palliation.Keywords: surgery in the elderly, geriatrics, surgical consultations, nursing home residents, congestive heart failure, frailty, palliative care, dementia, coronary artery disease, surviva

Hemodynamics and Kinetics of Heart Failure with Preserved Ejection Fraction Shock

The classical paradigm of cardiogenic shock is severe impairment of left ventricular, right ventricular, or biventricular contractility resulting in decreased cardiac output and end-organ failure. In patients with preserved ejection fraction, cardiogenic shock results from impaired left ventricular filling leading to decreased cardiac output and end-organ hypoperfusion. Heart failure with preserved ejection fraction (HFpEF) comprises a heterogenous group of myocardial and systemic metabolic derangements. Cardiogenic shock with preserved left ventricular ejection is thought to be less common than with reduced left ventricular ejection fraction, and therapeutic approaches are not well standardized. We aim to review the pathophysiology of cardiogenic shock in HFpEF, define various etiologies that culminate in the HFpEF shock state, and present our algorithmic approach to managing these complex patients

Intracoronary administration of autologous adipose tissue-derived stem cells improves left ventricular function, perfusion, and remodelling after acute myocardial infarction

Aims This study was designed to assess whether intracoronary application of adipose tissue-derived stem cells (ADSCs) compared with bone marrow-derived stem cells (BMSCs) and control could improve cardiac function after 30 days in a porcine acute myocardial infarction/reperfusion model. Methods and results An acute transmural porcine myocardial infarction was induced by inflating an angioplasty balloon for 180 min in the mid-left anterior descending artery. Two million cultured autologous stem cells were intracoronary injected through the central lumen of the inflated balloon catheter. Analysis of scintigraphic data obtained after 28 + 3 days showed that both absolute and relative perfusion defect decreased significantly after intracoronary administration of ADSCs or BMSCs (relative 30 or 31%, respectively), compared with carrier administration alone (12%, P ¼ 0.048). Left ventricular ejection fraction after 4 weeks increased significantly more after ADSC and BMSC administration than after carrier administration: 11.39 + 4.62 and 9.59 + 7.95%, respectively vs. 1.95 + 4.7%, P ¼ 0.02). The relative thickness of the ventricular wall in the infarction area after cell administration was significantly greater than that after carrier administration. The vascular density of the border zone also improved. The grafted cells co-localized with von Willebrand factor and alpha-smooth muscle actin and incorporated into newly formed vessels. Conclusion This is the first study to show that not only bone marrow-derived cells but also ADSCs engrafted in the infarct region 4 weeks after intracoronary cell transplantation and improved cardiac function and perfusion via angiogenesis

Secondary mitral regurgitation in heart failure with reduced or preserved left ventricular ejection fraction

Secondary mitral regurgitation (MR) has been extensively studied in heart failure due to reduced ejection fraction. In contrast, the occurrence and the pathogenesis of secondary MR are much less known in heart failure with preserved ejection fraction (HFpEF). The present review aimed at describing this common but ignored feature of HFpEF

Respite for hybrid coronary revascularization

Hybrid coronary revascularization incorporates a surgical anastomosis of the left internal mammary artery to the left anterior descending coronary artery through a thoracotomy and percutaneous implantation of drug eluting stents in diseased non-left anterior descending coronary arteries. Hybrid coronary artery revascularization can be performed as a 1-stage procedure in a hybrid operating room or as a tightly scheduled 2-stage procedure. Hybrid coronary artery revascularization is seldom the selected modality for coronary revascularization due to the lack of a hybrid operating room in many hospitals, the recommended thoracotomy approach for bypass, or the rigid schedule of surgical and endovascular revascularization. A 2-stage approach, using a sternotomy as compared to standard thoracotomy, and a flexible schedule between surgical and endovascular procedures may facilitate the adoption of hybrid coronary revascularization with non-complex multi-vessel stable coronary artery disease