Indication for percutaneous aortic valve implantation

The incidence of valvular aortic stenosis has increased over the past decades due to improved life expectancy. Surgical aortic valve replacement is currently the only treatment option for severe symptomatic aortic stenosis that has been shown to improve survival. However, up to one third of patients who require lifesaving surgical aortic valve replacement are denied surgery due to high comorbidities resulting in a higher operative mortality rate. In the past such patients could only be treated with medical therapy or percutaneous aortic valvuloplasty, neither of which has been shown to improve mortality. With advances in interventional cardiology, transcatheter methods have been developed for aortic valve replacement with the goal of offering a therapeutic solution for patients who are unfit for surgical therapy. Currently there are two catheter-based treatment systems in clinical application (the Edwards SAPIEN aortic valve and the CoreValve ReValving System), utilizing either a balloon-expandable or a self-expanding stent platform, respectively

Intestinal blood flow in patients with chronic heart failure: A link with bacterial growth, gastrointestinal symptoms, and cachexia

Background: Blood flow in the intestinal arteries is reduced in patients with stable heart failure (HF) and relates to gastrointestinal (GI) symptoms and cardiac cachexia. Objectives: The aims of this study were to measure arterial intestinal blood flow and assess its role in juxtamucosal bacterial growth, GI symptoms, and cachexia in patients with HF. Methods: A total of 65 patients and 25 controls were investigated. Twelve patients were cachectic. Intestinal blood flow and bowel wall thickness were measured using ultrasound. GI symptoms were documented. Bacteria in stool and juxtamucosal bacteria on biopsies taken during sigmoidoscopy were studied in a subgroup by fluorescence in situ hybridization. Serum lipopolysaccharide antibodies were measured. Results: Patients showed 30% to 43% reduced mean systolic blood flow in the superior and inferior mesenteric arteries and celiac trunk (CT) compared with controls (p < 0.007 for all). Cachectic patients had the lowest blood flow (p < 0.002). Lower blood flow in the superior mesenteric artery and CT was correlated with HF severity (p < 0.04 for all). Patients had more feelings of repletion, flatulence, intestinal murmurs, and burping (p < 0.04). Burping and nausea or vomiting were most severe in patients with cachexia (p < 0.05). Patients with lower CT blood flow had more abdominal discomfort and immunoglobulin A–antilipopolysaccharide (r = 0.76, p < 0.02). Antilipopolysaccharide response was correlated with increased growth of juxtamucosal but not stool bacteria. Patients with intestinal murmurs had greater bowel wall thickness of the sigmoid and descending colon, suggestive of edema contributing to GI symptoms (p < 0.05). In multivariate regression analysis, lower blood flow in the superior mesenteric artery, CT (p < 0.04), and inferior mesenteric artery (p = 0.056) was correlated with the presence of cardiac cachexia. Conclusions: Intestinal blood flow is reduced in patients with HF. This may contribute to juxtamucosal bacterial growth and GI symptoms in patients with advanced HF complicated by cachexia

Pathophysiology of heart failure - traditional paradigms and innovative concepts

Die chronische Herzinsuffizienz wird zunehmend als Systemerkrankung verstanden, bei der eine primäre Schädigung des Herzens zur Ausbildung von Symptomen führt, die viele Organe und Organsysteme betreffen. Eine besondere Rolle dabei spielt die systemische Inflammationsreaktion, die zur Prognoseverschlechterung und Perpetuierung der Herzinsuffizienz beiträgt. Der klinische und therapeutische Stellenwert der Inflammation bei Herzinsuffizienz werden diskutiert und in Zusammenschau aktueller Konzepte dargestellt.Chronic heart failure is increasingly being recognized as a systemic disease. After a primary damage to the heart maladaptive counter-regulative mechanisms lead to symptoms characterizing heart failure as a syndrome involving several organ systems. Substantially, chronic inflammation plays a crucial role in the pathogenesis of heart failure, supporting its aggressive pathophysiology and bad prognosis. The impact and scientific scope of chronic inflammation will be discussed and integrated into therapeutical approaches

Studies on bacterial endotoxin and serum lipoproteins in patients with chronic heart failure

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

The relationship between cholesterol and survival in patients with chronic heart failure

AbstractObjectivesWe sought to describe the relationship between cholesterol and survival in patients with chronic heart failure (CHF).BackgroundIncreasing lipoprotein levels are a cardiovascular risk factor. In patients with CHF, the prognostic value of endogenous lipoproteins is not fully clarified.MethodsA group of 114 patients with CHF recruited to a metabolic study was followed for a minimum of 12 months (derivation study). The results were applied to a second group of 303 unselected patients with CHF (validation study). The relationship between endogenous lipoproteins and survival was explored.ResultsIn the derivation study, survival at 12 months was 78% (95% confidence interval [CI] 70% to 86%) and 56% (95% CI 51% to 62%) at 36 months. Increasing total serum cholesterol was a predictor of survival (hazard ratio 0.64, 95% CI 0.48 to 0.86), independent of the etiology of CHF, age, left ventricular ejection fraction, and exercise capacity. Receiver-operating characteristic curves demonstrated a best cut-off value of ≤5.2 mmol/l (200.8 mg/dl) as being the best predictor of mortality at 12 months (sensitivity 80.0%, specificity 62.9%). In the validation population, one-year survival was 88% (95% CI 84 to 91%) and three-year survival was 68% (95% CI 63 to 73%). The chance of survival increased 25% for each mmol/l increment in total cholesterol. Survival rates above and below the cut-off value for cholesterol in patients with ischemic heart disease (n = 181) were 92% (95% CI 89 to 94) versus 75% (95% CI 64 to 85%) at one year and 72% (95% CI 67 to 76%) versus 50% (95% CI 43 to 56%) at three years.ConclusionsIn patients with CHF, lower serum total cholesterol is independently associated with a worse prognosis

Uric acid in cachectic and noncachectic patients with chronic heart failure: Relationship to leg vascular resistance☆

Background: Chronic heart failure (CHF) is a hyperuricemic state, and capillary endothelium is the predominant site of xanthine oxidase in the vasculature. Upregulated xanthine oxidase activity (through production of toxic free radicals) may contribute to impaired regulation of vascular tone in CHF. We aimed to study the relationship between serum uric acid levels and leg vascular resistance in patients with CHF with and without cachexia and in healthy control subjects. Methods: In 23 cachectic and 44 noncachectic patients with CHF (age, 62 ± 1 years, mean ± SEM) and 10 healthy control subjects (age, 68 ± 1 years), we assessed leg resting and postischemic peak vascular resistance (calculated from mean blood pressure and leg blood flow by venous occlusion plethysmography). Results: Cachectic patients, compared with noncachectic patients and control subjects, had the highest uric acid levels (612 ± 36 vs 459 ± 18 and 346 ± 21 μmol/L, respectively, both P < .0001) and the lowest peak leg blood flow and vascular reactivity (reduction of leg vascular resistance from resting to postischemic conditions: 83% vs 88% and 90%, both P < .005). In all patients, postischemic vascular resistance correlated significantly and independently of age with uric acid (r = 0.61), creatinine (r = 0.47, both P < .0001), peakV̇o 2 (r = 0.34), and New York Heart Association class (r = 0.33, both P < .01). This correlation was not present in healthy control subjects (r = -0.04, P = .9). In multivariate and stepwise regression analyses, serum uric acid emerged as the strongest predictor of peak leg vascular resistance (standardized coefficient = 0.61, P < .0001) independent of age, peakV̇o 2, creatinine, New York Heart Association class, and diuretic dose. Conclusions: Hyperuricemia and postischemic leg vascular resistance are highest in cachectic patients with CHF, and both are directly related independent of diuretic dose and kidney function. The xanthine oxidase metabolic pathway may contribute to impaired vasodilator capacity in CHF