Severe Chronic Congestive Heart Failure Research Articles

1084. Nocardia Cyriacigeorgica Endocarditis

BackgroundNocardia are beaded, branching Gram-positive rods that are partially acid fast and usually slow growing. Nocardia cyriacigeorgica was first described in 2001, and antimicrobial susceptibility patterns correspond with type VI Nocardia asteroides complex. Nocardia species are not a commonly associated with endocarditis, less than 20 cases to date have been documented. However, when Nocardia endocarditis is identified, the mortality rate is reported to be as high as 41% making antibiotic selection vital in the inpatient and outpatientMethodsA 62-year-old male with a past medical history significant for severe chronic obstructive pulmonary disease (COPD), atrial fibrillation, atrial tachyarrhythmia, and congestive heart failure (CHF) presented to the emergency department (ED) with shortness of breath for 1 week. The patient was initiated on IV diltiazem, meropenem, and eventually required intubation. On hospital day, two blood cultures grew Gram-positive rods, which were eventually identified as aerobic Actinomycete. Culture was sent out for DNA sequencing and N. cyriacigeorgica was identified. Transthoracic echocardiogram showed possible mitral vegetation.ResultsAntimicrobial therapy was initially de-escalated from meropenem to ampicillin, but had to be escalated to ceftriaxone once N. cyriacigeorgica was identified by DNA sequencing. The organism was reported to be susceptible to amikacin, ceftriaxone, linezolid, tobramycin, and trimethoprim/sulfamethoxazole. The patient received 1 week of ceftriaxone therapy inpatient, and was discharged on an additional 3 weeks of ceftriaxone and 6 months of minocycline suppressive therapy.Two months later the patient was re-admitted for N. cyriacigeorgica bacteremia and a pulmonary embolism. During his hospital stay, the patient had a STEMI, but due to multiple comorbidities did not undergo cardiac catheterization. The family elected to withdrawal care, and the patient expired.Conclusion N. cyriacigeorgica is more commonly identified in brain abscesses or skin infections, in the setting of immunosuppression. We report here on an unusual case of N. cyriacigeorgica endocarditis in a patient with COPD. Other than COPD the patient had no known risk factors for N. cyriacigeorgica, including chronic steroid use.Disclosures All authors: No reported disclosures.

Respiratory syncytial virus-associated illness in adults with advanced chronic obstructive pulmonary disease and/or congestive heart failure.

BackgroundRespiratory syncytial virus (RSV) is recognized as a serious pathogen in people with chronic cardiopulmonary conditions. Immunoprophylaxis might be considered for adults at high‐risk for frequent and severe RSV infection. Thus, we studied the incidence of RSV‐related medically attended acute respiratory illness (MARI) in adults with severe chronic obstructive pulmonary disease (COPD) and/or congestive heart failure (CHF).MethodsSubjects ≥50 years of age with Gold Class III/IV COPD and/or American Heart Association class III/IV CHF and exposure to children ≥once per month were recruited. Subjects were evaluated over 1.5 to 2.5 years for RSV‐associated MARI, defined as polymerase chain reaction (PCR) and/or seroresponse.ResultsFour hundred forty‐five subjects were enrolled between October 2011 and May 2012. Overall, 99 RSV infections were documented by PCR or serology for a cumulative incidence of 22.2%. Of these, 42 (9.4%) subjects had protocol‐specified RSV‐MARI for an incidence of 4.68/100 patient‐seasons. All‐cause MARI was common (63.85/100 patient‐seasons) with rhinovirus most commonly identified.ConclusionRSV infection was common in adults with severe COPD and/or advanced CHF. Given the severity of underlying cardiopulmonary diseases in the study population, most illnesses were surprisingly mild. Thus, active immunization rather than passive immunoprophylaxis with monoclonal antibodies may be a more cost‐effective strategy.

A rare case of acromegaly with normal IGF-1, severe chronic congestive heart failure, and impaired glucose tolerance

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Failing Heart or Failing Liver? Reverse Cavo-Portal Shunt with Bleeding Gastric Varices, in Severe Congestive Heart Failure. A Novel Report in Literature

Upper gastrointestinal (GI) bleedings of esophageal or gastric varices occur in the settings of portal hypertension due to well-known porto-systemic shunts. In this communication we report a previously unrecognized pathophysiological mechanism of gastric varices formation, via spontaneous reno-gastric shunt, as a result of Inferior Vena Cava (IVC) hypertension, rather than portal hypertension. We report a case of 54 years old male with severe chronic congestive heart failure and bleeding gastric varices. Cardiac cirrhosis was initially suspected as a cause for his condition. However, direct venography measurements showed high central venous and portal pressures without significant porto-systemic gradient, and hepatopetal flow direction from the IVC though left renal vein and via spontaneous reno-gastric shunt towards gastric varices. This paradoxical cavo-portal, collateralization pathway should be considered in differential diagnosis of upper GI bleeding in patients with severe congestive heart failure, it can be diagnosed by venography and treated by trans-caval embolization.

Leopard‐spot pattern of yellow‐orange subretinal deposits in central serous chorioretinopathy

AbstractPurpose Central serous chorioretinopathy (CSC) is characterized by a serous detachment of the neurosensory retina caused by focal or diffuse dysfunction of the retinal pigment epithelium. A patient with a leopard‐spot pattern of yellow‐orange subretinal deposits as a rare dramatic form of CSC is described.Methods A 65 year‐old man with severe chronic obstructive pulmonary disease and congestive heart failure noticed a poor visual acuity after waking up from a coma elicited by an acute exacerbation of COPD and need for ventilation treatment. He underwent a full ophthalmic exam and extensive imaging including fluorescein‐angiography, OCT and the use of infrared and auto‐fluorescent light.Results In the ocular history there was prior cataract surgery because of severe subcapsular posterior cataract in both eyes. Visual acuity (VA) was reduced to counting fingers in the right eye and perception of light in the left eye. Fundoscopy showed a leopard‐spot pattern of yellow‐orange subretinal deposits in the posterior pole more pronounced in the right eye compared to the left. On FFA, the deposits were hypofluorescent with additional multiple pinpoint areas of hyperfluorescence spread over the posterior pole. Spectral OCT demonstrated a shallow detachment of the neurosensory retina with extensive intraretinal fluid and alternating atrophic areas and deposits at the level of the RPE which corresponded with hypo‐ and hyperfluorescent areas with autofluorescent light.Conclusion Coarsely mottled or leopard‐spot hyperpigmentation and secondary retinal detachment may develop as a rare dramatic complication in patients with CSC.

The Tumultuous Journey of Nesiritide

Almost 3 decades ago, we witnessed the discovery of the natriuretic peptides and the role of the heart as an endocrine organ in which peptides of cardiovascular origin emerged as a humoral link between the heart and the kidney in cardiorenal homeostasis. In the United States, one such natriuretic peptide, B-type natriuretic peptide (BNP), was approved by the US Food and Drug Administration in 2001 as a drug (nesiritide) for the treatment of acute decompensated heart failure (ADHF). The rationale for the use of BNP as a cardiovascular therapy was in response to laboratory-based research and a series of clinical trials. What emerged was a theme that BNP was an endogenous ligand for the natriuretic peptide-A receptor that is linked to particulate guanylyl cyclase and the second messenger 3′,5′-cyclic guanosine monophosphate (cGMP).1 After receptor activation, the biological actions of BNP include vasodilatation, diuresis and natriuresis, positive lusitropism, inhibition of the renin-angiotensin-aldosterone system, suppression of the myocardial hypertrophy response to pressure overload, and attenuation of myocardial fibrosis. Article p 9 Although a hallmark of acute and chronic congestive heart failure (CHF) is an increased plasma level of BNP, there are functional derangements in the BNP/cGMP signaling pathway that provide additional rationale for the exogenous administration of BNP or nesiritide to treat CHF. The 2 most compelling abnormalities include increased production of less biologically active BNP forms and increased renal resistance to BNP in severe experimental CHF.2–5 Since the initial report in 1991 by Yoshimura et al6 and after several clinical trials over the past decade,7–10 the consensus has been that human recombinant BNP (nesiritide) in patients with ADHF improved cardiovascular hemodynamics and/or renal function in association with improved symptoms of HF. Moreover, some investigators reported that nesiritide therapy was safer than the use of positive inotropic drugs …

Dramatically improved left ventricular function after biventricular pacemaker implantation-a case report

A case study of a patient suffering from severe chronic congestive heart failure resulting from ischemic cardiomyopathy in whom a biventricular (BiV) pacing system was implanted is reported. After a 1-year follow-up, left ventricular (LV) ejection fraction improved dramatically from an initial 15% to 60%, left ventricular end-diastolic diameter decreased, as did left atrial dimension. Tissue Doppler data and acute hemodynamic measurements taken during the biventricular pacemaker implantation procedure are presented. The case represents an exceptional example of left ventricular reverse remodeling with practically normalized left ventricular function after 1 year of synchronized pacing.

Exercise in Heart Failure: Should Aqua Therapy and Swimming Be Allowed?

Although exercise training is established as an integrated part of treatment regimes in both patients with transmural myocardial infarction (MI) and chronic congestive heart failure (CHF), there is no consensus yet on the appropriateness of water exercises and swimming. One reason is the lack of information concerning both central hemodynamic volume and pressure responses during immersion in these patients. This paper presents explorative studies on changes in cardiac dimensions and central hemodynamics during graded immersion and swimming in patients with moderate and/or severe MI and in patients with moderate and/or compensated severe CHF. For comparison purposes, healthy subjects were assessed. Measurements were performed by using Swan-Ganz right heart catheterization, subxiphoidal echocardiography, and Doppler-echocardiography. The major findings were: 1) Indicators of an increase in preload were seen in patients with moderate and severe MI. In both patient groups, upright immersion to the neck and supine body position at rest in the water resulted in abnormal mean pulmonary artery pressure (PAm) and mean pulmonary capillary pressures (PCPm), respectively. During low-speed swimming (20-25 m.min(-1)), the PAm and/or PCPm were higher than during supine cycle ergometry at a load of 100 W. 2) Left ventricular overload and decrease and/or no change in stroke volume occurred in patients with severe CHF who were immersed up to the neck. 3) Patient's well-being was maintained despite hemodynamic deterioration. The acute responses during immersion and swimming suggest the need for additional studies on long-term changes in cardiac dimensions and central hemodynamic in both patients with severe MI and severe CHF who undergo a swimming program, compared with nonswimming patients with MI and CHF of similar etiology and severity of disease.

Prognosis of severe congestive heart failure patients refractory to high-dose frosemide and treated with continuous hemodiafiltration

Continuous hemodiafiltration (CHDF) is an effective alternative to treat congestive heart failure (CHF) with renal dysfunction by forcibly normalizing volume overload. In order to assess the efficacy of CHDF for patients with severe chronic CHF refractory to high-dose frosemide, we retrospectively analyzed the echocardiography and blood examination from 33 cases (total 29 patients) with severe CHF (New York Heart Association Class IV) who underwent CHDF during the past 5 years in our hospital. The cause of CHF was ischemic in 15 cases, valvular in 8, hypertensive in 6, and cardiomyopathy in 4. Seventeen cases showed improvement of NYHA Class IV to III and discharged (survival group), while the rest 16 cases could not discontinue CHDF and died in hospital (non-survival group). There was no significant difference between age, sex, and echocardiographic data. Only serum sodium level (sNa) showed significant difference (135 ± 4.5 mmol/l vs 12 ± 95.1 mmol/l, p < 0.05), and no patients of high total bilirubin level (T-Bil) more than 2 mg/dl could survive. The prognosis of severe chronic CHF patients was quite poor even with the use of CHDF, and the sNa and T-Bil level might provide a convenient indicator of efficacy of CHDF.

374 Laboratory indices of subclinical malnutrition in patients with chronic severe congestive heart failure

374 Laboratory indices of subclinical malnutrition in patients with chronic severe congestive heart failure

Ultrafiltration in the treatment of severe congestive heart failure.

Fluid removal remains a fundamental goal in the treatment of congestive heart failure (CHF). Vacuum ultrafiltration, hemodialysis, or a combination of both was used in patients with severe CHF (NYHA class IV), severe edema, and insensitivity to pharmacological treatment with diuretics. The aim of the study was to remove the overload fluid in eighteen patients, 13 men and 5 women, aged 38 to 83, with a man age of 66 years with intractable congestive heart failure. All patients were hospitalized because of severe congestive heart failure and did not respond to treatment with intravenous administration of a high dose of diuretics and positive inotropic agents. They thus underwent vacuum ultrafiltration (1 to 27 sessions) while in 4 of them hemodialysis was also performed because of high serum creatinine levels (over 4 mg/dl). Subclavian catheters were used in all patients and arteriovenous fistula was later performed in 2, because of the need for long term treatment. The average fluid removed was 2 L per session and the total fluid removed ranged from 4 to 29 L. Fourteen of the 18 patients (78%) showed significant improvement in their clinical status. Ten patients (56%) had a short term improvement but expired after 7 to 107 days of hospitalization. Four patients (22%) died after only one session of dialysis and 4 patients (22%) recovered after 8 to 23 dialysis sessions and were discharged from hospital. The majority of patients with severe chronic CHF which is intractable to conventional therapy including intravenous diuretics and inotropes improve by the use of ultrafiltration. However, a limited proportion of them survive to be discharged from the hospital.

Acute effects of non-invasive ventilatory support on functional mitral regurgitation in patients with exacerbation of congestive heart failure.

The purpose of this study was to evaluate the acute effects of continuous positive airway pressure (CPAP) and bi-level airway pressure (BiPAP) on functional mitral regurgitation (MR) in patients with acute exacerbation of severe chronic congestive heart failure (CHF). A cross-over study. A cardiopulmonary intensive care unit. Ten male patients affected by an acute exacerbation of congestive heart failure and hemodynamically significant MR were submitted to an echocardiograph color Doppler ultrasound evaluation during CPAP and BiPAP non-invasive ventilation. We analyzed left ventricle ejection fraction, area of MR and deceleration time (Dec-t). The primary end point was to evaluate whether CPAP and BiPAP were effective in reducing functional MR. After 30 min, the area of MR decreased from 10.0+/-2.7 to 8.0+/-2.9 cm(2) with CPAP and from 9.9+/-2.6 to 8.6+/-2.6 cm(2) with BiPAP ( p<0.01); Dec-t increased from 120.9+/-12.7 to 136.0+/-8.7 ms after CPAP and from 120.5+/-11.4 to 134.2+/-13.6 ms after BiPAP ( p<0.01). In patients with exacerbation of severe CHF and functional MR, both modalities of non-invasive ventilation (CPAP and BiPAP) significantly improved ejection fraction and were equally effective in reducing MR.

Endovascular Stent-Graft Treatment of a Ruptured Thoracic Aortic Ulcer

To describe a ruptured ulcer of the descending thoracic aorta treated with an endovascular stent-graft deployed under transesophageal echocardiographic (TEE) guidance. An 82-year-old man with severe chronic obstructive pulmonary disease and congestive heart failure presented with sharp pain in the back radiating to the left flank. Computed tomography (CT) and angiography demonstrated a penetrating ulcer of the descending thoracic aorta associated with aortic dissection commencing 6 cm from the origin of the left subclavian artery with extravasation of contrast outside the aortic wall. The patient remained symptomatic with a decrease in hematocrit from 36% to 23%. Endovascular repair was performed using self-expanding nitinol stents sutured to a 35-mm x 12-cm Dacron conduit. The device was deployed with a 24-F delivery system under TEE guidance and fluoroscopy. Successful exclusion of the ruptured ulcer was demonstrated by TEE Doppler, arteriography, and CT. The patient remains asymptomatic 18 months after the procedure with no CT evidence of endoleak. Endovascular stent-graft repair under TEE guidance assists in the oftentimes difficult treatment of ruptured penetrating thoracic aortic ulcer.

Plasma oxidized low-density lipoprotein as a prognostic predictor in patients with chronic congestive heart failure

ObjectivesThe aim of this study was to evaluate the relationship between plasma oxidized low-density lipoprotein (oxLDL), a marker of oxidative stress, and the prognosis of patients with chronic congestive heart failure (CHF). BackgroundOxidative stress appears to play a role in the pathophysiology of CHF. We have recently reported the usefulness of plasma oxLDL as a marker of oxidative stress in CHF patients with dilated cardiomyopathy. MethodsWe measured the plasma level of oxLDL by sandwich enzyme-linked immunosorbent assay using a specific monoclonal antibody against oxLDL in 18 age-matched normal subjects and in 84 patients with chronic CHF (New York Heart Association functional class II to IV) and monitored them prospectively for a mean follow-up period of 780 days. ResultsPlasma oxLDL level was significantly higher in severe CHF patients than in control subjects and mild CHF patients. A significant negative correlation existed between the plasma level of oxLDL and left ventricular ejection fraction (LVEF) and a significant positive correlation between the plasma level of oxLDL and plasma norepinephrine level. Twenty-six patients had cardiac events; 14 had cardiac death and 12 were hospitalized for heart failure or other cardiovascular events. Among 10 variables including LVEF and neurohumoral factors, only high plasma levels of brain natriuretic peptide and oxLDL were shown to be independent predictors of mortality. ConclusionsThese results indicate that the plasma level of oxLDL is a useful predictor of mortality in patients with CHF, suggesting that oxidative stress plays an important role in the pathophysiology of CHF.

Effect of high- versus low-dose angiotensin converting enzyme inhibition on cytokine levels in chronic heart failure

OBJECTIVESWe examined the effect of long-term treatment with two doses of the angiotensin converting enzyme (ACE) inhibitor enalapril on various immunological variables in patients with chronic congestive heart failure (CHF).BACKGROUNDImmunological mediators are increasingly recognized to play a pathogenic role in the pathophysiology of CHF. Whether ACE inhibitor therapy modifies immunological variables has not previously been investigated.METHODSSeventy-five patients (mean age 52 ± 11 years) with CHF were randomized between low- (5 mg daily) and high-dose (40 mg daily) enalapril in a double-blind trial. Circulating levels of immunological parameters (i.e., proinflammatory cytokines, chemokines and adhesion molecules) were measured at baseline, at 10 weeks and at the end of the study (34 weeks).RESULTSAll immunological parameters, except soluble interleukin (IL)-6 receptor, were increased in CHF compared with 21 healthy controls. During the study immunoreactive IL-6 levels decreased (p < 0.05) and soluble IL-6 receptor increased (p < 0.05) during high-dose but not during low-dose enalapril therapy. Furthermore, IL-6 bioactivity decreased only during the high-dose (p < 0.001), resulting in a significant difference in change during treatment between the two dosage groups (p < 0.001). This decrease in IL-6 bioactivity was significantly associated with decreased interventricular septum thickness as assessed by echocardiography (r = 0.56, p = 0.013). No other variables changed during treatment.CONCLUSIONSIn patients with severe CHF, high-dose enalapril therapy is associated with a significant decrease in IL-6 activity. However, despite treatment with a high-dose ACE inhibitor, a persistent immune activation exists in these patients which may be of importance for the progression of CHF.

Congestive heart failure as an indication for continuous renal replacement therapy

Congestive heart failure as an indication for continuous renal replacement therapy

Therapy of terminal dilated cardiomyopathy with growth hormone

The data from animal and human in-vivo studies suggest that cardiac function is dependent in part on the normal function of the GH/IGF-1 axis (growth hormone/insulin-like growth factor-1). The syndrome of heart failure appears to be associated with a perturbation of the GH/IGF-1 axis. So far encouraging results from phase II clinical trials evaluating the effects of long-term growth hormone treatment in patients with moderate to severe chronic congestive heart failure due to dilated cardiomyopathy have been published. In these studies growth hormone (i.e., DNA-derived recombinant human growth hormone) was not used alone but in addition to standard optimal therapy for chronic heart failure. The following rationale is the basis of this new approach for the treatment of chronic congestive heart failure due to dilated cardiomyopathy. According to Laplace's Law, cardiac wall stress(i.e., the force acting per unit of cross-sectional area of the ventricular wall) is directly related to intraventricular pressure and ventricular radius and inversely related to ventricular wall thickness. Cardiac (ventricular) wall stress if increased in dilated cardiomyopathy (mainly because of the dilatation of the ventricles and to a minor extent because of the relative reduction in ventricular thickness). Growth hormone seems to be capable of increasing ventricular wall thickness in dilated cardiomyopathy, thus, reducing cardiac wall stress which in turn leads to an improvement in systolic cardiac performance. Recombinant human growth hormone as a pharmacologic treatment is not only an expensive but also risky therapeutic modality (e.g., potential risk of inducing colonic carcinoma, de-novo leukemias, relapses of leukemias and central nervous system tumors). Given these prerequisites and a receptivity for cost effectiveness and risk-benefit analyses, it seems as if subcutaneous recombinant human growth hormone-as an additional therapeutic substance in conjunction with one of the widely accepted drugs for end-stage chronic congestive heart failure due to dilated cardiomyopathy-e.g., angiotensin converting-enzyme inhibitors, diuretics, nitrates, digoxin, and beta-adrenergic receptor blockers (Carvedilol) could either become a bridge to transplantation (i.e., supporting patients awaiting transplantation) or an alternative to the very expensive cardiac transplantation. There are three reasons for this hypothesis. First, the fact that end-state dilated cardiomyopathy along with ischemic heart disease are the main indications for heart transplantation in adults; second, the worldwide small supply of human donor organs for heart transplantation; and, third, the urgent need to find alternative cost-effective and risk-beneficial therapeutic modalities.

Sustained Improvement in Vascular Endothelial Function After Short-term Dobutamine Infusion in Patients With Severe Chronic Congestive Heart Failure

Sustained Improvement in Vascular Endothelial Function After Short-term Dobutamine Infusion in Patients With Severe Chronic Congestive Heart Failure

Sustained improvement in vascular endothelial function after short-term dobutamine infusion in patients with severe chronic congestive heart failure

Sustained improvement in vascular endothelial function after short-term dobutamine infusion in patients with severe chronic congestive heart failure

Predictors of response to exercise training in severe chronic congestive heart failure

We prospectively assessed whether baseline central hemodynamics and exercise capacity can predict improvement of V̇O 2 at ventilatory threshold (VT) after exercise training in patients with severe chronic congestive heart failure. Eighteen patients (mean ± SEM; age 52 ± 2 years), half of them listed for transplant, underwent 3 weeks of exercise training (interval cycle and treadmill walking; 5 × /week) and 3 weeks of activity restriction in a random-order crossover trial. Baseline data were not significantly different for groups with exercise training first and activity restriction first: cardiac index at rest (2.1 ± 0.1 L/m 2/min), maximum cardiac index (3.1 ± 0.2 L/m 2/min) (Fick), and echocardiographic ejection fraction (21 ± 1%). The same was true for cardiopulmonary exercise data (cycle ergometry; ↑ 12.5 W/min): V̇O 2 at VT (9.3 ± 0.4 ml/kg/min), maximum V̇O 2 (12.2 ± 0.7 ml/kg/min), VT in percentage of predicted maximum V̇O 2 (31 ± 2%), heart rate at VT (95 ± 4 beats/ min), and decrease of dead space-to-tidal volume ratio from rest to VT (33 ± 1 → 29 ± 1). Improvement of V̇O 2 at VT after training (2.2 ± 0.4 ml/kg/min; p < 0.001) was not related to baseline central hemodynamics (r = < 0.10 for each), but was greater in patients with a lower baseline V̇O 2 at VT (r = −0.65; p < 0.01), peak V̇O 2 (r = −0.66; p < 0.01), VT in percentage of predicted maximum V̇O 2 (r = −0.74; p < 0.001), heart rate at VT (r = −0.63; p < 0.01), and smaller decrease of dead space-to-tidal volume ratio from rest to VT (r = 0.65; p < 0.01). Ejection fraction after exercise training (24 ± 2%) and activity restriction (23 ± 2%) did not differ significantly compared with baseline, and patient status (heart failure and cardiac rhythm) remained stable. Three parameters accounted for 84% of the variance of improvement in V̇O 2 at VT: V̇O 2 at VT in percent predicted maximum V̇O 2, decrease of dead space-to-tidal volume ratio, and heart rate at VT. The findings suggest that there was a greater increase in V̇O 2 at VT after exercise training in patients with greater peripheral deconditioning at baseline. The improvement was unrelated to central hemodynamics. Clinically stable patients with severe chronic congestive heart failure, potential heart transplant candidates, and those awaiting transplantation may benefit from involvement in a short-term exercise training program.