Faculty Bibliography

The clinical management of takotsubo cardiomyopathy is challenging. Its diagnosis must be made on clinical grounds and differentiated from alternative diagnoses with echocardiography, serum biomarkers, cardiac catheterization, and cardiac magnetic resonance imaging. Acute therapy includes supportive care, targeting the precipitating trigger if known, b-blockade, inhibitors of the renin-angiotensin system, and consideration of systemic anticoagulation in all patients. Recovery of left ventricular function to normal is expected regardless of early therapy. Although the prognosis is generally favorable, monitoring for early dangerous complications is essential. There is no evidence to support use of long-term medical therapy to reduce the risk of recurrence.

Ventricular remodeling is a complex process mediated by pathogenic factors all of which interact at the cellular, ventricular and systemic levels to cause progressive left ventricular dilation and subsequently a heart failure syndrome. Remodeling is a well-characterized response to insult or injury and is initiated early on by neurohormonal activation. Neurohormonal antagonists have formed the foundation of therapy to alter the progression of remodeling and concomitantly improve outcomes. Surgical ventricular reconstruction was designed as a surgical means to reduce the ventricular radius and in principal decrease ventricular wall stress as defined by the Law of Laplace. Despite optimistic initial results from case series, the Surgical Treatment for Ischemic Heart Failure Trial (STICH) trial, a large randomized trial of ventricular reconstruction in addition to coronary artery bypass surgery (CABG) therapy for management of patients with heart failure with a reduced ejection fraction showed no clinical benefit. We will summarize the evidence that demonstrates the foundational role of neurohormonal blockade in improving outcomes in patients with heart failure with a reduced ejection and the evidence behind its role in "medical ventricular reconstruction".

BACKGROUND: Hemoconcentration has been proposed as a putative biomarker of effective decongestion therapy in heart failure patients. The prevalence and clinical correlates of hemoconcentration in hospitalized patients with acute decompensated heart failure (ADHF) have not been previously described. METHODS AND RESULTS: We retrospectively reviewed paired values of hemoglobin at admission and discharge to identify evidence of hemoconcentration in 295 subjects hospitalized with ADHF and determined the association between hemoconcentration and risk of worsening renal function and survival. Subjects with hemoconcentration (n = 75) received higher diuretic doses and demonstrated greater weight loss during hospitalization when compared with subjects without hemoconcentration (median [IQR] loop diuretic dose 180 (120) versus 160 (150) mg, P = .014; mean +/- SD weight loss 4.0 +/- 3.1 versus 2.2 +/- 3.1 kg, P < .001). In univariate analysis, hemoconcentration was associated with increased risk of worsening renal function (odds ratio 2.34, 95% CI 1.27-4.30, P = .006), but decreased risk of all-cause mortality (hazard ratio 0.53, 95% CI 0.29-0.96, P = .035). In multivariate analysis, hemoconcentration remained independently associated with worsening renal function, but not mortality. CONCLUSIONS: Hemoconcentration is significantly associated with increased diuretic dose, greater weight loss, and increased risk of worsening renal function during hospitalization. Hemoconcentration was significantly associated with mortality in univariate analysis, but not in multivariate analysis

The impact of left ventricular ejection fraction (LVEF) on outcome in patients with heart failure (HF) undergoing noncardiac surgery has not been extensively evaluated. In this study, 174 patients (mean age, 75+/-12 years, 47% male, mean LVEF (47%+/-18%) underwent intermediate- or high-risk noncardiac surgery. Patients were stratified by LVEF, and adverse perioperative complications were identified and compared. Adverse perioperative events occurred in 53 patients (30.5%), including 14 (8.1%) deaths within 30 days, 26 (14.9%) myocardial infarctions, and 44 (25.3%) HF exacerbations. Among the factors associated with adverse perioperative outcomes in the first 30 days were advanced age (>80 years), diabetes, and a severely decreased LVEF (<30%). Long-term mortality was high, and Cox proportional hazards analysis demonstrated that LVEF was an independent risk factor for long-term mortality.

BACKGROUND: Lung transplantation is currently limited by the number of suitable donor organs. Many lung-transplant programs use lungs that do not meet the formal criteria for acceptability; however, the immediate and long-term consequences of this approach remain unclear. METHODS: We performed a retrospective cohort study of all patients who underwent lung transplantation at the Columbia University Medical Center from July 2001 to July 2003. We assessed the outcomes of recipients of extended donor lungs compared with those of recipients of optimal donor lungs after adjusting for confounding variables. RESULTS: Fifty-one patients underwent lung transplantation, of which 27 (53%) received extended donor lungs. Recipients of extended donor lungs had fewer intensive care unit-free days at 30 days (P=0.002) and a longer time to hospital discharge (P=0.007) than did recipients of optimal donor lungs. Extended donor recipients also had lower forced expiratory volume in 1 second % predicted at 1 year than did optimal donor recipients (P=0.03). There were no differences in the 30-day or longer-term survival of extended and optimal donor lung recipients. CONCLUSIONS: Recipients of extended donor lungs have a longer intensive care unit course, a prolonged hospital stay, and lower pulmonary function at 1 year than recipients of optimal lungs. Despite these differences, survival is similar between the two groups. The criteria for the optimal lung donor should be re-evaluated considering the current shortage of acceptable organs. Although some outcomes may differ with the use of extended donor lungs, the clinical impact of these differences should be assessed in future prospective multicenter studies

STUDY DESIGN: A case report is presented. OBJECTIVE: To highlight the potential for spontaneous resolution of large extruded intervertebral lumbar disc herniations in a patient with three independent herniations. SUMMARY OF BACKGROUND DATA: The most effective methods of treatment for lumbar intervertebral disc herniations remain in question. This is partly because the potential for intrinsic spontaneous resolution is not understood, and because many believe that large extruded lumbar intervertebral disc herniations require surgical intervention. This case report addresses both issues. METHODS: A case is reported and the literature is reviewed. RESULTS: In the patient described, multiple independent lumbar intervertebral disc herniations resolved spontaneously both clinically and radiographically with nonoperative treatment. CONCLUSIONS: Not only is the question concerning the cause of disc herniation unresolved, but the best methods of treatment also are generally unclear. This case report documents a patient with the intrinsic capability not only to herniate multiple lumbar intervertebral discs, but also to resolve them clinically and anatomically. Extruded lumbar intervertebral disc herniations may be treated without surgery, as highlighted by this case report. The immunohistologic pathomechanism for resorption remains unclear