The Physiological Burden of the 6-Minute Walk Test Compared With Cardiopulmonary Exercise Stress Test in Patients With Severe Aortic Atenosis.

BACKGROUND: Management of aortic stenosis (AS) relies on symptoms. Exercise testing is recommended for asymptomatic patients with significant AS but is often experienced as forbidding and/or technically unrealistic for patients who are often frail, deconditioned, and intimidated by the exercise test. We compared the physiological burden assessed with gas exchange assessments to gauge and respiratory exchange ratio (RER) of a 6-minute walk test (6MWT) to a cardiopulmonary exercise stress test (CPET) in patients with severe AS. peak oxygen utilization. METHODS: Adults with equivocal symptoms and severe AS (1-aortic valve area [AVA] ≤ 1.0 cm2 or AVA index ≤ 0.6 cm2/m2, 2-peak aortic jet velocity ≥ 4.0 m/sec, 3-mean transvalvular pressure gradient ≥ 40 mm Hg by rest or dobutamine stress echocardiography, or 4-aortic valve calcification ≥ 1200 in women or ≥ 2000 AU in men) were studied. All participants completed both a 6MWT and symptom-limited progressive bicycle exercise testing. Breath-by-breath gas analysis and 12-lead electrocardiography were completed during 6MWT and CPET. Results: Eleven patients were studied. Patients walked on average 330 ± 75 m during the 6MWT and achieved a maximal workload of 48 ± 14 watts during the CPET. During the 6MWT, peak maximal oxygen uptake ( V ˙ O2peak) was 12.8 ± 2.5 vs 10.8 ± 4.2 mL/kg/min during the CPET. Respiratory exchange ratio exceeded 1.1 in both the 6MWT and CPET indicating similarly high exertion. Compared with the CPET, a larger proportion of the 6MWT was performed at a high intensity level (78% ± 28% vs 33% ± 24% at > 85% V̇O2peak; P = 0.004). CONCLUSIONS: The 6MWT with breath-by-breath gas analysis was well tolerated and able to achieve a physiological intense RER and V ˙ O2peak that are similar to symptom-limited CPET in patients with severe AS.

INTRODUCTION: La prise en charge de la sténose aortique (SA) dépend des symptômes. L'épreuve d'effort est recommandée aux patients asymptomatiques qui ont une SA significative, mais elle est souvent perçue comme dangereuse et/ou théoriquement irréaliste chez ces patients qui sont souvent fragiles, en mauvaise forme et craintifs par l'épreuve d'effort. Nous avons comparé le fardeau physiologique calculé par la consommation maximale de l'oxygène ( V ˙ O2max) et le quotient respiratoire (QR) d'un test de marche de 6 minutes (TM6) et d'une épreuve d'effort maximal chez des patients avec une SA sévère. MÉTHODES: Tous les patients présentaient une SA symptomatique et sévère (1-aire valvulaire aortique [AVA] ≤ 1,0 cm2 ouAVA ≤ 0,6 cm2/m2, 2-une vélocité maximale du flux aortique ≥ 4,0 m/sec, 3-un gradient de pression transvalvulaire moyen ≥ 40 mmHg au repos ou à l'échocardiographie à l'effort sous dobutamine ou 4-une calcification valvulaire aortique (AU) ≥ 1200 chez les femmes ou ≥ 2000 AU chez les hommes). Les participants ont effectué un TM6 et une 'épreuve d'effort maximal de type rampe sur vélo. L'analyse des échanges gazeux respiration par respiration et un électrocardiogramme à 12 dérivations ont été effectués durant le TM6 et l'épreuve d'effort maximal. RÉSULTATS: Un total de 11 patients ont participé à l'étude. Les patients ont marché en moyenne 330 ± 75 m durant le TM6 et ont atteint une charge de travail maximale de 48 ± 14 watts durant l'épreuve d'effort maximal. Durant le TM6, le V ˙ O2max était de 12,8 ± 2,5 vs 10,8 ± 4,2 ml/kg/min durant l'épreuve d'effort maximal. Le QR était supérieur à 1,1 au TM6 ainsi qu'à l'épreuve d'effort maximal. Comparativement à l'épreuve d'effort maximal, un pourcentage plus important au TM6 a été réalisée à une intensité élevée (78 % ± 28 % vs 33 % ± 24 % à > 85 % V̇O2max; P = 0,004). CONCLUSIONS: Le TM6 avec mesure directe des échanges gazeux était bien toléré et susceptible d'atteindre des valeurs physiologiques d'intensité élevée pour le QR et le V ˙ O2max. Les valeurs atteintes au TM6 étaient semblables à celles de l'épreuve d'effort maximal chez les patients avec une SA sévère.

Effect of PPARγ agonist on aerobic exercise capacity in relation to body fat distribution in men with type 2 diabetes mellitus and coronary artery disease: a 1-yr randomized study.

Targeting metabolic determinants of exercise performance with pharmacological agents that would mimic/potentiate the effects of exercise represents an attractive clinical alternative to counterbalance the poor exercise capacity in patients with type 2 diabetes mellitus (T2DM). We examined the effect of 1-yr treatment with the insulin sensitizer peroxisome proliferator-activated receptor (PPAR)γ agonist rosiglitazone on aerobic exercise capacity and body fat composition/distribution in men with T2DM and stable coronary artery disease (CAD). One-hundred four men (age: 64 ± 7 yr; body mass index: 30.0 ± 4.4 kg/m2) with T2DM and CAD were randomized to receive rosiglitazone or placebo for 1 yr. Aerobic exercise capacity (exercise duration) was assessed with a maximal treadmill test, and body composition/distribution were assessed by dual-energy X-ray absorptiometry/computed tomography scans. At 1 yr, patients with T2DM under PPARγ agonist treatment showed a reduction in aerobic exercise capacity compared with the control group (exercise duration change, -31 ± 8 versus 7 ± 11 s, P = 0.009). Significant increases in body fat mass (3.1 ± 0.4 kg, 12%), abdominal and mid-thigh subcutaneous adipose tissue (AT) levels, and mid-thigh skeletal muscle fat were found (all P < 0.01), whereas no effect on visceral AT levels was observed (P > 0.05) under treatment. Subcutaneous fat mass gained under PPARγ agonist was the strongest predictor of the worsening in aerobic exercise capacity (P > 0.0001); no association was found with skeletal muscle fat infiltration nor visceral AT. Treatment with the insulin sensitizer PPARγ agonist rosiglitazone in patients with T2DM and CAD is associated with a worsening in aerobic exercise capacity, which seems to be mainly attributable to weight gain and subcutaneous fat mass expansion.

Bariatric Surgery-Induced Resolution of Hypertension and Obstructive Sleep Apnea: Impact of Modulation of Body Fat, Ectopic Fat, Autonomic Nervous Activity, Inflammatory and Adipokine Profiles.

BACKGROUND: Obesity-associated systemic hypertension (HTN) and obstructive sleep apnea (OSA) have multiple pathophysiological pathways including ectopic fat deposition, inflammation, altered adipokine profile, and increased sympathetic nervous activity. We characterized these potential mechanisms in severely obese patients with or without HTN and OSA. We also compared changes of these mechanisms at 12 months following biliopancreatic diversion with duodenal switch (BPD-DS) surgery according to HTN and OSA resolution. METHODS: Sixty-two severely obese patients were evaluated at baseline and 12 months; 40 patients underwent BPD-DS. Blood samples, bioelectrical impedance analysis, computed tomography scan, and 24-h heart rate monitoring were performed. OSA have been determined with polysomnography and HTN with blood pressure measurement and medical file. RESULTS: Patients with HTN (n = 35) and OSA (n = 32) were older men with higher ectopic fat deposition and lower parasympathetic nervous activity without difference in adipokines and inflammatory markers. Lower reduction in weight was observed in patients with unresolved HTN (-40.9 ± 3.3 kg vs. -55.6 ± 3.8 kg; p = 0.001) and OSA (-41.4 ± 10.7 kg vs. -51.0 ± 15.2 kg; p = 0.006). Visceral adipose tissue reduction was lower in patients with unresolved HTN (-171.0 ± 25.7 cm2 vs. -274.5 ± 29.0 cm2; p = 0.001) in contrast to a trend for lower abdominal subcutaneous adipose tissue reduction in patients with unresolved OSA (-247.7 ± 91.5 cm2 vs. -390.5 ± 109.1 cm2; p = 0.08). At 12 months, parasympathetic activity was lowest in unresolved HTN and OSA patients, without difference in adipokines and inflammatory biomarkers. CONCLUSION: Lower ectopic fat mobilization, lower level of parasympathetic nervous activity, and lower subcutaneous adiposity mobilization may play a role in the pathophysiology of unresolved HTN and OSA following BPD-DS surgery.

Association between nesfatin-1 levels and metabolic improvements in severely obese patients who underwent biliopancreatic derivation with duodenal switch.

CONTEXT: Nesfatin-1 is a neuroendocrine peptide with potent anorexigenic activity in rodents. The potential role of nesfatin-1 on the regulation of energy balance, metabolic functions and inflammation is currently debated in obese humans. In the present study, nesfatin-1 fluctuations and their associations with metabolic factors were investigated in severely obese patients who underwent biliopancreatic diversion with duodenal switch (BPD/DS) and severely obese controls (SOC). BASIC PROCEDURES: Sixty severely obese patients who underwent BPD/DS and 15 SOC (matched for BMI and age) were included in the study. Associations between nesfatin-1 levels and body composition, glucose metabolism, lipid profile as well as inflammatory markers were evaluated at baseline and over a post-surgery12-month (12M) period. MAIN FINDINGS: Body weight was reduced at 6M and at 12M in BPD/DS patients (P<0.001). Nesfatin-1 levels were reduced at 6M (women: P<0.05) and at 12M (men and women; P<0.001) in BPD/DS patients. At baseline, nesfatin-1 levels negatively correlated with weight, fat (FM) and fat-free mass (FFM) in the whole population (combined BPD/DS and SOC patients). At 12M, nesfatin-1 concentrations positively correlated with weight, FM, fasting insulin, insulin resistance, total cholesterol, LDL-cholesterol, triglyceride and apoB values. At 12M, % changes in nesfatin-1 were positively associated with% changes in weight, FM, FFM, fasting insulin, insulin resistance, total cholesterol, LDL-cholesterol, apoB and C-reactive protein. CONCLUSION: Nesfatin-1 levels decrease following BPD/DS-induced weight loss and are significantly associated with parameters of metabolic health.

Is There a Role for Visceral Adiposity in Inducing Type 2 Diabetes Remission in Severely Obese Patients Following Biliopancreatic Diversion with Duodenal Switch Surgery?

BACKGROUND: Severe obesity is often characterized by ectopic fat deposition, which is related to development of type 2 diabetes (T2D). Thus, resolution of T2D may not be linearly associated with weight loss. The importance of ectopic fat reduction after bariatric surgery and T2D resolution is uncertain. OBJECTIVE: The aim of this pilot study is to compare body composition and body fat distribution in severely obese patients with or without T2D after biliopancreatic diversion with duodenal switch (BPD-DS) surgery in relation to diabetes resolution. METHODS: Sixty-two severely obese patients were evaluated at baseline, 6, and 12 months. Of these, 40 patients underwent BPD-DS surgery. Anthropometric measurements and abdominal and mid-thigh computed tomography scans were performed at each visit. RESULTS: Before BPD-DS surgery, obese patients with T2D had higher weight as well as greater ectopic fat deposition in the abdomen and mid-thigh level than obese patients without T2D (p < 0.05). Resolution of T2D was 65 and 90 % at 6 and 12 months, respectively. No difference in body composition changes at 6 and 12 months could be found between patients without T2D, patients with T2D resolution, and patients who remained T2D. Resolution of T2D was associated with a greater absolute loss of visceral adipose tissue (VAT) in comparison to patients without T2D (-1175 ± 570 cm(3) vs. -729 ± 394 cm(3) at 6 months and -1647 ± 816 cm(3) vs. -1103 ± 422 cm(3) at 12 months; all p ≤ 0.05). CONCLUSION: Ectopic fat mobilization, particularly the absolute loss of VAT, may play a major role in T2D resolution following BPD-DS surgery, regardless of the amount of weight loss.

Biliopancreatic diversion with duodenal switch modifies plasma chemerin in early and late post-operative periods.

OBJECTIVE: Bariatric surgery remains the most effective treatment for obesity and metabolic syndrome. Surgical benefit arises from early-phase resolution of hyperglycemia and late-phase weight loss. The adipokine chemerin is of interest given its roles in immunity, adipogenesis, and metabolism. The study objective was to examine the effects of biliopancreatic diversion with duodenal switch (BPD-DS) on plasma chemerin in the early and late post-operative stages. METHODS: 83 adults with obesity undergoing BPD-DS, 45 obese non-surgical controls, and 9 lean surgical controls were enrolled. Plasma parameters and anthropometric measures were obtained at baseline and at, early (24 h, 5 D) and late (6 months and 12 months) post-operative stages. RESULTS: Plasma chemerin dropped from 176±49 ng/mL at baseline to 132±52 ng/mL 24 h after BPD-DS, rebounded to 200±66 ng/mL after 5 D, and declined to 124±51 and 110±34 ng/mL after 6 and 12 months. Plasma chemerin correlated negatively with measures of inflammation and hepatic injury and positively with measures of obesity, metabolic syndrome, and inflammation in the early and late post-operative periods, respectively. CONCLUSIONS: Chemerin has a novel role in surgical injury but not hyperglycemia resolution early after BPD-DS. Over the long term, plasma chemerin declines to a new set point that is partially determined by body fat reductions.

If not dieting, how to lose weight? Tips and tricks for a better global and cardiovascular health.

Weight loss is a popular topic and may be of serious concern for many patients. Even with the abundant literature on obesity and cardiometabolic risk, it is always challenging to demystify and reinforce the determinants of safe approaches to lose weight. Measures of central obesity are essential to characterize the patient's adiposity distribution and should be part of the routine medical examination. Beyond this, screening for fasting lipids and glucose are important for the assessment of the cardiometabolic risk which may lead to increased cardiovascular morbidity and mortality. Differences in adiposity as well as in weight loss exist between sexes and should be taken into consideration. Rather than avoiding some food or following certain type of diet, any planned weight loss interventions should promote lifestyle and environmental modifications with healthy eating and appropriate physical activity. With clear objectives, this appears to be the best way in order to achieve weight loss goals permanently.

Increased vaspin levels are associated with beneficial metabolic outcome pre- and post-bariatric surgery.

PURPOSE: Vaspin (visceral-adipose-tissue-derived-serine-protease-inhibitor) is a recently identified adipokine with putative insulin-sensitizing properties. Plasma vaspin responses to surgery-induced weight loss are sparse and contradictory. DESIGN AND PARTICIPANTS: We evaluated changes in vaspin levels and relationship to post-operative outcomes in men (n = 22) and women (n = 55) undergoing biliopancreatic-diversion/duodenal-switch bariatric surgery. Body composition and plasma parameters were measured at baseline, acutely (1 and 5 days) and medium-term (6 and 12 months) post-surgery. RESULTS: Fasting preoperative vaspin concentrations were comparable in men vs women. The distribution was biphasic (both men and women) with a nadir of 2.5 ng/ml. Subjects were divided into high (≥2.5 ng/mL, HI-group) and low (<2.5 ng/mL, LO-group) vaspin level. Both groups had comparable sex distribution, age and BMI, but the HI-vaspin group had lower insulin, HOMA, and triglyceride and higher HDL-cholesterol, acylation stimulating protein (ASP) and IL-6 levels (all p<0.05). Post-operatively, both groups decreased BMI comparably over 12 months; the HI-vaspin group maintained high vaspin levels, while the LO-vaspin group gradually increased their levels with weight loss over 12 months. The HI-vaspin group maintained a better glucose, insulin, HOMA, fructosamine, HDL-cholesterol, and triglyceride profile throughout. The HI-vaspin group also had higher gamma-glutamyltransferase and ASP profiles. Finally, baseline vaspin level inversely correlated significantly with baseline and 12-month insulin, HOMA, triglyceride and positively correlated with HDL and ASP. Twelve-month vaspin also correlated similarly, including an inverse correlation with BMI. CONCLUSION: Globally, this study supports the concept of vaspin as a beneficial adipokine in obesity, which may potentially lead to possible therapeutic targets.

Omentin changes following bariatric surgery and predictive links with biomarkers for risk of cardiovascular disease.

BACKGROUND: Although no receptor has yet been identified, changes in circulating levels of the adipokine designated as Omentin have been demonstrated in obesity and related comorbidities such as cardiovascular disease, insulin resistance, metabolic syndrome and chronic inflammation. METHODS: Changes in Omentin levels at 1 and 5 days and 6 and 12 months in response to biliopancreatic diversion with duodenal switch bariatric surgery were evaluated, specifically to investigate if changes preceded gain of insulin sensitivity. RESULTS: Pre-operative plasma Omentin was not different between men (n = 18) vs women (n = 48), or diabetic status but correlated with body mass index (BMI). Altogether, Omentin increased as early as 24-h post-surgery, with changes maintained up to 1-year. Fifty-nine percent of subjects increased Omentin >10% by 24-H following surgery (OmentinINC p < 0.0001), while 18% of subjects decreased (OmentinDEC p < 0.0001), with changes maintained throughout one-year. These two groups had comparable age, sex distribution, diabetes, BMI, waist circumference and fat mass, however OmentinDEC had elevated levels of cardiovascular risk markers; homocysteine (p = 0.019), NT-proBNP (p = 0.006) and total bilirubin (p = 0.0001) while red blood cell (RBC) count was lower (p = 0.0005) over the one-year period. Omentin levels at 1-DAY also correlated with immune parameters (white blood cell count, % neutrophil, % monocytes, % lymphocytes). CONCLUSION: OmentinDEC at 1 day following surgery may be a marker of cardiovascular "at-risk" group before weight loss or insulin sensitivity restoration.

Acute post-bariatric surgery increase in orexin levels associates with preferential lipid profile improvement.

CONTEXT: Orexin is a recently identified neuropeptide hormone. OBJECTIVES: Acute and long-term post-bariatric changes in Orexin and relationship to post-operative metabolic outcomes. DESIGN AND PARTICIPANTS: Men and women undergoing biliopancreatic diversion with duodenal switch bariatric surgery (n = 76, BMI≥35 kg/m(2)) were evaluated for body composition and plasma parameters at baseline, acutely (1 and 5 days) and long-term (6 and 12 months) post-surgery. SETTING: University Hospital Centre, Canada. INTERVENTIONS AND MAIN OUTCOME MEASURES: Groups were subdivided based on acute (average 1 and 5 day) changes in Orexin prior to weight loss: (i)>10% Orexin decrease (n = 33, OrexinDEC) and (ii)>10% Orexin increase (n = 20, OrexinINC), to evaluate impact on long-term changes. RESULTS: Both groups had comparable preoperative Orexin levels, BMI, age, sex distribution, diabetes and lipid lowering medication, plasma glucose and lipid parameters except for apolipoproteinB (p<0.007). Orexin increase was rapid and maintained throughout one year, while OrexinDEC subjects remained significantly lower throughout. Over 12 months, changes in BMI, fat mass, and %fat mass were comparable. Fasting glucose and insulin increased immediately 1-day post-operatively, decreasing rapidly (5-day) and declining thereafter with the OrexinINC group remaining lower than the OrexinDEC group throughout (p = 0.001). Similarly, plasma cholesterol, triglyceride, LDL-C and HDL-C decreased at 1-day, increased slightly (5-day), except HDL-C, then decreased over 1 year, with greater decreases in OrexinINC group relative to OrexinDEC group. CONCLUSION: Rapid postoperative increases in plasma Orexin are associated with better improvement of glucose and lipid profiles following bariatric surgery.

Overview of epidemiology and contribution of obesity to cardiovascular disease.

The prevalence of obesity has increased worldwide and is a source of concern since the negative consequences of obesity start as early as in childhood. The most commonly used anthropometric tool to assess relative weight and classify obesity is the body mass index (BMI); BMI alone shows a U- or a J-shaped association with clinical outcomes and mortality. Such an inverse relationship fuels a controversy in the literature, named the 'obesity paradox', which associates better survival and fewer cardiovascular (CV) events in patients with elevated BMI afflicted with chronic diseases compared to non-obese patients. However, BMI cannot make the distinction between an elevated body weight due to high levels of lean vs. fat body mass. Generally, an excess of body fat (BF) is more frequently associated with metabolic abnormalities than a high level of lean body mass. Another explanation for the paradox is the absence of control for major individual differences in regional BF distribution. Adipose tissue is now considered as a key organ regarding the fate of excess dietary lipids, which may determine whether or not body homeostasis will be maintained (metabolically healthy obesity) or a state of inflammation/insulin resistance will be produced, with deleterious CV consequences. Obesity, particularly visceral obesity, also induces a variety of structural adaptations/alterations in CV structure/function. Adipose tissue can now be considered as an endocrine organ orchestrating crucial interactions with vital organs and tissues such as the brain, the liver, the skeletal muscle, the heart and blood vessels themselves. Thus, the evidence reviewed in this paper suggests that adipose tissue quality/function is as important, if not more so, than its amount in determining the overall health and CV risks of overweight/obesity.

Changes in predicted cardiovascular disease risk after biliopancreatic diversion surgery in severely obese patients.

OBJECTIVE: To determine the impact of biliopancreatic diversion with duodenal switch (BPD-DS) surgery on cardiovascular risk profile and predicted cardiovascular risk in severely obese patients. MATERIALS/METHODS: We compared 1-year follow-up anthropometric and metabolic profiles in severely obese who underwent BPD-DS (n = 73) with controls (severely obese without surgery) (n =3 3). The 10-year predicted risk for coronary heart disease (CHD) was estimated using the Framingham risk-tool. We assigned 10-year and lifetime predicted risks to stratify subjects into 3 groups: 1) high short-term predicted risk (≥ 10% 10-year risk or diagnosed diabetes), 2) low short-term (<10% 10-year risk)/low lifetime predicted risk or 3) low short-term/high lifetime predicted risk. RESULTS: During the follow-up period, body weight and body mass index decreased markedly in the surgical group (-52.1 ± 1.9 kg and -19.0 ± 0.6 kg/m(2) respectively, p<0.001) vs. (-0.7 ± 1.0 kg and -0.3 ± 0.4 kg/m(2), p = 0.51). Weight loss in the surgical group was associated with a reduction in HbA1C (6.2% vs. 5.1%), HOMA-IR (61.5 vs. 9.3), all lipoprotein levels, as well as blood pressure (p<0.001). The 10-year CHD predicted risk decreased by 43% in women and 33% in men, whereas the estimated CHD risk in the non surgical group did not change. Before surgery, none of the women and only 18% of men showed low short-term/low lifetime predicted risk, whereas a significant proportion of subjects had high short-term predicted risk (36% in women and 12% in men). Following surgery, 52% of women and 55% of men have a low short-term/low lifetime predicted risk. CONCLUSIONS: These results highlight the cardiovascular benefits of BPD-DS and suggest a positive impact on predicted CHD risk in severely obese patients. Long-term studies are needed to confirm our results and to ascertain the effects on CHD risk estimates after BPD-DS surgery.

Influence of cardiac dysfunction and systemic inflammation on pulmonary function and airway responsiveness in obese subjects.

PURPOSE: Obesity is associated with left ventricular diastolic dysfunction and altered heart rate variability, as well as pulmonary dysfunction. The relationship between asthma and cardiac dysfunction in severely obese subjects is unknown, although it has been hypothesized that cardiac dysfunction may contribute to increase airway hyper-responsiveness (AHR). This study aimed to determine if AHR is associated with left ventricular diastolic dysfunction and heart rate variability in severely obese subjects. METHODS: Sixty-one subjects with severe obesity (BMI ≥35 kg/m2 with comorbidities) completed this study. All subjects completed respiratory questionnaires, spirometry, lung volume measurements, methacholine inhalation test, 24hour Holter monitoring and a complete echocardiography evaluation. Blood samples were obtained for measurement of metabolic markers. Subjects with AHR, defined by a provocative concentration of methacholine inducing a 20% fall in FEV1 (PC20) < 8 mg/ml, were compared with those with no AHR (PC20 ≥8 mg/ml). RESULTS: According to these criteria, 32 subjects had AHR and 29 had no AHR(mean PC201.70 mg/ml and 15.3 mg/ml respectively, p < 0.001). The groups were similar for anthropometric data and comorbidities. Fasting glucose, Hb1Ac, total cholesterol, LDL, triglycerides, Apo-B, C-reactive protein (CRP) and pro-BNP levels were also comparable between groups (p > 0.05). CRP level correlated with PC20 (AHR, r=0.38, p=0.03). Indices of heart rate variability and overall cardiac function were similar in subjects with or without AHR but grade 2 left ventricular diastolic dysfunction was more prevalent in subjects with AHR (p=0.037). CONCLUSIONS: Altered cardiac function, dysglycemia and dyslipidemia do not seem to be significantly associated with AHR in severely obese subjects in contrast to systemic inflammation.

Acute and chronic effects of biliopancreatic diversion with duodenal switch surgery on plasma visfatin and apelin levels in patients with severe obesity.

BACKGROUND: Visfatin is an adipokine linked to obesity and inflammation, and it has insulin-mimetic properties. Apelin is an adipokine with positive cardiac inotropic effects, and it may be related to inflammatory molecules. Variations in plasma visfatin and apelin levels following bariatric surgery remain controversial. METHODS: In this study, patients who underwent a biliopancreatic diversion with duodenal switch (BPD-DS) were compared to a severely obese group (control group). Anthropometric measures and blood samples were taken before surgery, on days 1 and 5, as well as at 6 and 12 months after surgery in the BDP-DS group. For the control group, the tests were performed at baseline and at 6 and 12 months. RESULTS: Seventy subjects in the BPD-DS group and 28 in the control group were included. The expected reduction in body weight at 1 year after a BPD-DS was observed (85.9 ± 18.5 vs. 136.6 ± 27.7 kg at baseline; p < 0.001). Plasma visfatin levels decreased at day 1 (16.13 ± 5.56 vs. 18.82 ± 7.36 ng/mL at baseline; p = 0.001), while plasma apelin levels decreased at day 5 (0.50 ± 0.28 vs. 0.55 ± 0.33 ng/mL at baseline; p = 0.040) after surgery. There were no changes at 6 and 12 months compared to baseline, and no changes were observed in the control group. CONCLUSIONS: Our data show that 1-year weight loss induced by BPD-DS did not influence the overall plasma visfatin and apelin levels in severely obese patients.

Impact of bariatric surgery on N-terminal fragment of the prohormone brain natriuretic peptide and left ventricular diastolic function.

BACKGROUND: Obesity is often associated with left ventricular (LV) diastolic dysfunction (DD). Elevated N-terminal fragment of the prohormone brain natriuretic peptide (NT-proBNP) is considered a biomarker of LV dysfunction. Weight loss induced by bariatric surgery may improve LV DD, but conflicting results regarding NT-proBNP levels have been reported. Our objective was to determine the impact of bariatric surgery-induced weight loss on NT-proBNP levels and LV DD. METHODS: Seventy (70) patients were evaluated before and 6 and 12 months following a biliopancreatic diversion with duodenal switch (BPD-DS), and 33 subjects were followed as controls at baseline and 6 and 12 months later. Blood was collected for NT-proBNP measurement, and LV diastolic function was assessed with echocardiography. RESULTS: Among the 103 severely obese patients, 82% presented some degree of LV DD. Systolic function was preserved in all subjects. Along with significant weight loss, LV DD significantly improved (P < 0.001) in the BPD-DS group, whereas there was no change in the control group. NT-proBNP levels decreased over time in the control group (P = 0.016) and increased in subjects following BPD-DS (baseline vs 6-month vs 12-month follow-up: 51.8 ± 62.8 vs 132.0 ± 112.9 vs 143.3 ± 120.4 pg/mL; P < 0.001). The most significant associations with changes in NT-proBNP levels were improvements in the metabolic profile. CONCLUSIONS: In severely obese patients, NT-proBNP levels decrease with sustained obesity for 1 year. Despite significant improvements in LV DD following bariatric surgery, NT-proBNP levels increase. These results suggest that monitoring NT-proBNP levels following bariatric surgery may be misleading regarding LV DD and symptoms of dyspnea.

Assessment of management of cardiovascular risk factors in patients with thoracic aortic disease.

BACKGROUND: Cardiovascular risk profiles and adiposity assessment data in patients with thoracic aortic disease (TAD) are sparse. HYPOTHESIS: Despite the fact that TAD patients are considered as a high-risk population, they will not be managed as aggressively as they should in terms of their cardiovascular risk profile. MATERIALS AND METHODS: Anthropometric, blood pressure (BP) data, and blood samples were collected prospectively from patients followed at our TAD dedicated clinic. The same measures have been taken in a control group initiating a cardiac rehabilitation program. RESULTS: In all, 286 patients with TAD and 116 controls were recruited. BMI was higher among the controls than the patients with TAD (30.0±6.1 vs. 27.2±4.9 kg/m(2), respectively; P<0.001). We found no statistical difference between the groups for waist circumference (TAD: 93.1±15.2 and 103.6±14.5 cm, control: 95.0±13.4 and 106.3±14.8 cm, respectively, for women and men; P=0.06). In terms of lipid profile, low-density lipoprotein cholesterol was 2.44±0.88 in patients with TAD and 2.09±0.82 mmol/l in the controls (P<0.001). A higher percentage of patients with TAD had low-density lipoprotein cholesterol values that were beyond the target (63.3% in TAD vs. 46.1% in control; P<0.01). The values of apolipoprotein-B were similar between groups (P=0.41). BP was higher in patients with TAD (135±19/76±11 mmHg) versus the controls (129±17/71±11 mmHg; P<0.01). On the basis of ambulatory BP monitoring, 49.3% of patients with TAD were not well controlled for daytime and/or night-time BP. CONCLUSION: Cardiovascular risk factors, particularly BP, are not well controlled in patients with TAD followed in a dedicated clinic when compared with another high-risk control group in a cardiac rehabilitation program.

Comparison between arterial and venous sampling of circulating hormones, substrates and peptides in severe obesity.

PURPOSE: Severely obese patients are being encountered more frequently in clinical practice. Factors implicated in the relationship between obesity and cardiovascular disease may be measured from a blood sample obtained through arterial access in a cardiology setting, such as during cardiac catheterization or heart surgery. The comparability of a given sample site (arterial vs. venous) with regards to blood parameters is yet to be established. METHODS: Fifteen severely obese patients undergoing bariatric surgery were recruited. Fasting blood samples were collected simultaneously from the radial artery (A) and the superior vena cava (V), both representing general circulating levels, after anesthesia but before the surgical procedure. Blood samples were analysed for glucose, insulin, non-esterified fatty acids (NEFA), leptin, adiponectin, total ghrelin, high sensitive C-reactive protein (hs-CRP) and amino-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations. RESULTS: Arterial and venous concentrations of all factors analysed showed no statistical difference (all p values > 0.1); leptin A: 39 ± 16 vs. V: 42 ± 18 ng/mL; total ghrelin A : 0.86 ± 0.27 vs. V : 0.76 ± 0.35 ng/mL; adiponectin A: 7.7 ± 3.3 vs. V: 7.7 ± 3.6 µg/mL; insulin A: 17.9 ± 9.7 vs. V: 18.6 ± 10.5 µU/mL; glucose A: 8.3 ± 2.1 vs. V: 7.9 ± 2.2 mM; NEFA A: 0.98 ± 0.93 vs. V: 0.89 ± 0.38 mM ; hs-CRP A: 10.17 ± 7.68 vs. V: 10.27 ± 7.30 µg/mL and NT-proBNP A: 54.3 ± 47.9 vs. V: 54.7 ± 49.3 pg/mL. CONCLUSION: These results suggest that radial artery and superior vena cava blood collection sites are comparable and may be used clinically with respect to fasting glucose, NEFA, leptin, adiponectin, total ghrelin, hs-CRP and NT-proBNP concentrations in a group of severely obese patients.