Association of diet quality and weight increase in adult heart transplant recipients.

BACKGROUND: Understanding the quality of the diet of heart transplant recipients (HTRs) is essential to developing effective dietary interventions for weight control, but relevant evidence is scarce. We investigated diet quality and its association with post-transplant increase in weight adjusted for height (body mass index [BMI]) in Australian HTRs. METHODS: We recruited adult HTRs from Queensland's thoracic transplant clinic, 2020-2021. Study participants completed a 3-day food diary using a smart-phone app. Socio-demographic information was collected by self-administered questionnaire, and height, serial weight and clinical information were obtained from medical records. We calculated the Dietary Approaches to Stop Hypertension (DASH) index based on nine food groups and nutrients (index of 90 indicates highest possible quality), and any changes in BMI (≤ 0 kg m-2 or >0 kg m-2) post-transplantation. Median DASH index values were assessed in relation to sex and BMI change using Mann-Whitney U test. RESULTS: Among 49 consented HTRs, 25 (51%) completed the food diary (median age 48 years, 52% females). Median BMI at enrolment was 27.2 kg m-2; median BMI change since transplant was +3.7 kg m-2. Fruit, vegetable, and whole grain intakes were generally lower than recommended, giving a low overall median DASH index of 30 with no sex differences. HTRs for which the BMI increased post-transplant had significantly lower median DASH indices than those whose BMI did not increase (30 vs. 45, p = 0.013). CONCLUSIONS: The diet quality of HTRs appears suboptimal overall, with fruit and vegetable intakes especially low. HTRs whose BMI increased post-transplant had substantially lower quality diets than HTRs whose BMI did not increase.

Long-term changes in body weight and serum cholesterol in heart transplant recipients.

INTRODUCTION: Long-term changes in weight and blood lipids beyond 12 months after heart transplantation are largely unknown. We quantified changes in weight, body mass index (BMI), blood cholesterol, and triglycerides in heart transplant recipients (HTRs) during the 36 months after transplantation, and we assessed the influence of statin therapy on these outcomes. METHODS: Retrospective cohort study of adult HTRs, transplanted 1990-2017, in Queensland, Australia. From each patient's medical charts, we extracted weight, total cholesterol, triglycerides, and statin therapy at four time-points: time of transplant (baseline), and 12-, 24-, 36-month post-transplant. Changes in weight and blood lipids were assessed according to baseline BMI. RESULTS: Among 316 HTRs, 236 (median age 52 years, 83% males) with available information were included. During the 36 months post-transplant, all patients gained weight (83.5-90.5 kg; p < .001), especially those with baseline BMI < 25.0 km/m2 (67.9-76.2 kg; p < .001). Mean blood cholesterol (4.60-4.90 mmol/L; p = .004) and mean blood triglycerides (1.79-2.18 mmol/L; p = .006) also increased significantly in all patients, particularly in those with baseline BMI ≥ 25.0 km/m2 but the differences were not significant (total cholesterol 4.42-5.13 mmol/L; triglycerides 1.76-2.47 mmol/L). Total cholesterol was highest in patients not taking statins, and levels differed significantly (p = .010) according to statin dosing changes during the 36 months post-transplant. CONCLUSION: Patients demonstrate significant rises in weight and blood lipids in the 36 months after heart transplantation.

Changes in body weight and serum cholesterol after heart transplant in relation to ventricular assist device implantation.

Weight gain is common after implantation of a ventricular assist device (VAD) prior to heart transplantation, but post-transplant changes in weight and also in blood lipids in those with VAD is virtually unknown. This study aimed to determine the influence of pre-transplant VAD implantation on body weight, blood cholesterol and triglyceride levels in Australian adult heart transplant recipients (HTRs), 1990-2017, from time of transplantation to 36 months post-transplantation. Information on VAD implantation, weight and blood lipids was collected for HTRs from medical records. Changes in weight and blood lipids from post-transplant to 12-, 24 and 36 months later, were assessed by VAD status using linear mixed-effects models. Of 236 heart transplant recipients, 48 (20%) had VAD implants. HTRs irrespective of VAD status, tended to increase their mean weight (p < 0.001) over 36 months (VAD implant: 76.9-84.4 kg; no VAD: 81.3-88.2 kg). Patients with VAD tended to have lower mean blood lipids but experienced increases similar to those with no VAD, from baseline to 36 months (cholesterol: VAD: 4.24-4.66 mmol/l; no VAD: 4.73-4.88 mmol/l; p = 0.05; triglycerides: VAD 1.59-1.63 mmol/l; no VAD 1.85-2.22 mmol/l; p = 0.09). We conclude that HTRs in general experience weight gain and lipid increases in the first 36 months after transplantation, regardless of prior VAD implantation.

Weight Gain After Heart Transplantation in Adults: Systematic Review and Meta-Analysis.

Gain in weight is common after heart transplantation but the magnitude of usual weight gain and whether this varies by country is unknown. We systematically reviewed all relevant studies to quantify weight change among heart transplant recipients (HTRs) in the years after transplantation and assess variation with geographic location. We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica Database databases to September 2020. Eligible studies reported adult HTRs' mean/median weight and/or body mass index (BMI) up to time of transplantation (baseline) and posttransplantation in any language. Weighted mean differences (WMDs) (95% confidence intervals [CIs]) of weight/BMI from baseline to posttransplantation were estimated using a random-effects model. Ten studies met the inclusion criteria. Pooled analysis showed weight gain of 7.1 kg (95% CI, 4.4-9.8 kg) in HTRs 12 months posttransplant, with corresponding BMI increase of 1.69 kg/m 2 (95% CI, 0.83-2.55 kg/m 2 ). Greatest weight gain at 12 months posttransplant occurred in US HTRs (WMD weight 10.42 kg, BMI 3.25 kg/m 2 ) and least, in European HTRs (WMD weight 3.10 kg, BMI 0.78 kg/m 2 ). In conclusion, HTRs gain substantial weight in the years after transplantation, but varying widely by geographic location.

Diagnostic approach to chronic dyspnoea in adults.

Chronic dyspnoea, or breathlessness for more than four weeks duration, is a common symptom in adults presenting to primary and tertiary care. It often presents a diagnostic challenge due to the wide spectrum of underlying disease, which is multifactorial in approximately one third of cases. Challenges in diagnosis include an often non-diagnostic clinical assessment, difficulty in selecting the most appropriate investigations and correct speciality referral for further diagnostic assessment. In patients presenting with chronic dyspnoea, history and physical examination are often non-specific with key findings more useful as negative predictive factors. There is a broad range of simple to specialised investigations that may be utilised in the diagnostic workup. Several diagnostic algorithms incorporating different tiers of investigations have been tested in studies of chronic dyspnoea patients but there is currently very limited data that test a diagnostic algorithm against standard clinical care. In this review we propose a diagnostic pathway with primary, secondary and tertiary level investigations for patients with chronic dyspnoea. This pathway is based on the combination of previously tested diagnostic algorithms in the literature, to assist clinicians in their diagnostic workup of chronic dyspnoea patients. Further research is needed to further evaluate diagnostic algorithms in this setting and to test this diagnostic pathway in clinical practice.

Autologous Adoptive T-cell Therapy for Recurrent or Drug-resistant Cytomegalovirus Complications in Solid Organ Transplant Recipients: A Single-arm Open-label Phase I Clinical Trial.

Background: Opportunistic infections including cytomegalovirus (CMV) are a major cause of morbidity and mortality in solid organ transplant (SOT) recipients. The recurrent and protracted use of antiviral drugs with eventual emergence of drug resistance represents a significant constraint to therapy. Although adoptive T-cell therapy has been successfully used in hematopoietic stem cell transplant recipients, its extension to the SOT setting poses a considerable challenge because of the inhibitory effects of immunosuppressive drugs on the virus-specific T-cell response in vivo and the perceived risk of graft rejection. Methods: In this prospective study, 22 SOT recipients (13 renal and 8 lung and 1 heart transplants) with recurrent or ganciclovir-resistant CMV infection were recruited, and 13 of them were treated with in vitro-expanded autologous CMV-specific T cells. These patients were monitored for safety, clinical symptoms, and immune reconstitution. Results: Autologous CMV-specific T-cell manufacture was attempted for 21 patients, and was successful in 20. The use of this adoptive immunotherapy was associated with no therapy-related serious adverse events. Eleven (84%) of the 13 treated patients showed improvement in symptoms, including complete resolution or reduction in DNAemia and CMV-associated end-organ disease and/or the cessation or reduced use of antiviral drugs. Furthermore, four of these patients showed coincident increased frequency of CMV-specific T cells in peripheral blood after completion of T-cell therapy. Conclusions: The data presented here demonstrate for the first time the clinical safety of CMV-specific adoptive T-cell therapy and its potential therapeutic benefit for SOT recipients with recurrent and/or drug-resistant CMV infection or disease. Clinical Trials Registration: ACTRN12613000981729.

Quadriceps Muscle Strength and Body Mass Index Are Associated With Estimates of Physical Activity Postheart Transplantation.

BACKGROUND: Although exercise capacity improves postheart transplantation (HTx), it remains unclear if the level of physical activity (PA) shows similar improvement. The purpose of this study was to (1) describe PA levels and (2) identify factors which may be associated with levels of PA post-HTx. METHODS: A prospective observational cross-sectional study was conducted at a single center HTx outpatient clinic. Medically stable adult recipients 6 months or longer post-HTx were recruited. Physical activity level (PAL) and average daily time spent at least moderately active (≥3 metabolic equivalents) were estimated using a multisensor device. Factors investigated were demographic (age, sex, body mass index [BMI], time post-HTx, and reason for HTx), corticosteroid use, exercise capacity (6-min walk distance), and quadriceps muscle strength corrected for body weight (QS%). RESULTS: The mean post-HTx time of the 75 participants was 9.2 ± 7.0 years (0.5-26 y). Twenty-seven (36%) participants were classified as extremely inactive (PAL, <1.40), 26 (34.6%) sedentary (1.40 ≤ PAL ≤ 1.69), and 22 (29.3%) active (PAL, ≥1.70). Multivariable analysis showed greater QS% (ß = 0.004 (0.002-0.006) P = 0.001) to be independently associated with increased PAL. For increased time, 3 or more metabolic equivalents both greater QS% (ß = 0.0164 [0.003-0.029]; P = 0.014) and lower BMI (ß = -0.0626 [-0.115 to -0.0099]; P = 0.021) were independently associated. CONCLUSIONS: The degree of observed sedentary behavior post-HTx is surprising, with the majority of participants not reaching levels of PA recommended for health benefits. QS% and BMI were the only factors found to be independently associated with estimates of PA. Further quality trials are required to demonstrate the long-term benefits of regular PA and investigate ways of increasing adherence to PA post-HTx.

Diagnosis of the cause of chronic dyspnoea in primary and tertiary care: characterizing diagnostic confidence.

BACKGROUND: Chronic dyspnoea (breathlessness) in adults is a common symptom, the exact cause of which may be difficult to diagnose on initial presentation. We characterised the diagnostic complexity of chronic dyspnoea in primary care and tertiary care. METHODS: This retrospective observational study screened consecutive referral letters of all adult patients referred to cardiology or respiratory clinics at a tertiary referral hospital, during May to June 2015. For patients referred due to chronic dyspnoea, data were analysed from the initial referral letter and subsequent specialist clinic letters for the 6-month time period after referral. RESULTS: Of 1,370 patient referrals, 122 patients (mean age 63 y, 55% female) were referred due to chronic dyspnoea. One hundred and five patients (86%) were referred from primary care and 17 (14%) from other hospital clinics. Sixty-one percent were referred with an evident diagnosis (referrer was confident of the initial diagnosis), whereas 39% had non-evident or unclear diagnoses. By 6 months after referral, a definitive final diagnosis had been determined by the specialist clinics in 62% of patients. The majority of patients had been referred appropriately to a cardiology or respiratory clinic, based on the final diagnosis. However, only 26% of diagnoses were fully concordant between the initial referrer diagnosis and the final specialist clinic diagnosis, with 26% being partially concordant and 48% non-concordant. Diagnostic certainty of the referrer was associated with concordance of diagnosis between the referrer and specialist clinic (P<0.001). CONCLUSIONS: In adult patients referred due to chronic dyspnoea to hospital specialist clinics, there is considerable diagnostic uncertainty about its aetiology, for both referring doctors and specialist clinics. These results demonstrate the current difficulty in diagnosing the cause of chronic dyspnoea in adults, and highlight the need for evidence-based diagnostic pathways.

Reliability of thermodilution derived cardiac output with different operator characteristics.

Cardiac output (CO) is commonly measured using the thermodilution technique at the time of right heart catheterisation (RHC). However inter-operator variability, and the operator characteristics which may influence that, has not been quantified. Therefore, this study aimed to assess inter-operator variability with the thermodilution technique using a mock circulation loop (MCL) with calibrated flow sensors. Participants were blinded and asked to determine 4 levels of CO using the thermodilution technique, which was compared with the MCL calibrated flow sensors. The MCL was used to randomly generate CO between 3.0 and 7.0 L/min through changes in heart rate, contractility and vascular resistance with a RHC inserted through the MCL pulmonary artery. Participant characteristics including gender, specialty, age, height, weight, body-mass index, grip strength and RHC experience were recorded and compared to determine their relationship with CO measurement accuracy. In total, there were 15 participants, made up of consultant cardiologists (6), advanced trainees in cardiology (5) and intensive care consultants (4). The majority (9) had performed 26-100 previous RHCs, while 4 had performed more than 100 RHCs. Compared to the MCL-measured CO, participants overestimated CO using the thermodilution technique with a mean difference of +0.75 ± 0.71 L/min. The overall r2 value for actual vs measured CO was 0.85. The difference between MCL and thermodilution derived CO declined significantly with increasing RHC experience (P < 0.001), increasing body mass index (P < 0.001) and decreasing grip strength (P = 0.033). This study demonstrated that the thermodilution technique is a reasonable method to determine CO, and that operator experience was the only participant characteristic related to CO measurement accuracy. Our results suggest that adequate exposure to, and training in, the thermodilution technique is required for clinicians who perform RHC.

Cardiac magnetic resonance imaging predicts recovery of left ventricular function in acute onset cardiomyopathy.

BACKGROUND: In acute onset cardiomyopathy, acute myocarditis is an important cause, as it is associated with a greater likelihood of recovery of cardiac function and its presence may direct specific therapies. Myocarditis can be detected by cardiac magnetic resonance imaging (CMR); however its diagnostic utility and relation to prognosis in acute onset cardiomyopathy are unknown. METHODS: We performed CMR on 61 patients with acute onset cardiomyopathy and a left ventricular ejection fraction (LVEF) <55%. CMR included assessment of myocardial function, relative myocardial oedema, myocardial inflammation (using global relative enhancement [GRE] of the myocardium 4 minutes post Gad-DTPA contrast) and necrosis or fibrosis (with late gadolinium enhancement [LGE]). Patients were followed up at six months to evaluate LVEF, morbidity and mortality. RESULTS: There was a greater improvement in LVEF at follow up in those with myocardial inflammation identified by elevated GRE compared to those without (mean increase 19.2±2.5% vs. 6.7±1.7%, p<0.001). However, the presence of myocardial oedema or LGE alone was not associated with a greater recovery of LVEF (p=NS for both). Myocardial inflammation in patients with a baseline LVEF<35% was also associated with a greater recovery of LVEF (mean increase 21.5±2.9% vs. 9.1±3.0%, p<0.01). CONCLUSION: Myocardial inflammation identified by an elevated GRE predicts recovery of LV function in patients with acute onset cardiomyopathy.

Bradycardia in a patient taking black cohosh.

Cimicifuga racemosa, better known as black cohosh, has been widely used in Western cultures as a herbal treatment for relieving symptoms of menopause. It has previously been linked to cases of liver toxicity. We report a case of reversible complete heart block in a woman who had recently begun taking a herbal supplement containing black cohosh. We review the known side effect profile of black cohosh and its relationship to our case.