Editorial Alternatives to Transplantation in the Treatment...

EditorialAlternatives to Transplantation in the Treatment of HeartFailure: New Diagnostic and Therapeutic Insights

Francesco Nicolini,1 Massimo F. Piepoli,2 Giulio Agnetti,3,4 and Giuseppe Siniscalchi5

1Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma,Via A. Gramsci 14, 43126 Parma, Italy2Heart Failure Unit, Cardiology Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy3Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA4DIBINEM, University of Bologna, 40126 Bologna, Italy5Department of Cardiovascular Surgery, University Hospital Lausanne, 1011 Lausanne, Switzerland

Correspondence should be addressed to Francesco Nicolini; [email protected]

Received 19 October 2015; Accepted 20 October 2015

Copyright © 2015 Francesco Nicolini et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

The aim of our current special issue was to present a seriesof original researches and reviews on recent advances in thediagnosis, medical therapy, and surgical approaches of heartfailure.

As reported in the introductive review of Agnetti et al.,cardiovascular disease is the leading cause of mortality in theUS and in westernized countries with ischemic heart diseaseaccounting for the majority of these deaths. Paradoxically,the improvements in the medical and surgical treatmentsof acute coronary syndromes are leading to an increasingnumber of “survivors” who are then developing heart failure.Despite considerable advances in its management, the goldstandard for the treatment of end-stage heart failure patientsremains heart transplantation. Nevertheless, this procedurecan be offered only to a small percentage of patients whocould benefit from a new heart due to the limited availabilityof donor organs. The authors reported in this comprehensivereview the evaluation of the safety and efficacy of innovativeapproaches in the diagnosis and treatment of patients refrac-tory to standard medical therapy and excluded from cardiactransplantation lists.

Among the studies included in this special issue, two ofthem investigated specific pathogenic aspects of heart failure.M. Kunin et al. studied the role of proinflammatory cytokinesin congestive heart failure. In particular the authors evalu-ated the effect of peritoneal dialysis used in the long-term

management of these patients on the peripheral-circulatinglevels of these cytokines. Interestingly, they found that peri-toneal dialysis treatment caused a reduction in circulatinginflammatory cytokines levels along with improvement inplasma markers of inflammation in patients with refractorychronic heart failure, concluding that this effectmay be partlyresponsible for the efficacy of peritoneal dialysis for refractoryheart failure.

It is described that heart failure is accompanied bythe development of an imbalance between oxygen- andnitric oxide-derived free radical production leading toprotein nitration. To cast further light on this issue, A.Cabassi et al. investigated the relationship between plasmamyeloperoxidase-related chlorinating activity, ceruloplas-min, and ferroxidase I and nitrosative stress and inflamma-tory, neurohormonal, and nutritional biomarkers in heartfailure patients.This elegant study supported the conclusionsthat plasmamyeloperoxidase chlorinated activity is increasedin elderly patients who suffer from chronic heart failure andpositively associated with ceruloplasmin and inflammatory,neurohormonal, and nitrosative parameters, suggesting a keyrole in heart failure progression.

A major focus of studies on acute heart failure is theneed for methods that allow the early detection of hemo-dynamic variables that can be a key prognostic role aftercardiac surgery. F. Corradi et al. in their study investigated

Hindawi Publishing CorporationBioMed Research InternationalVolume 2015, Article ID 278163, 2 pageshttp://dx.doi.org/10.1155/2015/278163

2 BioMed Research International

the Renal Doppler Resistive Index as a marker of oxygensupply and demand mismatch in 61 postoperative cardiacsurgery patients. Interestingly, bymultivariate analysis, RenalDoppler Resistive Index was significantly correlated withmixed-venous oxygen saturation, suggesting that, inmechan-ically ventilated patients after cardiac surgery, it could be usedas a marker of early vascular response to tissue hypoxia.

We must not forget that there are many patients suffer-ing from heart failure secondary to extracardiac diseases.Among the causes of heart failure, an important placeis held by cardiotoxicity due to antineoplastic treatmentsthat has emerged as a clinically relevant problem as aconsequence of the relevant improvement of survival aftercancer. In the last decade recent advances have emergedin clinical and pathophysiological aspects of left ventriculardysfunction induced by the most widely used anticancerdrugs. M. Molinaro et al., in their comprehensive reviewentitled “Recent Advances on Pathophysiology, Diagnosticand Therapeutic Insights in Cardiac Dysfunction Inducedby Antineoplastic Drugs,” have particularly examined therole of early, sensitive markers of cardiac dysfunction, inorder to predict this form of cardiomyopathy before leftventricular ejection fraction is reduced. It seems actually thatthis is increasingly important issue, along with the evalu-ation of novel therapeutic and cardioprotective strategies,to protect cardiooncologic patients from the developmentof congestive heart failure. As reported by A. Adegunsoyeet al., there are also a consistent number of patients whodie due to right heart failure and pulmonary hypertensionsecondary to fibrotic lung diseases. Significant factors whichappear to play a role in the mechanism of progression ofright heart dysfunction include chronic hypoxia, defectivecalcium handling, hyperaldosteronism, pulmonary vascularalterations, cyclic strain of pressure and volume changes,elevation of circulating TGF-𝛽, and elevated systemic NOlevels. The authors have reported an exhaustive review ofnovel therapeutic strategies for reducing right heart failureassociated mortality in fibrotic lung diseases, because only“an early, effective and individualized therapy may preventovert right heart failure in fibrotic lung disease leading toimproved outcomes and quality of life.”

Another major focus of studies on acute heart failureis related to the evaluation of new surgical alternatives totransplantation or new systems or new materials availablefor future cardiac assist devices. In this special issue thereview of J. Anand et al. explores the evolution of mechanicalcirculatory support and its potential for providing long-term therapy, which may address the limitations of cardiactransplantation.The innovation progresses have led to a solu-tion of current challenges involving device complications.Moreover outcomes continue to improve and further datafromboth small and large registries help to advance evidence-based practices: thus patients in the most advanced stagesof heart failure appear to have more hope than ever before.On the other hand the high costs, expanding indications,and rapidly increasing number of devices implanted willultimately require important decisions to be made on thepart of society, clinicians, and administrative agencies inorder to establish the potential amount of economic resources

to spend on this expensive, yet effective, therapy. Patientselection will remain paramount, although a very largepopulation of patients will have the potential to benefit.

In particular, K. Unthan et al. reported a study on thedesign and evaluation of a fully implantable control unitfor blood pumps. It is well known that pneumatic devicessufficiently supply the patients with blood flow, althoughthe patient’s quality of life is limited by the percutaneouspressure lines and the size of the external control unit.General requirements for any implantable control unit aredefined from a technical and medical point of view: need fora Transcutaneous Energy Transmission, autonomous opera-tion, safety, geometry, and efficiency. The authors describedthe development of the control unit of the ReinHeart, a fullyimplantable Total Artificial Heart that, in validation tests,is demonstrated to be a stable operation with a promisinggood efficiency. Finally P. Morillas-Sendı́n et al. assessedthe effect of sevoflurane and propofol on organ blood flowin a porcine model with a left ventricular assist device.The authors demonstrated that, compared with propofol,sevoflurane increases blood flow in the brain, liver, and heartafter implantation of a left ventricular assist device underconditions of partial support, giving interesting indicationsfor the intensive pharmacological care of these high-riskpatients.

The modern approach to the diagnosis and treatment ofheart failure is multidisciplinary and should be based on aclose collaboration among researchers, clinicians, and cardiacsurgeons particularly given thatmandatorymultiorgan atten-tion is required in these high-risk patients.

Future therapies for heart failure could include ventric-ular assist devices implantation or ventricular restorationtechniques with the aim to obtain a reverse, positive remod-eling in the unloaded heart. With an expanding “toolbox”of comprehensive basic, medical, surgical, and technologicalapproaches, it is expected that these novel findings will soonbe translated to the clinical practice. In fact, new therapeuticstrategies are needed by the millions of patients sufferingfrom heart failure. We hope that this special issue will helpreaders become familiarized with recent progress regardingthe diagnosis and treatment of heart failure.

Acknowledgments

We want to give special thanks to all the authors who sharedtheir excellent work to be included in our special issue and thereviewers whose criticisms and advices were fundamental forthe selection of the best work.

Francesco NicoliniMassimo F. Piepoli

Giulio AgnettiGiuseppe Siniscalchi

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