Previous research on quality of life (QOL) and its relation to BNP levels in heart failure (HF) has been widely studied. However, the impact of physicians' knowledge of BNP levels at time of clinic visit on QOL and hospital length of stay (LOS) has yet to be fully investigated. The purpose of this study were to determine if physicians' knowledge of BNP levels affected a change in QOL scores at 90 days and reduce hospital length of stay among heart failure patients. QOL data from HF clinic patients (N = 108, 67.5 ± 12.3, 56% male, ejection fraction 26.5 ± 8.2) were analyzed. QOL was measured at time of clinic visit (T1) and at 90 days (T2) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). An independent t-test was utilized to compare the two groups. Findings: Both groups were comparable regarding demographic and baseline characteristics. There was no significant association observed between the experimental and control group at 90 days, although the data indicated a decrease in the mean QOL scores at 90 days (37.46 ± 28.67) as compared to the mean QOL scores at baseline (46.87 ± 29.63) for both groups. Because the QOL scale is reversed, this indicated that there was a positive change in QOL scores during the 90 day time interval. Hospital LOS was similar for both groups (mean=3 days). BNP levels were significantly correlated with both baseline QOL scores (r=.25, p=.01) and physical subscale scores (r=.24, p=.01). Mortality was higher in the control when compared to the experimental group (t=1.99, df=90, p=.04). Conclusion: While physicians' awareness of BNP levels had not shown a significant change in QOL at 90 days, patients' QOL might already have been quite positive. Chronic HF patients may have adapted to their disease and have adjusted their perception of their QOL. Therefore, QOL may be a stable construct at this time. Findings may have been different on newly diagnosed HF patients since they may not have adapted to their health condition.

Heart failure (HF) affects an estimated 5.8 million Americans, accounting for near 250,000 deaths each year. With shortages in available donor hearts, mechanical circulatory support (MCS) has emerged as a life-saving treatment for advanced stage HF. With growth in MCS use, a clinical and developmental need has emerged for a standard characterization and evaluation platform that may be utilized for inter-device comparison and system training. The goal of this research was to harness SynCardia's total artificial heart (TAH) to meet this need. We first sought to characterize the TAH in modern physiological terms - i.e. hemodynamics and pressure-volume loops. We then developed a model of HF using the TAH and mock circulatory system operating in a reduced output mode. We demonstrated that MCS devices could be incorporated and evaluated within the HF model. Finally, we characterized the operational envelope of SynCardia's Freedom (portable), Driver operating against varying loading conditions. Our results describe the hemodynamic envelope of the TAH. Uniquely, the TAH was found not to operate with time-varying elastance, to be insensitive to variations in afterload up to at least 135 mmHg mean aortic pressure, and exhibit Starling-like behavior. After transitioning the setup to mimic heart failure conditions, left atrial pressure and left ventricular pressure were noted to be elevated, aortic flow was reduced, sensitivity to afterload was increased, and Starling-like behavior was blunted, consistent with human heart failure. The system was then configured to allow ready addition of ventricular assist devices, which upon placement in the flow circuit resulted in restoration of hemodynamics to normal. Lastly, we demonstrated that the Freedom Driver is capable of overcoming systolic pressures of 200 mmHg as an upper driving limit. Understanding the physiology and hemodynamics of MCS devices is vital for proper use, future device development, and operator training. Characterization of the TAH affords insight into the functional parameters that govern artificial heart behavior providing perspective on differences compared to the human heart. The use of the system as a heart failure model has the potential to serve as a valuable research and teaching tool to foster safe MCS device use.

Single ventricle heart defects are a rare but serious form of congenital heart disease, which affect approximately 2000 children born in the United States each year. Staged surgical palliation, culminating with the “Fontan Procedure,” is typically required to achieve adequate supply of blood to both the pulmonary and systemic circulations while avoiding chronic ventricular volume overload. This surgery reroutes the systemic veins to the pulmonary arteries, forming a total cavopulmonary connection (TCPC), to completely bypass the right side of the heart and restore a series configuration to the cardiovascular circuits. Despite improved survival through this operative course in first weeks and years of life, Fontan patients are subjected gradual attrition and decreased life expectancy through a multitude of chronic complications. It is suspected that the adverse hemodynamics of this surgically altered physiology, including those specific to the surgical TCPC, play a role in determining patient outcome. However, the small and heterogeneous patient population has hindered decisive progress and there is still not a good understanding of the optimal care strategies on a patient-by-patient basis. In recent decades, advances in medical imaging and image-based computational fluid dynamics (CFD) have redefined the realm of possibility for studying complex biomedical phenomena. Combined, these methods provide the means to create and evaluate patient-specific models of a wide range of cardiovascular structures, including the TCPC, with high fidelity. Results from these models can then be used for a wide array of different analyses, such as identifying regions of flow separation or stagnation, calculating hemodynamic power loss, or quantifying local flow distribution patterns. Through significant effort from numerous past investigators, a robust set of validated computational and image processing tools has been assembled, along with the largest library of cardiac magnetic resonance (CMR) data of TCPC anatomy and flow. These tools are leveraged in this thesis to characterize the functional implications of TCPC power loss at an unprecedented scale: we report the largest CFD analysis of patient-specific TCPC hemodynamics to date with particular focus on identifying functional correlates. Combining these data with imaging-based analysis of ventricle function, we directly compare the CFD-derived hemodynamics to the performance of the single ventricle for the first time. Motivated by the physiologic significance of these findings, the same patient-specific CFD framework is used for the translational application of prospective surgery planning for hemodynamic optimization, including the first implementation of a novel TCPC connection design hypothesized to uniquely streamline the energetic performance. We conclude with a first look at the longitudinal evolution of patient functional status to begin understanding how factors such as TCPC hemodynamics contribute to poor long-term performance in these patients.

Bibliography: leaves 476-502 / xvi, 502 leaves : ill ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (Ph.D.)--University of Adelaide, 1985

Thesis (M.S.)--University of Michigan, 1998. / Running title: CHD Web site. Includes bibliographical references.

Thesis (M.S.)--University of Michigan, 1998. / Running title: CHD Web site. Includes bibliographical references.

Introduction: Chronic kidney disease (CKD) and congestive heart failure (CHF) patients have higher serum B-type natriuretic peptide (BNP), which alters the test interpretation. We aim to define BNP cutoff levels to diagnose acute decompensated heart failure (ADHF) in CKD according to CHF subtype: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). Material and methods: We reviewed 1,437 charts of consecutive patients who were admitted for dyspnea. We excluded patients with normal kidney function, without measured BNP, echocardiography, or history of CHF. BNP cutoff values to diagnose ADHF for CKD stages according to CHF subtype were obtained for the highest pair of sensitivity (Sn) and specificity (Sp). We calculated positive and negative likelihood ratios (LR+ and LR–, respectively), and diagnostic odds ratios (DOR), as well as the area under the receiver operating characteristic curves (AUC) for BNP. Results: We evaluated a cohort of 348 consecutive patients: 152 had ADHF, and 196 had stable CHF. In those with HFpEF with CKD stages 3–4, BNP < 155 pg/ml rules out ADHF (Sn90%, LR– = 0.26 and DOR = 5.75), and BNP > 670 pg/ml rules in ADHF (Sp90%, LR+ = 4 and DOR = 6), with an AUC = 0.79 (95% CI: 0.71–0.87). In contrast, in those with HFrEF with CKD stages 3–4, BNP < 412.5 pg/ml rules out ADHF (Sn90%, LR– = 0.19 and DOR = 9.37), and BNP > 1166.5 pg/ml rules in ADHF (Sp87%, LR+ = 3.9 and DOR = 6.97) with an AUC = 0.78 (95% CI: 0.69–0.86). All LRs and DOR were statistically significant. Conclusions: BNP cutoff values for the diagnosis of ADHF in HFrEF were higher than those in HFpEF across CKD stages 3–4, with moderate discriminatory diagnostic ability. / Revisión por pares

In this study, lumped parameter cardiovascular modeling has been used to understand the influence of muscle properties on mechanical dyssynchrony (MD) as well as general muscle dynamics. Incorporating viscous influence into the model allowed for an expanded view when analyzing muscle parameter response to MD. A unique method of ventricle segmentation was introduced that allowed fast analysis of regional and global ventricular properties. This segmentation process produced a ventricle with four identical sections each consisting of separately tunable muscle properties in the form of minimum and maximum elastance, elastance waveform delay, and myocardial viscous friction, yet these regional sections remained globally dependent. Elastance waveform delay proved to be the most influential property on MD as measured by internal flow fraction (IFF), followed by regional elastance magnitude, and finally regional viscosity influence. Due to the unique segmentation of this model, two metrics for IFF were derived: (1) the "true" IFF (IFF-4seg) and (2) the IFF as would be measured by an ideal conductance catheter (IFF-CC). The results of IFF-CC versus IFF-4seg show that conductance catheters are not capable of measuring IFF during a side-to-side volume transfer within the stacked cylinder under measurement. Finally, unique energetic situations were observed with this model that point to likely myocardium remodeling situations.

No description available.

Stress hormones, adrenaline and noradrenaline, have been shown to be critical for heart development. Mice lacking dopamine greek lower case letter beta]-hydroxylase (Dbh), an enzyme responsible for synthesis of these adrenergic hormones, die during mid-gestation due to cardiac failure. Prior research showed that adrenergic cells are found within the electrical conduction system of the heart, and adrenergic deficiency leads to slowed cardiac conduction during embryogenesis. Microarray analysis of wild-type (Dbh+/+) and knockout (Dbh-/-) mouse hearts revealed significant differences in expression of retinoic acid (RA) signaling genes. RA signaling has also been shown to be critical for heart development. These data suggest that heart failure due to adrenergic deficiency may be dependent upon RA signaling. This led to the hypothesis that adrenergic hormones promote the development of the electrical conduction system through modulation of RA signaling. To test this, embryonic mouse hearts were cultured with LE 135, a RA receptor blocker. Heart rate, arrhythmic index (AI) and conduction time were measured. Under these conditions there was a marked increase in arrhythmias. Hearts treated with LE 135 showed a mean AI of 0.232±0.057 after 24 hours of treatment while when untreated had an AI of 0.083±0.028 (p<0.05;n=15). In contrast, there was no significant change in heart rate or conduction speed after 24 hours with or without the retinoic acid receptor blocker. To determine if adrenergic stimulus influences retinoic acid response, an established RA-sensitive reporter cell line was employed. These F9-RARE-LacZ cells were treated with forskolin (cAMP regulator) and isoproterenol (greek lower case letter beta]-agonist) to measure changes in RA signaling. Evaluation of RA signaling showed an increase in retinoic acid responsiveness when treated with an adrenergic signaling agonist.; These results suggest that proper retinoic acid signaling is essential for maintaining cardiac rhythmicity during embryonic development and adrenergic stimulation can influence this response.