Cardiology

Part 2: Disease of the Heart and Liver: A Relationship That Cuts Both Ways Diseases known to affect both the heart and liver include a variety of infectious, autoimmune and metabolic disorders, as well as toxins: most commonly alcohol. As damage to both the heart and liver progresses, transplantation is a reasonable therapeutic option. Heart failure patients with underlying congestive hepatopathy receiving cardiac transplant have demonstrated improved liver enzyme levels post-transplant. Patients with severe end-stage liver disease requiring a liver transplant must undergo careful preoperative evaluation as surgical stress exposes the myocardium to high levels of catecholamines. Clinicians must consider both cardiac and hepatic complications when evaluating heart failure, cirrhosis, and non-alcoholic fatty liver disease. In part 2 of this review, we discuss new noninvasive techniques for assessing liver fibrosis in the pre-operative stage. Both serum and radiologic studies, such as transient elastography, have begun to take the place of liver biopsy due to their decreased morbidity. Lastly, we explore the current research examining the benefit of combined heart-liver transplant, although more longitudinal outcome studies are needed. The authors declare no conflict of interest in the preparation of this manuscript. Correspondence: Dr. Edward Lebovics MD Chief, Section of Gastroenterology & Hepatobiliary Diseases Ambulatory Care Pavilion – 3rd Floor 100 Woods Valhalla, NY 10595 Telephone: 914-340-4875 Email: Edward.Lebovics@wmchealth.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Part 1: Disease of the Heart and Liver: A Relationship That Cuts Both Ways The heart and the liver display multifaceted, complex interactions that can be divided into cardiac effects of liver disease, hepatic effects of heart disease, and disease processes affecting both organs. In Part 1 of this 2 part series, we discuss how acute and chronic heart failure can have devastating effects on the liver, such as acute cardiogenic liver injury and congestive hepatopathy. On the other hand, primary liver disease, such as cirrhosis, can lead to a plethora of cardiac insults representative in cirrhotic cardiomyopathy as systolic dysfunction, diastolic dysfunction, and electrophysiological disturbances. Non-alcoholic fatty liver disease has long been associated with cardiovascular events that increase mortality. The management of both disease processes changes when the other organ system becomes involved. This consideration is important with regard to a variety of interventions, most notably transplantation of either organ, as risk of complications dramatically rises in the setting of both heart and liver disease (discussed in Part 2). As our understanding of the intricate communication between the heart and liver continues to expand so does our management. The authors declare no conflict of interest in the preparation of this manuscript. For Correspondence: Dr. Edward Lebovics MD Chief, Section of Gastroenterology & Hepatobiliary Diseases Ambulatory Care Pavilion – 3rd Floor 100 Woods Valhalla, NY 10595 Telephone: 914-340-4875 Email: Edward.Lebovics@wmchealth.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Effect of bariatric surgery on natriuretic peptide levels: a systematic review and meta-analysis The effect of bariatric surgery on natriuretic peptide levels in patients with obesity is unclear. The purpose of this study was to conduct a systematic review and meta-analysis to determine the effect of bariatric surgery on BNP and NT-proBNP levels. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to February 2020. Primary outcomes included change in NT-proBNP or BNP levels following bariatric surgery and change in weight and body mass index (BMI). Secondary outcomes included change in blood pressure, echocardiographic findings, and heart failure symptoms. MINORS tool was used to assess quality of evidence. Twelve studies with 622 patients were included. Most patients underwent Roux-en-Y gastric bypass (RYGB) (70.5%). Mean absolute reduction in BMI was 23%. NT-proBNP levels increased significantly from baseline at 6 months (mean difference (MD) 53.67 pg/mL; 95% CI, 28.72-78.61; P = <0.001, I2 = 99%; 8 studies) and 12 months (MD 51.16 pg/mL; 95% CI, 20.46-81.86; P = 0.001, I2 = 99%; 8 studies) post-bariatric surgery. BNP levels also increased significantly at 6 months (MD 17.57 pg/mL; 95% CI, 7.62-27.51; P <0.001, I2 = 95%; 4 studies). Systolic and diastolic blood pressure decreased significantly 12 months after surgery. Studies measuring echocardiographic findings saw improvement in LV mass and E/A ratio, but no significant change in ejection fraction. Bariatric surgery is associated with increased natriuretic peptide levels in the absence of deteriorating cardiac function, and may be associated with improved cardiac and metabolic function after the procedure. The above authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation Acknowledgement of Grant Support: No financial support was used to fund this work. Conflicts of Interest: The authors do not have any conflicts of interest to disclose Corresponding Author: Aristithes G. Doumouras, MD MPH FRCSC. Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, Canada. L8N 4A6 Phone: 905 522 1155 ext. 35148. Fax: (905) 521-6123. E-mail: aristithes.doumouras@medportal.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Uremic and Dialysis-Associated Pericarditis Uremic pericarditis occurs as a result of inflammation of the pericardium due to toxins and immune complexes in patients with renal disease. The initial clinical manifestations of pericarditis and acute coronary syndrome may be similar, and initial EKG findings may overlap. The management of this disease needs the combined efforts of internists, cardiologists, and nephrologists. Its incidence has been reduced since the introduction of renal replacement therapy. Dialysis continues to be the mainstay of treatment. The authors declare no conflict of interest in the preparation of this manuscript. CORRESPONDING AUTHOR: Savneek Singh Chugh, MD, Division of Nephrology Westchester Medical Center, Valhalla, NY Savneek.Chugh@wmchealth.org, Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Cirrhotic Cardiomyopathy – A Veiled Threat Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without pre-existing cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and/or echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically-stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Conflict of Interest: The authors declare that they have no conflict of interest. All authors contributed to the study conception and design. Literature search and data analysis were performed by Scarlatescu Ecaterina. The first draft of the manuscript was written by Scarlatescu Ecaterina. Sergey Marchenko and Dana Tomescu critically revised the work, commented and modified on previous versions of the manuscript. All authors read and approved the final manuscript. Corresponding Author: Ecaterina Scarlatescu MD, PhD Fundeni Clinical Institute, Fundeni Street No. 258, Bucharest 022238, Romania. Email: katyscarlatescu@yahoo.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Bariatric Surgery as a Bridge to Heart Transplantation in Morbidly Obese Patients: a Systematic Review and Meta-Analysis Class 2 obesity or greater (body mass index [BMI] >35 kg/m2) is a relative contraindication for heart transplant due to its associated perioperative risks and mortality. Whether bariatric surgery can act as a potential bridging procedure to heart transplantation is unknown. The aim of this systematic review and meta-analysis is to investigate the role of bariatric surgery on improving transplant candidacy in patients with end-stage heart failure (ESHF). MEDLINE, EMBASE, CENTRAL, and PubMed databases were searched up to September 2019 for studies that performed bariatric surgery on patients with severe obesity and ESHF. Outcomes of interest included incidence of patients listed for heart transplantation after bariatric surgery, proportion of patients that successfully received transplant, the change in BMI after bariatric surgery, and 30-day complications. Pooled estimates were calculated using a random effects meta-analysis of proportions. Eleven studies with 98 patients were included. Mean preoperative BMI was 44.9 (2.1) kg/m2 and BMI after surgery was 33.2 (2.3) kg/m2 with an absolute BMI reduction of 26.1%. After bariatric surgery, 71% (95% confidence interval [CI], 55%-86%) of patients with ESHF were listed for transplantation. The mean time from bariatric surgery to receiving a heart transplant was 14.9 (4.0) months. Of the listed patients, 57% (95% CI, 39-74%) successfully received heart transplant. The rate of 30-day mortality after bariatric surgery was 0%, and the 30-day major and minor complications after bariatric surgery was 28% (95% CI, 10%-49%). Bariatric surgery can facilitate sustained weight loss in obese patients with ESHF, improving heart transplant candidacy and the incidence of transplantation. Conflicts of Interest and Funding Disclosure: None. Corresponding author: Aristithes G. Doumouras, MD MPH Division of General Surgery St. Joseph's Healthcare 50 Charlton Avenue East, Room G814 Hamilton, Ontario, Canada. L8N 4A6 Phone: 905 522 1155 ext. 32938. Fax: (905) 521-6123. E-mail: aristithes.doumouras@medportal.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Controversies Regarding Post-Menopausal Hormone Replacement Therapy for Primary Cardiovascular Disease Prevention in Women The debate over the safety and benefit of hormone replacement therapy (HRT) in postmenopausal women for primary prevention of cardiovascular disease has been ongoing for the past several decades. Observational trials in the 1980's suggested a benefit of HRT for primary cardiovascular disease prevention. However, randomized controlled trials in the 1990's suggested potential harm. Because of these discrepancies, recommendations from authorities on the usage of postmenopausal HRT have fluctuated. Many believed that the timing of HRT initiation relative to the onset of menopause, also known as the "timing hypothesis," was the factor that could explain the differences among these studies. Some recent investigations have concluded that HRT initiated in postmenopausal women near the onset of menopause confers a cardioprotective benefit, while others simply showed that HRT does not cause harm. Research has expanded to evaluate alternative doses, preparations, routes, and formulations, including selective estrogen receptor modulators, to demonstrate their suitability for this purpose. This article is a review of the major research studies of HRT in postmenopausal women with respect to its safety and efficacy for the primary prevention of cardiovascular disease. No disclosures The authors have no conflict of interest. Address for Correspondence: Jennifer Taylor MD, PhD St. Louis University Hospital, Division of Cardiology, 3635 Vista Ave., St. Louis, MO 63110 phone: 314-268-7992, fax: 314-268-5410 jennifer.taylor.1@health.slu.edu; corresponding author Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Fetal Supraventricular Tachycardia: What the Adult Cardiologist Needs to Know Fetal supraventricular tachycardia management is challenging, with consequences for both the fetus and the mother. If left untreated, fetal hydrops may ensue, at which point delivery and treatment of the arrhythmia is preferred. However, if the fetus is not at term nor near-term, significant doses of antiarrhythmics may be needed to achieve adequate transplacental bioavailability. Although digoxin has classically been the mainstay of treatment, the use of flecainide or sotalol as monotherapy or in combination with digoxin is being studied. Interdisciplinary team management and shared decision-making between the physician and patient are key to achieving successful outcomes. Adult cardiologists, particularly inpatient consultation services or through burgeoning cardio-obstetrics programs, may, in some practice settings, be asked to evaluate or co-manage pregnant women with fetal arrhythmia. Disclosures: AEB served as site principal investigator for multi-center trials sponsored by Abbott, AstraZeneca, Sanofi-Aventis, CSL-Behring, for which her institution received compensation and received an honorarium from ClearView Healthcare Partners, LLC. Funding: AEB acknowledges support from an American Heart Association Mentored and Clinical Population Research Award 17MCPRP33630098 and National Institutes of Health, NHLBI grant K23HL146982. The authors have no conflict of interest. Corresponding Author: Anna E. Bortnick MD, PhD, MSc Jack D. Weiler Hospital 1825 Eastchester Road, Suite 2S-46 Bronx, NY 10461 Phone: 718-904-3388 Fax: 718-904-3133 E-mail: abortnic@montefiore.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation for In-Hospital Cardiac Arrest Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used in cardiac arrest. Currently, public registries report the outcomes of cardiac arrest regardless of the setting (out-of-hospital versus in-hospital). Meanwhile, in-hospital cardiac arrest represents a more favorable setting for ECMO-assisted cardiopulmonary resuscitation than out-of-hospital cardiac arrest. Survival to discharge varies, but looks promising overall, ranging from 18.9 to 65%, with the bulk of the studies reporting survival to discharge between 30% and 50%, with about one-third to half of the patients discharged with no or minimal neurologic deficit. Based on the reported outcomes, in-hospital cardiac arrests can become a next focus for studies on successful implementation of VA ECMO. Financial support: None Conflict of interest: none Corresponding author: Maya Guglin MD, PhD 1801 Senate Avenue Suite 2000 Indianapolis, IN 46202 Fax 317-316-7655 Phone 248-346-3507 Email mguglin@iu.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Inflammatory Cardiomyopathy: Case-based Review on Clinical Presentation, Diagnosis, and Management Inflammatory cardiomyopathy is a broad term encompassing any disease leading to myocardial inflammation with associated cardiac dysfunction. While endomyocardial biopsy remains the gold standard for diagnosis, non-invasive imaging techniques, such as cardiac magnetic resonance imaging and positron emission tomography, have become powerful tools to facilitate the identification of underlying myocardial inflammation. This review presents a series of clinical cases with some common etiologies of inflammatory cardiomyopathy, including diagnosis and management. Disclosure: Authors have no financial conflict of interest to disclose. The research described in this article has not received any public or private funding. Corresponding author: Stephen Pan MD, MS Director, Infiltrative Cardiomyopathy Program 100 Woods Road, Macy 135 Valhalla, NY 10601 Stephen.Pan@wmchealth.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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