Search

This paper provides an empirical study of combined land - ocean transport within the Belt and Road Initiative (BRI). The analysis is based on primary data in each transport activity taking place between Yiwu and Madrid. Five scenarios are modelled using alternative transport routes. Optimal choices for multi-modal transport combinations with regards to both economic and environmental perspectives are identified. By investigating freight transport from Yiwu to Madrid using the Yixinou line, the results suggest that the BRI has significant potential to reduce the cost of freight transport from China to Europe.

Aims: There is uncertainty about the definition of iron deficiency (ID) and the association between ID and prognosis in patients with advanced heart failure. We evaluated three definitions of ID in patients referred for heart transplantation., Methods and Results: Consecutive patients assessed for heart transplantation at a single UK centre between January 2010 and May 2022 were included. ID was defined as (1) serum ferritin concentration of <100 ng/ml, or 100-299 ng/ml with transferrin saturation <20% (guideline definition), (2) serum iron concentration ≤13 μmol/L, or (3) transferrin saturation <20%. The primary outcome measure was a composite of all-cause mortality, urgent heart transplantation or need for mechanical circulatory support. Overall, 801 patients were included, and the prevalence of ID was 39-55% depending on the definition used. ID, defined by either serum iron or transferrin saturation, was an independent predictor of the primary outcome measure (hazard ratio [HR] 1.532, 95% confidence interval [CI] 1.264-1.944, and HR 1.595, 95% CI 1.323-2.033, respectively), but the same association was not seen with the guideline definition of ID (HR 1.085, 95% CI 0.8827-1.333). These findings were robust in multivariable Cox regression analysis. ID, by all definitions, was associated with lower 6-min walk distance, lower peak oxygen consumption, higher intra-cardiac filling pressures and lower cardiac output., Conclusions: Iron deficiency, when defined by serum iron concentration or transferrin saturation, was associated with increased frequency of adverse clinical outcomes in patients with advanced heart failure. The same association was not seen with guideline definition of ID., (© 2023 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Acute cellular rejection (ACR) is common in the first year after cardiac transplantation, and regular surveillance endomyocardial biopsy (EMB) is required. An inexpensive, simple noninvasive diagnostic test would be useful. Prior studies suggest cardiac troponin (cTn) has potential as a "rule-out" test to minimize the use of EMB. Our aim was to determine whether a new high-sensitivity cardiac troponin I (hs-cTnI) assay would have utility as a "rule-out" test for ACR after heart transplantation., Methods: Blood samples at patient follow-up visits were collected and stored over a period of 5 y. Serum cTnI concentrations were measured using the ARCHITECTSTAT hs-cTnI assay and compared with an EMB performed on the same day. Receiver-operator curve analysis based on mixed-effects logistic regression models that account for repeated measurements in individuals was performed to determine a serum troponin level below which ACR could be reliably excluded., Results: One hundred seventy patients had 883 serum hs-cTnI results paired to a routine surveillance EMB. Fifty-one (6%) EMB showed significant ACR (grade ≥2R). Receiver-operator curve analysis approximated the null hypothesis area under the curve 0.509 (95% CI, 0.428-0.591). Sub-analysis including repeated hs-cTnI levels in a single individual, and early (<3 mo) EMB also showed no diagnostic utility of hs-cTnI measurement (area under the curve 0.512)., Conclusions: In the largest published study to date, we found no association between hs-cTnI concentration and the presence of significant ACR on surveillance EMB. Measurement of hs-cTnI may not be a useful technique for diagnosis or exclusion of ACR after heart transplantation., Competing Interests: K.K.L. has received an honorarium unrelated to this research from Abbotts Diagnostics and N.L.M. has received honorarium and grants unrelated to this research, from Abbots Diagnostics, Roche Diagnostics, and Siemens Healthcare. The other authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) improve sensitivity of cardiac allograft vasculopathy (CAV) detection compared to invasive coronary angiography (ICA), but their ability to predict clinical events is unknown. We determined whether severe CAV detected with ICA, IVUS, or OCT correlates with graft function., Methods: Comparison of specific vessel parameters between IVUS and OCT on 20 patients attending for angiography 12-24 months post-orthotopic heart transplant. Serial left ventricular ejection fraction (EF) was recorded prospectively., Results: Analyzing 55 coronary arteries, OCT and IVUS correlated well for vessel CAV characteristics. A mean intimal thickness (MIT) OCT  > .25 mm had a sensitivity of 86.7% and specificity of 74.3% at detecting Stanford grade 4 CAV. Those with angiographically evident CAV had significant reduction in graft EF over 7.3 years follow-up (median ΔEF -2% vs +1.5%, P = .03). Patients with MIT OCT  > .25 mm in at least one vessel had a lower median EF at time of surveillance (57% vs 62%, P = .014). Two MACEs were noted., Conclusion: Imaging with OCT correlates well with IVUS for CAV detection. Combined angiography and OCT to screen for CAV within 12-24 months of transplant predicts concurrent and future deterioration in graft function., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: The pulmonary artery pulsatility index (PAPi) is a composite measure of right heart function, and low PAPi is associated with increased likelihood of mortality in patients hospitalized with cardiogenic shock. Our aim was to determine how PAPi correlates with other measures of right heart function and whether PAPi is associated with outcomes in ambulatory outpatients with advanced heart failure., Methods: We assessed 673 consecutive ambulatory outpatients for heart transplantation over 10 years. The median age was 52 years, 72% were male, and dilated cardiomyopathy was the most common cause. All patients underwent detailed assessment, including right heart catheterization, and PAPi was calculated. The coprimary endpoints were death, urgent heart transplantation and mechanical circulatory support., Results: Median PAPi was 2.2 (interquartile range 1.42-3.62), and variation was predominantly due to variation in right atrial pressure. PAPi was well correlated with the right atrial pressure to pulmonary capillary wedge pressure ratio (rho -0.766) but less well correlated with the right ventricular stroke work index (rho 0.561) and tricuspid annular plane systolic excursion (rho 0.292). Patients in the lowest PAPi quartile (0.16-1.41) had lower event-free survival at 1 year (68.7%) and 3 years (45.6%) compared with all other PAPi quartiles (log rank P = 0.0286)., Conclusions: PAPi offers a composite measure of right heart function that differs from other right heart catheter or echocardiographic measures. A PAPi of less than 1.41 is associated with adverse clinical outcomes in ambulatory outpatients with advanced heart failure., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Patients supported with implantable left ventricular assist devices (LVAD) have a significant risk of bleeding and thromboembolic complications. All patients require anticoagulation with warfarin, aiming for a target international normalised ratio (INR) of 2.5 and most patients also receive antiplatelet therapy. We found marked variation in the frequency of INR measurements and proportion of time outside the therapeutic INR range in our LVAD-supported patients. As part of a quality improvement initiative, home INR monitoring and a networked electronic database for recording INR results and treatment decisions were introduced. These changes were associated with increased frequency of INR measurement. We anticipate that changes introduced in this quality improvement project will reduce the likelihood of adverse events during long-term LVAD support., Competing Interests: Competing interests: None declared.

Aims: Many patients have a cardiac implantable electronic device (CIED) extracted at the time of heart transplantation. CIED components may be retained after heart transplantation, but their frequency, nature, and clinical significance is uncertain., Methods and Results: Consecutive patients that underwent heart transplantation over 10 years from 1 January 2007 until 1 January 2017 were identified from the unit database. Pre- and post-operative chest radiographs were reviewed by two independent observers for the presence of CIED components. Adverse events relating to any retained CIED component were recorded. Two hundred and six patients had a CIED removed at the time of transplantation. Retained CIED components were present in 86 (42%) patients. The most common retained CIED components were suture sleeves and superior vena cava (SVC) coils of dual coil implantable cardioverter-defibrillator (ICD) leads. An SVC coil was retained in 25% of patients that had a dual coil ICD lead. Seven adverse events were associated with CIED removal or retained CIED components, including one fatal event. However, retained CIED components were not associated with reduced long-term survival after heart transplantation., Conclusion: Retained CIED components were seen in 42% of patients that had a CIED prior to transplantation, may be associated with serious adverse events but are not associated with reduced long-term survival. Cardiac surgeons should be aware of all CIED system components and be familiar with techniques for their complete removal at the time of transplantation.

Background: Acute cellular rejection (ACR) is a common complication in the first year after heart transplantation (HT). Routine surveillance for ACR is undertaken by endomyocardial biopsy (EMB). Measurement of cardiac troponins (cTn) in serum is an established diagnostic test of cardiac myocyte injury. This systematic review aimed to determine whether cTn measurement could be used to diagnose or exclude ACR., Methods: PubMed, Google Scholar and the JHLT archive were searched for studies reporting the result of a cTn assay and a paired surveillance EMB. Significant ACR was defined as International Society for Heart and Lung Transplantataion (ISHLT) Grade ≥3a/≥2R. Considerable heterogeneity between studies precluded quantitative meta-analysis. Individual study sensitivity and specificity data were examined and used to construct a pooled hierarchical summary receiver-operator characteristic (ROC) curve., Results: Twelve studies including 993 patients and 3,803 EMBs, of which 3,729 were paired with cTn levels, had adequate data available for inclusion. The overall rate of significant ACR was 12%. There was wide variation in diagnostic performance. cTn assays demonstrated sensitivity of 8% to 100% and specificity of 13% to 88% for detection of ACR. The positive predictive value (PPV) was low but the negative predictive value (NPV) was relatively high (79% to 100%). High-sensitivity cTn assays had greater sensitivity and NPV than conventional cTn assays for detection of ACR (sensitivity: 82% to 100% vs 8% to 77%; NPV: 97% to 100% vs 81% to 95%, respectively)., Conclusions: cTn assays do not have sufficient specificity to diagnose ACR in place of EMB. However, hs-cTn assays may have sufficient sensitivity and negative predictive value to exclude ACR and limit the need for surveillance EMB. Further research is required to assess this strategy., (Copyright © 2018 International Society for the Heart and Lung Transplantation. All rights reserved.)

Objectives: The aim of this study was to systematically collate and appraise the available evidence regarding the association between high-sensitivity cardiac troponin (hs-cTn) and incident heart failure (HF) and the added value of hs-cTn in HF prediction., Background: Identification of subjects at high risk for HF and early risk factor modification with medications such as angiotensin-converting enzyme inhibitors may delay the onset of HF. Hs-cTn has been suggested as a prognostic marker for the incidence of first-ever HF in asymptomatic subjects., Methods: PubMed, Embase, and Web of Science were systematically searched for prospective cohort studies published before January 2017 that reported associations between hs-cTn and incident HF in subjects without baseline HF. Study-specific multivariate-adjusted hazard ratios (HRs) were pooled using random-effects meta-analysis., Results: Data were collated from 16 studies with a total of 67,063 subjects and 4,165 incident HF events. The average age was 57 years, and 47% were women. Study quality was high (Newcastle-Ottawa score 8.2 of 9). In a comparison of participants in the top third with those in the bottom third of baseline values of hs-cTn, the pooled multivariate-adjusted HR for incident HF was 2.09 (95% confidence interval [CI]: 1.76 to 2.48; p < 0.001). Between-study heterogeneity was high, with an I 2 value of 80%. HRs were similar in men and women (2.29 [95% CI: 1.64 to 3.21] vs. 2.18 [95% CI: 1.68 to 2.81]) and for hs-cTnI and hs-cTnT (2.09 [95% CI: 1.53 to 2.85] vs. 2.11 [95% CI: 1.69 to 2.63]) and across other study-level characteristics. Further adjustment for B-type natriuretic peptide yielded a similar HR of 2.08 (95% CI: 1.64 to 2.65). Assay of hs-cTn in addition to conventional risk factors provided improvements in the C index of 1% to 3%., Conclusions: Available prospective studies indicate a strong association of hs-cTn with the risk of first-ever HF and significant improvements in HF prediction., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Cardiac allograft vasculopathy (CAV) can be detected early with intravascular ultrasound (IVUS), but there is limited information on the most efficient imaging protocol., Methods: Coronary angiography and IVUS of the three coronary arteries were performed. Volumetric IVUS analysis was performed, and a Stanford grade determined for each vessel., Results: Eighteen patients were included 18 (range 12-24) months after transplantation. Angiographic CAV severity ranged from none (CAV0) to mild (CAV1), whereas IVUS CAV severity ranged from none (Stanford grade I) to severe (grade IV). Maximal intimal thickness measured with IVUS was significantly greater in the LAD (0.84 ± 0.48 mm) than in the LCX (0.46 ± 0.32 mm) or the RCA (0.53 ± 0.41 mm, P = .005). Diagnostic accuracy of IVUS in the left anterior descending artery was 100% (18 of 18 Stanford grades matched the patient's highest overall Stanford grade), 66% in the right coronary artery (12 of 18), and 56% in the left circumflex artery (11 of 18). The minimal required length of left anterior descending artery pullbacks to attain 100% accuracy was 36 mm (range 3-36 mm) distal from the guide catheter ostium., Conclusions: These data suggest that focal IVUS imaging of the proximal LAD followed by volumetric analysis may suffice when screening for transplant vasculopathy., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

A phaeochromocytoma (PC) is a rare, catecholamine-secreting neuroendocrine tumour arising from the adrenal medulla. Presenting symptoms of this rare tumour are highly variable but life-threatening multiorgan dysfunction can occur secondary to catecholamine-induced hypertension or hypotension and subsequent cardiovascular collapse. High levels of circulating catecholamines can induce an acute stress cardiomyopathy, also known as Takotsubo cardiomyopathy. Recent studies have focused on early diagnosis and estimation of the prevalence of acute stress cardiomyopathy in patients with PC, but very little is reported about management of these complex cases. Here, we report the case of a 38-year-old lady who presented with an acute Takotsubo or stress cardiomyopathy and catecholamine crisis, caused by an occult left-sided 5 cm PC. The initial presenting crisis manifested with symptoms of severe headache and abdominal pain, triggered by a respiratory tract infection. On admission to hospital, the patient rapidly deteriorated, developing respiratory failure, cardiogenic shock and subsequent cardiovascular collapse due to further exacerbation of the catecholamine crisis caused by a combination of opiates and intravenous corticosteroid. An echocardiogram revealed left ventricular apical hypokinesia and ballooning, with an estimated left ventricular ejection fraction of 10-15%. Herein, we outline the early stabilisation period, preoperative optimisation and intraoperative management, providing anecdotal guidance for the management of this rare life-threatening complication of PC., Learning Points: A diagnosis of phaeochromocytoma should be considered in patients presenting with acute cardiomyopathy or cardiogenic shock without a clear ischaemic or valvular aetiology.Catecholamine crisis is a life-threatening medical emergency that requires cross-disciplinary expertise and management to ensure the best clinical outcome.After initial resuscitation, treatment of acute catecholamine-induced stress cardiomyopathy requires careful introduction of alpha-blockade followed by beta-blockade if necessary to manage β-receptor-mediated tachycardia.Prolonged α-adrenergic receptor stimulation by high levels of circulating catecholamines precipitates arterial vasoconstriction and intravascular volume contraction, which can further exacerbate hypotension. Invasive pressure monitoring can aid management of intravascular volume in these complex patients.

Background: Socioeconomic deprivation (SED) is associated with shorter survival across a range of cardiovascular and noncardiovascular diseases. The association of SED with survival after heart transplantation in England, where there is universal healthcare provision, is unknown., Methods and Results: Long-term follow-up data were obtained for all patients in England who underwent heart transplantation between 1995 and 2014. We used the United Kingdom Index of Multiple Deprivation (UK IMD), a neighborhood level measure of SED, to estimate the relative degree of deprivation for each recipient. Cox proportional hazard models were used to examine the association between SED and overall survival and conditional survival (dependant on survival at 1 year after transplantation) during follow-up. Models were stratified by transplant center and adjusted for donor and recipient age and sex, ethnicity, serum creatinine, diabetes mellitus, and heart failure cause. A total of 2384 patients underwent heart transplantation. There were 1101 deaths during 17 040 patient-year follow-up. Median overall survival was 12.6 years, and conditional survival was 15.6 years. Comparing the most deprived with the least deprived quintile, adjusted hazard ratios for all-cause mortality were 1.27 (1.04-1.55; P =0.021) and 1.59 (1.22-2.09; P =0.001) in the overall and conditional models, respectively. Median overall survival and conditional survival were 3.4 years shorter in the most deprived quintile than in the least deprived., Conclusions: Higher SED is associated with shorter survival in heart transplant recipients in England and should be considered when comparing outcomes between centers. Future research should seek to identify modifiable mediators of this association., (© 2016 American Heart Association, Inc.)

This report describes a 63-year-old man with a dilated cardiomyopathy, who was supported with a continuous flow left ventricular assist device (LVAD), and on the waiting list for heart transplantation. After a long period of stability, he presented with recurrent ventricular tachycardia and rapidly developed progressive right ventricular (RV) failure. He required implantation of a temporary RV assist device to regain stability and subsequently underwent urgent heart transplantation. The explanted heart showed multiple areas of ischaemic damage to the RV myocardium, but there was no significant underlying coronary artery disease. It appears that the ventricular arrhythmias and subsequent RV failure were due to an embolic event in the territory of the right coronary artery. The case highlights that coronary embolism is a rare cause of RV failure during LVAD support and demonstrates the utility of temporary RV assist device support as a bridge to heart transplantation., (2015 BMJ Publishing Group Ltd.)

Background: Selected patients with cardiac sarcoidosis undergo heart transplantation, but outcomes may be adversely affected by recurrent cardiac sarcoidosis or progressive extra-cardiac sarcoidosis., Objectives: We present our single-center experience of patients with cardiac sarcoidosis who underwent heart transplantation., Methods: Consecutive patients that underwent heart transplantation between 1990 and 2012 were assessed. Cardiac sarcoidosis was defined by the presence of multiple non-caseating epithelioid cell granulomata in the explanted heart. Baseline characteristics and clinical outcomes were compared with a control group without cardiac sarcoidosis that underwent heart transplantation during this period., Results: 901 patients underwent heart transplantation during the study period, of whom 4 patients had a pre-transplant diagnosis of cardiac sarcoidosis and 8 patients had sarcoidosis identified in the explanted heart. Patients with cardiac sarcoidosis had excellent post-transplant outcomes with survival of 92% at one year and 83% at five years. Survival was similar to patients that underwent heart transplantation for an alternate diagnosis. We did not encounter recurrent cardiac sarcoidosis or progressive extra-cardiac sarcoidosis during 1001 months of follow-up., Conclusions: Carefully selected patients with advanced heart failure due to cardiac sarcoidosis have an acceptable outcome after transplantation. Cardiologists should be aware that reported experience of transplantation for cardiac sarcoidosis mostly represents isolated cardiac sarcoidosis that was only diagnosed at pathological examination of the explanted heart.