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ORIGINAL ARTICLE |
Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
Thitipong Tepsuwan, MD, Tel: +66 53 94 5533, Fax: +66 53 94 6139, Email: Thitipong_tepsuwan{at}yahoo.com, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand.
ABSTRACT
Cardiac cachexia is a wasting feature of advanced heart failure, which is due to several etiologies and associated with a poor prognosis. This study assessed the incidence and impact of cardiac cachexia retrospectively in 353 patients who underwent valve surgery from June 2005 to June 2006. Using 80% of ideal body weight as a cut-off point, 46 (13%) of these patients were considered to have cardiac cachexia. Patients with cachexia were predominantly male with more underlying diseases and a lower body mass index than those without cachexia. The New York Heart Association functional class was significantly worse in patients with cachexia (class III/IV: 54.4% vs. 21.2%) and they had greater incidences of active infective endocarditis (21.7% vs. 5.2%) and tricuspid regurgitation (41.3% vs. 21.8%) compared to those with normal body weight. The cachexia group had significantly longer postoperative hospitalization and more complications (37% vs. 21.5%); perioperative mortality tended to be higher (6.5% vs. 2.3%) although not statistically significant. Cardiac cachexia remains an important problem in patients undergoing valve surgery, which indicates end-staged disease, and contributes to poor perioperative outcomes. Special care and attention are needed in this particular group of patients.
Key Words: Cachexia • Heart Failure • Heart Valve Diseases
INTRODUCTION
One of the important features in patients with chronic heart failure (CHF) is the significant weight loss or wasting syndrome named cardiac cachexia.1 Neuroendocrine, immunologic, and metabolic abnormalities have crucial roles in the pathogenesis of this multifactorial condition. It is associated with a poor prognosis, and currently there is no established effective therapy.2–4 Definitions of cardiac cachexia vary among studies, but most focus on weight loss and body components. These definitions include weight loss >6% in 6 months, ideal body weight <85% or 80% of predicted, or ideal body fat <27% in males or <29% in females.5 In previous studies, the incidence of this condition ranged from 13% to 36% in patients with CHF, but these were conducted in Western countries and among patients with heart failure in general or ischemic heart diseases.6,7 Many studies have focused on whether body weight or body mass index influences outcomes after coronary bypass surgery.8–10 In contrast, most patients in Thailand and many regions in Asia have CHF due to heart valve problems, and there is little information on cardiac cachexia in this group. Thus the purpose of this study was to explore the effects of this syndrome in patients undergoing valve operations.
PATIENTS AND METHODS
A retrospective review was carried out in patients who underwent cardiac valve operations at Chiang Mai University Hospital from June 2005 to June 2006. Data were collected from the Cardiothoracic Unit database and from the hospital’s computer-based medical records. The study protocol was reviewed and approved by the Medical Faculty Review Board of Chiang Mai University. Inclusion criteria were patients over 18 years of age with acquired heart valve disease and a first-time isolated cardiac valve operation; younger patients and those with congenital or ischemic causes, redo or concomitant cardiac procedures were excluded.
Operative techniques were similar in most cases. The approach was through a median sternotomy. Cardiopulmonary bypass was established with ascending aortic cannulation, atrial/caval venous drainage, aortic crossclamping, antegrade and/or retrograde cold blood cardioplegia with mild hypothermia. Beating heart techniques were used in 1.8% of cases. The patients were divided in 2 groups based on the presence or absence of cardiac cachexia. The definition of cachexia was <80% of ideal body weight estimated by the Devine equation which is commonly used for nutritional and pharmacologic assessment:11 ideal body weight (kg) in males = [50 +2.3 + (height in cm/2.54 – 60)]; ideal body weight (kg) in females = [45.5 +2.3 x (height in cm/2.54 – 60)].
Data on preoperative patient characteristics, hemodynamic status, valve diseases and pathology, operative procedures, and postoperative courses including complications and mortality were collected and compared between cachexia and non-cachexia groups. Numerical variables are presented as proportions and/or percentages. Continuous variables are expressed as the mean and standard deviation. Data were compared between groups using the standard t test and Fisher’s exact test. A p value of less than 0.05 was considered statistically significant.
RESULTS
During the study period, 353 patients fitted the inclusion criteria. Completeness of data collection was 97%–99% for all study parameters except pulmonary artery pressure which was available in 185 (52%) patients. There were 46 patients whose weights were <80% of ideal body weight; the incidence of cardiac cachexia in these valve surgery patients was 13%. Preoperative characteristics are shown in Table 1
. The cachexia group contained significantly more males, smokers, and cases of renal failure, with lower body weight, body mass index, and hemoglobin levels than the control group of those with 
80% of ideal body weight. Table 2 compares the preoperative hemodynamic status between the 2 groups. Although ejection fraction and pulmonary artery pressure were comparable, the cachexia group presented in worse New York Heart Association functional class (class III/IV: 54.4% vs. 21.2%) and required more inotropic support and resuscitation before the operation. The cachexia group had a higher incidence of active infective endocarditis as a cause of valve disease (21.7% vs. 5.2%; Figure 1). A greater proportion of the cachexia patients had moderate to severe tricuspid insufficiency (41.3% vs. 21.8%; Figure 2). A higher percentage of patients in the cachexia group underwent non-elective surgery (19.6% vs.7.5%) and triple-valve operations (13.0% vs. 3.9%), as shown in Table 3. However, there were no differences in cardiopulmonary bypass and crossclamp times between groups. The cachexia group required significantly longer ventilator time, intensive care unit stay, and overall hospital stay, with more complications (37% vs. 21.5%). Mortality tended to be higher among cachexia patients, but it was not statistically significant (Table 4). Postoperative complications are compared between groups in Table 5. There were 30 complications affecting 17 patients in the cachexia group, and 95 complications in 66 control patients. The incidence of new postoperative renal failure was higher in the cachexia group.
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The 13% incidence of cardiac cachexia in valve surgery patients in this study is similar to the incidence of 13%–36% in previous reports.6,7 This means that surgeons have to operate on a significant number of these end-stage patients. Using weight criteria to determine cardiac cachexia, low body weight, low body mass index, and history of weight loss are related to this condition, and they are poor prognostic factors for CHF patients. Although hemoglobin levels were reduced, serum albumin and cholesterol were not linked to cachexia in this study, whereas others have shown a strong relationship of these 2 parameters to CHF as predictors of poor outcome.12–14
According to its pathophysiology, cardiac cachexia usually affects patients with chronic progressive heart problems, leading to disturbances in many systems including neuroendocrine, inflammatory, and metabolic, which eventually result in loss of cardiac muscle, energy, and function, creating cardiac cachexia.4,7 These processes explain why this group had worse symptoms and more often required resuscitation and urgent operations. This study confirms that ejection fraction and pulmonary artery pressure are not associated with cachexia. However, Florea and colleagues15 demonstrated a relationship between cardiac cachexia and loss of left ventricular mass.
Advanced tricuspid regurgitation should be regarded as evidence of cardiac cachexia, and it is one of the major criteria for diagnosis of cardiac cachexia in patients with mitral valve diseases.16,17 Thus more patients with cardiac cachexia had triple-valve operations. Tricuspid lesions associated with rheumatic disease also contribute to poorer short- and long-term survival, as reported by Bernal and colleagues.18 The reason why the cachexia group had a higher incidence of active infective endocarditis may be explained by prior uncorrected underlying valve diseases and malnutrition, which increase the patient’s risk of severe infection. Another reason may be that inadequate medical treatment of infection and heart failure resulted in body wasting. Cardiac cachexia is related to worse short- and long-term survival in patients with CHF (53% vs. 83% at 3 years).1,4 This study demonstrates a strong correlation between cardiac cachexia and prolonged perioperative courses with increased complications, including devastating conditions such as new postoperative renal insufficiency.
Because this study was retrospective, limitations include uncontrolled bias and interrelated factors. There have been few studies that were prospective and/or focused on the strategies to prevent or improve this condition, such as nutritional intervention, neurohormonal and immunologic modulation, and rehabilitation.19,20 It was concluded from our findings that cardiac cachexia affects a significant number of patients undergoing valve surgery. It indicates a more advanced disease process and worse perioperative course. Strategies to prevent and to improve this condition are worth considering.
ACKNOWLEDGMENTS
We thank Wilaiwun Jongraksat, MNs, Consultant Statistician, Pakamas Bunyapisomparn, MNs, for her work on data processing, and the surgical teams caring for our patients.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:617-621
© 2009 by SAGE Publications
DOI: 10.1177/0218492309349093
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