Patients with advanced heart failure requiring ventricular assist device (VAD) implantation present two broad nutritional support challenges. In those patients with acute onset such as fulminant viral myocarditis, nutritional support needs resemble those of other critically ill patients. These patients have usually been recently healthy and are well conditioned. In the other category, those with chronic advanced heart failure may be undernourished and can be deconditioned upon admission.1 Such patients may have depleted reserves and cannot afford in-hospital fasting periods. Both groups are weakened and often unable to maintain adequate oral intake before VAD implant. This is aggravated by the need for fasting before some of the required evaluations. Such scenarios may include delays in testing or sedation which further add to the possibility of coming to surgery in a state of suboptimal nutrition.
The need for nutritional support in the critically ill and in those undergoing surgery is well studied. Such trials have focused on enteral and parenteral feeding.2 Although the benefits of enteral feeding are universally accepted, there is controversy regarding early versus late institution of parenteral nutrition.3 It is important to note that in the landmark study by Casaer et al.,4 the late parenteral group was initially supported with a 5% glucose solution. Indeed, early parenteral feeding may not prevent muscle wasting suggesting that this occurrence is complex.5 From an energy standpoint, it is possible that this means that endogenous carbohydrate production may not be decreased by this strategy in the early phase of critical illness. Less documented in current literature is the benefit of dextrose in traditional maintenance intravenous solutions during fasting episodes, particularly during the preoperative period.6 An ingenious trend has been to question the usual overnight fast before elective surgery.7 There are a significant number of studies lead by Ljungqvist and associates from the Karolinska Institute in Sweden indicating that ingestion or infusion of a carbohydrate solution 2–3 hours before major surgery is beneficial.8,9 This has been observed to prevent postoperative insulin resistance associated with endogenous carbohydrate production. There have also been reports of decreased postoperative muscle wasting and improved immune function when using this strategy.10,11 This suggests that preoperative exogenous carbohydrate can affect postoperative metabolism. In assist device candidates, the simplest usage of such an approach would comprise a maintenance intravenous solution containing dextrose to compensate for poor oral intake. More complex schemes perhaps using preoperative enteral feeds need further investigation.
The nutritional support study by Scurlock et al.12 in the current issue of our journal derives its importance from within this perspective. The authors are to be commended for using a standardized protocol in VAD recipients. They have included the preimplant period together with the postoperative period. These may have to be separated in future studies. They have shown that enteral feeding should be attempted despite low-flow states or when on inotropic support. Such feeding even in small quantities could be beneficial in stimulating the intestinal mucosa and preventing bacterial translocation.13 They have also shown that when needed, parenteral nutrition is safe in assist device patients. This is significant because, as the authors discuss, it has been suggested that parenteral nutrition may be unsafe in VAD recipients. The authors have laid the foundation for an evolving protocol that can be modified and validated with prospective studies in the future. Such studies could borrow from general surgery strategies but not necessarily assume that patients with advanced heart failure will respond similarly. This should stimulate the development of tailored nutritional support guidelines for all phases of management in the course of treating patients with advanced heart failure.
1. Aggarwal A, Kumar A, Gregory MP, et al. Nutrition assessment in advanced heart failure patients evaluated for ventricular assist devices or cardiac transplantation. Nutr Clin Pract. 2013;28:112–119
2. Radrizzani D, Bertolini G, Facchini R, et al. Early enteral immunonutrition vs.
parenteral nutrition in critically ill patients without severe sepsis: A randomized clinical trial. Intensive Care Med. 2006;32:1191–1198
3. Casaer MP, Mesotten D, Hermans G, et al. Early versus
late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506–517
4. Casaer MP, Langouche L, Coudyzer W, et al. Impact of early parenteral nutrition on muscle and adipose tissue compartments during critical illness. Crit Care Med. 2013;41:2298–2309
5. Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013;310:1591–1600
6. Wolfe RR, Allsop JR, Burke JF. Glucose metabolism in man: Responses to intravenous glucose infusion. Metabolism. 1979;28:210–220
7. Ljungqvist O, Thorell A, Gutniak M, Häggmark T, Efendic S. Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance. J Am Coll Surg. 1994;178:329–336
8. Soop M, Nygren J, Thorell A, et al. Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery. Clin Nutr. 2004;23:733–741
9. Svanfeldt M, Thorell A, Hausel J, et al. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg. 2007;94:1342–1350
10. Yuill KA, Richardson RA, Davidson HI, Garden OJ, Parks RW. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively—A randomised clinical trial. Clin Nutr. 2005;24:32–37
11. Melis GC, van Leeuwen PA, von Blomberg-van der Flier BM, et al. A carbohydrate-rich beverage prior to surgery prevents surgery-induced immunodepression: A randomized, controlled, clinical trial. JPEN J Parenter Enteral Nutr. 2006;30:21–26
12. Scurlock C, Pinney SP, Lin HM, et al. The safety of parenteral nutrition in patients receiving a ventricular assist device. ASAIO J.
13. Hodin CM, Lenaerts K, Grootjans J, et al. Starvation compromises Paneth cells. Am J Pathol. 2011;179:2885–2893