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Nutritional Support and Advanced Heart Failure

Marelli, Daniel

doi: 10.1097/MAT.0000000000000094
Invited Commentaries

From the Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

Submitted for consideration March 17, 2014; accepted for publication in revised form April 22, 2014.

Disclosure: The authors have no conflicts of interest to report.

Correspondence: Daniel Marelli, MD, Bayhealth CV Surgical Associates, 540 South Governors Avenue, Suite 101A, Dover, Delaware 19904. Email:

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.

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