Dendritic Cells in Subcutaneous and Epicardial Adipose Tissue of Subjects with Type 2 Diabetes, Obesity, and Coronary Artery Disease.

Dendritic cells (DCs) are professional antigen-presenting cells contributing to regulation of lymphocyte immune response. DCs are divided into two subtypes: CD11c-positive conventional or myeloid (cDCs) and CD123-positive plasmacytoid (pDCs) DCs. The aim of the study was to assess DCs (HLA-DR+ lineage-) and their subtypes by flow cytometry in peripheral blood and subcutaneous (SAT) and epicardial (EAT) adipose tissue in subjects with (T2DM, n = 12) and without (non-T2DM, n = 17) type 2 diabetes mellitus undergoing elective cardiac surgery. Subjects with T2DM had higher fasting glycemia (8.6 ± 0.7 vs. 5.8 ± 0.2 mmol/l, p < 0.001) and glycated hemoglobin (52.0 ± 3.4 vs. 36.9 ± 1.0 mmol/mol, p < 0.001) and tended to have more pronounced inflammation (hsCRP: 9.8 ± 3.1 vs. 5.1 ± 1.9 mg/ml, p = 0.177) compared with subjects without T2DM. T2DM was associated with reduced total DCs in SAT (1.57 ± 0.65 vs. 4.45 ± 1.56% for T2DM vs. non-T2DM, p = 0.041) with a similar, albeit insignificant, trend in EAT (0.996 ± 0.33 vs. 2.46 ± 0.78% for T2DM vs. non-T2DM, p = 0.171). When analyzing DC subsets, no difference in cDCs was seen between any of the studied groups or adipose tissue pools. In contrast, pDCs were increased in both SAT (13.5 ± 2.0 vs. 4.6 ± 1.9% of DC cells, p = 0.005) and EAT (29.1 ± 8.7 vs. 8.4 ± 2.4% of DC, p = 0.045) of T2DM relative to non-T2DM subjects as well as in EAT of the T2DM group compared with corresponding SAT (29.1 ± 8.7 vs. 13.5 ± 2.0% of DC, p = 0.020). Neither obesity nor coronary artery disease (CAD) significantly influenced the number of total, cDC, or pDC in SAT or EAT according to multiple regression analysis. In summary, T2DM decreased the amount of total dendritic cells in subcutaneous adipose tissue and increased plasmacytoid dendritic cells in subcutaneous and even more in epicardial adipose tissue. These findings suggest a potential role of pDCs in the development of T2DM-associated adipose tissue low-grade inflammation.

[Hyperglycemia and its control in the critically ill patient]. / Hyperglykémie a její kontrola u dospelých pacientu v intenzivní péci.

In the critically ill patient, hyperglycemia was believed to be a response by the body to a stressful situation. Stress-induced hyperglycemia is the consequence of increased levels of cortisol, cytokines, growth hormones, catecholamines, and glucagon resulting in the stimulation of endogenous glucose production through glycogenolysis and gluconeogenesis as well as other mechanisms including central and peripheral insulin resistance. Among other things, hyperglycemia has an effect on inflammation and function of the myocardium, kidney, central nervous system, and the immune system. The protective role of intensified insulin therapy (glycemia of 4.4-6.1 mmol/l) in the critically ill patient, as suggested by the Leuven trial, resulted in the quick and widespread adoption of this approach in practice. However, later studies did not support the Leuven trial results while pointing to the possibility of developing severe hyperglycemia. The large multicenter NICE-SUGAR study in 6,022 patients showed higher 90-day mortality in the group with tight glycemic control. The results of NICE-SUGAR led to revision of the guidelines for glycemic control in the critically, recommending to control glycemia below 10 mmol/l. The aim of this overview is to summarize available data on glycemic control in the critically ill patient.

Comprehensive management of severe intestinal bleeding in a patient supported for 94 days by the biventricular Levitronix CentriMag system.

The use of short-term mechanical circulatory support during postcardiotomy acute heart failure provides an opportunity to stabilize the patient's hemodynamic state while determining the best long-term strategy. Because all of these devices require anticoagulation treatment of various intensities, management of major bleeding can be critical for the overall outcome of the therapy. In this regard, the newest generation of magnetically levitated centrifugal-flow pumps affords several potential advantages in terms of thrombogenicity and eventual discontinuation of anticoagulation treatment. We report the use of a short-term biventricular assist device (Levitronix CentriMag) for 94 days in a 55-year-old man with refractory ventricular arrhythmias after combined heart surgery. Despite serious complications while the patient was on the assist device, including severe intestinal bleeding with the necessity of discontinuing anticoagulation for 10 days and, ultimately, hemicolectomy, the circulatory support was completed with successful heart transplantation.

Perioperative Tight Glucose Control Reduces Postoperative Adverse Events in Nondiabetic Cardiac Surgery Patients.

CONTEXT: Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. OBJECTIVE: The purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients. DESIGN: This was a single center, single-blind, parallel-group, randomized controlled trial. SETTINGS: The setting was an academic tertiary hospital. PARTICIPANTS: Participants were 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative intensive care unit treatment for at least 2 consecutive days. INTERVENTION: Intensive insulin therapy was initiated perioperatively or postoperatively with a target glucose range of 4.4 to 6.1 mmol/L. MAIN OUTCOME MEASURES: Adverse events from any cause during postoperative hospital stay were compared. RESULTS: In the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2% vs 34.1%, 95% confidence interval [CI], 0.60-0.78) despite only minimal improvement in glucose control (blood glucose, 6.6 ± 0.7 vs 6.7 ± 0.8 mmol/L, P < .001; time in target range, 39.3% ± 13.7% vs 37.3% ± 13.8%, P < .001). The positive effects of TGC on postoperative complications were driven by nondiabetic subjects (21.3% vs 33.7%, 95% CI, 0.54-0.74; blood glucose 6.5 ± 0.6 vs 6.6 ± 0.8 mmol/L, not significant; time in target range, 40.8% ± 13.6% vs 39.7% ± 13.8%, not significant), whereas no significant effect was seen in diabetic patients (29.4% vs 35.1%, 95% CI, 0.66-1.06) despite significantly better glucose control in the perioperative group (blood glucose, 6.9 ± 1.0 vs 7.1 ± 0.8 mmol/L, P < .001; time in target range, 34.3% ± 12.7% vs 30.8% ± 11.5%, P < .001). CONCLUSIONS: Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.

Case report: atypical fungal obstruction of the left ventricular assist device outflow cannula.

We describe a very rare case of outflow cannula obstruction with fungal infectious thrombus formation. Discussion includes the etiology, diagnosis, and management of fungal infection complications related with long-term mechanical circulatory support. Left ventricular assist devices (LVADs) are increasingly used as bridge to transplant and permanent long-term therapy in the population with end-stage heart failure. Even though better clinical outcomes have been achieved with the newer-generation continuous-flow devices, infection complications are still a major risk for patients with continuous-flow LVAD implantation in long-term follow-up [Ann Thorac Surg 90:1270-1277, 2010]. Device-related infections can be categorized as driveline infections, pump-pocket infections, and LVAD-associated endocarditis [Expert Rev Med Devices 8: 627-634, 2011]. The microbiological profile is very heterogeneous; the most common pathogens are Staphylococcus, Pseudomonas, Streptococcus species, and Candida. Severe fungal infection may lead to dysfunction of the LVAD due to obstructive mass formation within the device. Due to the only anecdotal reports in the current literature, we present a very rare case of outflow fungal infectious thrombus formation leading to outflow cannula obstruction in patient with LVAD.

Total artificial heart support with two continuous-flow ventricular assist devices in a patient with an infiltrating cardiac sarcoma.

Primary cardiac sarcoma is normally fatal, but cardiac replacement may provide some hope for long-term survival. A 38 year-old man with cardiac sarcoma, involving the interventricular septum and posterior wall with intermittent mitral obstruction, underwent implantation of two HeartMate II ventricular assist devices for total artificial heart support. After cardiectomy, the HeartMate sewing rings were sewn to the right neoatrium and the left atrial remnants. After the outflow grafts were sewn end to end to the pulmonary artery and aorta, the two drivelines were externalized through the abdominal wall, and perfusion started. The postoperative course was complicated by respiratory and renal dysfunction, which resolved. After 6 months of support, the patient has normal organ function and is ambulatory. Follow-up oncologic evaluation of positron emission tomography-computed tomography scan is negative.

Is severe cardiac dysfunction a contraindication for complex combined oncotherapy of Hodgkin's lymphoma? Not any more.

Hodgkin's lymphoma is a quite frequent diagnosis, particularly in younger patients, which is normally treated effectively with combined chemotherapy and radiotherapy. Cardiomyopathy induced by these treatments is not uncommon and may progress to advanced-stage heart failure. Due to the cardiotoxicity of chemotherapy for Hodgkin's disease, preexisting heart failure precludes usual therapy. We present a novel strategy of hemodynamic stabilization with an implantable left ventricular assist device (LVAD) prior to radical oncotherapy for Hodgkin's lymphoma. A 33-year-old man with a short history of progressive heart failure was hospitalized due to progressive symptoms. An echocardiogram revealed a dilated left ventricle with an ejection fraction of 18%, moderate right ventricular dysfunction, and moderate to severe tricuspid regurgitation. Supradiaphragmatic-stage Hodgkin's lymphoma was also diagnosed. Due to severe cardiac dysfunction, the patient was not a candidate for the usual chemotherapy and radiotherapy prescribed for this diagnosis. After multidisciplinary consultation and consent from the patient, an LVAD was implanted with tricuspid valve repair. Additionally, affected lymph nodes from the ventral upper mediastinum were excised, and pathological analysis confirmed the lymphoma diagnosis. The patient recovered from surgery and the postoperative course was uneventful. With LVAD support and normalized hemodynamics, chemotherapy and radiotherapy for his Hodgkin's lymphoma were completed, and the patient remains in complete remission documented by positron emission tomography/computed tomography and is well one since LVAD implantation.

Anesthesia management of a patient with a ventricular assist device for noncardiac surgery.

Congestive heart failure represents a severe health condition with unfavourable long-term prognosis despite all the progress in pharmacological therapy of heart failure. Another therapeutic option is represented by mechanical cardiac support devices. Ventricular assist devices (VAD) constitute largest subgroup of these devices. Patients supported with VAD carry many considerations which are important for successful perioperative management of these patients for noncardiac surgery. The general perioperative considerations include consultation with VAD management personnel, detailed assessment of end-organ dysfunction before surgery, appropriate antibiotic prophylaxis, deactivation of implantable cardioverter-defibrillator for the time of surgical procedure, and the choice between general and regional anesthesia. Intraoperative monitoring depends primarily on the type of blood flow generated by VAD. For devices generating pulsatile blood flow, standard monitoring arrangements are needed. In the patients supported by devices which provide nonpulsatile blood flow, pulse oximetry and noninvasive blood pressure measurement are not reliable monitoring methods, and placement of intra-arterial catheter is warranted. In all the patients supported with VAD, transesophageal echocardiography is extremely useful method for monitoring the function of VAD itself, and in the case of univentricular VAD for monitoring the function of nonsupported cardiac ventricle. The most important issue in hemodynamic management of the patients with VAD is avoiding hypovolemia because it can cause inadequate VAD output with resulting low cardiac output and hypotension. All the patients with VAD need some degree of anticoagulation, and for noncardiac surgery the question of interrupting or decreasing the level of anticoagulation should be discussed among members of the caring team.

Single-stage extensive chronic type A dissecting aortic aneurysm repair and continuous-flow ventricular assist device implantation.

The surgical technique of simultaneous heart transplantation and aortic aneurysm repair has been reported previously. However, there is a subgroup of patients with end-stage cardiomyopathy requiring major aortic surgery who do not meet heart transplant criteria. The optimal treatment strategy for these patients is still to be defined. In this report, we describe the use of an implantable continuous-flow left ventricular assist device (LVAD) as an adjunct to extensive aortic repair for providing patients with an acceptable risk surgical alternative to palliative treatment. To the best of our knowledge, this is the first report of this approach in the published literature.

Comparison of three protocols for tight glycemic control in cardiac surgery patients.

OBJECTIVE: We performed a randomized trial to compare three insulin-titration protocols for tight glycemic control (TGC) in a surgical intensive care unit: an absolute glucose (Matias) protocol, a relative glucose change (Bath) protocol, and an enhanced model predictive control (eMPC) algorithm. RESEARCH DESIGN AND METHODS: A total of 120 consecutive patients after cardiac surgery were randomly assigned to the three protocols with a target glycemia range from 4.4 to 6.1 mmol/l. Intravenous insulin was administered continuously or in combination with insulin boluses (Matias protocol). Blood glucose was measured in 1- to 4-h intervals as requested by the protocols. RESULTS: The eMPC algorithm gave the best performance as assessed by time to target (8.8 +/- 2.2 vs. 10.9 +/- 1.0 vs. 12.3 +/- 1.9 h; eMPC vs. Matias vs. Bath, respectively; P < 0.05), average blood glucose after reaching the target (5.2 +/- 0.1 vs. 6.2 +/- 0.1 vs. 5.8 +/- 0.1 mmol/l; P < 0.01), time in target (62.8 +/- 4.4 vs. 48.4 +/- 3.28 vs. 55.5 +/- 3.2%; P < 0.05), time in hyperglycemia >8.3 mmol/l (1.3 +/- 1.2 vs. 12.8 +/- 2.2 vs. 6.5 +/- 2.0%; P < 0.05), and sampling interval (2.3 +/- 0.1 vs. 2.1 +/- 0.1 vs. 1.8 +/- 0.1 h; P < 0.05). However, time in hypoglycemia risk range (2.9-4.3 mmol/l) in the eMPC group was the longest (22.2 +/- 1.9 vs. 10.9 +/- 1.5 vs. 13.1 +/- 1.6; P < 0.05). No severe hypoglycemic episode (<2.3 mmol/l) occurred in the eMPC group compared with one in the Matias group and two in the Bath group. CONCLUSIONS: The eMPC algorithm provided the best TGC without increasing the risk of severe hypoglycemia while requiring the fewest glucose measurements. Overall, all protocols were safe and effective in the maintenance of TGC in cardiac surgery patients.

Pulmonary valve replacement for pacing electrodes related bacterial endocarditis.

Infective endocarditis of pulmonary valve requiring surgery is rare. We report a case of 80-year-old woman with a permanent pacemaker implanted 14 years ago. She had signs of infection resistant to antibiotic therapy, secondary cachexia, and dyspnea. Echocardiography examination revealed an infectious mass on pacing electrodes in the right atrium, right ventricular dysfunction, and pulmonary hypertension. Removal of the infected pacing system was indicated. During the operation, destruction of the pulmonary valve due to bacterial endocarditis was diagnosed. Replacement with a stented porcine valve was performed. The patient was discharged on postoperative day 20. Seven months after the operation, the patient is in a good condition.