Implementation of a Cardiogenic Shock Team in a Tertiary Academic Centre.

BACKGROUND: Observational studies have shown that the management of patients with cardiogenic shock (CS) by dedicated multidisciplinary teams improve clinical outcomes. Nevertheless, these studies reflect a specific organisational setting with most patients being transfers from referring hospitals, hospitalised in cardiac intensive care units (ICU), or treated with mechanical circulatory support (MCS) devices. The purpose of this study was to document the organisation and outcomes of a CS team offering acute care in all-comer population. METHODS: A CS team was developed in a large academic tertiary institution. The team consisted of emergency care physicians, critical care cardiologists, interventional cardiologists, cardiac surgeons, ICU physicians and heart failure specialists and was supported by predefined operating protocol, dedicated communication platform and regular team meetings. RESULTS: Over 12 months, 70 CS patients (69±13 years old, 67% males) were included. Acute myocardial infarction (AMI-CS) was the most common cause (64%); 31% of the patients presented post-resuscitated cardiac arrest and 56% needed invasive mechanical ventilation (IMV). Coronary angiography was performed in 70% and 53% had percutaneous coronary intervention. MCS was used in 10% and 6% were referred for urgent cardiac surgery. The in-hospital mortality in our centre was 40% with 39% of the patients dying within 24-hours from presentation. 76% of the alive patients were discharged home. CONCLUSIONS: Across an all-comer population, AMI was the most common cause of CS. A significant number of patients presented post cardiac arrest, and the majority required IMV. Mortality was high with a significant number dying within hours of presentation.

Is TEVAR an Effective Approach to Prevent Complications after Surgery for Aortic Dissection Type A? A Systematic Review.

Introduction: A residual false lumen after treatment for Aortic Dissection type A (AD) has been associated with early complications, such as A malperfusion or rupture and mid-term or delayed complications, such as aneurysm formation or dissection expansion. Thoracic Endovascular Aortic Repair (TEVAR) is considered an effective solution by several surgical teams to prevent future complications. In this systematic review, all published data regarding the implementation of TEVAR after previous treatment for AD were collected in order to investigate indications, methods, clinical outcomes and aortic remodeling in these patients. Methods: The aim of this study was to investigate the indications, the methods and the efficacy of TEVAR usage after surgical treatment of AD. Data for this study were collected from four widely used medical databases (MEDLINE, SCIENCE DIRECT, GOOGLE SCHOLAR, OVID). All the results for each database were recorded and were analyzed with a systematic method. Techniques and clinical outcomes were investigated. Aortic remodeling was evaluated based on the following parameters in these studies: aortic diameter, true lumen diameter, false lumen diameter, false lumen thrombosis and false lumen patency. Results: The results obtained from the search among all databases comprised 1410 articles and of these articles 9 were included in the review. The majority of the studies were retrospective (seven out of nine studies), while no study was randomized. The total number of patients was 157 and 133 of them (84.7% of patients) were treated with TEVAR in zone 3 without extension below the diaphragm intraoperatively. Among 142 patients, the calculated mortality rate was 12.7% (18 of 142 patients), with 2.8% (4 of 142 patients) presenting with stroke. The percentage of patients with total or partial thrombosis combined was 65.9% (62 patients in a population of 92). The reintervention rate was 18.7%. Conclusions: TEVAR after AD surgery is an approach usually chosen in clinical practice, but the criteria of its usage are uncertain. This method is safe and enhances aortic remodeling with an acceptable reintervention rate. Definite guidelines in this field should be created in order to delineate whether TEVAR after AD surgery is beneficial as a preventive measure to aorta-related complications and to decide under which criteria this approach should be chosen.

Extracorporeal Membrane Oxygenation (ECMO)-Associated Coagulopathy in Adults.

Extracorporeal membrane oxygenation (ECMO) is used for the management of severe respiratory and cardiac failure and as a bridge to achieve definite treatment or transplantation. ECMO-associated coagulopathy (EAC) is a frequent complication leading to high rates of thrombosis or severe haemorrhage, contributing to morbidity and mortality among patients. Understanding the pathophysiology of EAC is substantial for effectively managing patients on ECMO. We analyse the underlying mechanism of EAC and discuss the monitoring of the coagulation profile, combining the viscoelastic point-of-care assays with the conventional coagulation laboratory tests.

Bioprosthetic Valves for Lifetime Management of Aortic Stenosis: Pearls and Pitfalls.

This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons.

Sarcopenia Adversely Affects Outcomes following Cardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Sarcopenia is a degenerative condition characterised by the loss of skeletal muscle mass and strength. Its impact on cardiac surgery outcomes remains poorly investigated. This meta-analysis aims to provide a comprehensive synthesis of the available evidence to determine the effect of sarcopenia on cardiac surgery outcomes. METHODS: A systematic review and meta-analysis followed PRISMA guidelines from inception to April 2023 in EMBASE, MEDLINE, Cochrane database, and Google Scholar. Twelve studies involving 2717 patients undergoing cardiac surgery were included. Primary outcomes were early and late mortality; secondary outcomes included surgical time, infection rates, and functional outcomes. Statistical analyses were performed using appropriate methods. RESULTS: Sarcopenic patients (906 patients) had a significantly higher risk of early mortality (OR: 2.40, 95% CI: 1.44 to 3.99, p = 0.0007) and late mortality (OR: 2.65, 95% CI: 1.57 to 4.48, p = 0.0003) compared to non-sarcopenic patients (1811 patients). There were no significant differences in overall surgical time or infection rates. However, sarcopenic patients had longer ICU stays, higher rates of renal dialysis, care home discharge, and longer intubation times. CONCLUSION: Sarcopenia significantly increases the risk of early and late mortality following cardiac surgery, and sarcopenic patients also experience poorer functional outcomes.

Investigation of the Role of BMP2 and -4 in ASD, VSD and Complex Congenital Heart Disease.

Congenital heart malformations (CHMs) make up between 2 and 3% of annual human births. Bone morphogenetic proteins (BMPs) signalling is required for chamber myocardium development. We examined for possible molecular defects in the bone morphogenetic protein 2 and 4 (BMP2, -4) genes by sequencing analysis of all coding exons, as well as possible transcription or protein expression deregulation by real-time PCR and ELISA, respectively, in 52 heart biopsies with congenital malformations (atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy ofFallot (ToF) and complex cases) compared to 10 non-congenital heart disease (CHD) hearts. No loss of function mutations was found; only synonymous single nucleotide polymorphisms (SNPs) in the BMP2 and BMP4 genes were found. Deregulation of the mRNA expression and co-expression profile of the two genes (BMP2/BMP4) was observed in the affected compared to the normal hearts. BMP2 and -4 protein expression levels were similar in normal and affected hearts. This is the first study assessing the role of BMP-2 and 4 in congenital heart malformations. Our analysis did not reveal molecular defects in the BMP2 and -4 genes that could support a causal relationship with the congenital defects present in our patients. Importantly, sustained mRNA and protein expression of BMP2 and -4 in CHD cases compared to controls indicates possible temporal epigenetic, microRNA or post-transcriptional regulation mechanisms governing the initial stages of cardiac malformation.

Disseminated Intravascular Coagulation Post Endovascular Aortic Repair.

BACKGROUND: Disseminated Intravascular Coagulation (DIC) after Endo-Vascular Aneurysm Repair (EVAR) is a highly uncommon clinical entity. With only a few case-reports available, its management strategy still remains enigmatic. OBJECTIVES: The purpose of this study was to retrieve, synthesize, and appraise all existing data for DIC after EVAR. MATERIALS AND METHODS: All published articles regarding DIC post-EVAR were identified from 3 major databases and analyzed. Clinical parameters, predisposing factors, along with mortality and morbidly were assessed. RESULTS: The total number of publications included in the review was 15 describing 17 cases. DIC presented with a broad spectrum of clinical manifestations, while the time of diagnosis varied significantly. Endoleak was the main causative factor, with an incidence reaching 71%. The mortality of DIC after EVAR reached 29%, regardless of the therapeutic approach chosen. DIC was treated effectively in 47% of the patients (8/17), with better outcomes among patients who received conservative therapy or among those who were submitted to endovascular interventions. CONCLUSIONS: DIC after EVAR, although rare, is a potentially lethal clinical condition which requires prompt diagnosis and urgent medical consideration. Treatment of endoleak may help in quick restoration of normal parameters.

Intraoperative accurate assessment of septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM).

Surgical restoration of the left ventricular outflow tract (LVOT) is necessary for patients suffering from hypertrophic obstructive cardiomyopathy (HOCM), when symptoms are present despite the administration of medical treatment. One point of great significance during the procedure is the evaluation of the LVOT gradient after completion of septal myectomy. Most physicians choose to measure this value by transesophageal echocardiography (TEE) in combination with the direct measurement with the use of needles inserted into the aorta and left ventricle. In this article, we present the implementation of a new technique to estimate the peak-to-peak pressure gradient between the left ventricle and the aorta intraoperatively using a single double lumen central venous catheter inserted through the antegrade cardioplegia cannulation site across the aortic valve into the left ventricle.

Regional and directional variations in the layer-specific resistance to tear propagation in ascending thoracic aortic aneurysms.

Aortic dissection often initiates a few centimeters distal to the coronary ostia in the right lateral wall, with an intimal-medial tear that tends to be transversely directed and occupy half of the aortic circumference, sometimes less, but seldom the entire circumference. To elucidate these clinical observations, tear tests were presently used to determine the layer-specific resistance to tear propagation in ascending thoracic aortic aneurysms, assessing variations over the four circumferential quadrants and two directions. Aneurysmal tissue strips of standardized dimensions from sixteen patients were anatomically separated into layers (seven hundred and twelve) and an incision made along one-third of their length. They underwent tear testing via uniaxial loading and then unloading before crack propagation had proceeded along their complete length. The average tear tension and tear energy per reference area generated were many-fold greater in outer- (adventitial) compared to inner- (intimal with small medial portion) and middle-layer (medial) strips, explaining why the tear is restricted to the inner wall. They were greater in inner- compared to middle-layer strips of the anterior and left lateral quadrants, suggesting that the tear will propagate to the less-resistant media even if initiated in the intima. In most longitudinally-cut middle- and inner-layer strips, the cracks deviated toward the circumferential direction and tore out through the side, justifying the circumferential course of the tear. Both fracture parameters were significantly higher in the right than the left lateral quadrant in outer-layer strips and the anterior quadrant in middle-layer strips, potentially affecting the circumferential extent of the tear.

Can the Ratio SUVmax of the Lesion/SUVmax of Mediastinal Tissues Guide the Choice of Surgical Access for the Resection of Thymic Epithelial Tumors?

Background: There are studies showing the utility of the 18-fluorodeoxyglucose positron emission tomography (18FDG PET) scan in the management of patients with thymic epithelial tumors. It seems to be a correlation between the standard uptake value (SUVmax) of thymic epithelial tumors and the histological type and the stage. This study aims to use the ratio of the SUVmax of the lesion to the SUVmax of the adjacent mediastinal tissues in order to guide the choice of the surgical access. Methods: All patients who presented an anterior mediastinal lesion with a high suspicion of being of thymic origin were included in a prospective database. A ratio inferior to 1 could predict a benign nature and less aggressive behavior, and a minimally invasive approach was performed. A ratio superior to 1 suggested a malignant and aggressive behavior, and a median sternotomy (or a thoracotomy) was performed. Results: There were 15 male (mean age 44.6 ± 16.26 years, range 25-73) and 15 female patients (mean age 50.1 ± 16.94 years, range 25-76). When the ratio is inferior to 1, it predicts benign disease in 80% of cases. When it is superior to 1, it predicts in half of cases advanced histological types (high risk thymomas and thymic carcinomas). On the contrary, it can quite accurately predict advanced Masaoka-Koga stages. Conclusions: The protocol of this study is in accordance with the current literature showing the utility of 18FDG PET scan in the treatment of thymic epithelial tumors. This study goes one step further since the choice of surgical access is based on the SUVmax values. The ratio SUVmax of the lesion/SUVmax of the mediastinal tissues could be a new marker, more pertinent than absolute SUVmax values.

Failure properties of ascending thoracic aortic aneurysms with dysfunctional tricuspid aortic valves.

OBJECTIVES: Ascending thoracic aortic aneurysms (ATAAs) often coexist with dysfunctional tricuspid aortic valves (TAVs). How valvular pathology relates to the aortic wall mechanical properties requires detailed examination. METHODS: Intact-wall and layer-specific mechanical properties from 40 and 21 patients with TAV-ATAAs, respectively, were studied using uniaxial tensile testing, longitudinally and circumferentially. Failure stress (tensile strength), failure stretch (extensibility) and peak elastic modulus (stiffness) measurements, along with histological assays of thickness and elastin/collagen contents, were compared among patients with no valvular pathology (NVP), aortic stenosis (AS) or aortic insufficiency (AI). RESULTS: Intact-wall stiffness longitudinally and medial strength and stiffness, in either direction, were significantly lower in AI patients than in AS and NVP patients. Intact-wall/medial thickness and extensibility in either direction were significantly lower in AS patients than in AI and NVP patients. In contrast, intact-wall/medial stiffness circumferentially was significantly higher in AS patients than in NVP patients, consistent with the significantly increased medial collagen in AS patients. Failure properties and medial thickness and elastin/collagen contents were significantly lower (more impaired) in females. The left lateral was the thickest quadrant in NVP patients, but the 4 quadrants were equally thick in AS and AI patients. There were significant differences in strength and stiffness among quadrants, which varied however in the 3 patient groups. CONCLUSIONS: The aortic wall load-bearing capacity was impaired in patients with ATAA in the presence of TAV stenosis or insufficiency. These findings lend biomechanical support to the current guidelines suggesting lower thresholds for elective ascending aorta replacement in cases of aortic valve surgery.

Regional distribution of delamination strength in ascending thoracic aortic aneurysms.

Considering that the biomechanical factors underlying aortic dissection remain poorly understood as does the rationale for the anatomic localization of the dissection channel, we have attempted to determine the regional distribution of delamination/tensile strengths of ascending thoracic aortic aneurysm wall tissue. Whole aneurysms were taken from seventeen patients undergoing elective surgery and cut into a couple of specimens per quadrant and direction. The specimens were subjected to delamination- and tensile-testing, from which average peel tension (=delamination strength) and failure stress (=tensile strength) were assessed. Histology revealed no differences with region and direction in the roughness of the delaminated surfaces of the inner (intima with most of media) and outer layers (leftover media with adventitia). Compared to the right, the left lateral region exhibited significantly higher thickness and peel tension in both directions, but lower failure stress of the inner and outer layers longitudinally. Failure stress of the inner layers mostly but also of the outer layers was significantly higher circumferentially than longitudinally, with significantly higher values for the outer compared to the inner layers. Differing heterogeneity was evidenced in the delamination and tensile strength of aneurysmal tissue, with important implications for dissection propagation. Particularly, the increased resistance to propagation in the left lateral region helps address the question why part of the circumference, characteristically the right lateral wall, is involved by the dissection and the other part of the aortic wall remains intact. The deterioration of delamination strength with aging suggests the greater potential of aged individuals for dissection propagation.

Identification of regional/layer differences in failure properties and thickness as important biomechanical factors responsible for the initiation of aortic dissections.

Thoracic aortic dissections involving the ascending aorta represent one of the most dramatic and lethal emergencies in cardiovascular surgery. It is therefore critical to identify the mechanisms driving them and biomechanical analyses hold great clinical promise, since rupture/dissection occur when aortic wall strength is unable to withstand hemodynamic stresses. Although several studies have been done on the biomechanical properties of thoracic aortic aneurysms, few data are available about thoracic aortic dissections. Detailed mechanical tests with measurement of tissue thickness and failure properties were performed with a tensile-testing device on 445 standardized specimens, corresponding to 19 measurement sites per inner (intima with most of media)/outer layer (leftover media with adventitia); harvested from twelve patients undergoing emergent surgical repair for type A dissection. Our data suggested inherent differences in tissue properties between the origin of dissection and distal locations, i.e. thinner and stiffer inner layers that might render them more vulnerable to tearing despite their increased strength. The strength of tissue circumferentially was greater than that longitudinally, likely determining the direction of tear. The relative strengths of the inner: ∼{65,40}N/cm2 and outer layer: ∼{350,270}N/cm2 in the two principal directions of dissected tissue were differentiated from the intima: ∼{100,75}N/cm2, media: ∼{150,55}N/cm2, and adventitia: ∼{270,190}N/cm2 of non-dissected ascending aortic aneurysms (Sokolis et al., 2012), in favor of weaker inner and stronger outer layers, allowing an explanation as to why the presently-studied tissue suffered dissection, i.e. tear of the inner layers, and not rupture, i.e. full tearing across the entire wall thickness.

Effect of Aneurysm and Bicuspid Aortic Valve on Layer-Specific Ascending Aorta Mechanics.

BACKGROUND: Previous studies have not examined the participation of intimal, medial, and adventitial layers in providing mechanical strength to the ascending thoracic aortic aneurysm (ATAA) wall compared with the nonaneurysmal aorta. In this study we compared the mechanical properties of intact wall and its layers among ATAAs and nonaneurysmal aortas, with explicit consideration of the effects of valve morphology; that is, bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV), and aortic quadrant. METHODS: Whole ATAAs were taken from patients undergoing elective repair and nonaneurysmal aortas from age-matched autopsy subjects. These were cut into 2 circumferential and longitudinal tissue strips for the intact wall and its layers per quadrant, permitting examination of the aortic wall as a multilayered structure. Tissue underwent tensile testing for determination of failure properties. RESULTS: Intact wall and layer-specific failure stretches (ie, extensibilities) were significantly greater in nonaneurysmal and BAV-ATAA than in TAV-ATAA, unaccounted for by elastin/collagen content changes. Intact wall failure stress (ie, strength) was significantly greater in BAV-ATAA than in TAV-ATAA, in analogy with medial failure stress. Failure stress and stretch associated negatively with age in most subject groups, layers, and intact wall, but failure stretch correlated positively with residual stretch (ie, structural bonds between layers). CONCLUSIONS: No mechanical vulnerability of BAV-ATAA was found, corroborating current conservative guidelines regarding the management of bicuspid aortopathy. Weakening and added vulnerability was found in patients with valvular deficiency, aortic root aneurysm, hypertension, and hyperlipidemia. Aging led to increased susceptibility to dissection initiation or full rupture, or both, in both patient classes.