Electrocardiogram alterations in non-traumatic brain injury: a systematic review.

The presence of abnormal electrocardiograms in individuals without known organic heart disease is one of the most common manifestations of cardiac dysfunction occurring during acute non traumatic brain injury. The primary goal of the present review is to provide an overview of the available data and literature regarding the presence of new-onset electrocardiographic (ECG) alterations in acute non traumatic brain injury. The secondary aim is to identify the incidence of ECG alterations and consider the prognostic significance of new-onset ECG changes in this setting. To do so, English language articles from January 2000 to January 2022 were included from PubMed using the following keywords: "electrocardiogram and subarachnoid hemorrhage", "electrocardiogram and intracranial hemorrhage", "Q-T interval and subarachnoid hemorrhage ", "Q-T interval and intracranial bleeding ", "Q-T interval and intracranial hemorrhage", and "brain and heart- interaction in stroke". Of 3162 papers, 27 original trials looking at electrocardiogram alterations in acute brain injury were included following the PRISMA guideline. ECG abnormalities associated with acute brain injury could potentially predict poor patient outcomes. They could even herald the future development of neurogenic pulmonary edema (NPE), delayed cerebral ischemia (DCI), and even in-hospital death. In particular, patients with SAH are at increased risk of having severe ventricular dysrhythmias. These may contribute to a high mortality rate and to poor functional outcome at 3 months. The current data on ECG QT dispersion and mortality appear less clearly associated. While some patients demonstrated poor outcomes, others showed no relationship with poor outcomes or increased in-hospital mortality. Observing ECG alterations carefully after cerebral damage is important in the critical care of these patients as it can expose preexisting myocardial disease and change prognosis.

Timing, positioning and ancillary therapies: the triad for successful Impella RP.

Clear clinical guidelines for the assessment and treatment of right ventricular failure (RVF) remain an unmet need. Although high complexity patients are common in this setting, the ideal management remains uncertain, resulting in high mortality rates despite presumably optimal medical therapy. Timely treatment with Impella RP may offer benefits by supplying circulatory support during the acute RVF phase and providing the time and unloading necessary for native right heart recovery. As such, mastering the technicalities and ancillary therapies is crucial to best utilize this salvage opportunity, particularly in these high complexity patients. Here, we report three different clinical scenarios of medically refractory RVF supported with Impella RP to provide examples and discuss the contribution of mechanical RV support to patient outcomes.

Cerebral Perfusion and Neuromonitoring during Complex Aortic Arch Surgery: A Narrative Review.

Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed.

Impella 5.0/5.5 Implantation via Innominate Artery: Further Expanding the Opportunities for Temporary Mechanical Circulatory Support.

When axillary/subclavian arteries are not suitable because of size or anatomy, alternative access for the Impella pump 5.0/5.5 via the innominate artery allows circulatory support and eventually de-escalation from VA-ECMO to isolated left-side support. Moreover, less invasive surgery without the need to open the pericardium reduces the risk of RV dysfunction and bleeding. Finally, upper body strategies allow early rehabilitation during support, which is associated with improved survival in cardiogenic shock.

Surgical embolectomy in a 34-week pregnant woman with high risk pulmonary embolism and haemodynamic instability.

Pulmonary embolism represents the leading cause of maternal mortality in developed countries. The optimal treatment of high-risk pulmonary embolism with cardiovascular instability and at high hemorrhagic risk is still debated but surgical embolectomy represents an effective option. We describe the case of a 35-year-old woman in week 34 of pregnancy who was referred to our hospital because of exertional dyspnea and tachycardia and a few hours later became hypotensive and hypoxic. Pulmonary embolism was detected by performing an angio-computed tomography (CT) scan. After a successful cesarean section, emergent embolectomy was performed without inducing uterine hemorrhage. Both mother and the newborn recovered without postoperative sequelae.

Optimal Management of Patients Treated With Minimally Invasive Cardiac Surgery in the Era of Enhanced Recovery After Surgery and Fast-Track Protocols: A Narrative Review.

OBJECTIVES: Use of minimally invasive cardiac surgery (MICS) is increasing, but to exert its maximum effect on patient outcomes, MICS must be coupled with improved perioperative management, including the Enhanced Recovery after Surgery (ERAS) and fast-track protocols. This study aimed to evaluate the impact of ERAS and fast track in this context. DESIGN: NARRATIVE REVIEW: The authors performed a narrative review that included patients treated with MICS and patients treated with the ERAS/fast-track protocols in the MEDLINE/PubMed database. The keywords ERAS and fast-track were combined with the following key words: minimally invasive cardiac surgery OR robotic cardiac surgery OR minimally invasive mitral surgery OR minimally invasive aortic surgery. RESULTS: Overall, the authors selected six studies in which either the ERAS or fast-track protocol was applied. The reported adherence to ERAS protocols was high, and neither protocol-related complications nor in-hospital mortality occurred. Patients managed based on ERAS had significantly lower postoperative pain scores, fewer rates of blood transfusions, and shorter hospital and intensive care unit stays compared with those who received standard management. All ERAS patients were managed safely, with early extubation. Similarly, fast-track cardiac surgery, with immediate postprocedure extubation and early transfer to the ward, was shown to be safe, with no increased morbidity or mortality. CONCLUSION: Use of standardized ERAS and fast-track protocols seems to be feasible and safe in the context of MICS, with improved outcomes. Both ERAS and fast track allow for a faster return to full functional status while minimizing perioperative complications.

Prognostic value of SARS-CoV-2 on patients undergoing cardiac surgery.

OBJECTIVE: To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID-19) status. METHODS: From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID-19 status, 1306 (96.5%) were negative to SARS-CoV-2 (COVID-N), and 48 (3.5%) were positive to SARS-CoV-2 (COVID-P); among the COVID-P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non-CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID-N (10.4% vs. 2.5%, p = .01). RESULTS: Overall in-hospital mortality was 1.6% (22 cases), being significantly higher in COVID-P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID-P condition as a predictor of in-hospital mortality together with emergency status. In the COVID-P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in-hospital mortality. CONCLUSION: As expected, SARS-CoV-2 infection, either before or soon after cardiac surgery significantly increases in-hospital mortality. Moreover, among COVID-19-positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.

Partially Resorbable Mesh Inclusion between Dissected Layers during Surgical Repair of Aortic Dissection.

Surgical management of aortic dissection is technically challenging for different reasons. Reapproximation of dissected layers because of fragility of the dissected aortic wall layers is of major concern. Many techniques have been described to restore the integrity of aortic wall. Inclusion of a partially resorbable mesh fixed with glue, between the dissected layers, may be a simple and effective method for providing a secure and viable end-to-end anastomosis between aortic stump and a Dacron graft.

Direct proximal right subclavian artery cannulation during surgery of the thoracic aorta.

OBJECTIVE: To evaluate outcomes of single sternum access for right subclavian artery cannulation without infraclavicular incision in surgery of the thoracic aorta. METHODS: Between January 2015 and December 2019, 44 consecutive patients underwent surgery of the thoracic aorta with cannulation of the right subclavian artery, after sternotomy and before pericardiotomy, through a direct percutaneous cannula with a single access without additional infraclavicular skin incision. The indication for surgery was type A acute aortic dissection in 29 patients (65.9%), proximal aortic aneurysm in 11 (25%), and aneurysm of the aortic arch in 4 (9%). Operative procedures were replacement of the ascending aorta in 23 patients, Bentall procedure in 10, hemiarch replacement in 6, and total arch replacement in 5. The mean cardiopulmonary bypass (CPB) and cross-clamp times were 185 ± 62 minutes and 138 ± 41 minutes, respectively. RESULTS: The in-hospital mortality rate was 6.8%. Permanent neurologic dysfunction occurred in 3 patients (6.8%) and temporary neurologic dysfunction occurred in 4 patients (9.0%). There were no vascular complications related to this technique. No lesions to the vagus and recurrent laryngeal nerves have been reported. CONCLUSIONS: In our experience, a single sternum access for right subclavian artery cannulation avoids the risk and complications of an infraclavicular incision required for axillary artery cannulation. This technique is safe and represent a valid option for CBP and antegrade cerebral perfusion during surgery of the thoracic aorta.

Invasive strategy for COVID patients presenting with acute coronary syndrome: The first multicenter Italian experience.

OBJECTIVE: To report our initial experience of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)/acute coronary syndrome (ACS) patients undergoing standard of care invasive management. BACKGROUND: The rapid diffusion of the SARS-CoV-2 together with the need for isolation for infected patients might be responsible for a suboptimal treatment for SARS-CoV-2 ACS patients. Recently, the group of Sichuan published a protocol for COVID/ACS infected patients that see the thrombolysis as the gold standard of care. METHODS: We enrolled 31 consecutive patients affected by SARS-COV-2 admitted to our emergencies room for suspected ACS. RESULTS: All patients underwent urgent coronary angiography and percutaneous coronary intervention (PCI) when required except two patients with severe hypoxemia and unstable hemodynamic condition that were conservatively treated. Twenty-one cases presented diffuse ST-segment depression while in the remaining cases anterior and inferior ST-elevation was present in four and six cases, respectively. PCI was performed in all cases expect two that were diagnosed as suspected myocarditis because of the absence of severe coronary disease and three with apical ballooning at ventriculography diagnostic for Tako-Tsubo syndromes. Two patients conservatively treated died. The remaining patients undergoing PCI survived except one that required endotracheal intubation (ETI) and died at Day 6. ETI was required in five more patients while in the remaining cases CPAP was used for respiratory support. CONCLUSIONS: Urgent PCI for ACS is often required in SARS-CoV-2 patients improving the prognosis in all but the most advanced patients. Complete patient history and examination, routine ECG monitoring, echocardiography, and careful evaluation of changes in cardiac enzymes should be part of the regular assessment procedures also in dedicated COVID positive units.

Early cardiac rehabilitation: could it improve functional outcomes and reduce length of stay and sanitary costs in patients aged 75 years or older? A retrospective case-control study.

BACKGROUND: Cardiac rehabilitation (CR) is considered as a cornerstone in improving physical function in older people after cardiac procedures; however, its effects in patients aged more than 75 years are still debated. AIMS: To assess the effectiveness of early CR in improving functional outcomes and reducing the length of stay (LOS) and sanitary costs in patients aged ≥ 75 years. METHODS: We retrospectively analysed data from medical records of patients aged ≥ 75 years performed CR after cardiac procedures. Patients were divided into two groups according to the median timing lasting from the cardiac procedure and CR start: 'early rehabilitation' (< 8 days) and 'delayed rehabilitation' (≥ 8 days). Six-minutes walking test (6MWT), left ventricular ejection fraction (LVEF), LOS, and sanitary costs were assessed. RESULTS: The 160 patients (mean aged 79.18 ± 3.13 years) included were divided into two groups: 'early rehabilitation' (n = 80) and 'delayed rehabilitation' (n = 80). Both groups showed a significant improvement (p < 0.0001) in 6MWT and LVEF but there were no differences between groups in all clinical outcomes. On the other hand, the 'early rehabilitation' group showed significantly lower LOS (25.8 ± 5.3 vs 34.1 ± 10.8 days; p < 0.0001) and sanitary costs (22,282.08 ± 3242.68 euros vs. 44,954.03 ± 22,160.11 euros; p < 0.0001). DISCUSSION: Beginning CR in the first week seems to be effective in improving physical performance after cardiac procedures in patients aged ≥ 75 years, reducing LOS and sanitary costs. CONCLUSIONS: Our findings suggest that early CR could be performed with positive effects on functional outcomes, leading to a reduction in LOS and sanitary costs in elderly.

Right subclavian artery cannulation for aortic dissection surgery, without infraclavicular incision.

The choice of arterial cannulation strategy for acute type A dissection surgery remains a controversial  issue and a subject of great debate because of its impact on clinical outcomes. A review of retrospective studies shows that surgeons are tending to switch from a retrograde to an antegrade perfusion strategy. Innominate artery cannulation has a number of advantages when compared to other cannulation techniques; however when the vessel is dissected, the proximal right subclavian artery can be used for arterial return. Also, because cannulation of the right subclavian artery does not require a second surgical incision in addition to median sternotomy, this decreases the number of incision sites and further simplifies the procedure.

Gut Alterations in Septic Patients: A Biochemical Literature Review.

BACKGROUND: Sepsis is a life-threatening organ dysfunction with high mortality and morbidity rate and with the disease progression many alterations are observed in different organs. The gastrointestinal tract is often damaged during sepsis and septic shock and main symptoms are related to increased permeability, bacterial translocation and malabsorption. These intestinal alterations can be both cause and effect of sepsis. OBJECTIVE: The aim of this review is to analyze different pathways that lead to intestinal alteration in sepsis and to explore the most common methods for intestinal permeability measurement and, at the same time to evaluate if their use permit to identify patients at high risk of sepsis and eventually to estimate the prognosis. MATERIAL AND METHODS: The peer-reviewed articles analyzed were selected from PubMed databases using the keywords "sepsis" "gut alteration", "bowel permeability", "gut alteration", "bacterial translocation", "gut permeability tests", "gut inflammation". Among the 321 papers identified, 190 articles were selected, after title - abstract examination and removing the duplicates and studies on pediatric population,only 105 articles relating to sepsis and gut alterations were analyzed. RESULTS: Integrity of the intestinal barrier plays a key role in the preventing of bacterial translocation and gut alteration related to sepsis. It is obvious that this dysfunction of the small intestine can have serious consequences and the early identification of patients at risk - to develop malabsorption or already malnourished - is very recommended to increase the survivor rate. Until now, in critical patients, the dosage of citrullinemia is easily applied test in clinical setting, in fact, it is relatively easy to administer and allows to accurately assess the functionality of enterocytes. CONCLUSION: The sepsis can have an important impact on the gastrointestinal function. In addition, the alteration of the permeability can become a source of systemic infection. At the moment, biological damage markers are not specific, but the dosage of LPS, citrulline, lactulose/mannitol test, FABP and fecal calprotectin are becoming an excellent alternative with high specificity and sensitivity.

Bedside Cardiac Pocus in Emergency Setting: A Practice Review.

BACKGROUND: In the last years, ultrasound technology has entered clinical practice as a tank and today, it has also allowed no-cardiologists to extend their medical examination without needing to call the consultant and having a good profile of diagnostic accuracy. The ultrasound bedside does not replace the consultant, but it allows not to perform inappropriate consultations with more savings for hospitals. OBJECTIVE: The aim was to review the recently published literature to inform the clinician about the most up to date management of use bedside echography in the emergency setting. In this short review, we focused on two types of syndromes, no traumatic- hypotension and dyspnea, common to the three holistic disciplines of medicine, showing the main and basic questions and answers that ultrasound can give us for rapid identification of the problems. METHODS: We conducted a systematic review using Pubmed/Medline, Ovid/Willey and Cochrane Library, combining key terms such as "cardiac ultrasound, "cardiac diseases", "emergency medicine", "pocus", "dyspnea", " hypotension". We selected the most relevant clinical trials and review articles (excluding case reports) published in the last 19 years and in our opinion, 59 publications appeared to be the best choice according to the PRISMA statement. In additional papers identified from individual article reference lists were also included. CONCLUSION: Recent studies have shown a promise in establishing best practices for evaluation of heart, lung abdomen and deep vessels At the moment, bedside US is widely used in an integrated ultrasound vision just like the holistic view have internal medicine, intensive care and emergency medicine and many medical schools in Europe and the USA are inserting ultrasonography into the core curriculum, but we still have to find a standard method for the training program for minimum competence acquisition.

Acute Pulmonary Embolism in SARS-CoV-2 Infection Treated With Surgical Embolectomy.

A cluster of pneumonia cases caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly throughout China, Europe, and the United States. The pneumonia might evolve to acute respiratory distress syndrome, requiring assisted mechanical ventilation. The prolonged immobilization combined with respiratory failure, sepsis, and dehydration might expose SARS-CoV-2 patients to increased risk of complication, including pulmonary embolism. We report a case of SARS-CoV-2 complicated by a massive pulmonary embolism in a patient who underwent successful surgical embolectomy. We believe that maintaining the same proactive attitude suggested by current European Society of Cardiology and European Respiratory Society guidelines might help in reducing morality and improving survival in SARS-COV-2 patients.

Decrease and Delay in Hospitalization for Acute Coronary Syndromes During the 2020 SARS-CoV-2 Pandemic.

The diffusion of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) forced the Italian population to restrictive measures that modified patients' responses to non-SARS-CoV-2 medical conditions. We evaluated all patients with acute coronary syndromes admitted in 3 high-volume hospitals during the first month of SARS-CoV-2 Italian-outbreak and compared them with patients with ACS admitted during the same period 1 year before. Hospitalization for ACS decreased from 162 patients in 2019 to 84 patients in 2020. In 2020, both door-to-balloon and symptoms-to-percutaneous coronary intervention were longer, and admission levels of high-sensitive cardiac troponin I were higher. They had a lower discharged residual left-ventricular function and an increased predicted late cardiovascular mortality based on their Global Registry of Acute Coronary Events (GRACE) scores.

Clinical Experience with Very High-Pressure Dilatation for Resistant Coronary Lesions.

BACKGROUND: Calcific coronary lesions can be so resistant to prevent symmetric stent dilatation with high risk of ISR/thrombosis. The aim of the current study is to evaluate the safety and efficacy of super high-pressure dilatation (>30-to-45Atm) using a dedicated NC-balloon (OPN, SIS-Medical-AG, Winterthur-Switzerland). METHODS: We retrospectively evaluated 326 consecutive undilatable lesions in which conventional NC-balloons failed to achieve adequate post-dilatation luminal gain. After the failed attempt an OPN-balloon was inflated up to achieve a uniform balloon expansion (maximal dilatation pressure of 45-50 Atm). Lesions were divided into two groups according to the final inflation pressure: Group-I: lesion responsive to 30-40Atm and Group-2:>40 Atm. Angiographic success was defined as residual angiographic stenosis<30% assessed by visual estimation with TIMI3-flow. Procedural success was defined as the achievement of angiographic success without any MACE. RESULTS: Angiographic success was achieved in 97.5%, procedural success in 96.6%; 53% of the lesions were responsive to a slower inflation pressure (Group I) while in the remaining 47%, the optimal expansion required a pressure > 40ATM (Group II). In 3 patients coronary rupture occurred after balloon inflation and was successfully treated with stent implantation with a final TIMI3-flow. The OPN alone was able to achieve adequate expansion in >90%. 0.9% days MACE were reported. CONCLUSION: The OPN-dedicated high-pressure balloon provides an effective and safe strategy for treatment of severe resistant coronary lesions.

Percutaneous or Side-Arm Graft Right Subclavian Artery Cannulation via Median Sternotomy.

Several cannulation sites alternative to the ascending aorta, such as femoral, right axillary, carotid, innominate artery, and, less commonly, apical sites, have been proposed. Cannulation of the right subclavian artery, through sternotomy, is one possible means of establishing cardiopulmonary bypass, hence avoiding a second surgical incision. In our experience, cardiopulmonary bypass flow was adequate and circulatory arrest with antegrade cerebral perfusion was successfully performed in all cases. There was no in-hospital mortality.

One-stage transmediastinal surgical approach for extensive aortic pathology.

"One-stage" transmediastinal replacement of the thoracic aorta provides an alternative treatment to single or multiple stage hybrid procedures for patients with ascending, arch, and descending thoracic aorta aneurysm. The patient is placed on bypass and cooled. During circulatory arrest, after surgical treatment of the aortic valve and root where appropriate, the entire ascending aorta is excised and the transverse arch is opened longitudinally. The heart is retracted cephalad and the left pleural cavity is entered longitudinally. The descending aorta is exposed through the posterior pericardium and opened transversely. After supra-aortic vessel reimplantation, a quadrifurcated Dacron graft is pulled into thorax behind the left lung, towards the hilum, and anastomosed to the descending thoracic aorta in an end-to-end fashion at the level of the transverse aortotomy. This anastomosis effectively seals the descending thoracic aorta. A Dacron patch is used also to close the upper descending aorta. The proximal graft is then sewn to the ascending aorta. The patient is rewarmed and weaned from cardiopulmonary bypass.