Advanced Respiratory Failure Requiring Tracheostomy-A Marker of Unfavourable Prognosis after Heart Transplantation.

Advanced respiratory failure with tracheostomy requirement is common in heart recipients. The aim of the study is to assess the tracheostomy rate after orthotopic heart transplantation and identify the subgroups of patients with the highest need for tracheostomy and these groups' association with mortality at a single centre through a retrospective analysis of 140 consecutive patients transplanted between December 2012 and July 2018. As many as 28.6% heart recipients suffered from advanced respiratory failure with a need for tracheostomy that was performed after a median time of 11.5 days post-transplant. Tracheostomy was associated with a history of stroke (OR 3.4; 95% CI) 1.32-8.86; p = 0.012), previous sternotomy (OR 2.5; 95% CI 1.18-5.32; p = 0.017), longer cardiopulmonary bypass time (OR 1.01; 95% CI 1.00-1.01; p = 0.007) as well as primary graft failure (OR 6.79; 95% CI2.93-15.71; p < 0.001), need of renal replacement therapy (OR 19.2; 95% 2.53-146; p = 0.004) and daily mean SOFA score up to 72 h (OR 1.50; 95% 1.23-1.71; p < 0.01). One-year mortality was significantly higher in patients requiring a tracheostomy vs. those not requiring one during their hospital stay (50% vs. 16%, p < 0.001). The need for tracheostomy in heart transplant recipients was 30% in our study. Advanced respiratory failure was associated with over 3-fold greater 1-year mortality. Thus, tracheostomy placement may be regarded as a marker of unfavourable prognosis.

Safety of tracheostomy during extracorporeal membrane oxygenation support: A single-center experience.

BACKGROUND: Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients. METHODS: This is a retrospective observational single-center study. RESULTS: Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V-V ECMO support over an 8-year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3-40.1) vs 37.2 (26.5-53.2) days, p = 0.013] and a shorter ECMO-to-tracheostomy time [13.3 (8.5-19.7) vs 27.8 (16.3-36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V-V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID-19, who did not show significantly higher rates of major bleeding when compared to non-COVID-19 patients (p = 0.297). Within the COVID-19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0). CONCLUSIONS: Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID-19 patients, if relevant clinical expertise is available.

Comparison of outcomes between aortic root replacement and supra-coronary interposition graft for type A aortic dissection: A retrospective case series.

BACKGROUND: The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardized practice. This single-center retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD. METHODS: Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into two groups: (a) ascending aorta (interposition) graft (AAG) without valve replacement and (b) nonvalve-sparing aortic root replacement (ARR). Preoperative covariates were compared, as well as operative characteristics and postoperative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis. RESULTS: In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, nine developed severe aortic regurgitation and two patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p = .004). CONCLUSIONS: With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Prognostic significance of serum lactate following cardiac transplantation.

Aim: Hyperlactatemia is common post-heart transplantation. Lactate measurements in the first 24 h were analyzed with respect to mortality. Methods: A total of 153 consecutive cardiac transplant patients were reviewed. Recipients of organs maintained in a state of ex vivo perfusion were included. Results: A total of 143 heart recipients were included. Hyperlactatemia (>2 mmol/l) was present in all patients. Despite maximum lactate and lactate clearance being significantly higher in nonsurvivors (p = 0.002, p = 0.004), neither receiver operator curve analysis nor multivariate logistic regression showed association with 1-year mortality. In comparison, the minimum lactate was significantly associated with mortality (area under the curve 0.728 [p < 0.001]; odds ratio 1.28 [95% 1.01-162; p = 0.04]). Conclusion: The minimum lactate, a surrogate of persistent hyperlactatemia, was demonstrated to be superior compared with maximum lactate and lactate clearance in determining patient prognosis.

Utility of echocardiographic right ventricular subcostal strain in critical care.

AIMS: Right ventricular (RV) strain is a known predictor of outcomes in various heart and lung pathologies but has been considered too technically challenging for routine use in critical care. We examined whether RV strain acquired from the subcostal view, frequently more accessible in the critically ill, is an alternative to conventionally derived RV strain in intensive care. METHODS AND RESULTS: RV strain data were acquired from apical and subcostal views on transthoracic echocardiography (TTE) in 94 patients (35% female), mean age 50.5 ± 15.2 years, venovenous extracorporeal membrane oxygenation (VVECMO) (44%). RV strain values from the apical (mean ± standard deviation; -20.4 ± 6.7) and subcostal views (-21.1 ± 7) were highly correlated (Pearson's r -0.89, P < 0.001). RV subcostal strain correlated moderately well with other echocardiography parameters including tricuspid annular plane systolic excursion (r -0.44, P < 0.001), RV systolic velocity (rho = -0.51, P < 0.001), fractional area change (r -0.66, P < 0.01), and RV outflow tract velocity time integral (r -0.49, P < 0.001). VVECMO was associated with higher RV subcostal strain (non-VVECMO -19.6 ± 6.7 vs. VVECMO -23.2 ± 7, P = 0.01) but not apical RV strain. On univariate analysis, RV subcostal strain was weakly associated with survival at 30 days (R2 = 0.04, P = 0.05, odds ratio =1.08) while apical RV was not (P = 0.16). CONCLUSION: RV subcostal deformation imaging is a reliable surrogate for conventionally derived strain in critical care and may in time prove to be a useful diagnostic marker in this cohort.

Cardiac Decompression by Pericardiectomy for Constrictive Pericarditis: Multimodality Imaging to Identify Patients at Risk for Prolonged Inotropic Support.

BACKGROUND: Post-pericardiectomy right ventricular (RV) failure has been reported but it remains not well-studied. To investigate imaging parameters that could predict RV function and the outcome of patients post-pericardiectomy. METHODS: We analysed data from a total of 53 CP patients undergoing pericardiectomy. Preoperative, early and at 6 months postoperative echocardiographic (echo) imaging datasets were analysed and correlated with preoperative cardiac magnetic resonance (CMR), cardiac computed tomography scans and histology. The primary endpoint of the study was RV functional status early postoperatively and at 6 months. Secondary endpoint was the need for prolonged inotropic support. RESULTS: A cause of CP was identified in 26 patients (49%). Inotropic support ≥ 48 hours was required in n = 28 (53%) of patients and was correlated with lower preoperative RV areas by echo or RV volumes by CMR (p < 0.05 for all). A pericardial score based on pericardial thickness/calcification and epicardial fat thickness had good diagnostic accuracy to identify patients requiring prolonged use of inotropes (area under the curve, 0.825; 95% confidence interval, 0.674-0.976). Pericardiectomy resulted in RV decompression and impaired RV function early postoperatively (fractional area change: 40.5% ± 8.8% preoperatively vs. 31.4% ± 10.4% early postoperatively vs. 42.5% ± 10.2% at 6 months, p < 0.001). CONCLUSIONS: We show that a smaller RV cavity size and a pericardial scoring system are associated with prolonged inotropic support in CP patients undergoing pericardiectomy. RV systolic impairment post decompression is present in most patients, but it is only transient.

Right ventricular dysfunction in critically ill COVID-19 ARDS.

AIMS: Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS). METHODS: Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data. RESULTS: Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0-81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3-93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0-33.9), RVS' (11.9%, 95% CI 6.6-20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6-49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028). CONCLUSIONS: Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.

Isolated left atrial cryoablation of atrial fibrillation in conventional mitral valve surgery.

BACKGROUND: Recent trends of surgery for atrial fibrillation (AF) are towards more safe and effective energy sources, as well as to simplified sets of atrial lesions. METHODS: One hundred eighteen (mean age, 67.4 ± 9.2 years) selected patients with paroxysmal/persistent AF and mitral valve (MV) disease underwent cryoablation of AF combined with conventional (not via mini-thoracotomy) MV surgery; the lesion set was limited to only the left atrium. Multivariable analyses identified predictors of cardiac rhythm at hospital discharge and follow-up. RESULTS: There were 7 (5.9%) hospital deaths; 33 (28%) patients were discharged on AF. Higher values of preoperative left atrial volume index (odds ratio [OR] = 1.07, 95% confidence interval [95%CI]: 1.01-1.13) and mixed etiology of MV disease (OR = 4.19, 95%CI: 1.23-14.2) were predictors of hospital discharge on AF. Seventy-four (66.7%) patients were on stable sinus rhythm at follow-up (median period, 6.6 years); the 1, 5, and 10-year nonparametric estimates of adjusted freedom from AF were 98.1%, 89.2% and 45.6%, respectively. Higher values of preoperative systolic pulmonary artery pressure (hazard ratio [HR] = HR = 1.04, 95%CI: 1.01-1.08) and AF at hospital discharge (HR = 4.14, 95%CI: 1.50-11.4) were predictors of AF at follow-up. CONCLUSIONS: During conventional MV surgery, a cryo-lesion set limited to only the left atrium may give good, immediate and long-term results. Left atrial dilation and mixed etiology of MV disease were predictors of hospital discharge on AF. Preoperative pulmonary hypertension and AF at discharge combined with an increased risk of AF at follow-up.

Supravalvular mitral remnant: The other side of the valve.

We report a challenging clinical case of an atypical supravalvular mitral remnant in recent mitral and aortic valve replacement with mechanical valve prostheses, associated with postoperative recurrent inflammatory episodes overlapped with difficult anticoagulation. Negative myocardial scintigraphy was associated with persistence of negative blood cultures. Serial echocardiographic evaluation was performed before and after antimicrobial treatment, and at 3 months follow-up a transesophageal echocardiography showed the persistence of the mass. Diagnostic suspect was finally confirmed.

Extensive cardiac infiltrative melanoma.

We report an unusual clinical case of a 66-year-old patient with cardiac involvement from a metastatic melanoma, causing the formation of a large right atrial mass with extensive infiltration of the right atrial free wall, the interatrial septum, the coronary sinus, and up to the mitral annulus and posterior wall of the right ventricle, unamendable to complete surgical excision. As secondary cardiac tumors are not part of routine daily clinical practice, we thought that this clinical case would be a good educational opportunity for the practicing clinicians, both specialists and nonspecialists.

Lessons of the month 1: Fatal oesophago-pericardial fistula with cerebral air embolism after elective atrial fibrillation ablation.

Oesophago-pericardial fistula following any electrophysiological procedure is a rare, and potentially, life-threatening condition. Initial presentation can easily be misdiagnosed, as symptoms vary and are not specific. Echocardiography is an invaluable tool to diagnose and rule out complications. We present the case of a 68-year-old patient who developed an oesophago-pericardial fistula complicated with purulent pericarditis, sepsis and cerebral air embolism. In conclusion, this case report encourages physicians to use strategies that may help with early diagnosis and lead to potential lifesaving interventions.

Do rebreathing manoeuvres for non-invasive measurement of cardiac output during maximum exercise test alter the main cardiopulmonary parameters?

BACKGROUND: Inert gas rebreathing has been recently described as an emergent reliable non-invasive method for cardiac output determination during exercise, allowing a relevant improvement of cardiopulmonary exercise test clinical relevance. For cardiac output measurements by inert gas rebreathing, specific respiratory manoeuvres are needed which might affect pivotal cardiopulmonary exercise test parameters, such as exercise tolerance, oxygen uptake and ventilation vs carbon dioxide output (VE/VCO2) relationship slope. METHOD: We retrospectively analysed cardiopulmonary exercise testing of 181 heart failure patients who underwent both cardiopulmonary exercise testing and cardiopulmonary exercise test+cardiac output within two months (average 16 ± 15 days). All patients were in stable clinical conditions (New York Heart Association I-III) and on optimal medical therapy. RESULTS: The majority of patients were in New York Heart Association Class I and II (78.8%), with a mean left ventricular ejection fraction of 31 ± 10%. No difference was found between the two tests in oxygen uptake at peak exercise (1101 (interquartile range 870-1418) ml/min at cardiopulmonary exercise test vs 1103 (844-1389) at cardiopulmonary exercise test-cardiac output) and at anaerobic threshold. However, anaerobic threshold and peak heart rate, peak workload (75 (58-101) watts and 64 (42-90), p < 0.01) and carbon dioxide output were significantly higher at cardiopulmonary exercise testing than at cardiopulmonary exercise test+cardiac output, whereas VE/VCO2 slope was higher at cardiopulmonary exercise test+cardiac output (30 (27-35) vs 33 (28-37), p < 0.01). CONCLUSION: The similar anaerobic threshold and peak oxygen uptake in the two tests with a lower peak workload and higher VE/VCO2 slope at cardiopulmonary exercise test+cardiac output suggest a higher respiratory work and consequent demand for respiratory muscle blood flow secondary to the ventilatory manoeuvres. Accordingly, VE/VCO2 slope and peak workload must be evaluated with caution during cardiopulmonary exercise test+cardiac output.

Clinical and prognostic impact of chronotropic incompetence in patients with hypertrophic cardiomyopathy.

BACKGROUND: A blunted heart rate (HR) response is associated with an impaired peak oxygen uptake (pVO2), a powerful outcome predictor in hypertrophic cardiomyopathy (HCM). The present multicenter study sought to determine the prognostic role for exercise-induced HR response in HCM. METHODS: A total of 681 consecutive HCM outpatients on optimized treatment were recruited. The heart failure (HF) end-point was death due to HF, cardiac transplantation, NYHA III-IV class progression, HF worsening leading to hospitalization and severe functional deterioration leading to septal reduction. The sudden cardiac death (SCD) end-point included SCD, aborted SCD and appropriate implantable cardioverter defibrillator discharges. RESULTS: During a median follow-up of 4.2 years (25-75th centile: 3.9-5.2), 81 patients reached the HF and 23 the SCD end-point. Covariates with independent effects on the HF end-point were left atrial diameter, left ventricular ejection fraction, maximal left ventricular outflow tract gradient and exercise cardiac power (ECP = pVO2∗systolic blood pressure) (C-Index = 0.807) whereas the HCM Risk-SCD score and the ECP remained associated with the SCD end-point (C-Index = 0.674). When the VO2-derived variables were not pursued, peak HR (pHR) re-entered in the multivariate HF model (C-Index = 0.777) and, marginally, in the SCD model (C-index = 0.656). A pHR = 70% of the maximum predicted resulted as the best cut-off value in predicting the HF-related events. CONCLUSIONS: The cardiopulmonary exercise test is pivotal in the HCM management, however the pHR remains a meaningful alternative parameter. A pHR < 70% identified a HCM population at high risk of HF-related events, thus calling for a reappraisal of the chronotropic incompetence threshold in HCM.

Double versus single source left-sided coronary revascularization using bilateral internal thoracic artery graft alone.

Left-sided coronary revascularization with bilateral internal thoracic artery (BITA) graft is performed usually either with an in situ (double source) or Y-graft configuration (single source). Two hundred fifty-three (mean age, 67.1 ± 9.5 years) patients underwent isolated left-sided coronary revascularization with BITA graft alone at the present authors' institution (2000-2015). Skeletonized BITA grafts were used either in an in situ (n = 199) or Y-graft configuration (n = 54). Forty pairs were identified with the propensity score-matching. Outcomes of the two groups were compared both in unmatched and matched series. Cardiopulmonary exercise testing was performed in five pairs of selected, asymptomatic matched patients having patent BITA grafts at coronary computed tomography angiography. BITA in situ patients had lower risk profiles than BITA Y-graft patients (median EuroSCORE II, 1.9 vs. 2.9%, p = 0.051). In-hospital mortality (5.6 vs. 0, p = 0.0093) and the rates of postoperative complications except deep sternal wound infection were higher in BITA Y-graft patients. However, these differences were not confirmed in matched groups. During the follow-up period (mean, 5.9 ± 4.3 years), between BITA in situ and BITA Y-graft matched patients, there were no differences in non-parametric estimates of freedom from cardiac death (p = 0.6), major adverse cardiac and cerebrovascular events (MACCEs, p = 0.65), and repeat coronary revascularization (p = 0.44). Adjusted risk estimates of MACCEs according to BITA configuration confirmed no superiority of the one configuration over the other (p ≥ 0.44). No significant differences were found at the cardiopulmonary exercise testing. Results of left-sided coronary revascularization with BITA graft alone are independent from BITA configuration, even after stress testing.

Exercise performance, haemodynamics, and respiratory pattern do not identify heart failure patients who end exercise with dyspnoea from those with fatigue.

AIMS: The two main symptoms referred by chronic heart failure (HF) patients as the causes of exercise termination during maximal cardiopulmonary exercise testing (CPET) are muscular fatigue and dyspnoea. So far, a physiological explanation why some HF patients end exercise because of dyspnoea and others because of fatigue is not available. We assessed whether patients referring dyspnoea or muscular fatigue may be distinguished by different ventilator or haemodynamic behaviours during exercise. METHODS AND RESULTS: We analysed exercise data of 170 consecutive HF patients with reduced left ventricular ejection fraction in stable clinical condition. All patients underwent maximal CPET and a second maximal CPET with measurement of cardiac output by inert gas rebreathing at peak exercise. Thirty-eight (age 65.0 ± 11.1 years) and 132 (65.1 ± 11.4 years) patients terminated CPET because of dyspnoea and fatigue, respectively. Haemodynamic and cardiorespiratory parameters were the same in fatigue and dyspnoea patients. VO2 was 10.4 ± 3.2 and 10.5 ± 3.3 mL/min/kg at the anaerobic threshold and 15.5 ± 4.8 and 15.4 ± 4.3 at peak, in fatigue and dyspnoea patients, respectively. In fatigue and dyspnoea patients, peak heart rate was 110 ± 22 and 114 ± 22 beats/min, and VE/VCO2 and VO2 /work relationship slopes were 31.2 ± 6.8 and 30.6 ± 8.2 and 10.6 ± 4.2 and 11.4 ± 5.5 L/min/W, respectively. Peak cardiac output was 6.68 ± 2.51 and 6.21 ± 2.55 L/min (P = NS for all). CONCLUSIONS: In chronic HF patients in stable clinical condition, fatigue and dyspnoea as reasons of exercise termination do not highlight different ventilatory or haemodynamic patterns during effort.

Clinical and echocardiographic predictors of long-term outcome of a large cohort of patients with bicuspid aortic valve.

BACKGROUND AND OBJECTIVES: Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation. The aim of the present article is to determine clinical and echocardiographic prognostic factors and provide a predictive model of outcome of a large cohort of patients with BAV. METHODS: We retrospectively enrolled 337 patients consecutively assessed for echocardiography at our Cardiology Department from 1993 to 2014. We considered aortic valve replacement, aortic surgery and cardiovascular death as a clinical combined end-point. Predictors of outcome were determined by Cox regression. RESULTS: Mean age was 29.2 ±â€Š19.8 years, median 27.1 years. A total of 38.4% patients presented a history of hypertension. Mean duration of follow-up was 8.4 ±â€Š6.1 years, range 0-21 years. A total of 73 patients underwent aortic valve replacement and/or aortic surgery during follow-up. Age at surgery was 45.2 ±â€Š15.6 years. Seven patients died because of cardiovascular causes. At multivariate analysis, baseline clinical predictors were history of hypertension [hazard ratio (HR) 2.289, 95% confidence interval (CI) 1.350-3.881, P = 0.002], larger ascending aortic diameter (HR 2.537, 95% CI 1.888-3.410, P < 0.001), moderate-to-severe aortic regurgitation (HR 2.266, 95% CI 1.402-3.661, P = 0.001) and moderate-to-severe aortic stenosis (HR 2.807, 95% CI 1.476-5.338, P = 0.002). A predictive model was created by integrating these four independent covariates. It allows the calculation of calculate a risk score for each patient, which helps better tailor appropriate treatment in BAV patients. CONCLUSION: At enrolment, history of hypertension, a wider aortic diameter, moderate-to-severe aortic regurgitation and aortic stenosis were independently correlated to combined end-point. Long-term follow-up showed low cardiovascular mortality (2.1%) and a high prevalence of cardiac surgery (21.6%).