Activity-based protein profiling of the human failing ischemic heart reveals alterations in hydrolase activities involving the endocannabinoid system.

AIM: Acute myocardial infarction and subsequent post-infarction heart failure are among the leading causes of mortality worldwide. The endocannabinoid system has emerged as an important modulator of cardiovascular disease, however the role of endocannabinoid metabolic enzymes in heart failure is still elusive. Herein, we investigated the endocannabinoids and their metabolic enzymes in ischemic end-stage failing human hearts and non-failing controls. METHODS AND RESULTS: Quantitative real-time PCR, targeted lipidomics, and activity-based protein profiling (ABPP) enabled assessment of the endocannabinoids and their metabolic enzymes in ischemic end-stage failing human hearts and non-failing controls. Based on lipidomic analysis, two subgroups were identified within the ischemic heart failure group; the first similar to control hearts and the second with decreased levels of the endocannabinoid 2-arachidonoyl-glycerol (2-AG) and drastically increased levels of the endocannabinoid anandamide (AEA), other N-acylethanolamines (NAEs) and free fatty acids. The altered lipid profile was accompanied by strong reductions in the activity of 13 hydrolases, including the 2-AG hydrolytic enzyme monoacylglycerol lipase (MGLL). CONCLUSIONS: Our findings suggest the presence of different biological states within the ischemic heart failure group, based on alterations in the lipid and hydrolase activity profiles. In addition, this study demonstrates that ABPP is a valuable tool to rapidly analyze enzyme activity in clinical samples with potential for novel drug and biomarker discovery.

The coronary sinus interatrial connection with total unroofing coronary sinus discovered late after correction of secundum atrial septal defect.

A coronary sinus (CS) interatrial connection is a rare congenital anomaly which can be in various types from atrial septal defect type unroofing CS to the total absence of the CS. The pathology usually accompanies the left superior caval vein (LSCV) draining to CS and in case of its absence directly to the left atrium (LA). We present a 53-year-old woman after surgical correction of a secundum atrial septal defect in 1974, with a CS interatrial connection and paroxysmal atrial fibrillation (PAF). She gave a history of PAF and was admitted to our clinic due to progressive exertional intolerance, peripheral edema, and mild hypoxia (SatO2 92%) with subsequent cyanosis. Transthoracic echocardiography showed a left-to-right shunt in the posteroinferior part of the atrial septum. Computed tomography revealed a persistent LSCV draining directly into the LA, the absence of the CS, and cardiac veins draining into the LA. The right atrium (RA) and the LA were connected via a tunnel with a visible contrast passage from the left to the right side-the persisting mouth of the coronary sinus. The patient was qualified for surgical correction. A glutaraldehyde-treated autologous pericardial patch was used to construct the tunnel connecting the LSVC and the RA. The second part of the patch was used to close the atrial communication at the inferior vena cava level. The patient had an uncomplicated postoperative course and is now classified in New York Heart Association Class II.

The usefulness of cardiac CT in the diagnosis of perivalvular complications in patients with infective endocarditis.

OBJECTIVES: The aim of the study was to compare the usefulness of cardiac CT to transthoracic (TTE) and transesophageal (TEE) echocardiography in the diagnosis of infective endocarditis (IE) and perivalvular complications using surgical inspection as the gold standard. MATERIAL AND METHODS: Fifty-three consecutive patients (42 men, mean age 58.3 ± 12.5) with IE requiring surgical procedures were enrolled in the study. All patients underwent preoperative TTE, TEE, and CT. The presence of vegetations, perivalvular abscess/pseudoaneurysm, leaflet perforation, inflammatory infiltration, and prosthesis dehiscence was assessed. RESULTS: We analyzed 71 affected valves (58 native, 13 prosthetic). Intraoperative assessment revealed 11 abscesses/pseudoaneurysms. Sensitivity and specificity of echocardiography (TTE + TEE) and CT were 63%, 90% and 81%, 90%, respectively. The combination of CT and echocardiography allowed diagnosing all abscesses/pseudoaneurysms. Inflammatory infiltration was found intraoperatively in 15 patients. Sensitivity and specificity of TEE and CT were 53%, 94% and 46%, 100%, respectively. Intraoperative assessment revealed leaflet perforation in 16 patients. Sensitivity and specificity of TEE and CT were 75%, 79% and 43%, 89%. The sensitivity of the combination of TTE + TEE + CT was 81%. Perivalvular leakage was found in eight patients with a prosthetic valve. Sensitivity and specificity of echocardiography and CT were 100%, 100% and 88%, 100%, respectively. TEE showed higher sensitivity (97%) than CT (89%) in the diagnosis of vegetations. CONCLUSIONS: The combination of TTE, TEE, and CT increased the sensitivity for the detection of valvular and perivalvular complications of IE. KEY POINTS: • CT is a useful modality in the diagnosis of IE and its local complications in addition to echocardiography. • For the detection of abscesses and pseudoaneurysms, CT is superior to echocardiography. Combining these two modalities can increase the sensitivity of diagnosing abscess/pseudoaneurysm up to 100%. • Adding CT to TEE increases the sensitivity for detection of inflammatory infiltrate. CT is not superior to echocardiography in diagnosing vegetations, valvular leaflet perforations, and perivalvular leaks, but it can be a useful tool when echocardiography is indeterminate.

Outcome Prediction After Coronary Surgery and Redo Surgery for Bleeding (From the KROK Registry).

OBJECTIVES: To assess the reliability of EuroSCORE II in an entire population after isolated coronary artery surgery and separately among patients who underwent redo surgery due to bleeding, and to create a model predicting hospital death among patients who underwent redo surgery owing to bleeding. DESIGN: Retrospective study based on data from the Polish National Registry of Cardiac Surgical Procedures. SETTING: Multi-institutional study. PARTICIPANTS: The study comprised 41,353 patients who underwent isolated coronary artery surgery in Poland between January 2012 and December 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: EuroSCORE II reliability was estimated using the area under the receiver operating characteristics curve (AUC), the observed-to-expected surgical mortality ratio (O/E), and the Hosmer-Lemeshow test. Parameters of the function correcting the original EuroSCORE II were determined using the least squares method. The original score was adjusted using a created formula. Among the 41,353 patients, 1,406 (3.4%) underwent reexploration. Even though EuroSCORE II was reliable in predicting hospital mortality in the entire population (AUC 0.76, O/E ratio 1.08), it greatly underestimated mortality for patients who required reexploration (AUC 0.74, O/E ratio 4.33). In this subpopulation, the worst performance of the EuroSCORE II was noted among patients with the lowest predicted mortality (0.50%-0.82%) Accurate calibration was obtained by adding a coefficient and creating a nomogram. CONCLUSIONS: EuroSCORE II was reliable in a Polish population undergoing isolated coronary surgery. After redo surgery for bleeding, the observed mortality was much higher than in the overall coronary population, but the rate was made more accurate by adding a coefficient to the initially calculated EuroSCORE II.

Transapical Beating-Heart Mitral Valve Repair With an Expanded Polytetrafluoroethylene Cordal Implantation Device: Initial Clinical Experience.

BACKGROUND: Degenerative mitral valve (MV) disease is a common cause of severe mitral regurgitation (MR) and accounts for the majority of MV operations. Conventional MV surgery requires cardiopulmonary bypass, aortic cross-clamping, cardioplegia, and a thoracotomy or sternotomy and, therefore, is associated with significant disability, risks, and unpredictable rates of MV repair. Transesophageal echocardiography-guided beating-heart MV repair with expanded polytetrafluoroethylene cordal insertion has the potential to significantly reduce surgical morbidity. We report the first-in-human clinical experience with a novel preformed expanded polytetrafluoroethylene knot implantation device (Harpoon TSD-5) designed to treat degenerative MR. METHODS: Through a small left thoracotomy, the device was inserted into the heart and guided by transesophageal echocardiography to the ventricular surface of the prolapsed leaflet. Multiple expanded polytetrafluoroethylene cords were anchored in the leaflet and then adjusted to the correct length to restore MV leaflet coaptation and secured at the epicardium. RESULTS: Eleven patients with posterior leaflet prolapse and severe MR, with mean±SD age of 65±13 years and mean ejection fraction of 69±7%, were treated with 100% procedural success. Immediate postprocedural mean MR grade was trace. At 1 month, the mean MR grade was mild with significant decreases in end-diastolic volume (139 to 107 mL; P=0.03) and left atrial volume (118 to 85 mL; P=0.04). CONCLUSIONS: A novel device used for beating-heart image-guided MV repair demonstrates a significant reduction in MR with favorable left ventricular and left atrial reverse remodeling. This approach has the potential to decrease invasiveness and surgical morbidity. Further follow-up is necessary to assess long-term efficacy. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT02432196.

Analysis of necroptotic proteins in failing human hearts.

BACKGROUND: Cell loss and subsequent deterioration of contractile function are hallmarks of chronic heart failure (HF). While apoptosis has been investigated as a participant in the progression of HF, it is unlikely that it accounts for the total amount of non-functional tissue. In addition, there is evidence for the presence of necrotic cardiomyocytes in HF. Therefore, the objective of this study was to investigate the necroptotic proteins regulating necroptosis, a form of programmed necrosis, and thereby assess its potential role in human end-stage HF. METHODS: Left ventricular samples of healthy controls (C) and patients with end-stage HF due to myocardial infarction (CAD) or dilated cardiomyopathy (DCM) were studied. Immunoblotting for necroptotic and apoptotic markers was performed. Triton X-114 fractionated samples were analyzed to study differences in subcellular localization. RESULTS: Elevated expression of RIP1 (receptor-interacting protein), pSer227-RIP3 and its total levels were observed in HF groups compared to controls. On the other hand, caspase-8 expression, a proapoptotic protease negatively regulating necroptosis, was downregulated suggesting activation of necroptosis signaling. Total mixed-lineage kinase domain-like protein (MLKL) expression did not differ among the groups; however, active cytotoxic forms of MLKL were present in all HF samples while they were expressed at almost undetectable levels in controls. Interestingly, pThr357-MLKL unlike pSer358-MLKL, was higher in DCM than CAD. In HF, the subcellular localization of both RIP3 and pThr357-MLKL was consistent with activation of necroptosis signaling. Expression of main apoptotic markers has not indicated importance of apoptosis. CONCLUSIONS: This is the first evidence showing that human HF of CAD or DCM etiology is positive for markers of necroptosis which may be involved in the development of HF.

Red Cell Distribution Width as a Prognostic Marker in Patients Undergoing Valve Surgery.

BACKGROUND: Numerous studies have shown that elevated red cell distribution width (RDW) is associated with poor outcomes in patients with cardiovascular diseases such as acute myocardial infarction, stroke, and chronic heart failure. The prognostic utility of RDW in patients with valvular disease undergoing heart valve surgery is unknown. METHODS: A prospective study was conducted on a group of consecutive patients with hemodynamically significant valvular heart disease that underwent elective valvular surgery. The preoperative complete blood count, data on risk factors, course of operations and the postoperative period were assessed. The primary and secondary endpoints were 30-day mortality and any major adverse event within 30 days. The data were analyzed with Kaplan-Meier survival curves, regression analyses, and receiver operator characteristic (ROC) curves. RESULTS: The study group included 500 consecutive patients who underwent replacement or repair of the valve/valves. Sixteen patients died during the follow up period. On multivariate analysis, creatinine (p = 0.04), red blood cell (RBC) count (p = 0.005) and RDW (p = 0.02) were each associated with an increased risk of death. The composite endpoint occurred in 208 patients. On multivariate analysis, chronic kidney disease (p = 0.003), raised pulmonary blood pressure (p = 0.02) and RDW (p = 0.001) remained independent predictors of the secondary endpoint. The preoperative RDW in patients with valvular disease undergoing valve surgery, combined with EuroSCORE II, predicted 30-day mortality significantly better than did EuroSCORE II alone. CONCLUSIONS: An elevated RDW is associated with a worse outcome following valve surgery. The predictive ability of the RDW, when assessed by the area under the ROC curve, improved the predictive ability of the EuroSCORE II calculator.

Myostatin and IGF-I signaling in end-stage human heart failure: a qRT-PCR study.

BACKGROUND: Myostatin (Mstn) is a key regulator of heart metabolism and cardiomyocyte growth interacting tightly with insulin-like growth factor I (IGF-I) under physiological conditions. The pathological role of Mstn has also been suggested since Mstn protein was shown to be upregulated in the myocardium of end-stage heart failure. However, no data are available about the regulation of gene expression of Mstn and IGF-I in different regions of healthy or pathologic human hearts, although they both might play a crucial role in the pathomechanism of heart failure. METHODS: In the present study, heart samples were collected from left ventricles, septum and right ventricles of control healthy individuals as well as from failing hearts of dilated (DCM) or ischemic cardiomyopathic (ICM) patients. A comprehensive qRT-PCR analysis of Mstn and IGF-I signaling was carried out by measuring expression of Mstn, its receptor Activin receptor IIB (ActRIIB), IGF-I, IGF-I receptor (IGF-IR), and the negative regulator of Mstn miR-208, respectively. Moreover, we combined the measured transcript levels and created complex parameters characterizing either Mstn- or IGF-I signaling in the different regions of healthy or failing hearts. RESULTS: We have found that in healthy control hearts, the ratio of Mstn/IGF-I signaling was significantly higher in the left ventricle/septum than in the right ventricle. Moreover, Mstn transcript levels were significantly upregulated in all heart regions of DCM but not ICM patients. However, the ratio of Mstn/IGF-I signaling remained increased in the left ventricle/septum compared to the right ventricle of DCM patients (similarly to the healthy hearts). In contrast, in ICM hearts significant transcript changes were detected mainly in IGF-I signaling. In parallel with these results miR-208 showed mild upregulation in the left ventricle of both DCM and ICM hearts. CONCLUSIONS: This is the first demonstration of a spatial asymmetry in the expression pattern of Mstn/IGF-I in healthy hearts, which is likely to play a role in the different growth regulation of left vs. right ventricle. Moreover, we identified Mstn as a massively regulated gene in DCM but not in ICM as part of possible compensatory mechanisms in the failing heart.

The Usefulness of Magnetic Resonance Imaging in the Diagnosis of Infectious Endocarditis.

BACKGROUND: Whilst echocardiography is currently the 'gold standard' for the diagnosis of infective endocarditis (IE), it has certain limitations and alternative imaging methods are being sought. The study aim was assess the usefulness of cardiac magnetic resonance (CMR) imaging when diagnosing IE. METHODS: Twenty consecutive patients with diagnosed IE were included in the study. All patients underwent CMR and transthoracic echocardiography, and 16 (80%) underwent also transesophageal echocardiography. RESULTS: CMR revealed vegetations in 15 patients (75%). Following echocardiography, vegetations were identified in 19 patients (95%) and valve perforation was suspected in seven (35%); vegetations were identified by CMR in six (30%) of these patients. Echocardiography identified two patients suspected of perivalvular abscess; in one patient the abscess was diagnosed also by CMR and intraoperatively, but in the second patient neither CMR nor intraoperative examination confirmed this diagnosis. Late gadolinium enhancement (LGE) was reported at CMR in eight patients (40%), associated with an extension of the inflammatory process and myocardium infiltration. The valve insufficiency fraction allowed the degree of insufficiency of the valves affected by inflammatory processes to be estimated. A positive correlation was found between the degree of valve insufficiency assessed with CMR and echocardiography. CONCLUSIONS: CMR may serve as a useful method for diagnosing perivalvular complications in IE patients, although vegetation visualization is limited by the low spatial resolution of the method. CMR may prove superior to echocardiography in evaluating the degree of inflammatory process involvement in the myocardium. The degree of valve insufficiency and its hemodynamic significance can also be assessed.

Percutaneous Edwards SAPIEN(™) valve implantation for significant pulmonary regurgitation after previous surgical repair with a right ventricular outflow patch.

BACKGROUND: Current indications for percutaneous pulmonary valve implantation (PPVI) are limited to patients who had their outflow tracts repaired with the use of a "full" condui-homograft. Patients after a patch repair are believed to have an unfavorable anatomy for PPVI. OBJECTIVES: To evaluate a novel use of Edwards SAPIEN(TM) valve for percutaneous treatment of moderate and severe pulmonary regurgitation after tetralogy of Fallot (TF) repair with a right ventricular outflow (RVOT) patch. METHODS: PPVI was intended in 10 patients (age 21-39 years, 2 ♂) with regurgitant fraction of 30-59%, measured by cardiac magnetic resonance imaging (CMRI) 16-30 years after repair with a RVOT patch. Balloon test-inflations were used for definitive measurements and location of the landing site for the valve. All RVOTs were prestented. RESULTS: Successful valve implantation was achieved in nine patients. In one patient a bare-metal stent used for prestenting embolized into pulmonary artery. A 26-mm valve was implanted in seven and a 23-mm in two patients. CMRI at 1-2 month follow-up (n = 8) demonstrated both, sustained relief of pulmonary incompetence (regurgitant fraction = 0-14%) and significant decrease of the right ventricular end-diastolic volume indexes (from 169.9 ± 43.8 to 140.0 ± 40.3 ml/m(2) , P < 0.001). At that follow-up no adverse event occurred. No stent fractures were observed. CONCLUSIONS: We report the first case series of patients with significant PR after a RVOT patch repair, successfully treated with a percutaneous Edwards SAPIEN(TM) valve implantation. The procedure is technically feasible and may be offered to patients with the outflow tracts larger than those limited by the Melody(®) system available currently.

Extracellular Vesicles to Predict Outcomes After Transcatheter Aortic Valve Implantation - a Prospective, Multicenter Cohort Study.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is an established treatment for aortic stenosis (AS) in patients at intermediate and high surgical risk. Circulating extracellular vesicles (EVs) are nanoparticles involved in cardiovascular diseases. We aimed to (i) determine the effect of TAVI on plasma concentrations of five EV subtypes and (ii) evaluate the predictive value of EVs for post-TAVI outcomes. METHODS: Blood samples were collected 1 day before TAVI and at hospital discharge. Concentrations of EVs were evaluated using flow cytometry. RESULTS: Concentration of leukocytes EVs decreased after TAVI, compared to the measurement before (p = 0.008). Among 123 patients discharged from the hospital, 19.5% experienced MACCE during the median of 10.3 months. Increased pre-TAVI concentration of phosphatidylserine-exposing EVs was an independent predictor of MACCE in multivariable analysis (OR 5.313, 95% CI 1.164-24.258, p = 0.031). CONCLUSIONS: Patients with increased pre-TAVI concentration of procoagulant, PS-exposing EVs have over fivefold higher odds of adverse outcomes.

The association of body composition assessment with hospital length of stay in off-pump coronary artery bypass patients.

Introduction: Bioelectrical impedance analysis is a widely available, non-invasive method for body composition assessment. Aim: To elucidate the perioperative body composition alterations and their prognostic utility for hospital length of stay (LOS) in low risk, off-pump coronary artery bypass (OPCAB) patients. Material and methods: Fifty patients undergoing elective OPCAB were included in the study. Body composition assessments were performed 1 day before the scheduled surgery and on the 6th postoperative day. Patients were grouped into < 9 days (n = 29, 58%) and ≥ 9 days (n = 21, 42%). Multivariate logistic regression analysis was performed to create a body composition-based screening panel for prolonged hospital stay. Results: No significant differences in anthropometric measurements, clinical characteristics or occurrence of postoperative complications were detected between the study groups. Patients with longer hospitalization had significantly higher content of fat mass (FM%) and fat mass index (FMI), and significantly lower content of fat free mass (FFM%) baseline parameters (p = 0.011, p = 0.04 and p = 0.012, respectively). High FM% values had 15-fold, low FFM% values had 13-fold and high FMI values had 7-fold higher risk of experiencing longer stay in the hospital (p = 0.001, p = 0.001 and p = 0.005, respectively). The combined panel of three variables (higher FM%, lower FFM% and higher FMI) had 16-fold higher risk of longer hospitalization (adjusted OR = 16.40; 95% CI: 3.52-76.34; p = 0.0004). Conclusions: Preoperative high FM and low FFM content are independent predictors of prolonged hospital length of stay in normal- and increased-BMI patients after OPCAB.

Impact of previous coronary artery revascularization on outcomes in patients undergoing transcatheter aortic valve implantation.

Introduction: Coexistence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI) raises questions regarding the safety and efficacy of TAVI in this subset of patients. Aim: To evaluate the impact of previous coronary revascularization in terms of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on clinical outcomes after TAVI. Material and methods: A total of 507 consecutive patients who underwent TAVI were divided into: non-revascularization (NR), post-PCI and post-CABG groups. The endpoints were established according to VARC-2 definitions. Results: Patients with previous coronary revascularization (36.7% of the population) were younger, more often male and their EuroSCORE II risk evaluation was significantly higher (NR 7.9% vs. post-PCI 8.0% vs. post-CABG 20.5%, p < 0.0001). Patients after PCI or CABG prior to TAVI had similar 30-day all-cause mortality rates as those without coronary revascularization at baseline (NR vs. post-PCI vs. post-CABG: 8.1% vs. 5.5% vs. 6.8%, respectively; p = 0.6). There were no differences in 12-month all-cause mortality rates between groups (NR vs. post-PCI vs. post-CABG: 15.3% vs. 14.2% vs. 16.9%, respectively; log-rank p = 0.67). In the Cox proportional-hazards regression model, acute kidney injury stage 2-3 (HR = 3.7, 95% CI: 2.14-6.33; p < 0.001) and post-TAVI stroke (HR = 3.5, 95% CI: 1.57-7.8; p = 0.002) were independently correlated with 1-year mortality. Conclusions: TAVI seems to be a safe and effective procedure for the treatment of severe AS in patients with previous coronary revascularization.

Nationwide experience with transcarotid transcatheter aortic valve implantation: Insights from the POL-CAROTID registry.

BACKGROUND: The carotid artery is an alternative access route for transcatheter aortic valve implantation (TAVI), especially useful in patients unsuitable for traditional access routes including transfemoral (TF), subclavian, transapical, and aortic. AIMS: To investigate the feasibility and safety of transcarotid (TC) access for TAVI in comparison to the TF approach in a multicenter setting. METHODS: A total of 41 patients, treated between December 2014 and December 2018, were retrospectively reported to the Polish Registry of Common Carotid Artery Access for TAVI (POL-CAROTID). The median follow-up time was 619 (365-944) days, and Valve Academic Research Consortium-2 (VARC-2) definitions were applied. Clinical outcomes were compared with 41 propensity-matched TF-TAVI patients. RESULTS: The mean (standard deviation [SD]) patients' age was 78.0 (7.2) years, and 29 patients (70.7%) were men. Prohibitive iliofemoral anatomy and/or obesity (46.3%) and/or the presence of a stent graft in the abdominal aorta (31.7%) were the most common indications for TC-TAVI. Device success for TC-TAVI was comparable with the matched TF-TAVI group (90.2% vs. 95.3%, respectively, P = 0.396), and no periprocedural mortality was observed. Moreover, early safety was similar between the two groups (92.7% vs. 95.3%, respectively, log-rank P = 0.658) with only 1 case of non-disabling stroke during the first month after TC-TAVI. Consequently, no cerebrovascular events were observed in the mid-term, and the clinical efficacy of TC-TAVI corresponded well with TF-TAVI (90.2% vs. 92.7%, respectively, log-rank P = 0.716). A total of 4 (9.8%) deaths were noted in the TC-TAVI cohort in comparison to 3 (7.3%) in the TF-TAVI group. CONCLUSIONS: The results of the study indicated that the first cohort of Polish patients with implantations of second-generation transcarotid transcatheter heart valves had a similar prognosis to TF-TAVI with regard to safety and feasibility. TC access may be considered an optimal alternative for patients in whom the TF approach is precluded.

Heart team consultations for patients with severe coronary artery disease or valvular heart disease in the era of the COVID-19 pandemic: a single-center experience.

Introduction: The Heart Team (HT) as a group of experienced specialists is responsible for optimal decision-making for high-risk cardiac patients. The aim of this study was to investigate the impact of the COVID-19 pandemic on HT functioning. Methods: In this retrospective, single-center study, we evaluated the cooperation of HT in terms of the frequency of meetings, the number of consulted patients, and the trends in choosing the optimal treatment strategies for complex individuals with severe coronary artery disease (CAD) or valvular heart disease (VHD) before and during the COVID-19 pandemic in Poland. Results: From 2016 to May 2022, 301 HT meetings were held, and a total of 4,183 patients with severe CAD (2,060 patients) or severe VHD (2,123 patients) were presented. A significant decrease in the number of HT meetings and consulted patients (2019: 49 and 823 vs. 2020: 44 and 542 and 2021: 45 and 611, respectively, P < 0.001) as well as changes in treatment strategies-increase of conservative, reduction of invasive (2019: 16.7 and 51.9 patients/month vs. 2020: 20.4 and 24.8 patients/month and 2021:19.3 and 31.6 patients/month, respectively, P < 0.001)-were demonstrated with the spread of the COVID-19 pandemic. As the pandemic slowly receded, the observed changes began to return to the pre-pandemic trends. Conclusions: The COVID-19 pandemic resulted in a decrease in the number of HT meetings and consulted patients and significant reduction of invasive procedures in favor of conservative management. Further studies should be aimed to evaluate the long-term implications of this phenomenon.

ARTERIAL HYPEROXIA AND MORTALITY IN PATIENTS UNDERGOING VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION.

ABSTRACT: Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can easily lead to supranormal oxygenation. The impact of hyperoxygenation beyond the early VA-ECMO support phase is unexplored. We sought to investigate its association with short- and long-term mortality. Methods: A total of 10,615 arterial blood gases of 179 patients undergoing VA-ECMO between 2013 and 2018 in our cardiosurgical tertiary center were analyzed for partial pressure of oxygen (PaO2) and its association with in-hospital, 90-day, and 1-year mortality. Patients were stratified into terciles (T) based on PaO2. Results: The median systemic PaO2 during VA-ECMO was 122 mm Hg (Q1-Q3, 111-158 mm Hg) and was significantly higher in 90-day nonsurvivors versus survivors (134 mm Hg [Q1-Q3, 114-175 mm Hg] vs. 114 mm Hg [Q1-Q3, 109-136 mm Hg]; P < 0.001). The incidence of mortality increased at all time points tested after VA-ECMO implantation along with the increasing terciles of PaO2. The lowest mortality rates were noted for patients with median PaO2 values of <115 mm Hg (T1), whereas patients with median PaO2 values of >144 mm Hg (T3) had the highest mortality rates. Bonferroni multiple testing analysis found the T3 of PaO2 to be a predictor of decreased 90-day survival in comparison with T1 (P < 0.001) and T2 (P = 0.002). Multivariable Cox regression analyses for in-hospital, 90-day, and 1-year mortality showed a significant association of the T3 compared with the T2 and the T1 of PaO2 to mortality across all endpoints. Conclusion: Hyperoxygenation during VA-ECMO might be associated with increased all-cause mortality. The results of our study further document the known toxicity of hyperoxygenation in general critical care patients and mark the need to focus specifically on VA-ECMO patients.

Computed tomographic characteristics of congenital coronary artery fistulas in an adult population.

BACKGROUND: Coronary artery fistulas (CAFs) are usually congenital coronary artery anomalies of termination. AIMS: This study aimed to assess the prevalence, anatomic characteristics, and clinical significance of CAFs detected by computed tomography (CT) in an adult population. METHODS: We performed 45 817 CT examinations in 39 066 subjects between 2008 and 2020. The electronic database was manually checked using specific keywords to identify patients with CAFs. The CT characteristics of CAFs were evaluated. CAF was defined as clinically significant if it was the most plausible cause of myocardial infarction, infective endocarditis, heart failure, death during follow-up, hospitalization, or if it required either percutaneous or surgical intervention. RESULTS: Of 39 066 patients, 56 CAFs were detected in 42 subjects (20 men, 47.6%) with a prevalence of 0.11%. Most CAFs originated from the right coronary artery (RCA) (48.2%) and drained into the pulmonary artery (PA) (58.9%). CAFs terminating in the PA were more frequently multiple (P <0.001) and tortuous (P <0.001) as compared to CAFs without PA drainage. Clinically significant CAFs, identified in 7 of 42 patients, were more common in younger (P = 0.03) and male (P = 0.04) subjects and had larger lumen area and diameter at the site of origin (P = 0.03, P = 0.03, respectively). CONCLUSIONS: In the unselected adult population undergoing coronary CT angiography, the RCA and the PA are the most common sites of origin and termination of CAFs, respectively. CAFs draining into the PA are more often multiple and tortuous. Clinically meaningful CAFs are larger and most frequently detected in younger and male patients.