Heart failure with preserved ejection fraction (HFpEF): Implications for the anesthesiologists.

Heart failure (HF) is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. American College of Cardiology Foundation / American Heart Association 2013 guidelines have classified HF into two categories: (i) HF with reduced (≤40%) ejection fraction (HFrEF) or systolic HF, and (ii) HF with preserved (≥50%) ejection fraction (HFpEF) or diastolic HF. Risk factors for HFpEF include age more than 70 years, female gender, hypertension, wide pulse pressure, diabetes mellitus, chronic renal insufficiency, left ventricular hypertrophy, atrial fibrillation, smoking, recent weight gain, and exercise intolerance. Cardiac catheterization and echocardiography are used for the confirmation of diagnosis of HFpEF. Intraoperatively, the hemodynamic goals in patients with HFpEF are avoidance of tachycardia, maintenance of sinus rhythm, and maintenance of higher than usual filling pressure. No specific treatment for HFpEF is established, and therapeutic options include an intravenous diuretic, a beta blocker or calcium channel blocker, a venodilator, and management of co-morbidities.

A feature engineering-based machine learning technique to detect and classify lung and colon cancer from histopathological images.

Globally, lung and colon cancers are among the most prevalent and lethal tumors. Early cancer identification is essential to increase the likelihood of survival. Histopathological images are considered an appropriate tool for diagnosing cancer, which is tedious and error-prone if done manually. Recently, machine learning methods based on feature engineering have gained prominence in automatic histopathological image classification. Furthermore, these methods are more interpretable than deep learning, which operates in a "black box" manner. In the medical profession, the interpretability of a technique is critical to gaining the trust of end users to adopt it. In view of the above, this work aims to create an accurate and interpretable machine-learning technique for the automated classification of lung and colon cancers from histopathology images. In the proposed approach, following the preprocessing steps, texture and color features are retrieved by utilizing the Haralick and Color histogram feature extraction algorithms, respectively. The obtained features are concatenated to form a single feature set. The three feature sets (texture, color, and combined features) are passed into the Light Gradient Boosting Machine (LightGBM) classifier for classification. And their performance is evaluated on the LC25000 dataset using hold-out and stratified 10-fold cross-validation (Stratified 10-FCV) techniques. With a test/hold-out set, the LightGBM with texture, color, and combined features classifies the lung and colon cancer images with 97.72%, 99.92%, and 100% accuracy respectively. In addition, a stratified 10-fold cross-validation method also revealed that LightGBM's combined or color features performed well, with an excellent mean auc_mu score and a low mean multi_logloss value. Thus, this proposed technique can help histologists detect and classify lung and colon histopathology images more efficiently, effectively, and economically, resulting in more productivity.

Quadricuspid Aortic Valve: Interesting Images.

ABSTRACT: The quadricuspid aortic valve is a rare congenital anomaly, usually associated with aortic regurgitation requiring surgical intervention. It may be associated with other congenital anomalies such as coronary anomalies, patent ductus arteriosus, ventricular septal defect, pulmonary stenosis, and subaortic stenosis. The diagnosis is generally established by either transthoracic or transesophageal echocardiography. Herein, we report a case of a 52-year-old woman who was diagnosed to have quadricuspid aortic valve by intraoperative transesophageal echocardiography.

Impact of intraoperative haemoadsorption on outcomes of patients undergoing aortic surgery: a single-centre, prospective, observational study.

OBJECTIVES: To investigate the impact of a cytokine haemoadsorption (HA) device (CytoSorb®) on inflammatory markers and patients' outcome during aortic root surgery. METHODS: Prospective, observational study including all-comers with quasi-randomization by strictly alternating inclusion (1:1 basis). Sixty patients undergoing elective aortic surgery were assigned to either HA group (n = 30) with intraoperative HA, or a control (C) group (n = 30). Primary outcomes were: (i) impact of HA on haemodynamic stability and need for vasopressors (vasoactive-inotropic score) and (ii) sequential organ failure assessment (SOFA) score. Secondary parameters included the impact of HA on the course of hyperinflammation using interleukin-6 and procalcitonin, duration of mechanical ventilation, and lengths of intensive care unit and hospital stay. RESULTS: Noradrenaline requirement was significantly reduced in the HA group postoperatively compared to the C group (HA: 0.03 µg/kg/min vs C: 0.08 µg/kg/min, P = 0.004 at 2 h, and HA: 0.02 µg/kg/min vs C: 0.04 µg/kg/min, P = 0.004 at 24 h). This translated into a significantly lower vasoactive-inotropic score in the HA group. SOFA score was less in the HA group at all time points and reached statistical significance 2 h postoperatively (HA: 5.77 vs C: 7.43, P < 0.001). Intraoperative HA significantly reduced interleukin-6 levels (P < 0.05) at all time points, and procalcitonin at 2 h after discontinuation from cardiopulmonary bypass (P = 0.005). The duration of ventilation, intensive care unit and hospital stays were shorter in the HA group compared to the C group. CONCLUSIONS: Intraoperative HA has the potential to mitigate hyperinflammatory response leading to improved haemodynamics after aortic root surgery, thereby shortening the duration of ventilation, and lengths of intensive care unit and hospital stay. However, it must be evaluated in larger cohorts.

Combined Bentall and modified Ravitch procedures in a patient with Marfan syndrome.

Marfan syndrome is an inherited, connective-tissue disorder transmitted as an autosomal dominant trait. Cardinal features of the disorder include tall stature, ectopia lentis, mitral valve prolapse, aortic root dilatation, and aortic dissection. Pectus excavatum may exist as an isolated lesion or in association with a genetic syndrome such as Marfan syndrome. We report the successful management of a simultaneous correction of pectus excavatum and the underlying cardiovascular diseases.

Aortic valve replacement in a patient with systemic lupus erythematosus.

Valvular heart disease in systemic lupus erythematosus (SLE) is associated with substantial morbidity and mortality. Current therapy includes symptomatic measures and valve replacement. SLE can present major challenges because of accrued organ damage, coagulation defects and complex management regimes. The peri-operative goals are to maintain strict asepsis, avoid use of nephrotoxic drugs and thereby renal insult, and to promote early ambulation post-operatively.

Absent right superior vena cava and persistent left superior vena cava: An incidental finding.

A patient with Marfan syndrome undergoing Bentall operation was found to have an absent right superior vena cava and persistent left superior vena cava. The dilation of coronary sinus raised the suspicion of persistent left superior vena cava. The diagnosis was confirmed by agitated saline contrast echocardiography and computed tomography of the chest.

Successful Extracorporeal Cytokine Hemoadsorption in a Marfan Syndrome Patient with COVID-19 Undergoing Redo Bentall Procedure.

BACKGROUND Patients with COVID-19 undergoing emergency or complex surgical procedures are at increased risk of developing perioperative complications. CytoSorb is a blood purification therapy used to remove circulating cytokines in conditions of hyperinflammation. This report is of a patient with COVID-19 requiring redo replacement of the aortic valve and aorta due to aortic aneurysm of the ascending aorta (Bentall procedure) associated with Marfan syndrome. The patient was successfully treated with extracorporeal cytokine hemoadsorption. CASE REPORT A 34-year-old man with Marfan syndrome, who had undergone a Bentall procedure in 2018, was admitted with symptoms of worsening dyspnea, tachycardia, fever, and confirmed COVID-19. Further diagnostic workup revealed dehiscence of the aortic root as well as moderate aortic regurgitation, in the context of a hyperinflammatory state. Anti-infective treatment was initiated. Given the severity of symptoms, COVID-19, echocardiography findings, and risk of aortic rupture, urgent Bentall surgery was performed. Additionally, a CytoSorb hemoadsorber was integrated into the cardiopulmonary bypass circuit to attenuate the anticipated systemic hyperinflammation. Intraoperatively, several blood products were administered due to excessive bleeding from the friable tissues and the pre-existing anemia and thrombocytopenia. Treatment was associated with marked improvements in vital parameters and inflammatory markers, and weaning from the ventilator and inotropes was possible after 48 hours. The remaining time in hospital was uneventful. CONCLUSIONS This report supports the findings from recent studies and reports that extracorporeal cytokine hemoadsorption has a role to play in reducing the systemic effects of cytokine storm associated with complex surgery involving cardiopulmonary bypass alongside severe infections, including COVID-19.

Supramitral membrane with left atrial appendage thrombus: A rare entity.

A 4-year-old child with supramitral membrane (SMM) causing severe mitral stenosis (MS) was taken for excision of the membrane. Intraoperative transesophageal echocardiography showed a large thrombus in the left atrial appendage (LAA) in addition to SMM. The case underscores the importance of this extremely rare association and prompt therapy to prevent catastrophic consequences.

Stability Issues, Probable Approaches for Stabilization and Associated Patents in the Pharmaceutical Field for Oleosome, A Novel Carrier for Drug Delivery.

Oleosomes are oil-containing micro-carriers of natural origin that are comprised of special oleosin proteins embedded with a monolayer of phospholipids having a triacylglycerol core. Due to their unique structure and non-toxicity in the biological system, these oil carriers are becoming very eye-catching for formulation development in the field of pharmacy. Consequently, oleosome offers emoliency, occlusivity, self-emulsification, anti-oxidant, and film-forming properties, which leads to controlled and sustained release of encapsulated bio-actives. It is also feasible to load oil-soluble ingredients, such as fragrance, vitamins (retinol), and lipophilic drug moieties inside the core. Being a natural carrier, it shows some stability issues (leakage of oil from the core, oxidation of the loaded oil, aggregation of oil droplets), which are controllable. In this review, we have focused on the various stability issues, the techniques (coating, surface modification, solvents) and how to overcome those problems, and how to load any lipophilic drug into the oil core, and we have also linked patent research works in the field of formulation development.

Migration and surgical retrieval of transcatheter aortic valve.

Migration of transcatheter aortic valve can occur during or after the deployment of the valve. We report a case of the migrated transcatheter aortic valve that required surgical intervention for its removal. The case highlights the importance of the availability of a cardiac surgical team and cardiopulmonary bypass machine when the percutaneous technique of retrieval is not feasible.