Aortic Valve Replacement with Single-Strip Autologous Pericardium.

BACKGROUND: Aortic valve replacement with mechanical valves is the standard treatment for aortic valve disease in Indonesia. Its usage is associated with high cost, risk of endocarditis and thromboembolic event, and lifetime consumption of anticoagulants. We performed a novel replacement technique of the aortic valve using an autologous pericardium and evaluated the short-term outcomes. METHODS: From April 2017 to April 2020, 16 patients underwent aortic valve replacement with a single-strip autologous pericardium. Outcomes of the left ventricular reverse remodeling (LVRR), 6-minute walk test (6MWT), and soluble suppression of tumorigenicity-2 (sST-2) were measured at 6 months postoperation. RESULTS: A total of 16 surgeries were performed using aortic valve replacement with single-strip pericardium without conversion to mechanical valve replacement. The patients included eight males and eight females, and the mean age was 49.63 ± 12.54 years. The most common diagnosis was mixed aortic valve stenosis and regurgitation (9 cases). Five patients underwent a concomitant coronary artery bypass graft (CABG) procedure and 12 patients underwent either mitral or tricuspid valve repair. The mean aortic cross-clamp time was 139.88 ± 23.21 minutes and cardiopulmonary bypass time was 174.37 ± 33.53 minutes. At 6 months postoperation, there was an increase in the distance walked at the 6MWT (p = 0.006) and a decrease of the sST-2 level (p = 0.098). Echocardiogram showed two patients had LVRR. Survival and freedom from reoperation are 100% at 1 year of follow-up. CONCLUSION: Aortic valve replacement with a single strip of pericardium is a good alternative to aortic valve replacement with a mechanical valve. Short-term evaluation at 6 months postoperation showed improvement in clinical status and echocardiographic parameters compared to baseline.

Tocilizumab as a Treatment for 'Cytokine Storm Syndrome' in COVID-19: A Case Report.

Coronavirus disease 19 (COVID-19) which is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has been a problem worldwide, particularly due to the high rate of transmission and wide range of clinical manifestations. Acute respiratory distress syndrome (ARDS) and multiorgan failure are the most common events observed in severe cases and can be fatal. Cytokine storm syndrome emerges as one of the possibilities for the development of ARDS and multiorgan failure in severe cases of COVID-19. This case report describes a case of a 53-year-old male patient who has been diagnosed with COVID-19. Further evaluation in this patient showed that there was a marked increase in IL-6 level in blood accompanied with hyperferritinemia, which was in accordance with the characteristic of cytokine storm syndrome. Patient was treated with tocilizumab, a monoclonal antibody and is an antagonist to IL-6 receptor. The binding between tocilizumab and IL-6 receptors effectively inhibit and manage cytokine storm syndrome. Although this case report reported the efficacy of tocilizumab in managing cytokine storm syndrome, tocilizumab has several adverse effects requiring close monitoring. Further clinical randomized control trial is required to evaluate the efficacy and safety of tocilizumab administration in participants with various clinical characteristics and greater number of subjects.

The Role of Acute Hyperglycemia on the Risk of Malignant Arrhythmia in Acute Myocardial Infarction Patients: A Study of Myocardial Damage, Ion Channel Changes and Inflammatory Factors.

BACKGROUND: acute myocardial infarction (AMI) is often followed by hyperglycemia. To date, there is no study that examine the role of myocardial damage, ion channel changes and increased inflammatory response as a pathomechanism of malignant arrhythmias due to hyperglycemia in AMI patients. The aim of this study is to determine the effect of acute hyperglycemia on the occurence of malignant arrhythmias, troponin I, VLP, echocardiographic strain, ion channel changes (CaMKII) and hsCRP. This study also aims to assess the effect of troponin I, VLP, GLS, CaMKII and hsCRP on the occurence of malignant arrhythmias in AMI patients with acute hyperglycemia. METHODS: a cross-sectional study followed by a cohort study was conducted on AMI patients treated at ICCU Cipto Mangunkusumo Hospital Jakarta during November 2018 to May 2019 period. Patients with severe infections and who had experienced malignant arrhythmias at admission were excluded from the study. The occurence of malignant arrhythmias as the main outcome of this study and CaMKII level were assessed on the fifth day of treatment. Patients who died before the fifth day of treatment due to causes other than malignant arrhythmias were excluded from analysis. The association between acute hyperglycemia with VLP and the occurence of malignant arrhythmias was analyzed through a chi-square test, whereas the differences between troponin I, GLS, CaMKII and hsCRP, based on the hyperglycemia status of the patient, were analyzed by Mann-Whitney U test. RESULTS: a total of 110 patients were included in the study. Two patients died on the third day of observation due to malignant arrhythmias. No significant relationship was found between acute hyperglycemia in AMI and malignant arrhythmias (RR = 1,38, 95%CI 0.50-3.77). There were differences of CaMKII level on day-1 and day-5 between those who were experienced malignant arrhytmia and those who were not (p-value for differences are 0,03 and 0,01, respectively. In the acute hyperglycemia group, there was difference of CaMKII day-5 levels between positive and negative VLP (p = 0.03). CONCLUSION: it was concluded that the inititial stage of AMI causes more dominant myocardial damage, as compared to metabolic factors. In the next stage of AMI, acute hyperglycemia increases ROS and the activation of ion channel changes described by CaMKII. This change results in electrophysiological remodeling of the heart, as seen in the VLP image on SA-ECG.

Cardiac Performance by Echocardiography, Cardiovascular Biomarker, Kidney Function, and Venous Oxygen Saturation as Mortality Predictors of Septic Shock.

BACKGROUND: cardiac function in patients with septic shock at the cellular level can be assessed by measuring troponin I and NT Pro BNP levels. Venous oxygen saturation is measured to evaluate oxygen delivery and uptake by organ tissue. Our study may provide greater knowledge and understanding on pathophysiology of cardiovascular disorder in patients with septic shock. This study aimed to evaluate the roles of echocardiography, cardiovascular biomarkers, venous oxygen saturation and renal function as predictors of mortality rate in patients with septic shock. METHODS: this is a prospective cohort study in patients with infections, hypotension (MAP < 65 mmHg) and serum lactate level of > 2 mmol/L. On the first and fifth days, septic patients underwent echocardiography and blood tests. Statistical analysis used in our study included t-test or Mann-Whitney test for numeric data and chi-square test for nominal data of two-variable groups; while for multivariate analysis, we used Cox Regression model. RESULTS: on 10 days of observation, we found 64 (58%) patients died and 47 (42%) patients survived. The mean age of patients was 48 (SD 18) years. Patients with abnormal left ventricular ejection fraction (LVEF) had 1.6 times greater risk of mortality than those with normal LVEF (RR 1.6; p = 0.034). Patients with abnormal troponin I level showed higher risk of mortality as many as 1.6 times (RR: 1.6; p = 0.004). Patients with impaired renal function had 1.5 times risk of mortality (RR 1.5; p = 0.024). Patients with abnormal troponin I level and/or impaired renal function showed increased mortality risk; however, those with normal troponin I level and impaired renal function also showed increased mortality risk. Multivariate analysis revealed that left ventricular ejection fraction and troponin I level may serve as predictors of mortality in patients with septic shock. (HR 1.99; 95% CI: 1.099  ̶  3.956 ; p = 0.047 and HR: 1.83 ; 95%CI: 1.049  ̶ 3,215 ; p = 0.043). CONCLUSION: left ventricular ejection fraction and biomarkers such as troponin I level are predictors of mortality in septic shock patients.

Higher cut-off serum procalcitonin level for sepsis diagnosis in metastatic solid tumor patients.

OBJECTIVE: The current study aimed to know procalcitonin levels in patients with metastatic tumor, and to discover the cut-off point for sepsis in this population. A cross-sectional study was conducted with patients with solid tumor. Sepsis and systemic inflammation response syndrome (SIRS) were identified using clinical, laboratory, and microbiological criteria. The cut-off point was determined using receiver operating characteristic (ROC) curve. RESULTS: A total of 112 subjects enrolled in this study, 51% male, mean age 47.9 ± 12.47 years. Among 71 (63.4%) patients who had metastasis, 36 (32.1%) had sepsis and 6 (5.3%) experienced SIRS. In the absence of sepsis, the procalcitonin levels were significantly higher in patients with metastatic tumor compared to those without [0.25 ng/mL (0.07-1.76) vs. 0.09 ng/mL (0.03-0.54); p < 0.001]. The ROC curve showed that levels of procalcitonin for sepsis in metastatic solid tumors were in the area under curve (AUC) [0.956; CI 0.916-0.996]. Cut-off point of procalcitonin for sepsis was 1.14 ng/mL, Sn 86%, and Sp 88%. Thus, the results show that metastatic tumor affects the patients' procalcitonin level, even in the absence of sepsis. The cut-off point of procalcitonin level for diagnosing sepsis in the meta-static solid tumor was higher compared to the standard value.

Protein 53 (P53) Expressions and Apoptotic Index of Amniotic Membrane Cells in the Premature Rupture of Membranes.

BACKGROUND: The premature rupture of membranes (PROM) represents an obstetric issue causing significant maternal and neonatal morbidity and mortality. Although protein 53 (p53), one of the proapoptotic proteins suspected of causing PROM at the molecular level is closely correlated with the occurrence of PROM, the exact mechanism remains still unclear. AIM: This study aims to investigate the hypothesis that p53 expression and the apoptotic index play a role in the PROM mechanism. METHODS: Placentas from 20 pregnancies (37-42 weeks gestation) and 20 pregnancies complicated by PROM were collected at delivery. The independent variable is represented by pregnant mothers with a single live fetus experiencing PROM (followed by labour and birth) while without PROM mothers represent the control. The research material was taken from the amnion tissue in the placenta. Also, p53 and apoptotic index (TUNEL) immunohistochemical examination were conducted at the Integrated Biomedical Laboratory, Medical Faculty of Udayana University, Bali. The correlation between the apoptotic index and p53 expression of the PROM group was tested using a McNemar Test. RESULTS: No statistically significant differences were found between the two groups (p > 0.05). There was a significant difference in p53 expression in PROM cases compared to those without PROM (11.15 + 5.59% vs. 0.95 + 2.52%) with χ2 = 19.538 and p = 0.001. The apoptotic index in PROM cases was higher than in those without PROM (19.10 + 5.63% vs. 1.15 + 2.46%) with χ2 = 32.40 and p = 0.001. There was a strong correlation between p53 expression and PROM with PR = 3.449 (95% CI = 1.801-6.605; p = 0.001). There was a strong correlation between the apoptotic index and PROM with PR = 19 (95% CI = 2.81-128.69; p = 0.001). CONCLUSION: p53 expression and the apoptotic index of amniotic membrane cells in cases of PROM was higher than in those without PROM, there was a strong correlation between p53 expression and apoptotic index with the occurrence of PROM.