GoogleTrends as a patient therapeutic education resource on extracorporeal life support: What do patients want to know?

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is implemented as rescue therapy in COVID-19 related acute distress respiratory syndrome (ARDS) and refractory hypoxemia. Google Trends (GT) is an ongoing-developing web kit providing feedback on specific population's interests. This study uses GT to analyze the United States (US) general population interest in ECMO as COVD-19/ARDS salvage therapy. METHODS: GT was used to access data searched for the term ECMO and COVID-19. The gathered information included data from March 2020 to July 2021 within US territories. Search frequency, time intervals, sub-regions, frequent topics of interest, and related searches were analyzed. Data were reported as search frequency on means, and a value of 100 represented overall peak popularity. RESULTS: The number of Google searches related to the terms ECMO and COVID-19 has surged and sustained interest over time ever since the initial reports of COVID-19 in the US, from an initial mean of 34% in March 2020 to a 100% interest by April 2020, resulting in an up-to-date overall average of 40% interest. Over time West Virginia, Gainesville, and Houston, lead the frequency of searches in sub-region, metro and city areas, respectively. Top search terms by frequency include: ECMO machine, COVID ECMO, what is ECMO, ECMO treatment and VV ECMO. Parallel to this, the related rising terms are: COVID ECMO, ECMO machine COVID, ECMO for COVID, ECMO machine coronavirus, and ECMO vs ventilator. Seemingly, medical-relevant websites fail to adequately address these for patient therapeutic education (PTE) purposes. CONCLUSIONS: GT complements the understanding of interest in ECMO for COVID-19. When properly interpreted, the use of these trends can potentially improve on PTE and therapy awareness via specific medical relevant websites.

Shifting surgical archetypes of ICG fluorescent-angiography for bowel perfusion assessment in cardiogenic shock under ECMO support.

Extracorporeal membrane oxygenation (ECMO) has been adopted to support patients with acute severe cardiac or pulmonary failure that is potentially reversible and unresponsive to conventional management. Mesenteric ischemia (MI) can present as a life-threatening complication in patients receiving veno-arterial echocardiogram (ECHO) support. Due to the nature and acuity of these conditions, determining adequate perfusion upon surgical intervention is challenging for the operating surgeon, especially in cardiogenic shock (CS) patients on ECMO support persenting low arterial pulsatility. Indocyanine green fluorescent angiography (ICG-FA) has proven to be useful for real-time assessment of vascular perfusion, which may help determine the extent of bowel ischemia in patients receiving ECMO support. The case report here-in presented, breaks the paradigm of performing non-cardiac surgical procedures on ECMO support via a pioneering visual aid technique. LEARNING OBJECTIVE: ICG-FA is a promising visual intraoperatory technique providing real-time feedback for the adequate identification and assessment of target tissue/organs. The high morbidity and mortality rates associated to MI and CS-particularly when concomitantly present-hinders salvage surgical therapy. The use of ECMO provides hemodynamic stability This case report highlights the importance of adequate surgical intervention under extracorporeal life support in the presence of both CS and MI. To the authors' knowledge, this is the first report of application of ICG-FA to evaluate mesenteric perfusion in a patient receiving ECMO support.

En-Bloc Simultaneous Heart-Liver Transplantation in Adult Patients.

INTRODUCTION: Complexity of combined heart-liver transplantation has resulted in low adoption rates. We report a case series of adult patients receiving en-bloc heart-liver transplantation (HLTx), describe technical aspects, and discuss benefits of the technique. METHODS: Retrospective review of patients receiving en-bloc HLTx over 18 months, with clinical follow up to 1 year. Primary outcomes included postoperative mortality and major complications. Secondary outcomes included 1-year survival, cardiac or hepatic allograft rejection, and infection. RESULTS: Five patients received en-bloc HLTx. Mean recipient age was 43 years (26-63), and 3 patients were male. Total operative time was 430 minutes (393-480), cold and warm ischemic times of 85 (32-136) and 37.5 (31-47) minutes. Hospital survival was 80%. One patient died on postoperative day 55 due to fungal sepsis. Major postoperative complications included prolonged mechanical ventilation in 2 of 5 patients (40%), and renal insufficiency requiring hemodialysis in 2 of 5 patients (40%). Among patients discharged from hospital 1-year survival was 100%, with no evidence of rejection or infectious complications. CONCLUSION: En-bloc HLTx technique is a safe and effective strategy, decreasing operative times, and allograft ischemic times, whereas offering protection of implanted allografts during early stages of reperfusion while patient is hemodynamically supported on cardiopulmonary bypass.

Cardiogenic shock and machine learning: A systematic review on prediction through clinical decision support softwares.

BACKGROUND AND AIM: Cardiogenic shock (CS) withholds a significantly high mortality rate between 40% and 60% despite advances in diagnosis and medical/surgical intervention. To date, machine learning (ML) is being implemented to integrate numerous data to optimize early diagnostic predictions and suggest clinical courses. This systematic review summarizes the area under the curve (AUC) receiver operating characteristics (ROCs) accuracy for the early prediction of CS. METHODS: A systematic review was conducted within databases of PubMed, ScienceDirect, Clinical Key/MEDLINE, Embase, GoogleScholar, and Cochrane. Cohort studies that assessed the accuracy of early detection of CS using ML software were included. Data extraction was focused on AUC-ROC values directed towards the early detection of CS. RESULTS: A total of 943 studies were included for systematic review. From the reviewed studies, 2.2% (N = 21) evaluated patient outcomes, of which 14.3% (N = 3) were assessed. The collective patient cohort (N = 698) consisted of 314 (45.0%) females, with an average age and body mass index of 64.1 years and 28.1 kg/m2 , respectively. Collectively, 159 (22.8%) mortalities were reported following early CS detection. Altogether, the AUC-ROC value was 0.82 (α = .05), deeming it of superb sensitivity and specificity. CONCLUSIONS: From the present comprehensively gathered data, this study accounts the use of ML software for the early detection of CS in a clinical setting as a valid tool to predict patients at risk of CS. The complexity of ML and its parallel lack of clinical evidence implies that further prospective randomized control trials are needed to draw definitive conclusions before standardizing the use of these technologies. BRIEF SUMMARY: The catastrophic risk of developing CS continues to be a concern in the management of critical cardiac care. The use of ML predictive models have the potential to provide the accurate and necessary feedback for the early detection and proper management of CS. This systematic review summarizes the AUC-ROCs accuracy for the early prediction of CS.

"Heart and kidney transplant from donor with recent veno-arterial extracorporeal cardiopulmonary resuscitation".

OBJETIVES: ECMO is progressively being adopted as a last resort to stabilize patients receiving cardiopulmonary resuscitation (ECMO CPR). A significant number of these patients will present recovery of end-organ function, but evolve with brain death, accounting for only 30% of patients discharged from the hospital alive. Harvesting organs from donors on VA ECMO has recently been proposed as a strategy to expand the pool of available organs for transplantation. METHODS: We present a case of combined heart and kidney transplantation from a brain death donor with recent out of hospital cardiac arrest rescued with eCPR. RESULTS: A 31 year old male patient was admitted to local hospital with diagnosis of drowning after seizure episode. Patient received two rounds of CPR for 8 and 30 minutes respectively, and required emergency insertion of VA ECMO. Patient developed compartment syndrome of right lower extremity (RLE) with CPK = 30,720, prompting discontinuation of ECMO support within 48 hours as cardiac function had recovered, reflected on echocardiographic and enzymatic parameters. Patient was declared brain death and became organ donor. Multiple organ procurement was performed. Combined heart and right kidney transplant was then performed on a 61-year-old male with uneventful course, and with normal function of all implanted allografts at 3 months follow up. CONCLUSION: Our experience supports the concept that VA ECMO is not a contraindication for solid organ donation. Individual evaluation of organ function can lead to successful transplantation of multiple organs from donors with recent history of VA ECMO support.

Advanced heart failure therapies in patients with stable HIV infection.

BACKGROUND: Human immunodeficiency virus (HIV) infection affects nearly 38 million people worldwide. Patients living with HIV (PLHIV) on modern highly active antiretroviral therapy face significant morbidity and mortality related to the progression of chronic diseases, which lead to an increase in the burden of end-stage organ disease and organ failure. PLHIV present a two fold increased risk of heart failure as compared with the general population, with a prevalence of clinical heart failure of 6.5 %. Orthotopic heart transplantation (OHT) is rarely performed in HIV-positive patients despite the fact that HIV-associated cardiomyopathy is a major long-term complication of HIV infection. MATERIAL AND METHODS: We present a case of PLHIV presenting with decompensated heart failure, requiring initial therapy with left ventricular assist device, followed by heart transplantation, accompanied by an update on current concepts, and experience in the field. DISCUSSION AND CONCLUSION: HIV-associated cardiomyopathy is a major long-term complication of HIV infection. LVAD support or OHT should also be encouraged among HIV-positive patients as current data indicates that AHFT is safe in carefully selected HIV-positive patients and outcomes are similar to those of HIV-negative patients.

Long-term outcomes of elderly patients receiving continuous flow left ventricular support.

BACKGROUND: Heart failure is an epidemic affecting over 6 million people in the United States. Eighty percent of all heart failure patients are older than 65 years of age. Heart transplant is the gold standard treatment for patients suffering advanced heart failure, but only 18.5% of patients receiving heart transplant in the United States are 65 years of age or older. Continuous-flow left ventricular assist devices are a safe and effective therapy for patients with advanced heart failure, and can be used to bridge patients to a heart transplant or to support patients long-term as destination therapy. MATERIAL AND METHODS: We sought to characterize long-term outcomes of elderly patients receiving continuous-flow left ventricular support in our program. CONCLUSION: Elderly patients with advanced heart failure presented comparable operative results to those of younger patients. The rate of complications up to 6 years of support was low, and comparable to those of younger patients. An effective and safe alternative for patients whom are less likely to receive heart transplantation.

Combined off-pump coronary bypass grafting without heparin and liver transplantation: A novel approach to a complex dilemma.

Cardiac disease is a leading cause of early mortality for patients undergoing liver transplantation (LT), and severe coronary artery disease (CAD) is usually considered a contraindication for LT in patients with cirrhosis. Incidence of CAD in LT candidates has increased in recent years. While stable patients might be candidates for percutaneous interventions, patients with decompensated liver failure, or critical coronary lesions present a therapeutic challenge, and are often not considered candidates for LT. We present the case of a 60 year old male patient with decompensated liver failure, and critical CAD, who received successful combined off-pump coronary bypass grafting without heparin and LT using ex vivo normothermic liver perfusion machine. This approach represents a novel strategy to offer LT to this very selective group of patients.

Heparineless off-pump coronary artery bypass in a patient with gunshot wound to chest and heart.

OBJECTIVES: Administration of heparin is standard in coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (OPCABG). In some circumstances, the risk of heparinization may outweigh its benefits, and there is scarce literature on how to proceed in these cases. We describe the technique used for OPCABG without heparin. METHODS: We report the case of a patient with a gunshot wound to the chest resulting in multiple lung lacerations and transection of the proximal left anterior descending coronary artery (LAD) leading to hemorrhagic shock with tamponade, and cardiogenic shock due to myocardial ischemia who received OPCABG without heparin. RESULTS: A 23-year-old patient suffered multiple gunshot wounds to the chest and was admitted in shock with massive left hemothorax. Emergency left thoracotomy revealed multiple lung lacerations and transection of the proximal left anterior coronary artery. The patient presented acute myocardial ischemia and progressed to cardiogenic shock requiring insertion of intra-aortic balloon pump (IABP) to try to support hemodynamics. OPCABG with a segment of reversed saphenous vein graft to the LAD coronary artery was performed using standard techniques but without heparinization. The graft was flushed with normal saline before completing both anastomosis. Myocardial ischemic changes reversed, and the patient stabilized immediately after completing OPCABG, allowing to wean off IABP in the operating room. Postoperative recovery was unremarkable, and the patient was discharged home on postoperative day 9. CONCLUSION: Benefits of OPCABG include decreased bleeding and lower requirement of blood transfusions. This experience shows that OPCABG can be performed without systemic heparinization in selected cases.

Sepsis in cardiothoracic surgery.

Sepsis is a life-changing condition that can occur in patients undergoing cardiothoracic surgery. It is characterized by a dysregulated inflammatory response to infection, often leading to higher rates of organ dysfunction and mortality. The importance of early recognition and prompt intervention in managing sepsis-related complications in cardiothoracic surgery is pivotal to adequate surgical practice. Due to the multiple subsections that construct the broad spectrum of cardiothoracic surgery, it is important to address the presence of sepsis in elective cardiothoracic surgery, urgent/emergency cardiothoracic surgery, solid organ transplantation, and both temporary and permanent mechanical circulatory support (ie, left ventricular assist devices, extracorporeal membrane oxygenation, and percutaneous temporary devices [eg, Impella series]). Exploring the incidence, prevalence, and risk factors of said subsections can lead to improvement in postoperative outcomes. The impact of accompanying infections can progress into further operative morbidity and mortality. To this effect, the perioperative management of cardiothoracic surgery transcends surgical techniques and should undergo additional recognition of other occurrences such as wound infections, bloodstream infections, urinary tract infections, and pneumonia. Sepsis remains a concern in cardiothoracic surgery, as it can lead to devastating consequences. Hence, there is an evident need for heightened vigilance, early recognition, and effective management strategies to mitigate the risk of sepsis in this patient population. The purpose of this article is to provide an overview of sepsis in the different cardiothoracic surgery areas.

The dual prevalence of advanced degrees of obesity and heart failure: a study from the National Inpatient Sample database.

BACKGROUND: National prevalence rates for obesity and heart failure (HF) have been steadily increasing, which predisposes patients to higher morbidity and mortality rates. OBJECTIVES: The purpose of this study was to evaluate the prevalence of HF stages in hospitalized patients according to their body mass index (BMI). SETTING: Academic institution. METHODS: National Inpatient Sample data from 2016 to 2018 were examined to identify patients with obesity, HF (presence or absence of advanced HF [AHF]), and cardiogenic shock (CS). The proportion of hospital admissions was determined for each category on the basis of the presence of AHF with/without CS. A comparative analysis was performed between patients with and without AHF, and multivariate logistic regression analysis was performed for the event of AHF. The same analyses were performed for the event of CS. RESULTS: A total of 3,354,970 hospital admissions were identified. The prevalence of hospital admissions with a diagnosis of AHF and class III obesity and a diagnosis of CS and class III obesity was 21% and .5%, respectively. The prevalence of AHF and other classes of BMI and CS and other classes of BMI was 17% and .5%, respectively. The univariate analysis showed that there were significant variations in 10 factors between hospital admissions with/without the diagnosis of both AHF and CS. Statistical analyses indicated the following findings: Hospitalized patients in higher obesity groups are more likely to have AHF, and they are less likely to have CS compared with those with a BMI of ≤29.9. CONCLUSIONS: This study revealed that the prevalence of AHF was significantly higher in hospitalized patients with class III obesity. These findings have implications for clinical management, and it can be inferred that these patients are less likely to receive advanced cardiac replacement therapies and might benefit from innovative approaches to address severe dual morbidity.

The pandemic effect: The outlook of lung transplantation.

Lung transplant (LT) is a life-saving treatment for patients with end-stage lung disease. In the setting of COVID-19-associated acute respiratory distress syndrome (ARDS), LT emerged as a therapeutic option for select cases. It is challenging to determine the extent of the knowledge and interest the United States (US) general population has on LT as salvage therapy during and following the COVID-19 pandemic. It is the authors' opinion that patient therapeutic education (PTE) can directly influence established practices by creating an open channel of communication based on needs and expectations for healthcare services. This perspective is a cursory reflection of the nuances between healthcare providers, their services, the interests and expectations of the general population, specifically on LT following COVID-19. The main endpoint of this study is to analyze the US general population's interest in LT as COVID-19 salvage therapy via the Google Trends (GT) web-kit tool.

Endovascular therapy for thoracic aortic aneurysms: state of the art in 2012.

OPINION STATEMENT: Conventional surgery for thoracic aortic pathology involves replacing the affected segment of aorta with an interposition graft and often requires the use of extracorporeal circulatory support with or without deep hypothermic circulatory arrest. Although operative results have improved consistently over 60 years, patients with extensive aneurysms face a considerable risk with conventional surgery, particularly when burdened with multiple comorbidities. Thoracic endovascular aortic repair (TEVAR) was first performed in 1994 and has become a well-established alternative therapy for many thoracic aortic pathologies. TEVAR is most frequently performed through a small groin incision to access the common femoral artery. Wires and catheters are used to deliver and deploy the stent graft in the thoracic aorta under fluoroscopic control. Occasionally, TEVAR is performed as part of a complex hybrid procedure including one stage of conventional open surgery that may utilize a thoracic incision and cardiopulmonary bypass support. The less invasive nature of TEVAR offers the potential for lower mortality and peri-procedural morbidity. Although long-term results of TEVAR are still being gathered, mid-term results are excellent and most late vascular complications can be treated with additional transcatheter procedures. Recent development of fenestrated and branched stent grafts is expanding the application of endovascular therapies to complex aortic pathologies involving the thoracoabdominal aorta and aortic arch. Although conventional techniques continue to be the gold standard for treatment of ascending aortic pathology, recent reports have proven TEVAR to be a viable alternative in specific situations. Design improvements continue to expand the indications for TEVAR, and technological advancements in the field of imaging facilitate safer and more accurate planning, delivery, and assessment of patients with thoracic aortic aneurysms. Hybrid operating rooms provide the optimal environment with state of the art imaging technology for the cardiovascular team to perform TEVAR or alternative hybrid procedures.

The Multicenter Collaborative to Enhance Biologic Understanding, Quality, and Outcomes in Cardiogenic Shock (VANQUISH Shock): Rationale and Design.

BACKGROUND: Despite efforts to advance therapies in cardiogenic shock (CS), outcomes remain poor. This is likely due to several factors, including major gaps in our understanding of the pathophysiology, phenotyping of patients, and challenges with conducting adequately powered clinical studies. An unmet need exists for a comprehensive multicentre "all-comers" prospective registry to facilitate characterising contemporary presentation, treatment (in a device-agnostic fashion), and short- and intermediate-term outcomes and quality of life (QOL) of CS patients. METHODS: The Multicenter Collaborative to Enhance Biological Understanding, Quality and Outcomes in Cardiogenic Shock (VANQUISH Shock) registry is a prospective observational registry that will study unrestricted adult patients with a primary diagnosis of CS at 4 North American centres with multidisciplinary shock programs. Both acute myocardial infarction (AMI-CS) and acute heart failure (HF-CS) etiologies will be included, and the registry will be device agnostic and widely inclusive. The primary end point will be survival at 30 days after hospital discharge. Secondary outcomes will include in-hospital adverse events and survival to 6 and 12 months. Patients will also undergo neurologic and health-related QOL assessments with the Cerebral Performance Category (CPC) and Short-Form 36 (SF-36) health survey tools before discharge and during follow-up. Serial biospecimens will facilitate biomarker studies. CONCLUSIONS: The VANQUISH Shock registry provides a unique opportunity to study the pathophysiology, contemporary management, clinical course, and outcomes of CS. By capturing detailed and high-quality longitudinal data, the registry will address existing knowledge gaps and serve as a springboard for future mechanistic clinical studies to advance the field.

Nuclear Osteopontin Is a Marker of Advanced Heart Failure and Cardiac Allograft Vasculopathy: Evidence From Transplant and Retransplant Hearts.

BACKGROUND: Heart transplant is the gold standard therapy for patients with advanced heart failure. Over 5,500 heart transplants are performed every year worldwide. Cardiac allograft vasculopathy (CAV) is a common complication post-heart transplant which reduces survival and often necessitates heart retransplantation. Post-transplant follow-up requires serial coronary angiography and endomyocardial biopsy (EMB) for CAV and allograft rejection screening, respectively; both of which are invasive procedures. This study aims to determine whether osteopontin (OPN) protein, a fibrosis marker often present in chronic heart disease, represents a novel biomarker for CAV. METHODS: Expression of OPN was analyzed in cardiac tissue obtained from patients undergoing heart retransplantation using immunofluorescence imaging (n = 20). Tissues from native explanted hearts and three serial follow-up EMB samples of transplanted hearts were also analyzed in five of these patients. RESULTS: Fifteen out of 20 patients undergoing retransplantation had CAV. 13/15 patients with CAV expressed nuclear OPN. 5/5 patients with multiple tissue samples expressed nuclear OPN in both 1 st and 2 nd explanted hearts, while 0/5 expressed nuclear OPN in any of the follow-up EMBs. 4/5 of these patients had an initial diagnosis of dilated cardiomyopathy (DCM). CONCLUSION: Nuclear localization of OPN in cardiomyocytes of patients with CAV was evident at the time of cardiac retransplant as well as in patients with DCM at the time of the 1 st transplant. The results implicate nuclear OPN as a novel biomarker for severe CAV and DCM.

Treatment of Refractory Intraoperative Hypoxemia After Trauma With Venovenous Extracorporeal Membrane Oxygenation: A Case Report.

Extracorporeal membrane oxygenation has emerged as a treatment of choice for refractory hypoxemia in the intensive care unit. Severe hypoxemia unresponsive to conventional lung-protective mechanical ventilation could also occur in the operating room from severe bronchospasm, pulmonary contusions, or acute respiratory distress syndrome. We report a case of acute hypoxic respiratory failure in an adolescent with blunt chest trauma that was successfully managed with the intraoperative initiation of venovenous extracorporeal membrane oxygenation during the initial damage control surgery.

Donor lungs with pulmonary embolism evaluated with ex vivo lung perfusion.

Acute pulmonary embolism (PE) compromises oxygenation and is typically considered a contraindication to lung donation for transplantation. We report the use of ex vivo lung perfusion (EVLP) to evaluate and possibly improve a pair of donor lungs with PE and poor oxygen exchange to a condition that might have been suitable for subsequent transplantation. A pair of donor lungs was procured for research after being declined for clinical use and placed on the EVLP circuit for 7 hours. Functional monitoring of the lungs revealed an increase in the partial pressure of oxygen to fraction of inspired oxygen ratio (P/F ratio) from 268 in situ to 458 after EVLP. While on the circuit, pulmonary vascular resistance decreased as dynamic compliance of the lungs increased, suggesting they might have been acceptable for transplantation.