RESUMEN
SARS-CoV-2 (COVID-19) infections have been recently shown to be associated with a high rate of thromboembolic events due to pro-coagulative mechanisms that have not yet been fully understood. This paper reports on a 55-year-old female COVID-19 patient with severe ARDS and pulmonary embolism (PE) complicated by cardiogenic shock after 12 days of hospitalization under initial prophylactic anticoagulation with low molecular weight heparin (LMWH). An ultima-ratio va (veno-arterial) ECMO implantation and subsequent rapid upgrade to vvaECMO due to insufficient oxygenation was performed. The patient developed severe coagulopathy with intrapulmonary bleeding. The present report aims to highlight and discuss the pros and cons of various anticoagulation strategies in COVID-19 patients focusing on current scientific debates to address this frequently observed complication in the current situation worldwide.
Asunto(s)
COVID-19 , Oxigenación por Membrana Extracorpórea , Embolia Pulmonar , Anticoagulantes/uso terapéutico , Femenino , Heparina de Bajo-Peso-Molecular , Humanos , Persona de Mediana Edad , Embolia Pulmonar/complicaciones , SARS-CoV-2RESUMEN
PURPOSE: Baroreflex activation therapy (BAT) has been shown to lower blood pressure in patients with resistant hypertension. The purpose of this study was to analyze whether this translates into a reduction of more relevant clinical endpoints. METHODS: Patients with resistant hypertension were treated with the second-generation BAT system. Records on hospitalization (dates of admission and discharge, main diagnosis) were obtained from medical insurance companies. RESULTS: Records on hospitalization were available for a period of 1 year before BAT in two patients and 2 years in 22 patients. The total number of hospitalizations per patient was 3.3 ± 3.5/year before BAT and 2.2 ± 2.7/year after BAT (p = 0.03). Hospitalizations related to hypertension were significantly decreased from 1.5 ± 1.6/year before BAT to 0.5 ± 0.9/year after BAT (p < 0.01). The cumulative duration of hypertension-related hospital stays was significantly reduced from 8.0 ± 8.7 days/year before BAT to 1.8 ± 4.8 days/year after BAT (p < 0.01). Office cuff blood pressure was 183 ± 27 mmHg over 102 ± 17 mmHg under 6.6 ± 2.0 antihypertensive drugs before BAT and 157 ± 32 mmHg over 91 ± 20 mmHg (both p < 0.01) under 5.9 ± 1.9 antihypertensive drugs (p = 0.09 for number of drugs) at latest follow-up. Daytime ambulatory blood pressure was 164 ± 21 mmHg over 91 ± 14 mmHg before BAT and 153 ± 21 mmHg (p = 0.03) over 89 ± 15 mmHg (p = 0.56) at latest follow-up. Heart rate was 75 ± 16 bpm before BAT and 72 ± 12 bpm at latest follow-up (p = 0.35). CONCLUSIONS: Rate and duration of hypertension-related hospitalizations in patients with severe resistant hypertension were lowered after BAT. Whether the response is mediated through improvements in blood pressure control requires further studies.
Asunto(s)
Barorreflejo , Hipertensión , Antihipertensivos/uso terapéutico , Presión Sanguínea , Monitoreo Ambulatorio de la Presión Arterial , Hospitalización , Humanos , Hipertensión/tratamiento farmacológicoRESUMEN
BACKGROUND: There has been conflicting evidence concerning the effect of levosimendan on clinical outcomes in patients undergoing cardiac surgery. Therefore, we performed a systematic review and conducted this meta-analysis to provide evidence for/against the administration of levosimendan in cardiac surgery patients. METHODS: We performed a meta-analysis from literature search in PubMed, EMBASE, and Cochrane Library. Only randomized controlled trials comparing the administration of levosimendan in cardiac surgery patients with a control group (other inotrope, standard therapy/placebo, or an intra-aortic balloon pump) were included. In addition, at least one clinical outcome had to be mentioned: mortality, myocardial infarction, low cardiac output syndrome (LCOS), acute kidney injury, renal replacement therapy, atrial fibrillation, prolonged inotropic support, length of intensive care unit, and hospital stay. The pooled treatment effects (odds ratio [OR], 95% confidence intervals [CI]) were assessed using a fixed or random effects model. RESULTS: The literature search retrieved 27 randomized, controlled trials involving a total of 3,198 patients. Levosimendan led to a significant reduction in mortality (OR: 0.67; 95% CI: 0.49-0.91; p = 0.0087). Furthermore, the incidence of LCOS (OR: 0.56, 95% CI: 0.42-0.75; p < 0.0001), acute kidney injury (OR: 0.63; 95% CI: 0.46-0.86; p = 0.0039), and renal replacement therapy (OR: 0.70; 95% CI: 0.50-0.98; p = 0.0332) was significantly decreased in the levosimendan group. CONCLUSION: Our meta-analysis suggests beneficial effects for the prophylactic use of levosimendan in patients with severely impaired left ventricular function undergoing cardiac surgery. The administration of levosimendan was associated with a reduced mortality, less LCOS, and restored adequate organ perfusion reflected in less acute kidney injury.
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Gasto Cardíaco Bajo/prevención & control , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Cardiotónicos/uso terapéutico , Simendán/uso terapéutico , Gasto Cardíaco Bajo/etiología , Gasto Cardíaco Bajo/mortalidad , Gasto Cardíaco Bajo/fisiopatología , Procedimientos Quirúrgicos Cardíacos/mortalidad , Cardiotónicos/efectos adversos , Factores de Riesgo de Enfermedad Cardiaca , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Simendán/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: The latest generation of balloon-expandable valve, the Edwards Sapien 3 valve (S3V), was designed to reduce paravalvular regurgitation (PVR). We retrospectively compared S3V with Edwards Sapien XT valve (SXTV) with regard to postprocedural transvalvular pressure gradients (PGs). METHODS: Analysis of 152 patients receiving SXTV and 125 patients receiving S3V between February 2009 and April 2015 was performed. Transvalvular PGs and the incidence and extent of aortic regurgitation (AR) were compared postprocedurally by echocardiography for each valve size. RESULTS: Postprocedurally, mean PGs for the 23 mm valves were 10.9 ± 5.3 versus 13.9 ± 5.1 (p = 0.017), whereas maximum PGs were 19.9 ± 8.3 versus 26.1 ± 10.4 mm Hg (p = 0.005) in SXTV and S3V patients, respectively. For the 26 mm valves, gradients were also significantly higher in S3V patients (mean PG: 11.6 ± 4.9 vs. 9.2 ± 4.2 [p = 0.004]; maximum PG: 23.0 ± 10.1 vs. 17.2 ± 7.4 mm Hg [p < 0.001]). Analysis revealed no significant differences in postprocedural transvalvular PGs for 29 mm valves (mean PG of 9.3 ± 3.9 and 11.2 ± 4.3 mm Hg [p = ns] and maximum PG of 17.5 ± 7.2 vs. 20.9 ± 6.8 mm Hg [p = ns]) between SXTV and S3V groups, respectively. With respect to PVR, the incidence of AR was significantly lower in S3V group (p = 0.001). CONCLUSION: S3V shows lower incidence of PVR; however, it is associated with significantly higher postprocedural transvalvular PGs for 23 and 26 mm valve sizes. These data might contribute to the scientific discussion, especially with respect to prosthesis selection in individual patients with small annular dimension.
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Insuficiencia de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Hemodinámica , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/epidemiología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/epidemiología , Estenosis de la Válvula Aórtica/fisiopatología , Femenino , Alemania/epidemiología , Humanos , Incidencia , Masculino , Diseño de Prótesis , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
The aim of this study was to provide early and mid-term results of the newly established extracorporeal membrane oxygenation (ECMO) retrieval service in a tertiary cardiothoracic center using the miniaturized portable Cardiohelp System (Maquet, Rastatt, Germany). A particular attention was paid to organizational and logistic specifics as well as challenges and pitfalls associated with initial phase of the program. From January 2015 until January 2017 a heterogenic group of 28 consecutive patients underwent ECMO implantation in distant hospitals for acute cardiac, pulmonary or combined failure as a bridge-to-decision and were subsequently transported to our institution. Each cannulation was performed bedside on intensive care units (ICU) using the Seldinger's technique. Early outcomes and mid-term overall survival with up to two-year follow-up along with the impact of ongoing cardiopulmonary resuscitation (CPR) on outcome were presented. Also, changes in hemodynamics and tissue perfusion factors 24 h after ECMO implantation were evaluated. ECMO implantations were performed in 15 distant departments with the median distance of 23(10;40) (maximum 60) km. A total of 15 patients (54%) were cannulated under CPR with the median duration of 30(20;110) (maximum 180) min. After 24 h of support there were significant improvements in SvO2 (P = 0.021), mean arterial pressure (P = 0.027), FiO2 (P = 0.001), lactate (P = 0.001), and pH (P < 0.001). The mean ECMO support duration was 96 ± 100 (maximum 384) hours, whereas 11 patients (40%) were weaned off support and discharged from hospital. Overall cumulative survival in patients without the need for CPR was 61.5% at one week and 38.5% at 1 month, 6 month, and 1 year, whereas patients requiring CPR survived in 40% at one week, and 33.3% at 1 month, 6 month, and 1 year (Log-Rank (Mantel-Cox) P = 0.374, Breslow (Generalized Wilcoxon) P = 0.162). Our initial experience shows that launching new ECMO retrieval programs in centers with sufficient ICU capacities and local ECMO experience can be feasible and associated with acceptable "real world" results despite the initial learning curve. Rapid logistical organization and team flexibility are the key points to ensure comparable survival of patients requiring prolonged CPR.
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Reanimación Cardiopulmonar/métodos , Oxigenación por Membrana Extracorpórea/métodos , Adulto , Anciano , Reanimación Cardiopulmonar/instrumentación , Oxigenación por Membrana Extracorpórea/instrumentación , Femenino , Estudios de Seguimiento , Alemania , Hemodinámica , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: The objective of the current work was to evaluate flow and turbulent kinetic energy in different transcatheter aortic valve implants using highly undersampled time-resolved multi-point 3-directional phase-contrast measurements (4D Flow MRI) in an in vitro setup. MATERIALS AND METHODS: A pulsatile flow setup was used with a compliant tubing mimicking a stiff left ventricular outflow tract and ascending aorta. Five different implants were measured using a highly undersampled multi-point 4D Flow MRI sequence. Velocities and turbulent kinetic energy values were analysed and compared. RESULTS: Strong variations of turbulent kinetic energy distributions between the valves were observed. Maximum turbulent kinetic energy values ranged from 100 to over 500 J/m3 while through-plane velocities were similar between all valves. CONCLUSION: Highly accelerated 4D Flow MRI for the measurement of velocities and turbulent kinetic energy values allowed for the assessment of hemodynamic parameters in five different implant models. The presented setup, measurement protocol and analysis methods provides an efficient approach to compare different valve implants and could aid future novel valve designs.
Asunto(s)
Válvula Aórtica , Técnicas de Imagen Cardíaca/métodos , Prótesis Valvulares Cardíacas , Imagen por Resonancia Magnética/métodos , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/cirugía , Velocidad del Flujo Sanguíneo , Hemorreología , Humanos , Imagenología Tridimensional/métodos , Técnicas In Vitro , Imagen por Resonancia Cinemagnética/métodos , Diseño de PrótesisRESUMEN
BACKGROUND: Choice of cardioplegic solution plays a pivotal role in special subgroups of patients referred for on-pump cardiac surgery. This retrospective analysis aimed to assess the impact of intermittent warm (Calafiore, Cala) versus intermittent cold blood cardioplegia (Buckberg, Buck) in patients referred to coronary artery bypass graft (CABG) surgery due to acute coronary syndromes (ACS). METHODS: From 2008 to 2015, all consecutive patients undergoing urgent on-pump CABG surgery due to ACS (n = 950) were retrospectively analyzed. Intraoperative cardiac arrest was achieved using Buck (n = 273) or Cala (n = 677). Patients were compared regarding clinical outcomes and perioperative myocardial injury (PMI). Propensity score matching was performed to control for differences in preoperative patient characteristics. RESULTS: Prevalences of left main stenosis >50%, COPD, and advanced New York Heart Association (NYHA) class were higher for intermittent warm blood cardioplegia (IWC)-patients while more Buck-patients had preoperative intra-aortic balloon pump (IABP) and redo procedures. Buck-patients needed more intraoperative defibrillations and showed longer cardiopulmonary bypass (CPB) and aortic clamping times. 30-day all-cause mortality (10.6 versus 9.3%), major adverse cardiac events (MACE) (52.7 versus 48.6%), and PMI (50.5 versus 55.7%; all p > 0.05) rates were comparable for Buck- and Cala-patients. Propensity score matching resulted in equal group sizes (n = 212 each) and balanced distribution of preoperative covariates. Although more Buck-patients still needed inotropic support >24 hours postoperatively (25.7 versus 14.7%; p = 0.005) compared with Cala-group, outcome variables of interest did not differ between treatment groups (30-day mortality: 7.5 versus 9.0%; MACE: 49.5 versus 40.6%; PMI: 48.1 versus 37.3%; all p > 0.05). CONCLUSION: Buckberg and Calafiore cardioplegia offer comparable myocardial protection and similar postoperative results in patients undergoing CABG surgery due to ACS.
Asunto(s)
Síndrome Coronario Agudo/cirugía , Soluciones Cardiopléjicas/administración & dosificación , Puente de Arteria Coronaria/métodos , Estenosis Coronaria/cirugía , Paro Cardíaco Inducido/métodos , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/fisiopatología , Anciano , Anciano de 80 o más Años , Soluciones Cardiopléjicas/efectos adversos , Puente Cardiopulmonar , Distribución de Chi-Cuadrado , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Estenosis Coronaria/diagnóstico , Estenosis Coronaria/mortalidad , Estenosis Coronaria/fisiopatología , Femenino , Paro Cardíaco Inducido/efectos adversos , Paro Cardíaco Inducido/mortalidad , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Temperatura , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Profoundly impaired left ventricular (LV) function in patients undergoing femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can result in intra-cardiac stasis and thrombus formation. There have been several attempts to improve LV unloading in patients with peripheral VA-ECMO, either by improving contractility or by venting the LV. METHODS: Data from all patients who underwent femoral VA-ECMO between 2007 and 2015 due to cardiogenic decompensation were retrospectively analysed regarding intra-cardiac thrombus formation. RESULTS: In total, 11 of 281 patients (3.91%) with femoral VA-ECMO developed an intra- or extra-cardiac thrombus despite adequate anticoagulation therapy. None of the patients survived this serious complication. CONCLUSION: Management strategies for patients with femoral VA-ECMO support and severely impaired LV function must be reassessed to avoid insufficient LV unloading at an early stage of ECMO therapy. Early LV decompression should be considered in patients with insufficient unloading of the LV to prevent intra-cardiac thrombus formation.
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Oxigenación por Membrana Extracorpórea/efectos adversos , Ventrículos Cardíacos/patología , Trombosis/etiología , Trombosis/patología , Adolescente , Adulto , Anciano , Femenino , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Choque Cardiogénico/patología , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/terapia , Trombosis/fisiopatologíaRESUMEN
OBJECTIVES: Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in older patients and requiring immediate surgical repair. The aim of this study was to evaluate early outcome and short- and long-term survival of patients under and above 65 years of age. METHODS: Two hundred and forty patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015 in our center. After statistical analysis and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up, comprising patients under and above 65 years of age. RESULTS: The proportion of patients above 65 years of age suffering from Stanford A AAD was 50% (n=120). The group of patients above 65 years of age compared to the group under 65 years of age showed statistically significant differences in terms of higher odds ratios (OR) for hypertension (p=0.012), peripheral vascular disease (p=0.026) and tachyarrhythmia absoluta (p=0.004). Patients over 65 years of age also showed significantly poorer short- and long-term survival. Our subgroup analysis revealed that male patients (Breslow p=0.001, Log-Rank p=0.001) and patients suffering with hypertension (Breslow p=0.003, Log-Rank p=0.001) were reasonable for these results whereas younger and older female patients showed similar short- and long-term outcome (Breslow p=0.926, Log-Rank p=0.724). After stratifying all patients into 4 age groups (<45; 55-65; 65-75; >75years), short-term survival of the patients appeared to be significantly poorer with increasing age (Breslow p=0.026, Log-Rank p=0.008) whereas long-term survival of patients free from cerebrovascular events (Breslow p=0.0494, Log-Rank p=0.489) remained similar. CONCLUSIONS: All patients referred to our hospital for repair of Stanford A AAD with higher age had poorer short- and long-term survival, caused by male patients and patients suffering from hypertension, whereas survival of women and survival free from cerebrovascular events of the entire patient cohort was similar, irrespective of age.
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Disección Aórtica/mortalidad , Disección Aórtica/cirugía , Procedimientos Quirúrgicos Cardiovasculares , Adulto , Factores de Edad , Anciano , Disección Aórtica/fisiopatología , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
INTRODUCTION: Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD. METHODS: In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up. RESULTS: The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients. CONCLUSIONS: Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.
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Disección Aórtica/complicaciones , Disección Aórtica/cirugía , Hipertensión/complicaciones , Anciano , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Cardiac rupture (CR) is one of the most serious and life-threatening complications of blunt chest trauma (BCT) usually associated with high mortality. Moreover, its diagnosis and treatment strategies may be extremely challenging for clinicians due to various anatomical localisations of the tear. Whereas most injuries fall under the category of right atrial ruptures, left ventricular lesions represent a rare type of this injury, with greater mortality, particularly in cases of multi-chamber injuries. However, not only cardiac chamber or great vessel ruptures may occur as a result of BCT; a growing number of reports also describe BCT-induced isolated coronary artery injuries, including ruptures. Whereas CR requires immediate surgical treatment, less invasive interventional techniques, such as stent placement and closure with fibrin glue or coils, can be the treatment of choice in selected cases of hemodynamically less relevant coronary artery ruptures. In this report, we present a rare case of a ventricular rupture following BCT, with the tear localized in the right ventricular wall and an occult connection to the left ventricle without ventricular septum injury. Also, another contemporaneous emergency in our department that had to be managed at the same time resulted in challenging the decision-making process. As such an emergency constellation is difficult to manage, this report may help clinicians in difficult situations in terms of diagnosis and choosing the right treatment strategy.
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Lesiones Cardíacas , Ventrículos Cardíacos , Traumatismos Torácicos , Heridas no Penetrantes , Anciano , Lesiones Cardíacas/diagnóstico por imagen , Lesiones Cardíacas/cirugía , Tabiques Cardíacos/diagnóstico por imagen , Tabiques Cardíacos/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , Humanos , Masculino , Traumatismos Torácicos/diagnóstico por imagen , Traumatismos Torácicos/cirugía , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugíaRESUMEN
The progression of heart failure with reduced ejection fraction is promoted by sympathovagal imbalance. Baroreflex activation therapy (BAT) by the electrical stimulation of baroreceptors at the carotid sinus significantly improved exercise capacity and NT-proBNP levels in a randomized trial; however, no significant difference in left ventricular ejection fraction (LV-EF) between groups was found. Here, we report the case of a 30-year-old man with a long history of dilated cardiomyopathy and severely reduced LV-EF despite optimal medical therapy, who was treated with BAT since October 2014 and showed a remarkable improvement in both symptoms and LV-EF under this treatment.
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Cardiomiopatía Dilatada/terapia , Terapia por Estimulación Eléctrica , Adulto , Barorreflejo , Humanos , Masculino , Volumen SistólicoRESUMEN
Progression of heart failure with reduced ejection fraction (HFrEF) is promoted by sympathovagal imbalance. Baroreflex activation therapy, i.e., electrical stimulation of baroreceptors at the carotid sinus, can restore sympathovagal balance. Large animal studies of baroreflex activation therapy revealed improvements in cardiac function, susceptibility to ventricular arrhythmias, and a survival benefit as compared to untreated controls. Recently, the first randomized and controlled trial of optimal medical and device therapy alone or plus baroreflex activation therapy in patients suffering from HFrEF was published. It demonstrated a reasonable safety profile in this severely ill patient population. Moreover, the study found significant improvements in New York Heart Association class, quality of life, 6-min walk distance, and NT-proBNP levels. This review provides an overview on baroreflex activation therapy for the treatment of HFrEF-from the concept and preclinical findings to most recent clinical data and upcoming trials.
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Barorreflejo/fisiología , Terapia por Estimulación Eléctrica , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Seno Carotídeo/fisiología , Humanos , Presorreceptores/fisiología , Volumen Sistólico/fisiologíaRESUMEN
The use of non-heart-beating donor (NHBD) lungs may help to overcome the shortage of lung grafts in clinical lung transplantation, but warm ischaemia and ischaemia/reperfusion injury (I/R injury) resulting in primary graft dysfunction represent a considerable threat. Thus, better strategies for optimized preservation of lung grafts are urgently needed. Surfactant dysfunction has been shown to contribute to I/R injury, and surfactant replacement therapy is effective in enhancing lung function and structural integrity in related rat models. In the present study we hypothesize that surfactant replacement therapy reduces oedema formation in a pig model of NHBD lung transplantation. Oedema formation was quantified with (SF) and without (non-SF) surfactant replacement therapy in interstitial and alveolar compartments by means of design-based stereology in NHBD lungs 7 h after cardiac arrest, reperfusion and transplantation. A sham-operated group served as control. In both NHBD groups, nearly all animals died within the first hours after transplantation due to right heart failure. Both SF and non-SF developed an interstitial oedema of similar degree, as shown by an increase in septal wall volume and arithmetic mean thickness as well as an increase in the volume of peribron-chovascular connective tissue. Regarding intra-alveolar oedema, no statistically significant difference could be found between SF and non-SF. In conclusion, surfactant replacement therapy cannot prevent poor outcome after prolonged warm ischaemia of 7 h in this model. While the beneficial effects of surfactant replacement therapy have been observed in several experimental and clinical studies related to heart-beating donor lungs and cold ischaemia, it is unlikely that surfactant replacement therapy will overcome the shortage of organs in the context of prolonged warm ischaemia, for example, 7 h. Moreover, our data demonstrate that right heart function and dysfunctions of the pulmonary vascular bed are limiting factors that need to be addressed in NHBD.
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Trasplante de Pulmón/métodos , Surfactantes Pulmonares/uso terapéutico , Análisis de Varianza , Animales , Edema/prevención & control , Femenino , Modelos Animales , Preservación de Órganos/métodos , PorcinosRESUMEN
BACKGROUND: Tissue-engineered blood vessels (TEBVs) represent an innovative approach for overcoming reconstructive problems associated with vascular diseases by providing small-caliber vascular grafts. This study aimed to evaluate a novel biomaterial of bacterially synthesized cellulose (BC) as a potential scaffold for small-diameter TEBV. METHODS: Small-diameter blood vessels with a supramolecular fiber network structure consisting of tubular hydrogels from biodesigned cellulose were created using Gluconacetobacter strains and Matrix reservoir technology. BC tubes (length: 100 mm, inner diameter: 4.0-5.0 mm) were applied to replace the carotid arteries of 10 sheep for a period of 3 mo to gain further insights into (a) functional (in vivo) performance, (b) ability of providing a scaffold for the neoformation of a vascular wall and (c) their proinflammatory potential, and the (d) technical feasibility of the procedure. RESULTS: Preoperative analysis revealed a bursting strength of the grafts of approximately 800 mm Hg and suture retention strength of 4-5 N. Postexplantation analysis showed a patency rate of 50% (n = 5) and physiological performance of the patent grafts at 4, 8, and 12 wk postoperatively, compared with native arteries. Histologic analysis revealed a neoformation of a vascular wall-like structure along the BC scaffold consisting of immigrated vascular smooth muscle cells and a homogeneous endothelialization of the inner graft surface without signs of prothrombogenic or inflammatory potential. Scanning electron microscopy revealed a confluent luminal endothelial cell layer and the immigration of vascular smooth muscle cells into the BC matrix. CONCLUSIONS: BC grafts provide a scaffold for the neoformation of a three-layered vascular wall exhibit attractive properties for their use in future TEBV programs for cardiovascular surgery.
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Implantación de Prótesis Vascular , Prótesis Vascular , Celulosa , Gluconacetobacter xylinus , Ingeniería de Tejidos , Animales , Arteriolas , Estudios de Factibilidad , Femenino , Reacción a Cuerpo Extraño , Ensayo de Materiales , Ovinos , Andamios del Tejido , Grado de Desobstrucción VascularRESUMEN
AIMS: The Neo™ System (CVRx) is an implantable device, CE certified for the treatment of resistant hypertension and investigationally used to treat systolic heart failure by electrical stimulation of the carotid baroreceptors. It is unknown whether interaction might exist between the Neo System and implantable cardioverter-defibrillators (ICDs). METHODS AND RESULTS: Compatibility of the Neo device was tested in seven consecutive patients with pre-existing ICDs. Intra- and post-operative testing was completed with ICD and Neo settings programmed to provoke interaction. Intracardiac electrograms were printed to determine interaction with the ICD. Interaction testing during implantation and follow-up showed that there was no device-device interaction. No interaction was observed at maximum atrial and ventricular sensitivity settings and maximum Neo output settings. CONCLUSION: Combined therapy with the Neo device and at least in this study reported that transvenous ICD systems can be performed safely.
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Barorreflejo/efectos de la radiación , Desfibriladores Implantables , Terapia por Estimulación Eléctrica/instrumentación , Insuficiencia Cardíaca/prevención & control , Hipertensión/prevención & control , Terapia Asistida por Computador/instrumentación , Adulto , Anciano , Terapia Combinada/instrumentación , Terapia Combinada/métodos , Terapia por Estimulación Eléctrica/métodos , Diseño de Equipo , Análisis de Falla de Equipo , Femenino , Insuficiencia Cardíaca/diagnóstico , Humanos , Hipertensión/diagnóstico , Masculino , Persona de Mediana Edad , Terapia Asistida por Computador/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: This review was performed to pool the current surgical strategies for cardiac liposarcoma. METHODS: A literature search was performed and all studies published in full-text or abstract forms were eligible for inclusion without applying any language restrictions. Case reports without surgical intervention, reporting noncardiac liposarcoma, animal cases, or review articles were excluded after initial abstract review. Analyzed postoperative outcomes included intraoperative and in-hospital mortality, longest reported survival, and recrudescence. RESULTS: After a critical evaluation 53 unique surgically treated case reports published between the years 1966 and December 2012 were included in this review. Most of the reported cardiac liposarcoma are myxoid (49.1%), pleomorphic liposarcoma occur with a prevalence of 20.8%, and well-differentiated tumors are observed in 13.2%. One-year survival rate increases the more differentiated the tumor is categorized: 54.5% for pleomorphic, 65.4% for myxoid, and 100% for well-differentiated liposarcoma (p = 0.096). CONCLUSION: Total surgical resection of cardiac liposarcoma is the only curative option, as it tends to local and distant recurrence. Therefore, a frequent follow-up examination should be considered.
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Procedimientos Quirúrgicos Cardíacos , Neoplasias Cardíacas/cirugía , Liposarcoma/cirugía , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Quimioradioterapia Adyuvante , Angiografía Coronaria , Femenino , Neoplasias Cardíacas/patología , Humanos , Liposarcoma/secundario , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Resultado del TratamientoRESUMEN
BACKGROUND: We assessed the short-term outcomes and predictors of 30-d mortality in patients requiring temporary, peripheral extracorporeal membrane oxygenation (ECMO) for postcardiotomy cardiac failure. METHODS: The data were retrospectively obtained using our institutional patient database. All patients who had received peripheral ECMO support after surgery for acquired heart disease from 2006 to 2010 were included in the present study. The demographic and perioperative variables of the 30-d survivors and nonsurvivors were compared using the chi-square and t-test, and multivariate logistic regression analysis was performed to identify the predictors of 30-d all-cause mortality. RESULTS: A total of 77 patients with a mean age of 60 ± 13 years were included in the present analysis. Successful weaning from peripheral ECMO was achieved in 62% after 79 ± 57 h of ECMO support. The overall 30-d mortality rate was 70%, and mortality was reduced to 52% in the patients in whom ECMO support could be weaned successfully. Age (per year) at ECMO implantation was the only independent preoperative predictor of 30-d mortality (odds ratio 1.09, 95% confidence interval 1.03-1.15; P = 0.003). In addition, greater lactate levels after 24 h of ECMO therapy, a longer duration of ECMO support, and the presence of any ECMO-related or gastrointestinal complications were independent predictive factors for 30-d mortality (P < 0.05). CONCLUSIONS: ECMO therapy provides a valuable therapeutic strategy for postcardiotomy myocardial failure but is still limited by high complication rates with fewer than 30% of patients discharged from the hospital. Patient age appears to be an essential preoperative predictor for mortality, and the blood lactate level is a relevant marker for the assessment of efficient ECMO support.
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Procedimientos Quirúrgicos Cardíacos , Oxigenación por Membrana Extracorpórea/métodos , Complicaciones Posoperatorias/terapia , Choque Cardiogénico/terapia , Adulto , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Oxigenación por Membrana Extracorpórea/mortalidad , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Choque Cardiogénico/etiología , Choque Cardiogénico/mortalidad , Resultado del TratamientoRESUMEN
BACKGROUND/PURPOSE: Recent evidence suggests that statin-mediated cardioprotection after chronic statin therapy decreases over time and can be reactivated by preprocedural high-dose statin reloading therapy. We tested in a porcine cardiopulmonary bypass (CPB) model whether statin-related cardioprotection is further enhanced by a preoperative rosuvastatin reloading therapy. METHODS: Control (n = 6), rosuvastatin-pretreated (n = 6; 20 mg/day for 7 days p.o.) and rosuvastatin-reloaded (n = 6; p.o. treatment plus 0.10 mg/kg/h i.v. during surgery) pigs (Deutsche Landrasse) were subjected to CPB for 2 h with 1 h of cardioplegic cardiac arrest. Systemic hemodynamics, cardiac index (CI), coronary blood flow (CBF) and left ventricular (LV) function [pressure-volume area (PVA), preload recruitable stroke work (PRSW)] were determined before and 4 h after CPB. Myocardial expression (PCR) and protein content (Western blot) of endothelial NO synthase (eNOS) and phosphatase and tensin homolog deleted on chromosome ten (PTEN) were measured, and right coronary relaxation was assessed postmortem. All data are given as mean ± SD. RESULTS: Preoperative plasma LDL, HDL and cholesterol did not differ between treatment groups. Compared to control, oral treatment improved post-CPB CI, CBF, first derivative of maximal LV-pressure (LVdp/dt) and PVA (p < 0.05). Significant enhancement was achieved with perioperative reloading therapy (CI: 5.2 ± 1.0 vs. 3.9 ± 1.5 l/min/m(2); CBF: 76 ± 32 vs. 43 ± 8 ml/min; LVdp/dt: 1,980 ± 333 vs. 1,249 ± 461 mm Hg/s; PVA: 6,954 ± 941 vs. 3,252 ± 1,822 mm Hg·ml; p < 0.05) with improved in vitro NO-dependent coronary relaxation (102 ± 10 vs. 79 ± 14%; p = 0.003). Irrespective of recapture therapy statin pretreatment augmented myocardial eNOS and PTEN (p < 0.05), but failed to increase cardiac eNOS or PTEN expression after CPB. CONCLUSIONS: Periprocedural statin reloading therapy enhances myocardial and coronary function after cardiac surgery with CPB and may therefore provide a valuable therapeutic approach for the reduction of myocardial ischemia-reperfusion injury.