Silent brain infarcts and early cognitive outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis.

BACKGROUND: Silent brain infarcts (SBIs) are frequently identified after transcatheter aortic valve implantation (TAVI), when patients are screened with diffusion-weighted magnetic resonance imaging (DW-MRI). Outside the cardiac literature, SBIs have been correlated with progressive cognitive dysfunction; however, their prognostic utility after TAVI remains uncertain. This study's main goals were to explore (i) the incidence of and potential risk factors for SBI after TAVI; and (ii) the effect of SBI on early post-procedural cognitive dysfunction (PCD). METHODS AND RESULTS: A systematic literature review was performed to identify all publications reporting SBI incidence, as detected by DW-MRI after TAVI. Silent brain infarct incidence, baseline characteristics, and the incidence of early PCD were evaluated via meta-analysis and meta-regression models. We identified 39 relevant studies encapsulating 2408 patients. Out of 2171 patients who underwent post-procedural DW-MRI, 1601 were found to have at least one new SBI (pooled effect size 0.76, 95% CI: 0.72-0.81). The incidence of reported stroke with focal neurological deficits was 3%. Meta-regression noted that diabetes, chronic renal disease, 3-Tesla MRI, and pre-dilation were associated with increased SBI risk. The prevalence of early PCD increased during follow-up, from 16% at 10.0 ± 6.3 days to 26% at 6.1 ± 1.7 months and meta-regression suggested an association between the mean number of new SBI and incidence of PCD. The use of cerebral embolic protection devices (CEPDs) appeared to decrease the volume of SBI, but not their overall incidence. CONCLUSIONS: Silent brain infarcts are common after TAVI; and diabetes, kidney disease, and pre-dilation increase overall SBI risk. While higher numbers of new SBIs appear to adversely affect early neurocognitive outcomes, long-term follow-up studies remain necessary as TAVI expands to low-risk patient populations. The use of CEPD did not result in a significant decrease in the occurrence of SBI.

An intensivist-led ECMO accreditation pathway and safety data over the first 4 years.

Objective: To describe the training and accreditation process behind an intensivist-led extracorporeal membrane oxygenation (ECMO) cannulation program, and identify the rate of complications associated with the ECMO cannulation procedure. Design: A narrative review of the accreditation process, and a retrospective review of complications related to cannulation during the first four years of the intensivist program. Setting: Royal Prince Alfred Hospital, a quaternary referral hospital in Sydney. Participants: All patients initiated onto ECMO during the first four years of the intensivist cannulation program (August 2018 to August 2022).Main outcome measures: All cases were reviewed for identification of 14 pre-defined adverse events which were classified as low, medium or high clinical significance complications. Results: A total of 402 cannulations were attempted by the intensivist group in 194 separate cannulation episodes involving 179 patients. This included 93 V-V initiations, 69 V-A initiations (36 of these ECMO-CPR), 3 V-AV (veno-arteriovenous) initiations, 25 ECMO reconfigurations and four patients cannulated for peripheral cardiopulmonary bypass in cardiothoracic theatre. One of the 402 cannulations was halted as resuscitation was ceased, and one was halted and the patient transferred to theatre for central arterial cannulation. 394 out of the remaining 400 cannulations were successful (98.5%). Of 402 total cannulations, 32 complication events occurred (7.96% event rate), of which 15 (3.7% event rate) were low significance complications, 10 medium significance (2.5% event rate), and seven high clinical significance (1.7% event rate). Conclusions: Our experience of the first four years of an intensivist-led ECMO service demonstrates that our training process and cannulation technique result in the provision of a complex therapy with low levels of complications, on par with those in the published literature.

Implementing enhanced extracorporeal membrane oxygenation for CPR (ECPR) in the emergency department.

Refractory out-of-hospital cardiac arrest (OHCA) has a very poor prognosis, with survival rates at around 10%. Extracorporeal membrane oxygenation (ECMO) for patients in refractory arrest, known as ECPR, aims to provide perfusion to the patient whilst the underlying cause of arrest can be addressed. ECPR use has increased substantially, with varying survival rates to hospital discharge. The best outcomes for ECPR occur when the time from cardiac arrest to implementation of ECPR is minimised. To reduce this time, systems must be in place to identify the correct patient, expedite transfer to hospital, facilitate rapid cannulation and ECMO circuit flows. We describe the process of activation of ECPR, patient selection, and the steps that emergency department clinicians can utilise to facilitate timely cannulation to ensure the best outcomes for patients in refractory cardiac arrest. With these processes in place our survival to hospital discharge for OHCA patients is 35%, with most patients having a good neurological function.

Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study.

BACKGROUND: A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program. METHODS: A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale). RESULTS: 35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance. CONCLUSIONS: We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues.

Management of a Mycotic Right Coronary Artery Aneurysm With Contained Rupture.

Infected coronary artery aneurysm is a rare complication of bacteremia with significant risk of mortality. We describe a case where contained rupture had caused purulent pericarditis and an alternative surgical approach to management was required as aortocoronary bypass grafting was unfeasible. (Level of Difficulty: Advanced.).

One-Year Outcomes of Early, Compassionate Use of the PASCAL Ace Implant System for Transcatheter Mitral Valve Repair.

Background: Continued development of transcatheter mitral repair technologies is needed to address the large and diverse population of high-risk patients with symptomatic mitral regurgitation (MR). The new PASCAL Ace implant system, with its narrower profile, complements the original PASCAL transcatheter valve repair system. The aim of this study is to report 1-year outcomes from the early, compassionate-use observational experience with the novel PASCAL Ace implant system. Methods: After heart team assessment, adults with symptomatic moderate-to-severe (3+) or severe (4+) MR despite optimal medical therapy were treated under compassionate use at 3 hospitals internationally. Data were prospectively collected, and outcomes were assessed over a 12-month follow-up period. Results: Seventeen patients (mean age 76 years, 65% male, mean Society of Thoracic Surgeons Predicted Risk of Operative Mortality score 9.6) were treated. MR etiology was degenerative in 29%, functional in 65%, and mixed in 6%; 59% were in New York Heart Association (NYHA) class III-IV. Technical success was achieved in 100%, and procedural success in 94%. At 1 year, MR grade ≤2+ was achieved in 93% (p < 0.001) with 88% survival rate and 94% free from heart failure hospitalization. The composite major adverse event rate was 6% and 100% of patients had ≤NYHA class II symptoms (p < 0.001). Conclusions: At 1 year, the PASCAL Ace implant system demonstrated feasibility in this early, compassionate use experience in a small group of symptomatic patients with anatomically complex MR. The unique features of the PASCAL Ace implant may expand the treatable MR population.

Long-term outcomes of adults with acute respiratory failure treated with veno-venous extracorporeal membrane oxygenation.

Veno-venous extracorporeal membrane oxygenation is increasingly used for severe but potentially reversible acute respiratory failure in adults; however, there are limited data regarding long-term morbidity. At our institution, most patients requiring veno-venous extracorporeal membrane oxygenation have been followed up by a single physician. Our primary aim was to describe the serial long-term morbidity for respiratory, musculoskeletal and psychological functioning.A retrospective audit of inpatient and outpatient medical records was conducted. A total of 125 patients treated with veno-venous extracorporeal membrane oxygenation for primary respiratory failure were included. The patients were young (mean (standard deviation) age 43.7 (4.1) years), obese (mean (standard deviation) body mass index 30.8 (10.4) kg/m2), and mostly were male (59%). Most patients (60%) had no comorbidities.The survival rate to discharge was 70%, with body mass index and the number of comorbidities being independent predictors of survival on multiple logistic regression analysis. Over half (57%) of the Australian survivors had regular outpatient follow-up. They had a median of three reviews (range 1-9) over a median of 11.8 months (range 1.5-79) months. Breathlessness and weakness resolved in most within six months, with lung function abnormalities taking longer to resolve. Over half (60%) returned to employment within six months of discharge. Over a quarter (29%) displayed symptoms of anxiety, depression or post-traumatic stress disorder.

Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome.

CONTEXT: The novel influenza A(H1N1) pandemic affected Australia and New Zealand during the 2009 southern hemisphere winter. It caused an epidemic of critical illness and some patients developed severe acute respiratory distress syndrome (ARDS) and were treated with extracorporeal membrane oxygenation (ECMO). OBJECTIVES: To describe the characteristics of all patients with 2009 influenza A(H1N1)-associated ARDS treated with ECMO and to report incidence, resource utilization, and patient outcomes. DESIGN, SETTING, AND PATIENTS: An observational study of all patients (n = 68) with 2009 influenza A(H1N1)-associated ARDS treated with ECMO in 15 intensive care units (ICUs) in Australia and New Zealand between June 1 and August 31, 2009. MAIN OUTCOME MEASURES: Incidence, clinical features, degree of pulmonary dysfunction, technical characteristics, duration of ECMO, complications, and survival. RESULTS: Sixty-eight patients with severe influenza-associated ARDS were treated with ECMO, of whom 61 had either confirmed 2009 influenza A(H1N1) (n = 53) or influenza A not subtyped (n = 8), representing an incidence rate of 2.6 ECMO cases per million population. An additional 133 patients with influenza A received mechanical ventilation but no ECMO in the same ICUs. The 68 patients who received ECMO had a median (interquartile range [IQR]) age of 34.4 (26.6-43.1) years and 34 patients (50%) were men. Before ECMO, patients had severe respiratory failure despite advanced mechanical ventilatory support with a median (IQR) Pao(2)/fraction of inspired oxygen (Fio(2)) ratio of 56 (48-63), positive end-expiratory pressure of 18 (15-20) cm H(2)O, and an acute lung injury score of 3.8 (3.5-4.0). The median (IQR) duration of ECMO support was 10 (7-15) days. At the time of reporting, 48 of the 68 patients (71%; 95% confidence interval [CI], 60%-82%) had survived to ICU discharge, of whom 32 had survived to hospital discharge and 16 remained as hospital inpatients. Fourteen patients (21%; 95% CI, 11%-30%) had died and 6 remained in the ICU, 2 of whom were still receiving ECMO. CONCLUSIONS: During June to August 2009 in Australia and New Zealand, the ICUs at regional referral centers provided mechanical ventilation for many patients with 2009 influenza A(H1N1)-associated respiratory failure, one-third of whom received ECMO. These ECMO-treated patients were often young adults with severe hypoxemia and had a 21% mortality rate at the end of the study period.

Blunt cardiac rupture in the setting of previous sternotomy.

Most cases of blunt cardiac rupture (BCR) are associated with mortality at the scene of the injury. For the fortunate 13% to 17% of patients who survive the journey to the hospital, the treatment is definitive surgical repair. In the setting of previous sternotomy, the pericardial adhesions may limit the damage and protect against cardiac tamponade. We describe a patient who sustained 2 right ventricular tears from blunt trauma in a motor vehicle accident 18 years after coronary artery bypass graft surgery. He did not demonstrate hemodynamic compromise and was successfully managed conservatively.