Treatment of type A dissection: Searching for the Holy Grail.

Current principles of surgical treatment of type A dissections are for the most part based on best evidence practice for the lack of controlled randomized studies providing definitive scientific evidence. Despite its widespread use, axillary cannulation still remains a debated topic as the preferred method of cannulation and perfusion strategy in the treatment of this complex condition.

Bedside veno-venous ECMO cannulation: A pertinent strategy during the COVID-19 pandemic.

BACKGROUND: Patient selection and cannulation arguably represent the key steps for the successful implementation of extracorporeal membrane oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real-time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients' critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite. AIMS: Therefore, with the objective of avoiding delay with the initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation. MATHERIAL AND METHODS: A total of 89 patients required ECMO support at Hennepin County Medical Center between March 2015 and December 2019. Twenty-eight (31%) required veno-venous support and were all cannulated at the bedside. Overall survival was 71% with no morbidity or mortality related to the cannulation procedure. CONCLUSION: In the current pandemic, the strategy of veno-venous bedside cannulation may have additional benefits for the care of patients with refractory acute respiratory distress syndrome due to coronavirus-disease-2019, decreasing the risk of exposure of health care worker or other patients to the novel severe acute respiratory syndrome coronavirus-2 occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation.

Clevidipine versus sodium nitroprusside in acute aortic dissection: A retrospective chart review.

AIM: Intravenous vasodilators are often added to beta-blocking agents to reach blood pressure (BP) goals in aortic dissection. Control of BP using clevidipine has been described in hypertensive emergencies and cardiac surgery but not in aortic dissection. The aim of this study was to compare clevidipine versus sodium nitroprusside (SNP) as adjunct agents to esmolol for BP management in aortic dissection. METHODS: A single-center retrospective chart review evaluated patients diagnosed with aortic dissection. The primary outcome measure was time to reach patient specific systolic blood pressure (SBPPT) goals after initiation of esmolol infusion. Efficacy of clevidipine and SNP was assessed using area under the curve analysis of positive and negative excursions outside of SBPPT goals (AUCSBPe). Cost data was calculated using average wholesale price in U.S. dollars. RESULTS: Fourteen patients were included in final analyses. Median systolic BP immediately prior to initiation of esmolol was 162mm Hg vs 161mm Hg for clevidipine and SNP groups, respectively (p=0.99). Median time to reach SBPPT goal was similar between clevidipine and SNP (1.68 versus 1.03h [p=0.99]). Median AUCSBPe was similar for clevidipine and SNP (206.9 versus 538.9 mm Hg∗min∗hr-1 [p=0.11]). Cost was significantly reduced using clevidipine versus SNP ($1223.28/day versus $7674.24/day [p<0.001]). CONCLUSIONS: Clevidipine administration during initial medical management of aortic dissection showed similar efficacy compared to SNP when used as adjunct therapy to esmolol. These data suggest clevidipine is a less costly, reasonable alternative to SNP in acute aortic dissection as adjunct therapy to esmolol. Further studies are needed to validate these results.

COLLABORADI: a rule-based diagnostic imaging prescription system to help the general practitioner to choose the most appropriate radiological imaging procedures.

Significant advances in medical imaging have been made in the past decades, enabling physicians to reach high precision in diagnosing patients' diseases by means of sophisticated imaging tools. However, the use of sophisticated tools is limited by the high costs and, in some cases, by the utilization of ionizing radiation, which have both great impact on the economy of a nation and on citizens' health, respectively. Guidelines have been published among countries to provide physicians with structured rules to be followed to suggest the correct imaging technique, suiting better the diagnostic question and avoiding inappropriate imaging requests. The COLLABORADI is a research project that addressed the phenomenon of inappropriate imaging prescriptions in Sicily (Italy) and proposed the design and implementation of a clinical decision support system to help physicians to set up the most appropriate diagnostic route for their patients. The aim of this paper is to describe the characteristics of the COLLABORADI software and its potential impact in diminishing inappropriate imaging.

Real-world outcomes of hemostatic matrices in cardiac surgery.

OBJECTIVE: While hemostatic matrices are efficacious in achieving hemostasis, outcomes research is limited; therefore, this study analyzed clinical outcomes of flowable hemostatic matrices in a real-world cardiac surgical population. DESIGN: Retrospective database analysis of cardiac surgical cases from 2006 to 2012. SETTING: Data were extracted from Premier's United States (US) Perspective Database, developed for quality and utilization benchmarking and containing approximately 25% of US hospital discharges. PARTICIPANTS: Coronary artery bypass grafting (CABG), aortic, valve, or valvular with CABG surgery cases in which FLOSEAL or SURGIFLO was included. INTERVENTIONS: Three study groups were formed, given usage of hemostatic matrices: (1) FLOSEAL or SURGIFLO, exclusively; (2) FLOSEAL or SURGIFLO, with fibrin sealants, sealants, or powder hemostats; and (3) FLOSEAL or SURGIFLO, with nonflowable hemostats with or without thrombin. Outcomes included complications, transfusions, surgical revisions, mortality, length of stay (LOS) and surgery time. MEASUREMENTS AND MAIN RESULTS: Group A included 4,480 FLOSEAL and 326 SURGIFLO cases. Results suggested SURGIFLO cases were associated with significantly higher risk of multiple adverse outcomes, including major (odds Ratio [OR] 2.12; 95% CI 1.34-3.35; p = 0.001) and minor complications (OR 1.84; 95% CI 1.33-2.55; p<0.001); surgical revisions (OR 2.01; 95% CI 1.03- 3.94; p = 0.042); transfusions for any blood products (OR 4.90; 95% CI 3.50-6.87; p<0.001); and longer surgery times (adjusted mean difference = 64 minutes, p<0.001) than the FLOSEAL group. There were no significant differences in mortality and LOS. Results were similar in groups B and C. CONCLUSIONS: These retrospective outcomes suggested FLOSEAL was associated with fewer negative consequences than SURGIFLO in this surgical population.

Policy-Based Holistic Application Management with BPMN and TOSCA.

With the wide adoption of cloud computing across technology industries and research institutions, an ever-growing interest in cloud orchestration frameworks has emerged over the past few years. These orchestration frameworks enable the automated provisioning and decommissioning of cloud applications in a timely and efficient manner, but they offer limited or no support for application management. While management functionalities, such as configuring, monitoring and scaling single components, can be directly covered by cloud providers and configuration management tools, holistic management features, such as backing up, testing and updating multiple components, cannot be automated using these approaches. In this paper, we propose a concept to automatically generate executable holistic management workflows based on the TOSCA standard. The practical feasibility of the approach is validated through a prototype implementation and a case study.

A revised landslide inventory of the Campania region (Italy).

Landslides represent a severe geohazard in many countries. The availability of inventories depicting the spatial and temporal distribution of landslides is crucial for assessing landslide susceptibility and risk for territorial planning or investigating landscape evolution. Nevertheless, these inventories are usually affected by limitations due to their nonpublic availability and inhomogeneities in characterization and mapping. Such problems are fully recognizable by the analysis of the multiple landslide inventories of the Campania region, which is one of the Italian regions with the highest exposure to landslide hazard and risk. On this basis, a revised Landslide Inventory of the Campania region (LaICa), resulting from the processing of multiple existing landslide inventories, has been reconstructed. It aims to (i) provide a new geodatabase that is able to overcome issues derived from the coexistence of multiple inventories and (ii) provide a methodological paradigm able to support the reorganization of existing official inventories. The implication of LaICa, with its 83,284 records, will possibly improve the assessment of landslide susceptibility and then reassess the related risk.

Management of Perioperative Iron Deficiency in Cardiac Surgery: A Modified RAND Delphi Study.

BACKGROUND: Over the last decade, preoperative anemia has become recognized as a clinical condition in need of management. Although the etiology of preoperative anemia can be multifactorial, two thirds of anemic elective surgical patients have iron deficiency anemia. At the same time, one third of nonanemic elective surgical patients are also iron deficient. METHODS: Modified RAND Delphi methodology was used to identify areas of consensus among an expert panel regarding the management of iron deficiency in patients undergoing cardiac surgery. A list of statements was sent to panel members to respond to using a five-point Likert scale. All panel members subsequently attended a face-to-face meeting. The initial survey was presented and discussed, and panel members responded to each statement on the Likert scale again. Based on the second survey, the panel came to a consensus on recommendations. RESULTS: The panel recommended all patients undergoing cardiac surgery be evaluated for iron deficiency, whether or not anemia is present. Evaluation should include iron studies and reticulocyte hemoglobin content. If iron deficiency is present, with or without anemia, patients should receive parenteral iron. Erythropoietin-stimulating agents may be appropriate for some patients. CONCLUSIONS: Consensus of an expert panel resulted in a standardized approach to diagnosing and managing iron deficiency in patients undergoing cardiac surgery.

Is Compliance With Guideline Recommended Follow-Up After Aortic Dissection Associated With Survival?

BACKGROUND: Patients with acute aortic dissection (AD) remain at risk for long-term complications and thus are recommended to adhere closely to American College of Cardiology and American Heart Association aorta guideline-based follow-up imaging and clinic visits. The long-term outcomes of compliance with such a model are not well understood. METHODS: This was a retrospective cohort study of patients at a regional AD center who survived hospital discharge for AD and who were analyzed by compliance with initial follow-up at 3 months and long term after AD. The primary end point was death. RESULTS: A total of 172 (66% type A; 33% type B) patients survived hospitalization and were followed up over 48 months (interquartile range [IQR], 21, 88 months). Of these patients, 122 (71%) attended the first follow-up appointment, and 90 (52%) attended more than two-thirds of recommended appointments. Patients who attended the first follow-up visit had improved long-term follow-up compliance (75% [IQR, 50%, 91%]) compared with patients who did not attend the first visit (18% [IQR, 0%, 57%]). Noncompliance with the scheduled long-term follow-up was associated with a 50% increase in the risk of death (hazard ratio, 1.6; 95% confidence interval, 1.2, 2.1; P < .001). Furthermore, in patients with low compliance (consistently attending less than one-third of follow-up appointments), the lifetime risk of death after AD was more than double that of patients with high compliance (consistently attending more than two-thirds of appointments) (hazard ratio, 2.2; 95% confidence interval, 1.5, 3.1; P < .001). CONCLUSIONS: Nearly one-third of patients with AD do not attend the first recommended follow-up visit, and such failure was associated with later noncompliance with subsequent follow-up. Low-compliant patients have double the lifetime risk of death after AD than do high-compliant patients.

Repair of an ascending aortic aneurysm using reduction aortoplasty in a Jehovah's Witness.

Reduction ascending aortoplasty has been advocated as a possible alternative to traditional graft replacement for treatment of aneurysms of the ascending aorta and root. We report a case of a 58-year-old Jehovah's Witness female, with a 5.5-cm ascending aortic aneurysm and critical aortic stenosis. She underwent aortic valve replacement and reduction aortoplasty buttressed with a Dacron graft. We reviewed the history and contemporary applications of this technique and concluded that aortic reduction with externally supported aortoplasty may represent a viable option to treat Jehovah's Witness patients with ascending aorta and root aneurysm.

A case report of open-aorta, direct transcatheter valve-in-valve implantation: an innovative approach to manage the hazard of coronary flow compromise in transcatheter aortic valve re-interventions.

BACKGROUND: Coronary flow compromise is a significant risk of transcatheter aortic valve therapy. Warranting preservation of coronary flow is even more challenging with transcatheter aortic valve re-intervention since the implantation of a transcatheter valve within a degenerated bioprosthetic or transcatheter valve increases significantly this hazard. CASE SUMMARY: We present a case of heart failure secondary to transcatheter aortic valve degeneration requiring a transcatheter aortic valve re-intervention. Pre-operative imaging studies demonstrated a high risk for iatrogenic coronary flow impairment. The patient underwent a successful surgical removal of the prosthetic valve leaflets followed by direct transcatheter aortic valve implantation. CONCLUSION: We reviewed the literature on the approach to difficult coronaries in transcatheter aortic valve therapy, and we describe an innovative hybrid approach that may represent a viable alternative in cases where catheter techniques of coronary flow preservation are not applicable.

Findings of prosthetic valve endocarditis in the balloon-expandable trans-catheter aortic valve: review of the literature and tips of management.

Prosthetic valve endocarditis after transcatheter aortic valve implantation (TAVI) is a rare complication associated with a high mortality rate. Nonetheless, the rapid expansion of TAVI in recent years has proportionally increased the number of patients exposed to the risk of developing transcatheter valve infection. A 71-year-old female with recent history of TAVI was diagnosed with prosthetic valve obstruction secondary to endocarditis. The characteristics of clinical presentation of endocarditis in the balloon-expandable transcatheter valve and the intra-operative findings are discussed with a review of the literature and tips of management.

A novel methodology for Groundwater Flooding Susceptibility assessment through Machine Learning techniques in a mixed-land use aquifer.

Many areas around the world are affected by Groundwater Level rising (GWLr). One of the most severe consequences of this phenomenon is Groundwater Flooding (GF), with serious impacts for the human and natural environment. In Europe, GF has recently received specific attention with Directive 2007/60/EC, which requires Member States to map GF hazard and propose measures for risk mitigation. In this paper a methodology has been developed for Groundwater Flooding Susceptibility (GFS) assessment, using for the first time Spatial Distribution Models. These Machine Learning techniques connect occurrence data to predisposing factors (PFs) to estimate their distributions. The implemented methodology employs aquifer type, depth of piezometric level, thickness and hydraulic conductivity of unsaturated zone, drainage density and land-use as PFs, and a GF observations inventory as occurrences. The algorithms adopted to perform the analysis are Generalized Boosting Model, Artificial Neural Network and Maximum Entropy. Ensemble Models are carried out to reduce the uncertainty associated with each algorithm and increase its reliability. GFS is mapped by choosing the ensemble model with the best predictivity performance and dividing occurrence probability values into five classes, from very low to very high susceptibility, using Natural Breaks classification. The methodology has been tested and statistically validated in an area of 14,3 km2 located in the Metropolitan City of Naples (Italy), affected by GWLr since 1990 and GF in buildings and agricultural soils since 2007. The results of modeling show that about 93% of the inventoried points fall in the high and very high GFS classes, and piezometric level depth, thickness of unsaturated zone and drainage density are the most influencing PFs, in accordance with field observations and the triggering mechanism of GF. The outcomes provide a first step in the assessment of GF hazard and a decision support tool to local authorities for GF risk management.

Acute mesenteric and aortic thrombosis associated with antithrombin deficiency: a rare occurrence.

Antithrombin is a potent inhibitor of the coagulation cascade exerting its primary effects on activated factors X, IX and II. It is the mechanism by which heparin and low-molecular weight heparin cause anti-coagulation. Deficiency of antithrombin presents as a hypercoagulable state, and may result in unexplained deep venous thrombosis, arterial thrombosis and systemic embolization.

Severe Hypothermia and Frostbite Requiring ECMO and Four Limb Amputations.

Severe hypothermia and frostbite can result in significant morbidity and mortality. We present a case of a patient with severe hypothermia and frostbite due to cold exposure after a snowmobile crash. He presented in cardiac arrest with a core temperature of 19°C requiring prolonged cardiopulmonary resuscitation, active internal rewarming, venoarterial extracorporeal membrane oxygenation, and subsequently amputations of all four extremities. Although severe hypothermia and frostbite can be a fatal condition, the quick action of Emergency Medical Services, emergency physicians, trauma surgeons, cardiothoracic surgeons, intensivists, and the burn team contributed to a successful recovery for this patient including a good neurological outcome. This case highlights the importance of a strong interdisciplinary team in treating this condition.

Treatment of mediastinitis with wound-vacuum without muscle flaps.

Wound vacuum may represent a new solution to the treatment of patients with mediastinitis. We herein present case reports of two patients with very serious deep wound infections of the sternum (mediastinitis) treated with wound vacuum without muscle flaps. The implications of this new modality of treatment are discussed.

Valve-sparing aortic root remodeling with reinforcement of the proximal aortic suture-line.

Valve-sparing aortic root remodeling is associated with the risk of bleeding from the proximal aortic-graft suture line and subsequent annular dilation leading to aortic valve failure. Herein we describe a simple technique that may be used in valve-sparing root operations to prevent bleeding and improve annular stability.