The role of tissue Doppler imaging in predicting left ventricular filling pressures in patients undergoing cardiac surgery: an intraoperative study.

INTRODUCTION: The perioperative management of patients undergoing cardiac surgery usually requires the accurate assessment of left ventricular filling pressures (LVFP). The gold standard for determining LVFP involves the use of pulmonary artery catheters (PAC). Using tissue Doppler indices (TDI) obtained by transthoracic echocardiography, the ratio of early transmitral filling velocity to the corresponding early mitral annular velocity (E/E') has a strong correlation with pulmonary capillary wedge pressure (PCWP). Little is known, however, on whether this relationship between E/E' and PCWP is valid intraoperatively using transesophageal echocardiography (TEE) during cardiac surgery. OBJECTIVE: The objective of our study was to determine whether TDI obtained by intraoperative TEE during cardiac surgery can accurately estimate PCWP using PAC as the gold standard. METHODS AND RESULTS: A total of 34 patients (26 males, mean age 64 ± 9 years) undergoing cardiac surgery were prospectively enrolled between 2010 and 2011 at a single tertiary care center. Conventional diastolic and tissue Doppler parameters were evaluated using intraoperative TEE with concurrent PAC monitoring before and after cardiopulmonary bypass (CPB) surgery. At both pre- and post-CPB, there was no significant correlation between lateral, septal, and mean E/E' obtained by TEE and PCWP. CONCLUSION: Intraoperative TEE was unable to accurately predict LVFP in patients undergoing cardiac surgery. PAC may continue to be the gold standard in the assessment of LVFP for this patient population.

Bilateral subdural hematoma after inadvertent dural puncture during epidural analgesia.

BACKGROUND: Post-dural puncture headache (PDPH) is typically a benign complication of dural puncture that is clinically diagnosed. It commonly presents as a throbbing and positional headache that occurs 24-48 h after dural puncture. Subdural hematomas, if unrecognized, may occur as a rare and life-threatening complication of dural puncture. OBJECTIVES: We aim to describe the clinical features and sequelae of a rare complication that may result as a consequence of inadvertent dural puncture that, if unrecognized, has the potential to become a life-threatening complication from a common procedure. CASE REPORT: We report the case of a previously healthy 17-year-old primigravida female who initially presented 4 days postpartum with clinical features and imaging studies consistent with PDPH. The patient's symptoms were unremitting, and within 4 weeks, she developed bilateral subdural hematoma. With prompt recognition and diagnosis, she was treated with conservative medical management and subsequently improved on follow-up. CONCLUSION: Patients with unremitting PDPH should prompt the clinician to suspect the development of subdural hematoma as a potential life-threatening complication of an otherwise benign condition.

Key performance indicators in extracorporeal membrane oxygenation (ECMO): protocol for a systematic review.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is an intervention used in critically ill patients with severe cardiopulmonary failure that is expensive and resource intensive and requires specialised care. There remains a significant practice variation in its application. This systematic review will assess the evidence for key performance indicators (KPIs) in ECMO. METHODS AND ANALYSIS: We will search Ovid MEDLINE, Ovid EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and databases from the National Information Center of Health Services Research and Health Care Technology, for studies involving KPIs in ECMO. We will rate methodological quality using the Newcastle-Ottawa Quality Assessment Scale. Randomized controlled trials (RCTs) will be evaluated with the Cochrane Risk of Bias tool, and qualitative studies will be evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN checklist). Grey literature sources will be searched for technical reports, practice guidelines and conference proceedings. We will identify relevant organisations, industry leaders and non-profit organisations that represent key opinion leads in the use of ECMO. We will search the Agency of Healthcare Research and Quality National Quality Measures Clearinghouse for ECMO-related KPIs. Studies will be included if they contain quality measures that occur in critically ill patients and are associated with ECMO. The analysis will be primarily descriptive. Each KPI will be evaluated for importance, scientific acceptability, utility and feasibility using the four criteria proposed by the US Strategic Framework Board for a National Quality Measurement and Reporting System. Finally, KPIs will be evaluated for their potential operational characteristics, their potential to be integrated into electronic medical records and their affordability, if applicable. ETHICS AND DISSEMINATION: Ethical approval is not required as no primary data will be collected. Findings will be published in a peer-reviewed journal and presented at academic. PROSPERO REGISTRATION NUMBER: 9 August 2022. CRD42022349910.

The impact of repeated marathon running on cardiovascular function in the aging population.

BACKGROUND: Several studies have correlated elevations in cardiac biomarkers of injury post marathon with transient and reversible right ventricular (RV) systolic dysfunction as assessed by both transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR). Whether or not permanent myocardial injury occurs due to repeated marathon running in the aging population remains controversial. OBJECTIVES: To assess the extent and severity of cardiac dysfunction after the completion of full marathon running in individuals greater than 50 years of age using cardiac biomarkers, TTE, cardiac computed tomography (CCT), and CMR. METHODS: A total of 25 healthy volunteers (21 males, 55 ± 4 years old) from the 2010 and 2011 Manitoba Full Marathons (26.2 miles) were included in the study. Cardiac biomarkers and TTE were performed one week prior to the marathon, immediately after completing the race and at one-week follow-up. CMR was performed at baseline and within 24 hours of completion of the marathon, followed by CCT within 3 months of the marathon. RESULTS: All participants demonstrated an elevated cTnT post marathon. Right atrial and ventricular volumes increased, while RV systolic function decreased significantly immediately post marathon, returning to baseline values one week later. Of the entire study population, only two individuals demonstrated late gadolinium enhancement of the subendocardium in the anterior wall of the left ventricle, with evidence of stenosis of the left anterior descending artery on CCT. CONCLUSIONS: Marathon running in individuals over the age of 50 is associated with a transient, yet reversible increase in cardiac biomarkers and RV systolic dysfunction. The presence of myocardial fibrosis in older marathon athletes is infrequent, but when present, may be due to underlying occult coronary artery disease.

Multimodality imaging of anomalous pulmonary veins.

Partial anomalous pulmonary venous connection (PAPVC) is an extremely rare congenital condition where one or more of the pulmonary veins are connected to the venous circulation. Although initially suspected with unexplained right ventricular enlargement on transthoracic echocardiography (TTE), cardiac MRI is able to delineate the anatomical variant. We present a case of a 65-year-old male diagnosed with left sided PAPVC using multimodality cardiac imaging.

Critical Care Management of the Acute Postimplant LVAD Patient.

Left ventricular assist devices (LVADs) improve survival and quality of life in refractory end-stage heart failure. However, the therapy itself is associated with some degree of morbidity and mortality at highest risk during the first 30 days postimplantation. Management of the patient with a freshly implanted LVAD requires an in-depth understanding of the acute postimplant period and common critical care issues including coagulopathy, hemodynamic lability, and metabolic derangements. This requires meticulous hemostatic control and a firm understanding of hemodynamic principles that focus on optimizing end-organ perfusion, right-ventricular function, and measured LVAD titration. This contemporary practical guide to management of the acute postimplant LVAD patient includes a focused approach to troubleshooting common LVAD issues that may arise from the operating room to discharge from critical care.

Resuscitative extracorporeal membrane oxygenation for in hospital cardiac arrest: a Canadian observational experience.

BACKGROUND: Among patients with reversible conditions who sustain cardiac arrest, extracorporeal membrane oxygenation (ECMO) may support end organ perfusion while bridging to definitive therapy. METHODS: A single center retrospective review (February 2008­September 2013) of adults receiving ECMO for cardiac arrest ≥15 min duration refractory to conventional management (E-CPR) or profound cardiogenic shock following IHCA (E-CS) was conducted. The primary outcome was 30-day survival with good neurologic function defined as a cerebral performance category (CPC) of 1­2. Secondary outcomes included intensive care unit (ICU) and hospital length of say, duration of mechanical ventilation, and univariate predictors of 30-day survival with favorable neurologic function. RESULTS: Thirty-two patients (55 ± 11 years, 66% male) were included of which 22 (69%) received E-CPR and 10 (31%) received E-CS following return of spontaneous circulation (ROSC). Cardiac arrest duration was 48.8 ± 21 min for those receiving E-CPR and 25 ± 23 min for the E-CS group. Patients received ECMO support for 70.7 ± 47.6 h. Death on ECMO support occurred in 7 (21.9%) patients, while 7 (21.9%) were bridged to another form of mechanical circulatory support, and 18 (56.3%) were successfully decannulated. ICU length of stay was 7.5 [3.3­14] days and ICU survival occurred in 16 (50%) of patients. 30-Day survival was 5 (50%) in the E-CS group, 10 (45.4%) in the E-CPR group, and 15 (47%) overall. All survivors had CPC 1­2 neurologic status. CONCLUSION: In this single center experience, the use of resuscitative ECMO was associated with neurologically favorable 30-day survival in 47% of patients with prolonged IHCA (H2012:172).