Videolaryngoscope versus conventional technique for insertion of a transesophageal echocardiography probe in intubated ICU patients (VIDLARECO trial): A randomized clinical trial.

BACKGROUND: Transesophageal echocardiogram probe insertion in intubated critically ill patients can be difficult, leading to complications, such as gastric bleeding or lesions in the oropharyngeal mucosa. We hypothesised that the use of a videolaryngoscope would facilitate the first attempt at insertion of the transesophageal echocardiogram probe and would decrease the incidence of complications compared to the conventional insertion technique. METHODS: In this clinical trial, patients were randomly assigned the insertion of a transesophageal echocardiogram probe using a videolaryngoscope or conventional technique. The primary outcome was the successful transesophageal echocardiogram probe insertion on the first attempt. The secondary outcomes included total success rate, number of insertion attempts, and incidence of pharyngeal complications. RESULTS: A total of 100 intubated critically ill patients were enrolled. The success rate of transesophageal echocardiogram probe insertion on the first attempt was higher in the videolaryngoscope group than in the conventional group (90% vs. 58%; absolute difference, 32%; 95% CI 16%-48%; p < 0.001). The overall success rate was higher in the videolaryngoscope group than in the conventional group (100% vs. 72%; absolute difference, 28%; 95% CI 16%-40%; p < 0.001). The incidence of pharyngeal mucosal injury was smaller in the videolaryngoscope group than in the conventional group (14% vs. 52%; absolute difference, 38%; 95% CI 21%-55%; p < 0.001). CONCLUSIONS: Our study showed that in intubated critically ill patients required transesophageal echocardiogram, the use of videolaryngoscope resulted in higher successful insertion on the first attempt with lower rate of complications when compared with the conventional insertion technique. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04980976.

Clinical study of an outbreak of postoperative mediastinitis caused by Serratia marcescens in adult cardiac surgery.

OBJECTIVES: Nosocomial infection caused by Serratia marcescens after cardiac surgery is rare but causes high rates of morbidity and mortality. Knowledge about postoperative mediastinitis due to S. marcescens is limited. The purpose of this work was to study the clinical presentation, management and outcome of an outbreak of postoperative sternal infection due to S. marcescens. METHODS: During a 7-week period, a total of 54 patients underwent open heart procedures in our hospital. A postoperative wound infection caused by S. marcescens was diagnosed in 10 patients. We performed a clinical study to investigate patient characteristics and outcomes as well as the possible source of the infection. RESULTS: The mean age of the infected patients was 74.5 ± 10 years. Mediastinitis was present in 6 cases, superficial wound infection in 3 and isolated bacteraemia in 1. Purulent exudate through the sternal incision was observed in all infected cases except in 1 patient, who presented only with bacteraemia. Serratia marcescens was isolated from the samples taken from all infected wounds. The mean time elapsed between the operation and the isolation S. marcescens was 5.9 ± 2.4 days. Response to treatment was favourable in all cases except 1, who died. Contamination of the aqueous chlorhexidine solution used to prepare the patients' skin with S. marcescens was reported. Microbiological studies demonstrated that S. marcescens strains isolated from patients and from the aqueous chlorhexidine solution belonged to the same clone. CONCLUSIONS: The use of an aqueous chlorhexidine solution contaminated with S. marcescens caused an outbreak of postoperative sternal wound infections. The time elapsed between wound contamination and signs of infection was brief, but the systemic inflammatory response and tissue necrosis were limited. Alcohol-based solutions are recommended for the prevention of surgical site infections.

Floating thrombus in the ascending aorta causing repeated arterial embolisms.

Free-floating thrombus in an otherwise normal ascending aorta is a rare finding. We report the case of a 61-year-old woman admitted for brain and peripheral arterial embolisms. Echocardiography was not able to detect the source of embolus. Computed tomographic scan demonstrated a large floating mass attached to the posterior wall of the distal ascending aorta. The thrombus was successfully removed with the patient under deep hypothermic circulatory arrest. Some aspects regarding pathogenesis, diagnosis and treatment are discussed.

O trombo flutuante na aorta ascendente sem alterações degenerativas basais é um achado raro. Apresenta-se o caso de uma doente de 61 anos admitida por embolias cerebrais e periféricas. No ecocardiograma não foram detetadas alterações. A tomografia computorizada demonstrou uma massa flutuante na parede posterior da aorta ascendente distal. O trombo foi removido com sucesso com o doente em paragem circulatória hipotérmica. São discutidos aspetos relativos à patogénese, diagnóstico e tratamento.

Effects of dapagliflozin on human epicardial adipose tissue: modulation of insulin resistance, inflammatory chemokine production, and differentiation ability.

Aims: In patients with cardiovascular disease, epicardial adipose tissue (EAT) is characterized by insulin resistance, high pro-inflammatory chemokines, and low differentiation ability. As dapagliflozin reduces body fat and cardiovascular events in diabetic patients, we would like to know its effect on EAT and subcutaneous adipose tissue (SAT). Methods and results: Adipose samples were obtained from 52 patients undergoing heart surgery. Sodium-glucose cotransporter 2 (SGLT2) expression was determined by real-time polymerase chain reaction (n = 20), western blot, and immunohistochemistry. Fat explants (n = 21) were treated with dapagliflozin and/or insulin and glucose transporters expression measured. Glucose, free fatty acid, and adipokine levels (by array) were measured in the EAT secretomes, which were then tested on human coronary endothelial cells using wound healing assays. Glucose uptake was also measured using the fluorescent glucose analogue (6NBDG) in differentiated stromal vascular cells (SVCs) from the fat pads (n = 11). Finally, dapagliflozin-induced adipocyte differentiation was assessed from the levels of fat droplets (AdipoRed staining) and of perilipin. SGLT2 was expressed in EAT. Dapagliflozin increased glucose uptake (20.95 ± 4.4 mg/dL vs. 12.97 ± 4.1 mg/dL; P < 0.001) and glucose transporter type 4 (2.09 ± 0.3 fold change; P < 0.01) in EAT. Moreover, dapagliflozin reduced the secretion levels of chemokines and benefited wound healing in endothelial cells (0.21 ± 0.05 vs. 0.38 ± 0.08 open wound; P < 0.05). Finally, chronic treatment with dapagliflozin improved the differentiation of SVC, confirmed by AdipoRed staining [539 ± 142 arbitrary units (a.u.) vs. 473 ± 136 a.u.; P < 0.01] and perilipin expression levels (121 ± 10 vs. 84 ± 11 a.u.). Conclusions: Dapagliflozin increased glucose uptake, reduced the secretion of pro-inflammatory chemokines (with a beneficial effect on the healing of human coronary artery endothelial cells), and improved the differentiation of EAT cells. These results suggest a new protective pathway for this drug on EAT from patients with cardiovascular disease.

Orosomucoid secretion levels by epicardial adipose tissue as possible indicator of endothelial dysfunction in diabetes mellitus or inflammation in coronary artery disease.

OBJECTIVE: Type 2 diabetes mellitus (T2DM) is associated with fat and autonomic system dysfunction. Epicardial adipose tissue (EAT) plays an endocrine role over the heart. Since orosomucoid (ORM) has local actions around the coronaries, our aim was to assess the relationship between its secretion profile by EAT and its catecholaminergic regulation in patients with T2DM and coronary artery disease (CAD). METHODS: We obtained EAT, subcutaneous adipose tissue (SAT) and plasma from 55 patients undergoing cardiac surgery. Fat explants were stimulated with isoproterenol (ISO) 1 µM for 6 h. After, the fat explants released-ORM and plasma levels were analyzed by ELISA. mRNA or protein expression was analyzed by real time PCR or western blot, respectively. The effects of ORM on endothelial cells were analyzed by impedance and wound healing assays. RESULTS: We observed that EAT-released ORM levels were higher than SAT (328 ± 185 vs 58 ± 45 ng/mL; p < 0.001). Interestingly, EAT secretion was lower in patients with than those without T2DM (260 ± 141 vs 370 ± 194 ng/mL; p < 0.05) and this difference was enhanced after ISO stimulation (p < 0.01). However, plasma levels (412 ± 119 vs 594 ± 207 µg/mL) and EAT-released ORM levels were higher in patients with than those without CAD (384 ± 195 vs 279 ± 159 ng/mL; p < 0.05). ISO stimulation, also reduced the EAT released-ORM levels in patients with CAD. On human endothelial cells, ORM induced an increase of healing and proliferation in a dose-dependent manner. CONCLUSION: EAT-released ORM levels in patients with T2DM or CAD and its regulation by catecholamines might be the mirror of local endothelium dysfunction or inflammatory process in different cardiovascular disorders.

Relation of Skin Flora of Hands with Glove Perforation and Contamination in Cardiac Surgery.

BACKGROUND AND OBJECTIVES: Surgical scrub reduces the number of microorganisms, but fails to sterilize hands, and therefore the use of sterile gloves is recommended. Glove perforation allows bacteria passage from the surgeons´ hands to the patient´s tissues. We analyze the relationship between skin flora of hands, glove perforation and contamination. METHODS: A prospective study comprising 139 patients undergoing open heart surgery through a median sternotomy was conducted. Surgeons´hands were studied. Gloved and ungloved fingertips were placed on culture plates after scrubbing and before sternal closure. Removed gloves were evaluated for perforations. Samples from the surgical wound were taken for culture. Identification of isolated microorganisms was performed by conventional biochemical tests. RESULTS: Culture of fingertips after scrubbing resulted positive in 29.13% of the samples and increased to 34.53% at the end of the procedure. Culture of gloved fingertips before closing the sternum demonstrated contamination of the outer surface in 11.87% of samples. Gloves removed before sternal closure showed perforations in 23.02% of samples. Holes were observed in 33% of contaminated gloves. No relationship between perforation and contamination of gloves was observed. The culture of the sternal wound resulted positive in 7.91% of cases. A significant relationship between the presence of microorganisms in the wound and glove contamination was demonstrated. (P<0,001). CONCLUSIONS: Perforation does not cause significant contamination of the outer surface of surgical gloves. The statistical correlation between glove contamination and surgical wound colonization could be explained by the presence of other sources of contaminating microorganisms.

Preoperative statin therapy in cardiac surgery is more effective in patients who display preoperative activation of the inflammatory system.

We sought to determine whether preoperative statin treatment is more effective in reducing, after cardiac surgery with cardiopulmonary bypass, systemic inflammatory response and myocardial damage markers in patients who have elevated preoperative interleukin-6 levels than in patients who have normal preoperative interleukin-6 levels. The study involved a prospective cohort of 164 patients who underwent coronary and valvular surgery with cardiopulmonary bypass. There were 2 study groups: group A (n = 60), patients with elevated preoperative interleukin-6 levels; and group B (n = 104), patients with normal preoperative interleukin-6 levels. Each group was subdivided according to whether patients were (group 1) or were not (group 2) treated preoperatively with statins. Accordingly, the subdivided study groups were A1 (n = 40), A2 (n = 20), B1 (n = 56), and B2 (n = 48). The plasma levels of proinflammatory interleukin-6 were measured 1, 6, 24, and >72 hours after surgery. The baseline, operative, and postoperative morbidity and mortality characteristics were similar in all groups. Group A1 had significantly lower levels of interleukin-6 and troponin I than did group A2 at all postoperative time points. Group B1 had significantly lower levels of interleukin-6 than did group B2 postoperatively. There were no significant differences in troponin I levels between groups B1 and B2. We conclude that, in patients with preoperative activation of the inflammatory system, preoperative treatment with statins is associated with lower postoperative interleukin-6 and troponin I levels after cardiac surgery with cardiopulmonary bypass.

Early calcification of the aortic Mitroflow pericardial bioprosthesis in the elderly.

BACKGROUND: We report our experience in the elderly with aortic valve replacement using the Mitroflow A12 pericardial bioprosthesis. METHODS: From January 1993 to January 2006, 491 patients over the age of 70 years received an aortic Mitroflow A12 bioprosthesis implantation. Concomitant procedures included coronary artery bypass grafting in 20% of patients. All patients had routine postoperative Echo-Doppler studies at discharge, one month and a mean of 11.1 months after surgery and annually thereafter. RESULTS: Twenty (4%) patients underwent a second aortic valve replacement due to bioprosthetic valve dysfunction (Group 2). Calcified stenosis was the most common finding at reoperation (98%). Median time to valve reoperation was 76 months. Of patients requiring reoperation, median age at first and second implantation was 73 (70-78) and 79 (76-83) years, respectively. For all patients, freedom from structural valve dysfunction (SVD) was 95+/-3% at 5 years and 55.8+/-2% at 10 years. Bioprosthetic valve deterioration was identified in 27 patients (Group 1). Median age of these patients at first operation and at diagnosis of deterioration by echo was 75 (70-84) and 77 (70-82) years, respectively. The median interval between operation and detection of bioprosthesis valve deterioration was 46 months. Among the total patient population, freedom from bioprosthetic deterioration was 85.7+/-2% at 5 years and 33.5+/-4% at 10 years. CONCLUSION: The Mitroflow A12 pericardial bioprosthesis provides less than optimal performance in elderly patients.

Preoperative statin treatment reduces systemic inflammatory response and myocardial damage in cardiac surgery.

OBJECTIVE: To determine if preoperative statin treatment is associated with a reduction in systemic inflammatory response (SIR) and myocardial damage markers following cardiac surgery with cardiopulmonary bypass (CPB). METHODS: We study a prospective cohort of 138 patients who underwent coronary and valvular surgery with CPB. We differentiate two study groups: patients with (group A, n=72) or without (group B, n=66) statins. Plasma levels of pro-inflammatory interleukins (tumour necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8 and IL-2R), creatine phosphokinase (CPK), CPK-MB and troponin I were measured before and 1, 6, 24 and >72 h after surgery. RESULTS: The baseline, operative and postoperative morbidity and mortality characteristics were similar for both the groups. Group A had significantly lower postoperative levels of IL-6 than group B at 6h (68.8+/-5 pg ml(-1) vs 108.9+/-108 pg ml(-1), p=0.01), 24h (71.7+/-7 pg ml(-1) vs 110.4+/-106 pg ml(-1), p=0.01) and before hospital discharge (21.6+/-12 pg ml(-1) vs 32.8+/-27 pg ml(-1), p=0.005), as well as significantly lower average IL-6 levels in the first 24h following surgery (71.8+/-5 pgml(-1) vs 112.8+/-82 pg ml(-1), p=0.002). The postoperative CPK-MB at 24h (19.7+/-23 ng ml(-1) vs 33.1+/-32 ng ml(-1), p=0.02) and troponin I levels at the end of the intervention (2.2+/-2.2 ng ml(-1) vs 3.3+/-3.1 ng ml(-1), p=0.03) and at 24h (4.1+/-3.5 ng ml(-1) vs 6.6+/-8 ng ml(-1), p=0.04) were also significantly lower in the group treated with statins prior to surgery. CONCLUSIONS: Preoperative treatment with statins is associated with a lower biochemical parameters of SIR and myocardial damage following cardiac surgery with CPB, regardless of it being coronary bypass grafting (CABG) or valvular surgery.

[Aortic valve replacement with a Cryolife O'Brien stentless bioprosthesis]. / Reemplazo valvular aórtico con bioprótesis no soportada de Cryolife O'Brien.

INTRODUCTION AND OBJECTIVES: The Cryolife O'Brien xenograft is a stentless bioprosthesis constructed from noncoronary leaflets from three porcine aortic valves. The aim of this study was to investigate short-term results after aortic valve replacement with this composite xenograft. METHODS: Since October 1993, Cryolife O'Brien bioprostheses have been implanted in 210 patients. The patients' mean age was 70.9 (7.5) years (range 23-83 years). The indication was aortic stenosis in 132 cases, aortic insufficiency in 25 cases, and both lesions in 53 cases. Valve function was studied by echocardiography preoperatively, at discharge, and 6 and 12 months postoperatively. RESULTS: The 30-day mortality rate was 5.2% (11/210). Over time, the mean gradients decreased and the effective area index increased. In addition, the left ventricular mass index, wall thickness, and septum thickness also decreased shortly after surgery. CONCLUSIONS: Use of the Cryolife O'Brien stentless bioprosthesis demonstrated satisfactory results at 1-year follow-up. Additional follow-up is required to assess the performance of this bioprosthesis over the long term.

Off-pump total arterial revascularization: our experience.

BACKGROUND AND AIM: Off-pump coronary artery bypass grafting with both the internal thoracic arteries, such as the Tector technique, can reduce the morbidity associated with extracorporeal circulation and aortic cross-clamp. The aim of the present study is to describe our experience and the results obtained. METHODS: From April 1998 to December 2003, the off-pump Tector technique was performed on 743 patients, of whom 621 were male (83.5%), with a mean age of 65.3 +/- 9.5 years (23-90). Preoperative risk factors were diabetes mellitus in 29.5% and peripheral vasculopathy in 14.7% of the patients. Angiography showed left main disease in 25.6% and triple-vessel disease in 50.3% of the patients, with a mean ejection fraction of 60%+/- 13% (23-88). Both the internal thoracic arteries were harvested using the skeletonization technique and were anastomosed as "Y" or "T" grafts. Intraoperative graft patency was checked using a Doppler flowmeter. RESULTS: A total of 2028 distal anastomoses were performed, the average being 2.7 (1 to 5) per patient. At least three distal anastomoses were undertaken in 62% of the patients. Postoperative complications included atrial fibrillation in 40 patients (5.4%), myocardial infarction in 24 (3.2%), mediastinitis and reoperation for bleeding in 7 (0.9%) and stroke in 3 (0.4%). Twenty-four patients (3.2%) died in the first month postoperatively. CONCLUSIONS: The off-pump Tector technique appears to be safe, showing a low surgical morbidity.