Assessing the venous system: Correlation of mean systemic filling pressure with the venous excess ultrasound grading system in cardiac surgery.

BACKGROUND: Evaluation of the venous system has long been underestimated as an important component of the circulatory system. As systemic venous pressure increases, the perfusion pressure to the tissues is compromised. During initial resuscitation in cardiac surgery, excessive fluid administration is associated with increased morbidity and mortality. METHODS: We conducted a cross-sectional study of 60 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain the venous excess ultrasound (VExUS) grading system and mean systemic filling pressure (Pmsf) in the postoperative period upon admission, at 24 and 48 h. We then determined the correlation between VExUS grading and Pmsf. RESULTS: On admission, patients with VExUS grading 0 predominated, with a progressive increase in venous congestion and an increase in Pmsf over the course of the first 48 h. There was a strong positive correlation between VExUS grading and the invasive measurement of Pmsf at 24 and 48 h after arrival. The presence of grade 2 or grade 3 venous congestion in the postoperative period poses an increased risk of developing acute kidney injury. CONCLUSION: The VExUS grading system indicates a high degree of systemic venous congestion in the first 48 h of the postoperative period after cardiac surgery and correlates with the Pmsf, which is the best surrogate of stressed circulatory volume.

A contrast echocardiography-based protocol to rule out thrombus in Venous-Arterial ECMO: A proof of concept.

Using an ultrasound-enhancing agent (UEA) has several indications, especially in diagnosing left ventricular thrombus. Herein, we present three cases of patients who were candidates for venous-arterial extracorporeal membrane oxygenation, among whom thrombus was ruled out via contrast echocardiography. The use of a UEA in these patients was a novel approach.

Correlation between transhepatic and subcostal inferior vena cava ultrasonographic images for evaluating fluid responsiveness after cardiac surgery.

BACKGROUND: Echocardiographic monitoring during the postoperative period following cardiac surgery is essential because patients often develop hemodynamic instability from hypovolemia and other causes. Therefore, predicting fluid responsiveness by measuring respirophasic variation in the inferior vena cava (IVC) is essential in this population. Yet it is not always possible to evaluate using the traditional subcostal view. METHODS: This cross-sectional study of 36 consecutive adult patients who underwent cardiac surgery included those in whom it was possible to adequately visualize the IVC in both the subcostal and transhepatic views. The maximum and minimum diameters and respirophasic variation were measured in each view. These views were then correlated and the capacity of the transhepatic view to predict fluid responsiveness was evaluated. RESULTS: There was a strong positive correlation between IVC maximum and minimum diameters and respirophasic variation according to subcostal and transhepatic views. Evaluation of IVC respirophasic variation indices using the transhepatic view also showed high sensitivity for predicting fluid responsiveness. CONCLUSION: There is a correlation between the transhepatic and subcostal views for determining maximum and minimum IVC diameters, and distensibility and variability indices for predicting fluid responsiveness in postoperative cardiac surgery patients.

Right ventricular dysfunction and right ventricular-arterial uncoupling at admission increase the in-hospital mortality in patients with COVID-19 disease.

BACKGROUND: Coronavirus disease 2019 (COVID-19) frequently involves cardiovascular manifestations such as right ventricular (RV) dysfunction and alterations in pulmonary hemodynamics. We evaluated the application of the critical care ultrasonography ORACLE protocol to identify the most frequent alterations and their influence on adverse outcomes, especially those involving the RV (dilatation and dysfunction). METHODS: This cross-sectional study included 204 adult patients with confirmed COVID-19 admitted at three centers. Echocardiography and lung ultrasound images were acquired on admission using the ORACLE ultrasonography algorithm. RESULTS: Two-hundred and four consecutive patients were evaluated: 22 (11.9%) demonstrated a fractional shortening of < 35%; 33 (17.1%) a tricuspid annular plane systolic excursion (TAPSE) of < 17 mm; 26 (13.5%) a tricuspid peak systolic S wave tissue Doppler velocity of < 9.5 cm/sec; 69 (37.5%) a RV basal diameter of > 41 mm; 119 (58.3%) a pulmonary artery systolic pressure (PASP) of > 35 mm Hg; and 14 (11%) a TAPSE/PASP ratio of < .31. The in-hospital mortality rate was 37.6% (n = 71). Multiple logistic regression modeling showed that PASP > 35 mm Hg, RV FS of < 35%, TAPSE < 17 mm, RV S wave < 9.5, and TAPSE/PASP ratio < .31 mm/mm Hg were associated with this outcome. PASP and the TAPSE/PASP ratio had the lowest feasibility of being obtained among the investigators (62.2%). CONCLUSION: The presence of RV dysfunction, pulmonary hypertension, and alteration of the RV-arterial coupling conveys an increased risk of in-hospital mortality in patients presenting with COVID-19 upon admission; therefore, searching for these alterations should be routine. These parameters can be obtained quickly and safely with the ORACLE protocol.

Use of pulmonary ultrasound to predict in-hospital mortality in patients with COVID-19 infection.

INTRODUCTION: Lung ultrasound (LUS) implementation in patients with COVID-19 can help to establish the degree of pulmonary involvement, evaluate treatment response and estimate in-hospital outcome. OBJECTIVE: To evaluate the application of a LUS protocol in patients with COVID-19 infection to predict in-hospital mortality. METHODS: The study was carried out from April 1 to August 1, 2020 in patients with COVID-19 infection admitted to the Intensive Care Unit. Lung evaluation was carried out by physicians trained in critical care ultrasonography. RESULTS: Most patients were males, median age was 56 years, and 59 % required mechanical ventilation. In-hospital mortality was 39.4 %, and in those with a LUS score ≥ 19, mortality was higher (50 %). The multiple logistic regression model showed that a LUS score ≥ 19 was significantly associated with mortality (hazard ratio = 2.55, p = 0.01). CONCLUSIONS: LUS is a safe and fast clinical tool that can be applied at bedside in patients with COVID-19 infection to establish the degree of parenchymal involvement and predict mortality.

INTRODUCCIÓN: La implementación del ultrasonido pulmonar (LUS) en los pacientes con COVID-19 puede ayudar a establecer el grado de afectación pulmonar, evaluar la respuesta al tratamiento y estimar el desenlace intrahospitalario. OBJETIVO: Evaluar la aplicación de un protocolo LUS en pacientes con infección por COVID-19 para predecir mortalidad intrahospitalaria. MÉTODOS: El estudio se realizó del 1 de abril al 1 de agosto de 2020 en pacientes con infección por COVID-19, ingresados en la Unidad de Terapia Intensiva. Se realizó evaluación pulmonar por médicos entrenados en ultrasonografía crítica. RESULTADOS: La mayoría de los pacientes fue del sexo masculino, la edad mediana fue de 56 años y 59 % requirió ventilación mecánica. La mortalidad intrahospitalaria fue de 39.4 % y en aquellos con puntuación de LUS ≥ 19, de 50 %. El modelo de regresión logística múltiple mostró que la puntuación de LUS ≥ 19 se asoció significativamente a mortalidad (cociente de riesgo = 2.55, p = 0.01). CONCLUSIONES: El LUS es una herramienta clínica segura y rápida que puede realizarse al lado de la cama de los pacientes con infección por COVID-19, para establecer el grado de afectación parenquimatosa y predecir la mortalidad.

Critical care ultrasonography during COVID-19 pandemic: The ORACLE protocol.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is characterized by severe lung involvement and hemodynamic alterations. Critical care ultrasonography is vital because it provides real time information for diagnosis and treatment. Suggested protocols for image acquisition and measurements have not yet been evaluated. METHODS: This cross-sectional study was conducted at two centers from 1 April 2020 to 30 May 2020 in adult patients with confirmed COVID-19 infection admitted to the critical care unit. Cardiac and pulmonary evaluations were performed using the ORACLE protocol, specifically designed for this study, to ensure a structured process of image acquisition and limit staff exposure to the infection. RESULTS: Eighty-two consecutively admitted patients were evaluated. Most of the patients were males, with a median age of 56 years, and the most frequent comorbidities were hypertension and type 2 diabetes, and 25% of the patients had severe acute respiratory distress syndrome. The most frequent ultrasonographic findings were elevated pulmonary artery systolic pressure (69.5%), E/e' ratio > 14 (29.3%), and right ventricular dilatation (28%) and dysfunction (26.8%). A high rate of fluid responsiveness (82.9%) was observed. The median score (19 points) on pulmonary ultrasound did not reveal any variation between the groups. Elevated pulmonary artery systolic pressure was associated with higher in-hospital mortality. CONCLUSION: The ORACLE protocol was a feasible, rapid, and safe bedside tool for hemodynamic and respiratory evaluation of patients with COVID-19. Further studies should be performed on the alteration in pulmonary hemodynamics and right ventricular function and its relationship with outcomes.

ELANE rs17223045C/T and rs3761007G/A variants: Protective factors against COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for causing coronavirus disease 2019 (COVID-19). The development and severity of this infectious disease is influenced by a combination of environmental and genetic factors. Angiotensin-converting enzyme 2 (ACE2) facilitates SARS-CoV-2 entry into human cells, with transmembrane serine protease 2 (TMPRSS2) playing a crucial role in S protein priming. Other proteases, such as cathepsin L and elastase, neutrophil-expressed (ELANE), have the capability to prime the S protein and contribute to SARS-CoV-2 infection. ELANE variants have not been previously examined in COVID-19 patients. We aimed to assess the association of single nucleotide variants (SNVs) within ELANE with COVID-19 and biochemical markers. The study included 319 SARS-CoV-2-infected patients and 288 controls. Genotyping of ELANE rs17216663C/T (Pro257Leu), rs17223045C/T (As1n30Asn), and rs3761007G/A was conducted using a 5'-nuclease allelic discrimination assay (TaqMan assay). Our findings indicate that ELANE rs17223045C/T (C vs T: odds ratio [OR] 0.08, P = 0.005, and CC vs CT: OR 0.08, P = 0.005) and rs3761007G/A (G vs A: OR 0.38, P = 0.009, and GG vs GA: OR 0.40, P = 0.008) confer protection against COVID-19. However, these variants were not associated with biochemical markers. In conclusion, our data suggests that ELANE rs17223045C/T and rs3761007G/A SNVs may play a protective role against COVID-19.

Circulatory support with triple cannulation V-PaA ECMO in a patient with acute right ventricular failure and refractory hypoxemia secondary to diffuse alveolar hemorrhage: A case report.

A 48-year-old woman presented to the emergency department with a one-week history of progressive dyspnea. During her hospitalization, the diagnosis of diffuse alveolar hemorrhage was made. She subsequently developed respiratory failure and acute right ventricular failure. Despite medical treatment, she continued to experience distributive shock due to a generalized inflammatory response. Circulatory support with ECMO was needed. We opted for triple cannulation to manage the multiorgan failure as a bridge to recovery. We describe our experience with an uncommon cannulation technique: veno-pulmonary-arterial cannulation, which enabled us to address cardiogenic shock, refractory hypoxemia, and distributive shock, leading to the successful recovery of the patient.

[Circulatory support with venovenous ECMO in a patient with reperfusion pulmonary edema after pulmonary artery thromboendarterectomy]. / Soporte circulatorio con ECMO venovenoso en paciente con síndrome de reperfusión pulmonar secundario a tromboendarterectomía arterial pulmonar.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by the obstruction of pulmonary arteries secondary to chronic thromboembolism. Pulmonary thromboendarterectomy surgery (PTE) is the main treatment for patients with CTEPH, as it removes the chronic thrombi from the pulmonary arteries. Pulmonary reperfusion syndrome is a common complication of the surgery, which involves the development of pulmonary edema in the area where blood perfusion improves after the surgery. The incidence of this syndrome varies from 8 to 91% depending on the criteria used for diagnosis, and it is one of the most serious complications of pulmonary thromboendarterectomy. In such cases, circulatory support with extracorporeal membrane oxygenation (ECMO) has become a valuable therapeutic modality. We present the case of a 60-year-old woman with a history of acute pulmonary embolism due to deep vein thrombosis of the right pelvic limb who was diagnosed later with CTEPH who was admitted for scheduled surgical treatment involving bilateral PTE. However, during the immediate postoperative period, she developed cardiogenic shock and refractory hypoxemia secondary to pulmonary reperfusion syndrome following the surgical procedure. As a result, she required veno-venous ECMO circulatory support for 6 days, leading to resolution of the pulmonary condition and clinical improvement.

La hipertensión pulmonar tromboembólica crónica (HPTEC) es un subtipo de hipertensión pulmonar caracterizada por la obstrucción de las arterias pulmonares secundaria a tromboembolias crónicas. La cirugía de tromboendarterectomía pulmonar (TEAP) es el tratamiento principal para los pacientes con HPTEC, elimina los trombos crónicos de las arterias pulmonares. El síndrome de reperfusión pulmonar es una complicación común de la cirugía, se trata del desarrollo de edema pulmonar en el área en la que la perfusión sanguínea mejora después de la cirugía. La incidencia del síndrome varía del 8 al 91% según los criterios utilizados para diagnosticarlo y es una de las complicaciones más graves de la tromboendarterectomía pulmonar. En tales casos, el soporte circulatorio con oxigenación por membrana extracorpórea (ECMO) se ha convertido en una valiosa modalidad terapéutica. Presentamos el caso de una paciente de 60 años de edad con antecedente de tromboembolia pulmonar aguda secundaria a trombosis venosa profunda de miembro pélvico derecho a quien durante el seguimiento se realizó el diagnóstico de HPTEC e ingresó de manera programada para tratamiento quirúrgico con realización de TEAP bilateral, sin embargo durante el posquirúrgico inmediato presentó choque cardiogénico e hipoxemia refractaria secundarios a síndrome de reperfusión pulmonar, por lo cual requirió soporte circulatorio con ECMO venovenosa durante seis días, con resolución del cuadro pulmonar y mejoría clínica.

[North-south syndrome, a complication of circulatory assistance with Veno-Arterial ECMO. A case report.] / El síndrome de norte-sur, una complicación de la asistencia circulatoria con ECMO Venoarterial. Reporte de caso.

We present the case of a 34-year-old male patient with a history of Marfan syndrome who was admitted to the emergency room for acute aortic regurgitation secondary to aneurysmal dilation of the ascending thoracic aorta. In the postoperative period, post-cardiotomy cardiogenic shock was documented, so circulatory support was initiated with peripheral Veno-Arterial ECMO, which developed hypoxemia due to bacterial pneumonia and data compatible with North-South syndrome. We present a review, non-conventional cannulation strategies and a diagnostic alternative for this entity.

Usefulness of the velocity-time integral of the left ventricular outflow tract variability index to predict fluid responsiveness in patients undergoing cardiac surgery.

BACKGROUND: Haemodynamic monitoring of patients after cardiac surgery using echocardiographic evaluation of fluid responsiveness is both challenging and increasingly popular. We evaluated fluid responsiveness in the first hours after surgery by determining the variability of the velocity-time integral of the left ventricular outflow tract (VTI-LVOT). METHODS: We conducted a cross-sectional study of 50 consecutive adult patients who underwent cardiac surgery and in whom it was possible to obtain VTI-LVOT measurements. We then determined the variability and correlations with our pulse pressure variation (PPV) measurements to predict fluid responsiveness. RESULTS: A strong positive correlation was seen between the VTI-LVOT variability index absolute values and PPV for predicting fluid responsiveness in the first hours after cardiac surgery. We also found that the VTI-LVOT variability index has high specificity and a high positive likelihood ratio compared with the gold standard using a cut-off point of ≥ 12%. CONCLUSIONS: The VTI-LVOT variability index is a valuable tool for determining fluid responsiveness during the first 6 postoperative hours in patients undergoing cardiac surgery.

Left circumflex artery injury occurring during mitral valve surgery treated successfully with percutaneous intervention in a high surgical and bleeding risk patient.

Perioperative myocardial infarction is a complication of cardiac surgery, and the cause can be multifactorial. Injury of the left circumflex coronary artery has been described, particularly after mitral valve replacement. We present the case of a 72-year-old woman who underwent mitral valve replacement but developed a lesion in the proximal circumflex coronary artery related to partial mechanical kinking caused by a suture. The therapeutic options are surgical or percutaneous. In this patient, the percutaneous strategy was successful. Learning objective: • Percutaneous coronary intervention is an option in cases involving kinking of the left circumflex coronary artery after mitral valve replacement.• If unable to cross the lesion with a workhorse guide wire, one alternative is to use wires with good support properties and avoid very high tip loads to reduce the risk of perforation.In patients at high risk of bleeding, use of a drug-eluting stent and short-duration dual antiplatelet therapy is recommended.

Left atrial veno-arterial extracorporeal membrane oxygenation in post-myocardial infarction ventricular septal defect with cardiogenic shock: a case report.

Background: Ventricular septal defect (VSD) complicating acute myocardial infarction (MI) represents a life-threatening condition and has a mortality of >90% if left untreated. Case summary: A 53-year-old man with a prior medical history of diabetes and hypertension presented with cardiogenic shock secondary to VSD as a mechanical complication of non-reperfused inferior MI. Discussion: The choice of mechanical support can be difficult in this type of patient. Given the risk of an increased shunt because of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and the increase in left ventricle (LV) afterload, several measures were taken to plan the best ECMO configuration. Given the absence of any real improvement in the LV and an elevated residual ratio between pulmonary and systemic flow (Qp/Qs), the final decision was to switch to left atrial VA-ECMO (LAVA-ECMO). The use of LAVA-ECMO improved the patient's haemodynamics and allowed his condition to stabilize; LAVA-ECMO is feasible and may be effective as a mechanical circulatory support (MCS) strategy for patients in cardiogenic shock due to VSD as a mechanical complication of acute MI.

Pulmonary artery cannulation during venovenous extracorporeal membrane oxygenation: An alternative to manage refractory hypoxemia and right ventricular dysfunction.

Venovenous extracorporeal membrane oxygenation (ECMO) has become a rescue therapy for acute respiratory distress syndrome (ARDS) secondary to COVID-19 for patients who are refractory to conventional therapy. However, this therapy comes with complications, and alternative cannulation strategies are needed to overcome these difficulties. In this article, we present a case of venovenous ECMO presenting with refractory hypoxemia and right ventricular dysfunction, which were corrected by cannulating the pulmonary artery. This situation is rarely reported in literature and may constitute an alternative for managing these patients.

The rs8176740 T/A and rs512770 T/C Genetic Variants of the ABO Gene Increased the Risk of COVID-19, as well as the Plasma Concentration Platelets.

We conducted a case-control study in order to evaluate whether ABO gene polymorphisms were associated with a high risk of developing COVID-19 in a cohort of patients. Six ABO gene polymorphisms (rs651007 T/C, rs579459 T/C, rs495828 T/G, rs8176746 A/C, rs8176740 T/A, and rs512770 T/C) were determined using TaqMan genotyping assays in a group of 415 COVID-19 patients and 288 healthy controls. The distribution of rs651007 T/C, rs579459 T/C, rs495828 T/G, and rs8176746 A/C polymorphisms was similar in patients and healthy controls. Nonetheless, under co-dominant (OR = 1.89, pCCo-dominant = 6 × 10-6), recessive (OR = 1.98, pCRecessive = 1 × 10-4), and additive (OR = 1.36, pCAdditive = 3 × 10-3) models, the TT genotype of the rs8176740 T/A polymorphism increased the risk of developing COVID-19. In the same way, under co-dominant, recessive, and additive models, the TT genotype of the rs512770 T/C polymorphism was associated with a high risk of developing COVID-19 (OR = 1.87, pCCo-dominant = 2 × 10-3; OR = 1.87, pCRecessive = 5 × 10-4; and OR = 1.35, pCAdditive = 4 × 10-3, respectively). On the other hand, the GTC and GAT haplotypes were associated with a high risk of COVID-19 (OR = 5.45, pC = 1 × 10-6 and OR = 6.33, pC = 1 × 10-6, respectively). In addition, the rs8176740 TT genotype was associated with high-platelet plasma concentrations in patients with COVID-19. Our data suggested that the ABO rs512770 T/C and rs8176740 T/A polymorphisms increased the risk of developing COVID-19 and the plasma concentration of platelets.

Aortic Perforation and Ascending Dissection Due to Intra-Aortic Balloon Counterpulsation Implantation in Cardiac Surgery.

The intra-aortic balloon pump continues to be a useful ventricular assist device in cardiac surgery. Complications are estimated to be 7% to 40%, significantly high to catastrophic. We describe an aortic injury associated with the use of the device and an interdisciplinary management for the diagnostic and therapeutic approach. (Level of Difficulty: Intermediate.).

Acute Mitral Regurgitation Due to Chordae Tendineae Rupture: A Rare Presentation of Cardiac Amyloidosis.

BACKGROUND In cardiac amyloidosis (CA), misfolded proteins deposit in the extracellular space of cardiac tissue. These deposits classically cause restrictive cardiomyopathy with diastolic dysfunction. Although there are at least 30 proteins known to cause amyloid aggregates, 2 main types make up most diagnosed cases: light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). Since CA is considered a rare condition, it is often underdiagnosed or recognized in the advanced stages. Once amyloid deposits involve the heart tissue, they are associated with a worse outcome and higher mortality rates, especially in patients presenting symptoms of heart failure. CASE REPORT We report a case of a 22-year-old man presenting with acute severe mitral regurgitation, secondary to posterior mitral leaflet chordae tendineae rupture (CTR). Surgical mitral valve replacement with a mechanical prosthesis was performed, and cardiac tissue biopsy samples were obtained. After surgery, the patient improved significantly but suddenly presented with hemodynamic deterioration, until he died due to severe hemodynamic compromise and multiorgan failure. Although the etiology of the CTR was not established before surgical intervention, the histopathological analysis suggested CA. CONCLUSIONS CA diagnosis can be complex, especially in a 22-year-old-man with atypical clinical and imaging manifestations. In this patient, other differential diagnoses were considered, since CA presenting in a young patient is a rare phenomenon and acute mitral regurgitation secondary to CTR presents more frequently in other heart conditions. Furthermore, rapid postoperative deterioration resulted in the patient's death before biopsy samples were available because suspicion of amyloidosis had not been raised until that point.

Focused Transesophageal Echocardiography in Critical Care: The COVID-19 Pandemic.

Background: The use of transesophageal echocardiography (TEE) is controversial in patients with COVID-19. The aim of this case series was to demonstrate the usefulness of transesophageal echocardiography in acute cardiovascular care settings in patients with COVID-19 infection. Materials and Methods: We enrolled 13 patients with confirmed SARS-CoV-2 infection admitted to the critical care unit of our center from April 1, 2020, to July 30, 2020, in which transesophageal echocardiography was performed. TOE was performed by three cardiologists with training in echocardiography. Results: The main indication was suspected infective endocarditis in four cases, venovenous extracorporeal membrane oxygenation cannulation in four cases, suspected prosthetic mitral valve dysfunction in two patients, suspected pulmonary embolism in two patients, and acute right ventricular dysfunction and prone position ventilation in one patient. The final diagnosis was confirmed in 11 patients and discarded in 2 patients. None of the operators result infected. Conclusions: TOE is safe in the context of COVID-19 infection; it must be performed in well-selected cases and in a targeted manner.

Chagas Heart Disease: Beyond a Single Complication, from Asymptomatic Disease to Heart Failure.

Chagas cardiomyopathy (CC), caused by the protozoan Trypanosoma cruzi, is an important cause of cardiovascular morbidity and mortality in developing countries. It is estimated that 6 to 7 million people worldwide are infected, and it is predicted that it will be responsible for 200,000 deaths by 2025. The World Health Organization (WHO) considers Chagas disease (CD) as a Neglected Tropical Disease (NTD), which must be acknowledged and detected in time, as it remains a clinical and diagnostic challenge in both endemic and non-endemic regions and at different levels of care. The literature on CC was analyzed by searching different databases (Medline, Cochrane Central, EMBASE, PubMed, Google Scholar, EBSCO) from 1968 until October 2022. Multicenter and bioinformatics trials, systematic and bibliographic reviews, international guidelines, and clinical cases were included. The reference lists of the included papers were checked. No linguistic restrictions or study designs were applied. This review is intended to address the current incidence and prevalence of CD and to identify the main pathogenic mechanisms, clinical presentation, and diagnosis of CC.