Venoarterial Extracorporeal Membrane Oxygenation as A Bridge to Surgery in Post-Myocardial Infarction Ventricular Septal Defect with Cardiogenic Shock: Case Report.

We describe a 60-year-old woman with post-myocardial infarction (MI) ventricular septal defect (VSD) and cardiogenic shock who was successfully stabilized with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge therapy for the surgical closure of her VSD. This case highlights the role of VA-ECMO in the management of post-MI VSD to improve the results of surgical repair and patient survival.

Case report: Multi-site perfusion strategy for type A acute aortic dissection complicated with cerebral malperfusion.

Acute type A dissection presenting with cerebral malperfusion has high morbidity and mortality. Given the complexity of underlying vascular involvement, it is a challenging clinical scenario. Many of these patients are not deemed surgical candidates. If surgery is considered, it often requires complex aortic arch and neck vessel reconstruction. We present a 48-year-old male with an acute type A aortic dissection that presented with paraplegia and decreased level of consciousness. A Computed Tomography showed occlusion of both common carotid arteries. He was successfully treated with a multi-site perfusion strategy and a Hybrid Frozen Elephant Trunk graft to achieve fast restoration of the cerebral circulation and minimize brain ischemia and permanent neurological damage. From this case, we learn that aggressive arch and neck vessel reconstruction supported by multi-site perfusion could help improve mortality and neurological outcomes in selected patients.

Extracorporeal membrane oxygenation for tuberculosis pneumonia with empyema.

Acute respiratory distress syndrome (ARDS) caused by Mycobacterium Tuberculosis (TB) is a rare entity. Extracorporeal membrane oxygenation (ECMO) therapy had been used as an effective therapy for this cases, but the evidence is scarce. We present a case that took place in the middle of SARS-CoV2 pandemic. A 33-year-old female presented with ARDS due to pulmonary TB infection (pneumonia with empyema and pneumothorax), which required invasive mechanical ventilation with poor response. Long term veno-arterio-venous (VAV) ECMO, overlapped with veno-venous ECMO, was used as a salvage therapy with a good response for a total of 26 days. This is an example of the effectiveness of this therapy in this scenario, never described before. The fact that this therapy was used in the middle of SARS-CoV2 pandemic, with limited resources available, was remarkable, but it was encouraged by previous successful experiences.

Novel molecular insights and public omics data in pulmonary hypertension.

Pulmonary hypertension is a rare disease with high morbidity and mortality which mainly affects women of reproductive age. Despite recent advances in understanding the pathogenesis of pulmonary hypertension, the high heterogeneity in the presentation of the disease among different patients makes it difficult to make an accurate diagnosis and to apply this knowledge to effective treatments. Therefore, new studies are required to focus on translational and personalized medicine to overcome the lack of specificity and efficacy of current management. Here, we review the majority of public databases storing 'omics' data of pulmonary hypertension studies, from animal models to human patients. Moreover, we review some of the new molecular mechanisms involved in the pathogenesis of pulmonary hypertension, including non-coding RNAs and the application of 'omics' data to understand this pathology, hoping that these new approaches will provide insights to guide the way to personalized diagnosis and treatment.

VCAM-1 as a predictor biomarker in cardiovascular disease.

The vascular cellular adhesion molecule-1 (VCAM-1) is a protein that canonically participates in the adhesion and transmigration of leukocytes to the interstitium during inflammation. VCAM-1 expression, together with soluble VCAM-1 (sVCAM-1) induced by the shedding of VCAM-1 by metalloproteinases, have been proposed as biomarkers in immunological diseases, cancer, autoimmune myocarditis, and as predictors of mortality and morbidity in patients with chronic heart failure (HF), endothelial injury in patients with coronary artery disease, and arrhythmias. This revision aims to discuss the role of sVCAM-1 as a biomarker to predict the occurrence, development, and preservation of cardiovascular disease.

Preoperative soluble VCAM-1 contributes to predict late mortality after coronary artery surgery.

BACKGROUND: Soluble vascular cell adhesion molecule-1 has been associated with long-term cardiovascular mortality in patients with stable coronary artery disease and to the development of new atrial fibrillation in subjects with cardiovascular risk factors but no evidence of cardiac disease. HYPOTHESIS: Preoperative soluble vascular cell adhesion molecule-1 predicts the risk of future all-cause death and cardiovascular death among patients submitted to elective coronary artery bypass surgery. METHODS: From a cohort of 312 patients who underwent elective coronary artery bypass surgery prospectively followed for a median of 6.7 years, we evaluated the prognostic role of preoperative soluble vascular cell adhesion molecule-1, inflammatory markers, CHA2DS2-VASc score and development of postoperative atrial fibrillation (POAF). Univariable and multivariable Cox regression analyses were performed to establish an association of these parameters with long term all-cause death and cardiovascular death. RESULTS: During 2112 person-years of follow-up, we observed 41 deaths, 10 were cardiovascular deaths. Independently increased levels of preoperative soluble vascular cell adhesion molecule-1, POAF, and CHA2DS2-VASc score were associated with all-cause mortality. After multivariate adjustment, elevated preoperative soluble vascular cell adhesion molecule-1 and POAF were the only independent predictors of all-cause death. Also, preoperative soluble vascular cell adhesion molecule-1, POAF, and CHA2DS2-VASc score resulted in being independent predictors of cardiovascular mortality. CONCLUSIONS: Increased circulating levels of preoperative soluble vascular cell adhesion molecule-1, together with POAF and CHA2DS2-VASc score, were significantly associated with future all-cause death and cardiovascular death among patients submitted to coronary artery bypass surgery.

Venoarterial Extracorporeal Membrane Oxygenation as A Bridge to Surgery in Post-Myocardial Infarction Ventricular Septal Defect with Cardiogenic Shock: Case Report

ABSTRACT We describe a 60-year-old woman with post-myocardial infarction (MI) ventricular septal defect (VSD) and cardiogenic shock who was successfully stabilized with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge therapy for the surgical closure of her VSD. This case highlights the role of VA-ECMO in the management of post-MI VSD to improve the results of surgical repair and patient survival.

Clinical outcomes of aortic root replacement after previous aortic root replacement.

OBJECTIVE: The study objective was to examine the short- and long-term outcomes of reoperative aortic root replacement after a previous aortic root replacement. METHODS: From September 1985 to February 2011, 84 consecutive patients underwent reoperative aortic root replacement. The patients' mean age was 46 ± 15 years (range, 19-80 years), and 86% were men. The main indication for reoperation was failed biological or bioprosthetic aortic valve and prosthetic valve endocarditis. Cox proportional hazard regression modeling was performed to identify risk factors that adversely affected overall survival. RESULTS: The operative mortality was 6% (5 patients). Perioperative morbidity included myocardial infarction in 2 patients, low cardiac output syndrome in 7 patients, sepsis in 3 patients, pulmonary complications in 7 patients, renal failure in 3 patients, reoperation for bleeding or tamponade in 5 patients, superficial sternal wound infections in 3 patients, permanent transvenous pacemaker in 8 patients, and stroke in 1 patient. Kaplan-Meier estimates for survival at 5, 10, and 12 years were 82.5% ± 4.7%, 72.5% ± 6.4%, and 65.0% ± 7.6%, respectively; the freedom from reoperation was 100%, 92.3% ± 5.2%, 92.3% ± 5.2%, respectively; and valve-related mortality was 93.1% ± 3.4%, 90.8% ± 4.0%, and 86.2% ± 5.8%, respectively. During the follow-up, valve-related deaths occurred in 7 patients. Age by increments of 5 years (hazard ratio, 1.205; 95% confidence interval, 1.036-1.401) and prosthetic valve endocarditis (hazard ratio, 2.662; 95% confidence interval, 1.054-6.724) were independent risk factors for mortality. CONCLUSIONS: Aortic root replacement after a previous aortic root replacement is associated with a relatively low operative mortality and perioperative morbidity, but long-term survival is suboptimal. Increasing age and prosthetic valve endocarditis adversely affect survival.

Aortic valve replacement with Hancock II bioprothesis with and without replacement of the ascending aorta.

BACKGROUND: The purpose of this study was to compare the clinical outcomes and valve durability after aortic valve replacement with a Hancock II bioprothesis with and without supracoronary replacement of the ascending aorta (RAA). METHODS: From a cohort of 1,076 patients who had aortic valve replacement with a Hancock II bioprothesis who were prospectively followed for a median of 12.2 years, a propensity score analysis matched patients with and without RAA in a 1:4 ratio. Statistical analysis was performed using the χ2 test or Fisher's exact test for categorical variables, t tests or Wilcoxon rank sum test for continuous variables, and Kaplan-Meier estimates and log rank test for time-to-event data. RESULTS: The propensity score analysis selected 89 patients with RAA and 356 without RAA whose mean age was 66±12 years. Preoperative variables were similar in both groups, except that the ascending aorta was aneurysmal in patients who had RAA. Operative mortality was 2.3% and 3.9% in the RAA and non-RAA groups, respectively (p=0.75). Perioperative morbidity was also similar. Only 3 and 13 patients lived beyond 20 years in the RAA and non-RAA groups, respectively. For the non-RAA group and RAA group, respectively, at 10, 15, and 20 years, respectively, the Kaplan-Meier estimates for freedom from death were 62.2%±2.8%, 36.5%±3.3%, 20.8%±3.6%, and 56.8%±6.1%, 31.8%±6.7%, 17.2%±6.6% (p=0.51); for reoperation on the aortic valve for any reason, 95.3%±1.4%, 81.6%±3.9%, 70.5%±6.4%, and 91.7%±3.6, 85.7%±6.8%, 53.5%±18.8% (p=0.51); and for structural valve degeneration, 98.5%±0.9%, 85.0%±3.8%, 66.8%±7.1%, and 94.4%±3.2%, 84.3%±7.5%, and 70.2%±14.3% (p=0.38). CONCLUSIONS: Aortic valve replacement with a Hancock II bioprothesis with or without RAA has similar clinical outcomes. Supracoronary RAA does not affect the rate of structural valve degeneration of this bioprosthesis.

Effect of preoperative non-dialysis-dependent renal dysfunction on isolated aortic and mitral valve surgery: a propensity score analysis.

OBJECTIVE: Our objective was to examine whether preoperative non-dialysis-dependent renal dysfunction is associated with operative mortality or morbidity in isolated valve surgery. METHODS: We reviewed consecutive patients undergoing isolated aortic (n = 2132) or mitral valve (n = 1664) surgery, between 1996 and 2009. Preoperative renal dysfunction was defined as preoperative estimated glomerular filtration rate < 60 mL/min without dialysis. Propensity score 1:1 matched samples were created, one for aortic (n = 626) and one for mitral (n = 526) valve surgery. RESULTS: The mean age was 70 ± 9 and 65 ± 10 years for the aortic and mitral groups, respectively. In the aortic cohort, patients with preoperative renal dysfunction had greater need for inotropes (39% vs 29%; P = .009), length of intensive care unit stay (27 vs 25 hours; P = .006), and duration of mechanical ventilation (8.2 vs 6.6 hours; P < .001). Operative mortality was 3.2% in the group with preoperative renal dysfunction and 2.2% in the group without preoperative renal dysfunction (P = .5). In the mitral cohort, patients with preoperative renal dysfunction had greater need for inotropes (47% vs 36%; P = .013), length of intensive care unit stay (40 vs 26 hours; P = .01), and duration of mechanical ventilation (7.2 vs 6.5 hours; P = .004). Operative mortality was 0% and 2.7% in the groups without and with preoperative renal dysfunction, respectively (P = .015). CONCLUSIONS: Preoperative renal dysfunction is associated with higher morbidity in both cohorts, and patients undergoing mitral valve surgery also experienced higher mortality. The impact of non-dialysis-dependent preoperative renal dysfunction appears to be more pronounced in patients undergoing mitral valve surgery, potentially owing to their relative intolerance to volume overload.

The influence of operative techniques on the outcomes of bicuspid aortic valve disease and aortic dilatation.

BACKGROUND: Bicuspid aortic valve is associated with aortic aneurysm formation that may extend beyond the ascending aorta. METHODS: Between 1979 and 1997, 143 bicuspid aortic valve patients had aortic valve operations with replacement of an aneurysmal ascending aorta: 93 (65%) underwent full root replacement and 50 (35%) underwent separate valve and graft replacement. Distal aortic anastomosis was open in 42 patients (29%) and closed in 101 (71%). Late survival and complications were compared by surgical technique. RESULTS: Patients undergoing full root replacement tended to be younger (mean age 46 +/- 16 vs 59 +/- 13, p < 0.001) and presented with more aortic insufficiency (80% vs 35%, p < 0.001). Three (2.1%) hospital deaths occurred. Event-free survival was 82% (95% confidence interval, 75% to 88%) at 10 years and 41% (95% confidence interval, 11% to 71%) at 20 years. At a median follow-up of 11.5 years, the incidence of new aneurysms and late aortic complications were not significantly different among the procedure groups. Age at the time of operation was the only predictor of late survival (hazard ratio, 1.07; p = 0.007). CONCLUSIONS: Aortic root replacement with distal aortic reconstruction can be achieved with very low operative mortality and excellent long-term outcomes in patients with bicuspid aortic valve and dilated ascending aorta. The type of surgical procedure done in the aortic root and in the distal ascending aorta does not influence late survival, subsequent operation, or aortic complications. This is likely influenced by our patient-specific strategy when replacing the aortic root and distal ascending aorta.

Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis.

OBJECTIVES: The perioperative mortality for people with ruptured abdominal aortic aneurysms (RAAA) has not changed for two decades. Of patients who survive long enough to undergo open repair for ruptured aneurysms, half die (48%; 95% confidence interval [CI] 46 to 50). Randomized trials have shown that endovascular aneurysm repair (EVAR) for nonruptured abdominal aortic aneurysms decreases perioperative mortality compared with open repair. EVAR may similarly benefit patients with RAAA. We aimed to summarize studies of patients undergoing EVAR for ruptured aneurysms. METHODS: Two reviewers searched Medline and EMBASE databases from 1994 to July 2006, Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, the Cochrane Central Register of Controlled Trials, Best Evidence 1994 to 2006, reference lists, clinical trial registries, and conference proceedings; we also contacted authors. All published and unpublished studies in which a group of people with ruptured aneurysms, assessed objectively by imaging, was treated with EVAR (REVAR) were eligible. We used the generic inverse variance function of the REVMAN software to pool results for death in hospital. Sensitivity analyses, using prespecified subgroups, explored heterogeneity between studies. RESULTS: Pooled mortality in 18 observational studies describing 436 people who underwent REVAR was 21% (95% CI 13 to 29); however, 90% of the heterogeneity between studies was not explained by chance alone. Surgical volume explained substantial heterogeneity. According to study-specific criteria, 47% (95% CI 39 to 55) of people with ruptured aneurysms were potentially eligible for REVAR. CONCLUSIONS: Mortality in people who underwent REVAR is lower than that in historical reports of unselected people undergoing open repair. Further investigation is needed to determine whether the difference in mortality is attributable to patient selection alone or to this new approach to treatment.