Post-infarct mitral insufficiency: when to resort to reparative surgery, when to the mitral clip.

Severe mitral insufficiency is a feared complication that develops in 10-12% of patients with myocardial infarction and ST elevation. It results from the rupture of the papillary muscle or is secondary to an acute remodelling of the left ventricle in its entirety or of the infarcted region. The mortality of patients with acute clinical onset reaches 50%. The ideal treatment of acute mitral insufficiency is controversial and still a source of debate. Most of these patients are at high surgical risk or inoperable; therefore, they are treated conservatively and have a poor prognosis. In these candidates, percutaneous treatment of insufficiency with percutaneous edge to edge can be considered an alternative.

The Spectrum of COVID-19-Associated Myocarditis: A Patient-Tailored Multidisciplinary Approach.

BACKGROUND: Myocarditis lacks systematic characterization in COVID-19 patients. METHODS: We enrolled consecutive patients with newly diagnosed myocarditis in the context of COVID-19 infection. Diagnostic and treatment strategies were driven by a dedicated multidisciplinary disease unit for myocarditis. Multimodal outcomes were assessed during prospective follow-up. RESULTS: Seven consecutive patients (57% males, age 51 ± 9 y) with acute COVID-19 infection received a de novo diagnosis of myocarditis. Endomyocardial biopsy was of choice in hemodynamically unstable patients (n = 4, mean left ventricular ejection fraction (LVEF) 25 ± 9%), whereas cardiac magnetic resonance constituted the first exam in stable patients (n = 3, mean LVEF 48 ± 10%). Polymerase chain reaction (PCR) analysis revealed an intra-myocardial SARS-CoV-2 genome in one of the six cases undergoing biopsy: in the remaining patients, myocarditis was either due to other viruses (n = 2) or virus-negative (n = 3). Hemodynamic support was needed for four unstable patients (57%), whereas a cardiac device implant was chosen in two of four cases showing ventricular arrhythmias. Medical treatment included immunosuppression (43%) and biological therapy (29%). By the 6-month median follow-up, no patient died or experienced malignant arrhythmias. However, two cases (29%) were screened for heart transplantation. CONCLUSIONS: Myocarditis associated with acute COVID-19 infection is a spectrum of clinical manifestations and underlying etiologies. A multidisciplinary approach is the cornerstone for tailored management.

Complicated postoperative course in isolated tricuspid valve surgery: Looking for predictors.

BACKGROUND: This study aims at better defining the profile of patients with a complicated versus noncomplicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favorable/unfavorable hospital outcome. METHODS: All patients treated with isolated tricuspid surgery from March 1997 to January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit less than 4 days and/or postoperative length-of-stay less than 10days. Patients were therefore divided accordingly in two groups. RESULTS: One hundred and seventy-two patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p < .001) and higher in-hospital mortality (13% vs. 0%, p < .001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics' dose were predictors of complicated postoperative course. CONCLUSION: In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

Emergency Lung Transplantation after COVID-19: Immunopathological Insights on Two Affected Patients.

We herein characterize the immunopathological features of two Italian COVID-19 patients who underwent bilateral lung transplantation (bLTx). Removed lungs underwent histopathological evaluation. Gene expression profiling (GEP) for immune-related signatures was performed on lung specimens and SARS-CoV-2-stimulated peripheral blood mononuclear cells (PBMCs). Cytokine levels were measured on lungs, bronchoalveolar lavage fluids and in culture supernatants. Pathological assessment showed extensive lung damage with the pattern of proliferative to fibrotic phases, with diffuse alveolar damage mimicking usual interstitial pneumonia (UIP). Lungs' GEP revealed overexpression of pathogen recognition receptors, effector cytokines and chemokines, immune activation receptors and of the inflammasome components. Multiplex cytokine analysis confirmed a proinflammatory state, with high levels of monocyte/macrophage chemotactic and activating factors and of IL-6 and TNF-α. A similar profile was observed in SARS-CoV-2-stimulated PBMCs collected 7 days after transplant. The pattern of tissue damage observed in the lungs suggests that this may represent the output of protracted disease, resembling a diffuse UIP-like picture. The molecular immune profiling supports the paradigm of a persistent proinflammatory state and sustained humoral immunity, conditions that are maintained despite the iatrogenic immunosuppression.

Surgical transaxillary placement of the Impella 5.0 ventricular assist device.

OBJECTIVE: The aim of this study is to evaluate the open transaxillary placement of the Impella 5.0 with a modified surgical technique. METHODS: From January to July 2018, nine patients (eight males; mean age 60 years) underwent surgical transaxillary Impella 5.0 (Abiomed Inc., Danvers, MA) implantation. Patient and periprocedural data were recorded in a prospectively maintained institutional database. The primary endpoint was technical success. The secondary endpoints were: neurological complications (peripheral or central), bleeding, and wound infection, duration of Impella support, and device failure requiring device replacement. RESULTS: Assisted technical success was 100%. The right axillary artery was used in 8/9 cases. Three patients (all on extracorporeal membrane oxygenation) suffered from access site bleeding which required surgical reintervention. One patient suffered from peripheral neurological dysfunction which recovered in 1 month and one patient had a local hematoma which was managed conservatively. The median length of treatment was 16 days (range 8-35). Five patients had myocardial recovery and the Impella could be explanted; the remaining were transitioned to a durable left ventricular assist device with an uneventful postoperative course. Hospital mortality was 33%. CONCLUSIONS: Open Impella 5.0 device implantation through the axillary artery is safe and effective; technical success was 100% and low rates of major complications are reported.

A clinical evaluation of near-infrared cerebral oximetry in the awake patient to monitor cerebral perfusion during carotid endarterectomy.

STUDY OBJECTIVE: To evaluate the relationship between continuous noninvasive monitoring of cerebral saturation (regional cerebral oxygen saturation [rSo2]) and occurrence of clinical and electroencephalographic (EEG) signs of cerebral ischemia during carotid cross-clamping. DESIGN: Prospective clinical study. SETTING: University hospital. PATIENTS: Fifty ASA physical status II and III inpatients undergoing elective carotid endarterectomy with a cervical plexus block. INTERVENTIONS: rSo2 was continuously monitored throughout surgery, while an independent neurologist evaluated the occurrence of both clinical and EEG signs of cerebral ischemia induced during carotid cross-clamping. MEASUREMENTS AND MAIN RESULTS: rSo2 was recorded 1 and 3 minutes after clamping the carotid artery during a 3-minute clamping test. In 5 patients (10%), the carotid clamping test was associated with the occurrence of clinical and EEG signs of cerebral ischemia. All these patients were treated with the placement of a Javid shunt, which completely resolved the symptoms. In no patient was permanent neurological injury reported at hospital discharge. In 4 of these patients, EEG signs of cerebral ischemia were present at both observation times, and in one of them, the duration of cerebral ischemia was less than 2 minutes. The percentage rSo2 reduction from baseline during the carotid clamping test was 17% +/- 4% in patients requiring shunt placement and only 8% +/- 6% in those who did not require it (P = .01). A decrease in rSo2 15% or greater during the carotid clamping test was associated with a 20-fold increase in the odd for developing severe cerebral ischemia (odds ratio, 20; 95% confidence interval, 6.7-59.2) (P = .001); however, this threshold had a 44% sensitivity and 82% specificity, with only 94% negative predictive value. CONCLUSIONS: Continuous rSo2 monitoring is a simple and noninvasive method that correlates with the development of clinical and EEG signs of cerebral ischemia during carotid cross-clamping; however, we could not identify an rSo2 threshold that can be used alone to predict the need for shunt placement because of the low sensitivity and specificity.