Urine High-Sensitive Troponin T-Novel Biomarker of Myocardial Damage in Children.

Background: The use of high-sensitive cardiac troponin T (hsTnT) in urine as a marker of cardiac damage in children has not yet been reported. Elimination of cardiac troponins is dependent on renal function; persistently increased serum hsTnT concentrations were observed among individuals with impaired renal function. The aim of this study was to investigate serum and urine hsTnT levels and its correlation in infants and children younger than 24 months of age after cardiac surgery. Methods: This study was conducted on 90 infants and children under 24 months of age who were divided into three groups. The experimental group consisted of patients with intracardiac surgery of ventricular septal defect (VSD), first control group consisted of infants with extracardiac formation of bidirectional cavopulmonary connection (BCPC), and the second control group consisted of healthy children. Troponin T values ​​were determined in serum and urine at five time points: the first sample was taken on the day before cardiac surgery (measure 0) and the other four samples were taken after the surgery; immediately after (measure 1), on the first (measure 2), third (measure 3), and fifth postoperative day (measure 5). The first morning urine was sampled for determining the troponin T in the control group of healthy infants. Results: A positive correlation between troponin T values in serum and urine was found. Urine hsTnT measured preoperatively in children undergoing BCPC surgery was higher (median 7.3 [IQR 6.6-13.3] ng/L) compared to children undergoing VSD surgery (median 6.5 [IQR 4.4-8.9] ng/L) as well as to healthy population (median 5.5 [IQR 5.1-6.7] ng/L). After logarithmic transformation, there was no statistically significant difference in urine hsTnT concentration between the groups at any point of measurement preoperatively or postoperatively. Statistically significant negative correlation was found between serum and urine hsTnT concentrations and glomerular filtration rate estimated by creatinine clearance. Patients who underwent surgical repair of VSD had significantly higher concentrations of troponin T in serum on the first three postoperative measurements compared to those who had BCPC surgery. Conclusions: According to the results of this study, renal function after cardiac surgery appears to have a major effect on the urinary hsTnT concentrations, and we cannot conclude that this is an appropriate marker for the assessment of postoperative myocardial damage in children. Nevertheless, more research is needed to reach a better understanding of the final elimination of cardiac troponins in children.

Starting Pediatric VAD Program: Transforming Challenges into Opportunities; A Case Series of a Single Center.

BACKGROUND: The prevalence of heart failure is constantly increasing in both children and adults. End-stage heart failure in children unresponsive to medical therapy has limited treatment options. Surgical options include heart transplantation or implantation of durable ventricular assist devices (VADs). To start the VAD program, it was necessary to train core team members, invite experienced proctors and adjust the organizational approach. METHODS: We present our first seven pediatric patients who underwent a VAD implantation with primary indication end-stage dilated cardiomyopathy. RESULTS: The median age on implant was four and a half years and the median duration of VAD support was 39 days with long term survival achieved in three patients. The causes of death were multiorgan failure, thromboembolic events, sepsis, and low cardiac output syndrome. Ischemic stroke was the reason for successful neurointervention during VAD support in two patients. CONCLUSIONS: To establish a VAD program, numerous specialties must be included with adequate training and learning for all team members.

Right ventricular dissection after arterial switch operation.

Herein we present the right ventricular dissection and describe its successful management after arterial switch operation in a full-term male neonate. There are no evidence-based recommendations for the management of this rare complication. Our management included veno-arterial extracorporeal membrane oxygenation placement and delayed surgical evacuation of the dissecting haematoma with beneficial outcomes.

Cryopreserved human heart valve allografts: a ten-year single centre experience.

This study provides an overview of tissue banking activities at the Croatian Cardiovascular Tissue Bank (CTB) during past ten years and presents the outcomes of cryopreserved heart valve allografts (CHAs) use in different patient groups. From June 2011 until December 2021, 75 heart donations were referred to CTB: 41 recipient of heart transplant (RHT), 32 donors after brain death (DBD) and 2 donors after circulatory death (DCD) donations. Processing resulted in 103 valves of which 65 met quality requirements for clinical use. Overall tissue discard rate was 37%. The most frequent reasons for discard were inadequate morphology (12%) in RHT donations and microbiological contamination (19%) in DBD donations. Altogether, 38 CHAs were transplanted to 36 patients. Recipients were divided in three groups; infective endocarditis (IE), non-infectious heart disease and congenital heart disease group. In the IE group, the 30-day, 1-year and 3-year survival was 71%, 53% and 47%, respectively. Freedom from re-operation due to all graft-related causes was 76% and due to structural valve deterioration 88%. There were no cases of graft reinfection. In the congenital heart disease group CHAs were predominantly (94%) used for right ventricular outflow tract reconstruction and 88% of patients recovered without graft-related complications. At present, the number of demands for CHAs at CTB considerably outweighs their availability.

Development and validation of the project manager skills scale (PMSS): An empirical approach.

This paper presents the development and validation of the Project Manager Skills Scale (PMSS), a novel instrument designed to quantify and evaluate the critical skills of project managers. The PMSS is anchored in a comprehensive literature review and expert feedback and identifies five key dimensions of project manager skills: Technical Skills, Managerial Competences, Communication Skills, Management Style-Leadership, and Technological and Methodological Competences. The discovery of an additional fifth dimension in this study underscores the multidimensional nature of project manager skills and deviates from the initial four-cluster expectation outlined in the project management literature. The research framework employed in this study incorporated exploratory and confirmatory factor analysis. Empirical data were gathered from 257 project managers. The criteria for respondent selection were familiarity with the concept of project management and current or past engagement in a project. The findings reveal the relative importance of each dimension and highlight the multifaceted nature of project management. The study emphasizes the need for a balanced skill set that encompasses technical expertise, managerial competences, communication skills, leadership qualities, and technological and methodological competences to achieve successful project outcomes. Despite its significant contributions, this study acknowledges its limitations in terms of geographical scope and sample diversity and suggests future research directions for the development of a universally applicable understanding of project manager skills.

Penetrating injury to the left ventricle caused by attempted suicide-a case report.

Penetrating cardiac injuries are rare but are one of the most urgent emergencies because they require early intervention in order to prevent death. The mortality rate of such injuries, including pre-hospitalization deaths, goes up to 90%. The most commonly injured heart chamber is the right ventricle since it takes over half of the anterior thoracic wall. The left ventricle is injured less often, but these patients usually have worse prognoses and higher mortality rates because such injuries lead to hemodynamic instability faster. We present a unique case of a suicide attempt in which the patient stabbed himself with a knife, penetrated the left ventricle, and survived even though he transected the second diagonal branch of the left anterior descending coronary artery and pulled the knife out of his chest.

Urine high-sensitive troponin I in children cannot offer an applicable alternative to serum.

Introduction: In children, congenital heart defects represent the primary cause of increased serum troponin I. The elimination process of cardiac troponin I from the bloodstream and the factors influencing this process remain unknown. The objective of this study was to explore the role of troponin I as an indicator of cardiac damage in children both in serum and urine, a concept previously investigated in adults. Methods: Our prospective study involved 70 children under 24 months of age. The first group underwent ventricular septal defect repair, while the second group involved children who had undergone partial cavopulmonary anastomosis. For these groups, urine and serum troponin I were assessed on four occasions. The third group, consisting of healthy children, underwent a single measurement of urine troponin I. Results: Serum troponin I values exhibited an expected elevation in the early postoperative period, followed by a return to lower levels. Significantly higher concentrations of serum troponin I were observed in the first group of children (p < 0.05). A positive correlation was found between troponin I in the first three measurements and cardiopulmonary bypass and aortic cross-clamping time. There was no discernible increase in urine troponin I directly related to myocardial damage; troponin I couldn't be detected in most urine samples. Discussion: The inability to detect troponin I in urine remains unexplained. Potential explanatory factors may include the isoelectric point of troponin I, elevated urinary concentrations of salts and urea, variations in urine acidity (different pH levels), and a relatively low protein concentration in urine.

Veno-Arterial Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplant-Change of Paradigm.

Despite advances in medical therapy and mechanical circulatory support (MCS), heart transplant (HT) remains the gold standard therapy for end-stage heart failure. Patients in cardiogenic shock require prompt intervention to reverse hypoperfusion and end-organ damage. When medical therapy becomes insufficient, MCS should be considered. Historically, it has been reported that critically ill patients bridged with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) directly to HT have worse outcomes. However, when the heart allocation system gives the highest priority to patients on VA-ECMO support, those patients have a higher incidence of HT and a lower incidence of death or removal from the transplant list. Moreover, patients with a short waiting time on VA-ECMO have a similar hazard of mortality to non-ECMO patients. According to the reported data, bridging with VA-ECMO directly to HT may be a solution in the selection of critically ill patients when the anticipated waiting list time is short. However, when a prolonged waiting time is expected, more durable MCS should be considered. Regardless of the favorable results of the direct bridging to HT with ECMO in selected patients, the superiority of this strategy compared to the bridge-to-bridge strategy (ECMO to durable MCS) has not been established and further studies are mandatory in order to clarify this issue.

Extracorporeal Membrane Oxygenation After Glenn Procedure in a Child With Influenza B Pneumonia.

A five-month-old male with a hypoplastic left heart syndrome developed severe respiratory insufficiency due to influenza type B viral pneumonia following bidirectional Glenn. He was treated with extracorporeal membrane oxygenation and successfully weaned without neurological consequences.

Detecting volume responders prior to implantation of a cardiac resynchronization therapy device via minithoracotomy: the septal flash as a predictor of immediate left ventricular reverse remodeling.

BACKGROUND: Although cardiac resynchronization therapy (CRT) is well established as an adjunctive heart failure treatment, a 30% rate of nonresponders poses a challenge to improve the detection of potential responders prior to device implantation. A previously proposed mechanism-based approach to patient selection suggests in part that the septal flash is a sign of intraventricular dyssynchrony, which is predictive of CRT responsiveness. METHODS: In this pilot study, data from 5 consecutive patients (2 women and 3 men; mean + or - SD age, 62 + or - 9 years) referred for CRT device implantation via a minithoracotomy were analyzed. Intraoperative transthoracic and/or transesophageal echocardiography data, as well as Doppler myocardial imaging data, were acquired before and after CRT device activation. The septal flash was defined as an early ventricular inward and outward septal motion within the isovolumic contraction period and was imaged with grayscale imaging or tissue Doppler color M-mode. Reverse remodeling was defined as a reduction in the left ventricular end-systolic volume (LVESV) of > or =10%. The right atrial and right ventricular leads were placed transvenously, and the LV screw-in lead was positioned epicardially on the lateral wall. RESULTS: The septal flash was detected preoperatively in all patients and resolved immediately after the onset of biventricular pacing. Immediately following pacemaker activation, we measured a significant reduction in the LVESV (248 + or - 99 mL versus 190 + or - 100 mL, P = .01) and an increase in the ejection fraction (19% + or - 5% versus 28% + or - 5%, P = .01) in all patients. Likewise, a significant increase in the postactivation dP/dt (rate of LV pressure change) measured noninvasively from the mitral regurgitation trace was noted in all patients (298.6 + or - 58.0 mm Hg/s versus 601.7 + or - 111.2 mm Hg/s, P = .001). CONCLUSION: The preoperative presence of the septal flash is a valid predictor of the response to CRT. Immediately after CRT device activation, the septal flash disappears, and LV reverse remodeling and an increase in contractility are observed.

Epigenome alterations in aortic valve stenosis and its related left ventricular hypertrophy.

Aortic valve stenosis is the most common cardiac valve disease, and with current trends in the population demographics, its prevalence is likely to rise, thus posing a major health and economic burden facing the worldwide societies. Over the past decade, it has become more than clear that our traditional genetic views do not sufficiently explain the well-known link between AS, proatherogenic risk factors, flow-induced mechanical forces, and disease-prone environmental influences. Recent breakthroughs in the field of epigenetics offer us a new perspective on gene regulation, which has broadened our perspective on etiology of aortic stenosis and other aortic valve diseases. Since all known epigenetic marks are potentially reversible this perspective is especially exciting given the potential for development of successful and non-invasive therapeutic intervention and reprogramming of cells at the epigenetic level even in the early stages of disease progression. This review will examine the known relationships between four major epigenetic mechanisms: DNA methylation, posttranslational histone modification, ATP-dependent chromatin remodeling, and non-coding regulatory RNAs, and initiation and progression of AS. Numerous profiling and functional studies indicate that they could contribute to endothelial dysfunctions, disease-prone activation of monocyte-macrophage and circulatory osteoprogenitor cells and activation and osteogenic transdifferentiation of aortic valve interstitial cells, thus leading to valvular inflammation, fibrosis, and calcification, and to pressure overload-induced maladaptive myocardial remodeling and left ventricular hypertrophy. This is especcialy the case for small non-coding microRNAs but was also, although in a smaller scale, convincingly demonstrated for other members of cellular epigenome landscape. Equally important, and clinically most relevant, the reported data indicate that epigenetic marks, particularly certain microRNA signatures, could represent useful non-invasive biomarkers that reflect the disease progression and patients prognosis for recovery after the valve replacement surgery.

Changes in IgG and total plasma protein glycomes in acute systemic inflammation.

Recovery after cardiac surgery is a complex process that has to compensate for both individual variability and extensive tissue damage in the context of systemic inflammation. Protein glycosylation is essential in many steps of the inflammatory cascade, but due to technological limitations the role of individual variation in glycosylation in systemic inflammation has not been addressed until now. We analysed composition of the total plasma and IgG N-glycomes in 107 patients undergoing cardiac surgery. In nearly all individuals plasma N-glycome underwent the same pattern of changes in the first 72 h, revealing a general mechanism of glycosylation changes. To the contrary, changes in the IgG glycome were very individualized. Bi-clustering analysis revealed the existence of four distinct patterns of changes. One of them, characterized by a rapid increase in galactosylated glycoforms, was associated with nearly double mortality risk measured by EuroSCORE II. Our results indicate that individual variation in IgG glycosylation changes during acute systemic inflammation associates with increased mortality risk and indicates new avenues for the development of personalized diagnostic and therapeutic approach.

Cardiac myxoma the great imitators: comprehensive histopathological and molecular approach.

Cardiac myxomas are rare benign and slowly proliferating neoplasms of uncertain histogenesis with heterogeneous histomorphology and variable and sometimes clinically quite malignant pathological manifestations. Majority of cardiac myxoma occur sporadically while a relatively small proportion of diagnosed cases develop as a part of Carney complex syndrome with established familial pattern of inheritance. Although histologically indistinguishable these two forms of cardiac myxoma exhibit distinct cytogenetic make-up and apparent pathological differences important for their clinical presentation and prognosis. Additional problem is presented with secondary lesions with more aggressive histology and significantly faster cell proliferation suggesting their successive malignant alteration. Surgical resection of cardiac myxoma is currently the only treatment of choice. However, to avoid potentially hazardous operating procedures and possible postoperative complications and to prevent recurrence of the neoplastic lesions it is necessary to develop alternative approaches and identify a possible drug targets for their successful pharmacological treatment. Due to the rarity of the disease, a small number of cases in one institution and lack of comprehensive experimental data particularly concerning the cases of metastatic dissemination and secondary lesions with malignant nature, a comprehensive multi-institutional approach is required for better understanding of their molecular pathology and illumination of key molecular, genetic as well as epigenetic markers and regulatory pathways responsible for their development. In this article we provide comprehensive pathohistological, molecular and cytogenetic overview of sporadic cardiac myxoma cases restating the major hypothesis concerning their histogenesis and emphasizing potential approaches for their further reexamination.

In-hospital outcome of 212 consecutive patients with off-pump coronary artery bypass at Zagreb University Hospital Center.

AIM: To determine the in-hospital outcome of patients undergoing off-pump coronary artery bypass grafting. METHODS: The study included 212 consecutive patients (147 men and 65 women) undergoing off-pump coronary artery bypass grafting between March 2000 and March 2002. Mean +/- SD age of the patients was 60 +/- 8 years. We analyzed in-hospital mortality and perioperative and postoperative course of treatment of our patients. RESULTS: The mean +/- SD number of grafts was 2.9 +/- 0.9 per patient. More than 75% of patients were extubated within the first 6 h after surgery, and 6% received no blood transfusions. The mortality rate was 2.8% and there were no intraoperative deaths. CONCLUSION: Off-pump coronary artery bypass procedure seems a safe alternative to standard on-pump revascularization procedures and can also be safely suggested to elderly population.