Survival, ventricular arrhythmia, and implantable cardioverter-defibrillator usefulness in toxic cardiomyopathy due to substance abuse.

BACKGROUND: Toxic dilated cardiomyopathy (T-DCM) due to substance abuse is now recognized as a potential cause of severe left ventricular dysfunction. The burden of ventricular arrhythmias (VA) and the role of a prophylactic implantable cardioverter-defibrillator (ICD) are not well documented in this population. We aim to assess the usefulness of ICD implantation in a T-DCM cohort. METHODS: Patients younger than 65 years with a left ventricular ejection fraction (LVEF) < 35% followed at a tertiary center heart failure (HF) clinic between January 2003 and August 2019 were screened for inclusion. The diagnosis of T-DCM was confirmed after excluding other etiologies, and substance abuse was established according to the DSM-5 criteria. The composite primary endpoints were arrhythmic syncope, sudden cardiac death (SCD), or death of unknown cause. The secondary endpoints were the occurrence of sustained VA and/or appropriate therapies in ICD carriers. RESULTS: Thirty-eight patients were identified, and an ICD was implanted in 19 (50%) of these patients, only one for secondary prevention. The primary outcome was similar between the two groups (ICD vs. non-ICD; p = 1.00). After a mean follow-up of 33 ± 36 months, only two VA episodes were reported in the ICD group. Three patients received inappropriate ICD therapies. One ICD implantation was complicated with cardiac tamponade. Twenty-three patients (61%) had an LVEF ≥35% at 12 months. CONCLUSION: VA are infrequent in the T-DCM population. The prophylactic ICD benefit was not observed in our cohort. The ideal timing for potential prophylactic ICD implantation in this population needs further studies.

Non-invasive diagnostic imaging tests largely underdiagnose cardiac cirrhosis in patients undergoing advanced therapy evaluation: How can we identify the high-risk patient?

BACKGROUND: Patients with liver cirrhosis are generally considered ineligible for isolated cardiac transplantation or left ventricular assist device (LVAD) implantation. The aim of this retrospective study is to explore the diagnostic value of abdominal ultrasound, computed tomography scan (CT scan) and liver-spleen scintigraphy to detect the presence of cirrhosis in patients with advanced heart failure. METHODS: Among 567 consecutive patients who underwent pre-transplantation or LVAD evaluation, 54 had a liver biopsy to rule out cardiac cirrhosis; we compared the biopsy results with the imaging investigations. RESULTS: In about 26% (n = 14) of patients undergoing liver biopsy, histopathological evaluation identified cirrhosis. The respective sensitivity of abdominal ultrasound, CT scan and liver-spleen scintigraphy to detect cirrhosis was 57% [29-82], 50% [16-84], and 25% [3-65]. The specificity was 80% [64-91], 89% [72-98], and 44% [20-70], respectively. CONCLUSION: Ultrasonography has the best-combined sensitivity and specificity for the diagnosis of cirrhosis. However, more than a third of patients with cirrhosis will go undiagnosed by conventional imaging. As liver biopsy is associated with a low rate of complication, it should be considered in patients with a high-risk of cirrhosis or with evidence of portal hypertension to assess their eligibility for heart transplantation or LVAD implantation.

An autopsy view of the Hemi-commando procedure.

Invasive endocarditis involving the fibrous skeleton of the heart requires complex high-risk surgical management. For combined aortic and mitral infection in whom the posterior mitral leaflet and at least the free edge of anterior mitral valve could be spared, a modification of the Commando procedure was suggested: the "Hemi-commando procedure." We report the autopsy images of a Hemi-commando procedure after in unfortunate death in a 24 years old man 17 days after surgery.

Use of nebulized milrinone in cardiac surgery; Comparison of vibrating mesh and simple jet nebulizers.

Cardiopulmonary bypass triggers an ischemia-reperfusion injury with endothelial dysfunction in the pulmonary circulation which can result in pulmonary hypertension. Inhaled milrinone reduces this reperfusion phenomenon and two methods commonly available for administering it are simple jet and vibrating mesh nebulizations. However, neither their generated milrinone particle size profiles, nor their ability to aid endothelial relaxation have been compared. Simple jet and vibrating mesh particle size distributions of milrinone were verified through cascade impaction and their efficacy was tested on a cardiopulmonary bypass (CPB) swine model. Post-nebulizations, animals underwent 90 min of CPB, followed by 60 min of reperfusion and lung excision. Pulmonary arterial endothelium-dependent relaxations to acetylcholine and bradykinin were then performed on pulmonary vasculature rings and were subsequently modeled as inhibitory Emax functions. In vitro studies showed lower emitted and inhaled doses from the simple jet nebulizer and its particle size distribution indicated upper and middle airway targeting. During in vivo studies, milrinone pre-treated, unlike saline groups maintained baseline pulmonary pressures up to 30 min post-CPB. Ex vivo studies showed better endothelial relaxation of arteries from the two milrinone groups over those from the control group in an administration/pathway-dependent manner, favoring simple jet administration.

Preliminary experience with combined inhaled milrinone and prostacyclin in cardiac surgical patients with pulmonary hypertension.

OBJECTIVE: To retrospectively evaluate the effects of combined inhaled prostacyclin and milrinone to reduce the severity of pulmonary hypertension when administered prior to cardiopulmonary bypass. DESIGN: Retrospective case control analysis of high-risk patients undergoing cardiac surgery. SETTING: Single cardiac center. PARTICIPANTS: Sixty one adult cardiac surgical patients with pulmonary hypertension, 40 of whom received inhalation therapy. INTERVENTION: Inhaled milrinone and inhaled prostacyclin were administered before cardiopulmonary bypass (CPB). MEASUREMENTS AND MAIN RESULTS: Administration of both inhaled prostacyclin and milrinone was associated with reductions in central venous pressure, and mean pulmonary artery pressure, increases in cardiac index, heart rate, and the mean arterial-to-mean pulmonary artery pressure ratio (p < 0.05), with no significant change in mean arterial pressure. The rate of difficult and complex separation from CPB was 51% in the inhaled group and 70% in the control group (p = 0.1638). Postoperative vasoactive requirement was reduced at 12 hours (35.9 v 73.7% p<0.01) and 24 hours (25.6 v 57.9% p<0.05) postoperatively in the combined inhaled agent group. Hospital length of stay and mortality were similar between the groups. CONCLUSION: Preemptive treatment of pulmonary hypertension with a combination of inhaled prostacyclin and milrinone before CPB was associated with a reduction in the severity of pulmonary hypertension. In addition, a significant reduction in vasoactive support in the intensive care unit during the first 24 hours after cardiac surgery was observed. The impact of this strategy on postoperative survival needs to be determined.

Study protocol of a phase 2, randomised, placebo-controlled, double-blind, adaptive, parallel group clinical study to evaluate the efficacy and safety of recombinant alpha-1-microglobulin in subjects at high risk for acute kidney injury following open-chest cardiac surgery (AKITA trial).

INTRODUCTION: Acute kidney injury (AKI) is a common complication after cardiac surgery (CS) and is associated with adverse short-term and long-term outcomes. Alpha-1-microglobulin (A1M) is a circulating glycoprotein with antioxidant, heme binding and mitochondrial-protective mechanisms. RMC-035 is a modified, more soluble, variant of A1M and has been proposed as a novel targeted therapeutic protein to prevent CS-associated AKI (CS-AKI). RMC-035 was considered safe and generally well tolerated when evaluated in four clinical phase 1 studies. METHODS AND ANALYSIS: This is a phase 2, randomised, double-blind, adaptive design, parallel group clinical study that evaluates RMC-035 compared with placebo in approximately 268 cardiac surgical patients at high risk for CS-AKI. RMC-035 is administered as an intravenous infusion. In total, five doses will be given. Dosing is based on presurgery estimated glomerular filtration rate (eGFR), and will be either 1.3 or 0.65 mg/kg.The primary study objective is to evaluate whether RMC-035 reduces the incidence of postoperative AKI, and key secondary objectives are to evaluate whether RMC-035 improves postoperative renal function compared with placebo. A blinded interim analysis with potential sample size reassessment is planned once 134 randomised subjects have completed dosing. An independent data monitoring committee will evaluate safety and efficacy data at prespecified intervals throughout the trial. The study is a global multicentre study at approximately 30 sites. ETHICS AND DISSEMINATION: The trial was approved by the joint ethics committee of the physician chamber Westfalen-Lippe and the University of Münster (code '2021-778 f-A') and subsequently approved by the responsible ethics committees/relevant institutional review boards for the participating sites. The study is conducted in accordance with Good Clinical Practice, the Declaration of Helsinki and other applicable regulations. Results of this study will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER: NCT05126303.

Intraoperative changes in regional wall motion: can postoperative coronary artery bypass graft failure be predicted?

OBJECTIVE: To evaluate the accuracy of new intraoperative regional wall motions abnormalities (RWMAs) detected by transesophageal echocardiography (TEE) to predict early postoperative coronary artery graft failure. DESIGN: A retrospective study. SETTING: A tertiary care university hospital. PATIENTS: Five thousand nine hundred ninety-eight patients who underwent coronary artery bypass graft (CABG) surgery. INTERVENTIONS: An evaluation of RWMAs recorded with intraoperative TEE before and after cardiopulmonary bypass (CPB) in patients who had coronary angiography for suspected postoperative myocardial ischemia based on electrocardiogram (ECG), CK-MB, troponin T, hemodynamic compromise, low cardiac output, and malignant ventricular arrhythmia. Sensitivity, specificity, positive and negative predictive values, odds ratio, 95% confidence interval, and chi-square analysis were used. MEASUREMENTS AND MAIN RESULTS: Thirty-nine patients (0.7%) underwent early coronary angiography for the suspicion of early graft dysfunction. Of the 32 patients with diagnosed early graft dysfunction, 5 patients (15.6%) had shown new intraoperative RWMAs as detected by TEE, 21 patients (65.6%) had no new RWMAs, no report was available in 5 patients (15.6%), and 1 examination (3.1%) was excluded because of poor imaging quality. The sensitivity of TEE to predict graft failure was 15.6%, the specificity was 57.1%, and the positive predictive and negative values were 62.5% and 12.9%, respectively. The odds ratio and 95% confidence interval was 0.1190 (0.0099-1.4257) when TEE was positive compared with coronary angiography. No association was found between new RWMAs detected with TEE and graft failure as documented with coronary angiography (p = 0.106). CONCLUSIONS: In this retrospective study, RWMAs detected with TEE were of limited value to predict early postoperative CABG failure.

Heavy Burden of Toxic Dilated Cardiomyopathy Among Young Adults: A Retrospective Study and Review of the Literature.

BACKGROUND: Dilated cardiomyopathy (DCM) is a well described entity for heart failure (HF) with reduced left ventricular ejection fraction (LVEF). Recently, drugs and other substance of abuse have been recognised as potential triggers for DCM. The aim of this study was to assess the survival in patients ≤ 65 years of age with toxic cardiomyopathy (TCM). Left ventricular remodelling and the potential usefulness of left ventricular assist devices (LVADs) was also assessed. METHODS: This was a single-centre retrospective study from January 2003 to August 2019 of 553 patients ≤ 65 years old with LVEF < 40% at a tertiary-care cardiology centre. RESULTS: A total of 201 patients (36%) had a diagnosis of idiopathic DCM. Further analysis identified 38 patients (19%) for which a TCM was the most likely etiology (amphetamine [50%], cocaine [37%], anabolic steroids [8%], and energy drinks [5%]). Despite a mean LVEF of 17 ± 8% at presentation, most patients (n = 27; 71%) had event-free survival with guideline-directed medical therapy, and 61% (n = 23) recovered an LVEF ≥ 40% after a median follow-up of 21 ± 23 months. Seven patients (18%) required an LVAD and 1 patient (3%) a transplantation. All LVADs were explanted or decommissioned after partial or complete LVEF recovery after a median support time of 11 ± 4 months. CONCLUSIONS: TCM induced by substance abuse is a frequent cause of HF, accounting for almost 20% of patients ≤ 65 years of age with DCM of unknown etiology. Treatment must be tailored on an individual basis. Mechanical circulatory support demonstrated its usefulness in carefully selected patients.

Do Energy Drinks Really Give You Wings? Left Ventricular Assist Device Therapy as a Bridge to Recovery for an Energy Drink-Induced Cardiomyopathy.

The deleterious effect of energy drinks is increasingly recognized. We present a 26-year-old woman with inotrope-dependent severe dilated cardiomyopathy, potentially caused by chronic ingestion of energy drinks. The results of extensive investigation-consisting of cardiac magnetic resonance, F-18-fluorodesoxyglucose-positron emission tomography, coronary angiography, and endomyocardial biopsy-were normal. A left ventricular assist device (LVAD) was implanted as a potential bridge to recovery. After 10 months of mechanical support and pharmacological treatment, cardiac function was recovered, and the LVAD was successfully explanted. This is the first case report of energy drink abuse leading to severe heart failure requiring mechanical support for recovery.

Concurrent Epicardial Cardiac Resynchronization at Time of Complicated Biventricular Device Extraction: A Potentially Life-Saving Option.

A 60-year-old man with cardiac resynchronization therapy defibrillator (CRT-D) lead endocarditis underwent transvenous lead extraction that was complicated by coronary sinus laceration and tamponade. Severe left ventricular dysfunction and unstable hemodynamic parameters persisted after emergent sternotomy, drainage, and repair. Reinstitution of cardiac resynchronization therapy with an epicardial device resulted in immediate hemodynamic improvement. Our case illustrates the potentially life-saving nature of single-stage extraction and reimplantation in resynchronization responders.

Mitral Annular Calcification and Mitral Valve Replacement: A New Approach.

Mitral valve replacement is technically challenging in the context of mitral annular calcification. A new surgical strategy is described that was used in a 71-year-old obese patient, where intraatrial prosthesis insertion and valve fixation into native uncalcified structures were performed without calcium debridement.

Buttocks Hard as Rocks: Not Wanted after Aortic Dissection Repair.

The authors report the case of a patient developing a gluteal compartment syndrome after DeBakey type I dissection repair. Prompt recognition and treatment led to successful results. The surgical approach to the gluteal compartment is described.

Unusual Cause of Life-Threatening Hemoptysis During Cardiac Operation: Surgical Management Revisited.

The surgical management of life-threatening perioperative hemoptysis has been vastly replaced by radiologic embolization. In some situations, surgical therapy can prove useful. This case report describes life-threatening hemoptysis of an unusual cause during coronary artery bypass grafting, managed through an original technique of temporary pulmonary vascular exclusion by thoracotomy.

Transcatheter aortic valve implantation by the left axillary approach: a single-center experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an accepted alternative treatment for severe symptomatic aortic stenosis in high-risk and inoperable patients. Femoral or transapical accesses are commonly used. We report our initial clinical experience with TAVI using the left-axillary artery approach. METHODS: A single-center, retrospective study of patients undergoing transaxillary TAVI between January 2010 and December 2012 was performed. Procedural success was defined as successful device implantation with reduction in the mean aortic gradient and without need for conversion to open-heart surgery. Short-term echocardiographic follow-up was obtained in all patients. RESULTS: A total of 18 consecutive patients with severe aortic stenosis who were not candidates for surgical replacement underwent transaxillary TAVI. Mean age was 81.1±7.3 years and 14 patients (78%) were male. Median logistic European System for Cardiac Operative Risk Evaluation was 8.5% (range, 1.5% to 54.1%). Procedural success was obtained in 17 out of 18 patients (94%). There was no in-hospital or 30-day mortality. One major bleeding complication in the form of an upper gastrointestinal bleeding was observed. No stroke or major vascular complication was reported. Postoperative implantation of a permanent pacemaker was performed in 7 patients (39%). At a mean follow-up of 326±213 days, mean aortic gradient was 10.8±4.8 mm Hg. Mean aortic valve area was 1.7±0.4 cm2 and aortic insufficiency grade was mild or less in all but 1 patient, who showed moderate regurgitation. CONCLUSIONS: The transaxillary approach for TAVI is associated with high procedural success and low rates of stroke, vascular, or bleeding complications. This approach is an appealing alternative to the commonly used transfemoral and transapical TAVI.

Mitral annulus reconstruction and giant left atrial reduction plasty.

We describe a simple and reproducible technique permitting both effective left atrial reduction plasty and safe mitral annulus reconstruction, using a patch of left atrium tissue. In a 64-year-old patient undergoing redo mitral valve replacement for mechanical prosthesis disinsertion, a giant left atrium and extensive calcification of the mitral annulus were noted. This technique permitted a safe mechanical mitral prosthesis re-replacement and a significant reduction of left atrial volume by 70%.

Decreased incidence of low output syndrome with a switch from tepid to cold continuous minimally diluted blood cardioplegia in isolated coronary artery bypass grafting.

OBJECTIVES: The optimal temperature for blood cardioplegia remains unclear. METHODS: A retrospective analysis was performed on 138 patients undergoing isolated myocardial revascularization by a single surgeon in our institution over a period of 2 years. Patients operated on early in the study period received tepid (29°C) continuous minimally diluted blood cardioplegia (minicardioplegia), delivered in an antegrade continuous fashion. Later, our surgeon began using cold (7°C) blood minicardioplegia in all patients. Data pertaining to clinical outcomes and postoperative biochemical data were obtained, and the two groups were compared. RESULTS: Low cardiac output syndrome, defined as the need for intra-aortic balloon pump counter pulsation or inotropic medication for haemodynamic instability, was more frequent in the tepid cardioplegia group than in the cold cardioplegia group (16.0 vs 2.4%, P = 0.006). There was no difference in the maximal serum creatine kinase MB between the two groups (cold 25.4 ± 3.21 µg/ml vs tepid 36.5 ± 7.10 µg/ml, P = 0.62), in the rates of perioperative myocardial infarction (cold 1.2% vs tepid 6.0%, P = 0.15) and the need for postoperative insertion of an intra-aortic balloon pump (cold 4.8% vs tepid 0.0%, P = 0.3). There was no other statistically significant difference between the two groups in the measured parameters. CONCLUSIONS: A higher rate of low cardiac output syndrome in the tepid cardioplegia group suggests inferior myocardial protection with the tepid cardioplegia. Cold cardioplegia may provide better protection than tepid cardioplegia when minicardioplegia is used.

Management of early postoperative coronary artery bypass graft failure.

Perioperative graft failure following coronary artery bypass grafting (CABG) may result in acute myocardial ischaemia. Whether acute percutaneous coronary intervention, emergency reoperation or conservative intensive care treatment should be used is currently unknown. Between 2003 and 2009, 39 of the 5598 patients who underwent isolated CABG surgery underwent early postoperative coronary angiography for suspected myocardial ischaemia. Following angiography, two groups were identified: patients who underwent immediately reintervention (group 1); and those treated conservatively (group 2). Primary study endpoints were mortality and postoperative myocardial infarct size. Postoperative coronary angiography revealed early perioperative bypass graft failure in 32 of 39 patients. Acute percutaneous coronary intervention was performed in 15 patients, redo-CABG in 4 patients and conservative treatment in 13 patients. The number of failing bypass grafts were significantly higher in group 1 compared with group 2 (P = 0.0251). A trend toward lower post-procedural peak cardiac troponin T and creatinine phosphokinase serum levels in group 1 was observed (163.0 vs. 206.0 and 4.35 vs. 5.53, respectively) (P = 0.0662 and 0.1648). Early reintervention may limit the extent of myocardial cellular damage compared with conservative medical strategy in patients with myocardial ischaemia due to early graft failure.

Solitary fibrous tumour of the pleura: A case report.

Solitary fibrous tumours of the pleura are rare pleural neoplasms that are distinct from mesothelioma. Most of them are benign, although some behave aggressively; morphological and pathological features are important in distinguishing them from mesothelioma and in predicting clinical behaviour. Solitary fibrous tumours often grow to a large size before causing symptoms, and are characteristically associated with hypertrophic pulmonary osteoarthropathy in up to 20% of cases. In cases of benign lesions, complete resection is usually curative. A case involving a 62-year-old woman who underwent surgical resection of a solitary fibrous tumour of the pleura measuring 25 cm in size is described.