Minimum-incision trans-subclavian transcatheter aortic valve replacement with regional anesthesia.

BACKGROUND: Minimum-incision trans-subclavian transcatheter aortic valve replacement (MITS-TAVR) is usually performed in patients who are contraindicated for transfemoral TAVR, under regional anesthesia (RA). This study aimed to evaluate the safety and efficacy of MITS-TAVR under RA compared to MITS-TAVR under general anesthesia (GA). METHODS: This single-center observational study included 44 consecutive patients who underwent MITS-TAVR under RA (RA group, n = 19) and GA (GA group, n = 25). RA was achieved using an ultrasound-guided nerve block. RESULTS: The rates of respiratory disease (RA vs. GA, 36.8 % vs. 4.0 %; p < 0.01) and dialysis (79.0 % vs. 0 %; p < 0.01) were significantly higher in the RA group. STS score was significantly higher in the RA group (RA vs. GA, 10.8 ±â€¯1.06 % vs. 7.87 ±â€¯0.93 %; p < 0.01). Both groups had a 100 % procedural success rate. The two groups showed comparable operation room stay times (RA vs. GA, 160 ±â€¯6.96 min vs. 148 ±â€¯5.90 min; p = 0.058). The mean rate of change in blood pressure, used as an index of hemodynamic stability, was significantly lower in the RA group (RA vs. GA, 19.0 ±â€¯3.4 % vs. 35.5 ±â€¯3.0 %; p < 0.01). No in-hospital deaths occurred in either group. One case of minor dissection occurred in the GA group (RA vs.GA, 0 % vs. 4.0 %, p = 0.378). The intensive care unit stay (RA vs. GA, 0.21 ±â€¯0.11 days vs. 1.24 ±â€¯0.10 days; p < 0.01) and hospital stay (RA vs. GA, 7.00 ±â€¯1.73 days vs. 12.2 ±â€¯1.44 days; p < 0.01) were significantly shorter in the RA group. CONCLUSIONS: MITS-TAVR under RA is safe and effective and might be a promising alternative approach. It could ensure intraoperative hemodynamic stability and shorten intensive care unit and hospital stays.

Safety and efficacy of the percutaneous thoracic endovascular repair with regional anesthesia.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is typically performed with general anesthesia (GA) and surgical cutdown (G-TEVAR). As the latest generation of TEVAR delivery systems are smaller, we introduced percutaneous TEVAR with regional anesthesia (RA) (R-TEVAR) and an arteriotomy closure device. In this study, we compare the safety and efficacy of R-TEVAR to that of the G-TEVAR. METHODS: This single-center observational study included consecutive patients who underwent either G-TEVAR between January 2015 and October 2018 (33 patients) or R-TEVAR (41 patients) between January 2018 and April 2020. RA was achieved using an ultrasound-guided nerve block. RESULTS: The mean outer diameter of the delivery device was significantly smaller in R-TEVAR (18.5 vs. 22.7 Fr; p < 0.01) and the time from arriving into the operating room to beginning of surgery (34.1 vs. 68.5 min; p < 0.01), procedural time (46.4 vs. 103.6 min; p < 0.01), and operating room stay time (108.3 vs. 194.6 min; p < 0.01) were significantly shorter. The mean rate of change in blood pressure was significantly lower in the R-TEVAR group (7.7% vs. 32.2%; p < 0.01). One case of spinal cord ischemia occurred in the G-TEVAR group (0% vs. 3.0%; p = 0.262) and one case of inadequate hemostasis and conversion to surgical cutdown without GA occurred in the R-TEVAR group (2.4% vs. 0%; p = 0.366). CONCLUSIONS: The R-TEVAR is safe and minimally invasive. Further, RA may provide additional benefits of mean blood pressure stability and early recognition of neurologic complications.

Parenteral amino acid supplementation with high-dose insulin prevents hypoaminoacidemia during cardiac surgery.

OBJECTIVES: Surgery triggers a stress response that produces insulin resistance and hyperglycemia. During cardiac surgery, the administration of high-dose insulin along with dextrose titration maintains normoglycemia, but dramatically decreases plasma amino acids (AAs) compared with preoperative fasting levels. Hypoaminoacidemia limits protein synthesis and prevents anabolic responses after surgery. We investigated whether parenteral infusion of AAs during and immediately after cardiac surgery would prevent hypoaminoacidemia in patients who receive high-dose insulin therapy. METHODS: Sixteen patients undergoing coronary artery bypass grafting surgery were randomly allocated to receive AAs with % kcal equivalent to either 20% (n = 8) or 35% (n = 8) of their measured resting energy expenditure (REE). Insulin was infused at a constant rate of 5 mU/(kg × min), whereas dextrose was titrated to maintain normoglycemia during and until 5 h after surgery. Plasma AA concentrations were measured at baseline before and after surgery. RESULTS: Compared with the 20% AA group after surgery, AA concentrations were significantly higher in the 35% AA group for 12 of 20 AAs (P < 0.032), including all branched-chain AAs. In the 20% AA group, total essential AAs decreased by 21% and nonessential AAs decreased by 14% after surgery compared with preoperative fasting levels. In contrast, giving 35% AAs prevented this unfavorable decrease in AAs, and in fact allowed for a 23% and 12% increase in essential and nonessential AAs, respectively. CONCLUSIONS: AA supplementation at 35% REE, but not 20% REE, can effectively prevent hypoaminoacidemia caused by high-dose insulin therapy during cardiac surgery.

Oxygenic Phototrophs Need ζ-Carotene Isomerase (Z-ISO) for Carotene Synthesis: Functional Analysis in Arthrospira and Euglena.

For carotenogenesis, two biosynthetic pathways from phytoene to lycopene are known. Most bacteria and fungi require only phytoene desaturase (PDS, CrtI), whereas land plants require four enzymes: PDS (CrtP), ζ-carotene desaturase (ZDS, CrtQ), ζ-carotene isomerase (Z-ISO) and cis-carotene isomerase (CrtISO, CrtH). The gene encoding Z-ISO has been functionally identified in only two species, Arabidopsis thaliana and Zea mays, and has been little studied in other organisms. In this study, we found that the deduced amino acid sequences of Arthrospira Z-ISO and Euglena Z-ISO have 58% and 62% identity, respectively, with functional Z-ISO from Arabidopsis. We studied the function of Z-ISO genes from the cyanobacterium Arthrospira platensis and eukaryotic microalga Euglena gracilis. The Z-ISO genes of Arthrospira and Euglena were transformed into Escherichia coli strains that produced mainly 9,15,9'-tri-cis-ζ-carotene in darkness. In the resulting E. coli transformants cultured under darkness, 9,9'-di-cis-ζ-carotene was accumulated predominantly as Z-ISO in Arabidopsis. This indicates that the Z-ISO genes were involved in the isomerization of 9,15,9'-tri-cis-ζ-carotene to 9,9'-di-cis-ζ-carotene in darkness. This is the first functional analysis of Z-ISO as a ζ-carotene isomerase in cyanobacteria and eukaryotic microalgae. Green sulfur bacteria and Chloracidobacterium also use CrtP, CrtQ and CrtH for lycopene synthesis as cyanobacteria, but their genomes did not comprise Z-ISO genes. Consequently, Z-ISO is needed in oxygenic phototrophs, whereas it is not found in anoxygenic species.

Hyperinsulinemic Normoglycemia during Cardiac Surgery Reduces a Composite of 30-day Mortality and Serious In-hospital Complications: A Randomized Clinical Trial.

BACKGROUND: Hyperinsulinemic normoglycemia augments myocardial glucose uptake and utilization. We tested the hypothesis that hyperinsulinemic normoglycemia reduces 30-day mortality and morbidity after cardiac surgery. METHODS: This dual-center, parallel-group, superiority trial randomized cardiac surgical patients between August 2007 and March 2015 at the Cleveland Clinic, Cleveland, Ohio, and Royal Victoria Hospital, Montreal, Canada, to intraoperative glycemic management with (1) hyperinsulinemic normoglycemia, a fixed high-dose insulin and concomitant variable glucose infusion titrated to glucose concentrations of 80 to 110 mg · dl; or (2) standard glycemic management, low-dose insulin infusion targeting glucose greater than 150 mg · dl. The primary outcome was a composite of 30-day mortality, mechanical circulatory support, infection, renal or neurologic morbidity. Interim analyses were planned at each 12.5% enrollment of a maximum 2,790 patients. RESULTS: At the third interim analysis (n = 1,439; hyperinsulinemic normoglycemia, 709, standard glycemic management, 730; 52% of planned maximum), the efficacy boundary was crossed and study stopped per protocol. Time-weighted average glucose concentration (means ± SDs) with hyperinsulinemic normoglycemia was 108 ± 20 versus 150 ± 33 mg · dl with standard glycemic management, P < 0.001. At least one component of the composite outcome occurred in 49 (6.9%) patients receiving hyperinsulinemic normoglycemia versus 82 (11.2%) receiving standard glucose management (P < efficacy boundary 0.0085); estimated relative risk (95% interim-adjusted CI) 0.62 (0.39 to 0.97), P = 0.0043. There was a treatment-by-site interaction (P = 0.063); relative risk for the composite outcome was 0.49 (0.26 to 0.91, P = 0.0007, n = 921) at Royal Victoria Hospital, but 0.96 (0.41 to 2.24, P = 0.89, n = 518) at the Cleveland Clinic. Severe hypoglycemia (less than 40 mg · dl) occurred in 6 (0.9%) patients. CONCLUSIONS: Intraoperative hyperinsulinemic normoglycemia reduced mortality and morbidity after cardiac surgery. Providing exogenous glucose while targeting normoglycemia may be preferable to simply normalizing glucose concentrations.

Insertion/deletion polymorphism of the angiotensin-converting enzyme considerably changes postoperative outcome.

STUDY OBJECTIVE: To evaluate the influence of insertion/deletion (ID) polymorphism of the angiotensin-converting enzyme (ACE) gene on clinical outcome of cardiac valve surgery. DESIGN: Prospective, blinded observational study. SETTING: Operating room and intensive care unit (ICU) of a university hospital. PATIENTS: 110 adult patients requiring elective cardiac valve surgery requiring cardiopulmonary bypass. MEASUREMENTS: Patients' preoperative data (age, gender, body weight, New York Heart Association score, medication, biochemical data, and comorbid disorders), anesthetic management (blood pressure, heart rate, blood loss and transfusion, and cardiorespiratory complications and their treatment), and postoperative outcome (life-threatening complications, nosocomial infections, reintubation/reoperation, death, and duration of ICU stay and hospitalization) were recorded. ACE ID was detected by gel electrophoresis following conventional polymerase chain reaction. Patients were divided into two groups postoperatively; groups with II and non-II (ID and DD) genotypes, and group differences were analyzed. MAIN RESULTS: Distribution of ACE ID in II, ID, and DD genotypes was 29%, 59%, and 12%, respectively. The non-II group had significantly greater postoperative blood loss and transfusion (P < 0.05), more common postoperative infections, and longer ICU stay duration than the II group (P < 0.01). CONCLUSIONS: ACE ID polymorphism is associated with a higher incidence of postoperative complications, including postoperative infections, in patients undergoing cardiac valve surgery.