COVID-19 in recent heart transplant recipients: Clinicopathologic features and early outcomes.

BACKGROUND: The impact of COVID-19 on heart transplant (HTx) recipients remains unclear, particularly in the early post-transplant period. METHODS: We share novel insights from our experience in five HTx patients with COVID-19 (three within 2 months post-transplant) from our institution at the epicenter of the pandemic. RESULTS: All five exhibited moderate (requiring hospitalization, n = 3) or severe (requiring ICU and/or mechanical ventilation, n = 2) illness. Both cases with severe illness were transplanted approximately 6 weeks before presentation and acquired COVID-19 through community spread. All five patients were on immunosuppressive therapy with mycophenolate mofetil (MMF) and tacrolimus, and three that were transplanted within the prior 2 months were additionally on prednisone. The two cases with severe illness had profound lymphopenia with markedly elevated C-reactive protein, procalcitonin, and ferritin. All had bilateral ground-glass opacities on chest imaging. MMF was discontinued in all five, and both severe cases received convalescent plasma. All three recent transplants underwent routine endomyocardial biopsies, revealing mild (n = 1) or no acute cellular rejection (n = 2), and no visible viral particles on electron microscopy. Within 30 days of admission, the two cases with severe illness remain hospitalized but have clinically improved, while the other three have been discharged. CONCLUSIONS: COVID-19 appears to negatively impact outcomes early after heart transplantation.

Effect of Balloon-Expandable Transcatheter Aortic Valve Replacement Positioning: A Patient-Specific Numerical Model.

Transcatheter aortic valve replacement (TAVR) has emerged as a life-saving and effective alternative to surgical valve replacement in high-risk, elderly patients with severe calcific aortic stenosis. Despite its early promise, certain limitations and adverse events, such as suboptimal placement and valve migration, have been reported. In the present study, it was aimed to evaluate the effect of various TAVR deployment locations on the procedural outcome by assessing the risk for valve migration. The deployment of a balloon-expandable Edwards SAPIEN valve was simulated via finite element analysis in a patient-specific calcified aortic root, which was reconstructed from CT scans of a retrospective case of valve migration. The deployment location was parametrized in three configurations and the anchorage was quantitatively assessed based on the contact between the stent and the native valve during the deployment and recoil phases. The proximal deployment led to lower contact area between the native leaflets and the stent which poses higher risk for valve migration. The distal and midway positions resulted in comparable outcomes, with the former providing a slightly better anchorage. The approach presented might be used as a predictive tool for procedural planning in order to prevent prosthesis migration and achieve better clinical outcomes.

Cardiac Papillary Fibroelastoma: Atypical Presentation Mimicking Infective Endocarditis With False Positive Commensal Blood Cultures.

Cardiac papillary fibroelastomas (CPFs) are rare benign cardiac neoplasms that carry a high risk of embolization if not diagnosed and managed in a timely manner. As most patients are asymptomatic, CPF may be incidentally detected on transthoracic echocardiography (TTE) when performed for other indications. Management of incidental CPF in asymptomatic patients is debatable. We report an unusual case of an incidental CPF in an asymptomatic patient admitted to the hospital for presumed infective endocarditis (IE). Two weeks following laser resection of laryngeal cancer (LC), a new pansystolic murmur was audible during a routine cardiology visit. Outpatient TTE revealed a "vegetation-like" lesion on the mitral valve (MV). Blood cultures (BC) with Gram-positive cocci in clusters (GPC) were reported within 24 hours. This prompted hospital admission for empiric antibiotics. A transesophageal echocardiogram (TEE) confirmed the lesion to be an echogenic mass attached to the MV consistent with CPF. Repeat BC, prior to empiric antibiotic initiation, were all negative. In the absence of all other signs and symptoms of IE, it was determined that the initial BC was false positive and IE was ruled out. Surgical resection was performed due to the potential risk of embolization. The pathology confirmed the diagnosis of CPF with negative tissue cultures.

Subjective Assessment Underestimates Fraility in Patients With Heart Failure Referred for Advanced Therapies.

Assessment of frailty is key for evaluation for advanced therapies (ATs). Most programs use a subjective provider assessment (SPA) or "eye-ball" test; however, objective measures exist. The modified five-item Fried Frailty Index (mFFI) is a validated tool to assess frailty. We compared SPA to mFFI testing in patients referred for AT. We also compared levels of macrophage migration inhibitory factor (MIF), an inflammatory biomarker associated with worse outcomes in heart failure, between frail and not frail subjects. Seventy-eight patients referred for evaluation for AT underwent both SPA and mFFI testing. Three cardiac surgeons independently assessed patients for frailty (SPA). SPA significantly underestimated frailty compared with mFFI testing and correlation between SPA and mFFI was not strong (κ = 0.02-0.14). Providers were correct 84% of the time designating a subject as frail, but only 40% of the time designating as not frail. Agreement between all three providers was robust (76%), which was primarily driven by designation as not frail. There was no significant difference in plasma MIF levels between frail and not frail subjects (47.6 ± 25.2 vs . 45.2 ± 18.9 ng/ml; p = 0.6). Clinicians significantly underestimate frailty but are usually correct when designating a patient as frail.

Assessment of cardiac recovery in patients supported with venoarterial extracorporeal membrane oxygenation.

AIMS: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used to support patients in cardiogenic shock (CS). Early determination of disposition is paramount, as longer durations of support have been associated with worse outcomes. We describe a stepwise, bedside weaning protocol to assess cardiopulmonary recovery during VA-ECMO. METHODS AND RESULTS: Over 1 year, we considered all patients on VA-ECMO for CS for the Weaning Protocol (WP) at our centre. During the WP, patients had invasive haemodynamic monitoring, echocardiography, and blood gas analysis while flow was reduced in 1 LPM decrements. Ultimately, the circuit was clamped for 30 min, and final measures were taken. Patients were described as having durable recovery (DR) if they were free of pharmacological and mechanical support at 30 days post-decannulation. Over 12 months, 34 patients had VA-ECMO for CS. Fourteen patients were eligible for the WP at 4-12 days. Ten patients tolerated full flow reduction and were successfully decannulated. Twenty-four per cent of the entire cohort demonstrated DR with no adverse events during the WP. Patients with DR had significantly higher ejection fraction, cardiac index, and smaller left ventricular size at lowest flow during the WP. CONCLUSIONS: We describe a safe, stepwise, bedside weaning protocol to assess cardiac recovery during VA-ECMO. Early identification of patients more likely to recover may improve outcomes during ECMO support.

Left Ventricular Assist Devices and the Kidney.

Left ventricular assist devices (LVADs) are common and implantation carries risk of AKI. LVADs are used as a bridge to heart transplantation or as destination therapy. Patients with refractory heart failure that develop chronic cardiorenal syndrome and CKD often improve after LVAD placement. Nevertheless, reversibility of CKD is hard to predict. After LVAD placement, significant GFR increases may be followed by a late return to near baseline GFR levels, and in some patients, a decline in GFR. In this review, we discuss changes in GFR after LVAD placement, the incidence of AKI and associated mortality after LVAD placement, the management of AKI requiring RRT, and lastly, we review salient features about cardiorenal syndrome learned from the LVAD experience. In light of the growing number of patients using LVADs as a destination therapy, it is important to understand the effect of these devices on the kidney. Additional research and long-term data are required to better understand the relationship between the LVAD and the kidney.

Adjunctive extracorporeal carbon dioxide removal in refractory status asthmaticus.

Status asthmaticus (SA) is a life-threatening disorder. Severe respiratory failure may require extracorporeal membrane oxygenation (ECMO). Previous reports have demonstrated utility of ECMO in SA in various patients with varying success. A 25-year-old man was admitted with status asthmatics and severe hypercapnic respiratory failure. Despite tailored ventilator therapies, such as pressure control ventilation and maximal pharmacological therapy, including general anaesthesia, the patient’s condition deteriorated rapidly. Veno-venous ECMO (VV-ECMO) was provided for respiratory support. The patient’s clinical condition improved over the following 72 hours and was discharged from the intensive care unit on day 3. This case report demonstrates the successful use of VV-ECMO in a patient with severe respiratory failure due to SA, who failed to respond to maximal therapy. This case adds support to a growing body of literature that shows that ECMO can be used with success for refractory status asthmaticus.

A quantitative in vitro model of smooth muscle cell migration through the arterial wall using the human amniotic membrane.

OBJECTIVE: The development of intimal hyperplasia involves smooth muscle cell (SMC) migration into the intima and proliferation. Matrix metalloproteinases and their tissue inhibitors play important roles in this process. In this study, we describe a novel in vitro model for studying SMC migration through the vessel wall. METHODS AND RESULTS: Human aortic SMCs (hASMCs) labeled with 125I-iododeoxyuridine or unlabeled were grown on the stromal aspect of the human amniotic membrane. Mechanical damage to endothelial cells grown on the basement membrane and addition of growth factors or platelets were characterized for their effect on SMC migration into the stroma both by histological methods and by measuring the radioactivity associated with the membrane after removal of noninvasive SMCs. To assess the reliability of the model, the cells were infected with a recombinant adenovirus encoding the tissue inhibitor of metalloproteinase-1 (TIMP-1). Addition of a platelet-derived growth factor gradient stimulated hASMC infiltration into the stroma. This effect was abolished with TIMP-1-transduced hASMC, confirming that TIMP-1 overexpression blocks SMC invasion of the stroma. CONCLUSIONS: This in vitro model of SMC migration in the vessel wall provides an inexpensive, quantitative, and reliable tool to study the molecular and cellular mechanisms of intimal hyperplasia.

Efectividad de cirugía de Frey en pacientes con pancreatitis crónica del Hospital General Docente Dr. Agostinho Neto, Guantánamo / Efetividade de cirugía de Frey em pacientes com pancreatite crônica do Hospital General Docente Dr. Agostinho Neto, Guantánamo / Effectiveness of Frey's surgery in patients with chronic pancreatitis of the General Teaching Hospital Dr. Agostinho Neto, Guantanamo

Introducción: la pancreatitis crónica es la inflamación de la glándula pancreática de causa múltiple, que produce dolor y daños en el parénquima. Entre sus tratamientos se encuentra la resección local de la cabeza del páncreas (excavación) con pancreaticoyeyunostomía laterolateral, conocida como cirugía de Frey. Objetivo: demostrar la eficacia de la cirugía de Frey para pacientes con dolor por pancreatitis crónica. Método: se realizó un estudio descriptivo y prospectivo en 8 pacientes egresados con pancreatitis crónica intervenidos quirúrgicamente en el servicio de Cirugía General del Hospital General Docente Dr Agostinho Neto, Guantánamo, a los cuales se les aplicó cirugía de Frey. Entre las variables que se analizaron se encontraron: promedio de edad, sexo, antecedentes patológicos personales, tiempo promedio de la intervención quirúrgica, promedio de sangre transfundida, morbilidad, mortalidad y seguimiento promedio. Resultados: la edad promedio fue de 51 años, el sexo predominante fue el masculino y el alcoholismo fue la primera causa de pancreatitis crónica. El tiempo quirúrgico alcanzó un promedio de 282 min y el promedio de transfusión de sangre fue de 506,25 ml. La morbilidad posoperatoria fue de 25,0 por ciento y no hubo mortalidad. El seguimiento de los pacientes obtuvo un promedio de 42,25 meses y el 87,56 por ciento notó ausencia de dolor luego de la intervención. Conclusiones: la cirugía de Frey es segura, eficaz y con buenos resultados para tratar el dolor de la pancreatitis crónica, sobre todo aquellas con una masa inflamatoria en la cabeza del páncreas, por lo que recomendamos su uso(AU)

Introduction: chronic pancreatitis is the inflammation of the multiple-cause pancreatic gland, which produces pain and damage to the parenchyma, progressive and irreversible, with fibrosis and stenosis of the ducts. Among its treatments is the local resection of the head of the pancreas (excavation) with laterolateral pancreaticojejunostomy, known as Frey's surgery. Objective: to demonstrate the efficacy of Frey's surgery for patients with pain due to chronic pancreatitis. Method: a descriptive and prospective study was carried out in 8 patients suffering from chronic pancreatitis operated in the General Surgery Department of the General Teaching Hospital Dr Agostinho Neto, Guantanamo, to whom Frey's surgery was applied. The variables were analyzed: average age, sex, personal pathological history, average time of surgery, average blood transfusion, morbidity, mortality and average follow-up. Results: the average age was 51 years, the predominant sex was male and alcoholism was the first cause of chronic pancreatitis. The main conduit of the pancreas had an average diameter of 13.8 mm and the head of the pancreas had an average measurement of 49 mm; the surgical time averaged 282 min and the average blood transfusion was 506.25 ml. Postoperative morbidity was 25.0 percent and there was no mortality. The follow-up of the patients obtained an average of 42.25 months and 87.56 percent reported absence of pain after the intervention. During follow-up there was no new onset diabetes or steatorrhea. Conclusions: Frey's surgery is safe, effective and with good results to treat the pain of chronic pancreatitis, especially those with an inflammatory mass in the head of the pancreas, so the authors recommend its use(AU)

Introdução: pancreatite crônica é a inflamação da glândula pancreática de múltiplas causas, que produz dor e danifica o parênquima. Entre seus tratamentos está a ressecção local da cabeça do pâncreas (escavação) com pancreaticojejunostomia laterolateral, conhecida como cirurgia de Frey. Objetivo: demonstrar a efetividade da cirurgia de Frey em pacientes com dor por pancreatite crônica. Método: estudo descritivo e prospectivo, realizado em 8 pacientes com pancreatite crônica, submetidos à cirurgia no serviço de cirurgia geral do Hospital Universitário Dr. Agostinho Neto, Guantánamo, aos quais foi aplicada a cirurgia de Frey. Entre as variáveis analisadas estavam: idade média, sexo, histórico patológico pessoal, tempo médio de cirurgia, transfusão sanguínea média, morbidade, mortalidade e tempo médio de seguimento. Resultados: a média de idade foi de 51 anos, o sexo predominante foi masculino e o alcoolismo foi a primeira causa de pancreatite crônica. O tempo cirúrgico foi em média de 282 min e a transfusão de sangue média foi de 506,25 ml. A morbidade pós-operatória foi de 25,0 por cento e não houve mortalidade. O seguimento dos pacientes obteve uma média de 42,25 meses e 87,56 por cento relataram ausência de dor após a intervenção. Conclusões: a cirurgia de Frey é segura, efetiva e com bons resultados no tratamento da dor da pancreatite crônica, principalmente naqueles com massa inflamatória na cabeça do pâncreas, por isso recomendamos seu uso(AU)

Efectividad de cirugía de Frey en pacientes con pancreatitis crónica del Hospital General Docente Dr Agostinho Neto, Guantánamo / Effectiveness of Frey's surgery in patients with chronic pancreatitis of the General Teaching Hospital Dr Agostinho Neto, Guantanamo

Introducción: la pancreatitis crónica es la inflamación de la glándula pancreática de causa múltiple, que produce dolor y daños en el parénquima. Entre sus tratamientos se encuentra la resección local de la cabeza del páncreas (excavación) con pancreaticoyeyunostomía laterolateral, conocida como cirugía de Frey. Objetivo: demostrar la eficacia de la cirugía de Frey para pacientes con dolor por pancreatitis crónica. Método: se realizó un estudio descriptivo y prospectivo en 8 pacientes egresados con pancreatitis crónica intervenidos quirúrgicamente en el servicio de Cirugía General del Hospital General Docente Dr Agostinho Neto, Guantánamo, a los cuales se les aplicó cirugía de Frey. Entre las variables que se analizaron se encontraron: promedio de edad, sexo, antecedentes patológicos personales, tiempo promedio de la intervención quirúrgica, promedio de sangre transfundida, morbilidad, mortalidad y seguimiento promedio. Resultados: la edad promedio fue de 51 años, el sexo predominante fue el masculino y el alcoholismo fue la primera causa de pancreatitis crónica. El tiempo quirúrgico alcanzó un promedio de 282 min y el promedio de transfusión de sangre fue de 506,25 ml. La morbilidad posoperatoria fue de 25,0 por ciento y no hubo mortalidad. El seguimiento de los pacientes obtuvo un promedio de 42,25 meses y el 87,56 por ciento notó ausencia de dolor luego de la intervención. Conclusiones: la cirugía de Frey es segura, eficaz y con buenos resultados para tratar el dolor de la pancreatitis crónica, sobre todo aquellas con una masa inflamatoria en la cabeza del páncreas, por lo que recomendamos su uso(AU)

Introduction: chronic pancreatitis is the inflammation of the multiple-cause pancreatic gland, which produces pain and damage to the parenchyma, progressive and irreversible, with fibrosis and stenosis of the ducts. Among its treatments is the local resection of the head of the pancreas (excavation) with laterolateral pancreaticojejunostomy, known as Frey's surgery. Objective: to demonstrate the efficacy of Frey's surgery for patients with pain due to chronic pancreatitis. Method: a descriptive and prospective study was carried out in 8 patients suffering from chronic pancreatitis operated in the General Surgery Department of the General Teaching Hospital Dr Agostinho Neto, Guantanamo, to whom Frey's surgery was applied. The variables were analyzed: average age, sex, personal pathological history, average time of surgery, average blood transfusion, morbidity, mortality and average follow-up. Results: the average age was 51 years, the predominant sex was male and alcoholism was the first cause of chronic pancreatitis. The main conduit of the pancreas had an average diameter of 13.8 mm and the head of the pancreas had an average measurement of 49 mm; the surgical time averaged 282 min and the average blood transfusion was 506.25 ml. Postoperative morbidity was 25.0 percent and there was no mortality. The follow-up of the patients obtained an average of 42.25 months and 87.56 percent reported absence of pain after the intervention. During follow-up there was no new onset diabetes or steatorrhea. Conclusions: Frey's surgery is safe, effective and with good results to treat the pain of chronic pancreatitis, especially those with an inflammatory mass in the head of the pancreas, so the authors recommend its use(AU)

Introdução: pancreatite crônica é a inflamação da glândula pancreática de múltiplas causas, que produz dor e danifica o parênquima. Entre seus tratamentos está a ressecção local da cabeça do pâncreas (escavação) com pancreaticojejunostomia laterolateral, conhecida como cirurgia de Frey. Objetivo: demonstrar a eficácia da cirurgia de Frey em pacientes com dor por pancreatite crônica. Método: estudo descritivo e prospectivo, realizado em 8 pacientes com pancreatite crônica, submetidos à cirurgia no serviço de cirurgia geral do Hospital Universitário Dr Agostinho Neto, Guantánamo, aos quais foi aplicada a cirurgia de Frey. Entre as variáveis analisadas estavam: idade média, sexo, histórico patológico pessoal, tempo médio de cirurgia, transfusão sanguínea média, morbidade, mortalidade e tempo médio de seguimento. Resultados: a média de idade foi de 51 anos, o sexo predominante foi masculino e o alcoolismo foi a primeira causa de pancreatite crônica. O tempo cirúrgico foi em média de 282 min e a transfusão de sangue média foi de 506,25 ml. A morbidade pós-operatória foi de 25,0 por cento e não houve mortalidade. O seguimento dos pacientes obteve uma média de 42,25 meses e 87,56 por cento relataram ausência de dor após a intervenção. Conclusões: a cirurgia de Frey é segura, eficaz e com bons resultados no tratamento da dor da pancreatite crônica, principalmente naqueles com massa inflamatória na cabeça do pâncreas, por isso recomendamos seu uso(AU)