Effect of Body Mass Index on the Clinical Outcomes of Adult Patients Treated With Venoarterial ECMO for Cardiogenic Shock.

OBJECTIVE: Current guidelines consider obesity to be a relative contraindication to venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. The authors investigated the effect of body mass index (BMI) on clinical outcomes in patients treated with VA-ECMO for cardiogenic shock. DESIGN: This was a retrospective and observational study. SETTING: University hospital. PARTICIPANTS: The study comprised 150 adult patients who underwent VA-ECMO for cardiogenic shock. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intensive care unit (ICU) mortality. Of the 150 included patients, 10 were underweight (BMI < 18.5 kg/m²), 62 were normal weight (BMI = 18.5-24.9 kg/m²), 34 were overweight (BMI = 25.0-29.9 kg/m²), 34 were obese class I (BMI = 30.0-34.9 kg/m²), and 10 were obese class II (BMI = 35.0-39.9 kg/m²). All-cause ICU mortality was 62% (underweight, 70%; normal weight, 53%; overweight, 65%; class I obese, 71%; class II obese, 70%). After multivariate logistic regression, BMI was not associated with ICU mortality (adjusted odds ratio [aOR] 0.99 [0.92-1.07], p = 0.8). Analysis by BMI category showed unfavorable mortality trends in underweight patients (aOR 3.58 [0.82-19.6], p = 0.11) and class I obese patients (aOR 2.39 [0.95-6.38], p = 0.07). No statistically significant differences were found among BMI categories in the incidences of complications. CONCLUSION: The results suggested that BMI alone should not be considered an exclusion criterion for VA-ECMO. The unfavorable trend observed in underweight patients could be the result of malnutrition.

Antenatal Diagnosis of a Partial Atrioventricular Canal with Ebstein's Anomaly.

The simultaneous occurrence of an atrioventricular canal defect (AVCD) and Ebstein's anomaly is extremely rare, occurring in less than 0.5% of all patients with AVCD. Only 22 cases are described in the literature. This patient's antenatal diagnosis of both Ebstein's anomaly and partial AVCD was made at 25 weeks of gestation. The delivery was organized in a tertiary center. The initial neonatal course was difficult but with adequate treatment, a rapid improvement allowed for a gap of almost 2 years before a complete surgical repair including a cone tricuspid plasty. To our knowledge, this is the first case of antenatal diagnosis, with carefully tailored delivery, neonatal care and subsequent follow-up before indication for successful surgery.

Differentiation in vivo of cardiac committed human embryonic stem cells in postmyocardial infarcted rats.

Human embryonic stem (HES) cells can give rise to cardiomyocytes in vitro. However, whether undifferentiated HES cells also feature a myocardial regenerative capacity after in vivo engraftment has not been established yet. We compared two HES cell lines (HUES-1 and I6) that were specified toward a cardiac lineage by exposure to bone morphogenetic protein-2 (BMP2) and SU5402, a fibroblast growth factor receptor inhibitor. Real-time polymerase chain reaction (PCR) revealed that the cardiogenic inductive factor turned on expression of mesodermal and cardiac genes (Tbx6, Isl1, FoxH1, Nkx2.5, Mef2c, and alpha-actin). Thirty immunosuppressed rats underwent coronary artery ligation and, 2 weeks later, were randomized and received in-scar injections of either culture medium (controls) or BMP2 (+/-SU5402)-treated HES cells. After 2 months, human cells were detected by anti-human lamin immunostaining, and their cardiomyocytic differentiation was evidenced by their expression of cardiac markers by reverse transcription-PCR and immunofluorescence using an anti-beta myosin antibody. No teratoma was observed in hearts or any other organ of the body. The ability of cardiac-specified HES cells to differentiate along the cardiomyogenic pathway following transplantation into infarcted myocardium raises the hope that these cells might become effective candidates for myocardial regeneration.

Freedom SOLO valve: early- and intermediate-term results of a single centre's first 100 cases.

OBJECTIVE: The Freedom SOLO aortic valve is a bovine pericardial stentless valve, which requires only one suture line. The aim of our single-centre retrospective study was to assess postoperative and intermediate-term haemodynamic results of the first 100 consecutively implanted valves. METHODS: One hundred patients (39 male and 61 female) underwent aortic valve replacement with a Freedom SOLO from November 2006 to January 2008. Their clinical, operative, platelet levels, echocardiography and follow-up data were prospectively recorded. All but two patients were available for follow-up (98% completeness), which averaged 12.6 ± 5.06 months. RESULTS: Associated procedures were performed in 38 patients (38%): 27 coronary artery bypass grafting (CABG), 11 mitral valve replacement, 11 septal myectomy and one ablation for atrial fibrillation. The mean age at the time of surgery was 77.2 ± 6.43 years. The mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8.05 ± 2.07. Mean cross-clamp time of isolated valve replacements was 51.27 ± 4.7 min and 63.18 ± 21.7 min with associated procedures. The mean implanted valve size was 23.5 ± 1.9 mm. One patient was re-operated for bleeding, two for pericardial effusion and 39 were transfused. The overall hospital mortality was 3%. One patient died suddenly postoperatively, and a second due to a fatal atrio-ventricular block. A third patient died following a subdural bleed. Three patients required a pacemaker before hospital discharge. The overall patient survival was 97 ± 2.26% at 1 year. Echocardiographic results preoperative, 8 days postoperative and 12 months after surgery showed mean transvalvular gradients of 50.6 ± 15.3, 15.6 ± 5.2 and 11.5 ± 3.8 mm Hg, respectively, and mean left ventricular ejection fractions of 37.9 ± 10.2%, 44 ± 15.2% and 53.6 ± 10.4%. Effective orifice area index for valve sizes 19, 21, 23, 25 and 27 were 0.91 ± 0.08, 0.97 ± 0.1, 1.08 ± 0.07, 1.53 ± 0.12 and 1.57 ± 0.1cm(2)m(-2), respectively. There were three early non-structural dysfunctions (grade 1) of regurgitation, which remained stable at 12 months. CONCLUSIONS: Freedom SOLO valve has very good early- and intermediate-term results. Short implantation times and its haemodynamic performances, particularly in small diameters, allow us to use it by first intention in older and often sicker patients. These results must be confirmed by long-term outcomes.

Self-assembling peptide nanofibers and skeletal myoblast transplantation in infarcted myocardium.

Cell transplantation is currently limited by poor graft retention and survival in the postinfarction scar. Because this issue could potentially be addressed by embedding cells in bioinjectable scaffolds and boosting cell survival pathways, we induced a myocardial infarction in 72 rats to assess the effects of different self-assembling peptides with or without platelet-derived growth factor (PDGF-BB) on survival of transplanted skeletal myoblasts. Two weeks after coronary artery ligation, rats were randomized to receive in-scar injections of culture medium (controls, n = 11), self-assembling peptide (RAD16-I) nanofibers (NF, n = 9), skeletal myoblasts (n = 12), or skeletal myoblasts in combination with NF (n = 8). In separate experiments with different self-assembling peptides (RAD16-II), rats received in-scar injections of culture medium (controls, n = 6), skeletal myoblasts (n = 10), PDGF-loaded peptides (n = 7), or skeletal myoblasts (5 x 10(6)) in combination with PDGF-loaded peptides (n = 9). After 1 month, left ventricular function, as assessed by echocardiography, was not improved in either of the experimental groups compared with controls. This correlated with the failure of RAD16-I peptides or PDGF-loaded RAD16-II peptides to improve myoblast survival despite a greater angiogenesis. In vitro experiments confirmed that the number of myoblasts decreased over time when seeded on nanofiber gels. These data suggest that the optimal use of biomaterial scaffolds for survival of transplanted cells will require specific tailoring of the biomaterial to the cell type.

Combination of surgical and endoscopic approach for Zenker's diverticulum.

A simple technique to improve external surgical treatment of Zenker's diverticulum is presented. A rigid esophageal endoscopy is performed just before the operation. The diverticulum is explored and washed. A single lumen tracheal tube is inserted into the esophageal lumen to serve as a stent. The technique is safe and easy and improves the bacterial control of the operation field.