Takayasu's Arteritis: A Special Case Report and Review of the Literature.

Background: Takayasu's arteritis is a rare type of vasculitis with severe complications like stroke, ischemic heart disease, pulmonary hypertension, secondary hypertension, and aneurysms. Diagnosis is achieved using clinical and angiographic criteria. Treatment is medical and surgical, but unfortunately, the outcome is limited. Case presentation: A 34-year-old Caucasian woman had an ischemic stroke (2009). She was diagnosed with Takayasu's arteritis and received treatment with methotrexate, prednisolone, and antiplatelet agents, with a mild improvement in clinical state. After 6 years (2015), she experienced an ascending aorta aneurysm, pulmonary hypertension, and mild aortic regurgitation. Surgical treatment solved both the ascending aorta aneurysm and left carotid artery stenosis (ultrasound in 2009 and computed tomography angiogram in 2014). Morphopathology revealed a typical case of Takayasu's arteritis. Tumor necrosis factor inhibitors (TNF inhibitors) were prescribed with methotrexate. At 48 years old (2023), she developed coronary heart disease (angina, electrocardiogram); echocardiography revealed severe pulmonary hypertension, and angiography revealed normal coronary arteries, abdominal aorta pseudoaneurysm, and arterial-venous fistula originating in the right coronary artery with drainage in the medium pulmonary artery. The patient refused surgical/interventional treatment. She again received TNF inhibitors, methotrexate, antiplatelet agents, and statins. Conclusions: This case report presented a severe form of Takayasu's arteritis. Our patient had multiple arterial complications, as previously mentioned. She received immunosuppressive treatment, medication targeted to coronary heart disease, and surgical therapy.

The Evolution of Pulmonary Hypertension and Its Prognostic Implications Post-TAVI-Single Center Experience.

Background and Objectives: Since the first transcatheter aortic valve implantation (TAVI) procedure was performed in 2002, advances in technology and refinement of the method have led to its widespread use in patients with severe aortic stenosis (AS) and high surgical risk. We aim to identify the impact of TAVI on the clinical and functional status of patients with severe AS at the one-month follow-up and to identify potential predictors associated with the evolution of pulmonary hypertension (PH) in this category of patients. Materials and Methods: We conducted a prospective study which included 86 patients diagnosed with severe AS undergoing TAVI treatment. We analyzed demographics, clinical and echocardiographic parameters associated with AS and PH both at enrolment and at the 30-day follow-up. Results: In our study, the decrease of EUROSCORE II score (p < 0.001), improvement of angina (p < 0.001) and fatigue (p < 0.001) as clinical benefits as well as a reduction in NYHA functional class in patients with heart failure (p < 0.001) are prognostic predictors with statistical value. Regression of left ventricular hypertrophy (p = 0.001), increase in the left ventricle ejection fraction (p = 0.007) and improvement of diastolic dysfunction (p < 0.001) are echocardiographic parameters with a prognostic role in patients with severe AS undergoing TAVI. The pulmonary artery acceleration time (PAAT) (p < 0.001), tricuspid annular plane systolic excursion (TAPSE) (p = 0.020), pulmonary arterial systolic pressure (PASP) (p < 0.001) and the TAPSE/PASP ratio (p < 0.001) are statistically significant echocardiographic parameters in our study that assess both PH and its associated prognosis in patients undergoing TAVI. Conclusions: PAAT, TAPSE, PASP and the TAPSE/PASP ratio are independent predictors that allow the assessment of PH and its prognostic implications post-TAVI.

Hybrid Management of an Aortobronchial Fistula after Patch Aortoplasty for Aortic Coarctation in a Patient with SARS-CoV-2 Pneumonia: Case Report and Review of the Literature.

Aortobronchial fistula is a rare cause of repeated hemoptysis and a potentially fatal condition if left untreated. We present the case of a 40-year-old man with repeated hemoptysis, excessive cough, and epistaxis ongoing for several days after SARS-CoV-2 pneumonia diagnosis. The patient had a history of patch aortoplasty for aortic coarctation and aortic valve replacement with a mechanical valve for aortic insufficiency due to bicuspid aortic valve at the age of 24. Computed tomography scan performed at presentation revealed a severely dilated ascending aorta, a thoracic aorta pseudoaneurysm at the site of the former coarctation, an aortobronchial fistula suggested by the thickened left lower lobe apical segmental bronchus in contact with the pseudoaneurysm and signs of alveolar hemorrhage in the respective segment. The patient was treated with thoracic endovascular aneurysm repair (TEVAR) after prior hemi-aortic arch debranching and transposition of the left common carotid artery and subclavian artery through a closed-chest surgical approach. Our case report together with a systematic review of the literature highlight the importance of both considering an aortobronchial fistula in the differential diagnosis of hemoptysis in patients with prior history of thoracic aorta surgical intervention, regardless of associated pathology, and of taking into account endovascular and hybrid techniques as an alternative to open surgical repair, which carries a high risk of morbidity and mortality.

Prediction and Management of Surgical Site Infections in Hybrid Vascular Surgery for Peripheral Artery Disease.

OBJECTIVES: Postoperative complications are an important problem that all surgeons face. Among all possible complications, local and systemic infections are one of the most prevalent postprocedural adverse events. It is difficult to assess whether or not a patient will develop a surgical site infection (SSI), but there are certain basic investigations that can suggest the probability of such an event. We also investigated some clinically assessable signs to help us better predict the occurrence of SSIs. Every bit of information brings us closer to an ideal where we can bring postoperative complications to a minimum. Close examination and attention to detail is crucial in the prediction and prevention of SSIs. Methods: A multicenter, retrospective and prospective observational study was carried out between 01.01.2019 â?" 01.09.2021. All adult patients with peripheral artery disease (PAD) who had disabling intermittent claudication or rest pain, were included in this study. We excluded minor or vascular surgery emergencies (ruptured aneurysms, acute ischemia or vascular trauma). We followed the postoperative complications as well as their management with an emphasis on surgical site infections (SSIs). Receiver Operating Characteristic (ROC) curves were used to determine key values of statistical relevance by calculating the Area Under the Curve (AUC). Multivariate analysis was used to assess the statistical relevance of our data. Results: The study evaluates 128 patients diagnosed with PAD, aged between 47 and 97, with a mean age of 71.26 Ã+- 10.8 years. There were significantly more male than female patients 71.09% vs. 28.91% (p 0.01). All patients were treated using hybrid vascular techniques. All complication rates were recorded but we focused on SSIs, which was the most prevalent complication (25%). C-Reactive Protein with values higher than 5 mg/dl, was confirmed as a positive predictive factor for postoperative surgical site infections (AUC = 0.80). Another positive predictive factor for SSIs is hyperglycemia. Glycemic values higher than 140mg/dl are more frequently associated with postoperative infections (p = 0.02), a predictability curve of statistical significance was also obtained (AUC = 0.71). Postoperative SSIs were more prevalent in patients with preoperative distal trophic lesions (p 0.01). The presence of other complications such as edema and lymphoceles were also linked to SSIs (p 0.01). Nevertheless, patients who underwent surgery over negative wound pressure therapy (NWPT) for infection management had significantly shorter hospital stays (p 0.01). Conclusions: There are multiple clinical or paraclinical predictors of SSIs. The coexistence of several such factors can carry an additional risk of developing a SSI and should be evaluated and controlled separately in the preoperative phase as much as possible. Admission to a diabetes center and regulation of glycemic values prior to elective vascular surgery, for patients who can be surgically postponed is an effective method of preventing infections. Surgical management remains the most reliable form of treatment of SSIs, being the most efficient therapy and offering immediate results, while simultaneously shortening hospital stays.

Infective endocarditis after TAVI: a meta-analysis and systematic review of epidemiology, risk factors and clinical consequences.

Infective endocarditis (IE) represents one of the most challenging clinical entities, requiring a multidisciplinary approach. The increasing number of surgical and transcatheter heart valves replacements performed annually lead to a higher incidence of prosthetic valve endocarditis. Transcatheter aortic valve implantation (TAVI) brought a new alternative for the treatment of aortic stenosis and a new subgroup of IE with its features. We aimed to compare the incidence of IE in TAVI and surgical valve replacement (SAVR) to identify risk factors for TAVI-IE, evaluate the possible impact on mortality, and clarify the best treatment strategies. A digital scan in PubMed and SCOPUS databases was performed. 68 publications were selected to perform a meta-analysis and systematic review on epidemiology, risk factors, and mortality predictors in TAVI-IE. No significant difference in IE rate was noted between patients with TAVI and those with SAVR for in-hospital, early, mid-term and late IE. Male gender, intubation, new pacemaker implantation IE and CKD were correlated with TAVI-IE. Surgical treatment was performed in 22.3% of cases. Overall mortality for the pooled cohort was 38.3%. In a multivariate logistic regression model, surgical treatment and self-expandable device were linked to lower mortality in TAVI-IE. Even if the invasive procedure can trigger bacteremia, exposing the TAVI valve to future infection, no significant difference in IE rate was noted in our analysis between patients with TAVI and those with SAVR for in-hospital, early, mid-term and late IE. Surgical treatment of TAVI-IE can be a viable option in patients with a prohibitive risk score.

Determinants of acute kidney injury after cardiac surgery: a systematic review.

Acute kidney injury following cardiac surgery (CS-AKI) represents a severe postoperative complication, negatively impacting short-term and long-term mortality. Due to the lack of a specific treatment, effective prevention remains the most powerful tool to overcome the CS-AKI burden. Improving the preventive strategies is possible by establishing appropriate preoperative risk profiles. Various clinical models were proposed as a means to assist physicians in stratifying the risk of CS-AKI. However, these models are used for predicting severe forms of CS-AKI, while their predictive power for mild forms is insufficient. Our paper represents the first systematic approach to review all proposed preoperative risk factors and their predictive power. Our strategy is the starting point for selecting and comparing the predictive elements to be integrated into future risk models. Heart failure, chronic hyperglycemia, anemia, obesity, preoperative exposure to nephrotoxic drugs or contrast media, inflammation, proteinuria, and pre-existing kidney disease were systematically reviewed and were found to be associated with an increased risk of postoperative CS-AKI. As no externally validated and universally accepted risk models currently exist, the clinical judgment and a good knowledge of the preoperative risk factors in the light of new evidence may help personalize preoperative risk profiles as the cornerstone of prevention measures.

Cardiac surgery outcomes in patients with antecedent kidney, liver, and pancreas transplantation: a meta-analysis.

Cardiovascular events are among the most common causes of late death in the transplant recipient (Tx) population. Moreover, major cardiac surgical procedures are more challenging and risky due to immunosuppression and the potential impact on the transplanted organ's functional capacity. We aimed to assess open cardiac surgery safety in abdominal solid organ transplant recipients, comparing the postoperative outcomes with those of nontransplant (N-Tx) patients. Electronic databases of PubMed, EMBASE, and SCOPUS were searched. The endpoints were: overall rate of infectious complications (wound infection, septicemia, pneumonia), cardiovascular and renal events (stroke, cardiac tamponade, acute kidney failure), 30-days, 5-years, and 10-years mortality post-cardiac surgery interventions in patients with and without prior solid organ transplantation. This meta-analysis included five studies. Higher rates of wound infection (Tx vs. N-Tx: OR: 2.03, 95% CI: 1.54 to 2.67, I2 = 0%), septicemia (OR: 3.91, 95% CI: 1.40 to 10.92, I2 = 0%), cardiac tamponade (OR: 1.83, 95% CI: 1.28 to 2.62, I2 = 0%) and kidney failure (OR: 1.70, 95 %CI: 1.44 to 2.02, I2 = 89%) in transplant recipients were reported. No significant differences in pneumonia occurrence (OR: 0.95, 95% CI: 0.71 to 1.27, I2 = 0%) stroke (OR: 0.89, 95% CI: 0.54 to 1.48, I2 = 78%) and 30-day mortality (OR: 1.92, 95% CI: 0.97 to 3.80, I2 = 0%) were observed. Surprisingly, 5-years (OR: 3.74, 95% CI: 2.54 to 5.49, I2 = 0%) and 10-years mortality rates were significantly lower in the N-Tx group (OR: 3.32, 95% CI: 2.35 to 4.69, I2 = 0%). Our study reveals that open cardiac surgery in transplant recipients is associated with worse postoperative outcomes and higher long-term mortality rates.

Coronary revascularization during treatment of severe aortic stenosis: A meta-analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR).

BACKGROUND: The management of patients with coexisting severe aortic stenosis (AS) and coronary artery disease (CAD) is still facing a great deal of uncertainty when it comes to choosing between the entire surgical versus the complete percutaneous approaches, after accurately balancing risks versus outcomes. AIM: To evaluate clinical outcomes and mortality of transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI) compared with surgical aortic valve replacement (SAVR) plus coronary arteries bypass grafting (CABG) procedures in patients with concomitant AS and CAD. METHODS: Electronic databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles assessing outcome parameters of interest. The study endpoints were the rate of overall myocardial infarction and stroke within 30 days and the rate of 30-day mortality and 2-year mortality between patients with TAVR/PCI and those with SAVR/CABG. RESULTS: Random-effect meta-analysis did not reveal any significant difference between 30-day safety outcomes: myocardial infarction (TAVR/PCI vs SAVR/CABG: odds ratio [OR]: 0.52; 95% confidence interval [CI]: 0.20-1.33; I2 = 0%), stroke (TAVR/PCI vs SAVR/CABG: OR: 0.88; 95% CI: 0.45-1.73; I2 = 0%). No significant difference in 30-day mortality (OR: 0.72; 95% CI: 0.43-1.21; I2 = 0%) and 2-year mortality (OR: 1.50; 95% CI: 0.77-2.94; I2 = 81%) rate was noted between patients with TAVR/PCI and those with SAVR/CABG. CONCLUSIONS: When comparing the total percutaneous and total surgical treatment, no significant difference in short-term safety outcomes or early and late mortality was observed. More evidence is needed to guide the clinical decision.

Novel percutaneous interventional therapies in heart failure with preserved ejection fraction: an integrative review.

Heart failure with preserved ejection fraction (HFpEF) is a common disorder generating high mortality and important morbidity prevalence, with a very limited medical treatment available. Studies have shown that the pathophysiological hallmark of this condition is an elevated left intra-atrial pressure (LAP), exertional dyspnea being its clinical manifestation. The increasing pressure from LA is not based on volume overload (such as in heart failure with reduced ejection fraction) but on a diastolic left ventricular (LV) dysfunction combined with an inter-atrial dyssynchrony mimicking a pseudo-pacemaker syndrome. In this review, we aimed to summarize current knowledge and discuss future directions of the newest interventional percutaneous therapies of HFpEF. Novel interventional approaches developed to counter these mechanisms are as follows: LA decompression (inter-atrial shunt devices), enhancement of LV compliance (LV expanders), and inter-atrial resynchronization therapy (LA permanent pacing). To date, inter-atrial shunt devices (IASD) are the most studied, being the only devices currently tested in a phase 3 trial. Recent data showed that IASD are feasible, safe, and have a short-term clinical benefit in HFpEF patients. LV expanders and LA pacing therapy present with a smaller clinical benefit compared with IASD, but they are safe, without any major adverse outcomes currently noted. With further development and improvement of these mechanism-specific devices, it will be interesting to determine in the future whether a complex intervention of multiple HFpEF device implantation will be safe and have further benefits in HFpEF patients.

Strategies to Lower In-Hospital Mortality in STEMI Patients with Primary PCI: Analysing Two Years Data from a High-Volume Interventional Centre.

OBJECTIVES: We aimed to analyse data from our high-volume interventional centre (>1000 primary percutaneous coronary interventions (PCI) per year) searching for predictors of in-hospital mortality in acute myocardial infarction (MI) patients. Moreover, we looked for realistic strategies and interventions for lowering in-hospital mortality under the "5 percent threshold." Background. Although interventional and medical treatment options are constantly expanding, recent studies reported a residual in-hospital mortality ranging between 5 and 10 percent after primary PCI. Current data sustain that mortality after ST-elevation MI will soon reach a point when cannot be reduced any further. METHODS: In this retrospective observational single-centre cohort study, we investigated two-year data from a primary PCI registry including 2035 consecutive patients. Uni- and multivariate analysis were performed to identify independent predictors for in-hospital mortality. RESULTS: All variables correlated with mortality in univariate analysis were introduced in a stepwise multivariate linear regression model. Female gender, hypertension, depressed left ventricular ejection fraction, history of MI, multivessel disease, culprit left main stenosis, and cardiogenic shock proved to be independent predictors of in-hospital mortality. The model was validated for sensitivity and specificity using receiver operating characteristic curve. For our model, variables can predict in-hospital mortality with a specificity of 96.60% and a sensitivity of 84.68% (p < 0.0001, AUC = 0.93, 95% CI 0.922-0.944). CONCLUSIONS: Our analysis identified a predictive model for in-hospital mortality. The majority of deaths were due to cardiogenic shock. We suggested that in order to lower mortality under 5 percent, focus should be on creating a cardiogenic shock system based on the US experience. A shock hub-centre, together with specific transfer algorithms, mobile interventional teams, ventricular assist devices, and surgical hybrid procedures seem to be the next step toward a better management of ST-elevation MI patients and subsequently lower death rates.

Casting Light on The Hidden Prevalence: A Novel Perspective on Hypoplastic Coronary Artery Disease.

Background and Objectives: Coronary artery anomalies (CAAs) represent a group of rare cardiac abnormalities with an incidence of up to 1.2%. The aim of this retrospective study was to conduct a comprehensive epidemiological assessment of the prevalence of hypoplastic coronary arteries using coronary computed tomography angiography (CCTA) in patients with diagnosed CAAs and individuals presenting with cardiovascular manifestations in the north-eastern region of Romania. This study was motivated by the limited investigation of the CAAs conducted in this area. Methods: We analyzed data collected from 12,758 coronary computed tomography angiography (CCTA) records available at the "Prof. Dr. George I.M. Georgescu" Cardiovascular Diseases Institute, spanning the years 2012 to 2022. Results: Among 350 individuals with CAAs (2.7% of the total cohort), 71 patients (20.3% of the anomaly presenting group and 0.5% of the entire CCTA cohort) exhibited at least one hypoplastic coronary artery. The mean age of individuals diagnosed with hypoplastic coronary artery disease (HCAD) was 61 years, while the age distribution among them ranged from 22 to 84 years. Nearly equal cases of right and left dominance (33 and 31, respectively) were observed, with only 7 cases of co-dominance. Conclusions: HCAD may be considered underexplored in current published research, despite its potentially significant implications ranging to an increased risk of sudden cardiac arrest. The specific prevalence of HCAD among CAAs might be higher than previously reported, possibly reflecting better diagnostic accuracy of CCTA over classic coronary imaging. The absence of standard diagnostic and therapeutic protocols for HCAD underscores the necessity of a personalized approach for such cases.

Retinal Structural and Vascular Changes in Patients with Coronary Artery Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Retinal microvascular anomalies have been identified in patients with cardiovascular conditions such as arterial hypertension, diabetes mellitus, and carotid artery disease. We conducted a systematic review and meta-analysis (PROSPERO registration number CRD42024506589) to explore the potential of retinal vasculature as a biomarker for diagnosis and monitoring of patients with coronary artery disease (CAD) through optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA). METHODS: We systematically examined original articles in the Pubmed, Embase, and Web of Science databases from their inception up to November 2023, comparing retinal microvascular features between patients with CAD and control groups. Studies were included if they reported sample mean with standard deviation or median with range and/or interquartile range (which were computed into mean and standard deviation). Review Manager 5.4 (The Cochrane Collaboration, 2020) software was used to calculate the pooled effect size with weighted mean difference and 95% confidence intervals (CI) by random-effects inverse variance method. RESULTS: Eleven studies meeting the inclusion criteria were incorporated into the meta-analysis. The findings indicated a significant decrease in the retinal nerve fiber layer (WMD -3.11 [-6.06, -0.16]), subfoveal choroid (WMD -58.79 [-64.65, -52.93]), and overall retinal thickness (WMD -4.61 [-7.05, -2.17]) among patients with CAD compared to controls (p < 0.05). Furthermore, vascular macular density was notably lower in CAD patients, particularly in the superficial capillary plexus (foveal vessel density WMD -2.19 [-3.02, -1.135], p < 0.0001). Additionally, the foveal avascular zone area was statistically larger in CAD patients compared to the control group (WMD 52.73 [8.79, 96.67], p = 0.02). Heterogeneity was significant (I2 > 50%) for most features except for subfoveal choroid thickness, retina thickness, and superficial foveal vessel density. CONCLUSION: The current meta-analysis suggests that retinal vascularization could function as a noninvasive biomarker, providing additional insights beyond standard routine examinations for assessing dysfunction in coronary arteries.

Organ transplantation in Romania: challenges and perspectives.

Introduction: The interest in the field of organ transplantation and the first attempts at making experimental transplant interventions in Romania date from the very beginning of the 20th century. Nevertheless, the evolution of the donating activity and of organ transplantation in Romania has been confronted with a certain inconsistency and a lack of resources necessary to the development of the system. Method: The aim of this study is to analyze the dynamics of the transplantation activity in Romania between 2000 and 2020. The study was accomplished through the analysis of available data corresponding to the above-mentioned period, which were published in the database of the National Transplant Agency, Eurostat and the Global Observatory on Donation and Transplantation. The data were processed using the MedCalc Statistical Software, version 14.8.1 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2014). Results: The activity of donation and organ transplantation in Romania has been maintained at a low level, with a rate of 3.44 donators pmp and a transplantation rate of 12.55 pmp, as reported for the year 2020. Romania remains at a transplantation rate of under 6.6 pmp, despite the considerable increase in the number of patients on the waiting lists, a fact which describes the picture of a relatively weak system, incapable of providing surgical interventions to cover the minimum needs that emerge within a calendar year. Conclusions: Our study points to the fact that the transplantation system in Romania is confronted with a major deadlock. Romania holds the last-but-one place in the ranking of countries in the European Union on transplant activity. The major impediment is the donation rate, which continues to be way below the European average, in a society where the awareness of the necessity to donate is very low, bureaucracy is cumbersome and there is a high degree of mistrust in the medical system, where the equipment is lacking and the infrastructure is incapable of providing services adapted to the modern standards.

Comparative Analysis of Left Ventricular Mass Regression Following Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement - a Single Center Experience from Romania.

Introduction: Severe aortic stenosis is often associated with left ventricular hypertrophy (LVH). Elevated left ventricular mass (LVM) is linked to higher cardiovascular morbidity and mortality. Traditionally, surgical aortic valve replacement (SAVR) has been the standard treatment, but transcatheter aortic valve implantation (TAVI) offers an alternative for high-risk surgical patients. Understanding how these interventions affect left ventricular mass regression is crucial. Materials and methods: This retrospective study analyzed 315 patients treated between December 2014 and December 2022, categorizing them into surgical and transcatheter treatment groups. Clinical and echocardiographic data were collected at baseline and six-month follow-up. Statistical analysis assessed differences between groups and predictors of LV mass reduction. Results:The overall dataset indicated an average percentage reduction in LVM of 10.86%±29.41%. Segmenting the data, the TAVI subgroup exhibited a reduction of 4.28%±30.31%, while the SAVR subgroup highlighted a pronounced decline of 17.92%±26.76%. Preoperative LVMi and mean pressure gradient positively correlated with LVM reduction, while TAVI negatively impacted it. Conclusions: Both TAVI and SAVR interventions yield benefits in reducing left ventricular mass, with SAVR showing a superior outcome. Recognizing predictors of LV mass regression is crucial for optimizing treatment strategies, and early valve replacement should be considered to prevent irreversible LV hypertrophy.

Echocardiographic predictors of adverse short-term outcomes after heart surgery in patients with mitral regurgitation and pulmonary hypertension.

BACKGROUND: Pulmonary hypertension (PH) is a frequent occurrence and a negative prognostic indicator in patients with mitral regurgitation. Preoperative PH causes higher early and late mortality rates after heart surgery, adverse cardiac events, and postoperative systolic dysfunction in the left ventricle (LV). METHODS: The research consisted of a retrospective study of a group of 171 consecutive patients with mitral regurgitation and preoperative PH who had undergone mitral valve surgery between January 2008 and October 2011. The PH diagnosis was based on echocardiographic evidence (systolic pulmonary artery pressure [sPAP] >35 mm Hg). The echocardiographic examination included assessment of the following: LV volume, LV ejection fraction (LVEF), sPAP, right ventricular end-diastolic diameter, right atrium area indexed to the body surface area, the ratio of the pulmonary acceleration time to the pulmonary ejection time (PAT/PET), tricuspid annular plane systolic excursion (TAPSE), determination of the severity of the associated tricuspid regurgitation, and presence of pericardial fluid. Surgical procedures consisted of mitral valve repair in 55% of the cases and mitral valve replacement in the remaining 45%. Concomitant coronary artery bypass grafting (CABG) surgery was carried out in 52 patients (30.41%), and De Vega tricuspid annuloplasty was performed in 29 patients (16.95%). The primary end point was perioperative mortality. The secondary end points included the following: pericardial, pleural, hepatic, or renal complications; the need for a new surgical procedure; postoperative mechanical ventilation >24 hours; length of stay in the intensive care unit; duration of postoperative inotropic support; need for an intra-aortic balloon pump; and need for pulmonary vasodilator drugs. RESULTS: The mortality rate was 2.34%. In the univariate analysis, the clinical and echocardiographic parameters associated with mortality were preoperative New York Heart Association (NYHA) class IV, the PAT/PET ratio, TAPSE, the indexed area of the right atrium, and concomitant CABG surgery. In the multivariate analysis, the indexed area of the right atrium and concomitant CABG surgery remained statistically significant. The multivariate analysis also showed the indexed area of the right atrium, LVEF, presence of pericardial fluid, preoperative NYHA class, and concomitant CABG surgery as statistically significant for the secondary end point. The receiver operating characteristic (ROC) curves identified an sPAP value >65 mm Hg to have the highest specificity and sensitivity for the risk of perioperative death in mitral regurgitation patients (area under the ROC curve [AUC], 0.782; P < .001) and identified an sPAP value of 60 mm Hg as the secondary end point (AUC, 0.82; P < .001). Severe PH (sPAP >60 mm Hg) is associated with a significant increase in the mortality rate; a longer stay in the intensive care unit; a mechanical ventilation duration >24 hours; lengthy inotropic support; renal, hepatic, and pericardial complications; and a need for endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and/or prostanoids, both in the general group and in patients with preserved systolic functioning of the left ventricle. CONCLUSIONS: PH is a strong short-term negative prognostic factor for patients with mitral regurgitation. The surgical procedure should be performed in the early stages of PH. Echocardiographic examination has useful, simple, and reproducible tools for classifying operative risks. An ischemic etiology and a need for concomitant CABG surgery are additional risk factors for patients with mitral regurgitation and PH.

Cardiac Rehabilitation in Peripheral Artery Disease in a Tertiary Center-Impact on Arterial Stiffness and Functional Status after 6 Months.

Background and Objectives: Cardiac rehabilitation (CR) plays an essential role in peripheral artery disease (PAD), leading to improved functional status, increased quality of life, and reduced arterial stiffness. We aimed to assess factors associated with clinical improvement 6 months after enrolment in a rehabilitation program at an academic medical center in north-eastern Europe. Materials and Methods: We conducted a prospective cohort study on 97 patients with PAD admitted to a single tertiary referral center. At the 6-months follow-up, 75 patients (77.3%) showed improved clinical status. We analyzed demographics and clinical and paraclinical parameters in order to explore factors associated with a favorable outcome. Results: Hypertension (p = 0.002), diabetes mellitus (p = 0.002), dyslipidemia (p = 0.045), and obesity (p = 0.564) were associated with no clinical improvement. Smoking cessation (p < 0.001), changing sedentary lifestyle (p = 0.032), and improvement of lipid and carbohydrate profile as well as functional status parameters and ambulatory arterial stiffness index (p = 0.008) were factors associated with clinical improvement at the 6-months follow-up. Conclusions: PAD patients require an integrative, multidisciplinary management to maintain functional status and increase quality of life. Improving carbohydrate and lipid profile, adopting a healthy lifestyle, quitting smoking and increasing exercise capacity are predictors for clinical improvement 6 months after enrolment in a CR program.

Concept, Design, and Early Prototyping of a Low-Cost, Minimally Invasive, Fully Implantable Left Ventricular Assist Device.

Despite evidence associating the use of mechanical circulatory support (MCS) devices with increased survival and quality of life in patients with advanced heart failure (HF), significant complications and high costs limit their clinical use. We aimed to design an innovative MCS device to address three important needs: low cost, minimally invasive implantation techniques, and low risk of infection. We used mathematical modeling to calculate the pump characteristics to deliver variable flows at different pump diameters, turbomachinery design software CFturbo (2020 R2.4 CFturbo GmbH, Dresden, Germany) to create the conceptual design of the pump, computational fluid dynamics analysis with Solidworks Flow Simulation to in silico test pump performance, Solidworks (Dassault Systèmes SolidWorks Corporation, Waltham, MA, USA) to further refine the design, 3D printing with polycarbonate filament for the initial prototype, and a stereolithography printer (Form 2, Formlabs, Somerville, MA, USA) for the second variant materialization. We present the concept, design, and early prototyping of a low-cost, minimally invasive, fully implantable in a subcutaneous pocket MCS device for long-term use and partial support in patients with advanced HF which unloads the left heart into the arterial system containing a rim-driven, hubless axial-flow pump and the wireless transmission of energy. We describe a low-cost, fully implantable, low-invasive, wireless power transmission left ventricular assist device that has the potential to address patients with advanced HF with higher impact, especially in developing countries. In vitro testing will provide input for further optimization of the device before proceeding to a completely functional prototype that can be implanted in animals.

The Impact of the Early COVID-19 Pandemic on ST-Segment Elevation Myocardial Infarction Presentation and Outcomes-A Systematic Review and Meta-Analysis.

Background: The influence of the early COVID-19 pandemic on non-COVID-19 emergencies is uncertain. We conducted a systematic review and a meta-analysis to evaluate the impact of the first months of the COVID-19 pandemic on the presentation, management, and prognosis of patients presenting with ST-segment elevation myocardial infarction (STEMI). Methods: We searched the PubMed, Scopus, and Embase databases from January to August 2020. A meta-analysis of studies comparing the profile, STEMI severity at presentation, reperfusion delay, and in-hospital mortality for patients presenting before and during the early COVID-19 pandemic was conducted. Fifteen cross-sectional observational studies including 20,528 STEMI patients from the pre-COVID period and 2190 patients diagnosed and treated during the first months of the COVID-19 pandemic met the inclusion criteria. Results: Patients presenting with STEMI during the pandemic were younger and had a higher comorbidity burden. The time interval between symptoms and first medical contact increased from 93.22 ± 137.37 min to 142 ± 281.60 min (p < 0.001). Door-to-balloon time did not differ significantly between the two periods (p = 0.293). The pooled odds ratio (OR) for low left ventricular ejection fraction at presentation during the pandemic was 2.24 (95% confidence interval (CI) 1.54−3.26) and for a presentation delay >24 h was 2.9 (95% CI 1.54−5.45) relative to before the pandemic. In-hospital mortality did not increase significantly during the outbreak (p = 0.97). Conclusion: During the first months of the COVID-19 pandemic, patients presenting with STEMI were addressed later in the course of the disease with more severe left ventricular impairment. In-hospital emergency circuits and care functioned properly with no increase in door-to-balloon time and early mortality.

Organ Procurement, Donation, and Transplant Awareness in an Urban Eastern European Region: A General Population Survey.

BACKGROUND Despite significant improvements in Romania's transplantation system, actual donor numbers have paradoxically fallen, contrary to the European trend. With a donation rate of 3.44 donors per million inhabitants, Romania ranks near the bottom of European countries. This study aimed to identify several predictors of a positive attitude toward organ donation in the Romanian population that could aid in reshaping public policies to improve donation and transplantation rates. MATERIAL AND METHODS The study included a representative Iasi population. Data were collected by means of a questionnaire focused on revealing attitudes toward organ donation, importance of consent, willingness to donate a family member's organs, and role of medical staff in the donation decision. A perception score was calculated as a methodological approach to validate attitudes toward organ donation. RESULTS Of all respondents, 55% agreed to donate their organs if declared brain-dead, while 20% opposed this idea; 72.7% considered consent necessary; 70% believed that consent must belong to the family when it comes to brain-dead organ donors; and 44.5% supported the idea of financial compensation. Higher monthly income was correlated with a positive attitude toward organ donation. CONCLUSIONS Even though the study population had a positive attitude toward organ donation, the willingness to donate was lower than in other European countries and did not translate into actual donations. The necessity of informed consent, lack of knowledge on the topic, bureaucratic aspects, and openness to financial compensation could explain the current situation of the Romanian transplantation system.

The Challenge of High Coronary Thrombotic Events in Patients with ST-Segment Elevation Myocardial Infarction and COVID-19.

The aim of this observational study was to describe the characteristics and outcomes of coronavirus disease 2019 (COVID-19)-positive patients with ST-segment elevation myocardial infarction (STEMI), with a special focus on factors associated with a high risk of coronary thrombosis and in-hospital mortality. Comparing the two groups of patients with STEMI separated according to the presence of SARS-CoV-2 infections, it was observed that COVID-19 patients were more likely to present with dyspnea (82.43% vs. 61.41%, p = 0.048) and cardiogenic shock (10.52% vs. 5.40%, p = 0.012). A longer total ischemia time was observed in COVID-19 patients, and they were twice as likely to undergo coronary angiography more than 12 hours after the onset of symptoms (19.29% vs. 10.13%, p = 0.024). In 10 of 57 COVID-19-positive patients, a primary PCI was not necessary, and only thromboaspiration was performed (17.54% vs. 2.70%, p < 0.001). Platelet level was inversely correlated (r = −0.512, p = 0.025) with a higher risk of coronary thrombosis without an atherosclerotic lesion. Using a cut-off value of 740 ng/ml, D-dimers predicted a higher risk of coronary thrombosis, with a sensitivity of 80% and a specificity of 66% (ROC area under the curve: 0.826, 95% CI: 0.716−0.935, p = 0.001). These are novel findings that raise the question of whether more aggressive antithrombotic therapy is necessary for selected COVID-19 and STEMI patients.