A case report of recurrent acute myocardial infarction and cardiac arrest due to aortic dissection secondary to IgG4-related aortitis.

Occlusion of the right coronary artery is a relatively rare complication of type A aortic dissection and an example of type 2 myocardial infarction (MI) as well but when it occurs, it may have a fatal result for the patient. Aortic pseudoaneurysms are local type A dissections with a restricted extent in which the majority of the aortic wall has been breached and luminal blood is held in only by a thin rim of the remaining wall, mainly purely the adventitia. They typically occur from iatrogenic trauma by interventional procedures or previous cardiac surgery. We present a case of a 56 years old patient who suffered an acute functional MI due to such pseudoaneurysm formed in the context of an undiagnosed aortitis. The etiology remained unclear until the surgical aortic prosthesis was deemed necessary, finding chronic IgG4 infiltrates in the aortic tissue. To our knowledge, this is the first case of IgG4-related aortitis causing functional MI and cardiogenic shock.

Atrial fibrillation in transcatheter aortic valve implantation patients: Incidence, outcome and predictors of new onset.

BACKGROUND: There is controversial evidence if atrial fibrillation (AF) alters outcome after transcatheter aortic valve implantation (TAVI). TAVI itself may promote new-onset AF (NOAF). METHODS: We performed a single-center study including 398 consecutive patients undergoing TAVI. Before TAVI, patients were divided into a sinus rhythm (SR) group (n=226, 57%) and baseline AF group (n=172, 43%) according to clinical records and electrocardiograms. Furthermore, incidence and predictors of NOAF were recorded. RESULTS: Baseline AF patients had a significantly higher 1-year mortality than the baseline SR group (19.8% vs. 11.5%, p=0.02). NOAF occurred in 7.1% of patients with prior SR. Previous valve surgery was the only significant predictor of NOAF (HR 5.86 [1.04-32.94], p<0.05). NOAF was associated with higher rehospitalization rate (62.5 vs. 34.8%, p=0.04), whereas mortality was unaffected. CONCLUSIONS: This study shows that NOAF is associated with higher rates of rehospitalization but not mortality after TAVI. Overall, patients with pre-existing AF have higher mortality.

A 10min "no-touch" time - is it enough in DCD? A DCD animal study.

Donation after cardiac death (DCD) is under investigation because of the lack of human donor organs. Required times of cardiac arrest vary between 75s and 27min until the declaration of the patients' death worldwide. The aim of this study was to investigate brain death in pigs after different times of cardiac arrest with subsequent cardiopulmonary resuscitation (CPR) as a DCD paradigm. DCD was simulated in 20 pigs after direct electrical induction of ventricular fibrillation. The "no-touch" time varied from 2min up to 10min; then 30min of CPR were performed. Brain death was determined by established clinical and electrophysiological criteria. In all animals with cardiac arrest of at least 6min, a persistent loss of brainstem reflexes and no reappearance of bioelectric brain activity occurred. Reappearance of EEG activity was found until 4.5min of cardiac arrest and subsequent CPR. Brainstem reflexes were detectable until 5min of cardiac arrest and subsequent CPR. According to our experiments, the suggestion of 10min of cardiac arrest being equivalent to brain death exceeds the minimum time after which clinical and electrophysiological criteria of brain death are fulfilled. Therefore shorter "no-touch" times might be ethically acceptable to reduce warm ischemia time.

Measurement of cardiac output and pulmonary transit time for assessment of pulmonary vascular resistance in domestic piglets.

The degree of elevated pulmonary vascular resistance (PVR) is a crucial clinical parameter. Cardiac output (CO) and pulmonary transit time (PTT) can be ascertained by a number of radiological methods. A close functional relationship between CO, PTT and PVR would facilitate non-invasive PVR measurements. One-hundred and fifty-one measurements were made in six piglets. Pressures in the pulmonary and systemic circulation were measured invasively. Cardic output was determined by the use of a Doppler flow probe around the truncus pulmonalis. Temperature sensors were placed in the pulmonary truncus and left atrium. Elevated PVR was produced by repeated air embolism. After injection of ice-cold saline, the time span between the minimal temperature in the truncus pulmonalis and the left atrium was taken as PTT. The CO and PTT were inserted into a new formula derived from the Hagen-Poiseuille law for the calculation of the PVR model. Numerical constants of the formula were calculated by the robust method of minimization. The PVR values, as calculated from invasively measured mean pulmonary artery pressure, mean left atrial pressure and CO, served as reference. In the six piglets, the PVR model and PVR reference showed a strong linear correlation with r = 0.923. The Bland-Altman plot revealed a standard deviation of -0.64/+0.67 Wood units. Cardiac output, PTT and PVR showed a close functional relationship. With a correction for blood viscosity and body size, this relationship could be used for non-invasive clinical measurements of PVR.

Establishing extracorporeal membrane oxygenation in a university clinic: case series.

OBJECTIVES: Although extracorporeal membrane oxygenation (ECMO) is well established for respiratory failure in neonates, application in adults is still considered controversial. The survival of patients with acute respiratory distress syndrome and ECMO therapy is 50% to 70%. DESIGN: A retrospective analysis of 10 patients, who were placed on ECMO from September 2004 to December 2005, was performed. SETTING: University clinic. INTERVENTIONS: Venoarterial ECMO was established in 7 patients, venovenous ECMO in 2 patients, and combined venoarterial and venovenous ECMO in 1 patient. MEASUREMENTS AND MAIN RESULTS: Indications were pneumonia, acute respiratory distress syndrome, near drowning, pericardial tamponade with shock lung, right-heart failure after heart transplantation, shock lung after cardiopulmonary resuscitation, and right-heart failure in chronic thromboembolic pulmonary hypertension. Median maintenance of ECMO therapy was 56.5 hours (range, 36-240). The median Murray score was 3.3 for survivors and 4 for nonsurvivors. Overall mortality was 30%; 70% were weaned from ECMO and survived until discharge. Median pre-ECMO risk for fatal outcome according to Hemmila was 0.43 for survivors and 0.92 for nonsurvivors (p < 0.02). In 2 cases, surgical reintervention was necessary because of bleeding in one, and a side switch of the cannulae had to be performed because of femoral venous thrombosis in the other. CONCLUSIONS: ECMO has been shown to be a successful therapy for acute respiratory distress syndrome when conventional strategies have failed. Pre-ECMO risk assessment may be useful in the evaluation of patients.