Impact of a Cardiogenic Shock Program on Mortality in a Non-Transplant Hospital.

INTRODUCTION: Cardiogenic shock is associated with high in-hospital morbidity and mortality. Improvements in this care process could lead to better outcomes. METHODS: This retrospective study of patients with cardiogenic shock compared two periods: no specific program to address cardiogenic shock and implementation of a cardiogenic shock program. This program included the establishment of a multidisciplinary team (shock team), early alert to the transplant hospital, initiation of a ventricular assist extracorporeal membrane oxygenation (ECMO) program, and extension of continuous care by acute cardiovascular care specialists. The primary objective was to analyse whether there were differences between in-hospital mortality and mortality during follow-up. Predictors of in-hospital mortality were examined as a secondary objective. RESULTS: A total of 139 patients were enrolled: 69 of them in the previous period and 70 in the cardiogenic shock program period. There was a significant reduction in in-hospital mortality (55.1% vs 37.1%; p=0.03) and mortality during follow-up (62.7% vs 44.6%; p=0.03) in the second period. Diabetes mellitus, ejection fraction, out-of-hospital cardiac arrest, and implementation of the cardiogenic shock program were independent predictors of in-hospital mortality. CONCLUSIONS: The implementation of a comprehensive cardiogenic shock program in a non-transplanting hospital improved in-hospital and follow-up mortality of patients in cardiogenic shock.

Invasive management of significant tricuspid regurgitation in clinical practice.

BACKGROUND: Tricuspid regurgitation (TR) is a prevalent condition inside valvular heart disease (VHD) with relevant prognosis implications. However, concordance between real management in clinical practice and invasive treatment recommendations of European Society of Cardiology (ESC) guidelines is unknown. METHODS: A substudy of ESC VHD II survey was performed to evaluate the real treatment of TR compared to the clinical ESC guidelines recommendations published in 2012, 2017 and 2021 was performed. TR cases with surgical indication were divided in 3 groups: 1: severe isolated TR without previous left VHD; 2: moderate/severe TR and concomitant severe left VHD; 3: severe TR plus previous left VHD surgery. RESULTS: Of 902 patients assessed, 123 had significant TR. Fifty (41%) cases demonstrated ESC guidelines 2012-2017 Class I or IIa recommendations for invasive treatment: 9(18%) of group 1, 37(74%) of group 2 and 4(8%) of group 3. Surgery was performed in 24 patients (48%); 1 in group 1(4%), 22 in group 2(92%) and 1 in group 3(4%). Overall concordance was 48% (group 1: 11%; group 2: 59%; group 3: 25%). Regarding the 2021 ESC guidelines only one patient changed groups with an overall concordance of 47% (group 1: 10%; group 2: 59%; group 3: 25%). CONCLUSION: Concordance between 2012, 2017 and 2021 ESC guidelines recommendations and clinical practice for TR surgical intervention is low, especially in those without concomitant severe left VHD. These results suggest the need to improve further guideline implementation and alternative treatments, such as percutaneous, which could resolve potential discrepancies in those clinical scenarios.

Ventricular Intramyocardial Dissecting Hematoma: What Is its True Clinical Evolution and the Best Treatment?

Intramyocardial dissecting hematoma (IDH), in the setting of an acute coronary syndrome, is a rare type of cardiac rupture. However, the best treatment for IDH in each clinical scenario is not clearly defined. We present a case in which the best approach for IDH and its final outcome are discussed.

Multimodality Imaging in the Study of the Left Atrium.

The left atrium (LA) plays a vital role in maintaining normal cardiac function. Many cardiac diseases involve the functioning of the LA directly or indirectly. For this reason, the study of the LA has become a priority for today's imaging techniques. Assessment of LA size, function and wall characteristics is routinely performed in cardiac imaging laboratories when a patient undergoes transthoracic echocardiography. However, in cases when the LA is the focus of disease management, such as in atrial fibrillation or left atrial appendage closure, the use of multimodality is critical. Knowledge of the usefulness of each cardiac imaging technique for the study of LA in these patients is crucial in order to choose the most appropriate treatment. While echocardiography is the most widely performed technique for its evaluation and the study of wall deformation analysis is increasingly becoming more reliable, multidetector computed tomography allows a detailed analysis of its anatomy to be carried out in 3D reconstructions that help in the approach to interventional treatments. In addition, the evaluation of the wall by cardiac magnetic resonance imaging or the generation of electroanatomical maps in the electrophysiology room have become essential tools in the treatment of multiple atrial pathologies. For this reason, the goal of this review article is to describe the basic anatomical and functional information of the LA as well as their study employing the main imaging techniques currently available, so that practitioners specializing in cardiac imaging techniques can use these tools in an accurate and clinically useful manner.

Usefulness of Transesophageal Echocardiography in the Evaluation of Celiac Trunk and Superior Mesenteric Artery Involvement in Acute Aortic Dissection.

Mesenteric ischemia is a serious complication of acute aortic dissection (AAD), and its early diagnosis is vital for prognosis and appropriate treatment indication. Arteries affected by this complication are the celiac trunk and superior mesenteric artery, and their evaluation is usually based on computed tomographic angiography. Transesophageal echocardiography is also a useful technique for diagnosing AAD and is essential in monitoring surgical or endovascular treatment when computed tomographic angiography is not available. However, the usefulness of transesophageal echocardiography for evaluating celiac trunk and superior mesenteric artery involvement and mesenteric ischemia mechanisms in AAD is not well established. Real-time information on mesenteric malperfusion is needed at the bedside, in primary care facilities, and in the operating room to achieve prompt diagnosis and better therapeutic management. The aims of this review are to assess the role of TEE to diagnose celiac trunk and superior mesenteric artery involvement in AAD, determine the mechanisms that can cause flow obstruction in patients with mesenteric ischemia, and analyze possible implications in the treatment of this complication.

Beyond the term penetrating aortic ulcer: A morphologic descriptor covering a constellation of entities with different prognoses.

Penetrating aortic ulcer (AU) is defined as localized disruption of the intimal layer of the aortic wall, resulting in a crater-like lesion outpouching from the vessel contour. AU is a generic term which encompasses a constellation of entities with different etiologies and prognoses and may be a complication of infective, inflammatory, traumatic, iatrogenic, atherosclerotic processes or intramural hematoma. One of the most challenging scenarios of AU for a differential diagnosis, but also for treatment implications, is when they are associated with acute aortic syndrome. Despite advances in the field of aortic disease, lack of consensus defining these lesions and the significant semantic confusion in the medical literature of the acronym PAU (for penetrating aortic ulcer but also for penetrating atherosclerotic ulcer) have given rise to controversy in guidelines and expert consensus, leading to the same treatment being recommended for entities with different etiology and prognosis. Moreover, in the medical literature, most diagnoses were mainly based on imaging techniques which identified AU regardless of clinical symptoms, surrounding imaging findings or dynamic morphologic changes. In this Review, we provide the latest insight into the differential diagnosis between AU, also called penetrating aortic ulcers, based on clinical context and the newest imaging characteristics to aid treatment decision-making.

Clinical Prognosis of Right-Sided Infective Endocarditis not Associated with Cardiac Devices or Intravenous Drug use: a Cohort Study and Meta-Analysis.

Right-sided infective endocarditis (RSIE), classically associated with intravenous drug use or intracardiac devices, is considered a good-prognosis infective endocarditis (IE) form. However, predisposing factors and prognosis for "NODID" RSIE (NOt associated with cardiac Devices or Intravenous Drug use) remain unclear. The aim of this study was to evaluate predisposing factors and prognosis of NODID RSIE compared to other RSIE forms. A retrospective cohort study (January 2008-January 2019) was conducted in a reference center on 300 patients diagnosed with IE. Endocarditis-related events were defined as related to IE in mortality or open-heart surgery during follow-up. A review and meta-analysis of associated literature (January 2008-January 2019) were also performed. Fifty-seven patients presented RSIE (19%), 22 of which were NODID RSIE (39%). Use of intravascular catheters (23% vs 3%; p = 0.027) and congenital heart diseases (18% vs 0%; p = 0.019) were associated with NODID RSIE. This group had a higher in-hospital mortality (23% vs 3%; p = 0.027) and endocarditis-related event rates (41% vs 6%; p = 0.001) than non-NODID RSIE. Furthermore, NODID RSIE was independently associated with in-hospital endocarditis-related events (OR = 19.29; 95%CI:2.23-167.16; p = 0.007). Our meta-analysis evaluated four studies and identified 96 cases (30%) of NODID RSIE from 320 total RSIE cases. NODID RSIE patients demonstrated higher in-hospital mortality (RR = 2.81; 95%CI:1.61-4.90; p < 0.001; I2 = 0.0%) and necessity of open-heart surgery (RR = 13.89; 95%CI:4.14-46.60; p < 0.001; I2 = 0.0%) than non-NODID RSIE cases. Our study suggests that NODID RSIE has the highest endocarditis-related event rate and in-hospital mortality among RSIE cases and therefore should not be considered a good-prognosis IE.

Intimal disruption in type B aortic intramural hematoma. Does size matter? A systematic review and meta-analysis.

BACKGROUND: Type B intramural hematoma (IMH) is considered a low-risk entity for aortic complications if aortic dilation, containing rupture or clinical instability are absent. However, the development of intimal disruptions (ID), present in >40% of cases, poses an unknown risk. OBJECTIVES: To establish which ID characteristics imply a higher risk of aortic complications and, therefore, merit invasive treatment. METHODS: A systematic review and a meta-analysis were made following a search in EMBASE, MEDLINE and PsycINFO for articles published between January 1995 and December 2017. The combined endpoint was defined as aortic mortality, invasive treatment for aortic disease and/or increase in maximum aortic diameter ≥55 mm. Lesions with communicating orifice ≤3 mm were defined as tiny ID (TID) and those with >3 mm as focal ID (FID). RESULTS: Six studies with 564 participants diagnosed of type B IMH were included. Incidence of ID was 54.3% (306 individuals): 27.7% (156 individuals) initially met TID criteria; however, 13.9% of these (21 of 151 with morphologic evolution) evolved to FID within the first 6 months. Ninety-two cases suffered clinical aorta-related events (16.3%; mean follow-up range: 15-85 months; median: 52 months). Patients with TID had a similar risk of aorta-related events to those without ID (RR = 0.904; 95% CI, 0.335-2.440; P = 0.842; I2 = 42.5%), but lower than those with FID (RR = 0.299; 95% CI, 0.094-0.952; P = 0.041; I2 = 26.9%). CONCLUSIONS: Tiny intimal disruption in type B IMH evolution is not related to an increased risk of complications and should not be considered an indication for invasive treatment. However, since 14% of TID evolve to FID within the first 6 months, close follow-up with imaging techniques is advisable.

Tumor Grade Correlation Between Preoperative Biopsy and Final Surgical Specimen in Endometrial Cancer: The Use of Different Diagnostic Methods and Analysis of Associated Factors.

OBJECTIVE: This study aimed to identify the correlation between histology tumor grade of the preoperative biopsy using dilatation and curettage (D&C), Pipelle, or hysteroscopy and final surgical specimen in women with endometrioid endometrial cancer. MATERIALS AND METHODS: Patients on whom a preoperative biopsy was performed between 2009 and 2016 were reviewed and cases with apparent early-stage endometrioid endometrial cancer were included in the study. The accuracy of preoperative biopsy performed before hysterectomy using D&C, Pipelle, or hysteroscopy was compared. RESULTS: A total of 332 patients were included. The diagnostic method was D&C in 43 cases (13%), Pipelle in 102 (31%), and hysteroscopy in 187 (56%). The preoperative diagnosis included G1 tumors in 177 cases (53.3%), G2 in 103 (31%), and G3 in 52 (15.6%). The surgical specimen confirmed endometrioid endometrial tumor in 309 patients (93%).The accuracy rates of preoperative biopsy and surgical specimen were 74.69%, 73.19%, and 89.75% for G1, G2, and G3, respectively. Hysteroscopy showed better κ index (κ = 0.551) than did D&C (κ = 0.392) and Pipelle (κ = 0.430). Tumor diameter greater than 30 mm was the only factor independently associated with absence of correlation between preoperative and postoperative tumor grade (odds ratio [95% confidence interval], 1.959 [1.096-3.504], P = 0.023). CONCLUSIONS: Preoperative biopsy, regardless of the method, has its limitations in predicting the tumor grade compared with final surgical specimen in women with endometrioid endometrial cancer at an apparent early stage. Concordance between the biopsy and hysterectomy specimen is less likely to happen in the case of preoperative G1 or G2 tumors, as well as in big tumors. Although hysteroscopy was associated with the highest tumor grade agreement, no differences in correlation between the 3 methods (D&C, Pipelle, and hysteroscopy) were found.

Trombosis valvular «subclínica» tras implante percutáneo de válvula aórtica: ¿un riesgo latente? / «Subclinical» leaflet thrombosis in transcatheter aortic valve implantation: a latent risk?

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Clinical Implications of Focal Intimal Disruption in Patients With Type B Intramural Hematoma.

BACKGROUND: Focal intimal disruption (FID) has been described in >20% of type B intramural hematomas (IMH), with unclear prognosis and management. OBJECTIVES: This study aimed to evaluate the short- and long-term evolution of medically treated patients with type B IMH with and without FID. METHODS: There were 107 consecutive patients with acute type B IMH were included prospectively in a multicenter protocol of clinical and imaging follow-up. FID was defined as an intimal disruption with contrast material-filled outpouching from the aorta lumen with a communicating orifice of >3 mm. RESULTS: There were 43 patients (40%) who developed an FID with larger basal maximum aortic diameter and hematoma thickness. Patients with acute FID had a higher risk of aorta-related events than those without FID (hazard ratio: 24.43; 95% confidence interval: 7.65 to 78.04; p < 0.001). Of the 94 discharged patients, 33 (35%) developed an FID within the first 6 months of follow-up: 19 evolved with mild (<1 mm/year), 8 with moderate (1 to 2 mm/year), and 6 with severe (>2 mm/year) aortic enlargement. Chronic FID was not associated with aorta-related events (hazard ratio: 0.98; 95% confidence interval: 0.22 to 4.34; p = 0.987). CONCLUSIONS: The development of FID in the acute phase of type B IMH has a poor prognosis owing to the high risk of aortic rupture. In the chronic phase, most FIDs evolve with slow aortic dilation and without complications. Although acute FIDs should be treated early and invasively, lesions developing in the subacute-chronic phase can be managed with medical treatment and close imaging surveillance.

Differential Diagnosis and Clinical Implications of Remnants of the Right Valve of the Sinus Venosus.

Anatomic variants of the remnants of the right valve of the sinus venosus in adults are common and usually observed on cardiac imaging studies. Because the anatomy and function of these vestiges are not well known, errors may occur in the differential diagnosis and treatment of patients with unclear images in the right atrium. Clinical implications may arise from (1) differential diagnosis with some diseases, especially when the remnants act as sites of attachment for masses; (2) the need for invasive treatment if the anatomic variant displays obstructive behavior; (3) the association between remnants and patent foramen ovale; and (4) secondary complications related to these structures in invasive procedures. Thus, the aim of this review is to provide cardiologists and radiologists specializing in cardiac imaging techniques with the basic anatomic information and clinical implications required to understand morphologic variants of right sinus venosus valve vestiges in adults.

Chest physiotherapy revisited: evaluation of its influence on the pulmonary morbidity after pulmonary resection.

OBJECTIVE: The study aimed to evaluate if perioperative chest physiotherapy modifies the risk of pulmonary morbidity after lobectomy for lung cancer. METHODS: We have reviewed a prospectively recorded database of 784 lung cancer patients treated by scheduled lobectomy (361 operated after implementing a new physiotherapy program). No other changes were introduced in the patients' perioperative management during the study period. A propensity matching score was generated for all eligible patients and two logistic models were constructed and adjusted. The first one (model A) included age of the patient, forced expiratory volume in 1s (percent) (FEV1%) and predicted postoperative forced expiratory volume in 1s (percent) (ppoFEV1%); for the second model (model B); chest physiotherapy was added to the previous ones. Using each model, patients' individual probability of postoperative complication was calculated and maintained in the database as a new variable (risk A and risk B). Individual risks calculated by both models were plotted on a time series and presented in two different graphs. RESULTS: Rates of pulmonary morbidity were 15.5% before the intensive physiotherapy program and 4.7% for patients included in the implemented program (p = 0.000). The propensity score identified 359 pairs of patients. Model A included age (p = 0.012), FEV1% (p = 0.000), and ppoFEV1% (p = 0.031) as prognostic variables. Model B included age (p = 0.012), FEV1% (p = 0.000), and physiotherapy (p = 0.000). On graphic representation, a great decrease of the estimated risk could be seen after the onset of the physiotherapy program. CONCLUSIONS: Implementing a program of perioperative intensive chest physiotherapy reduced the overall pulmonary morbidity after lobectomy for lung cancer.

Chest physiotherapy in lung resection patients: state of the art.

The role of chest physiotherapy in limiting postoperative pulmonary complications and in the recovery of pulmonary function and exercise capacity after lung surgery is still unclear because of the lack of conclusive, well-designed clinical trials. In this article the available literature on these topics is reviewed, and the effects of respiratory physiotherapy, instituted preoperatively or administered after surgery to patients undergoing lung resection, are commented on. The authors conclude that chest physiotherapy improves preoperative exercise capacity; this is a parameter highly predictive of postoperative pulmonary complications. Also physiotherapy administered during the immediate period after lung resection probably decreases frequency of pulmonary complications. Finally, further investigation is required for a better understanding of the effects of long-term chest physiotherapy after hospital discharge in lung resection patients.

Results of a simple exercise test performed routinely to predict postoperative morbidity after anatomical lung resection.

BACKGROUND AND OBJECTIVE: Exercise tests are considered the most reliable ones for the preoperative workup of lung resection candidates but frequently are indicated only in cases with low predicted postoperative forced expiratory volume in 1s (FEV1) and carbon monoxide diffusing capacity (DLCO). The aim of this investigation is to evaluate if a simple, standardised incremental bicycle exercise test routinely performed in patients considered operable is predictive of postoperative cardio-respiratory complication and if its performance is comparable to a logistic regression model including frequently cited clinical predictive variables. METHODS: A series of 103 lung resection candidates were included in a prospective observational study. All patients underwent a standardised, incremental exercise test on a bicycle up to exhaustion. The analysed outcome was the occurrence of postoperative cardio-respiratory complications prospectively recorded and codified. The correlation of distance reached at the end of the test and the outcome was estimated by non-parametric tests. A logistic regression model including age, BMI, predicted postoperative (ppoFEV1%) and predicted postoperative DLCO (ppoDLCO) was adjusted and the individual probability of complication calculated and set as a new variable. Finally, two receiver operating characteristic (ROC) curves were constructed and compared: one with distance at the exercise test and the other with logistic regression probability of complication. RESULTS: Mortality of the series was nil. Outcome prevalence was 14%. Distance reached at the end of the exercise test was lower in cases with a positive outcome (3498.6m vs 4543.5m, p=0.001). On logistic regression analysis, age of the patient (p=0.016) and ppoDLCO (p=0.000) were predictive for the outcome. On ROC analysis, C-indices were 0.77 (distance) and 0.78 (logistic model, p=0.95). CONCLUSION: Reached distance in a simple standardised exercise test is related to postoperative morbidity after lung resection; and the accuracy of prediction using this variable alone is comparable to a logistic regression model including age and ppoDLCO.