Increased duration and similar outcomes of V-V ECLS in patients with COVID-19 ARDS compared to non-COVID ARDS: Single center experience.

BACKGROUND: Veno-venous extracorporeal life support (V-V ECLS or V-V ECMO) has been adopted as a rescue support in severe cases of COVID-19 ARDS. Initial reports on the use of V-V ECLS in COVID-19 patients reported very high mortality rates (57%-94%), but subsequent studies showed much lower rates (30%-40%). The aim of this study is to analyze demographic features, clinical course and outcomes of COVID-19 treated with V-V ECLS during the Italian 'third wave', in which the alpha variant was prevalent in the country. METHODS: Single-center, retrospective observational study conducted at the ECLS referral center of a teaching hospital in Italy from January 1st, 2021 and October 31st, 2021. RESULTS: Between January and October 2021, 18 consecutive adult patients who underwent V-V ECLS for severe ARDS due to COVID-19 were enrolled. Thirteen patients (72.2%) were male, and their median age was 50 years; the median P/F ratio before V-V ECLS initiation was 43 mm Hg (IQR, 40; 56), and the median RESP score was 0.5 (IQR, -2.25; 1.0). The mortality rate at 90 days was 55.6, compared to 55.7% in non-COVID patients in our center (p > 0.05); the median duration of ECLS was 29 days (IQR, 11; 32), compared to 10 days (IQR, 8; 15), in non-COVID patients (p = 0.004). Incidence of complications was high. CONCLUSIONS: In patients with COVID-19 ARDS receiving V-V ECLS, unadjusted mortality was similar to pre-pandemic V-V ECLS cases, while the duration of ECLS was almost three times longer and with frequent complications. This could be partly explained by the selection of very sick patients at the baseline that evolved to multiorgan failure during the course of ECLS.

Asymmetrical aortic root aneurism in patient with Filamin A mutation.

We report the case of a 28 years old woman with periventricular nodular heterotopia, due to Filamin A mutation. She had an asymmetrical aneurysm of the aortic root, involving, above all, noncoronary Valsalva sinus. She was asymptomatic and she had moderate aortic regurgitation. Reimplantation of the aortic valve with replacement of the aortic root was successfully accomplished. Filamin A is a protein that is encoded by the FLNA gene, which shows X-linked dominant inheritance. This protein is involved in neuronal migration, angiogenesis, cytoskeleton regulation, and cell signaling. Therefore, mutations of FLNA gene might result in brain, blood vessels, heart, and connective tissue disorders. A miscellany of cardiovascular abnormalities could be present in this subset of patients; cardiac symptoms may precede neurological manifestations. Aorta seems to be frequently affected. Consequently, in presence of FLNA gene mutations, cardiovascular evaluation should include vascular magnetic resonance imaging or computed tomography scan.

Radiation Therapy-Induced Cardiovascular Disease Treated by a Percutaneous Approach.

We report the case of a 51-year-old woman, treated with radiotherapy at the age of two years, for a pulmonary sarcoma. Subsequently she developed severe aortic stenosis and bilateral ostial coronary artery disease, symptomatic for dyspnea (NYHA III functional class). Due to the prohibitive surgical risk, she underwent successful stenting in the right coronary artery and left main ostia with drug eluting stents and, afterwards, transcatheter aortic valve replacement with transfemoral implantation of a 23 mm Edwards SAPIEN XT valve. The percutaneous treatment was successful without complications and the patient is in NYHA II functional class at 2 years' follow-up, fully carrying out normal daily activities.

An intriguing case report of functional mitral regurgitation treated with MitraClip.

Functional mitral regurgitation (FMR) is frequent in patients with heart failure (HF). It develops as a consequence of left ventricle (LV) geometry alterations, causing imbalance between increased tethering forces and decreased closing forces exerted on the mitral valve apparatus during systole.FMR is known to change at rest and during effort, due to preload-afterload changes, myocardial ischemia, and/or LV dysfunction. Despite optimized medical therapy, an FMR can be responsible of shortness of breath limiting quality of life and decompensation. In this report, we present a case of dynamic FMR treated with MitraClip.MitraClip implantation is a successful and innovative opportunity for HF patients with FMR.

How should I treat a challenging case of MitraClip implantation?

BACKGROUND: A 71-year-old woman affected by idiopathic dilated cardiomyopathy with normal coronary arteries and permanent atrial fibrillation was found to have severe mitral regurgitation at transthoracic echocardiography (TTE), due to annular dilatation and restricted motion of the posterior leaflet. Because of poor quality of life, high functional class (NYHA Class III) and the high risk of surgery, the patient agreed to undergo the implantation of a MitraClip device. During the procedure, the transoesophageal echocardiographic (TEE) images were of a poor quality since the view of the mitral valve in the mid-oesophageal and transgastric projections did not accurately show the valve leaflets and the convergence area of the regurgitation at colour Doppler, which is indispensable for the correct positioning of the clip. INVESTIGATION: Physical examination, transthoracic echocardiography, transoesophageal echocardiography. DIAGNOSIS: Severe mitral regurgitation suitable for MitraClip implantation. MANAGEMENT: Transthoracic, and not transoesophageal, echocardiography approach during MitraClip procedure.

Perioperative magnesium supplementation to prevent atrial fibrillation after off-pump coronary artery surgery: a randomized controlled study.

OBJECTIVE: Atrial fibrillation is a common complication after cardiac surgery. Magnesium is an effective and safe antiarrhythmic agent for arrhythmias that develop after cardiac surgery. The authors performed a study to evaluate the role of perioperative magnesium for prophylaxis of atrial fibrillation after off-pump coronary artery surgery. DESIGN: Randomized controlled study. SETTING: University teaching hospital. PARTICIPANTS: One hundred sixty consecutive patients undergoing elective, isolated, off-pump coronary artery bypass grafting were prospectively randomized into 2 groups. INTERVENTIONS: Patients in the magnesium group (n = 80) received a 2.5-g (20 mEq) magnesium sulphate infusion intraoperatively over 30 minutes, and the placebo group (n = 80) received normal saline solution. MEASUREMENTS AND MAIN RESULTS: Postoperative atrial fibrillation occurred in 16 of 80 patients (20%) in the magnesium group and in 18 of 80 (22.5%) in the placebo group (p = 0.9). CONCLUSION: The use of 2.5 g of intraoperative magnesium showed no effect in preventing atrial fibrillation after off-pump coronary artery bypass.

Renoprotective action of fenoldopam in high-risk patients undergoing cardiac surgery: a prospective, double-blind, randomized clinical trial.

BACKGROUND: Acute renal failure is a serious complication of cardiac surgery causing high morbidity and mortality. The aim of this study was to evaluate the usefulness of fenoldopam, a specific agonist of the dopamine-1 receptor, in patients at high risk of perioperative renal dysfunction. METHODS AND RESULTS: A prospective single-center, randomized, double-blind trial was performed after local ethical committee approval and after written consent was obtained from 80 patients undergoing cardiac surgery. Patients received either fenoldopam at 0.05 microg/kg per minute or dopamine at 2.5 microg/kg per minute after the induction of anesthesia for a 24-hour period. All these patients were at high risk of perioperative renal dysfunction as indicated by Continuous Improvement in Cardiac Surgery Program score >10. Primary end point was defined as 25% creatinine increase from baseline levels after cardiac surgery. The 2 groups (fenoldopam versus dopamine) were homogeneous cohorts, and no difference in outcome was observed. Acute renal failure was similar: 17 of 40 (42.5%) in the fenoldopam group and 16 of 40 (40%) in the dopamine group (P=0.9). Peak postoperative serum creatinine level, intensive care unit and hospital stay, and mortality were also similar in the 2 groups. CONCLUSIONS: Despite an increasing number of reports of renal protective properties from fenoldopam, we observed no difference in the clinical outcome compared with dopamine in a high-risk population undergoing cardiac surgery.

A prospective, randomized, double-blinded comparison of ropivacaine 0.5%, 0.75%, and 1% ropivacaine for peribulbar block.

STUDY OBJECTIVE: To evaluate the efficacy of three different concentrations of ropivacaine (0.5%, 0.75%, and 1%) together with a single concentration of hyaluronidase administered for peribulbar block. DESIGN: Prospective, randomized, double-blind study. SETTING: Anesthesia department of a university teaching hospital. PATIENTS: 68 ASA physical status I, II, and III patients undergoing elective cataract surgery. INTERVENTIONS: Patients were randomly allocated to receive peribulbar block with 6.5 mL of either 0.5% (Group Ropi-5; n = 22), 0.75% (Group Ropi-7.5; n = 22), or 1% ropivacaine (Group Ropi-10; n = 24). In all patients, 0.5 mL of hyaluronidase was added to the local anesthetic solution. MEASUREMENTS AND MAIN RESULTS: A larger proportion of patients in Groups Ropi-7.5 (82%) and Ropi-10 (83%) showed complete motor block 15 minutes after injection compared with Group Ropi-5 (55%;p = 0.05, andp = 0.03, respectively). Hypotension (reduction of systolic blood pressure by 30% or more from baseline) was observed in two Group Ropi-5 patients (9%), and two Group Ropi-7.5 patients (9%;p = 0.31), whereas bradycardia (reduction in heart rate < or = 50 bpm) was observed in one Group Ropi-5 patient (4%), and three Group Ropi-10 patients (12%;p = 0.18). Seven hours after surgery, a smaller proportion of Group Ropi-10 patients (64%) showed complete recovery of sensory function as compared with both Group Ropi-5 (94%) and Group Ropi-7.5 (90%;p = 0.03 and p = 0.03, respectively). Complete recovery of motor function 1 hour after surgery was more frequent in Group Ropi-5 (37%) than in Group Ropi-7.5 (5%) or Group Ropi-10 (9%;p = 0.05 and p = 0.05, respectively); however, no other differences in recovery of motor function were observed at any other observation times, with complete recovery in all patients 7 hours after surgery. CONCLUSIONS: While confirming that ropivacaine is a good option for peribulbar anesthesia, this study demonstrated that the use of 0.75% or 1% concentrations are preferred in that they produce quick and deep sensory and motor block of the operated eye. If recovery of normal motor function is important after surgery, the 0.75% concentration probably represents the best compromise.

Clinical properties of levobupivacaine or racemic bupivacaine for sciatic nerve block.

STUDY OBJECTIVE: To compare the intraoperative and postoperative clinical properties of the sciatic nerve block performed with either 0.5% bupivacaine or 0.5% levobupivacaine for orthopedic foot procedures. DESIGN: Randomized, double-blind study. SETTING: Inpatient unit of a university-affiliated hospital. PATIENTS: 30 ASA physical status I and II patients undergoing elective hallux valgus repair under regional anesthesia. INTERVENTIONS: After administering intravenous (IV) midazolam premedication (0.05 mg/kg), a femoral nerve block was performed with 15 mL of mepivacaine 2%. Patients were then randomly allocated to receive, in a double-blind fashion, a sciatic nerve block with 20 mL of either 0.5% bupivacaine (n = 15) or 0.5% levobupivacaine (n = 15). MEASUREMENTS AND MAIN RESULTS: An observer who was blinded to the study drug recorded the onset time, quality, and duration of the sciatic nerve block. Postoperative analgesia consisted of 100 mg IV ketoprofen every 8 hours, with the first administration given at the patient's request. Mean (+/-SEM) onset time of the sciatic nerve block was 35 +/- 5 minutes for bupivacaine and 31 +/- 6 minutes for levobupivacaine (p = not significant [NS]). The duration of motor and sensory blocks with bupivacaine was 761 +/- 112 minutes and 790 +/- 110 minutes, respectively, and 716 +/- 80 minutes and 814 +/- 73 minutes, respectively, with levobupivacaine (p = NS). The first pain medication was requested after 844 +/- 96 minutes with bupivacaine and 872 +/- 75 minutes after levobupivacaine (p = NS). No differences in the quality of nerve block and patient satisfaction were reported between the two groups. CONCLUSIONS: A dose of 20 mL of 0.5% levobupivacaine induces sciatic nerve block of similar onset, duration, and intensity as the block produced by the same volume and concentration of the racemic solution of bupivacaine.

A double-blinded, randomized comparison of either 0.5% levobupivacaine or 0.5% ropivacaine for sciatic nerve block.

UNLABELLED: To compare intraoperative and postoperative clinical properties of levobupivacaine and ropivacaine for sciatic nerve block, 50 ASA physical status I and II patients undergoing hallux valgus repair received a femoral nerve block with 15 mL of 2% mepivacaine. They were then randomly allocated in a double-blinded fashion to receive a sciatic nerve block with either 0.5% levobupivacaine (n = 25) or 0.5% ropivacaine (n = 25). An independent blinded observer evaluated the onset time of surgical anesthesia as well as the quality of the surgical block and postoperative analgesia. The median (range) onset time of surgical block at the sciatic nerve distribution was 30 min (5-60 min) with levobupivacaine and 15 min (5-60 min) with ropivacaine (P = 0.63). Four patients (two patients in each group) received a supplementary ankle block by the surgeon just before the beginning of surgery. All four patients also received IV fentanyl supplementation, but in three of them, propofol infusion was required to complete surgery (two in the Levobupivacaine group [8%] and one in the Ropivacaine group [4%]; P = 0.99). In six patients of the Levobupivacaine group (24%) and five patients of the Ropivacaine group (20%), IV fentanyl supplementation was required to complete surgery (P = 0.99). No differences in the time to recovery of sensory and motor function were observed between the two groups, whereas median (range) duration of postoperative analgesia was 16 h (8-24 h) with levobupivacaine and 16 h (8-24 h) with ropivacaine (P = 0.83). We conclude that 0.5% levobupivacaine and 0.5% ropivacaine provide comparable surgical anesthesia and postoperative analgesia. IMPLICATIONS: No studies have compared the clinical properties of levobupivacaine with those of ropivacaine when providing sciatic nerve block for hallux valgus repair. Results from this prospective, randomized, double-blinded study demonstrate that 20 mL of either 0.5% levobupivacaine or 0.5% ropivacaine provide comparable surgical block with prolonged postoperative analgesia.