ARTERIAL HYPEROXIA AND MORTALITY IN PATIENTS UNDERGOING VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION.

ABSTRACT: Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can easily lead to supranormal oxygenation. The impact of hyperoxygenation beyond the early VA-ECMO support phase is unexplored. We sought to investigate its association with short- and long-term mortality. Methods: A total of 10,615 arterial blood gases of 179 patients undergoing VA-ECMO between 2013 and 2018 in our cardiosurgical tertiary center were analyzed for partial pressure of oxygen (PaO2) and its association with in-hospital, 90-day, and 1-year mortality. Patients were stratified into terciles (T) based on PaO2. Results: The median systemic PaO2 during VA-ECMO was 122 mm Hg (Q1-Q3, 111-158 mm Hg) and was significantly higher in 90-day nonsurvivors versus survivors (134 mm Hg [Q1-Q3, 114-175 mm Hg] vs. 114 mm Hg [Q1-Q3, 109-136 mm Hg]; P < 0.001). The incidence of mortality increased at all time points tested after VA-ECMO implantation along with the increasing terciles of PaO2. The lowest mortality rates were noted for patients with median PaO2 values of <115 mm Hg (T1), whereas patients with median PaO2 values of >144 mm Hg (T3) had the highest mortality rates. Bonferroni multiple testing analysis found the T3 of PaO2 to be a predictor of decreased 90-day survival in comparison with T1 (P < 0.001) and T2 (P = 0.002). Multivariable Cox regression analyses for in-hospital, 90-day, and 1-year mortality showed a significant association of the T3 compared with the T2 and the T1 of PaO2 to mortality across all endpoints. Conclusion: Hyperoxygenation during VA-ECMO might be associated with increased all-cause mortality. The results of our study further document the known toxicity of hyperoxygenation in general critical care patients and mark the need to focus specifically on VA-ECMO patients.

Current applications and outcomes of venoarterial extracorporeal membrane oxygenation based on 6 years of experience: risk factors for in­hospital mortality.

INTRODUCTION: Data regarding venoarterial extracorporeal membrane oxygenation (VA ECMO) as a temporary circulatory support in cardiogenic shock (CS) for Central Europe are scarce. OBJECTIVES: The aim of the study was to disclose indications, in-hospital, and long-term (1-year) mortality along with risk factors. PATIENTS AND METHODS: The study is a retrospective investigation of patients who underwent VA ECMO for CS at a cardiosurgical tertiary center, from January 2013 to June 2018. A broad spectrum of pre- and postimplantation factors was tested using univariable analysis. RESULTS: A total of 198 patients met the inclusion criteria. The median (interquartile range) duration of support was 207 (91­339) hours, with no significant disparity among hospital survivors and nonsurvivors (P = 0.09). A total of 40.4% of patients died during ECMO support, while the joined in-hospital and 6-month mortality progressed to 65.2%, and 1-year mortality to 67.2%; 9% underwent a subsequent heart transplantation. Main adverse events were bleeding (76%), infection (56%), neurologic injury (15%), and limb ischemia (15%). Multiorgan failure was the most decisive risk factor of in-hospital mortality (odds ratio, 4.45; P <⁠0.001). Patients with postcardiotomy CS had a significantly lower out-of-hospital survival rate than the nonsurgical group (32.3% vs 45%; log-rank P = 0.037). CONCLUSION: The study showed survival benefit, despite frequent complications. The protocol focusing on proper candidate selection and timing can positively impact patient survival. Additional risk reduction can be achieved with a further increase of the team experience with ECMO.

Prevalence and management of driveline infections in mechanical circulatory support - a single center analysis.

BACKGROUND: Driveline infections in continuous-flow left ventricular assist devices (cf-LVAD) remain the most common adverse event. This single-center retrospective study investigated the risk factors, prevalence and management of driveline infections. METHODS: Patients treated after cf-LVAD implantation from December 2014 to January 2020 were enrolled. Baseline data were collected and potential risk factors were elaborated. The multi-modal treatment was based on antibiotic therapy, daily wound care, surgical driveline reposition, and heart transplantation. Time of infection development, freedom of reinfection, freedom of heart transplantation, and death in the follow-up time were investigated. RESULTS: Of 75 observed patients, 26 (34.7%) developed a driveline infection. The mean time from implantation to infection diagnosis was 463 (±399; range, 35-1400) days. The most common pathogen was Staphylococcus aureus (n = 15, 60%). First-line therapy was based on antibiotics, with a primary success rate of 27%. The majority of patients (n = 19; 73.1%) were treated with surgical reposition after initial antibiotic therapy. During the follow-up time of 569 (±506; range 32-2093) days, the reinfection freedom after surgical transposition was 57.9%. Heart transplantation was performed in eight patients due to resistant infection. The overall mortality for driveline infection was 11.5%. CONCLUSIONS: Driveline infections are frequent in patients with implanted cf-LVAD, and treatment does not efficiently avoid reinfection, leading to moderate mortality rates. Only about a quarter of the infected patients were cured with antibiotics alone. Surgical driveline reposition is a reasonable treatment option and does not preclude subsequent heart transplantation due to limited reinfection freedom.

Results and factors associated with adverse outcome after tricuspid valve replacement.

BACKGROUND AND AIM: This retrospective analysis of patients with severe tricuspid valve disease, who underwent tricuspid valve replacement (TVR) for either tricuspid regurgitation or stenosis, has been designed to determine the factors that predict poor hospital and long-term survival. METHODS: The study population comprised 86 patients, 65 women and 21 men, who underwent TVR with or without con-comitant surgical procedures between 2000 and 2010 at our institution. Patients with Ebstein's or other complex congenital anomalies were excluded from the study. RESULTS: Average age at operation was 58.5 ± 12.5 (range 16-78) years. Fifty (58.1%) patients had undergone previous cardiac surgery. Forty-two patients were in New York Heart Association (NYHA) class III functional capacity, and 18 were in class IV. Symptoms of right heart failure (HF) were present in 66 patients, of whom 19 had ascites. Bioprosthetic tricuspid valves were implanted in 84 patients and mechanical prostheses in two. The choice to proceed to TVR instead of repair was individualised and based on the surgeon's preference. In-hospital mortality was 18 (20.9%) patients, caused mainly by multi-organ and HF, and was significantly related to NYHA class and symptoms of right HF before surgery, with no mortality in patients with NYHA class I and II, 19% mortality with NYHA class III, and 55.6% mortality with NYHA class IV. Eighteen (20.9%) patients died during postoperative follow-up. The main risk factors associated with perioperative mortality were: the presence of severe symptoms at the time of surgery, low preoperative haematocrit, postoperative complications, postoperative ventilation time longer than 72 h, and renal failure requiring dialysis. Elevated pulmonary artery pressure, preoperative symptoms of right HF, and low haematocrit unfavourably affected the long-term results. CONCLUSIONS: Many earlier studies reported high mortality and morbidity after TVR in both early and late postoperative peri-ods. Our main finding is that good outcomes for TVR are achievable in properly selected patients. Sixty of 86 patients in our group had preoperative NYHA functional class III and IV, which suggests that surgical timing was late in many patients. Based on our observations, we propose that surgical correction of severe tricuspid valve disease should be considered before the development of advanced HF, when patients are asymptomatic or only oligosymptomatic.

[Constrictive pericarditis as complication of viral respiratory infection]. / Zaciskajace zapalenie osierdzia jako powiklanie wirusowej infekcji dróg oddechowych.

A 24 year-old man with 3-months medical history of recurrent respiratory infections and pericardial effusion, despite treatment with nonsteroid anti-inflammatory drugs, was admitted to the hospital with dyspnea on exertion. On admission he presented the symptoms of right heart insufficiency. Computed tomography of the chest demonstrated a thickened pericardium. Echocardiographic examination and right heart catheterisation established the diagnosis of constrictive pericarditis. Serologic tests suggested viral aetiology. The patient was referred to cardiothoracic surgery, partial pericardiectomy was performed with marked haemodynamic improvement.

[Angioplasty of the unprotected left main coronary artery stenosis with standby cardiopulmonary support--a case report]. / Angioplastyka pnia lewej tetnicy wiencowej w zabezpieczeniu krazeniem pozaustrojowym.

Stenosis of the unprotected left main coronary artery (LMCA) is a classical indication for coronary artery bypass graft surgery (CABG). Percutaneous coronary intervention (PCI) of LMCA may be an alternative to surgical treatment if atherosclerosis of distal segments is very advanced. The periprocedural risk is high, especially if comorbidities are present. However, long-term results remain unclear. The ongoing Syntax trial will clarify whether angioplasty of LMCA with drug-eluting stents can be equivalent to CABG. We present a case of a patient with occluded right coronary artery, severe stenoses of the LMCA, left anterior descending artery and left circumflex artery, and poor left ventricular ejection fraction in whom PCI for stenosis of unprotected LMCA with standby cardiopulmonary support was performed.

[Influence of cardiopulmonary bypass on risk of AF after coronary artery bypass grafting]. / Wplyw krazenia pozaustrojowego na wystepowanie AF po chirurgicznej rewaskularyzacji naczyn wiencowych.

Atrial fibrillation is the most common tachyarrhythmia after coronary artery bypass grafting. The etiology of this arrhythmia and factors responsible for its genesis are unclear. The aim of this study was to compare the frequency of AF in patients undergoing coronary artery bypass grafting without the use of cardiopulmonary bypass (CPB) with those undergoing CABG using standard CPB. The study population consisted of 325 patients who underwent coronary artery bypass grafting between June 2000 and December 2001 (mean age 60.02, range 38-83 years, 242 males). Each patient had continuous ECG monitoring since the operation to the third postoperative day. AF occurred in 100 of 325 patients (30.76%). Patients were divided into two groups according to the presence (group A-100 patients) or absence (group B-100 patients) of post-CABG AF. Patients in both groups were compared. Intraoperative variables were used to compare the two groups. Patients with AF were significantly older (66.04 +/- 7.88 vs. 60.49 +/- 9.74 p = 0.0001). There was no statistically significant difference in the incidence of atrial fibrillation between the patients after coronary artery bypass grafting procedures, performed with or without cardiopulmonary bypass.