Extracorporeal membrane oxygenation and COVID-19: The causes of failure.

INTRODUCTION: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a therapeutic strategy for the coronavirus disease 2019 (COVID-19) induced acute respiratory distress syndrome (ARDS). There are inconclusive data in this regard and causes of VV-ECMO failure are not yet understood well. CASE SERIES: Here, seven patients with COVID-19-induced ARDS who underwent VV-ECMO introduced and causes of VV-ECMO failure discussed. Medical records of seven COVID-19 patients treated with VV-ECMO were retrospectively evaluated to determine the clinical outcomes of VV-ECMO. Oxygenator failure occurred in four patients whom needed to oxygenator replacement. Successful VV-ECMO decannulation was done in three patients, however finally one patient survived. CONCLUSIONS: Hypercoagulability state and oxygenator failure were the most main etiologies for VV-ECMO failure in our study. All patients with COVID-19 undergoing VV-ECMO should be monitored for such problems and highly specialized healthcare team should monitor the patients during VV-ECMO.

Prevalence of Cesarean Section and Analysis of Neonatal Apgar Score and the Mean Time of Second Phase of Labor in Pregnant Women.

INTRODUCTION: The labor pain is probably the most severe pain a mother experiences in her lifetime and is usually severe and prolonged in women with pregnancy. AIM: To evaluate the effects of labor epidural and spinal analgesia on the incidence of cesarean section in painless delivery. METHODS: This randomized clinical trial was conducted on pregnant women aged 37-42 weeks of pregnancy. Female candidates for painless labor were divided into two groups: Epidural Analgesia (EA) and Spinal Analgesia (SA). Patients in the labor epidural group underwent analgesia using marcaine and fentanyl and after fully assuring the normal hemodynamic status of the mother and fetal hearth rate (FHR), labor spinal analgesia was used for other group. RESULTS: The average age of mothers was 27.5 years, their mean gestational age was 39 weeks and their mean weight was determined to be 72 kg. Frequency of cesarean delivery in mothers was found as 12.9%. Significantly, the incidence of cesarean section in the labor epidural analgesia group was higher than the labor spinal analgesia group (P = 0.02). In addition, the mean second phase of delivery in the labor epidural analgesia group was significantly higher than the labor spinal analgesia group (P = 0.03). There was no significant in 1st and 5th min Apgar scores between groups in infants (8.6 and 9.6, respectively). CONCLUSION: Labor epidural analgesia and labor spinal analgesia result in a significant reduction in pain due to normal delivery. Due to the similarity of Apgar and arterial blood gas (ABG) in neonates, labor epidural analgesia may serve as an alternative in childbirth delivery.

Our modified technique of combined antegrade-vein graft cardioplegia infusion versus conventional antegrade method in coronary artery bypass grafting. A randomized clinical trial.

BACKGROUND: To determine the efficacy of antegrade cardioplegia supplemented with venous graft perfusion in patients scheduled for coronary artery bypass grafting (CABG). METHODS: 223 consecutive patients scheduled for isolated CABG were randomized to receive either continuous crystalloid cardioplegia via vein grafts on completion of each distal anastomosis plus intermittent blood cardioplegia through aortic root (group 1, n = 110) or antegrade blood cardioplegia alone (group 2, n = 113). Two groups were similar in terms of preoperative patients' and procedural characteristics. The primary end-points were low output syndrome (LOS) variables. RESULTS: The inotrope and intra-aortic balloon pump demand during weaning were significantly higher in the control group (31.8% vs. 20%, p = 0.043 and 7.9% vs. 1.8%, p = 0.034 respectively). Postoperative level of potassium and arterial base excess (BE), stood in the normal range in both groups, despite significant inter-group differences. Peak serum level of myocardial injury biomarkers (CK, CK-MB, and cTnI) at 12 h following operation, though markedly greater in the group 2, did not reach the cut-off point of myocardial necrosis. Postoperative arrhythmia was more commonly encountered in the control group (p = 0.045). The duration of ventilation and hospital stay were considerably longer in the group 2. In a subgroup with LVEF<30%, the length of ICU stay was more prolonged in the control group, as well (p = 0.0145). The significant differences among groups regarding LOS parameters were more remarkable in the two high-risk subgroups (LVEF<30%, left main coronary stenosis). CONCLUSIONS: Given the better postoperative cardiac performance, we recommend this method to all CABG candidates, particularly in higher-risk patients.

Evaluation of left ventricular function in obese children without hypertension by a tissue Doppler imaging study.

BACKGROUND: The prevalence of obesity is increasing worldwide. Obese children without hypertension are becoming an important health challenge. AIMS: Complications of obesity in adults are well established, but in obese children, cardiac dysfunction has not been reported clinically. SETTINGS AND DESIGN: The present crosssectional study investigates subclinical systolic and diastolic dysfunction using echocardiographic modalities. MATERIALS AND METHODS: Twentyfive youngsters with body mass index (BMI) >30 and 25 healthy children with BMI <25 were assigned into case and control group, respectively. In all participants, complete cardiovascular examination, electrocardiography, and echocardiography were fulfilled. Echocardiography surveys included standard, pulsed wave Doppler (PWD), and tissue Doppler imaging (TDI). STATISTICAL ANALYSIS USED: SPSS software, version 24. RESULTS: The two groups were matched for age and sex. The resting heart rate and blood pressure were markedly higher in the obese group (P = 0.0001) though they were within the normal range in either category. Ejection fraction in the two groups was similar. Left ventricular (LV) mass (P = 0.0001), LV mass index (P = 0.029), left atrialtoaortic diameter ratio (P = 0.0001), and LV enddiastolic diameter (P = 0.008) were significantly greater in the case group, indicating cardiomegaly and subclinical systolic and diastolic dysfunction. Except for the aortic velocity, all PWD variables were considerably lower in the case group, suggesting subclinical diastolic dysfunction. All TDI parameters varied significantly between the two categories. There was a direct correlation between isovolumetric relaxation time and BMI. CONCLUSIONS: Obesity in children without hypertension is associated with subclinical systolic and diastolic cardiac dysfunction. We propose the evaluation of blood pressure as well as myocardial performance using PWD and TDI in all obese children without hypertension, regularly.

Effect of Sustained Use of Aspirin until the Time of Surgery on Outcomes following Coronary Artery Bypass Grafting: A Randomized Clinical Trial.

BACKGROUND: The topic of aspirin (acetylsalicylic acid, ASA) use in coronary artery disease patients planned for coronary artery bypass grafting during perioperative period is among the most disputed issues in cardiac surgery. We designed a study to weigh the risks and benefits of continued ASA ingestion until the time of surgery. METHODS: In this randomized double-blind clinical trial, 206 consecutive patients scheduled for isolated coronary artery bypass surgery (CABG) were randomly stratified into two groups. In group 1 (104 cases), patients were given 80 mg ASA per day until the day of surgery. In group 2 (102 patients), ASA (80 mg per day) was stopped 4 days before the operation. Patients in these two groups were similar in terms of preoperative patient and procedural characteristics. ASA was resumed 24 hours after the surgery in all patients. RESULTS: The rates of bleeding and reexploration within 24 hours of surgery were significantly higher in group 1 (824.3 vs. 492.1 mL, p < 0.001 and 5.7% vs. 0, p = 0.0138, respectively). The amount of intra- and postoperative packed red blood cell (PRBC) transfusion was considerably greater in group 1 (mean: 1.83 vs. 0.71 units, p < 0.001). The rate of hospital mortality was similar (1.9% in both the groups, p = 0.98). Patients in group 1 had significantly longer mean hospital stay than patients in group 2 (8 vs. 5.1 days, p < 0.001). Again the time interval between weaning from heart-lung machine and closing the sternum was strikingly longer in group 1 (mean: 32.1 vs. 14.5 minutes, p < 0.001). The incidence of adverse postoperative outcomes such as myocardial infarction, stroke, and renal failure was not statistically different between the two groups. CONCLUSION: Sustained ASA use until the day of surgery in patients planned for elective isolated CABG can result in excessive bleeding, increased rate of reexploration, and need for more PRBC transfusion without any proven beneficial effect on reducing unfavorable postoperative outcomes. Hence, we recommend discontinuing ASA between 3 and 5 days before non-urgent CABG while keeping it on in nonelective circumstances.

Evaluation of amiodarone versus metoprolol in treating atrial fibrillation after coronary artery bypass grafting.

INTRODUCTION: Atrial fibrillation (AF) is the most common arrhythmia affecting patients in open heart ICU after coronary artery bypass grafting (CABG). Most cardiac surgery textbooks recommend beta blockers as the drug of choice for treating such a condition while many experienced physicians and a number of anesthesiology references offer amiodarone as the drug of choice. Therefore, because of insufficient evidence and the aforementioned controversy, we decided to conduct a study evaluating these two antiarrhythmic medicines. METHODS: This is a double-blind, randomized, clinical trial performed on patients admitted for CABG at Amir al Momenin hospital in Arak province, Iran, who developed new onset AF after surgery. Based on the type of medication used, these patients were randomly divided into two groups: amiodarone (A) group and metoprolol (M) group. Each group consisted of 73 cases. All data were analyzed via SPSS 19. RESULTS: Among the results achieved in this study, amiodarone was successful in treating AF in 55 patients (73%), while metoprolol achieved normal rhythm in treating AF in 69 patients (92%). With a p-value of 0.04, it seems that metoprolol is more effective in treating AF. CONCLUSION: Metoprolol seems to be a most efficacious medication for post-CABG AF (p-value = 0.004).

The Impact of Sub-valvular Apparatus Preservation on Prosthetic Valve Dysfunction During Mitral Valve Replacement.

BACKGROUND: Sub-valvular apparatus preservation (SAP) during mitral valve replacement (MVR) is not a new concept. Some surgeons prefer to excise the apparatus. OBJECTIVES: The aim of this study was to reduce the risk of prosthetic valve dysfunction. MATERIALS AND METHODS: This retrospective study included 151 patients with the mean age of 46 years who underwent MVR (Female/male = 93/58). In the group I consisting of 39 patients, MVR with chordae preservation was performed (Bi-leaflet preservation = 20; posterior leaflet preservation = 19). In the group II consisting of 112 patients, sub-valvular apparatus was resected completely during MVR. Preoperative patients' characteristics, including age, sex, functional status, left ventricular ejection fraction, and end-diastolic or end-systolic dimensions were statistically similar in both groups. Mean follow-up period was 60.3 ± 26 months. RESULTS: The improvement of functional status was seen in almost all survivors but was more obvious in the group I. In early follow-up, 56.4% of group I cases and 44.1% of group II patients were classified as New York Heart Association class I. These rates were 84.2% and 71.2% in mid-term follow-up, respectively (P < 0.001). Mortality rate was significantly lower in the group I (2.6%) compared to the group II (8.9%) (P = 0.03). There was a trend for higher frequency of postoperative atrial fibrillation in the group II compared to that in the group I (52.7% vs. 38.5%, P = 0.12).The incidence of prosthetic valve dysfunction (PVD) was 5.1% in the group I and 4.5% in the group II, but this difference was not statistically significant (P = 0.56). CONCLUSIONS: Preservation of mitral annulus and papillary muscle continuity may enhance post- MVR cardiac performance with low mortality and morbidity rates. The risk of PVD was not significantly higher than conventional MVR in our series.

Supravalvar mitral ring: a case report.

Supravalvar mitral ring is a rare congenital heart defect of surgical importance. The condition is characterized by an abnormal ridge of the connective tissue on the atrial side of the mitral valve. It often substantially obstructs the mitral valve inflow. We herein introduce a case of a supravalvar mitral ring in a 17-year-old male, who was admitted to our hospital with cardiac syncope. He had undergone a cardiac operation for ventricular septal defect (VSD) closure and mitral valve repair 15 years before. Transthoracic echocardiography, transesophageal echocardiography, and finally cardiac catheterization revealed a neglected supravalvular mitral ring. The ring was resected in a second operation, and the patient was discharged from the hospital symptom free.

Feasibility of VSD Closure and Debanding Without Pulmonary Artery Patch Repair in VSD Patients After PA Banding.

From 2004 to 2008, 64 infants with large ventricular septal defects were managed using a two-stage surgical approach. In the first stage, banding of the main pulmonary trunk was performed. The defect was then repaired months later. Debanding of pulmonary artery was accomplished without the need for pulmonary artery reconstruction.