Morbid obesity's impact on COVID-19 patients requiring venovenous extracorporeal membrane oxygenation: The covid-19 critical care consortium database review.

Introduction: Obesity is associated with a worse prognosis in COVID-19 patients with acute respiratory distress syndrome (ARDS). Veno-venous (V-V) Extracorporeal Membrane Oxygenation (ECMO) can be a rescue option, however, the direct impact of morbid obesity in this select group of patients remains unclear.Methods: This is an observational study of critically ill adults with COVID-19 and ARDS supported by V-V ECMO. Data are from 82 institutions participating in the COVID-19 Critical Care Consortium international registry. Patients were admitted between 12 January 2020 to 27 April 2021. They were stratified based on Body Mass Index (BMI) at 40 kg/m2. The endpoint was survival to hospital discharge.Results: Complete data available on 354 of 401 patients supported on V-V ECMO. The characteristics of the high BMI (>40 kg/m2) and lower BMI (≤40 kg/m2) groups were statistically similar. However, the 'high BMI' group were comparatively younger and had a lower APACHE II score. Using survival analysis, older age (Hazard Ratio, HR 1.49 per-10-years, CI 1.25-1.79) and higher BMI (HR 1.15 per-5 kg/m2 increase, CI 1.03-1.28) were associated with a decreased patient survival. A safe BMI threshold above which V-V ECMO would be prohibitive was not apparent and instead, the risk of an adverse outcome increased linearly with BMI.Conclusion: In COVID-19 patients with severe ARDS who require V-V ECMO, there is an increased risk of death associated with age and BMI. The risk is linear and there is no BMI threshold beyond which the risk for death greatly increases.

Long-term survival and quality of life after extracorporeal membrane oxygenation.

OBJECTIVES: Long-term data on patient survivors after extracorporeal membrane oxygenation (ECMO) support remains limited. This study sought to examine the 5-year survival and health-related quality of life (HRQoL) of patients treated with venoarterial (VA)- or venovenous (VV)-ECMO. METHODS: A single-center retrospective chart review and survival analysis was conducted on all patients who required ECMO from December 2007 to June 2019. Cross-sectional HRQoL assessments were performed using 8 standardized questionnaires among survivors. RESULTS: Records for 370 ECMO patients (288 VA-ECMO, 82 VV-ECMO) were reviewed. Survival at 5 years was 33% (VA-ECMO) and 36% (VV-ECMO). Among patients that survived to 30 days, 5-year survival rates were 73% (VA-ECMO) and 71% (VV-ECMO). Sixty surviving patients (56%) had HRQoL assessments (48 VA-ECMO, 12 VV-ECMO). Median follow-up time was 4.2 (VA-ECMO) and 5.7 years (VV-ECMO). Fourteen (29%) VA-ECMO patients and 9 (75%) VV-ECMO patients reported difficulty with any activity of daily living whereas 13 (27%) VA-ECMO patients and 8 (67%) VV-ECMO patients reported difficulty with any instrumental activity of daily living. Eleven (23%) VA-ECMO patients and 7 (58%) VV-ECMO patients reported a high post-traumatic stress disorder score. Low decision regret scores in both cohorts indicated minimal regret that ECMO was initiated. CONCLUSIONS: Five-year clinical and patient-centered outcomes of patients requiring ECMO support is acceptable in those who survived the initial 30 days. Among ECMO survivors, persistent HRQoL concerns were apparent, highlighting the importance of longer-term postdischarge follow-up.

Validation of the Emory Risk Score in the Transcatheter Aortic Valve Implantation Population: A Canadian Perspective.

Background: Permanent pacemaker (PPM) implantation may be indicated post-transcatheter aortic valve implantation (TAVI). The Emory Risk Score (ERS) is a validated predictive risk score of the need for a PPM post-TAVI using a balloon-expandable valve. Our objectives were to determine the validity of the ERS in our local TAVI population with both balloon-expandable and self-expanding valves and to identify additional electrocardiographic (ECG) parameters predictive of the need for a PPM post-TAVI. Methods: Retrospective chart and electronic database reviews were performed to collect demographic and procedural information. Two expert readers reviewed all ECGs. Independent factors associated with PPM implantation were examined with multivariable logistic regression via a stepwise selection process with calculation of the area under the receiver operating characteristic curve to assess model discrimination. Results: The overall PPM implantation rate was 11.7%; rates were 9% for the Sapien 3 valves, 10% for the Evolut Pro valves, and 17% for the Evolut R valves. The ERS was found to not be predictive of need for PPM post-TAVI for the entire cohort. Right bundle branch block was the only ERS parameter independently associated with new PPM implant (8.5% vs 25%, odds ratio = 3.59, P = 0.01). No additional ECG parameters met the criteria for statistical significance. Conclusions: The poor predictive value of the ERS in determining the need for a PPM post-TAVI in our patient population suggests that further refinement of a formula (or risk-calculator) is warranted. Identification of a precise risk-calculator is likely to facilitate patient mobilization and reduce inpatient healthcare resource utilization.

Introduction: L'implantation d'un stimulateur cardiaque permanent (SCP) peut être indiquée après l'implantation valvulaire aortique par cathéter (post-IVAC). L'Emory Risk Score (ERS) est un score de prédiction du risque validé de la nécessité d'un SCP post-IVAC au moyen d'une valve expansible par ballonnet. Nous avions pour objectif de déterminer la validité de l'ERS auprès de notre population ayant eu une IVAC soit par valve expansible par ballonnet ou valve auto-expansible, et de déterminer d'autres paramètres électrocardiographiques (ECG) prédictifs de la nécessité d'un SCP post-IVAC. Méthodes: Nous avons réalisé des revues rétrospectives de dossiers et de bases de données électroniques pour collecter les données démographiques et interventionnelles. Deux experts ont lu et interprété tous les ECG. Les facteurs indépendants associés à l'implantation du SCP ont été examinés en effectuant la régression logistique multivariée par processus de sélection pas-à-pas au moyen du calcul de la surface sous la courbe caractéristique d'efficacité du récepteur afin d'évaluer la discrimination du modèle. Résultats: Le taux global d'implantation d'un SCP était de 11,7 % ; les taux étaient de 9 % pour les valves Sapien 3, de 10 % pour les valves Evolut Pro et de 17 % pour les valves Evolut R. Nous avons observé que l'ERS ne permettait pas de prédire si l'implantation d'un SCP post-IVAC était nécessaire pour la cohorte entière. Le bloc de branche droit était le seul paramètre de l'ERS indépendamment associé à la nouvelle implantation d'un SCP (8,5 % vs 25 %, rapport de cotes = 3,59, P = 0,01). Aucun autre paramètre ECG ne satisfaisait au critère de signification statistique. Conclusions: La faible valeur prédictive de l'ERS à déterminer la nécessité d'un SCP post-IVAC au sein de notre population de patients montre que des améliorations de la formule (ou calculateur de risques) sont justifiées. L'identification d'un calculateur de risques précis devrait favoriser l'adhésion des patients et réduire l'utilisation des ressources en soins de santé en milieu hospitalier.

Risk score for arch reconstruction under circulatory arrest with hypothermia: The ARCH score.

OBJECTIVE: Currently, there is no risk scores built to predict risk in thoracic aortic surgery. This study aims to develop and internally validate a risk prediction score for patients who require arch reconstruction with hypothermic circulatory arrest. METHODS: From 2002 to 2018, data for 2270 patients who underwent aortic arch surgery in 12 institutions in Canada were retrospectively collected. The outcomes modeled included in-hospital mortality and a modified Society of Thoracic Surgeons-defined composite for mortality or major morbidity. Multivariable logistic regression using least absolute shrinkage and selection operator selection method and mixed-effect regression model was used to select the predictors. Internal calibration of the final models is presented with an observed-versus-predicted plot. RESULTS: There were 182 in-hospital deaths (8.0%), and the incidence of Society of Thoracic Surgeons-defined composite for mortality or major morbidity was 27.9%. Variables that increased risk of mortality are age, chronic obstructive pulmonary disease, atrial fibrillation, peripheral vascular disease, New York Heart Association class ≥III symptoms, acute aortic dissection or rupture, use of elephant trunk, concomitant surgery, and increased cardiopulmonary bypass time, with median c-statistics of 0.85 on internal validation. The c-statistics was 0.77 for the model predicting Society of Thoracic Surgeons-defined composite. Internal assessment shows good overall calibration for both models. CONCLUSIONS: We developed and internally validated a risk score for patients undergoing arch surgery requiring hypothermic circulatory arrest using a multicenter database. Once externally validated, the ARCH (Arch Reconstruction under Circulatory arrest with Hypothermia) score would allow for better patient risk-stratification and aid in the decision-making process for surgeons and patient prior to surgery.

A previously undescribed pathogenic variant in FBN1 gene causing Marfan syndrome: a case report.

Background: Marfan syndrome (MFS) is an autosomal dominant multisystem connective tissue disorder with increased risk of aortopathy with a high risk of subsequent life-threatening aortic dissection. Diagnosing this condition is reliant on recognizing clinical features and genetic testing for confirming diagnosis, using the revised Ghent criteria. Case summary: We identified a 49-year-old patient who presented with dyspnoea, with Marfan syndrome (MFS) and a previously unreported variant in the fibrillin-1 gene (FBN1), designated c.7016G>C. Prior to identifying the new gene variant, this patient did not meet the revised Ghent criteria for MFS diagnosis. We present clinical and molecular evidence supporting the likely pathogenic nature of this variant, leading to earlier therapy and intervention. Discussion: The discovery of a new pathogenic gene will expand the current aortopathy and MFS database and may lead to more informed clinical management decisions for the timing and nature of interventions.

Impact of renin-angiotensin-aldosterone system inhibition on mortality in critically ill COVID-19 patients with pre-existing hypertension: a prospective cohort study.

BACKGROUND: The influence of renin-angiotensin-aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients. METHODS: Data from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 737 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission. RESULTS: A total of 737 patients were included-538 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 199 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.74, 95% CI 0.58-0.94). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.2 days (95% CI 19.7-22.8 days) in ICU and 6.7 days (5.9-7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1-18.6 days) and 6.4 days (5.1-7.9 days), respectively. When analysed separately, results for ACEi or ARB patient groups were similar for both death and discharge. CONCLUSIONS: In critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay. Clinical trial registration The registration number: ACTRN12620000421932; The date of registration: 30, March 2020; The URL of the registration: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12620000421932 .

Evolving Surgical Techniques and Improving Outcomes for Aortic Arch Surgery in Canada.

BACKGROUND: To explore evolving surgical techniques and outcomes for aortic arch surgery. METHODS: A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined. RESULTS: From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; P < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; P < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; P < 0.01). Total arch replacement rates were similar (P = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; P < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; P < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; P < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; P < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; P = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; P < 0.001) and transfusion rates (2008: 61%; 2018: 41%; P < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; P = 0.12). Outcomes remained the same over time for urgent or emergent cases. CONCLUSIONS: Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting.

INTRODUCTION: Examiner l'évolution des techniques chirurgicales et les résultats de l'intervention chirurgicale de l'arc aortique. MÉTHODES: Un total de 2 435 patients consécutifs ont subi une réparation de l'arc aortique en arrêt circulatoire en hypothermie entre 2008 et 2018 dans 12 établissements du Canada. Nous avons examiné les tendances en ce qui concerne les caractéristiques des patients, les techniques chirurgicales et les résultats cliniques intrahospitaliers, y compris les principales causes de morbidité ou de mortalité. RÉSULTATS: De 2008 à 2018, l'âge des patients (62,3 ± 13,2 ans) et la proportion de femmes (30,2 %) subissant l'intervention chirurgicale de l'arc n'a pas montré de changement significatif. Les diamètres aortiques à l'opération ont diminué (2008 : 58 ± 13 mm; 2018 : 53 ± 11 mm; P < 0,01). Les chirurgiens ont réalisé un plus grand nombre de remplacements de la racine aortique sans remplacement de la valve (2008 : 0 %; 2018 : 15 %; P < 0,001) et un moins grand nombre d'opérations de Bentall (2008 : 27 %; 2018 : 20 %; P < 0,01). Les taux totaux de remplacements de l'arc étaient similaires (P = 0,18). Toutefois, les taux de réparation avec la technique de la trompe d'éléphant; (2008 : 9,5 %; 2018 : 19 %; P < 0,001) et de la trompe d'éléphant congelée (2008 : 3,1 %; 2018 : 15 %; P < 0,001) ont augmenté. Avec le temps, des nadirs supérieurs de température (2008 : 18 [17-21]°C; 2018 : 25 [23-28]°C; P < 0,001) et des perfusions cérébrales antérogrades plus fréquentes (2008 : 61 %; 2018 : 83 %; P < 0,001) ont été utilisés. Pour les cas non urgents, les taux de mortalité intrahospitalière (2008 : 6,8 %; 2018 : 1,2 %; P = < 0,01) et les taux de morbidité grave et de mortalité (2008 : 24 %; 2018 : 13 %; P < 0,001) et de transfusion (2008 : 61 %; 2018 : 41 %; P < 0,001) ont décru, mais les taux d'accidents vasculaires cérébraux (2008 : 6,8 %; 2018 : 5,3 %; P = 0,12) sont demeurés constants. Les résultats cliniques sont demeurés identiques au fil du temps pour les cas urgents ou les nouveaux cas. CONCLUSIONS: Au Canada, les résultats de l'intervention chirurgicale non urgente de l'arc aortique se sont améliorés au cours de la dernière décennie dans le contexte de l'opération d'aortes plus petites et de l'utilisation plus fréquente de l'hypothermie modérée et de la perfusion cérébrale antérograde. D'autres recherches sont nécessaires pour améliorer les taux d'accidents vasculaires cérébraux et les résultats cliniques dans le cadre d'interventions urgentes.

Effect of Continuous Electrocardiogram Monitoring on Detection of Undiagnosed Atrial Fibrillation After Hospitalization for Cardiac Surgery: A Randomized Clinical Trial.

Importance: Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined. Objective: To determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care. Design, Setting, and Participants: This study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled. Interventions: The intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization. Main Outcomes and Measures: The primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription. Results: Of the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA2DS2-VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial. In the intent-to-treat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%; P < .001). AF lasting 6 hours or longer was detected in 14 patients (8.6%) in the intervention group vs 0 patients in the usual care group (absolute difference, 8.6%; 95% CI, 4.3%-12.9%; P < .001). Conclusions and Relevance: In post-cardiac surgical patients at high risk of stroke, no preoperative AF history, and AF lasting less than 24 hours during hospitalization, continuous monitoring revealed a significant increase in the rate of POAF after discharge that would otherwise not be detected by usual care. Studies are needed to examine whether these patients will benefit from oral anticoagulation therapy. Trial Registration: ClinicalTrials.gov Identifier: NCT02793895.

Two-year outcomes from the PARTNER 3 trial: where do we stand?

PURPOSE OF REVIEW: The PARTNER 3 trial was conducted to compare outcomes after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve and surgical aortic valve replacement (SAVR) in individuals at low surgical risk with aortic stenosis. Recently reported rates of death, stoke and valve thrombosis in the TAVR arm have raised concerns about the longevity of this intervention in low-risk individuals. It is incumbent on all members of the Heart Team to understand the potential consequences of these findings. RECENT FINDINGS: TAVR was initially superior to SAVR at 1 year for a primary composite endpoint of death, stroke and rehospitalization. Results at 2 years now indicate noninferiority. Potential causative factors, comparisons with other transcatheter valves and implications for patients, providers and trainees are explored. Recommendations are additionally provided regarding TAVR and SAVR in individuals with aortic stenosis. SUMMARY: Concerns regarding the longevity of TAVR in low-risk individuals notwithstanding, results from PARTNER 3 indicate that TAVR is at least noninferior to SAVR out to 2 years. Longer follow-up will be required to determine whether these newly founded concerns are justifiable.