Mechanical Circulatory Support During Surgical Revascularization for Ischemic Cardiomyopathy.

BACKGROUND: This study aimed to describe the use of perioperative mechanical circulatory support (MCS) and its impact on outcomes in patients with ischemic cardiomyopathy who were undergoing surgical revascularization. METHODS: Patients with an ejection fraction <35% who underwent isolated coronary artery bypass grafting (CABG) from 2015 to 2021 were identified (N = 378). Patients were divided into no MCS, preoperative MCS, and postoperative MCS groups on the basis of timing of MCS initiation, which included intraaortic balloon pump, extracorporeal membrane oxygenation, or Impella device (Abiomed) use. The primary outcome of interest was operative mortality. RESULTS: The median Society of Thoracic Surgeons Predicted Risk of Mortality was 2.4%. Sixty-six percent (n = 246) of patients had a previous myocardial infarction, and 61.8% of these patients were within 21 days of CABG. Twenty-one patients (5.6%) presented in cardiogenic shock. The preoperative MCS cohort consisted of 31 patients (8.2%) who underwent CABG a median of 2 days after MCS initiation. Thirty (7.9%) patients required postoperative MCS. Independent risk factors for requiring postoperative MCS included the preoperative ejection fraction (odds ratio, 0.93; P = .01 and the presence of preoperative MCS (odds ratio, 3.06; P = .02). Overall, operative mortality was 3.4%, and 3-year survival was 87.0%. Operative mortality in patients who did and did not receive preoperative MCS was 7.7% and 2.9% (P = .12) with no difference in long-term survival (P = .80), whereas patients requiring postoperative MCS had significantly increased operative (16.7%) and late mortality (63%; P <.01). CONCLUSIONS: CABG can be performed safely in patients with ischemic cardiomyopathy with selective use of perioperative MCS. Despite advanced disease severity, patients requiring preoperative MCS demonstrate acceptable short- and long-term survival. Patients requiring postoperative MCS have increased postoperative morbidity and mortality.

Trichite features contribute to the revision of the genus Strombidium (Alveolata, Ciliophora, Spirotricha).

Strombidium is a species-rich genus of oligotrichid ciliates mainly inhabiting the marine pelagial. In molecular phylogenies, the genus emerged as non-monophyletic, and cladistic analyses suggest that it is largely characterized by plesiomorphies. A reliable split of the genus and the establishment of new genera necessitate, however, support by novel morphological and/or ultrastructural features. In the present study, the arrangement and ultrastructure of trichites are proposed as taxonomically relevant characters. Strombidium biarmatum Agatha et al., 2005 differs in the trichite pattern from the type species Strombidium sulcatum and most congeners. Aside from the trichites inserting anteriorly to the girdle kinety and generating the typical funnel-shaped complex in the posterior cell portion, the species displays additional trichites between the adoral membranelles even visible in live cells. Here, this exceptional trichite arrangement is detailed based on transmission electron microscopic investigations. In molecular phylogenies, S. biarmatum forms a monophylum with two congeners sharing its trichite arrangement. Therefore, the strombidiid genus Heteropilum nov. gen. is established with S. biarmatum as type species to also include H. paracapitatum (Song et al., 2015) nov. comb. and H. basimorphum (Martin & Montagnes, 1993) nov. comb. Further differences discovered in the trichite ultrastructure support the organelles' taxonomic significance.

Acute right ventricular geometric change predicts outcomes in HeartMate 3 patients.

BACKGROUND: The physiological response of the right ventricle (RV) following left ventricular assist device (LVAD) implantation is difficult to predict. We aimed to investigate RV geometric and functional changes after LVAD insertion and their effects on clinical outcomes. METHODS: We retrospectively reviewed 188 patients who underwent HeartMate 3 implantation at our center between November 2014 and September 2021. The RV end-diastolic diameter (RVEDD) and RV end-diastolic area (RVEDA) were measured on preoperative and predischarge transthoracic echocardiography. The nonadapted group included patients with increased RVEDD and RVEDA at discharge. The composite outcome was defined as death or readmission due to worsening right heart failure. RESULTS: There were 82 patients (44%) who had a nonadapted and 106 patients (56%) who had an adapted RV. Preoperatively, the nonadapted group had smaller RVEDD (46 vs 49 mm, p < 0.001) and RVEDA (27 vs 31 cm2, p < 0.001). At discharge, the nonadapted group had larger RVEDD (51 vs 43 mm, p < 0.001) and RVEDA (33 vs 27 cm2, p < 0.001). Kaplan-Meier analysis demonstrated worse 3-year survival (77% vs 91%, p = 0.006) and freedom from composite outcome (58% vs 85%, p < 0.001) in the nonadapted group. A multivariable Cox proportional hazards model showed that nonadaption (hazard ratio [HR] 3.09, 95% confidence interval [CI] 1.29-7.40, p = 0.01) and age (HR 3.73, 95% CI 1.42-9.77, p = 0.007) were independent predictors of composite outcome. CONCLUSIONS: Acute RV dimensional changes after LVAD insertion may represent intrinsic RV function and may be a useful prognostic marker.

Comparing 3-year survival and readmissions between HeartMate 3 and heart transplant as primary treatment for advanced heart failure.

OBJECTIVE: To compare 3-year survival and readmissions of patients who received the HeartMate 3 (HM3) left ventricular assist device (LVAD) or underwent orthotopic heart transplantation (OHT) as primary treatment for advanced heart failure. METHODS: We retrospectively analyzed 381 adult patients who received an HM3 LVAD or were listed for OHT between January 2014 and March 2021 at our center. To minimize crossover bias, OHT recipients with a prior LVAD were excluded, and HM3 patients were censored at the time of transplant. Cohorts were propensity score-matched to reduce confounding variables. The primary outcome was 3-year survival, and the secondary outcome was mean cumulative all-cause unplanned readmission. RESULTS: The study population comprised 185 HM3 patients (49%) and 196 OHT patients (51%), with 104 propensity score-matched patients in each group. After propensity score matching, there was no statistical difference in 3-year survival (83.7% for HM3 vs 87.0% for OHT; P = .91; relative risk [RR], 1.00; 95% confidence interval [CI], 0.45-2.20). In the unmatched cohorts, patients age 18 to 49 years had comparable survival with HM3 and OHT (96.9% vs 95.9%; N = 91; P = 1.00; RR, 0.92; 95% CI, 0.09-9.78). Patients age 50+ years had slightly inferior survival with HM3 (75.0% vs 83.9%; N = 290; P = .60; RR, 1.51; 95% CI, 0.85-2.68). The mean number of readmissions at 3 years was higher in the HM3 group (3.89 vs 2.05; P < .001). CONCLUSIONS: This exploratory analysis suggests that for similar patients, HM3 may provide comparable 3-year survival to OHT as a primary treatment for heart failure but may result in more readmissions.

Does lateral approach preserve the right ventricular function after HeartMate 3 insertion?

OBJECTIVES: Lateral thoracotomy (LT) approach may preserve the right ventricular (RV) function after left ventricular assist device (LVAD) implantation. This study evaluated the short- and long-term RV function using echocardiography after LVAD implantation via LT or median sternotomy (sternotomy). METHODS: The patients who underwent HeartMate 3 implantation were retrospectively reviewed. The RV function was assessed before and 1 month and 1 year after LVAD implantation. The primary and secondary outcomes were all-cause mortality and a composite of death or readmission due to RV failure, respectively. RESULTS: Of the 195 patients, 55 (28%) underwent LT and 140 (72%) underwent sternotomy. There were no significant differences in the preoperative RV geometry or function. One month after the LVAD implantation, the LT group had a smaller RV end-diastolic dimension [42 (29-48) vs 47 (42-52) mm; P = 0.003] and RV end-diastolic area [25 (21-28) vs 29 (24-36) cm2; P < 0.001] and a greater RV fractional area change [30 (25-34)% vs 28 (23-31)%; P = 0.04] and peak systolic tissue velocity [8 (7-9) vs 7 (6-8) cm/s; P = 0.01]. Twenty-four patients died and 46 met the composite end point. Kaplan-Meier curve analysis did not reveal significant differences between LT and sternotomy in the 2-year survival (93% vs 83%; log-rank test, P = 0.28) and adverse event rate (76% vs 71%; log-rank test, P = 0.65). CONCLUSIONS: LT approach yielded a better-preserved RV function at 1 month; however, there were no significant differences in the 2-year survival and adverse event rates.

Preoperative Left Ventricular Diastolic Dimension Index Is Associated With Outcomes After HeartMate 3 Implantation.

OBJECTIVE: We investigated the association between indexed left ventricular diastolic dimension and clinical outcomes after HeartMate 3 implantation. METHODS: We retrospectively reviewed patients implanted with the HeartMate 3 at our center between November 2014 and September 2021. Left ventricular diastolic dimension was assessed via preoperative transthoracic echocardiography and left ventricular diastolic dimension index was calculated as left ventricular diastolic dimension/body surface area. The primary outcome was a composite of death or readmission due to right heart failure or stroke. The cut-off left ventricular diastolic dimension index value most closely associated with outcomes was determined by receiver-operating characteristic curve and restricted cubic spline analyses. RESULTS: Left ventricular diastolic dimension index measurements were available for 252 of 253 (99.6%) patients. Using a left ventricular diastolic dimension index cut-off value of 33.5 mm/m2, the cohort was divided: left ventricular diastolic dimension index ≤ (n = 131) or > (n=121) 33.5 mm/m2. While there were no significant differences in age, INTERMACS level, and preoperative hemodynamics between groups, patients with smaller left ventricular diastolic dimension index were more likely to have a larger body surface area (2.1 vs 1.9 m2, P<0.001), ischemic cardiomyopathy (64 [49%] vs 40 [33%], P=0.01), and smaller left atrium volume index (40.5 [32.3-54.0] mL/m2 vs. 54.0 [43.0-66.8] mL/m2, P<0.001). Smaller left ventricular diastolic dimension index patients had significantly worse survival (74% vs 88%, log-rank P=0.009) and freedom from adverse events (55% vs 73%, log-rank P=0.005) at 3-year follow-up. Smaller left ventricular diastolic dimension index was independently associated with the composite outcome (Hazard ratio 2.24, P=0.002). CONCLUSIONS: Smaller preoperative left ventricular diastolic dimension index is associated with worse outcomes in patients undergoing HeartMate 3 implantation.

Continuous near-infrared reflectance spectroscopy monitoring to guide distal perfusion can minimize limb ischemia surgery for patients requiring femoral venoarterial extracorporeal life support.

BACKGROUND: Patients requiring femoral venoarterial (VA) extracorporeal life support (ECLS) are at risk of distal lower limb hypoperfusion and ischemia of the cannulated leg. In the present study, we evaluated the effect of using continuous noninvasive lower limb oximetry with near-infrared reflectance spectroscopy (NIRS) to detect tissue hypoxia and guide distal perfusion catheter (DPC) placement on the rates of leg ischemia requiring surgical intervention. METHODS: We performed a retrospective analysis of patients who had undergone femoral VA-ECLS at our institution from 2010 to 2014 (pre-NIRS era) and 2017 to 2021 (NIRS era). Patients who had undergone cannulation during the 2015 to 2016 transition era were excluded. The baseline characteristics, short-term outcomes, and ischemic complications requiring surgical intervention (eg, fasciotomy, thrombectomy, amputation, exploration) were compared across the two cohorts. RESULTS: Of the 490 patients included in the present study, 141 (28.8%) and 349 (71.2%) had undergone cannulation before and after the routine use of NIRS to direct DPC placement, respectively. The patients in the NIRS cohort had had a greater incidence of hyperlipidemia (53.7% vs 41.1%; P = .015) and hypertension (71.4% vs 60%; P = .020) at baseline, although they were less likely to have been supported with an intra-aortic balloon pump before ECLS cannulation (26.9% vs 37.6%; P = .026). These patients were also more likely to have experienced cardiac arrest (22.9% vs 7.8%; P ≤ .001) and a pulmonary cause (5.2% vs 0.7%; P = .04) as an indication for ECLS, with ECLS initiated less often for acute myocardial infarction (15.8% vs 34%; P ≤ .001). The patients in the NIRS cohort had had a smaller arterial cannula size (P ≤ .001) and a longer duration of ECLS support (5 vs 3.25 days; P ≤ .001) but significantly lower rates of surgical intervention for limb ischemia (2.6% vs 8.5%; P = .007) despite comparable rates of DPC placement (49.1% vs 44.7%; P = .427), with only two patients (1.1%) not identified by NIRS ultimately requiring surgical intervention. CONCLUSIONS: The use of a smaller arterial cannula (≤15F) and continuous NIRS monitoring to guide selective insertion of DPCs could be a valid and effective strategy associated with a reduced incidence of ischemic events requiring surgical intervention.

Less is better? Comparing effects of median sternotomy and thoracotomy surgical approaches for left ventricular assist device implantation on postoperative outcomes and valvulopathy.

OBJECTIVE: Our objective was to compare outcomes after left ventricular assist device implantation performed via median sternotomy or lateral thoracotomy. METHODS: We retrospectively analyzed 222 adult patients with the HeartMate3 (Abbott Lab) left ventricular assist device implanted between November 2014 and November 2021. Outcomes stratified by surgical approach were evaluated in propensity score-matched groups. The primary outcome was 1-year survival. Secondary outcomes included in-hospital morbidity and mortality, readmissions, and significant valvular regurgitation. RESULTS: Our cohort consisted of 60 patients (27%) who underwent lateral thoracotomy and 162 patients (73%) who underwent median sternotomy. Propensity score matching compared 45 patients who underwent lateral thoracotomy with 68 patients who underwent median sternotomy. There were no differences in intensive care unit or hospital stay duration (median, 10 vs 11 days, P = .58; 46 vs 40 days, P = .279), time to extubation (median, 2 days, P = .627), vasoactive-inotropic scores at intensive care unit arrival (18.20 vs 16.60, P = .654), or in-hospital mortality (2 [5%] vs 4 [6.1%] patients, P = 1). One-year survival (95.56% vs 90.61%, P = .48) and all-cause hospital readmission rate (Gray's test: P = .532) were also comparable. Patients who underwent lateral thoracotomy had significantly less early right ventricular failure (24.4% vs 53.7%, P = .004), although they had more follow-up tricuspid regurgitation (17.6% vs 0%, P = .030) and volume overload readmissions (Gray's test: P = .0005). CONCLUSIONS: Our data suggest that lateral thoracotomy is a safe although not necessarily superior alternative to median sternotomy for HeartMate 3 implantation in the perioperative and postoperative periods, because it precludes concomitant tricuspid valve repairs and may be associated with increased risk of late tricuspid regurgitation and volume overload readmissions.

Measuring success in obesity prevention: a synthesis of Health Promotion Switzerland's long-term monitoring and evaluation strategy.

AIMS: Since 2007, Health Promotion Switzerland has implemented a national priority program for a healthy body weight. This article provides insight into the methodological challenges and results of the program evaluation. METHODS: Evaluation of the long-term program required targeted monitoring and evaluation projects addressing different outcome levels. The evaluation was carried out according to the Swiss Model for Outcome Classification (SMOC), a model designed to classify the effects of health promotion and prevention efforts. RESULTS: The results presented in this article emphasize both content and methods. The national program successfully achieved outcomes on many different levels within complex societal structures. The evaluation system built around the SMOC enabled assessment of program progress and the development of key indicators. However, it is not possible to determine definitively to what extent the national program helped stabilize the prevalence of obesity in Switzerland. CONCLUSION: The model has shown its utility in providing a basis for evaluation and monitoring of the national program. Continuous analysis of data from evaluation and monitoring has made it possible to check the plausibility of suspected causal relationships as well as to establish an overall perspective and assessment of effectiveness supported by a growing body of evidence.

The impact of radiotherapy in the treatment of desmoid tumours. An international survey of 110 patients. A study of the Rare Cancer Network.

PURPOSE: A multi-centre study to assess the value of combined surgical resection and radiotherapy for the treatment of desmoid tumours. PATIENTS AND METHODS: One hundred and ten patients from several European countries qualified for this study. Pathology slides of all patients were reviewed by an independent pathologist. Sixty-eight patients received post-operative radiotherapy and 42 surgery only. Median follow-up was 6 years (1 to 44). The progression-free survival time (PFS) and prognostic factors were analysed. RESULTS: The combined treatment with radiotherapy showed a significantly longer progression-free survival than surgical resection alone (p smaller than 0.001). Extremities could be preserved in all patients treated with combined surgery and radiotherapy for tumours located in the limb, whereas amputation was necessary for 23% of patients treated with surgery alone. A comparison of PFS for tumour locations proved the abdominal wall to be a positive prognostic factor and a localization in the extremities to be a negative prognostic factor. Additional irradiation, a fraction size larger than or equal to 2 Gy and a total dose larger than 50 Gy to the tumour were found to be positive prognostic factors with a significantly lower risk for a recurrence in the univariate analysis. This analysis revealed radiotherapy at recurrence as a significantly worse prognostic factor compared with adjuvant radiotherapy. The addition of radiotherapy to the treatment concept was a positive prognostic factor in the multivariate analysis. CONCLUSION: Postoperative radiotherapy significantly improved the PFS compared to surgery alone. Therefore it should always be considered after a non-radical tumour resection and should be given preferably in an adjuvant setting. It is effective in limb preservation and for preserving the function of joints in situations where surgery alone would result in deficits, which is especially important in young patients.