A comparison of different methods to maximise signal extraction when using central venous pressure to optimise atrioventricular delay after cardiac surgery.

Objective: Our group has shown that central venous pressure (CVP) can optimise atrioventricular (AV) delay in temporary pacing (TP) after cardiac surgery. However, the signal-to-noise ratio (SNR) is influenced both by the methods used to mitigate the pressure effects of respiration and the number of heartbeats analysed. This paper systematically studies the effect of different analysis methods on SNR to maximise the accuracy of this technique. Methods: We optimised AV delay in 16 patients with TP after cardiac surgery. Transitioning rapidly and repeatedly from a reference AV delay to different tested AV delays, we measured pressure differences before and after each transition. We analysed the resultant signals in different ways with the aim of maximising the SNR: (1) adjusting averaging window location (around versus after transition), (2) modifying window length (heartbeats analysed), and (3) applying different signal filtering methods to correct respiratory artefact. Results: (1) The SNR was 27 % higher for averaging windows around the transition versus post-transition windows. (2) The optimal window length for CVP analysis was two respiratory cycle lengths versus one respiratory cycle length for optimising SNR for arterial blood pressure (ABP) signals. (3) Filtering with discrete wavelet transform improved SNR by 62 % for CVP measurements. When applying the optimal window length and filtering techniques, the correlation between ABP and CVP peak optima exceeded that of a single cycle length (R = 0.71 vs. R = 0.50, p < 0.001). Conclusion: We demonstrated that utilising a specific set of techniques maximises the signal-to-noise ratio and hence the utility of this technique.

Implementación de un programa de terapia intravenosa en pacientes nefrológicos: análisis de los resultados / Implementation of an Intravenous Therapy Program in Nephrological Patients: Analysis of Results

Introducción:Evaluar la prevalencia y el impacto del uso de líneas medias canalizadas por el Equipo de Infusión y Accesos Vasculares mediante punción eco-guiada comparada con la es-trategia endovenosa convencional (punción de catéter venoso periférico por enfermeras de hospitalización) en una unidad de nefrología y trasplante renal.Material y Método: Estudio observacional retrospectivo. Se compararon 3 periodos: pre-implantación, implantación y consolidación del Equipo de Infusión y Accesos Vasculares. Se incluyeron todos los pacientes ingresados en las unidades de hospitalización de Nefrología y Trasplante Renal que requirie-ron de la colocación de catéteres vasculares periféricos y línea media. Se analizó la prevalencia de acceso venoso, el tiempo de permanencia y los motivos de retirada (complicaciones).Resultados: La incidencia de los catéteres vasculares perifé-ricos fue decreciente mientras que el de las líneas medias se incrementó progresivamente en los tres períodos. Así mismo, no se observaron diferencias en el tiempo medio de perma-nencia de los catéteres vasculares periféricos mientras que la permanencia de días de la línea media se incrementó.Se confirma en todos los periodos una tasa de complicaciones más elevada y variable en los catéteres vasculares periféricos; mientras que en la línea media la tasa de complicaciones fue menor y más estable.Conclusiones: La implementación de un programa de terapia intravenosa en pacientes nefrológicos ha permitido minimizar el número de dispositivos venosos por paciente, con la conse-cuente reducción de punciones durante el ingreso, así como la disminución de las complicaciones asociadas a la canaliza-ción venosa (menor morbilidad).Palabras clave: Equipo de Infusión y Accesos Vasculares (EIAV); Líneas Medias (LM); Catéteres Vasculares Periféricos (CVP); complicaciones; paciente nefrológico. (AU)

Objective:To evaluate the prevalence and impact of midline catheters inserted by the Infusion and Vascular Access Team using echo-guided puncture compared to conventional intra-venous strategies (peripheral venous catheter insertion by hospitalization nurses) in a nephrology and kidney transplant unit.Material and Method: This is a retrospective observational study. Three periods were compared: pre-implementation, implementation, and consolidation of the Infusion and Vas-cular Access Team. All patients admitted to the Nephrology and Kidney Transplantation hospitalization units requiring the placement of peripheral vascular catheters and midline were included. The prevalence of venous access, dwell time, and reasons for removal (complications) were analyzed. Resultados: The incidence of peripheral vascular catheters decreased while that of midlines progressively increased in all three periods. Moreover, there were no differences in the mean dwell time of peripheral vascular catheters, whereas the dwell time of midlines increased. A higher and variable rate of complications was confirmed in peripheral vascular catheters in all periods, while in midlines, the complication rate was lower and more stable.Conclusions: Implementing an intravenous therapy program in nephrology patients has allowed for minimizing the num-ber of venous devices per patient, resulting in a reduction in punctures during hospitalization and a decrease in com-plications associated with venous cannulation (lower mor-bidity). (AU)

Pulse Pressure Variance (PPV)-Guided Fluid Management in Adult Patients Undergoing Supratentorial Tumor Surgeries: A Randomized Controlled Trial.

Objective Appropriate fluid management in neurosurgery is critical due to the risk of secondary brain injury. Determination of volume status is challenging with static variables being unreliable. Goal-directed fluid therapy with dynamic variables allows reliable determination of fluid responsiveness and promises better outcomes. We aimed to compare the intraoperative fluid requirement between conventional central venous pressure (CVP)-guided and pulse pressure variance (PPV)-guided fluid management in supratentorial tumor surgeries. Materials and Methods This prospective, randomized, double-blind, single-center trial was conducted with 72 adults undergoing supratentorial tumor surgery in a supine position. Patients were divided into two groups of 36 patients each receiving CVP- and PPV-guided fluid therapy. The CVP-guided group received boluses to target CVP greater than 8 mm Hg along with hourly replacement of intraoperative losses and maintenance fluids. The PPV-guided group received boluses to target PPV less than 13% in addition to maintenance fluids. Total intraoperative fluids administered and the incidence of hypotension was recorded along with the brain relaxation score. Postoperatively, serum lactate levels, periorbital and conjunctival edema, as well as postoperative nausea and vomiting were assessed. Statistical Analyses All statistical analyses were performed with Statistical Package for Social Sciences, version-20 (SPSS-20, IBM, Chicago, Illinois, United States). To compare the means between the two groups (CVP vs. PPV), independent samples t -test was used for normal distribution data and Mann-Whitney U test for nonnormal distribution data. The chi-square test or Fischer's exact test was used for categorical variables. Results The CVP group received significantly more intraoperative fluids than the PPV group (4,340 ± 1,010 vs. 3,540 ± 740 mL, p < 0.01). Incidence of hypotension was lower in the PPV group (4 [11.1%] vs. 0 [0%], p = 0.04). Brain relaxation scores, serum lactate levels, periorbital and conjunctival edema, and incidence of postoperative nausea and vomiting were comparable between the groups. Conclusion The requirement for intraoperative fluids was less in PPV-guided fluid management with better hemodynamic stability, adequate brain conditions, and no compromise of perfusion.

Application of spatial transcriptomics analysis using the Visium system for the mouse nasal cavity after intranasal vaccination.

Intranasal vaccines that elicit mucosal immunity are deemed effective against respiratory tract infections such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but their ability to induce humoral immunity characterized by immunoglobulin A (IgA) and IgG production is low. It has been reported that vaccination with a mixture of a viscous base carboxyvinyl polymer (CVP) and viral antigens induced robust systemic and mucosal immune responses. In this study, we analyzed the behavior of immunocompetent cells in the nasal cavity over time by spatial transcriptome profiling induced immediately after antigen vaccination using CVP. We established a method for performing spatial transcriptomics using the Visium system in the mouse nasal cavity and analyzed gene expression profiles within the nasal cavity after intranasal vaccination. Glycoprotein 2 (Gp2)-, SRY-box transcription factor 8 (Sox8)-, or Spi-B transcription factor (Spib)-expressing cells were increased in the nasal passage (NP) region at 3-6 hr after SARS-CoV-2 spike protein and CVP (S-CVP) vaccination. The results suggested that microfold (M) cells are activated within a short period of time (3-6 hr). Subsequent cluster analysis of cells in the nasal cavity showed an increase in Cluster 9 at 3-6 hr after intranasal vaccination with the S-CVP. We found that Il6 in Cluster 9 had the highest log2 fold values within the NP at 3-6 hr. A search for gene expression patterns similar to that of Il6 revealed that the log2 fold values of Edn2, Ccl20, and Hk2 also increased in the nasal cavity after 3-6 hr. The results showed that the early response of immune cells occurred immediately after intranasal vaccination. In this study, we identified changes in gene expression that contribute to the activation of M cells and immunocompetent cells after intranasal vaccination of mice with antigen-CVP using a time-series analysis of spatial transcriptomics data. The results facilitated the identification of the cell types that are activated during the initial induction of nasal mucosal immunity.

Functional characterization of stap2b in zebrafish vascular development.

The genetic control and signaling pathways of vascular development are not comprehensively understood. Transcription factors Islet2 (Isl2) and nr2f1b are critical for vascular growth in zebrafish, and further transcriptome analysis has revealed potential targets regulated by isl2/nr2f1b. In this study, we focused on the potential activation gene signal-transducing adaptor protein 2b (stap2b) and revealed a novel role of stap2b in vascular development. stap2b mRNA was expressed in developing vessels, suggesting stap2b plays a role in vascularization. Knocking down stap2b expression by morpholino injection or Crispr-Cas9-generated stap2b mutants caused vascular defects, suggesting a role played by stap2b in controlling the patterning of intersegmental vessels (ISVs) and the caudal vein plexus (CVP). The vessel abnormalities associated with stap2b deficiency were found to be due to dysregulated cell migration and proliferation. The decreased expression of vascular-specific markers in stap2b morphants was consistent with the vascular defects observed. In contrast, overexpression of stap2b enhanced the growth of ISVs and reversed the vessel defects in stap2b morphants. These data suggest that stap2b is necessary and sufficient to promote vascular development. Finally, we examined the interaction between stap2b and multiple signaling. We showed that stap2b regulated ISV growth through the JAK-STAT pathway. Moreover, we found that stap2b was regulated by Notch signaling to control ISV growth, and stap2b interacted with bone morphogenetic protein signaling to contribute to CVP formation. Altogether, we demonstrated that stap2b acts downstream of the isl2/nr2f1b pathway to play a pivotal role in vascular development via interaction with multiple signaling pathways.

A Case of Resection of Hepatocellular Carcinoma in a Patient With Fontan-Associated Liver Disease.

The Fontan procedure (FP) is an operation used in patients with congenital single ventricle disease. The long-term prognosis after surgery has improved due to technological advances. However, the hemodynamics after FP are complicated. There are some reports of Fontan-associated liver disease (FALD) after FP. We report a case of a young woman who developed hepatocellular carcinoma due to FALD.

Clinical value of CVP+VIVC in predicting fluid resuscitation in patients with septic shock.

Objective: To explore the clinical value of central venous pressure (CVP) + inferior vena cava respiratory variability (VIVC) in fluid resuscitation in spontaneously breathing patients with septic shock. Methods: In retrospective observational study, during October 2019 to December 2021, 145 patients with septic shock treated in our hospital were enrolled by the method of observational study. According to the change rate of cardiac output (ΔCO) ≥15% or ΔCO<15% after 30 minutes, they were assigned into volume-responsive and volume-unresponsive group depending early fluid resuscitation in sepsis. The clinical value of combination of CVP and VIVC in predicting fluid resuscitation in patients with septic shock was compared. Results: The CVP of the study group was higher at 12h and 24h after fluid resuscitation, and the VIVC level of the study group at 6h, 12h and 24h after fluid resuscitation was higher (P<0.05). Pearson correlation analysis indicated that CVP, and VIVC levels were noticeably correlated with fluid resuscitation in patients with septic shock (P<0.05). The area under curve (AUC) of receiver operating characteristic curve (ROC) of CVP for predicting fluid resuscitation in septic shock patients was 0.694 and the cut-off value was 0.932, the sensitivity was 46.9%, and the specificity was 87.5%. VIVC predicted fluid resuscitation in septic shock patients with an AUC of 0.776, which was a cut-off value of 0.688, a sensitivity of 50.0%, and a specificity of 90.0%. Combination of CVP and VIVC predicted fluid resuscitation in septic shock patients with an AUC of 0.948, which was a cut-off value of 1.420, a sensitivity of 90.6%, and a specificity of 87.5%. Conclusion: Combination of CVP and VIVC may have a good effect on the evaluation of volume responsiveness in patients with septic shock, which is better than single CVP and VIVC. Combination of CVP and VIVC can be adopted to predict fluid responsiveness volume responsiveness in septic shock patients, which is of great significance for guiding clinical fluid responsiveness therapy.

GTP-Binding Protein 1-Like (GTPBP1l) Regulates Vascular Patterning during Zebrafish Development.

Genetic regulation of vascular patterning is not fully understood. Here, we report a novel gene, gtpbp1l (GTP-binding protein 1-like), that regulates vascular development in zebrafish. Amino acid sequence comparison and a phylogenetic study showed that gtpbp1l is conserved in vertebrates. Gtpbp1l mRNA is expressed in the vasculature during embryogenesis. Knockdown of gtpbp1l by morpholino impairs the patterning of the intersegmental vessel (ISV) and caudal vein plexus (CVP), indicating the role of gtpbp1l in vasculature. Further apoptosis assays and transgenic fish tests suggested that vascular defects in gtpbp1l morphants are not due to cell death but are likely caused by the impairment of migration and proliferation. Moreover, the altered expression of vessel markers is consistent with the vascular defects in gtpbp1l morphants. Finally, we revealed that gtpbp1l is regulated by VEGF/notch and BMP signaling. Collectively, these findings showed that gtpbp1l plays a critical role in vascular patterning during zebrafish development.

Comparing the associations of central venous pressure and pulmonary artery pulsatility index with postoperative renal injury.

Objective: Cardiac surgery-associated acute kidney injury (CS-AKI) is associated with significant morbidity and mortality. We investigated the association of postoperative central venous pressure (CVP) and pulmonary artery pulsatility index (PAPi) with the development of CS-AKI. Methods: This was a single-center, retrospective cohort study of patients undergoing cardiac surgery. CVP and PAPi were acquired hourly postoperatively and averaged for up to 48 h. PAPi was calculated as [(Pulmonary Artery Systolic Pressure-Pulmonary Artery Diastolic Pressure) / CVP]. The primary aim was CS-AKI. Secondary aims were need for renal replacement therapy (RRT), hospital and 30-day mortality, total ventilator and intensive care unit hours, and hospital length of stay. Logistic regression was used to calculate odds of development of renal injury and need for RRT. Results: One thousand two hundred eighty-eight patients were included. The average postoperative CVP was 10.3 mmHg and average postoperative PAPi was 2.01. Patients who developed CS-AKI (n = 384) had lower PAPi (1.79 vs. 2.11, p < 0.01) and higher CVP (11.5 vs. 9.7 mmHg, p < 0.01) than those who did not. Lower PAPi and higher CVP were also associated with each secondary aim. A standardized unit decrease in PAPi was associated with increased odds of CS-AKI (OR 1.39, p < 0.01) while each unit increase in CVP was associated with both increased odds of CS-AKI (OR 1.56, p < 0.01) and postoperative RRT (OR 1.49, p = 0.02). Conclusions: Both lower PAPi and higher CVP values postoperatively were associated with the development of CS-AKI but only higher CVP was associated with postoperative RRT use. When differences in values are standardized, CVP may be more associated with development of CS-AKI when compared to PAPi.

Suction cup on a piston-based chest compression device improves coronary perfusion pressure and cerebral oxygenation during experimental cardiopulmonary resuscitation.

Introduction: The presented study aimed to investigate whether a mechanical chest compression piston device with a suction cup assisting chest recoil could impact the hemodynamic status when compared to a bare piston during cardiopulmonary resuscitation. Methods: 16 piglets were anesthetized and randomized into 2 groups. After 3 minutes of induced ventricular fibrillation, a LUCAS 3 device was used to perform chest compressions, in one group a suction cup was mounted on the device's piston, while in the other group, compressions were performed by the bare piston. The device was used in 30:2 mode and the animals were manually ventilated. Endpoints of the study were: end tidal carbon dioxide, coronary and cerebral perfusion pressures, and brain oxygenation (measured using near infrared spectroscopy). At the end of the protocol, the animals that got a return to spontaneous circulation were observed for 60 minutes, then euthanized. Results: No difference was found in end tidal carbon dioxide or tidal volumes. Coronary perfusion pressure and cerebral oxygenation were higher in the Suction cup group over the entire experiment time, while cerebral perfusion pressure was higher only in the last 5 minutes of CPR. A passive tidal volume (air going in and out the airways during compressions) was detected and found correlated to end tidal carbon dioxide. Conclusions: The use of a suction cup on a piston-based chest compression device did not increase end tidal carbon dioxide, but it was associated to a higher coronary perfusion pressure.

Induction of aggressive arterial and venous dilation therapy in addition to pulmonary dilation therapy (super-Fontan strategy) improves Fontan circulation both at rest and during treadmill exercise.

Objective: Fontan circulation maintains preload and cardiac output by reducing venous capacitance and increasing central venous pressure (CVP). The resultant congestive end-organ damage affects patient prognosis. Therefore, a better circulatory management strategy to ameliorate organ congestion is required in patients with Fontan circulation. We sought to verify whether aggressive arterial and venous dilation therapy in addition to pulmonary dilation (super-Fontan strategy) can improve Fontan circulation and reduce congestion. Methods: Patients after Fontan surgery who received the super-Fontan strategy in a single center were recruited. Participants were examined using medical records between 2010 and 2018. We retrospectively analyzed the changes in hemodynamics at rest and during treadmill exercise before and after the introduction of this therapy. Results: The therapy significantly increased venous capacitance (3.21 ± 1.27 mL/kg/mm Hg to 3.79 ± 1.30 mL/kg/mm Hg, P = .017) and decreased total pulmonary resistance, leading to significantly reduced CVP (11.7 ± 2.4 mm Hg to 9.7 ± 2.2 mm Hg, P < .001) and increased cardiac index (CI) (3.09 ± 1.01 L/min/m2 to 3.54 ± 1.19 L/min/m2, P = .047). Furthermore, this strategy significantly reduced the elevations in CVP (19.6 ± 5.3 mm Hg to 15.4 ± 2.7 mm Hg, P = .002) with preserved CI in response to exercise. CVP at rest and during exercise was significantly positively correlated with serum markers of hepatic congestion and fibrosis, respectively. Conclusions: The super-Fontan strategy is a therapy that turns the heart failure condition of Fontan circulation into a more physiological condition. However, whether the strategy improves long-term prognosis warrants further studies.

Ifi30 Is Required for Sprouting Angiogenesis During Caudal Vein Plexus Formation in Zebrafish.

Interferon-gamma-inducible protein 30 (IFI30) is a critical enzyme that mainly exists in immune cells and functions in reducing protein disulfide bonds in endocytosis-mediated protein degradation. Regardless of this, it is also found to be expressed in vascular system. However, the functions of IFI30 in vascular development remains unknown. Vascular network formation is a tightly controlled process coordinating a series of cell behaviors, including endothelial cell (EC) sprouting, proliferation, and anastomosis. In this work, we analyzed the function of zebrafish Ifi30, orthologous to the human IFI30, in vascular development during embryogenesis. The ifi30 gene was found to be highly expressed in the caudal vein plexus (CVP) region of zebrafish embryos. Morpholino-mediated Ifi30 knockdown in zebrafish resulted in incomplete CVP formation with reduced loop numbers, area, and width. Further analyses implied that Ifi30 deficiency impaired cell behaviors of both ECs and macrophages, including cell proliferation and migration. Here, we demonstrate a novel role of IFI30, which was originally identified as a lysosomal thiol reductase involved in immune responses, in CVP development during embryogenesis. Our results suggest that Ifi30 is required for sprouting angiogenesis during CVP formation, which may offer an insight into the function of human IFI30 in angiogenesis under physiological or pathological conditions.

Volume-controlled ventilation versus pressure-controlled ventilation during spine surgery in the prone position: A meta-analysis.

Background: Many studies have investigated a comparison of the potency and safety of PCV versus VCV modes in spinal surgery in prone position. However, controversy about the maximal benefits of which ventilation modes remains. The main purpose of this meta-analysis was to investigate which one is the optimal ventilation for surgery patients undergoing spine surgery in prone position between the two ventilation modes as PCV and VCV. Methods: We conducted a comprehensive search of PubMed, Embase, Web of Science, the Cochrane Library, and Google Scholar for potentially eligible articles. The continuous outcomes were analyzed using the mean difference and the associated 95% confidence interval. Meta-analysis was performed using Review Manager 5.4 software. Results: Our meta-analysis included 8 RCTs involving a total of 454 patients between 2012 and 2020. The results demonstrated that IOB, Ppeak and CVP for VCV are significantly superior to PCV in spinal surgery in prone position. And PCV had higher Cdyn and PaO2/FiO2 than VCV. But there was no significant difference between PCV and VCV in terms of POB, Hb, HCT, HR and MAP. Conclusions: The PCV mode displayed a more satisfying effect than VCV mode. Compared to VCV mode in same preset of tidal volume, the patients with PCV mode in prone position demonstrated less IOB, lower Ppeak and CVP, and higher PaO2/FiO2 in spinal surgery. However, there is no obvious difference between PCV and VCV in terms of hemodynamics variables (HR and MAP).

Impact of extracorporeal CPR with transcatheter heart pump support (ECPELLA) on improvement of short-term survival and neurological outcome in patients with refractory cardiac arrest - A single-site retrospective cohort study.

Aim: Extracorporeal cardiopulmonary resuscitation (E-CPR) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a novel lifesaving method for refractory cardiac arrest. Although VA-ECMO preserves end-organ perfusion, it may affect left ventricular (LV) recovery due to increased LV load. An emerging treatment modality, ECPELLA, which combines VA-ECMO and a transcatheter heart pump, Impella, can simultaneously provide circulatory support and LV unloading. In this single-site cohort study, we assessed impact of ECPELLA support on clinical outcomes of refractory cardiac arrest patients. Method: We retrospectively reviewed 165 consecutive cardiac arrest patients, who underwent E-CPR by VA-ECMO with or without intra-aortic balloon pump (IABP) or ECPELLA from January 2012 to September 2021. We assessed 30-day survival rate, neurological outcome, hemodynamic data, and safety profiles including hemolysis, acute kidney injury, blood transfusion and embolic cerebral infarction. Results: Among 165 E-CPR patients, 35 patients were supported by ECPELLA, and 130 patients were supported by conventional VA-ECMO with or without IABP. Following propensity score matching of 30 ECPELLA and 30 VA-ECMO patients, the 30-day survival (ECPELLA: 53%, VA-ECMO: 20%, p < 0.01) and favorable neurological outcome determined by the Cerebral Performance Category score 1 or 2 (ECPELLA: 33%, VA-ECMO: 7%, p < 0.01) were significantly higher with ECPELLA. Patients receiving ECPELLA also showed significantly higher total mechanical circulatory support flow and lower arterial pulse pressure for the first 3 days (p < 0.01) of treatment. There were no statistical differences in safety profiles between treatment groups. Conclusion: ECPELLA may be associated with improved 30-day survival and neurological outcome in patients with refractory cardiac arrest.

Central Venous Pressure Measurement Is Associated With Improved Outcomes in Patients With or at Risk for Acute Respiratory Distress Syndrome: An Analysis of the Medical Information Mart for Intensive Care IV Database.

Background: Central venous pressure (CVP) monitoring is widely used in the intensive care unit (ICU). However, the formal utility of CVP measurement to altering patient outcomes among ICU patients with or at risk for acute respiratory distress syndrome (ARDS) has never been investigated. Our study aimed to explore the association of CVP measurement with 28-day mortality specifically in that population. Methods: This study was based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients were divided into CVP and no CVP groups according to whether they had CVP measurement within 24 h of admission to the ICU. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the association between CVP measurement and 28-day mortality, and propensity score matching (PSM) and propensity score-based overlap weighting (OW) were employed to verify the stability of our results. Results: A total of 10,198 patients with or at risk for ARDS were included in our study, of which 4,647 patients (45.6%) belonged to the CVP group. Multivariate logistic regression showed that the early measurement of CVP was independently associated with lower 28-day mortality (OR: 0.49; 95% CI: 0.42-0.57; p < 0.001). This association remained robust after PSM and OW (both p < 0.001). Patients in the CVP group had shorter ICU stay, lower in-hospital mortality, more fluid on day 1 and higher clearance of blood lactate than those in the no CVP group. Conclusion: Early CVP measurement is associated with an improvement in 28-day mortality among a general population of critically ill patients with or at risk for ARDS.

Impact of central venous pressure on the mortality of patients with sepsis-related acute kidney injury: a propensity score-matched analysis based on the MIMIC IV database.

Background: Sepsis has long been a life-threatening organ dysfunction. Sepsis associated acute kidney injury (SA-AKI) is an important complication of sepsis, as an important hemodynamic index, the impact of central venous pressure (CVP) on sepsis patients needs to be explored. Thus this study aimed to investigate the relationship between CVP and the mortality of SA-AKI. Methods: Clinical data of adult patients with sepsis-related acute kidney injury, defined as met both the Sepsis 3.0 criteria and the Kidney Disease Improving Global Outcomes Clinical Practice Guideline (KDIGO) criteria, were obtained from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. The included cohort was divided into a high CVP and a low CVP group were determined based on the cuf-off value from receiver operating characteristic curve, with propensity score-matched analysis of the 28-day mortality for both groups and sensitivity analysis using inverse the probability-weighting model, multifactorial regression, and doubly robust estimation, patients acquired chronic coronary syndrome (CCS) and diabetes were also taken into consideration. Results: Of 1,377 patients with sepsis-related acute kidney injury, low CVP group (<13 mmHg) was 67.4% (n=928) and high CVP group (≥13 mmHg) was 32.6% (n=449). The two groups were matched 1:1 by propensity score to obtain a matched cohort (n=288). The mortality rates in the low versus high CVP group (19.4% vs. 34.7%) were statistically difference (odds ratio OR: 0.454; 95% confidence interval 0.263, 0.771). Moreover, the bistable analysis of logistic regression of the matched cohort (OR: 0.434; 95% CI: 0.244, 0.757), propensity score inverse probability weighting (IPW) (OR: 0.547; 95% CI: 0.454, 0.658), and multifactorial logistic regression (OR: 0.352; 95% CI: 0.127, 0.932) all yielded the same results. Conclusions: In patients with sepsis-related acute kidney injury, a lower CVP level (<13 mmHg) is an independent variable associated with decreased mortality. The threshold of CVP needs to be controlled in clinical work to improve the prognosis of patients with SA-AKI.

A Glimpse Into the Future of Transcatheter Interventional Heart Failure Therapies.

Chronic heart failure is one of the most debilitating chronic conditions affecting millions of people and adding a significant financial burden to health care systems worldwide. Despite the significant therapeutic advances achieved over the last decade, morbidity and mortality remain high. Multiple catheter-based interventional therapies targeting different physiological and anatomical targets are already under different stages of clinical investigation. The present paper provides a technical overview of the most relevant catheter-based interventional therapies under clinical investigation.

Diagnosis and Management of Cirrhotic Cardiomyopathy.

BACKGROUND: Cirrhotic cardiomyopathy refers to the structural and functional changes in the heart leading to either impaired systolic, diastolic, electrocardiographic, and neurohormonal changes associated with cirrhosis and portal hypertension. Cirrhotic cardiomyopathy is present in 50% of patients with cirrhosis and is clinically seen as impaired contractility, diastolic dysfunction, hyperdynamic circulation, and electromechanical desynchrony such as QT prolongation. In this review, we will discuss the cardiac physiology principles underlying cirrhotic cardiomyopathy, imaging techniques such as cardiac magnetic resonance imaging and scintigraphy, cardiac biomarkers, and newer echocardiographic techniques such as tissue Doppler imaging and speckle tracking, and emerging treatments to improve outcomes. METHODS: We reviewed available literature from MEDLINE for randomized controlled trials, cohort studies, cross-sectional studies, and real-world outcomes using the search terms "cirrhotic cardiomyopathy," "left ventricular diastolic dysfunction," "heart failure in cirrhosis," "liver transplantation," and "coronary artery disease". RESULTS: Cirrhotic cardiomyopathy is associated with increased risk of complications such as hepatorenal syndrome, refractory ascites, impaired response to stressors including sepsis, bleeding or transplantation, poor health-related quality of life and increased morbidity and mortality. The evaluation of cirrhotic cardiomyopathy should also guide the feasibility of procedures such as transjugular intrahepatic portosystemic shunt, dose titration protocol of betablockers, and liver transplantation. The use of targeted heart rate reduction is of interest to improve cardiac filling and improve the cardiac output using repurposed heart failure drugs such as ivabradine. Liver transplantation may also reverse the cirrhotic cardiomyopathy; however, careful cardiac evaluation is necessary to rule out coronary artery disease and improve cardiac outcomes in the perioperative period. CONCLUSION: More data are needed on the new diagnostic criteria, molecular and biochemical changes, and repurposed drugs in cirrhotic cardiomyopathy. The use of advanced imaging techniques should be incorporated in clinical practice.

Direct Interstitial Decongestion in an Animal Model of Acute-on-Chronic Ischemic Heart Failure.

Removal of excess fluid in acute decompensated heart failure (ADHF) targets the intravascular space, whereas most fluid resides in the interstitial space. The authors evaluated an approach to interstitial decongestion using a device to enhance lymph flow. The device was deployed in sheep with induced heart failure (HF) and acute volume overload to create a low-pressure zone at the thoracic duct outlet. Treatment decreased extravascular lung water (EVLW) volume (mL/kg) (-32% ± 9%, P = 0.029) compared to controls (+46% ± 9%, P = 0.003). Device-mediated thoracic duct decompression effectively reduced EVLW. Human studies may establish device-based interstitial decongestion as a new ADHF treatment.

Association Between the Central Venous Pressure and All-Cause Mortality in Critically Ill Patients with Acute Kidney Injury.

PURPOSE: Elevated central venous pressure (CVP) plays an important role in the occurrence of acute kidney injury (AKI) and it is also independently associated with the prognosis of critically ill patients. However, the effect of CVP on critically ill AKI patients remains unclear. In this study, we analyzed the relationship between CVP and all-cause mortality of critically ill patients with AKI. PATIENTS AND METHODS: The clinical data of patients in intensive care unit (ICU) were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database and retrospectively analyzed. The all-cause mortality for up to 90 days was the main observed outcome. We used the minimum CVP value obtained during the first 72 hours after ICU admission for our analysis and patients were grouped according to this parameter. Patients were also analyzed after being further divided according to stages 1, 2 and 3 of AKI. Multiple Cox regression and Kaplan-Meier analyses were used to explore the association between CVP measurements and death of ICU patients with AKI. RESULTS: A total of 1986 ICU patients with AKI were studied. A total of 527 (26.5%) patients died by day 90. The high CVP group (patients with ≥10 mmHg) had the lowest 90-day survival rate (P =0.001 by log rank test) when according to Kaplan-Meier analysis. By using Cox regression analysis, high CVP was found to be linked to an increase in mortality (CVP ≥10 mmHg versus ≤5 mmHg, HR, 1.336, 95% CI, 1.064 to 1.677, P trend=0.014). Furthermore, when using in a multivariate Cox regression analysis with CVP as a continuous variable, the higher CVP levels were still an independent risk factor for 90-day all-cause mortality (per 1 mmHg increase, HR, 1.031, 95% CI, 1.013-1.049, P=0.001). In subgroup analysis, a similar trend was observed in patients with AKI stages 2 and 3. CONCLUSION: The minimum CVP level during the first 72h after ICU admission was positively associated with mortality in critically ill patients with AKI and this more marked in cases with severe AKI.