Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome.

Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.

Non-invasive assessment of liver abnormalities in pediatric Fontan patients.

Liver abnormalities are well known among long-term survivors of Fontan palliation, which remains the definite surgery for complex congenital heart disease and single ventricle physiology. Pediatric data however are scarce. We assessed the prevalence and degree of liver abnormalities in pediatric Fontan patients through non-invasive investigations suitable for longitudinal follow-up. Thirty-five patients with a median age of 11.8 years (5.2-16.6) and median time since Fontan of 6 years (1.17-13.83) were studied. Each child underwent a blood test, liver Doppler ultrasound (US), and transient elastography (TE). Healthy children were used as controls for TE measurement. AST, ALT, γGT, and direct bilirubin were abnormal in respectively 12 (34%), 5 (14%), 24 (69%), and 7 (20%) patients, while platelet count was decreased in 7 (20%). Splenomegaly was present in 7 (20%) patients. Portal vein mean flow velocity was < 15 cm/s in 19 (54%) patients indicative of portal hypertension. Twenty-two patients (63%) showed inferior vena cava collapsibility index values below 17%, indicating venous congestion. Hepatic artery and superior mesenteric artery resistance index were inversely correlated with time post Fontan (p < 0.05). TE values in Fontan patients were significantly higher than controls, with a median of 12.6 versus 4.6 kPa (p < 0.001) and were already increased shortly after Fontan completion. Conclusion: Liver abnormalities are frequently observed in pediatric Fontan patients. The non-invasive investigations used were not able to confirm liver fibrosis or differentiate hepatic congestion from fibrosis. Based on our findings, we propose a prospective screening protocol with serial measurements of laboratory, (Doppler) US, and TE parameters. What is Known: • Hepatic dysfunction is a well-known consequence of the Fontan circulation. • The natural history of Fontan-associated liver disease in the pediatric age group remains unclear. What is New: • Liver abnormalities are frequently observed in pediatric Fontan patients; however, differentiating liver fibrosis and hepatic congestion with non-invasive investigations remains challenging. Sonographic Doppler measurements may improve our insight in both Fontan-associated liver disease development and the functioning of the Fontan circulation. • A prospective screening protocol is proposed to improve our ability to detect Fontan-associated liver disease early on and understand its natural history.

Assessing Left Ventricular Early Diastolic Velocities With Tissue Doppler and Speckle Tracking by Transesophageal and Transthoracic Echocardiography.

BACKGROUND: Assessing diastolic dysfunction is essential and should be part of every routine echocardiography examination. However, clinicians routinely observe lower mitral annular velocities by transesophageal echocardiography (TEE) under anesthesia than described by awake transthoracic echocardiography (TTE). It would be important to know whether this difference persists under constant loading conditions. We hypothesized that mean early diastolic mitral annular velocity, measured by tissue Doppler imaging (TDI, JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic1/v/2021-04-15T211206Z/r/image-tiff) would be different in the midesophageal 4-chamber (ME 4Ch) than in the apical 4-chamber (AP 4Ch) view under unchanged or constant loading conditions. Secondarily we examined (1) JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic2/v/2021-04-15T211206Z/r/image-tiff in an alternative transesophageal view with presumed superior Doppler beam alignment, the deep transgastric view (DTG), compared to those in the AP 4Ch, and (2) early diastolic speckle tracking-based strain rate (JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic3/v/2021-04-15T211206Z/r/image-tiff), in the ME 4Ch and in the AP 4Ch. METHODS: Twenty-five consecutive adult patients undergoing on-pump cardiac surgery from February 2017 to July 2017 were included. Both TTE and TEE measurements were obtained under anesthesia in a randomized order in the AP 4Ch, ME 4Ch, and DTG views. Within-patient average values were compared by paired t tests with a Bonferroni adjustment. Box plots, correlation, and agreement by Bland-Altman were examined for all 3 comparisons. A second echocardiographer independently acquired and analyzed images; images were reanalyzed after 4 weeks. Image quality and reproducibility were also reported. RESULTS: Averaged JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic4/v/2021-04-15T211206Z/r/image-tiff measurements were lower in the ME 4Ch than in the AP 4Ch (6.6 ± 1.7 cm/s vs 7.0 ± 1.5 cm, P = .028; within-patient difference mean ± standard deviation: 0.6 ± 1.2 cm/s). An alternative TEE view for JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic5/v/2021-04-15T211206Z/r/image-tiff, the DTG, also exhibited lower mean values (6.0 ± 1.6 cm/s, P = .006; within-patient difference mean ± standard deviation: 1.1 ± 1.8 cm/s). JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic6/v/2021-04-15T211206Z/r/image-tiff strain rate showed a low degree of bias, but greater variability (ME 4Ch: 0.87 ± 0.32%/s vs AP 4Ch: 0.73 ± 0.18%/s, P = .078; within-patient difference mean ± standard deviation: -0.1 ± 0.2%/s). CONCLUSIONS: This study confirms that TEE modestly underestimates JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic7/v/2021-04-15T211206Z/r/image-tiff but not to a clinically relevant extent. While JOURNAL/asag/04.03/00000539-202105000-00029/inline-graphic8/v/2021-04-15T211206Z/r/image-tiff in the DTG is not a promising alternative, the future role for speckle tracking-based early diastolic strain rate is unknown.

Ethical and practical dilemmas in cardiac transplantation in infants: a literature review.

The waiting time in infants for a cardiac transplant remains high, due to the scarcity of donors. Consequently, waiting list morbidity and mortality are higher than those in other age groups. Therefore, the decision to list a small infant for cardiac transplantation is seen as an ethical dilemma by most physicians. This review aims to describe outcomes, limitations, and ethical considerations in infant heart transplantation. We used Medline and Embase as data sources. We searched for publications on infant (< 1 year) heart transplantation, bridge-to-transplant and long-term outcomes, and waiting list characteristics from January 2009 to March 2021. Outcome after cardiac transplant in infants is better than that in older children (1-year survival 88%), and complications are less frequent (25% CAV, 10% PTLD). The bridge-to-transplant period in infants is associated with increased mortality (32%) and decreased transplantation rate (43%). This is mainly due to MCS complications or the limited MCS options (with 51% mortality in infancy). Outcomes are worse for infants with CHD or in need of ECMO-support.Conclusion: Infants listed for cardiac transplantation have a high morbidity and mortality, especially in the period between diagnosis and transplantation. For those who receive cardiac transplant, the outlook is encouraging. Unfortunately, despite growing experience in VAD, mortality in children < 10 kg and children with CHD remains high. After transplantation, patients carry a psychological burden and there is a probability of re-transplantation later in life, with decreased outcomes compared to primary transplantation. These considerations are seen as an important ethical dilemma in many centers, when considering cardiac transplantation in infants (< 1 year). What is Known: • For infants, waitlist mortality remains high. In the pediatric population, MCS reduces the waiting list mortality. What is New: • Outcomes after infant cardiac transplantation are better than other age groups; however, MCS options remain limited, with persistently high waiting list mortality. • Future developments in MCS and alternative options to reduce waiting list mortality such as ABO-incompatible transplantation and pulmonary artery banding are encouraging and will improve ethical decision-making when an infant is in need of a cardiac transplant.

ACARPA, a rare case of ALCAPA.

An anomalous circumflex coronary artery arising from the right pulmonary artery is very rare. Clinical presentation varies from absence of symptoms to arrhythmia and sudden cardiac death. Since prevalence is very low, no definite therapy has been delineated yet. A 19-year-old patient, previously treated for a vascular ring and mitral valve stenosis, was diagnosed with this anomaly through echocardiography revealing collateral coronary flow, with confirmation of this coronary anomaly on subsequent computed tomography examination. To alleviate the burden for arrhythmia in this young patient, he was successfully treated with surgical reimplantation followed by an uneventful recovery.

Determinants of Physical Fitness in Children with Repaired Congenital Heart Disease.

The aim of this study was to determine factors associated with physical fitness (PF) in children who underwent surgery for congenital heart disease (CHD). Sixty-six children (7-14 years) who underwent surgery for ventricular septal defect (n = 19), transposition of great arteries (n = 22), coarctation of aorta (n = 10), and tetralogy of Fallot (n = 15) were included. All children performed PF tests: cardiorespiratory fitness, upper- and lower-limb muscle strength, speed, balance, and flexibility. Cardiac evaluation was done via echocardiography and cardiopulmonary exercise test. Factors related to child's characteristics, child's lifestyle, physical activity motivators/barriers, and parental factors were assessed. Linear regression analyses were conducted. The results showed no significant differences in physical activity (PA) level by CHD type. Boys had better cardiorespiratory fitness (difference = 1.86 ml/kg/min [0.51;3.22]) and were more physically active (difference = 19.40 min/day [8.14;30.66]), while girls had better flexibility (difference = - 3.60 cm [- 7.07;- 0.14]). Physical activity motivators showed an association with four out of six PF components: cardiorespiratory fitness, coefficient = 0.063 [0.01;0.11]; upper-limb muscle strength, coefficient = 0.076 [0.01;0.14]; lower-limb muscle strength, coefficient = 0.598 [0.07;1.13]; and speed, coefficient = 0.03 [0.01;0.05]. Age, sex, and motivators together reached a maximum adjusted R2 = 0.707 for upper-limb strength. Adding other possible determinants did not significantly increase the explained variance. Apart from age and sex as non-modifiable determinants, the main target which might improve fitness would be the introduction of an intervention which increases the motivation to be active.

QRS Duration During Follow-Up of Tetralogy of Fallot: How Valuable is it? Analysis of ECG Changes in Relation to Pulmonary Valve Implantation.

Long-term results after tetralogy of Fallot (TOF) repair are determined by the extent of right ventricular remodeling to chronic pulmonary regurgitation entailing progressive RV dysfunction and a risk of developing ventricular arrhythmia. Pulmonary valve replacement (PVR) can alleviate this burden. As a predictor of ventricular arrhythmia, QRS duration remains a strong parameter in this decision. We performed a retrospective analysis of all PVR patients between 2005 and 2018, studying the time evolution of electrocardiographic parameters before and after PVR through linear mixed model analysis. 42 TOF patients underwent PVR. The median timespan between primary repair and PVR was 18 years (IQR 13-30). The indication for PVR was primarily based on the association of exercise intolerance (67%) and significant RV dilation on cMRI (median RVEDVi 161 ml/m2 IQR 133-181). Median QRS length was 155 ms (IQR 138-164), 4 (10%) patients had a QRS > 180 ms. QRS duration increased significantly before PVR, but barely showed regression after PVR. Changes of QRS duration after PVR were independent of RV dilation. In conclusion, when the decision for PVR in TOF patients is primarily based on RV volume and/or function threshold, QRS duration > 180 ms is rarely observed. In contrast with the significant increase of QRS duration before PVR, QRS length regression appears to be independent of the extent of RV dilation or QRS > 160 ms. Considering that the decision for PVR is based on mechanical RV characteristics, the utility of serial follow-up of QRS duration in contemporary operated TOF patients becomes questionable in absence of clinical arguments for ventricular arrhythmia.

Perimembranous ventricular septal defect following His bundle lead implantation.

His bundle pacing (HBP) offers physiologic pacing by placing the pacing lead directly to the His bundle. We present a case in which a HBP lead, implanted at the fragile membranous septum, resulted in a persistent restrictive perimembranous ventricular septal defect (VSD). This complication of HBP has not been reported before but brings new insights in the discussion regarding the optimal position of a pacing lead in the ventricular septum. The fragility of the membranous septum and low rate of spontaneous closure of membranous VSD, might favor lead placement in the muscular septum when aiming for physiologic pacing.

Rapid, Single-View Speckle-Tracking-Based Method for Examining Left Ventricular Systolic and Diastolic Function in Point of Care Ultrasound.

OBJECTIVES: A rapid, reliable quantitative assessment of left ventricular systolic and diastolic function is important for patient treatment in urgent and dynamic settings. Quantification of annular velocities based on a single 2-dimensional image loop, rather than on Doppler velocities, could be useful in point-of-care or focused cardiac ultrasound. We hypothesized that novel speckle-tracking-based mitral annular velocities would correlate with reference standard tissue Doppler imaging (TDI) velocities in a focused cardiac ultrasound-esque setting. METHODS: Two echocardiographers each performed transthoracic echocardiographic measurements before and after induction of anesthesia in supine patients undergoing cardiac surgery. Speckle-tracking echocardiography (STE)-based systolic (S'STE ) and diastolic (E'STE and A'STE ) velocities were compared to TDI and global longitudinal strain/strain rate. We also compared mitral annular displacement by speckle tracking with M-mode imaging. RESULTS: Twenty-five patients were included and examined in both preinduction and postinduction states. Speckle-tracking-based velocities correlated with TDI measurements in both states (S', r = 0.73 and 0.76; E', r = 0.87 and 0.65; and A', r = 0.65 and 0.73), showing a mean bias of 25% to 30% of the reference standard measurement. The correlation of S'STE with strain and the strain rate (S-wave) and E'STE with the strain rate (E-wave) was good in awake, spontaneously breathing patients but was less strong in the ventilated state. Similarly, displacement by speckle tracking correlated with M-mode measurements in both states (r = 0.91 and 0.84). Measurements required medians of 31 and 34 seconds; reproducibility was acceptable for S'STE and E'STE . CONCLUSIONS: Speckle-tracking-based mitral annular velocities and displacement correlate well with conventional measures as well as with deformation imaging. They may be clinically useful in rapidly assessing both systolic and diastolic function from a single 2-dimensional image loop.

Congenital left ventricular diverticulum: A rare cause of cardiac arrhythmia.

Congenital left ventricular diverticula are rare cardiac malformations that usually remain asymptomatic. However, life-threatening complications as ventricular arrhythmias, systemic embolism, spontaneous rupture and development of valvular regurgitation, are described. Diagnosis is based on excluding coronary artery disease, traumatic or inflammatory causes, and other underlying cardiomyopathies. Treatment is directed towards the potential complications, yielding mainly therapy of ventricular arrhythmia. Surgical resection is required for larger-sized congenital aneurysms with adverse hemodynamic effects. We present two cases of a left ventricular diverticulum causing cardiac arrhythmia which led to further surgical treatment.

Analysis of clinical outcome and postoperative organ function effects in a propensity-matched comparison between conventional and minimally invasive mitral valve surgery.

BACKGROUND: Minimally invasive mitral valve (MV) surgery (MIVT) is increasingly performed with excellent clinical outcome, despite longer procedural times. This study analyzes clinical outcomes and effects on secondary organ functions in a propensity-matched comparison with conventional MV surgery. METHODS AND RESULTS: Out of 439 patients undergoing MV surgery from January 2005 to May 2017, 233 patients were included after propensity-matching: 90 sternotomy patients and 143 MIVT patients. Endpoints focused on survival, quality of MV repair, and organ function effects through analysis of biomarkers and functional parameters. Regardless of longer cardiopulmonary bypass (sternotomy: 101(IQR33) min-MIVT:143(IQR45) min, p < .001) and cardioplegic arrest times(sternotomy: 64(IQR25) min-MIVT:90(IQR34) min, p < .001), no differences in survival nor complication rate were found. Effect on renal function(creatinine, p = .751 - ureum, p = .538 - glomerular filtration, p = .848), myocardial damage by troponine I level (sternotomy:1.8 ± 3.9 ng/ml - MIVT:1.2 ± 1.3 ng/ml, p = .438) and prolonged ventilatory support >24 h (sternotomy:5.5% - MIVT:8.4%, p = .417) were comparable. The systemic inflammatory reaction by postoperative C-reactive protein count was markedly lower for MIVT(p < .001). Increased rhadomyolysis was found after MIVT surgery, based on a significant elevation of creatinine-kinase levels(sternotomy: 431 ± 237 U/L - MIVT: 701 ± 595 U/L, p < .001). CONCLUSION: Despite an inherent learning curve, minimally invasive MV surgery guarantees a clinical outcome and MV repair quality, at least non-inferior to those of MV surgery via sternotomy. Notwithstanding longer cardiopulmonary bypass and cardiac arrest times, the impact on secondary organ function is negligible, except for a lower systemic inflammatory response. The postoperative increase of CK-enzymes suggestive for enhanced rhabdomyolysis needs to be accounted for when procedural times tend to exceed the critical time threshold for severe limb ischemia.

Proximal pressure reducing effect of wave reflection in the pulmonary circulation disappear in obstructive disease: insight from a rabbit model.

Locating the site of increased resistance within the vascular tree in pulmonary arterial hypertension could assist in both patient diagnosis and tailoring treatment. Wave intensity analysis (WIA) is a wave analysis method that may be capable of localizing the major site of reflection within a vascular system. We investigated the contribution of WIA to the analysis of the pulmonary circulation in a rabbit model with animals subjected to variable occlusive pulmonary disease. Animals were embolized with different sized microspheres for 6 wk ( n = 10) or underwent pulmonary artery (PA) ligation for 6 wk ( n = 3). These animals were compared with a control group ( n = 6) and acutely embolized animals ( n = 4). WIA was performed and compared with impedance-based methods to analyze wave reflections. The control group showed a relatively high extent of reflected waves (15.7 ± 10.6%); reflections had a net effect of pressure reduction during systole, suggesting an open-end reflector. The pattern of wave reflection was not different in the group with partial PA ligation (12.4 ± 4.1%). In the chronically embolized group, wave reflection was not observed (3.6 ± 1.5%). In the acute embolization group, wave reflection was more prominent (37.3 ± 12.6%), with the appearance of a novel wave increasing pressure, suggesting the appearance of a closed-end reflector. Wave reflections of an open-end type are present in the normal rabbit pulmonary circulation. However, the pattern and nature of reflections vary according to the extent of pulmonary vascular occlusion. NEW & NOTEWORTHY The study proposes an original framework of a complementary analysis of wave reflections in the time domain and in the frequency domain. The methodology was used in the pulmonary circulation with different forms of chronic obstructions. The results suggest that the pulmonary vascular tree generates a reflection pattern that could actually assist the heart during ejection, and chronic obstruction significantly modifies the pattern.

Quality evaluation of the emergency program of three contemporary cell-washing machines.

This study evaluates the efficiency of emergency programs used by three contemporary cell washers. Both time necessary to process a given amount of blood and quality of the processed blood are investigated. The Fresenius Kabi Smart, Haemonetics Elite and LivaNova Xtra were validated using bovine blood, with a starting hematocrit of 13% or 21%. For all devices, the pre-programmed emergency program was used. The total volume processed in the 13% hematocrit group was 358 ± 68 mL for Fresenius, 375 ± 308 mL for Haemonetics and 497 ± 87 mL for LivaNova. In the 21% hematocrit group, the volumes were 533 ± 60 mL, 713 ± 142 mL and 798 ± 96 mL, respectively, showing a statistical difference between the Fresenius and LivaNova (p = 0.02). In the 13% hematocrit group, the Fresenius processed 45 ± 15 mL blood/min, the Haemonetics 62 ± 8 mL blood/min and the LivaNova 66 ± 1.5 mL blood/min. The difference between the Fresenius and LivaNova was statistically significant (p = 0.04). In the 21% hematocrit group, the processing speed was 69 ± 4 mL blood/min, 62 ± 8 mL blood/min and 77 ± 5 mL blood/min for the Fresenius, LivaNova and Haemonetics, respectively (p = 0.25). No major differences in the elimination of potassium, albumin and total protein or in hemolytic index were observed. No major differences were observed between discontinuous and continuous systems with respect to processing speed and wash quality with a starting hematocrit of 21%. Minor differences in processing speed were observed with a starting hematocrit of 13%.

Physical Fitness and Metabolic Syndrome in Children with Repaired Congenital Heart Disease Compared with Healthy Children.

OBJECTIVE: To determine whether children who underwent surgery for congenital heart disease (CHD) are as fit as their peers. STUDY DESIGN: We studied 66 children (6-14 years) who underwent surgery for ventricular septal defect (n = 19), coarctation of aorta (n = 10), tetralogy of Fallot (n = 15), and transposition of great arteries (n = 22); and 520 healthy children (6-12 years). All children performed physical fitness tests: cardiorespiratory fitness, muscular strength, balance, flexibility, and speed. Metabolic score was assessed through z-score standardization using 4 components: waist circumference, blood pressure, blood lipids, and insulin resistance. Assessment also included self-reported and accelerometer-measured physical activity. Linear regression analyses with group (CHD vs control) as a predictor were adjusted for age, body mass index, physical activity, and parental education. RESULTS: Measured physical activity level, body mass index, cardiorespiratory fitness, flexibility, and total metabolic score did not differ between children with CHD and controls, whereas reported physical activity was greater in the CHD group than control group. Boys with CHD were less strong in upper muscular strength, speed, and balance, whereas girls with CHD were better in lower muscular strength and worse in balance. High-density lipoprotein was greater in boys and girls with CHD, whereas boys with CHD showed unhealthier glucose homeostasis. CONCLUSION: Appropriate physical fitness was achieved in children after surgery for CHD, especially in girls. Consequently, children with CHD were not at increased total metabolic risk. Lifestyle counseling should be part of every patient interaction.

Early and late outcomes after surgical management of congenital vascular rings.

Persistent respiratory or feeding problems in children may be associated with a congenital vascular ring. Surgical management is fairly standardized, but long-term outcomes are not well described. This study aims to investigate clinical presentation, surgical treatment, and risk factors for early mortality and late outcome. Our database revealed 62 surgically treated vascular ring patients between 1993 and 2014. Double aortic arch was the most common diagnosis (53%). Median age at operation was 1 year. Symptoms were mainly respiratory (89%) and feeding problems (32%). Median extubation time and hospital stay were 4 h and 5 days. Mean follow-up was 7.8 ± 5.8 years. Early mortality was 8% and was related to anatomical diagnosis, concomitant anomalies, and a need for preoperative intubation. Freedom from residual symptoms at 1 and 6 months was 63 and 82%, respectively. Freedom from inhalation therapy at the last follow-up was 82% and was influenced by a type of vascular ring and preoperative ventilation. Dysphagia symptoms always disappeared. CONCLUSION: Surgical relief of tracheoesophageal compression is commonly effective in vascular ring anomalies. Respiratory symptoms necessitating chronic inhalation therapy only persist in a minority of children. Patients with double aortic arch are at increased risk to remain symptomatic, particularly with infectious exacerbations.

Outcome after prenatal and postnatal diagnosis of complex congenital heart defects and the influence of genetic anomalies.

OBJECTIVE: Determine prenatal detection rate, mortality and association with genetic abnormalities in patients with severe CHD. METHOD: Single center retrospective study in patients with severe CHD diagnosed prenatally or postnatally (2006 to 2014). RESULTS: A total of 567 patients were included, 176 (31%) after prenatal diagnosis, with large differences in prenatal detection rate among CHD types. Coarctation (24%), tetralogy of Fallot (21%) and univentricular heart (19%) were the most prevalent CHD. Overall mortality rate was 30% with important contributions of prenatal mortality including termination of pregnancy (40%) and postnatal compassionate care (15%). In the group requiring surgery, mortality rate was 12%. Genetic testing was available in 70%. A genetic cause was present in 140/394 patients tested (36%; 25% in the total group). Mortality was higher in the group with abnormal genetic testing compared with those with normal or no genetic testing (57/141 vs 112/423; p = 0,002). CONCLUSION: Only one third of severe CHD are detected; overall mortality remains high (30%) with major contributions of termination of pregnancy and compassionate care. A genetic cause was found in 36% and was associated with a decreased survival. Counseling must include the possibility of associated genetic pathology and its impact on survival. © 2017 John Wiley & Sons, Ltd.

An Alternative Strategy for Bridge-to-Transplant/Recovery in Small Children with Dilated Cardiomyopathy.

Dilated cardiomyopathy in children still has a poor prognosis with high rates of mortality and cardiac transplantation (resp. around 20 and 25%). Awaiting transplantation or possible recovery, these pediatric patients are mechanically supported with extracorporeal membrane oxygenation or a paracorporeal ventricular assist device, both resulting in higher survival rates but also entailing considerable risks of infection, thrombosis, or bleeding. A new indication for an old technique, i.e., pulmonary artery banding, presents itself as an interesting alternative to mechanical circulatory support in selected infants and small children with dilated LV cardiomyopathy and preserved RV function. Here we present a brief review of literature and report on two patients in whom PAB has been successfully implemented as either bridge-to-recovery or bridge-to-transplant.

Evaluation of different near-infrared spectroscopy technologies for assessment of tissue oxygen saturation during a vascular occlusion test.

An increasing number of NIRS devices are used to provide measurements of peripheral tissue oxygen saturation (StO2). The aim of the present study is to test the hypothesis that despite technological differences between devices, similar trend values will be obtained during a vascular occlusion test. The devices compared are NIRO-200NX, which measures StO2 and oxyhemoglobin by spatially resolved spectroscopy and the Beer-Lambert law, respectively, and INVOS 5100C and Foresight Elite, which both measure StO2 with the Beer-Lambert law, enhanced with the spatial resolution technique. Forty consenting adults scheduled for CABG surgery were recruited. The respective sensors of the three NIRS devices were applied over the brachioradial muscle. Before induction of anesthesia, 3 min of ischemia were induced by inflating a blood pressure cuff at the upper arm, whereafter cuff pressure was rapidly released. Tissue oxygenation measurements included baseline, minimum and maximum values, desaturation and resaturation slopes, and rise time. Comparisons between devices were performed with the Kruskal-Wallis test with post hoc Mann-Whitney pairwise comparisons. Agreement was evaluated using Bland-Altman plots. Oxyhemoglobin measured with NIRO responded faster than the other NIRS technologies to changes in peripheral tissue oxygenation (20 vs. 27-40 s, p ≤ 0.01). When comparing INVOS with Foresight, oxygenation changes were prompter (upslope 311 [92-523]%/min vs. 114[65-199]%/min, p ≤ 0.01) and more pronounced (minimum value 36 [21-48] vs. 45 [40-51]%, p ≤ 0.01) with INVOS. Significant differences in tissue oxygen saturation measurements were observed, both within the same device as between different devices using the same measurement technology.

The linear relationship between systolic pulmonary artery pressure and mean pulmonary artery pressure is maintained regardless of autonomic or rhythm disturbances.

BACKGROUND: In the pulmonary circulation, there is a linear relationship between systolic pulmonary arterial pressure (SPAP) and mean pulmonary arterial pressure (MPAP). The aim of this study was to determine the passive or active nature of this mechanism by exploring the relationship in patients with and without autonomic rhythm control of the heart and pulmonary circulation. METHODS: Pulmonary arterial pressure recordings from non-transplanted patients and patients with heart transplants or double lung transplants were retrospectively reviewed. The relationships between systolic, diastolic, and mean pulmonary arterial pressures were explored. RESULTS: A linear relationship was observed between the SPAP and MPAP, whether patients were paced (MPAP = 0.56 SPAP + 3.86 mmHg, r (2) = 0.889), treated with inotropes (MPAP = 0.55 SPAP + 5.52 mmHg, r (2) = 0.947) or pulmonary vasodilators (MPAP = 0.58 SPAP + 2.41 mmHg, r (2) = 0.927), were exercising (MPAP = 0.61 SPAP + 1.18 mmHg, r (2) = 0.967), had a heart transplant (MPAP = 0.66 SPAP +0.87 mmHg, r (2) = 0.849), a double lung transplant (MPAP = 0.7 SPAP +0.48 mmHg, r (2) = 0.915), or no intervention (MPAP = 0.59 SPAP +1.75 mmHg, r (2) = 0.937). CONCLUSION: We demonstrate that the linear relationship between SPAP and MPAP remains in several situations. Therefore, we conclude that the underlying mechanism is a passive consequence of the elastic properties of the cardiopulmonary unit.

Diagnostic accuracy of a novel method for detection of acute transmural myocardial ischemia based upon a self-applicable 3-lead configuration.

BACKGROUND: Delayed medical attendance is a leading cause of death in patients with ST elevation myocardial infarction (STEMI). METHODS: We aimed to introduce, develop, and validate a novel method (RELF method) for detection of transmural ischemia based on a new and easy-to-use 3-lead configuration and orthonormalization of ST reference vectors (STDVN). The study included 60 patients undergoing coronary artery occlusion (CAO) during balloon inflation and 30 healthy subjects. RESULTS: STDVN was significantly different and an optimal discriminator between CAO patients and healthy subjects (respectively 8.00±4.50 vs. 1.90±0.86 normalized units, p<0.001). Compared to the 12-lead ECG, the RELF method was sensitive (90 vs. 73%, p=0.13) and more specific (91 vs. 75%, p<0.001). CONCLUSIONS: The RELF method is highly accurate for early detection of acute occlusion related ischemia and it outperforms the conventional 12-lead ECG criteria for STEMI. This method provides a platform for self-detection of CAO with handheld devices or smart phones.