Background Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or ...cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. Method From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. Results Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. Conclusions Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.
Currently, it is unknown whether defects in stem cell growth and differentiation contribute to myocardial aging and chronic heart failure (CHF), and whether a compartment of functional human cardiac ...stem cells (hCSCs) persists in the decompensated heart. To determine whether aging and CHF are critical determinants of the loss in growth reserve of the heart, the properties of hCSCs were evaluated in 18 control and 23 explanted hearts. Age and CHF showed a progressive decrease in functionally competent hCSCs. Chronological age was a major predictor of five biomarkers of hCSC senescence: telomeric shortening, attenuated telomerase activity, telomere dysfunction-induced foci, and p21Cip1 and p16INK4a expression. CHF had similar consequences for hCSCs, suggesting that defects in the balance between cardiomyocyte mass and the pool of nonsenescent hCSCs may condition the evolution of the decompensated myopathy. A correlation was found previously between telomere length in circulating bone marrow cells and cardiovascular diseases, but that analysis was restricted to average telomere length in a cell population, neglecting the fact that telomere attrition does not occur uniformly in all cells. The present study provides the first demonstration that dysfunctional telomeres in hCSCs are biomarkers of aging and heart failure. The biomarkers of cellular senescence identified here can be used to define the birth date of hCSCs and to sort young cells with potential therapeutic efficacy.
Metabolic Syndrome (MetS), a multifactorial condition that increases the risk of cardio-vascular events, is frequent in Heart-transplant (HTx) candidates and worsens with immunosuppressive therapy. ...The aim of the study was to analyze the impact of MetS on long-term outcome of HTx patients. Since 2007, 349 HTx patients were enrolled. MetS was diagnosed if patients met revised NCEP-ATP III criteria before HTx, at 1, 5 and 10 years of follow-up. MetS was present in 35% of patients pre-HTx and 47% at 1 year follow-up. Five-year survival in patients with both pre-HTx (65% vs. 78%,
< 0.01) and 1 year follow-up MetS (78% vs 89%,
< 0.01) was worst. At the univariate analysis, risk factors for mortality were pre-HTx MetS (HR 1.86,
< 0.01), hypertension (HR 2.46,
< 0.01), hypertriglyceridemia (HR 1.50, p=0.03), chronic renal failure (HR 2.95,
< 0.01), MetS and diabetes at 1 year follow-up (HR 2.00,
< 0.01; HR 2.02,
< 0.01, respectively). MetS at 1 year follow-up determined a higher risk to develop Coronary allograft vasculopathy at 5 and 10 year follow-up (25% vs 14% and 44% vs 25%,
< 0.01). MetS is an important risk factor for both mortality and morbidity post-HTx, suggesting the need for a strict monitoring of metabolic disorders with a careful nutritional follow-up in HTx patients.
Thrombocytopenia is a common condition that recognizes an infinite number of possible causes, especially in specific settings like the one covered in this case report: the postoperative period of ...cardiac surgery. We report a case of an old male with multiple comorbidities who underwent a coronary angioplasty procedure and aortic valve replacement. He showed severe thrombocytopenia in the postoperative days. Differential diagnosis required a big effort, also for the experts in the field. Our goal was to aggressively treat the patient with prednisolone, platelets, and intravenous immunoglobulins to maximize the prognosis. Our patient developed no complications and was discharged successfully.
Purpose
To test the hypothesis that simultaneous closure of at least 2 independent
vascular territories supplying the spinal cord and/or prolonged hypotension
may be associated with symptomatic ...spinal cord ischemia (SCI) after thoracic
endovascular aortic repair (TEVAR).
Methods
A pattern matching algorithm was used to develop a risk
model for symptomatic SCI using a prospective 63-patient single-center
cohort to test the positive predictive value (PPV) of prolonged
intraoperative hypotension and/or simultaneous closure of at least 2 of 4
the vascular territories supplying the spinal cord (left subclavian,
intercostal, lumbar, and hypogastric arteries). This risk model was then
applied to data extracted from the multicenter European Registry on
Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the
19 centers participating in EuREC reported 38 (1.7%) cases of
symptomatic spinal cord ischemia among the 2235 patients in the
database.
Results
In the single-center cohort, direct correlations were seen between the
occurrence of symptomatic SCI and both prolonged intraoperative hypotension
(PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous
closure of at least 2 independent spinal cord vascular territories (PPV
0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a
single vascular territory was not associated with an increased risk of
symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16,
p=0.56). The combination of prolonged hypotension and simultaneous
closure of at least 2 territories exhibited the strongest association (PPV
0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to
the entire EuREC cohort found an almost perfect agreement between the
predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to
0.90).
Conclusion
Extensive coverage of intercostal arteries alone by a thoracic stent-graft is
not associated with symptomatic SCI; however, simultaneous closure of at
least 2 vascular territories supplying the spinal cord is highly relevant,
especially in combination with prolonged intraoperative hypotension. As
such, these results further emphasize the need to preserve the left
subclavian artery during TEVAR.
Extracorporeal blood purification has been widely used in intensive care medicine, nephrology, toxicology, and other fields. During the last decade, with the emergence of new adsorptive blood ...purification devices, hemoadsorption has been increasingly applied during CPB in cardiac surgery, for patients at different inflammatory risks, or for postoperative complications. Clinical evidence so far has not provided definite answers concerning this adjunctive treatment. The current systematic review aimed to critically assess the role of perioperative hemoadsorption in cardiac surgery, by summarizing the current knowledge in this clinical setting.
A literature search of PubMed, Cochrane library, and the database provided by CytoSorbents was conducted on June 1st, 2023. The search terms were chosen by applying neutral search keywords to perform a non-biased systematic search, including language variations of terms "cardiac surgery" and "hemoadsorption". The screening and selection process followed scientific principles (PRISMA statement). Abstracts were considered for inclusion if they were written in English and published within the last ten years. Publications were eligible for assessment if reporting on original data from any type of study (excluding case reports) in which a hemoadsorption device was investigated during or after cardiac surgery. Results were summarized according to sub-fields and presented in a tabular view.
The search resulted in 29 publications with a total of 1,057 patients who were treated with hemoadsorption and 988 control patients. Articles were grouped and descriptively analyzed due to the remarkable variability in study designs, however, all reported exclusively on CytoSorb
therapy. A total of 62% (18/29) of the included articles reported on safety and no unanticipated adverse events have been observed. The most frequently reported clinical outcome associated with hemoadsorption was reduced vasopressor demand resulting in better hemodynamic stability.
The role of hemoadsorption in cardiac surgery seems to be justified in selected high-risk cases in infective endocarditis, aortic surgery, heart transplantation, and emergency surgery in patients under antithrombotic therapy, as well as in those who develop a dysregulated inflammatory response, vasoplegia, or septic shock postoperatively. Future large randomized controlled trials are needed to better define proper patient selection, dosing, and timing of the therapy.
Cardiac stem cells (CSC) from explanted decompensated hearts (E‐CSC) are, with respect to those obtained from healthy donors (D‐CSC), senescent and functionally impaired. We aimed to identify ...alterations in signaling pathways that are associated with CSC senescence. Additionally, we investigated if pharmacological modulation of altered pathways can reduce CSC senescence in vitro and enhance their reparative ability in vivo. Measurement of secreted factors showed that E‐CSC release larger amounts of proinflammatory cytokine IL1β compared with D‐CSC. Using blocking antibodies, we verified that IL1β hampers the paracrine protective action of E‐CSC on cardiomyocyte viability. IL1β acts intracranially inducing IKKβ signaling, a mechanism that via nuclear factor‐κB upregulates the expression of IL1β itself. Moreover, E‐CSC show reduced levels of AMP protein kinase (AMPK) activating phosphorylation. This latter event, together with enhanced IKKβ signaling, increases TORC1 activity, thereby impairing the autophagic flux and inhibiting the phosphorylation of Akt and cAMP response element‐binding protein. The combined use of rapamycin and resveratrol enhanced AMPK, thereby restoring downstream signaling and reducing IL1β secretion. These molecular corrections reduced E‐CSC senescence, re‐establishing their protective activity on cardiomyocytes. Moreover ex vivo treatment with rapamycin and resveratrol improved E‐CSC capacity to induce cardiac repair upon injection in the mouse infarcted heart, leading to reduced cardiomyocyte senescence and apoptosis and increased abundance of endogenous c‐Kit+ CSC in the peri‐infarct area. Molecular rejuvenation of patient‐derived CSC by short pharmacologic conditioning boosts their in vivo reparative abilities. This approach might prove useful for refinement of CSC‐based therapies. Stem Cells 2014;32:2373–2385
The modified Bentall procedure is still the treatment of choice for patients requiring combined replacement of the ascending aorta and aortic valve. We compared the long-term outcome of patients ...>65 years of age undergoing Bentall procedure with biological vs mechanical valved conduits in a multi institutional study.
A total of 282 patients, undergoing a Bentall operation (January 1994–May 2015), with a biological (Group 1, 173 patients) or a mechanical (Group 2, 109 patients) conduit were reviewed, the primary outcome being analysis of late survival and freedom from major adverse events.
Hospital mortality was 5% (9 patients) and 2% (2 patients) for Group 1 and Group 2 (p = 0.2). Median follow-up was 77 months (range Q1–Q3: 49–111) for Group 1 vs 107 months (range Q1–Q3: 63–145) for Group 2 (p < 0.001). A not statistically significant advantage in late survival was found in patients receiving mechanical valved conduits (36% for Group 1 vs 58% for Group 2 at 12 years; p = 0.09), although freedom from major adverse events was similar between the 2 groups (33% in Group 1 vs 50% in Group 2 at 12 years; p = 0.3).
In conclusion, mechanical-valved conduits employed for the modified Bentall procedure show a trend towards an improved late survival in patients ≥65 years of age and particularly in those between 65 and 75 years, despite a higher incidence of major adverse events. Our results indicate the need for specific guidelines to better define the ideal age limit for each type of valved conduit.
•The type of valved conduit does not affect survival in patients ≥65 years.•Adverse events incidence not influenced by the conduit type in patients ≥65 years.•Choice of the valve conduit should be patient-tailored even in patients ≥65 years.
Objective It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at ...providing a contribution to this issue. Methods Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%. Results Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement ( P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% ( P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively ( P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively ( P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001). Conclusions Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates.
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