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Acute respiratory distress syndrome (ARDS) continues to be one of the most life-threatening conditions for patients in the intensive care unit (ICU). The 2023 European Society of Intensive Care Medicine guidelines on ARDS: definition, phenotyping and respiratory support strategies (2023 Guideline) update the 2017 An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with ARDS (2017 Guideline), including 7 aspects of 3 topics of definitions, phenotyping, and respiratory support strategies [including high flow nasal cannula oxygen (HFNO), non-invasive ventilation (NIV), neuromuscular blocking agents (NMBA), extracorporeal life support (ECLS), positive end-expiratory pressure (PEEP) with recruitment maneuvers (RM), tidal volume (VT), and prone positioning]. 2023 Guideline review and summarize the literature since the publication of the 2017 Guideline, covering ARDS and acute hypoxemic respiratory failure, as well as ARDS caused by novel coronavirus infection. Based on the most recent medical evidence, the 2023 Guideline provide clinicians with new ideas and approaches for nonpharmacologic respiratory support strategies for adults with ARDS. This article provides interpretation of the new concepts, the new approaches, the new recommended grading and new levels of evidence for ARDS in the 2023 Guideline.
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Adulto , Humanos , COVID-19 , Respiración Artificial , Respiración con Presión Positiva , Síndrome de Dificultad Respiratoria del Recién Nacido/terapia , Ventilación no InvasivaRESUMEN
Objective:To explore the surgical strategy of coronary artery bypass grafting(CABG) for moderate ischemic mitral regurgitation(IMR), and to clarify the impact of mitral valve surgical intervention(MVS) on the long-term prognosis of such patients.Methods:The clinical data of 234 consecutive patients with moderate IMR who received CABG from January 2013 to December 2018 were retrospectively included, with 184 males and 50 females. The age ranged from 29 to 78 years, with a mean of(61.5 ± 8.7) years old. According to whether MVS was performed at the same time, they were divided into CABG group(108 cases, CABG alone) and CABG+ MVS group(126 cases, CABG+ MVS at the same time). The long-term cardiac events, all-cause deaths, major cardiovascular and cerebrovascular adverse events(MACCE) and other end events were followed up. A matching queue was established by propensity matching score for statistical analysis.Results:After propensity matching score, a matching queue was established, including 78 pairs of patients. Survival analysis showed that the incidence of long-term cardiac events and postoperative new onset atrial fibrillation in CABG+ MVS group was significantly higher( P<0.05). However, there was no significant difference between the two groups in all-cause mortality, cardiogenic mortality, and the incidence of MACCE events( P>0.05). Cox regression analysis showed that simultaneous CABG+ MVS was a risk factor for long-term cardiac events and new postoperative atrial fibrillation. The results of subgroup studies showed that for patients without tricuspid regurgitation before operation, left ventricular end diastolic diameter>55 mm, and left ventricular ejection fraction(LVEF) ≤0.55, the probability of cardiac events after MVS at the same time of CABG was higher( P<0.05). However, patients with no tricuspid regurgitation before operation, left ventricular end diastolic diameter>55 mm, LVEF≤0.55, and left atrial diameter≥40 mm had a higher probability of atrial fibrillation after MVS at the same time of CABG( P<0.05). Conclusion:CABG can improve left ventricular remodeling in patients with moderate IMR, whether MVS intervention is performed at the same time or not, and the long-term survival rate of both is similar. CABG+ MVS in the same period can maintain a low residual reflux, but the incidence of long-term cardiac events and arrhythmias is high. The longer-term prognosis needs to be further studied. The surgical strategy of such patients should be selected individually according to the specific situation and the surgical quality in medical centers.
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@#The "2022 AHA/ACC/HFSA guideline for the management of heart failure" replaces the "2013 ACCF/AHA guideline for the management of heart failure" and the "2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure". The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose and manage patients with heart failure. Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to manage patients with heart failure, with the intent to improve quality of care and align with patients’ interests. New recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses. This article summarized and interpreted the new concept of heart failure in 2022 guidelines, especially the new evidence and suggestions related to cardiac surgery.
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Objective:To evaluate the early effects of combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic obstructive cardiomyopathy(HOCM).Methods:We consecutively enrolled 20 complex HOCM patients who received transaortic and transapical myectomy in fuwai hospital from January 2019 to October 2019. Echocardiography was performed to compare left atrial size, left ventricular end diastolic diameter, peak left ventricular outflow gradient, ventricular septal thickness, mitral systolic anterior motion and mitral regurgitation grade before and after operation. Furthermore, pre-operative and post-operative electrocardiogram were also analyzed to determine the incidence of bundle branch block. Functional status was evaluated by New York Heart Association functional class.Results:Of the 20 complex hypertrophic cardiomyopathy patients, 7(35%) HOCM patients with long-segment septal hypertrophy more than 7cm, 4(20%) patients had both mid-ventricular obstruction and left ventricular outflow obstruction. Apical hypertrophic cardiomyopathy with LOVT obstruction was observed in 5 patients(25%) and aneurysm was found in 4(20%) HOCM patients. Postoperative thickness of ventricular septum was significantly decreased compared with that of preoperation[(21.1±3.6)mm vs.(13.4±3.1)mm]. Peak LOVT gradient or mid-ventricular gradient also significantly reduced after operation[(77.0±21.0) mmHg vs.(9.2±3.4) mmHg] or [(71.0±23.0) mmHg vs. 0 mmHg, 1 mmHg=0.133 kPa]; After surgery, mitral systolic anterior motion disappeared, mitral regurgitation degree reduced from (1.9±1.5) to (0.2±0.4); NYHA class improved from(2.1±0.2) to(1.3±0.5). New incidence of left bundle branch block occurred in 9 patients, and 1 patient developed complete bundle branch block and implanted permanent pacemaker. The 30-day survival was 100%.Conclusion:Combined transaortic and transapical septal myectomy is an effective and reasonably safe procedure for patients with complex hypertrophic obstructive cardiomyopathy.
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@#Objective To explore the association between preoperative, perioperative parameters, especially estimated glomerular filtration rate (eGFR) and postoperative atrial fibrillation (POAF) after modified extended Morrow procedure. Methods A total of 300 hypertrophic obstructive cardiomyopathy (HOCM) patients who underwent modified extended Morrow procedure in our hospital from January 2012 to March 2018 were collected. There were 197 (65.67%) males and 103 (34.33%) females with an average age of 43.54±13.81 years. Heart rhythm was continuously monitored during hospitalization. The patients were divided into a POAF group (n=68) and a non-POAF group (n=232). The general data, perioperative parameters and echocardiographic results were collected by consulting medical records for statistical analysis. Univariate and multivariate logistic regression models were used to analyze the risk factors for POAF. Results Overall incidence of POAF during hospitalization was 22.67% (68/300). Compared with patients without POAF, patients with POAF were older, had higher incidence of chest pain and syncope, lower level of preoperative eGFR, higher body mass index and heart function classification (NYHA), larger preoperative left atrial diameter and left ventricular end diastolic diameter, and longer ventilator-assisted time, ICU stay and postoperative hospital stay. Age, heart function classification (NYHA)≥Ⅲ, hypertension, syncope history and eGFR were independent risk factors for POAF. Receiver operating characteristic curve analysis showed that the area under the curve of eGFR was 0.731 (95%CI 0.677-0.780, P<0.001), and the sensitivity and specificity were 82.4% and 57.8%, respectively. Conclusion Increased age, high preoperative heart function classification (NYHA), hypertension, preoperative syncope history and decreased eGFR are independent risk factors for POAF in HOCM patients who underwent surgical septal myectomy. Preoperative decreased eGFR can moderately predict the occurrence of POAF after modified extended Morrow procedure.
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@#Objective To evaluate the efficacy and safety of modified maze Ⅳ (Cox-maze Ⅳ) in hypertrophic obstructive cardiomyopathy (HOCM) patients. Methods From June 2016 to June 2019, 30 HOCM and persistent atrial fibrillation (pAF) patients received Cox-maze Ⅳ operation with modified extended Morrow operation, including 21 males and 9 females. The average age was 51.36±10.27 years and the average weight was 72.48±11.29 kg. All patients underwent left atrial appendectomy. Recurrence of AF, improvement of symptoms, cardiac function (NYHA) were assessed during follow-up. Results There was no death during the perioperative period. Postoperative left ventricular outflow tract gradient was significantly decreased compared with that before operation (P<0.01), and all systolic anterior motion (SAM) signs disappeared after operation. Thirty patients were all effectively followed up for 3-40 (16.24±8.26) months. During the follow-up period, there was no death, and the cardiac function (NYHA) of all patients recovered to gradeⅠ-Ⅱ. At the end of follow-up, twenty-four patients (80.00%) maintained sinus rhythm, and twenty-seven patients (90.00%) maintained sinus rhythm after amiodarone conversion. Univariate analysis showed that the smoking history (P=0.04), left atrial diameter≥55 mm before operation (P=0.03), left atrial diameter≥50 mm after operation (P=0.02), postoperative tricuspid regurgitation (P=0.02) were closely related to postoperative AF recurrence. The increase of left atrial diameter after operation was an independent risk factor for AF recurrence (P=0.02). Conclusion Morrow/Cox-maze Ⅳ procedure is safe and effective in treatment of patients with HOCM complicated with pAF, which helps to maintain postoperative sinus rhythm, and to improve the cardiac function. The increase of left atrial diameter after operation is an independent risk factor for AF recurrence.
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Objective To summarize 500 cases of surgical experience in restoration of adult congenital heart disease ( ACHD) treatment and early postoperative.Methods During January 2012 to December 2014 in Fuwai Hospital, 500 cases of ACHD treated by operation were chosen to collect the clinical data .We divided the groups according to whether the case was a complex malformation and whether the case had an ICU retention time is more than the 5 days.Results The average age was 35, the average weight was 59 kg.The operation average cardiopulmonary bypass(CPB) time was 102min.The average ICU treatment time was 2 days, the average duration of mechanical ventilation was 23 hours, 3 early deaths occurred.The complex malformation group had younger age and less weight than the simple malformation group , the complex malformation group had longer time of cardiopulmonary bypass time, aortic cross clamping time, mechanical ventilation time and ICU treatment time, had higher rate of complication and blood transfusion peri-operative period than the simple malformation group.(P<0.05) The group of ICU retention time less than 5 days had higher rate of the male proportion, had younger age and less weigh, had longer time of cardiopulmonary bypass time , mechanical ventilation time and ICU treatment time , had higher rate of complication and blood transfusion peri-operative period than the control group(P <0.01).Conclusion Although ACHD patients have long medical history and complicated pathological and physiological changes , when they get proper surgical operation and periopera-tive treatment, they should obtain satisfied effect.Professional medical team or organization service for the ACHD patient is very important and urgent to build.
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Objective: To summarize the major post-operative complication of modiifed extended Morrow procedure in patients with hypertrophic obstructive cardiomyopathy (HOCM) and to explore the major factors affecting its prognosis. Methods: We retrospectively analyzed 139 consecutive HOCM patients who received the procedure by same surgeon in our hospital from 2012-06 to 2014-07. There were 87 male and 52 female patients with the age of (10-67) years, body weightof (26-105) kg and pre-operative left ventricular outlfow tract peak gradient (LVOTPG) of (84.48 ± 44.75) mmHg. Concomitant operations were performed with known cardiac disease as necessary. Pre- and post-operative echocardiography, ECG and chest X-ray were examined to assess the adequacy of resection and mitral valve structure and function. Results: There was no peri-operative death. 73/139 (53%) patients received simple modiifed expanded Morrow procedure, the other 66 (47%) patients received concomitant surgery including 21 patients with coronary artery bypass grafting, 15 mitral valve plasty, 7 mitral valve replacement, 10 tricuspid valve plasty, 2 aortic valve replacement, 3 modiifed Maze procedure, 2 unblock of right ventricular outlfow tract, 2 sub aortic membrane resection, 1 ventricular aneurysm resection. The mechanical ventilation time was (24.05±36.74) hours, post-operative ICU and in-hospital stays were (2.85±3.18) days and (10.11±4.57) days; the complications included arrhythmia in 108 cases, pleural effusion in 25 cases, secondary intubation in 1 case, tracheotomy in 1 case, hemoifltration in 1 case, intra-aortic balloon pump in 1 case, back into ICU in 3 cases; no pneumothorax, secondary thoracotomy/operation. The post-operative left atrial diameter, LVOTPG, inter-ventricular septal thickness and LVEF were all decreased; mitral valve closed well or with mild regurgitation, systolic anterior motion (SAM) basically disappeared. The major factors for delayed ICU stay included age≥55 years, female, CPB time≥120 min, AOC time≥90 min, the patients combining with arrhythmia and right ventricular dysfunction. Late follow-up presented that the patients were almost without the symptoms, NYHA classiifcation at (I-II), no late death, complication or re-operation. Conclusion: Modified expand Morrow procedure has good surgical and short/late post-operative effects, concomitant operation does not increase the complication and mortality; correction of arrhythmia and improving right ventricular function at peri-operative period are important for treating the relevant patients.
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Objective The purpose of this sturdy was to conduct a meta-analysis of published randomised controlled trials(RCT) comparing the clinical outcomes of radiofrequency ablation(RFA) versus surgery alone(SA) in all patients with cardiac surgery.Methods PubMed, Embase, the Cochrane Controlled Trials Register databases, CNKI, CBM disc and VIP datebases were searched, and study eligibility and conducted data abstraction were determined independently and in duplicate.Literature searches from database establishment to November 2014.The heterogeneity and data were analyzed by the software of Rev Man 5.2.Results Of 564 studies identified, 8 studies met eligibility criteria, and included a total of 591 patients.In efficacy, The number of patients in sinus rhythm(SR) was signifcantly improved in RFA group compared to SA group at discharge(OR =10.59;95％ CI: 3.81-29.45).This effect on SR remained at all follow-up periods until ＞ 1 year.In safety, there was no significant difference in the incidence of hospital mortality(OR =1.17;95％ CI: 0.41-3.35) and mortality rate in follow up period(OR =0.77;95％ CI: 0.35-1.69) between RFA group and SA group.Similar results were shown in the incidence of permanent pacemaker(OR =0.65;95 ％ CI: 0.28-1.52;P =0.32) , thromboembolic events (OR =1.61;95 ％ CI: 0.54-4.84;P =0.40), postoperative re-intervention for bleeding (OR =0.45;95 ％ CI: 0.12-1.70;P =0.24).Conclusion The results of the current randomized trials demonstrates that concomitant surgical radiofrequency ablation and cardiac surgery is safe and effective at restoring sinus rhythm.
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Objective To summarize the clinical experience of one stage hybrid operation for aortic arch replacement and explore the indication. Methods From July,2009 to March,2010, 22 consecutive patients received one stage hybrid operation in our hybrid suite for aortic dissection or aortic aneurysm involving aortic arch. Two operative methods are used. (1)Bypass from ascending aorta to brachiocephalic arteries using midstemotomy and normothermia with antegrade aortic arch endovascular stented graft implantation. (2) Ascending aorta replacement and/or aortic valve replacement and/or coronary artery bypass grafting using midstemotomy and cardiopulmonary bypass with antegrade aortic arch endovascular stented graft implantation. Results All patients were technically successful. Angiography during the operation showed 100% patency of all the bypass grafts and no obvious translocation or endoleak of the stents. One patient in the first group died on sixth day after operation due to distal dissection rupture. There was one case of mediastinal lymph effusion in the second group and one case of death due to renal failure and respiratory failure 12 days after operation in the second group. The ICU stay and hospital stay were obviously shorter in hybrid open chest group than that in traditional open chest operation group(P ＜0.05). The blood product consumption and expenditure were also obviously less in hybrid open chest group than that in traditional open chest operation group (P ＜0.05). All the patients were followed up with a mean period of (14.45 ±2.33) months (range: 12 -20 months). All other patients were recovered with normal social life. CT showed neither endoleak nor translocation of the stented grafts. Faulse lumen closure rate at stented-graft segment is 100%. There was no obvious change of distal part of the dissection three months after operation except some thrombosis formation in some of the false lumen. Conclusion One stage hybrid operation for aortic arch replacement is safe and effective in shortening the duration of the operation and reducing the surgical trauma and risk of interval between procedures, shortening the hospital stay and reducing the blood product consumption compared with conventional operation with satisfactory early results. The midterm and long term results are still needed to be followed up.