Influence of Strict Lockdown on Vitamin D Deficiency in Pregnant Women: A Word of Caution.

The main source of vitamin D results from skin sunlight exposure. Vitamin D deficiency (VDD) is linked to several adverse events during pregnancy. While performing a cross-sectional study with 886 pregnant women in Elda (Spain) from September 2019 to July 2020 to determine the association of VDD with gestational diabetes mellitus in relation to body mass index, a strict lockdown (SL) due to the COVID-19 pandemic was declared from 15 March 2020 to 15 May 2020. To determine if VDD prevalence in the local population of pregnant women was influenced by SL, a retrospective cross-sectional study was conducted to estimate the prevalence odds ratio (POR) for the association of VDD and SL. A crude logistic regression model was calculated, and then further adjusted by the biweekly measured vitamin D-specific UVB dose in our geographical area. The POR during SL was 4.0 (95%CI = 2.7-5.7), with a VDD prevalence of 77.8% in the quarantine period. Our results revealed that VDD prevalence in pregnant women was influenced by SL. This valuable information could guide us in future if public officials order the population to stay indoors for any given reason.

Validation and quality measurements for EuroSCORE and EuroSCORE II in the Spanish cardiac surgical population: a prospective, multicentre study.

OBJECTIVES: Since its development in the late 1990s, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been the predictive model of choice for estimating mortality after cardiac surgery. As outcomes from cardiac surgery improved, the EuroSCORE showed a loss of calibration, and a revised version of the model was developed, EuroSCORE II. The objectives of this study were to examine the validity of both scores in the Spanish population, and to depict the performance of both models on a funnel plot. METHODS: A prospective multicentre study was performed, with requests to participate sent to all centres in Spain. Participating centres reported the EuroSCORE, EuroSCORE II and the actual mortality of each patient. Incomplete data were requested to get a zero incidence of lost data. Calibration of models was evaluated with the Hosmer-Lemeshow goodness-of-fit test, and discrimination with the areas under the receiver operating characteristic (ROC) curve. A funnel plot was constructed using mortality data from the 2010 European Registry, to represent risk-adjusted mortality. RESULTS: Twenty Spanish centres participated in the study; 4034 patients undergoing cardiac surgery between 1 October 2012 and 31 March 2013 were collected. Prevalence of risk factors was analysed. The observed mortality rate was 6.5%. The mean additive EuroSCORE was 6.5. The mean expected mortality rate was 9.8% for the logistic EuroSCORE, and 5.7% for EuroSCORE II. Areas under the ROC curves were EuroSCORE: 0.77 [95% confidence interval (CI): 0.75-0.80], EuroSCORE II: 0.79 (95% CI: 0.76-0.82). Results for the goodness-of-fit test were EuroSCORE: 33.02 (P < 0.001), EuroSCORE II: 38.98 (P < 0.001). Risk-adjusted mortality is far beyond the lower bound of the CI if EuroSCORE is used as the reference model, and is between the confidence limits, but near to the upper bound when EuroSCORE II is used. CONCLUSIONS: Spanish cardiac surgical patients have a high-risk profile. Areas under the ROC curve show good discrimination for both models. Predicted mortality using EuroSCORE II more closely matches actual mortality than that predicted by the original EuroSCORE. Both models show statistically significant differences from the actual mortality rate, with EuroSCORE overpredicting and EuroSCORE II underpredicting mortality. The funnel plot illustrates risk-adjusted mortality clearly out of boundaries when EuroSCORE is used, and near underprediction when the reference is EuroSCORE II.

Capillary supply to the sinus node in subjects with long-term atrial fibrillation.

BACKGROUND: Atrial ischemia, and sinus node ischemia in particular, may be involved in the pathogenesis of atrial fibrillation. In this study we compared the sinus node blood capillary content in normal hearts in sinus rhythm and in pathologic hearts with chronic atrial fibrillation and we analyzed the ultrastructural features of such capillaries. METHODS: Sinus node biopsy specimens were obtained from 16 patients in chronic atrial fibrillation undergoing open heart surgery. Control sinus node specimens of normal hearts were obtained at autopsy from 7 subjects. Specimens were processed for immunohistochemical, light microscopy and transmission electron microscopy analysis and compared grossly and with morphometric techniques. RESULTS: The proportion of sinus node tissue corresponding to capillaries, defined as blood vessel density (or BVD), was estimated as 1.06 +/- 1.47% for the atrial fibrillation group versus 2.12 +/- 2.0% for controls (p < 0001). Internal capillary diameter averaged 21.6 microm in the atrial fibrillation group and 24.2 microm in controls (p = 0.175), whereas external diameter averaged 32.2 microm in the atrial fibrillation group and 38.9 microm in controls (p = 0.052). Ultrastructural analysis demonstrated scarce and interrupted myoendocardial bridges and abnormal deposits of elastic fibers under the endothelial basal membrane at the level of precapillary sphincters and metaarterioles of atrial fibrillation specimens. CONCLUSIONS: There is a significant reduction in the amount of capillaries in the sinus node of hearts in chronic atrial fibrillation. Our findings would support a potential association between sinus node tissue ischemia and chronic atrial fibrillation.

Coronary bypass surgery in young adults. A long-term survey.

OBJECTIVES: There is little information in the literature on the long-term outcome of young patients undergoing coronary bypass grafting surgery. The aim of this study is to analyze the long-term clinical outcome of this technique when performed in young adults. METHODS: We included in this retrospective study all patients aged 40 years or younger undergoing coronary bypass surgery in our unit between January, 1989 and December, 2006. Relevant clinical data were retrieved from the patients' clinical records. Follow-up data were obtained by means of personal or telephone interviews with the patients themselves or with their relatives. RESULTS: There were 42 patients (3 females, 39 males), mean age 36.9 years (range 29-40 years). Nineteen of them suffered a previous myocardial infarction. Left ventricular function was impaired (ejection fraction lower than 50%) in six instances. Twenty-two patients underwent surgery in a state of unstable angina. The indication for surgery was 3-vessel disease in 17 patients, 2-vessel disease in 17 patients and single-vessel disease in seven instances, and in six cases the main steam of the left coronary artery was affected. A total of 102 grafts were constructed (mean 2.4 grafts per patient), 56 (54.9%) of them being arterial. There were no hospital deaths. Mean hospital stay was of 8.1 days. Four patients suffered relevant perioperative complications. One patient (2.3%) was lost for follow-up. Cumulative follow-up was 389.1 years, with a mean of 9.5 years per patient. There were five late deaths, all of them of cardiac origin, with an estimated actuarial probability of survival of 81.4%. Thirteen patients suffered 17 major cardiac non-lethal complications, with an estimated actuarial freedom from cardiac morbidity of 43.9%. Major peripheral vascular morbid events occurred in nine patients, the estimated actuarial probability of freedom from peripheral vascular complications being of 62.1%. Overall actuarial freedom from any cardiovascular lethal or morbid event was estimated at 27.7%. CONCLUSIONS: Peri-operative mortality and morbidity is low in young patients undergoing coronary bypass surgery. However, these patients present a high risk of suffering major adverse events of cardiovascular origin in the long-term.

Preoperative risk stratification in infective endocarditis. Does the EuroSCORE model work? Preliminary results.

OBJECTIVE: There is an important role for risk prediction in cardiac surgery. Prediction models are useful in decision making and quality assurance. Patients with infective endocarditis (IE) have a particularly high risk of mortality. The aim was to assess the performance of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in IE. METHODS: The additive and logistic EuroSCORE models were applied to all patients undergoing surgery for IE (Duke criteria) between January 1995 and April 2006 within our prospective institutional database. Observed and predicted mortalities were compared. Model calibration was assessed with the Hosmer-Lemeshow test. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. RESULTS: One hundred and eighty-one consecutive patients undergoing 191 operations were analyzed. Observed mortality was 28.8%. For the entire cohort the mean additive score was 10.4 (additive predicted mortality of 14.2%). The mean logistic predicted mortality was 27.1%. Discriminative power was good for the additive and the logistic models for the entire series. Area under ROC curve were 0.83 (additive) and 0.84 (logistic) for the entire cohort, 0.81 and 0.81 for the aortic position, 0.91 and 0.92 for the mitral position, 0.81 and 0.81 for the native valve, 0.82 and 0.83 for the prosthetic valves, and 0.81 and 0.51 for the gram-positive microorganisms, respectively. CONCLUSIONS: This initial sample may be small; however, additive and logistic EuroSCORE adequately stratify risk in IE. Logistic EuroSCORE has been calibrated in IE, a special group of very high-risk patients. Further studies with larger sample sizes are required to confirm these initial results.

One-step surgical approach of a thoracic aortic aneurysm in Wiskott-Aldrich syndrome.

Wiskott-Aldrich syndrome is a primary immunodeficiency characterized by infections, thrombocytopenia, and eczema. We present a 33-year-old man with this syndrome who underwent a one-stage ascending aorta, aortic arch and descending aortic aneurysm repair under moderate hypothermia and continuous visceral and cerebral perfusion. Histologic examination showed the presence of an aortitis with granulomatous inflammatory response and multinucleated cells.

Intra-aortic filtration is effective in collecting hazardous materials.

Neurological complications after cardiac operations are mostly due to particle embolization. This case illustrates the embolic potential of any material. A 77-year-old lady underwent re-operation for homograft aortic regurgitation and mitral valve replacement. Intra-aortic filtration was used. After cardiopulmonary bypass the filter was found to have captured a pledget from a suture used to secure the mitral replacement device.

Acute limb ischemia due to embolization of biological glue after repair of type A aortic dissection.

OBJECTIVE: We present two cases of type A aortic dissection repaired with the help of biological glue, that were followed by acute limb ischemia due to embolism of glue. METHODS AND RESULTS: A 30-year-old man was diagnosed with aortic dissection from left coronary sinus to right subclavian artery. Under deep hypothermic circulatory arrest (DHCA), distal aortic anastomotic site was reconstructed with injection of Bioglue between dissected layers, and a valve sparing inclusion technique was performed using a straight dacron graft. On postoperative day 14, he presented acute limb ischemia due to femoral artery glue embolism that required surgery. A 76-year-old woman with the diagnosis of type A dissection ending proximal to the celiac trunk was operated under cardiopulmonary bypass and DHCA. The ascending aorta was replaced with a straight dacron tube, with resuspension of aortic valve and reinforcement of proximal and distal anastomosis with Bioglue between the diseased layers. Absence of previously patent radial pulse was detected intraoperatively, solved with humeral thromboembolectomy. CONCLUSIONS: Management of the diseased aortic wall in acute dissections is a surgical challenge for the cardiac surgeon. Despite our group having a positive experience with biological glue in type A aortic dissection, this report reminds us that the use of bioadhesives to reinforce anastomotic sites may be an important tool but it is not free of problems.

Acute aortic and mitral valve regurgitation following blunt chest trauma.

Traumatic rupture of intracardiac structures is an uncommon phenomenon although there are a number of reports with regards to rupture of the tricuspid, mitral and aortic valves. We report the case of a 25-year-old patient who presented with acute aortic and mitral valve regurgitation of traumatic origin. Both lesions were seen separated by 2 weeks. Pathophysiology is reviewed. The combination of both aortic and mitral lesions following blunt chest trauma is almost exceptional.