Never Say Never: Successful Extracorporeal Cardiopulmonary Resuscitation (ECPR) Following A Prolonged Out-of-Hospital Cardiac Arrest Due to Spontaneous Coronary Artery Dissection.

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be a life-saving rescue therapy for patients with severe cardiac disease of any origin and circulatory failure. Data in the literature have demonstrated that the use of advanced mechanical circulation has resulted in improvements in both survival and quality of life; despite this, cardiogenic shock and refractory cardiac arrest remain conditions with high mortality. Opportune identification of patients who can benefit from it may improve outcomes. However, the shortage of guidelines on indications often results in a high mortality rate and poor outcome. Due to ethical issues, randomised controlled studies with VA-ECMO have not been conducted so no recommended evidence-based guidelines exist for VA-ECMO patient-selection criteria. Therefore, the indications depend only on expert opinion after reviewing the literature. Case description: We report the case of a young female patient who presented with an out-of-hospital cardiac arrest (OHCA) due to spontaneous coronary dissection. She was treated with extracorporeal cardiopulmonary resuscitation (ECPR) with excellent results in terms of short and long-term survival, and neurological outcome. This was despite the presence of several clinical and laboratory negative prognostic factors on the basis of the current literature, and the lack of general consensus among the relevant medical personnel. Conclusion: We were able to explain the favourable outcome only on the basis of clinical data. We can conclude that the availability of advanced resources in the area (timeliness of the rescues, quality of the resuscitation, an advanced haemodynamic management centre nearby) has contributed to determining the complete clinical and neurological recovery of the patient. LEARNING POINTS: Extracorporeal cardiopulmonary resuscitation to rescue patients with cardiac arrest refractory to conventional cardiopulmonary resuscitation could represent a life-saving technique in carefully selected patients.Refractory out-of-hospital cardiac arrest with evolution to a non-shockable rhythm and severe lactic acidosis are conditions that should not rule out ECPR.Evidence-based selection of ECPR patients remains challenging, but it could be considered as a therapeutic option in dedicated specialised centres.

Traumatic injuries after manual and automatic mechanical compression during cardiopulmonary resuscitation, a retrospective cohort study.

Introduction: Chest compressions during advanced cardiac life support is a life-saving, potential harmful procedure with high incidence of severe and life-threatening injuries. Previous studies suggest a possible correlation between the increased incidence of chest and/or abdominal trauma and the use of automatic mechanical compression devices. Methods: An observational monocentric retrospective cohort study was conducted including all patients admitted to our Intensive Care Unit suffering from out-of-hospital cardiac arrest (OHCA) in Canton Ticino (Switzerland) from 2012 to 2021. The primary endpoint was to describe any resuscitation-related body injury. The secondary endpoints were to explore possible predictors of cardiopulmonary resuscitation (CPR) related injuries and their association with the 30-day mortality. Results: We included 335 patients, 287 treated with manual chest compressions, 48 mechanically assisted. 55.5% of all resuscitated patients presented severe, or life-threatening lesions. Skeletal and thoracic injuries were the most frequent lesions followed by abdominal injuries. Mechanical assisted resuscitated patients presented higher risk of bleeding (OR 5.9; 95% CI 2.9-11.6) and increased CPR-related injuries (aOR 6.2; 95% CI 2.5-15.4) compared to standard manual chest compressions. In particular higher number of extra-thoracic and life-threatening lesions were described among the mechanical assisted CPR group. Patients with life-threatening had statistically significant higher mortality at 30-days compared to the severe and lesion's free cohort. Conclusion: Traumatic lesions occurred frequently after chest compression and their severity was associated with increased 30-day mortality. Mechanical devices, compared to manual chest compression, appear to be more harmful and may play a role in causing body lesions and hemorrhagic events.

Cost-effectiveness and diagnostic accuracy of focused cardiac ultrasound in the pre-participation screening of athletes: the SPORT-FoCUS study.

AIMS: The role of pre-participation screening (PPS) modalities in preventing sudden cardiac death (SCD) in athletes is debated due to a high false-positive rate. Focused cardiac ultrasound (FoCUS) has shown higher sensitivity and specificity, but its cost-effectiveness remains uncertain. This study aimed to determine the diagnostic performance and cost-effectiveness of FoCUS use in PPS. METHODS AND RESULTS: A total of 2111 athletes (77.4% male, mean age 24.9 ± 15.2years) underwent standardized family and medical history collection, physical examination, resting electrocardiography (ECG), FoCUS (10 min/5 views protocol), comprehensive echocardiography and exercise stress test. We prospectively evaluated three PPS incremental models: Model A, standardized medical history and physical examination Model B, Model A plus resting and stress ECG and Model C, Model B plus FoCUS (10 min/5 views protocol). We determined their incremental diagnostic accuracy and cost-effectiveness ratio. A total of 30 athletes were diagnosed with a cardiac condition associated with SCD: 3 were identified by Model A, 14 by Model B, and 13 athletes by Model C. The introduction of FoCUS markedly increased the sensitivity of PPS, compared with Model A and Model B (sensitivity 94% vs. 19% vs. 58% specificity 93% vs. 93% vs. 92%). The total screening costs were as follows: Model A 35.64 euros, Model B 87.68 euros, and Model C 120.89 euros. Considering the sole conditions at risk of SCD, the incremental cost-effectiveness ratio was 135.62 euros for Model B and 114.31 for Model C. CONCLUSIONS: The implementation of FoCUS into the PPS allows to identify a significantly greater number of athletes at risk of SCD and markedly lowers the false negative rate. Furthermore, the incorporation of FoCUS into the screening process has shown to be cost-effective.

A significant electrocardiography false-positive rate makes pre-participation screening (PPS) for sudden cardiac death (SCD) in athletes controversial. Focused cardiac ultrasound (FoCUS) may increase sensitivity and specificity however, its cost-effectiveness is unknown. This study evaluates the diagnostic performance and cost-effectiveness of FoCUS in PPS. Incorporating a simplified echocardiographic exam called FoCUS into PPS resulted in higher diagnostic reliability, with a lower rate of false negatives and a higher number of athletes at risk for SCD identified.The integration of FoCUS into the screening process resulted to be cost-effective in our athletes' cohort.

Longitudinal serum neurofilament light kinetics in post-anoxic encephalopathy.

Serum neurofilament light (sNfL) is a promising marker of outcome after cardiac arrest, but its kinetics are unclear. We prospectively measured sNfL concentrations in 62 patients at 0, 1, 3, 5, 7 and 10 days after cardiac arrest. Survivors and non-survivors had similar sNfL at admission (14.2 [8.6-21.9] vs. 22.5 [14.2-46.9] pg/mL) but largely different at 24 h (16.4 [10.2-293] vs. 464.3 [151.8-1658.2], respectively). The AUC for sNfL concentrations predicting death was above 0.95 from Day 1 to 10 (highest on Day 3). Late sNfL measurements may exert prognostic value, especially when early samples are unavailable or prognosis remains unclear.

Reporting quality of abstracts from randomised controlled trials published in leading critical care nursing journals: a methodological quality review.

OBJECTIVES: To evaluate the methodological quality of randomised controlled trial (RCT) abstracts in leading critical care nursing journals against the Consolidated Standards of Reporting Trials-Abstracts (CONSORT-A) checklist and to identify variables related with abstract reporting quality. DESIGN: Descriptive methodological quality review. DATA SOURCE: We searched the PubMed database and the websites of each included journal. ELIGIBILITY CRITERIA: We included RCT abstracts published between 2011 and 2021 in the first 11 Scopus-ranking (2021) critical care nursing journals that reported the results of RCTs in English that referred to the care of adult patients with acute/critical illness or their relatives and/or caregivers and conducted in ICUs. DATA EXTRACTION AND SYNTHESIS: Two independent investigators extracted the data using a prespecified 17-item checklist directly derived from CONSORT-A. For the primary outcome, each item was evaluated whether it was adequately reported or not and descriptive statistics were reported. An overall score was calculated by summing the results of all items and multivariate linear regression was conducted to detect potential predictors. RESULTS: Seventy-eight RCT abstracts were included in this review. The items with the highest CONSORT-A adherence were authors, objective, conclusion, participants, interventions and outcome. The randomisation item had the lowest CONSORT-A adherence, followed by trial registration, funding source, harms or side effects, recruitment, blinding and outcome results. The average CONSORT-A score was 8.5±1.5 points (of the maximum 17.5 points). Multivariate analysis indicated that the categorised word score and publication date were positively associated with the overall CONSORT-A score, while the first author's country being in Asia was negatively associated with the overall CONSORT-A score. CONCLUSIONS: The 78 RCT abstracts showed poor overall adherence to CONSORT-A. The results indicate that the methodological reporting quality of RCT abstracts in critical care nursing journals requires improvement to facilitate assessment of the applicability and relevance of the results reported.

Ten-Year Experience with Transapical and Direct Transaortic Transcatheter Aortic Valve Replacement to Address Patients with Aortic Stenosis and Peripheral Vascular Disease.

Objective: Transcatheter aortic valve replacement (TAVR) through alternative access routes is indicated in patients with severe aortic valve stenosis and diseased peripheral arteries. We analysed and compared the outcome of patients undergoing transapical (TA) and direct transaortic (TAO) TAVR procedures. Methods: Preoperative characteristics, procedural details, and thirty-day outcome of patients undergoing transapical (TA-TAVR group) and direct transaortic (TAO-TAVR group) TAVR procedures were prospectively collected and retrospectively analysed. Results: From March 2012 to March 2022, 81 TA and 82 TAO-TAVR (total: 163 cases) were performed with balloon-expanding (n = 120; 73.6%) and self-expandable (n = 43; 26.4%) valves. The mean age was 79.7 ± 6.2 and 81.9 ± 6.7 years for the TA- and TAO-TAVR groups, respectively (p = 0.032). Females were more represented in the TAO-TAVR group (56% vs. 32%; p = 0.003) while TA-TAVR patients showed a higher prevalence of previous vascular surgery (20% vs. 6%; p = 0.01), previous cardiac surgery (51% vs. 3.6%; p < 0.001), and porcelain aorta (22% vs. 5%; p = 0.001). The mean ejection fraction was 49.0 ± 14.6% (TA) and 53.5 ± 12.2% (TAO) (p = 0.035) while mean gradients were 35.6 ± 13.2 mmHg (TA) and 40.4 ± 16.1 mmHg (TAO) (p = 0.045). The median EuroSCORE-II was 5.0% (IQR: 3.0−11.0) and 3.9% (IQR: 2.5−5.4) for the TA- and TAO-TAVR groups, respectively (p = 0.005). The procedural time was shorter for TA procedures (97 min (IQR: 882−118) vs. 102 min (IQR: 88−129); p = 0.133). Mortality at day 30 was 6% in both groups (p = 1.000); the permanent pacemaker implantation rate was similar (8.6% vs. 9.7%; p = 1.000), and hospital stay was shorter for the TAO group (8 days (IQR: 6−11) vs. 10 days (IQR: 7−13); p = 0.025). Conclusions: Our results show that transapical and direct transaortic TAVR in high-risk patients with diseased peripheral arteries provide satisfactory clinical results with similar thirty-day outcomes.

Can a Glove-Coach Technology Significantly Increase the Efficacy of Cardiopulmonary Resuscitation on Non-healthcare Professionals? A Controlled Trial.

Introduction: Cardiovascular accidents are the world's leading cause of death. A good quality cardiopulmonary resuscitation (CPR) can reduce cardiac arrest-associated mortality. This study aims to test the coaching system of a wearable glove, providing instructions during out-of-hospital CPR. Materials and Methods: We performed a single-blind, controlled trial to test non-healthcare professionals during a simulated CPR performed on an electronic mannequin. The no-glove group was the control. The primary outcome was to compare the accuracy of depth and frequency of two simulated CPR sessions. Secondary outcomes were to compare the decay of CPR performance and the percentage of the duration of accurate CPR. Results: About 130 volunteers were allocated to 1:1 ratio in both groups; mean age was 36 ± 15 years (min-max 21-64) and 62 (48%) were men; 600 chest compressions were performed, and 571 chest compressions were analyzed. The mean frequency in the glove group was 117.67 vs. 103.02 rpm in the control group (p < 0.001). The appropriate rate cycle was 92.4% in the glove group vs. 71% in the control group, with a difference of 21.4% (p < 0.001). Mean compression depth in the glove group was 52.11 vs. 55.17 mm in the control group (p < 0.001). A mean reduction of compression depth over time of 5.3 mm/min was observed in the control group vs. 0.83 mm/min of reduction in the glove group. Conclusion: Visual and acoustic feedbacks provided through the utilization of the glove's coaching system were useful for non-healthcare professionals' CPR performance.

Comparison of two regional citrate anticoagulation modalities for continuous renal replacement therapy by a prospective analysis of safety, workload, effectiveness, and cost.

BACKGROUND: Currently, regional citrate anticoagulation (RCA) is the preferred approach for continuous renal replacement therapy (CRRT), and several RCA protocols are commercially available. This study was aimed at comparing two RCA modalities for CRRT in terms of safety, workload, effectiveness, and costs. METHODS: We prospectively evaluated two different RCA approaches in patients admitted to our intensive care unit (ICU) who needed CRRT. Patients with acute liver failure were excluded. We compared a hypertonic sodium-citrate solution 136 mmol/L added before the filter as anticoagulant during bicarbonate continuous hemodialysis (RCA-CVVHD) versus citrate-buffered replacement fluid 13.3 mmol/L infused by predilution setting in continuous venovenous hemofiltration (RCA-CVVH). Alkalosis, calcium homeostasis, nursing workload, filter lifespan, urea-creatinine metabolic control, and costs were recorded. RESULTS: Forty-five and 31 patients who underwent RCA-CVVH and RCA-CVVHD, respectively, were included. Alkalosis-free time distributions were significantly different in favor of a higher alkalosis incidence in the RCA-CVVHD group (log-rank test χ2(1)=8.18, P=0.004). Multivariable analysis showed that RCA-CVVHD was associated with a longer filter lifespan (HR=0.47; 95% CI: 0.28-0.78), higher total cost (1362 CHF [782-1901] vs. 976 CHF [671-1353], P<0.001), and higher number of anticoagulation adjustments (9 [IQR, 4-14] vs. 2 [IQR, 1-4]). The mean urea and creatinine reduction ratios at the first 24 hours were significantly higher in the RCA-CVVHD group. Calcium homeostasis and filter downtime were similar in the two groups. CONCLUSIONS: Pre-filter hypertonic sodium-citrate solution (136 mmol/L) results in longer filter patency and improves depuration effectiveness. However, compared to RCA-CVVHF, it causes metabolic alkalosis and increases nursing interventions and cost.

Early Repolarization in Pediatric Athletes: A Dynamic Electrocardiographic Pattern With Benign Prognosis.

Background Early repolarization pattern (ERP) is considered a common training-related and benign ECG finding in young adult athletes. Few data exist on ERP in the pediatric athletes population. Therefore, we aimed to evaluate the ERP prevalence, characteristics, and prognosis in pediatric athletes aged ≤16 years. Methods and Results Eight-hundred eighty-six consecutive pediatric athletes engaged in 17 different sports (mean age, 11.7±2.5 years; 7-16 years) were enrolled and prospectively evaluated with medical history, physical examination, resting and exercise ECGs, and transthoracic echocardiography during their preparticipation screening. Known cardiovascular diseases associated with sudden cardiac death was considered exclusion criteria. Athletes were followed up yearly for 4 years. The prevalence of ERP was 117 (13.2%), equally distributed in both sexes (P=0.072), irrespectively of body mass index and classification of sports. The most common ERP localizations were inferolateral and inferior leads (53.8% and 27.3%, respectively). Notching J-point morphology was the most prevalent (70%), and rapidly ascending ST elevation (96%) was the most common ST-segment morphology. Athletes with ERP were older (P<0.001) had lower rest and recovery heart rates (P<0.001), increased precordial and limb R-wave voltages (P<0.001), increased R/S Sokolow index (P<0.001), and longer PR interval (P=0.006) in comparison with the athletes without ERP. Neither major cardiovascular nor arrhythmic events, nor sudden cardiac death were recorded over a median follow-up of 4.2 years. One hundred seventeen (80.3%) athletes with ERP exhibited a persistent ERP. ERP localization and J-point morphology changed during follow-up in 11 (11.7%) and 17 (18%) of athletes, respectively. Conclusions ERP is common in pediatric athletes. It was mostly located in the inferolateral leads and associated with concave ascending ST segment with other training-related ECG changes. The lack of either sudden cardiac death or cardiomyopathies linked to sudden cardiac death over follow-up suggests that in pediatric athletes, ERP may be considered a benign training-related ECG phenomenon with a potential dynamic pattern.

Pediatric athletes' ECG and diagnostic performance of contemporary ECG interpretation criteria.

BACKGROUND: Electrocardiographic (ECG) pre-participation screening(PPS) can prevent sudden cardiac death(SCD) but the Interpretation of the athlete's ECG is based on specific criteria addressed for adult athletes while few data exist about the pediatric athlete's ECG. We aimed to assess the features of pediatric athletes' ECG and compared the diagnostic performance of 2017 International ECG recommendation, 2010 European Society of Cardiology recommendation and 2013-Seattle criteria in detecting clinical conditions at risk of SCD. METHODS: 886 consecutive pediatric athletes (mean age 11.7 ± 2.5 years; 7-16-years) were enrolled and prospectively evaluated with medical history, physical examination, resting and exercise ECG and transthoracic echocardiography during their PPS. RESULTS: The most common physiological ECG patterns in pediatric athletes were isolated left ventricular hypertrophy criteria (26.9%), juvenile T-wave pattern (22%) and early repolarization pattern (13.2%). The most frequent borderline abnormalities were left axis deviation (1.8%) and right axis deviation (0.9%) while T-wave inversion (0.8%) especially located in inferior leads (0.7%) was the most prevalent abnormal findings. Seven athletes (0.79%) were diagnosed with a condition related to SCD. Compared to Seattle and ESC, the International improved ECG specificity (International = 98% ESC = 64% Seattle = 95%) with lower sensitivity (ESC and Seattle 86%vs International 57%). The false-positive rate decreases from 36% of ESC to 2.2% of International but the latter showed a higher false-negative rate(0.34%). CONCLUSION: Pediatric athletes like the adult counterpart exhibit a high prevalence of ECG abnormalities mostly representing training-related ECG adaptation. The International criteria showed a lower false-positive rate but at the cost of loss of sensitivity.

Early cardiac unloading with ImpellaCP™ in acute myocardial infarction with ventricular septal defect.

Despite a relative contraindication, mechanical support with Impella™ left ventricular assist device has already been described for ischaemic ventricular septal defect treatment, either as a bridge to surgery, as intraoperative mechanical haemodynamic support, or to ensure intraprocedural haemodynamic stability during device closure. We describe two cases of ventricular septal defect complicating acute myocardial infarction, where the percutaneous ImpellaCP was implanted early (differently than previously described) with the aim of preventing haemodynamic instability, while deferring surgical repair. We present a report of haemodynamic, echocardiographic, biochemical, and clinical data of two consecutive cases of ImpellaCP use, within a minimally invasive monitoring and therapeutic approach. In two cases of subacute myocardial infarction-related ventricular septal defect not amenable to percutaneous device closure, the use ImpellaCP was successful: it was followed by effective and rapid right and left ventricular unloading, by major haemodynamic instability prevention and protection from systemic venous congestion, from kidney and splanchnic organ failures. This allowed bridging to appropriately timed surgical repair. These cases suggest a potentially effective, clinically grounded strategy in the early management of ischaemic ventricular septal defect patients, with the aim of deferring surgery beyond the safer 7 days cutoff associated with a lower perioperative mortality.

Serum neurofilament light chain as a prognostic marker in postanoxic encephalopathy.

Functional outcome in patients with postanoxic encephalopathy after cardiac arrest (CA) often remains unclear, and there is a strong need of new prognostication measures. We aimed at investigating serum neurofilament light (NfL) chain concentration in patients with a postanoxic encephalopathy after CA and its prognostic potential. Serum samples were prospectively collected at different time points after CA in consecutive patients admitted to the intensive care unit (ICU) of Ticino Cardiocentre (Lugano, Switzerland) between June 2017 and March 2018. Serum NfL concentration was measured using a single molecule array (SIMOA) assay. The association of NfL levels with time to return of spontaneous circulation (ROSC), serum neuronal specific enolase (NSE) concentration, time between CA and sample collection, electroencephalogram (EEG) pattern and clinical outcome (death status at one month) were explored. Fourteen patients experiencing 15 CAs were included in the study (median age = 58 (57-68) years, 8 males). Median serum NfL concentration was 1027.0 (25.5-6033.7) pg/ml. There were positive associations between serum NfL and time to ROSC (rho = 0.60, p < 0.0001), NSE concentration (rho = 0.76, p < 0.0001), and severity of brain damage as estimated by EEG, with the highest concentrations measured in patients with suppressed electrical activity (14,954.0 [9006.0-25,364.0] pg/ml). Neurofilament light concentration remained high in samples collected up to 17 days after CA. Median NfL levels were higher among dead than alive patients at one month (6401.7 [3768.5-15,573.3] vs 25.5 [25.2-75.4] pg/ml). High NfL levels performed better than NSE in predicting death status at one month (NfL area under the curve (AUC) = 0.98, 95% confidence interval (CI) = 0.94-1.00; NSE AUC = 0.80, 95% CI = 0.67-0.94). These results support the potential inclusion of serum NfL in the battery of prognostication measures to be used in patients with postanoxic encephalopathy in ICU settings. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

Blood Purification and Mortality in Sepsis and Septic Shock: A Systematic Review and Meta-analysis of Randomized Trials.

BACKGROUND: Sepsis and septic shock are severe inflammatory conditions related to high morbidity and mortality. We performed a systematic review with meta-analysis of randomized trials to assess whether extracorporeal blood purification reduces mortality in this setting. METHODS: Electronic databases were searched for pertinent studies up to January 2019. We included randomized controlled trials on the use of hemoperfusion, hemofiltration without a renal replacement purpose, and plasmapheresis as a blood purification technique in comparison to conventional therapy in adult patients with sepsis and septic shock. The primary outcome was mortality at the longest follow-up available. We calculated relative risks and 95% CIs. The grading of recommendations assessment, development and evaluation methodology for the certainty of evidence was used. RESULTS: Thirty-seven trials with 2,499 patients were included in the meta-analysis. Hemoperfusion was associated with lower mortality compared to conventional therapy (relative risk = 0.88 [95% CI, 0.78 to 0.98], P = 0.02, very low certainty evidence). Low risk of bias trials on polymyxin B immobilized filter hemoperfusion showed no mortality difference versus control (relative risk = 1.14 [95% CI, 0.96 to 1.36], P = 0.12, moderate certainty evidence), while recent trials found an increased mortality (relative risk = 1.22 [95% CI, 1.03 to 1.45], P = 0.02, low certainty evidence); trials performed in the United States and Europe had no significant difference in mortality (relative risk = 1.13 [95% CI, 0.96 to 1.34], P = 0.15), while trials performed in Asia had a positive treatment effect (relative risk = 0.57 [95% CI, 0.47 to 0.69], P < 0.001). Hemofiltration (relative risk = 0.79 [95% CI, 0.63 to 1.00], P = 0.05, very low certainty evidence) and plasmapheresis (relative risk = 0.63 [95% CI, 0.42 to 0.96], P = 0.03, very low certainty evidence) were associated with a lower mortality. CONCLUSIONS: Very low-quality randomized evidence demonstrates that the use of hemoperfusion, hemofiltration, or plasmapheresis may reduce mortality in sepsis or septic shock. Existing evidence of moderate quality and certainty does not provide any support for a difference in mortality using polymyxin B hemoperfusion. Further high-quality randomized trials are needed before systematic implementation of these therapies in clinical practice.

Development and Initial Evaluation of a Novel, Ultraportable, Virtual Reality Bronchoscopy Simulator: The Computer Airway Simulation System.

BACKGROUND: Virtual reality (VR) simulation is an effective and safe method of teaching bronchoscopic skills. Few VR bronchoscopy simulators exist; all are expensive. The present study aimed to describe the design, development, and evaluation of a new, affordable, VR bronchoscopy simulator. METHODS: Anesthesiologists and engineers collaborated to design and develop the Computer Airway Simulation System (CASS), an iPad-based, high-fidelity, VR bronchoscopy simulator. We describe hardware and software development, as well as the technical and teaching features of the CASS. Twenty-two senior anesthesiologists evaluated various aspects of the simulator (using a 5-point Likert scale) to assess its face validity. RESULTS: Anesthesiologists performed a simulated bronchoscopy (mouth to carina) with a median (range) procedural time of 66 seconds (30-96). The simulator's ease of use was rated 4.3 ± 0.8 and the bronchoscope proxy's handling 4.0 ± 0.7. Criticisms included that excessive system reactivity created handling difficulties. Anatomical accuracy, 3-dimensional bronchial segmentation, and mucosal texture were judged to be very realistic. The simulator's usefulness for teaching and its educational value were highly rated (4.9 ± 0.3 and 4.8 ± 0.4, respectively). CONCLUSIONS: We describe the design, development, and initial evaluation of the CASS-a new, ultraportable, affordable, VR bronchoscopy simulator. The simulator's face validity was supported by excellent assessments from senior anesthesiologists with regard to anatomical realism, quality of graphics, and handling performance, even though some future refinements are required. All the practitioners agreed on the significant educational potential of the CASS.

Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The effects of perioperative statin therapy on clinical outcome after cardiac or non-cardiac surgery are controversial. We aimed to assess the association between perioperative statin therapy and postoperative outcome. METHODS: Electronic databases were searched up to May 1, 2018, for randomized controlled trials of perioperative statin therapy versus placebo or no treatment in adult cardiac or non-cardiac surgery. Postoperative outcomes were: myocardial infarction, stroke, acute kidney injury (AKI), and mortality. We calculated risk ratio (RR) or odds ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses. We performed meta-regression and subgroup analyses to assess the possible influence of statin therapy regimen on clinical outcomes and trial sequential analysis to evaluate the risk of random errors and futility. RESULTS: We included data from 35 RCTs involving 8200 patients. Perioperative statin therapy was associated with lower incidence of postoperative myocardial infarction in non-cardiac surgery (OR = 0.44 [95% CI 0.30-0.64], p < 0.0001), but not in cardiac surgery (OR = 0.93 [95% CI 0.70-1.24], p = 0.61) (psubgroup = 0.002). Higher incidence of AKI was present in cardiac surgery patients receiving perioperative statins (RR = 1.15 [95% CI 1.00-1.31], p = 0.05), nonetheless not in non-cardiac surgery (RR = 1.52 [95% CI 0.71-3.26], p = 0.28) (psubgroup = 0.47). No difference in postoperative stroke and mortality was present in either cardiac or non-cardiac surgery. However, low risk of bias trials performed in cardiac surgery showed a higher mortality with statins versus placebo (OR = 3.71 [95% CI 1.03-13.34], p = 0.04). Subgroup and meta-regression analyses failed to find possible relationships between length of statin regimens and clinical outcomes. Trial sequential analysis suggested no firm conclusions on the topic. CONCLUSIONS: Perioperative statins appear to be protective against postoperative myocardial infarction in non-cardiac surgery and associated with higher AKI in cardiac surgery. Possible positive or even negative effects on mortality could not be excluded and merits further investigations. Currently, no randomized evidence supports the systematic administration of statins in surgical patients.

New-onset pericardial effusion during transvenous lead extraction: incidence, causative mechanisms, and associated factors.

PURPOSE: Pericardial effusion (PE) may occur during the lead extraction procedure (TLE). Little is known about the incidence, causes, and predictors of this complication. METHODS: From January 2009 to October 2016, TLE was attempted for 297 leads in 212 patients (age 69.3 ± 12.9 years, 169 male, BMI 27.2 ± 9.9 m²/kg, LVEF 43.4 ± 24.6%) for lead dysfunction (62.7%), upgrade (16.0%), infection (14.2%), or other (7.0%) indications. TLE was performed under general anesthesia with continuous invasive arterial blood pressure and transesophageal echocardiography (TEE) monitoring. For lead removal, the mechanical approach was first attempted, followed by the laser-assisted technique when needed. Severity of PE was defined by the presence of hemodynamically significant PE > 10 mm at TEE. RESULTS: Clinical success was achieved for 292 leads (98.3%). New-onset PE was observed in 14 patients (6.6%) [mild entity in 7 patients (3.3%) and severe in 7 (3.3%)]. In these latter patients, intra-procedural management included surgery (n = 3), pericardiocentesis (n = 2), or a conservative approach (n = 2). Right ventricular (RV) site lesions were treated with a simple fluid infusion. Laceration of the superior vena cava and other vessels resulted in rescue surgery. Lesions of the right atrial free wall (n = 1) and coronary sinus (n = 1) were treated with pericardiocentesis. NYHA III/IV, LVEF < 35%, renal impairment, right-sided implant, and ≥2 leads targeted for TLE were associated with new-onset PE. More than two factors identified a higher risk group (16.2%, 95% CI 6.2-32.0%, P = 0.02). CONCLUSIONS: New-onset PE is common during TLE and is associated with specific factors. PE severity and subsequent patient management depend on the site of injury.