Multimodal measurement of glycocalyx degradation during coronary artery bypass grafting.

Background: Glycocalyx shedding and subsequent endothelial dysfunction occur in many conditions, such as in sepsis, in critical illness, and during major surgery such as in coronary artery bypass grafting (CABG) where it has been shown to associate with organ dysfunction. Hitherto, there is no consensus about the golden standard in measuring glycocalyx properties in humans. The objective of this study was to compare different indices of glycocalyx shedding and dysfunction. To this end, we studied patients undergoing elective CABG surgery, which is a known cause of glycocalyx shedding. Materials and methods: Sublingual glycocalyx thickness was measured in 23 patients by: 1) determining the perfused boundary region (PBR)-an inverse measure of glycocalyx thickness-by means of sidestream dark field imaging technique. This is stated double, 2) measuring plasma levels of the glycocalyx shedding products syndecan-1, hyaluronan, and heparan sulfate and 3) measuring plasma markers of impaired glycocalyx function and endothelial activation (Ang-2, Tie-2, E-selectin, and thrombomodulin). Measurements were performed directly after induction, directly after onset of cardiopulmonary bypass (CPB), and directly after cessation of CPB. We assessed changes over time as well as correlations between the various markers. Results: The PBR increased from 1.81 ± 0.21 µm after induction of anesthesia to 2.27 ± 0.25 µm (p < 0.0001) directly after CPB was initiated and did not change further during CPB. A similar pattern was seen for syndecan-1, hyaluronan, heparan sulfate, Ang-2, Tie-2, and thrombomodulin. E-selectin levels also increased between induction and the start of CPB and increased further during CPB. The PBR correlated moderately with heparan sulfate, E-selectin, and thrombomodulin and weakly with Syndecan-1, hyaluronan, and Tie-2. Shedding markers syndecan-1 and hyaluronan correlated with all functional markers. Shedding marker heparan sulfate only correlated with Tie-2, thrombomodulin, and E-selectin. Thrombomodulin correlated with all shedding markers. Conclusion: Our results show that glycocalyx thinning, illustrated by increased sublingual PBR and increased levels of shedding markers, is paralleled with impaired glycocalyx function and increased endothelial activation in CABG surgery with CPB. As correlations between different markers were limited, no single marker could be identified to represent the glycocalyx in its full complexity.

ECPella: Concept, Physiology and Clinical Applications.

Addition of Impella on top of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has gained wide interest as it might portend improved outcomes in patients with cardiogenic shock. This has been consistently reported in retrospective propensity-matched studies, case series, and meta-analyses. The pathophysiologic background is based on the mitigation of ECMO-related side effects and the additive benefit of myocardial unloading. In this perspective, thorough knowledge of these mechanisms is required to optimize the management of mechanical circulatory support with this approach and introduce best practices, as the interplay between the two devices and the implantation-explantation strategies are key for success.

Quality of life following adult veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used successfully for the past decade in adult patients with acute respiratory distress syndrome (ARDS) refractory to conventional ventilatory support. However, knowledge of the health-related quality of life (HRQoL) in VV-ECMO patients is still limited. Thus, this study aimed to provide a comprehensive overview of the HRQoL following VV-ECMO support in ARDS patients. METHODS: A systematic search was performed on PubMed and Web of Science databases from January 1st, 2009 to October 19th, 2020. Studies reporting on HRQoL following VV-ECMO for ARDS in adults were included. Two authors independently selected studies, extracted data, and assessed methodological quality. RESULTS: Eight studies were eligible for inclusion, consisting of seven observational studies and one randomized controlled trial (total N = 441). All eight studies had a quantitative design and reported 265 VV-ECMO survivors to have a reduced HRQoL compared to a generally healthy population. Follow-up time varied between six months to three years. Additionally, only four studies (total N = 335) compared the HRQoL of VV-ECMO (N = 159) to conventionally treated survivors (N = 176), with one study showing a significantly better HRQoL in VV-ECMO survivors, while three studies were stating comparable HRQoL across groups. Notably, most survivors in these studies appeared to experience varying degrees of anxiety, depression, and post-traumatic stress disorder (PTSD). CONCLUSIONS: ARDS survivors supported by VV-ECMO have a decline in HRQoL and suffered from physical and psychological impairments. This HRQoL reduction is comparable or even better to the HRQoL in conventionally treated ARDS survivors.

Extracorporeal membrane oxygenation in pregnancy and the postpartum period: a systematic review of case reports.

The use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for patients with severe cardiopulmonary failure has increased significantly in the past decade. However, the use of ECMO in pregnant and peripartum patients has received scant attention. We performed a systematic review of case reports in the literature, documenting indications and outcomes of ECMO in pregnancy and postpartum patients. Case reports on ECMO use in pregnant and postpartum patients were retrieved from MEDLINE, EMBASE and SCOPUS databases up to December 2018. Ninety publications reporting on 97 patients met our inclusion criteria. The majority of publications reported peripartum or postpartum ECMO use for cardiovascular failure (60.8%), while the remainder had respiratory failure. Adult Respiratory Distress Syndrome (91.9%) was the most common respiratory indication while pulmonary embolism (23.7%) and peripartum cardiomyopathy (16.9%) accounted for the two most common cardiovascular indications. Hemorrhage was the most common complication of ECMO reported (31.9%). Of 96 documented neonatal outcomes, 80 neonates (83.3%) survived while 88 of 97 (90.7%) mothers survived. Extracorporeal membrane oxygenation appears to be a viable life support modality in pregnant and postpartum women with severe cardiopulmonary failure, but publication bias in our study cohort should be considered.

Extracorporeal membrane oxygenation in peripartum cardiomyopathy: A review of the ELSO Registry.

AIMS: Data on the use of extracorporeal membrane oxygenation (ECMO) for cardiogenic shock in peripartum cardiomyopathy (PPCM) is limited. We queried the Extracorporeal Life Support Organization (ELSO) Registry for PPCM patients treated with ECMO in order to characterize demographic and clinical features, complications, survival, and variables associated with mortality. METHODS AND RESULTS: This was a retrospective review of patients voluntarily entered into the ELSO Registry. De-identified data was collected on patients with a diagnosis of PPCM based on ICD-9/ICD-10 coding who received ECMO between 2007 and 2019. Collected data included demographics, ECMO mode, cannulation strategies, pre-ECMO ventilator, biochemical, and hemodynamic parameters, run duration, complications, and survival to wean off ECMO and hospital discharge. Our primary outcome measure was survival to discharge. In the final analysis, 88 veno-arterial (VA) ECMO patients were included. Overall, 72% of patients were weaned off ECMO, including 10% who were weaned to ventricular assist device or heart transplantation, and 64% survived to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) was performed in 11% of patients with 60% survival. Factors associated with decreased survival included neurologic complications (p = 0.03), specifically central nervous system hemorrhage (p = 0.01). CONCLUSION: Our review is the largest to date of PPCM patients supported with VA ECMO for cardiogenic shock. ECMO and ECPR are valuable forms of short-term mechanical circulatory support with acceptable mortality profiles for PPCM patients who remain refractory to aggressive medical management. Complications should be meticulously avoided, especially neurologic complications.

Sleep disorders and cognitive dysfunction in acromegaly.

PURPOSE: In the general population, sleep disorders are associated with an increased risk of cognitive impairment. The prevalence of sleep disorders, such as sleep apnea, in acromegalic patients is higher than in the general population, and they may have additional risk of cognitive impairment due to acromegaly treatment and comorbidities. We aim to study the relationship between sleep disturbances and cognitive dysfunction in a group of acromegalic patients. METHODS: We studied 67 consecutive acromegalic patients. We performed a neurocognitive assessment and patients completed the Acromegaly Quality of Life Questionnaire (AcroQoL), Epworth Sleepiness Scale, and Pittsburgh Sleep Quality Index. RESULTS: Of the 67 acromegaly patients in the study, 38.8% were male and median age at the neurological examination was 56 (IQR 48, 65). Approximately 6-10% of patients had impaired cognitive assessment, depending on the test. In linear regression models adjusted for age, sex, BMI, disease duration, and disease activity, poorer sleep quality was associated with lower global cognitive z-score (B = -0.03, 95% CI -0.06, -0.002). Daytime somnolence was associated with poorer physical AcroQoL sub-score (B = -0.04, 95% CI -0.08, -0.002). Sleep quality was associated with poorer overall AcroQoL (B = -0.03, 95% CI -0.05, -0.006), physical AcroQoL (B = -0.04, 95% CI -0.07, -0.005), psychological AcroQoL (B = -0.02, 95% CI -0.04, -0.001), and social AcroQoL (B = -0.02, 95% CI -0.04, -0.0009). CONCLUSIONS: In acromegaly patients, we found robust evidence that poor sleep quality is associated with poorer quality of life, and some evidence that it is associated with poorer cognitive function.

Cross-Cultural Adaptation and Validation of the Italian Version of the Voice Symptom Scale (I-VoiSS).

OBJECTIVES: To evaluate the reliability and validity of the Italian Voice Symptom Scale (I-VoiSS). STUDY DESIGN: Cross-sectional, nonrandomized, prospective study with controls. METHODS: The study consisted of five phases: item generation, reliability analysis, normative data generation, validity and responsiveness analysis. A group of 113 dysphonic patients was enrolled for the internal consistency analysis. Seventy-three of them completed the I-VoiSS twice, 2 weeks apart, for test-retest reliability analysis. A group of 150 vocally healthy participants completed the I-VoiSS for normative data generation. I-VoiSS scores obtained by dysphonic and vocally healthy participants were compared for validity analysis. I-VoiSS scores were correlated with those of the Italian version of the Voice Handicap Index (I-VHI) in 49 dysphonic patients for criterion validity analysis. I-VoiSS scores obtained in a group of 37 nonsmoker dysphonic patients before and after surgical treatment for vocal fold polyps were compared for responsiveness analysis. Finally, the cutoff value of the I-VoiSS was calculated. RESULTS: All the enrolled participants managed to complete the I-VoiSS autonomously. Internal consistency and test-retest were satisfactory (α = 0.92 and r = 0.91). A significant difference in the I-VoiSS scores between the dysphonic and vocally healthy participants was found (p = 0.001). Positive significant correlations were found between I-VoiSS and I-VHI scores (r = 0.85). I-VoiSS scores obtained in the pretreatment condition were significantly higher than those obtained after surgery (p = 0.001). The cutoff value of I-VoiSS was 15.5. CONCLUSION: I-VoiSS is reliable, valid, responsive to changes, and recommended for clinical practice and outcome research.

Contemporary use of arterial and venous conduits in coronary artery bypass grafting: anatomical, functional and clinical aspects.

Although the benefits of using the left internal mammary artery to bypass the left anterior descending artery (LAD) have been extensively ascertained, freedom from major cardiovascular events and survival after coronary artery bypass grafting (CABG) also correlate with the completeness of revascularisation. Hence, careful selection of the second-best graft conduit is crucial for CABG success. The more widespread use of saphenous vein grafts contrasts with the well-known long-term efficacy of multiple arterial grafting, which struggles to emerge as the procedure of choice due to concerns over increased technical difficulties and higher risk of postoperative complications. Conduit choice is at the discretion of the operator instead of being discussed by the heart team, where cardiologists are not usually engaged in such decisions due to a hypothetical lack of technical knowledge. Furthermore, according to the ESC/EACTS guidelines, traditional CABG remains the gold standard for multi-vessel coronary artery disease with complex LAD stenosis, but hybrid procedures using percutaneous coronary intervention for non-LAD targets could combine the best of two worlds. With the aim of raising the cardiologist's awareness of the surgical treatment options, we provide a comprehensive overview of the anatomical, functional and clinical aspects guiding the decision-making process in CABG strategy.

Transnasal endoscopic microfractured fat injection in glottic insufficiency.

OBJECTIVE: We evaluated a novel treatment for glottic insufficiency involving the injection of autologous material with direct glottic visualisation in an outpatient setting. METHODS: Three patients with vocal cord palsy underwent laryngoplasty under local anaesthesia using only a flexible endoscope with a working canal for Microfractured Fat Fibre-endoscopic Injection (MFFI). Adipose tissue was processed using the Lipogems device, which allows optimal purity, fluidity, and mesenchymal stem cell content in the resultant emulsion. RESULTS: According to the preliminary data, MFFI was well tolerated and no complications were observed. During the 12-month follow-up period, voice improvement was constant in all three patients, hinting at the stem cell-related regenerative potential of the procedure. CONCLUSIONS: MFFI was proven to be a useful and straightforward tool, combining all of the relevant advantages of other known treatments for glottic insufficiency, and is an efficacious and innovative treatment that can be performed on an outpatient basis using only autologous material.

Effects of transcatheter aortic valve implantation on left ventricular mass and global longitudinal strain: tissue Doppler and strain evaluation.

INTRODUCTION: Transcatheter aortic valve implantation is the option of choice for high surgical risk patients suffering from symptomatic aortic stenosis. We aimed to evaluate the influence of baseline global longitudinal strain on left ventricular mass regression after the procedure. METHODS: We enrolled 23 patients with pure symptomatic severe aortic stenosis who underwent CoreValve prosthesis (Medtronic, Minneapolis, MN) implantation. Everyone had echocardiography registration before the procedure and after six months in order to analyze two-, three-, and four-chamber peak longitudinal strain and global longitudinal strain. RESULTS: After the procedure New York Heart Association class, peak and mean aortic valve gradients (p<0.001 for all) improved. Interventricular septum and posterior wall thicknesses decreased (p<0.001 for both). Moreover, left ventricular mass index for body surface area changed from 190±44 to 143±30 g/m(2), (p<0.001). Finally, global longitudinal strain significantly increased (from 9.4±0.9 to 11.5±0.8%; p<0.001), as well as its components. Baseline global longitudinal strain correlated with left ventricular mass regression (r=0.560; p=0.005; 2-sided) and predicted it at linear regression analysis (B=23.707; p=0.005; adjusted R(2)=0.281). CONCLUSIONS: Global longitudinal strain and its components improved six months after the procedure. Moreover, baseline global longitudinal strain seemed to predict left ventricular mass regression in patients with pure aortic stenosis undergoing transcatheter aortic valve implantation. This finding could be related to the extent of myocardial fibrosis which is also responsible for lack of left ventricular mass regression and poorer prognosis.

Elastic aortic properties in hypertrophic cardiomyopathy: a single center echocardiographic evaluation.

OBJECTIVE: Previous studies revealed that hypertrophic cardiomyopathy (HCM) patients have impaired aortic elastic properties with contrasting data about aortic dimensions. We aimed to extend our knowledge about this topic, considering tissue Doppler imaging (TDI) and tissue strain. PATIENTS AND METHODS: 25 HCM patients and 25 healthy volunteers matched for age and sex were enrolled. They underwent transthoracic echocardiography to measure aortic dimensions at four levels (Valsalva sinuses, sinotubular junction, tubular tract, aortic arch), elastic properties (i.e., distensibility, stiffness, M-mode strain, tissue strain), and TDI aortic wall velocities (S', E', A' waves). RESULTS: Aortic dimensions differed between the two groups only at sinotubular junction (18 ± 6 vs. 15 ± 3 mm/m2; p = 0.039) and aortic arch levels (19 ± 5 vs. 11 ± 8 mm/m2; p < 0.001). Aortic stiffness was significantly higher among patients (16.4 ± 23.2 vs. 5.9 ± 3.4; p = 0.034), and TDI waves greater (S': 5.2 ± 1.9 vs. 8.0 ± 2.7 cm/s, p < 0.001; E': -5.3 ± 2.4 vs. -7.2 ± 2.7 cm/s, p = 0.012; A': -5.3 ± 1.6 vs. -8.6 ± 4.5 cm/s, p = 0.002). M-mode and tissue strains, and aortic distensibility did not reach statistical significance, although showing a tendency to altered values in the HCM group. CONCLUSIONS: Patients affected by HCM show a larger aorta and altered aortic elastic properties compared with healthy volunteers. These findings could help to investigate treatment response and prognosis of these alterations.

Aortic valve stenosis and lipid-lowering therapy: the state of the art.

Aortic valve stenosis is the most common native valve disease and its most common cause in the United States and Europe is the calcification of a normal trileaflet. Recently, there is increasing evidence indicating that valve calcification has common underlying mechanisms with atherosclerosis. This connection raises interest in the potential efficacy of antiatherosclerosis medications in calcific valve stenosis (AS) therapy. Among them statins, are one of the most promising candidates, because of their pleiotropic effects. The aim of this review is to summarize and analyze the findings of contemporary studies and to discuss the rationale for statin usage in AS populations.

Stem cells and repair of the heart: cell-releasing epicardial scaffolds.

Cell transplantation represents the last frontier within the treatment of cardiac diseases. From the first paper published in 1992 that has documented the potentials of the transplantation of autologous skeletal muscle cells to treat the damage induced by acute myocardial infarction, innumerable techniques of implantation and types of cells used has been reported, greatly expanding this innovative and appealing field of search in cardiovascular medicine. Despite original promises and expectations, current evidences of stem cell transplantation are still weak and controversial. Therefore, alternative line of research are being explored, particularly in the field of techniques of cell implantation and engraftment. Besides direct implantation or myocardial colonization by bone marrow stimulation, epicardial application of cell-delivering systems (scaffold and patches) have gained popularity due to the possibility to apply selectively a cell-containing device which may gradually release the chosen cell type, alone or in combination with trophic substances. The scaffolds have proven to be successful in this respect and may represent a valid alternative to coronary, intra-myocardial, or venous injection of stem cells, or to stem cell stimulating factors. Finally these systems may be applied through minimally invasive procedures and act as external constraint to enhance ventricular reverse remodelling or limit further cardiac dilatation.

Cardiac Troponin I (cTnI) concentration in an ovine model of myocardial ischemia.

Cardiac Troponin I (cTnI) is a polypeptide involved in myocardial contraction and has been shown to be a highly sensitive biomarker of myocardial injury in humans. Chronic myocardial ischemia was induced in eight adult sheep by anterior coronary artery legation. Forty-five days after coronary artery legation, sheep underwent autologous myoblasts implantation to the infarct area to improve local tissue regeneration. Blood samples were taken at regular intervals before and after the induced coronary ischemia and myoblast implantation and serum levels of cTnI were assessed with chemiluminescent immunodosage using a commercially available anti-human cTnI monoclonal antibody. cTnI levels began to increase the day after coronary legation and after myoblast implantation and gradually recovered to physiological levels in the next 14 days. Furthermore, the commercial anti-human antibody was shown to completely cross react with the ovine polypeptide as well as with canine, swine and equine sera.

Modified liver hanging maneuver during orthotopic liver transplantation with inferior vena cava preservation: results after 120 consecutive applications.

The outflow venovenous anastomosis represent a crucial aspect during orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation. The modified Belghiti liver hanging maneuver applied to the last phase of hepatectomy, lifting the liver, provides a better exposure of the suprahepatic region and allows easier orthogonal clamping of the three suprahepatic veins with a minimal portion of IVC occlusion. The outflow anastomosis constructed with a common cloacae of the three native suprahepatic veins is associated with a lower incidence of graft related venous outflow complications. The procedure planned in 120 consecutive OLT was achieved in 118 (99%). The outflow anastomosis was constructed on the common cloaca of the three hepatic veins in 111/120 cases (92.5%). No major complications were observed (bleeding during tunnel creation, graft outflow dysfunction, etc) except in one patient with acute Budd-Chiari, who successfully underwent retransplantation.

Malignant insulinoma presenting as metastatic liver tumor. Case report and review of the literature.

Insulin-secreting tumors are the commonest hormone-producing neoplasm of the gastrointestinal tract. They occur with an incidence of 4 cases per million per year. About 10% of them are metastatic and malignant insulinomas very rarely observed in children and in elderly. We report a rare case of very large malignant insulinoma in a 71-year-old woman admitted in our Oncological Institute on October 2005. She presented with fasting hypoglicemia (blood glucose 35 mg/dl) and high serum insulin levels (insulin 115.9 microU/ml). A computerized tomographic scan showed a pancreatic tail lesion of about 6 cm in max diameter and multiple liver metastases. A whole body scintiscan using 111In-DTPA-D-Phe1-octreotide was made and an increased uptake in the tail of the pancreas has been found. The patient was submitted to liver biopsy and the diagnosis of a metastatic insulin-secreting tumor was immunoistochemically confirmed. Due to the presence of some hypoglicemic episodes uncontrolled by medical treatment, on December 2005 the patient was admitted to surgical intervention with a body and tail pancreatic resection. Post-operatively the patient experienced again syncope with hypoglycemia and hyperinsulinemia. It was then decided to start a schedule of treatment with somatostatin analog (octreotide subcutaneously 500 microg three times a day) with a good control of blood glucose levels (101 mg/dl). A trans-arterial chemioembolization was planned but the patient died for pancreatic and cardiovascular complications before this treatment started.