El verdadero origen histórico del trauma cardíaco penetrante / The true historical origin of penetrating cardiac trauma

Introducción. Los traumatismos cardíacos son lesiones graves y con elevado índice de letalidad, aspecto que influye en el interés mostrado por los lectores cada vez que aparecen reportados en publicaciones científicas. En ocasiones existe cierto grado de incongruencia a la hora de establecer el origen histórico de sucesos o eventos ocurridos y relacionados con la historia de la medicina. En el caso del trauma cardíaco penetrante han sido descritos diversos orígenes en algunos de los artículos científicos publicados, lo cual puede generar un grado de duda en los lectores. Métodos. Se realizó una revisión de la literatura, médica y no médica, para buscar información que ayudara a esclarecer el verdadero origen histórico de esta entidad. Resultados. El trauma cardíaco penetrante fue descrito por primera vez en la obra griega titulada La Ilíada, escrita por Homero en el siglo VIII A.C., y no en El papiro quirúrgico de Edwin Smith, como varios autores mencionan. Conclusiones. De todos los eventos de trauma cardíaco penetrante descritos, el más irrefutable es el narrado en el canto XIII, donde se cuenta la muerte de Alcátoo, producto de una herida cardíaca ocasionada por una lanza arrojada por Idomeneo durante una batalla

Introduction. Cardiac traumatic injuries are serious injuries with a high lethality rate, an aspect that influences the interest shown by readers each time they appear reported in scientific publications. Sometimes there is a certain degree of inconsistency when it comes to establishing the historical origin of occurrences or events related to the history of medicine. In the case of penetrating cardiac trauma, different origins have been described in some of the published scientific articles, which may generate a degree of doubt in the readers. Methods. A review of the medical and non-medical literature was carried out to seek information that would help to clarify the true historical origin of this entity. Results. Penetrating cardiac trauma was first described in a Greek work entitled The Iliad, written by Homer in the 8th century B.C., and not in The Surgical Papyrus of Edwin Smith as several authors mention. Conclusions. Of all the events of penetrating cardiac trauma described, the most irrefutable is the one narrated in canto XIII, where it recounts the death of Alcathous product of a cardiac wound caused by a spear thrown by Idomeneo during a battle.

Lesión cardíaca por arma blanca inadvertida durante la evaluación inicial en el servicio de emergencia / Missed cardiac stab injury during initial evaluation in the Emergency Department

Introducción. La incidencia reportada de traumatismo cardíaco es baja y su grado de resolución es variable, dependiendo de la causa, el mecanismo de la lesión, el lugar donde ocurra y las características del sistema sanitario. Su incidencia ha aumentado recientemente debido al incremento de los accidentes de tránsito y la violencia, predominando los traumatismos penetrantes asociados a heridas por armas cortopunzantes y de fuego. Los traumatismos cardíacos se acompañan de un alto grado de letalidad. Caso clínico. Mujer de 35 años que consultó a emergencia por trauma torácico penetrante ocasionado por arma blanca y fue intervenida de urgencia por derrame pleural izquierdo, sin mejoría hemodinámica. Fue reevaluada detectándose derrame pericárdico con taponamiento cardíaco, ocasionado por lesión cardíaca. Fue tratada quirúrgicamente con resultados satisfactorios. Resultados. Las manifestaciones clínicas en los traumatismos penetrantes generalmente son graves y fatales, pero en algunos casos puede no comprometer tanto la hemodinamia del paciente. Para consolidar el diagnóstico clínico pueden realizarse variados estudios, siendo la ecografía FAST extendida uno de los más recomendados por su elevada sensibilidad y especificidad. Dependiendo del adelanto tecnológico del centro hospitalario y la estabilidad hemodinámica del paciente, el tratamiento quirúrgico es el más indicado. Conclusión. El conocimiento del trauma cardíaco penetrante resulta de gran importancia, no solo para el médico del servicio de emergencia sino también para el médico general. Un diagnóstico rápido y acertado, unido a un manejo adecuado, pueden ser decisivos para salvar la vida del paciente.

Introduction. The reported incidence of cardiac trauma is low and its degree of resolution is variable depending on the cause, the mechanism of injury, the place where it occurs and the characteristics of the health care system. Their incidence has currently increased due to the increase in traffic accidents and violence, with a predominance of penetrating trauma associated with stab wounds and firearms. Cardiac trauma is accompanied by a high degree of lethality. Clinical case. A 35-year-old female patient, evaluated in the emergency room for penetrating thoracic trauma caused by stab wound. She underwent emergency intervention due to left pleural effusion, but without hemodynamic improvement. She was reevaluated and pericardial effusion with cardiac tamponade caused by cardiac injury was detected. She was treated surgically with satisfactory results. Results.The clinical manifestations generally described in penetrating cardiac trauma are severe and fatal, but in some cases and due to the characteristics of the injury caused, the patient's hemodynamics may not be so compromised. To consolidate the clinical diagnosis, several complementary studies can be performed, with FAST ultrasound being one of the most recommended due to its high sensitivity and specificity. Surgical treatment is still the most indicated, depending on the technological progress of the hospital and the hemodynamic stability of the patient. Conclusions.Knowledge of penetrating cardiac trauma is of great importance, not only for the emergency department physician but also for the general practitioner. A quick and accurate diagnosis, together with adequate management can be decisive in saving the patient's life.

Long noncoding RNA MCM3AP-AS1 attenuates sepsis-induced cardiomyopathy by improving inflammation, oxidative stress, and mitochondrial function through mediating the miR-501-3p/CADM1/STAT3 axis.

Oxidative stress and inflammation are highly important for sepsis-mediated myocardial damage. The long noncoding RNA (lncRNA) MCM3AP-AS1 is involved in inflammatory diseases, but its function in acute myocardial injury during sepsis has not been fully elucidated. LPS and cecal ligation and puncture (CLP) were used to construct in vitro and in vivo sepsis-induced myocardial damage models, respectively. qRT-PCR was used to evaluate alterations in MCM3AP-AS1 and miR-501-3p alterations. After the MCM3AP-AS1 and miR-501-3p knockdown or overexpression models were established, the viability, apoptosis, inflammation, oxidative stress, and mitochondrial function of the myocardial cells were examined. Dual luciferase activity assay, RNA immunoprecipitation, and fluorescence in situ hybridization (FISH) confirmed the correlation among MCM3AP-AS1, miR-501-3p, and CADM1. Previous studies revealed that MCM3AP-AS1 was downregulated in sepsis patients, myocardial cells treated with LPS, and in the CLP mouse sepsis model, whereas miR-501-3p expression was increased. MCM3AP-AS1 overexpression hampered myocardial damage mediated by LPS and abated inflammation, oxidative stress, and mitochondrial dysfunction in myocardial cells and THP-1 cells. In contrast, MCM3AP-AS1 knockdown or miR-501-3p overexpression promoted all the effects of LPS. In vivo, MCM3AP-AS1 overexpression increased the survival rate of CLP mice; ameliorated myocardial injury; decreased the levels of TNF-α, IL-1ß, IL-6, iNOS, COX2, ICAM1, VCAM1, PGE2, and MDA; and increased the levels of SOD, GSH-PX, Nrf2, and HO-1. Mechanistic studies demonstrated that MCM3AP-AS1 acted as a competitive endogenous RNA to repress miR-501-3p, enhance CADM1 expression, and dampen STAT3/nuclear factor-kappaB (NF-κB) activation. MCM3AP-AS1 suppresses myocardial injury elicited by sepsis by mediating the miR-501-3p/CADM1/STAT3/NF-κB axis.

Teste de Caminhada de Seis Minutos e Teste de Marcha Estacionária de Dois Minutos em uma população idosa participante de um programa de reabilitação cardíaca / Analysis and correlation of the Six-Minute Walk Test and Two-Minute Step Test in an elderly population participating in a cardiac rehabilitation program

The six-minute walk test (6MWT) and two-minute step test (2MST) are submaximal tests widely used in the elderly population functional capacity evaluation. Objective: To investigate whether the cardiac rehabilitation (CR) program was able to promote an increase in these tests and if there was an association between them; and to compare the hemodynamic stress caused by each of the tests. Methods: Retrospective, observational study in elderly participants in CR program. 24 elderly people were evaluated and classified according to the Fried frailty phenotype. The 6MWT and the 2MST were applied, observing the mean distance walked and the number of steps performed, respectively, as well as the double cardiac product (DP) at the beginning and after 4 months of the CR program. Results: There was an increase of 57 meters in the mean distance covered by the 6MWT (364.31±108.01 vs. 421.65±108.73, P<0.001) and 14 steps performed in the 2MST (62.17±22.50 vs. 76.17±25.56, P= 0.011) after 4 months of CR and we found a significant correlation between the tests and their results (P <0.001). When comparing the DP, both tests had a significant reduction (14469.92±2497.91 vs. 13348.21±2839.36, P= 0.022 and 15744.17±3591.87 vs. 13222.29±2505.39, P<0.001; respectively). Conclusion: A relationship between the number of steps performed in the 2MST with the mean distance covered of 6MWT suggest the use of them as an effective indicator in CR program and the association between them offers greater possibilities for treatment and evaluation of an elderly population.

O teste de caminhada de seis minutos (TC6m) e o teste de marcha estacionária de dois minutos (TME2min) são testes submáximos amplamente utilizados na avaliação da capacidade funcional da população idosa. Objetivo: Investigar se o programa de reabilitação cardíaca (RC) foi capaz de promover melhora nesses testes e se houve associação entre eles; além de comparar o estresse hemodinâmico causado por cada um dos testes nessa população. Métodos: Estudo retrospectivo e observacional em idosos participantes do programa de RC. Foram avaliados 24 idosos e classificados de acordo com o fenótipo de fragilidade de Fried. Foram aplicados o TC6m e o TME2min, observando-se a distância média percorrida e o número de passos realizados, respectivamente, bem como o duplo produto cardíaco (DP) no início e após 4 meses do programa de RC. Resultados: Houve aumento de 57 metros na distância média percorrida no TC6m (364,31±108,01 vs. 421,65±108,73, P<0,001) e 14 passos realizados no TME2min (62,17±22,50 vs. 76,17±25,56, P= 0,011) após 4 meses de RC e encontramos correlação significativa entre os testes e seus resultados (P<0,001). Ao comparar o DP, ambos os testes tiveram redução significativa (14.469,92±2.497,91 vs. 13.348,21±2.839,36, P= 0,022 e 15.744,17±3.591,87 vs. 13.222,29±2.505,39, P<0,001; respectivamente). Conclusão: A relação entre o número de passos realizados no TME2min com a distância média percorrida no TC6m sugere a utilização deles como um indicador eficaz em programa de RC e a associação entre eles oferece maiores possibilidades de tratamento e avaliação de uma população idosa.

Sequence and directivity in cardiac muscle injury of COVID-19 patients: an observational study.

Objective: To compare cardiac function indicators between mild and moderate to severe COVID-19 patients and to try to identify the sequence and directivity in cardiac muscle injury of COVID-19 patients. Methods: From December 2022 to January 2023, all patients with laboratory-confirmed SARS-CoV-2 infection in Shanghai General Hospital Jiading Branch were enrolled. The clinical classification was stratified into mild, moderate, or severe groups. We collected the clinical and laboratory information, transthoracic echocardiographic and speckle-tracking echocardiographic parameters of patients and compared the differences among different groups. Results: The values of echocardiographic parameters in mild group were lower than that in moderate or severe group (P < 0.05) except LVEF. The values of LVEF of mild and moderate group were higher than severe group (P < 0.05). There were no significant differences between moderate and severe group. Positive correlations were observed between left ventricular global longitudinal strain (LVGLS) and myoglobin (r = 0.72), E/e' and age (r = 0.79), E/e' and BNP (r = 0.67). The multivariate analysis shows that SpO2 (OR = 0.360, P = 0.02), LVGLS (OR = 3.196, P = 0.003) and E/e' (OR = 1.307, P = 0.036) were the independent risk factors for mild cases progressing to moderate or severe. According to the receiver operating characteristic (ROC) curves, when all the COVID-19 patients was taken as the sample size, the area under the curve (AUC) of the LVGLS was the highest (AUC = 0.861). The AUC of the LVGLS was higher than LVGCS (AUC = 0.565, P < 0.001). Conclusion: When mild COVID-19 progresses to moderate or severe, both systolic and diastolic functions of the heart are impaired. LVGLS was the independent risk factor for mild cases progressing to moderate or severe cases. Longitudinal changes may manifest earlier than circumferential changes as myocardial disease progresses in COVID-19.

Fracture of the Second Rib: An Indirect Sign of Serious Trauma Like Fracture of the First Rib?

Background: The first 3 ribs are anatomically well-protected, shielded by the large thoracic muscles, the shoulder girdle, and the arm. A significant force is required to fracture these ribs; thus, such fractures suggest a high-energy trauma and are associated with injuries to vital organs of the thorax, such as the aorta, the heart, the lungs and the great vessels. Methods: A retrospective analysis was conducted over a 10-year period at a single hospital. The study assessed patients with fractures of the second rib, including their concurrent injuries and the overall severity of their trauma. Results: Among the 76 patients included in the study, the average age was 47.35 years, 81.5% were men, and 19.5% were women. Thirteen patients (17.1%) survived their injuries. The most common causes of injury were road traffic accidents (63%) and pedestrian injuries (22%). The patients who did not survive sustained injuries to an average of 5 additional organs, while survivors had injuries to an average of 2.07 additional organs. Left rib fractures were the most frequently observed (46%). The most serious concurrent injuries reported were to the aorta (5.26%), heart (10.52%), lung (52.36%), head (57.89%), liver (30.2%), spleen (26.31%), and kidney (17.1%). Conclusion: As indicators of serious injury to vital endothoracic organs, isolated fractures of the second rib should be considered equal to first rib fractures in clinical importance.

Post-cardiac Injury Syndrome in a Systemic Lupus Erythematosus Patient After an Open-Heart Operation: A Case Report.

Post-cardiac injury syndrome (PCIS) is an inflammatory condition caused by a cardiac injury that can affect the pericardium, pleura, or both. We describe a female patient who underwent heart surgery and thereafter developed pericardium and pleural effusion. She was also known to have systemic lupus erythematosus (SLE). Due to the possibility that each of these symptoms could impact the pericardium or pleura, we came to the conclusion that they could be caused by either PCIS, SLE, or both. A 54-year-old woman underwent open heart surgery three weeks ago and required aortic valve replacement and coronary artery bypass grafting (CABG). She presented to the emergency room complaining of fatigue, chest pain, shortness of breath, coughing, and fever for five days. She had a history of SLE for seven years. The patient was found to have a right-side pleural effusion, a pericardial effusion, and a high inflammatory marker based on imaging and laboratory evaluations. A right pleural-side image-guided percutaneous pigtail catheter drainage was inserted. Exudative fluid appeared in the pleural fluid analysis, and a mild pericardial effusion was seen on echocardiography. The patient was diagnosed with pericarditis and treated with prednisone, colchicine, and antibiotics. Six days later, she was discharged in good general condition. In this particular case of SLE with a chronic inflammatory reaction, PCIS developed following valve replacement surgery. The activation and destruction of endothelial cells are frequently seen in both SLE and PCIS, leading us to believe that there may be a possible reciprocal interaction between these two distinct autoimmune illnesses.

Risk factors for myocardial injury during living donor liver transplantation in pediatric patients with biliary atresia.

BACKGROUND: Cold ischemia-reperfusion of the liver is an inevitable occurrence in liver transplantation that may also cause damage to the heart. Perioperative myocardial injury during liver transplantation can increase the incidence of postoperative mortality, but there is little research on the incidence of myocardial injury in children who undergo living donor liver transplantation (LDLT). Therefore, this study mainly explores the independent risk factors for myocardial injury in children who undergo LDLT. AIM: To analyze the data of children who underwent LDLT to determine the risk factors for intraoperative myocardial injury. METHODS: We retrospectively analyzed the inpatient records of pediatric patients who underwent LDLT in Tianjin First Central Hospital from January 1, 2020, to January 31, 2022. Recipient-related data and donor-related data were collected. The patients were divided into a myocardial injury group and a nonmyocardial injury group according to the value of the serum cardiac troponin I at the end of surgery for analysis. Univariate analysis and multivariate logistic regression were used to evaluate the risk factors for myocardial injury during LDLT in pediatric patients. RESULTS: A total of 302 patients met the inclusion criteria. The myocardial injury group had 142 individuals (47%), and the nonmyocardial injury group included 160 patients (53%). Age, height, and weight were significantly lower in the myocardial injury group (P < 0.001). The pediatric end-stage liver disease (PELD) score, total bilirubin, and international standardized ratio were significantly higher in the myocardial injury group (P < 0.001). The mean arterial pressure, lactate, hemoglobin before reperfusion, duration of the anhepatic phase, cold ischemic time, incidence of postreperfusion syndrome (PRS), and fresh frozen plasma transfusion were significantly different between the two groups (P < 0.05). The postoperative intensive care unit stay and peak total bilirubin values in the first 5 d after LDLT were significantly higher in the myocardial injury group (P < 0.05). The pediatric patients with biliary atresia in the nonmyocardial injury group who underwent LDLT had a considerably higher one-year survival rate than those in the myocardial injury group (P = 0.015). Multivariate logistic regression revealed the following independent risk factors for myocardial injury: a high PELD score [odds ratio (OR) = 1.065, 95% confidence interval (CI): 1.013-1.121; P = 0.014], a long duration of the anhepatic phase (OR = 1.021, 95%CI: 1.003-1.040; P = 0.025), and the occurrence of intraoperative PRS (OR = 1.966, 95%CI: 1.111-3.480; P = 0.020). CONCLUSION: A high PELD score, a long anhepatic phase duration, and the occurrence of intraoperative PRS were independent risk factors for myocardial injury during LDLT in pediatric patients with biliary atresia.

Serum pro-B-type natriuretic peptide levels and cardiac index as adjunctive tools of blunt cardiac injury.

BACKGROUND: Blunt cardiac injury (BCI) has a variety of symptoms that may be a potentially life-threatening injury that can lead to death. Depending on the diagnosis of BCI, treatment direction and length of stay may vary. In addition, the utility of other diagnostic tests for cardiac disease as diagnostic tools for BCI remain unclear. The purpose of this study was to investigate the competence of N-terminal pro-B-type natriuretic peptide (NT pro-BNP) and cardiac index (C.I) as adjunctive diagnostic tools for BCI. METHODS: From January 2018 to March 2020, severe trauma patients with sternum fracture who were admitted to the traumatic intensive care unit (TICU) were included this study. Patients with sternum fracture, 18 years of age or older, and with an injury severity score > 16 who required intensive care were included. Invasive measurement for the analysis of the pulse contour for C.I monitoring and intravenous blood sampling for NT pro-BNP measurement were performed. Sampling and 12-lead electrocardiogram were performed at different time points as follows: immediately after TICU admission and at 24 h and 48 h after trauma. RESULTS: Among 103; 33 patients with factors that could affect NT pro-BNP were excluded; therefore, 63 patients were included in this study. According to the American Association for the Surgery of Trauma Cardiac Injury Scale, 33 patients were diagnosed with non-BCI, and 30 patients constituted with BCI. The median ages of the patients were 58 (52-69), and 60 (45-69) years in the non-BCI and BCI groups, respectively (p = 0.77). The median NT pro-BNP values were higher in the BCI group on admission, hospital day (HD) 2, and HD 3, however, no statistical difference was observed (125 (49-245) vs. 130 (47-428) pg/mL, p = 0.08, 124 (68-224) vs. 187 (55-519) pg/mL, p = 0.09, and 121(59-225) vs. 133 (56-600) pg/mL, p = 0.17, respectively). On the contrary, significantly lower values were observed in the median C.I measurement on admission and HD 3 in the BCI group (3.2 (2.8-3.5) vs. 2.6 (2.3-3.5) L/min/m2, p < 0.01 and 3.2 (3.1-3.9) vs. 2.9 (2.4-3.2) L/min/m2, p < 0.01, respectively); however, no significant difference was observed on HD 2 (3.4 (3.0-3.7) vs. 2.6 (2.4-3.4) L/min/m2, p = 0.17), Furthermore, The median lactate levels in the BCI group upon admission, HD 2, and HD 3 were significantly higher than those in the non-BCI group (1.8 (1.1-2.6) vs. 3.1 (2.1-4.4) mmol/L, p < 0.01; 1.3 (0.8-2.3) vs. 3.0 (2.2-4.7) mmol/L, p < 0.01; and 1.5 (0.9-1.5) vs. 2.2 (1.3-3.7) mmol/L, p < 0.01, respectively). CONCLUSION: Consecutive values of NT pro-BNP and C.I show no correlation with ECG-based BCI diagnosis. However, lactate level measurement may help in the early recognition of BCI as an adjunctive tool. It should be noted that this is a hypothesis-generating study for BCI diagnosis. Further studies should be conducted in larger populations with a prospective approach.

Características de las intervenciones en cirugía cardiaca en un hospital general de Lima, Perú

Objetivos: Describir las características epidemiológicas, clínicas y quirúrgicas de las intervenciones en cirugía cardiaca en un hospital general de Lima - Perú. Material y métodos: Estudio observacional, descriptivo y retrospectivo. La población estudiada fue de pacientes operados de cirugía cardiaca electivamente entre 2009 y 2019 en el Hospital María Auxiliadora. Se incluyeron 41 pacientes. Resultados: La mediana de edad fue 44 (rango intercuartílico: 26,5 - 58,5) años y el sexo femenino fue 75,6%. Los principales antecedentes patológicos fueron: arritmia cardiaca (56,1%), hipertensión arterial (36,6%), accidente cerebrovascular (24,4%) y diabetes mellitus tipo 2 (14,6%). La cirugía realizada con más frecuencia fue el reemplazo valvular con válvula protésica (39%), principalmente de la válvula mitral; en segundo lugar, cirugías correctivas de defecto de tabique (26,8%), principalmente comunicación interauricular. Las complicaciones postoperatorias más frecuentes fueron: neumonía intrahospitalaria (14%), arritmia cardiaca nueva (14%) y síndrome de bajo gasto cardiaco (12%). Las medias de los tiempos de circulación extracorpórea y tiempo de pinzamiento aórtico fueron de 97,5 ± 39,0 min y 68,1 ± 35,5 min, respectivamente. La media de la estancia en unidad de cuidados intensivos fue 4,1 ± 2,9 días y la media de la estancia hospitalaria fue 22,3 ± 10,9 días. No hubo mortalidad hasta 30 días del postoperatorio. Conclusiones: Los pacientes intervenidos fueron principalmente adultos jóvenes y a predominio del sexo femenino, con comorbilidades cardiovasculares importantes. La principal cirugía realizada fue el reemplazo de válvula cardiaca y las demás características clínico-quirúrgicas fueron similares a lo reportado en Latinoamérica.

SUMMARY Objective: To describe the clinical, epidemiological, and surgical characteristics of cardiac interventions in a general hospital in Lima, Peru. Methods : a retrospective and descriptive study was carried-out at Hospital Maria Auxiliadora from 2009-2019, 41 patients were included. Results: Median age was 44 years (IQR: 26.5-58.5); 75.6% were females. Underlying conditions were arrhythmias (56.1%); blood hypertension (36.6%); strokes (24.4%) and diabetes (14.6%). Valve replacement using prosthetic valves was the most frequent procedure (39%), mainly mitral valve replacement; followed by surgical repairs of septum abnormalities, mainly atrial defects (26.8%). The most common post-operative complications were nosocomial pneumonia (14%), new arrhythmia (14%) and low output syndrome (12%). Mean times of extracorporeal circulation and aortic clamping were 97.5 ± 39.0 min and 68.1 ± 35.5 min, respectively. Mean ICU and hospital stays were 4.1 ± 2.9 and 22.3 ± 10.9 days, respectively. No fatalities were recorded 30-days after the procedures. Conclusions: Young, predominantly female adults with significant comorbidities were surgically intervened in this setting. The main surgical procedure was valve replacement, no differences with reports from Latin America were found.

Left atrial appendage rupture: A rare complication of right-sided haemothorax: A case report.

Cardiac injury accounts for less than 10 % of all traumas and it is a fatal condition associated with cardiac tamponade or massive haemothorax, which requires immediate intervention, such as resuscitative thoracotomy. However, in case of haemothorax without the findings suggestive of cardiac damage such as pericardial effusion, it is difficult to determine the complications of cardiac injury, because injury of the lung or intercostal arteries is usually considered first. We describe a rare case of left atrial appendage rupture with a right-sided massive haemothorax with slight cardiac effusion. A 47-year-old man with no significant medical history was transferred to our emergency department after crashing his motorcycle into a car. A right resuscitative thoracotomy for massive haemothorax was performed, followed by hilarious clamping and pericardial drainage. We found continuous bleeding from a right dorsal pericardial injury which indicated cardiac injury. Soon after the patient was referred to the operating room, left atrial appendage rupture was found, and ligated. The postoperative course was uneventful, and he was discharged on 15th postoperative day without complication. Left atrial appendage rupture is caused by a direct external force to the left atrium, so the pericardial injury is usually ipsilateral to the left side of the pericardium, resulting in perforation of the left thoracic cavity. Therefore, left atrial appendage rupture with a right-sided massive haemothorax is rare. In addition, when a cardiac injury is associated with a pericardial injury, most of the pericardial effusion drains into the thoracic cavity, resulting in a small amount of pericardial effusion, which make it difficult to recognize the cardiac injury. In conclusion, in blunt trauma, even in the case of a right-sided haemothorax, the possibility of cardiac injury in addition to pulmonary contusion should be considered and explored, because cardiac injury could be fatal.

Predictors and Prognostic Implications of Myocardial Injury After Transcatheter Aortic Valve Replacement.

Myocardial injury (MI) is not unusual after transcatheter aortic valve replacement (TAVR). To determine precipitating factors and prognostic outcomes of MI after TAVR, we retrospectively investigated relationships between MI after TAVR and aortic root dimensions, baseline patient characteristics, echocardiographic findings, and procedural features. Of 474 patients who underwent transfemoral TAVR for severe aortic stenosis in our tertiary center from June 2011 through June 2018, 188 (mean age, 77.7 ± 7.7 yr; 96 women [51%]) met the study inclusion criteria. Patients were divided into postprocedural MI (PMI) (n=74) and no-PMI (n=114) groups, in accordance with high-sensitivity troponin T levels. We found that MI risk was associated with older age (odds ratio [OR]=1.054; 95% CI, 1.013-1.098; P=0.01), transcatheter heart valve type (OR=10.207; 95% CI, 2.861-36.463; P=0.001), distances from the aortic annulus to the right coronary artery ostium (OR=0.853; 95% CI, 0.731-0.995; P=0.04) and the left main coronary artery ostium (OR=0.747; 95% CI, 0.616-0.906; P=0.003), and baseline glomerular filtration rate (OR=0.985; 95% CI, 0.970-1.000; P=0.04). Moreover, the PMI group had a longer time to hospital discharge (P=0.001) and a higher permanent pacemaker implantation rate (P=0.04) than did the no-PMI group. Our findings may enable better estimation of which patients are at higher risk of MI after TAVR and thus improve the planning and course of clinical care.

Coronary Sinus Rupture Due to Blunt Cardiac Trauma.

We present a very rare case of devastating blunt cardiac trauma with large right atrial rupture, contusion of the right atrioventricular groove, and coronary sinus tear. Surgical repair was successfully performed by urgently establishing cardiopulmonary bypass via the femoral vein and artery simultaneously with a median sternotomy. (Level of Difficulty: Intermediate.).

Is cardiac Troponin I Considered as A Predictor of In-hospital Mortality among COVID-19 Patients? A Retrospective Cohort Study.

OBJECTIVE: To describe the levels of troponin I in COVID-19 patients and its role in the prediction of their in-hospital mortality as a cardiac biomarker. METHODS: The current retrospective cohort study was performed on the clinical records of 649 COVID-19-related hospitalized cases with at leat one positive polymerase chain reaction (PCR) test in Tehran, Iran from February 2020 to early June 2020. The on admission troponin I level divided into two groups of ≤0.03ng/mL (normal) and >0.03ng/mL (abnormal). The adjusted COX-regression model was used to determine the relationship between the studied variables and patient's in-hospital mortality. RESULTS: In this study, the median age of subjects was 65 years (54.8% men) and 29.53% of them had abnormal troponin I levels. Besides, the in-hospital mortality rate among patients with abnormal troponin I levels was found to be 51.56%; whereas, patients with normal levels exhibited 18.82% mortality. Also, the multivariable analysis indicated that the risk of death among hospitalized COVID-19 patients displaying abnormal troponin I levels was 67% higher than those with normal troponin I levels (Hazard ratio=1.67, 95% confidence interval=1.08-2.56, p=0.019). CONCLUSION: It seems that troponin I is one of the important factors related to in-hospital mortality of COVID-19 patients. Next, due to the high prevalence of cardiac complications in these patients, it is highly suggested to monitor and control cardiac biomarkers along with other clinical factors upon the patient's arrival at the hospital.

Integrated RNA- and miRNA-sequencing analysis identifies molecular basis for stress-induced heart injury in mouse models.

BACKGROUND: Work stress and its contribution to cardiovascular diseases are well documented in recent years, but its molecular mechanisms are still not clear. In this study, we aimed to explore the potential pathophysiological mechanisms of stress-induced heart injury in mouse models. METHODS: The RNA- and miRNA- sequencing profiles from five stress-treated mice and five control mice were performed. After normalization, differentially expressed genes (DEGs) and miRNAs (DEmiRs) were identified using the edgeR method. Then, based on the functional enrichment analysis and protein-protein interaction (PPI) network, as well as miRNA-mRNA interactome, the core DEGs and DEmiRs associated with stress-induced heart injury were marked and validated by qPCR, and the DEmiR targets were validated in vitro. RESULTS: A total of 293 genes and 29 miRNAs were identified as DEGs and DEmiRs respectively, and Alb, Stat1, C3, Irf7, Usp18 were hub genes in the PPI network. The enrichment pathways were related to inflammation and immune, coagulation, oxidative phosphorylation, vascular development, cell cycle and extracellular matrix (ECM), which likely mediated the biological injury processes or reflected the results of damage. The target DEGs of DEmiRs were clustered in angiogenesis, immune system process and ECM. After the validation in vitro, we found that miR-29b-3p mimics could down-regulate the expression of its predicted targets, Pxdn and Col15a1. CONCLUSIONS: The findings revealed a molecular basis from the gene and miRNA level for the heart injury associated with stress. miR-29b-3p, as a potential target to repair stress-induced ECM disorder in heart, deserves further study.

Study on the preprotective effect of dapagliflozin administration on doxorubicin induced cardiomyopathy in SD rats / 中国医师进修杂志

Objective:To explore if protective effects of dapagliflozin (Dapa) administration on attenuating DOX-induced myocardial injury in rats.Methods:A total of 30 specific pathogens free grade 8 week old male Sprague Dawley rats. Rats were randomly divided into three groups. Control group (Con group, n = 5), rats received intraperitoneal saline (1.25 ml/kg) injection once per week plus saline (8 mg/kg) daily via gavage for 6 weeks. Dox group ( n = 15) rats received intraperitoneal Dox (2.5 mg/kg) injection once per week plus saline (8 mg/kg) daily via gavage for 6 weeks. Dox + Dapa group ( n = 10), rats received intraperitoneal Dox (2.5 mg/kg) injection once per week plus Dapagliflozin (4 mg/kg) daily via gavage for 6 weeks, observed to week 10. Survival status, echocardiography, pathology, and expression of Bcl-2, Bax gene and protein were observed. Results:The survival rate of ats in Con, Dox, and Dapa+Dox groups was 100.0%, 66.7% and 90.0% respectively. The echocardiography were performed in Con, Dox, and Dapa+Dox groups left ventricular ejection fraction was (95.40 ± 2.51)%, (83.09 ± 4.92)% and (91.71 ± 3.45)%, respectively; left ventricular fraction shortening was (66.80 ± 7.43)%, (47.27 ± 5.10)% and (59.43 ± 6.92)%, respectively; Both indexes in Dapa+Dox group was higher than that in Dox group, but lower than that in Con group, all P<0.05; Left ventricular end-diastolic diameter was (4.80 ± 0.83) mm, (5.90 ± 0.83) mm and (4.85 ± 0.69) mm respectively; left ventricular end-systolic diameterwas (1.80 ± 0.44) mm, (2.90 ± 0.53) mm and (2.00 ± 0.57) mm in Con, Dox, and Dapa + Dox groups, respectively; Both indexes in Dapa + Dox group was decreased than that in Dox group, but Dapa + Dox group was increased than that in Con group, all P<0.05. Pathologic changes have been shown that myocardial fibers arranged neatly in the Con group under HE staining, while those broken myocardial fibers disordered arranged in the Dox group, and those changes in the Dapa + Dox group were slightly relieved than that in Dox group. The collagen volume fraction of rats in Con, Dox and Dapa+Dox groups were (2.64 ± 1.04)%, (16.85 ± 1.70)% and (6.75 ± 1.89)% under sirius red staining, Dapa+Dox group was lower than that in Dox group but higher than that in Con group, all P<0.05. Pathologic changes under transmission electron microscope have been shown that a few of normal structure mitochondria in the Con group. A large number of swollen mitochondria with disappeared mitochondrial crest in the Dox group; but neatly arranged with mitochondrial crest blurred in the Dapa+Dox group. The quantitative real-time PCR was used to detected Bcl-2 and Bax, there were 0.93 ± 0.09, 0.35 ± 0.30 and 0.89 ± 0.25 in Bcl-2, 0.99 ± 0.10, 3.10 ± 0.10 and 0.86 ± 0.04) in Bax, while Bcl-2/Bax 0.94 ± 0.17, 0.11 ± 0.06 and 1.03 ± 0.27, respectively. The westernblot was used to detected Bcl-2 and Bax, there were 1.00 ± 0.18, 0.32 ± 0.20 and 1.30 ± 0.41 in Bcl-2, 0.66 ± 0.11, 2.44 ± 0.66 and 0.90 ± 0.61 in Bax, while Bcl-2/Bax: 1.50 ± 0.18, 0.12 ± 0.05 and 1.80 ± 0.82, respectively; the above results shown that both myocardial Bax mRNA and protein expression in Dox group were higher than that in Dapa + Dox group and Con group, both P<0.05, and there was no difference in the two later groups, P>0.05; both the myocardial Bcl-2 mRNA and protein expression in Dox group were lower than that in Dapa+Dox group and Con group, both P<0.05, and there was no difference between two later groups, P>0.05; Bcl-2/Bax in Dox group was significantly lower thanthat in Dapa+Dox groupand Con group, both P<0.05, and there was no difference between Dapa+Dox group and Con group, P>0.05. Conclusions:Simultaneous dapagliflozin treatment significantly attenuated DOX-induced cardiotoxicity, which might be related to prevent myocardial apoptosis.

Exercise-Induced Cardiac Troponin Elevations: From Underlying Mechanisms to Clinical Relevance.

Serological assessment of cardiac troponins (cTn) is the gold standard to assess myocardial injury in clinical practice. A greater magnitude of acutely or chronically elevated cTn concentrations is associated with lower event-free survival in patients and the general population. Exercise training is known to improve cardiovascular function and promote longevity, but exercise can produce an acute rise in cTn concentrations, which may exceed the upper reference limit in a substantial number of individuals. Whether exercise-induced cTn elevations are attributable to a physiological or pathological response and if they are clinically relevant has been debated for decades. Thus far, exercise-induced cTn elevations have been viewed as the only benign form of cTn elevations. However, recent studies report intriguing findings that shed new light on the underlying mechanisms and clinical relevance of exercise-induced cTn elevations. We will review the biochemical characteristics of cTn assays, key factors determining the magnitude of postexercise cTn concentrations, the release kinetics, underlying mechanisms causing and contributing to exercise-induced cTn release, and the clinical relevance of exercise-induced cTn elevations. We will also explain the association with cardiac function, correlates with (subclinical) cardiovascular diseases and exercise-induced cTn elevations predictive value for future cardiovascular events. Last, we will provide recommendations for interpretation of these findings and provide direction for future research in this field.

Solving the impossible: penetrating cardiac injuries, a case series of diagnostic workup and management / Resolviendo lo imposible: heridas penetrantes cardíacas, serie de casos del abordaje diagnóstico y terapéutico

For a long time, any heart-based injury was an off-limits area for surgeons; a patient with a traumatic cardiac injury was doomed to die. Little more than one hundred years have passed since the first surgical correction of a penetrating cardiac injury and there is still a high rate of mortality, despite the medical advances. We present the case of 6 patients with penetrating cardiac injuries that were repaired at a third level hospital of Mexico, alongside relevant findings on the literature about the topic. From 2019 to 2020, an incidence of 6 patients with penetrating cardiac injuries was present; all men aged 30 years or older. The etiology of 4 (67%) patients was stab wounds and 2 (33%) gunshot wounds. Left anterolateral thoracotomy was used on 5 (83%) patients and midline sternotomy on 1 (17%) patient. 2 (33%) injuries on the left ventricle presented along with coronary arteries injuries. Left ventricle and right atrium injuries presented each 50% of mortality. The mortality was of 33%, 1 patient died due to intraoperative complications and another one due to massive cerebral infarction and polyuric syndrome because of diabetes insipidus. There is a long path ahead of the surgical field on this topic and further to be analyzed. An excellent tool for cardiac tamponade diagnosis due to penetrating cardiac injuries is cardiac ultrasound, therefore it should be used on every hemodynamic unstable patient in the context of PCI. Definitively, time is of the essence, and the survival of patients depends on immediate transport to a hospital and an opportune surgical intervention.

Durante mucho tiempo las heridas en el corazón eran un área prohibida para el cirujano. Cualquier persona con herida penetrante cardíaca estaba condenada a morir. Poco más de cien años han transcurrido desde la primera corrección quirúrgica de una herida penetrante cardíaca y sigue habiendo una tasa alta de mortalidad, a pesar de los avances médicos. Se presenta una serie de casos de 6 pacientes con heridas penetrantes cardíacas que fueron reparadas en un hospital de tercer nivel de México, junto con revisión de la literatura. Desde el 2019 al 2020, hubo una incidencia de 6 pacientes con heridas penetrantes cardíacas; todos fueron hombres de 30 años o mayores. La etiología en 4 (67%) casos fueron heridas por arma blanca y 2 (33%) por herida por proyectil de arma de fuego. Se usó el abordaje por toracotomía anterolateral izquierda en 5 (83%) pacientes y esternotomía media en 1 (17%) paciente. Dos (33%) heridas se suscitaron en el ventrículo izquierdo en conjunto con heridas en arterias coronarias. Heridas en el ventrículo izquierdo y atrio derecho presentaron una mortalidad del 50% cada una. La mortalidad total fue de 33%, 1 paciente falleció por complicaciones intraoperatorias y otro más por infarto cerebral masivo y síndrome poliúrico causado por diabetes insípida. Hay un gran camino por recorrer en el ámbito quirúrgico de este tipo de heridas y más por ser analizado. Una herramienta útil para el diagnóstico del taponamiento cardíaco por heridas penetrantes cardíacas es el ultrasonido cardíaco, y, por ende, debe ser usado en todo paciente con inestabilidad hemodinámica en el contexto de una herida penetrante cardíaca. Definitivamente, el tiempo es vida, y la sobrevivencia de estos pacientes depende del transporte inmediato a un hospital y una intervención quirúrgica oportuna.