Predictors of Pneumothorax in People With COVID-19 Pneumonia: A Multicenter Retrospective Investigation.

This multicenter retrospective investigation aimed to identify predictors of pneumothorax (PTX), pneumomediastinum (PM), and subcutaneous emphysema (SE) in patients with COVID-19 pneumonia admitted to the ICU. A total of 256 patients were included, with 128 in the case group and 128 in the control group. The study sample consisted of predominantly male patients with a mean age of around 53 years and a high prevalence of comorbidities. Significant predictors of PTX, PM, and SE included the presence of coronary artery disease, non-rebreather mask usage, high-flow oxygen therapy, mechanical ventilation, pressor usage, inpatient dialysis, steroid usage, sedative usage, narcotic usage, paralytic usage, elevated C-reactive protein levels, increased lung infiltration, the presence of PM and SE, mode of ventilation, duration of various respiratory support interventions, and severity of illness as indicated by APACHE and SOFA scores. These findings have important implications for the clinical management of patients with COVID-19 pneumonia, as they may help identify and closely monitor at-risk individuals, allowing for timely intervention and potentially improving clinical outcomes. Future research should focus on validating these predictors in larger cohorts and investigating the underlying mechanisms to develop targeted preventive and therapeutic strategies.

Heyde's Syndrome - An Enigma.

Heyde's syndrome (HS) is described as the association between recurrent bleeding from angiodysplasia of the gastrointestinal tract and aortic stenosis. Aortic valve replacement has been reported to stop the bleeding. In unfit patients, the options available are interventional or conservative management. We hereby report an elderly obese patient with severe comorbidity with complicated HS involving a narrow aortic root. She underwent left ventricular outlet myomectomy and aortic root replacement to promote better forward flow and prevent restenosis and recurrence of symptoms. She was discharged home symptom-free despite being on coumadin anticoagulants.

Multiple Migrated Superior Vena Cava Stents With Cardiac Injury - A Stepwise Open Cardiotomy Strategy to Mitigate Potential Fatality.

Iatrogenic injuries with migrated interventional stents can sometimes be life-threatening. The interventional retrieval management is generally the treatment of choice, as surgical procedures carry a high mortality risk with only a few cases reported. We report a patient with two stents migrated into the right atrium from superior vena cava resulting in cardiac perforation. She was successfully treated using pericardiocentesis followed by surgical intervention with rapid post-operative resolution of symptoms. The technique presented here substantiates the steps for a safe and effective removal of these multiple displaced stents with minimal postprocedural complications.

Absent pericardium and lung hypoplasia in a child with severe mitral regurgitation.

An 8-year-old girl with severe mitral regurgitation presented with symptoms of heart failure. Clinical investigations did not raise suspicion of an absent left pericardium. Congenital defects of the pericardium are rare and frequently associated with other cardiac lesions. We describe a case of severe mitral regurgitation in a child in whom an absent left-sided pericardium with hypoplasia of left lung was found incidentally during surgery to repair the mitral valve. We believe such associations with other heart diseases is usually circumstantial but can influence the perioperative morbidity, length of hospital stay, and even alter the surgical management.

Management issues during postinfarction ventricular septal defect and role of perioperative optimization: A case series.

The development of a myocardial infarction ventricular septal rupture is a rare fatal complication, and the surgical repair is the treatment of choice. In most of the scenarios, the operation will be done as an emergency procedure that carries high mortality. Prognosis of these patients depends on prompt echocardiographic diagnosis and the proactive medical and surgical therapy. More recently, various options have been put forward including the timing for surgery, percutaneous closure devices, and the improved outcome with initial stabilization with medical treatment including mechanical support. In this retrospective case series, we are presenting the management of these patients who presented us in different clinical scenarios and trying to identify the risks for the poor outcome and to formulate a strategy to improve the outcome.

Is baseline cerebral oximetry a better predictor than carotid scan for postoperative delirium in cardiac surgery?

Guidelines recommend screening patients for carotid-artery stenosis, but unfortunately, measurement of baseline cerebral oximetry levels is still not a routine practice prior to cardiac surgery. We report a 41-year-old woman who presented with a normal carotid scan and unexpectedly low baseline cerebral oximetry levels. She had delayed postoperative recovery and discharge from hospital following her coronary-artery bypass surgery. This case report reiterates the prognostic significance of cerebral oximetry in the preoperative checkup and the association of low intraoperative values to postoperative cerebral impairment. It can also be identified as a comparatively better tool for preventing cognitive disturbances after cardiac surgery.

An unsuspected diagnosis of mucoepidermoid carcinoma of lung.

A 40-year-old man with dry cough for 5 years, no history of smoking, and a right lung mass, underwent a radiologically-guided core needle biopsy. The initial histopathological diagnosis was adenocarcinoma of the lung. After lobectomy, the final pathology was mucoepidermoid carcinoma. The initial biopsies sampled only a mucinous component of the tumor, leading to a diagnosis of adenocarcinoma. The possibility of mucoepidermoid carcinoma could be suspected on the basis of clinical history and radiologic evidence. This unusual case highlights the importance of adequate multidisciplinary review of patients who increasingly receive pathologic diagnoses based on ever smaller tissue samples.

Dilatation of the pulmonary autograft and native aorta after the Ross procedure: a comprehensive echocardiographic study.

OBJECTIVES: Dilatation of the pulmonary autograft has been observed after the Ross procedure. Whether the remaining native aorta dilates is not known. The aim of the study was to describe the prevalence and severity of autograft and native aortic dilatation over time and to identify possible determinants. METHODS: Ninety-one adult patients underwent the Ross procedure with the full root replacement technique. In 31 (34%) patients, the ascending aorta was downsized during surgical intervention. A baseline postoperative echocardiographic investigation was performed. A comprehensive investigation of the aorta from the annulus to the proximal descending aorta was performed (n = 71) after a median follow-up of 8.9 years. An intermediate investigation was performed (n = 29) after a median of 7.6 years. Autograft and native aortic dimensions were compared over time and with those of a control group (n = 38). For each patient in the study group, the expected aortic dimensions were predicted based on findings in the control group. Enlargement was defined as a z score of greater than 1.96 from the predicted value. RESULTS: The autograft and native aortic dimensions increased significantly from baseline to the intermediate follow-up and continued to increase to the final follow-up. The proportion of patients with enlarged autografts and proximal ascending aortas was 13% and 16% at baseline, increasing to 33% (P = .006) and 44% (P = .0014), respectively, at the end of follow-up. Enlargement of the aorta at the final follow-up was related to larger baseline pulmonary autograft dimensions but not to native bicuspid valve or the need to downsize the aortic root. CONCLUSIONS: Pulmonary autograft dilatation is common after the Ross procedure in adults. The dilatation progresses over time and is often accompanied by dilatation of the native aorta.

The relative contribution of prosthetic gradients, systemic arterial pressure, and pulse pressure to the left ventricular pressure in patients with aortic prosthetic valves.

AIMS: aortic valve replacement (AVR) in patients with aortic stenosis reduces the left ventricular (LV) pressure and the LV mass. However, residual LV hypertrophy at follow-up is a common finding with negative prognostic impact. In the present study, we investigate the contribution of the prosthesis (size, type, and gradients) and the load opposed by the arterial system to the mean LV pressure (MLVP). METHODS AND RESULTS: twenty-five patients with a bileaflet mechanical (n = 12, size 19-27) or stented biological (size 21-25) valve were included. After weaning from bypass, continuous Doppler recordings (transoesophageal transducer) and simultaneous LV and aortic pressure measurements were performed (high-fidelity catheters). The mean prosthesis gradients with catheter or Doppler were moderately correlated to MLVP (R(2) = 0.40 and 0.34, P = 0.002 and <0.0001). In a multiple regression model, the relationship between MLVP and prosthesis gradient, mean blood pressure, and pulse pressure was strong for both mechanical and biological valves. Using catheter prosthesis gradients, we could explain 97% of the variability in MLVP and when using Doppler gradients 91%. CONCLUSION: in the present study of patients with aortic prosthetic valves, we demonstrate the importance of the load opposed by the arterial system for the LV pressure. Our findings suggest that the MLVP can be estimated from easily obtainable Doppler data and blood pressure measurements. In analysing predictors of LV mass regression, morbidity, and mortality following AVR, the equations might be of interest.

Survival and quality of life after aortic root replacement with homografts in acute endocarditis.

BACKGROUND: Treatment of prosthetic aortic valve endocarditis and native aortic valve endocarditis with abscess formation is associated with high mortality and morbidity. Aortic root replacement with a freestanding aortic homograft is an attractive alternative. We report outcome and quality of life after homograft replacement for infective endocarditis. METHODS: Sixty-two patients with infective prosthetic valve endocarditis (n = 31) or native valve endocarditis with abscess (n = 31), operated with homograft replacement were included. Thirty-day mortality, severe operative complications (dialysis, stroke, pacemaker implantation, myocardial infarction, and prolonged mechanical ventilation), midterm survival, reoperations, and quality of life were assessed after a mean follow-up of 37 ± 11 months. RESULTS: Nine patients (15%) died within 30 days and 22 patients (35%) had severe perioperative complications. Preoperative and perioperative variables univariately associated with early mortality were higher (Cleveland Clinic risk score [p = 0.014], extracorporeal circulation time [p = 0.003], prolonged inotropic support [p = 0.03], reoperation for bleeding [p = 0.01], and perioperative myocardial infarction [p < 0.001].) Cumulative survival was 82%, 78%, 75%, and 67% at one, three, five, and ten years, respectively. One patient was reoperated due to recurrence of endocarditis nine months after surgery and one after five years due to homograft failure. Quality of life, as assessed by the 36 item short-form health survey scales for physical and mental health, was not significantly different to an age-matched and gender-matched healthy control group. CONCLUSIONS: Severe acute aortic endocarditis treated with homograft replacement is still associated with a substantial early complication rate and mortality. Long-term survival and quality of life are satisfactory in patients surviving the immediate postoperative period.

Doppler-catheter discrepancies in patients with bileaflet mechanical prostheses or bioprostheses in the aortic valve position.

The aims of the present study were to investigate in vivo Doppler-catheter discrepancies in aortic bileaflet mechanical and stented biologic valves and evaluate whether these can be predicted using Doppler echocardiography. Results of in vitro studies of bileaflet mechanical valves suggested overestimation using Doppler gradients. Findings in stented biologic valves were conflicting. Patients who underwent valve replacement with a St. Jude Medical mechanical (n = 14, size 19 to 29) or a St. Jude Medical Biocor (Biocor, n = 13, size 21 to 25) valve were included. Simultaneous continuous Doppler recordings (transesophageal transducer) and left ventricular and aortic pressure measurements were performed using high-fidelity catheters. Gradients after pressure recovery were predicted from Doppler using a validated equation. Doppler overestimated catheter gradients in both the mechanical and Biocor. Mean Doppler catheter differences for the mechanical/Biocor were for mean gradients of 4 +/- 3 (SD; p = 0.002)/6 +/- 4 mm Hg (p = 0.002). There was a strong relation between catheter and Doppler gradients (r = 0.85 to 0.92). Doppler catheter discrepancy as a percentage of the Doppler mean gradient for the mechanical was median 41% (range -30% to 76%) and for the Biocor was median 35% (range -7% to 75%). The catheter-Doppler discrepancy was not significant using the predicted net gradient from Doppler. In conclusion, this was the first in vivo investigation of prosthetic valves using simultaneous Doppler and high-fidelity catheters. Doppler overestimated catheter gradients in both mechanical and stented biologic valves. However, the discrepancy can be predicted considering pressure recovery in the aorta.

Inflammatory response and platelet activation after off-pump coronary artery bypass surgery.

BACKGROUND: Cardiac surgery induces a systemic inflammatory activation and alterations in the hemostatic cascade. The responses contribute to postoperative complications but may also have protective effects. We investigated the relationship between inflammation, hemostasis and bleeding after off-pump coronary artery bypass surgery (OPCAB). METHODS: Ten OPCAB patients were included in a prospective descriptive study. Selected markers of inflammation (IL-6, IL-8, PMN-elastase, C3a, and SC5b-9), and hemostasis (platelet count, ss-thromboglobulin, anti-thrombin, D-dimer and fibrinogen) were measured before and immediately after surgery. Postoperative bleeding was registered. RESULTS: Inflammatory variables did not alter significantly during surgery while ss-thromboglobulin concentrations increased and anti-thrombin and fibrinogen decreased. There were significant postoperative correlations between PMN-elastase and ss-thromboglobulin (r=0.82, p=0.004), between PMN-elastase and fibrinogen (r=0.69, p=0.03) and between C3a and ss-thromboglobulin (r=0.71, p=0.02). In addition, there were significant inverse correlations between postoperative bleeding and pre- and postoperative fibrinogen levels (r=-0.76, p=0.011 and r=-0.84, p=0.002 respectively), between bleeding and postoperative ss-thromboglobulin levels (r=-0.66, p=0.04) and between bleeding and postoperative PMN-elastase (r=-0.75, p=0.01). CONCLUSIONS: The results give further evidence for an association between the inflammatory response and hemostasis after cardiac surgery.

The effect of autologous fibrin sealant (Vivostat) on morbidity after pulmonary lobectomy: a prospective randomised, blinded study.

OBJECTIVE: Postoperative air leakage is the most frequent complication after pulmonary surgery. The development of modern surgical techniques has been influenced strongly by the need to manage air leakage effectively during pulmonary resection. This study evaluated the effect of using an autologous fibrin sealant (Vivostat) during lobectomy on morbidity following surgery. METHODS: This was a prospective, blinded, randomised clinical study. Patients undergoing lobectomy were enrolled into two groups (Vivostat or non-treatment control, 20 per group). Air leakage was measured over a 1-h period (using a mechanical suction pump) on the day of operation, and both air leakage and bleeding/exudation (drainage volume) were recorded every morning postoperatively until the chest tubes were removed. Personnel recording these parameters were blinded to the intervention received. RESULTS: Compared with the control group, mean bleeding/exudate volumes were significantly reduced in the Vivostat group (day 1,370 vs. 525 ml; total, 424 vs. 782 ml; both P<0.001), and drains were inserted for a shorter time (medians, 1 vs. 2 days, P=0.07). Significantly fewer patients had air leakage at any time in the Vivostat group (40 vs. 80%, P=0.02), and air leakage volumes were significantly lower compared with the control group (median differences: day of surgery: 0.6l/min, P=0.01; total 0.8l/min, P=0.03). Postoperative hospitalisation time was shorter in the Vivostat group than in the control group but the difference was not significant (0.5 days, P=0.12). CONCLUSIONS: Vivostat fibrin sealant significantly reduces post-surgical air leakage and drainage volumes following lobectomy in pulmonary surgery and is suitable for routine use in this procedure.