Adequacy of protein and calorie delivery according to the expected calculated targets: a day-by-day assessment in critically ill patients undergoing enteral feeding.

BACKGROUND: In critically ill patients requiring mechanical ventilation for longer than 48-72 h enteral nutrition (EN) should be started early. Because EN alone may be unable to reach the target nutritional requirement, supplemental parenteral nutrition (PN) should be administered. This study aimed at describing the daily rate of administered calories and proteins according to the expected calculated targets. The impact of calorie adequacy, deficit or excess on relevant clinical outcomes was explored. METHODS: A retrospective cohort study was conducted in 217 patients undergoing cardiac surgery, admitted postoperatively in intensive care unit and undergoing EN. The effective intake provided via EN, PN, oral nutritional supplements (ONS) and nonnutritional calories (NNC) was documented for a maximum of 20 days. The administered/required calorie and protein ratios (KcalA/R , ProtA/R ) were calculated daily. Patients receiving 80%-100%, <80% or >100% of KcalA/R and ProtA/R were identified. The association between mean KcalA/R between days 4-7 and 30 days' mortality was explored. RESULTS: A mean KcalA/R ratio of 92.0 ± 40.6% was ensured between days 4 and 20. During days 4-7 the 80%-100% calorie target was achieved in 26.9% of patients, whereas 44.9% were below and 28.2% over this range. EN contributed 47.1% and PN 41.2% to the total energy intake. An increase in 30-day mortality risk was documented for patients exceeding 100% of KcalA/R ratio (adjusted-hazard ratio [HR] 5.2; 95% confidence interval [CI] 1.1 -23.9; p = 0.035). CONCLUSIONS: Despite a preliminary estimate of nutritional requirement, a steady daily optimal 80%-100% KcalA/R was not ensured for all patients. EN contributed only partially to both energy and protein intakes so that PN was largely used to achieve the desired nutritional targets.

Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study.

BACKGROUND: Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients. OBJECTIVE: The aim of this study was to compare the risk of diarrhea occurrence in two cohorts of patients fed a blenderized natural food diet or commercial enteral feeding preparations, respectively. DESIGN: Retrospective cohort study. SETTING: Cardiac-Surgery Intensive Care Unit of a University Hospital. PARTICIPANTS: Two-hundred and fifteen patients admitted to the postoperative cardiac surgery intensive care unit were included, 103 fed blenderized natural enteral feeding and 112 fed commercial formulas. METHODS: Commercial enteral formulas were delivered by continuous pump administration, while natural enteral feeding by bolus 3 times per day. Diarrhea was documented in the presence of three or more evacuations of loose or watery stool (or an amount above 250 ml) per day. The presence of diarrhea was recorded daily from the beginning to the end of the enteral feeding, up to a maximum of 8 days. The unadjusted time to the first event of diarrhea between the two enteral feeding groups was compared. Adjusted comparison was then performed by fitting a multivariable Cox Proportional-Hazards model, adjusted for potential confounders for diarrhea occurrence (i.e. administration of inotropes, vasopressors, prokinetics, antibiotics, oral nutritional supplements, antifungal agents, sedatives, opioids, probiotics, laxatives). RESULTS: In unadjusted survival analysis the probability of diarrhea was significantly lower in the natural enteral feeding group (log rank test: p = 0.023). In the multivariable model patients in natural enteral feeding cohort showed a non-significant trend towards an almost halved risk of experiencing diarrhea (hazard ratio: 0.584; 95% confidence interval: 0.335-1.018; p = 0.058) compared to those fed commercial enteral feeding. CONCLUSIONS: Administration of a blenderized diet based on natural food for enteral feeding can reduce the incidence of diarrhea in cardiac surgery critically ill patients. This strategy may reduce the risk of diarrhea-associated malnutrition and systemic and local complications, also having a positive impact on nursing workload and patient wellbeing.

Midline or long peripheral catheters in difficult venous access conditions? A comparative study in patients with acute cardiovascular diseases.

BACKGROUND: Midline catheters (MCs) are commonly inserted in patients with difficult venous access (DVA) needing peripheral access. Recently, the alternative placement of ultrasound-guided long peripheral catheters (LPCs) has spread. However, no study has compared the reliability of the 2 devices. This study aims to compare the safety and reliability of MCs and LPCs in DVA patients. METHODS: A retrospective cohort study was conducted, enrolling 184 DVA patients. Polyurethane MCs and 2 lengths of polyethylene LPCs (8/10 cm and 18 cm) were compared. The independent effect of catheter type on uncomplicated catheter survival was determined through a Cox regression analysis. RESULTS: The relative incidences of overall catheter-related complications (CRCs) were 15.84 of 1,000, 10.64 of 1,000, and 6.27 of 1,000 catheter-days for 8/10 cm-LPCs, 18 cm-LPCs, and MCs, respectively. The relative incidences of catheter-related bloodstream infections were 0.72 of 1,000 for both length LPCs and 0.48 of 1,000 catheter-days for MCs. Compared to MCs, a significant increase in CRC risk for 8/10 cm LPCs (hazard ratio [HR] 5.328; 95% confidence interval [CI] 2.118-13.404; P < 0.001) was found, along with a nonsignificant trend toward an increased risk for 18 cm-LCPs (HR 2.489; 95% CI 0.961-6.448; P = 0.060). CONCLUSION: MCs allow for longer uncomplicated indwelling times than LPCs. The decision regarding which catheter to use should consider the planned duration of intravenous therapy, the patient's clinical condition, and the cost of the device.

Predictors of extubation failure after open-chest cardiac surgery based on routinely collected data. The importance of a shared interprofessional clinical assessment.

BACKGROUND: Extubation failure (ExtF) is associated with prolonged hospital length of stay and mortality in adult cardiac surgery patients postoperatively. In this population, ExtF-related variables such as the arterial partial pressure of oxygen to fraction of inspired oxygen ratio (PaO2/FiO2), rapid shallow breathing index, cough strength, endotracheal secretions and neurological function have been sparsely researched. AIM: To identify variables that are predictive of ExtF and related outcomes. METHOD: Prospective observational longitudinal study. Consecutively presenting patients ( n=205) undergoing open-heart cardiac surgery and admitted to the Cardiosurgical Intensive Care Unit (CICU) were recruited. The clinical data were collected at CICU admission and immediately prior to extubation. ExtF was defined as the need to restart invasive or non-invasive mechanical ventilation while the patient was in the CICU. RESULTS: The ExtF incidence was 13%. ExtF related significantly to hospital mortality, CICU length of stay and total hospital length of stay. The risk of ExtF decreased significantly, by 93% in patients with good neurological function and by 83% in those with a Rapid Shallow Breathing Index of ≥57 breaths/min per litre. Conversely, ExtF risk increased 27 times when the PaO2/FiO2 was <150 and 11 times when it was ≥450. Also, a reassuring PaO2/FiO2 value may hide critical pulmonary or extra-pulmonary conditions independent from alveolar function. CONCLUSION: The decision to extubate patients should be taken after thoroughly discussing and combining the data derived from nursing and medical clinical assessments. Extubation should be delayed until the patient achieves safe respiratory, oxygenation and haemodynamic conditions, and good neurocognitive function.

Delirium after cardiac surgery. Incidence, phenotypes, predisposing and precipitating risk factors, and effects.

BACKGROUND: In cardiac surgical patients little is known about different phenotypes of delirium and how the symptoms fluctuate over time. OBJECTIVES: Evaluate risk factors, incidence, fluctuations, phenotypic characteristics and impact on patients' outcomes of delirium. METHODS: Prospective longitudinal study. In postoperative intensive care unit 199 patient were assessed three-times a day through an adapted versions of the Intensive Care Delirium Screening Checklist. RESULTS: Delirium and subsyndromal delirium incidence were 30.7% and 31.2%, respectively. Delirium manifested mostly in the hypoactive form and showed a fluctuating trend for several days. Atrial fibrillation, benzodiazepine/opioids dosages, hearing impairment, extracorporeal circulation length, SAPS-II and mean arterial pressure were independent predictors for delirium. Delirium was a statistically significant predictor of chemical/physical restraint use and hospital length of stay. CONCLUSIONS: Given the fluctuating and phenotypic characteristics, delirium screening should be a systematic/intentional activity. Multidisciplinary prevention strategies should be implemented to identify and treat the modifiable risk factors.

Tunnelling a midline catheter: When the traffic light shifts from yellow to green.

INTRODUCTION:: A safe, largely used practice for difficult venous access patients is positioning a catheter in deeper veins under ultrasound guide. However, the risk of complications is increased when there is a high catheter-to-vein ratio or when the insertion site is in a zone with particular anatomical/physiological characteristics. CASE DESCRIPTION:: A 60-year-old woman admitted to a post-operative intensive care unit after cardiac surgery had a complicated post-operative course. After the removal of a central venous catheter, it was necessary to insert a midline catheter. A complete ultrasound evaluation showed that only the axillary vein was suitable for direct cannulation. To avoid creating an exit site in the axillary cavity, the decision was made to tunnel the catheter to locate an exit site in a safer position. A guidewire was introduced through a needle in the axillary vein. A tunnel was created using a subcutaneous injection of lidocaine. A 14 G/13.3 cm peripheral venous catheter was inserted in the subcutaneous tract. A 4 Fr/20 cm catheter was introduced through the peripheral venous catheter and moved to the axillary vein through the previously inserted sheath. No acute complications occurred. The catheter was accessed several times a day during the period following its insertion to infuse drugs and take blood samples. It was removed 50 days after its placement because it was no longer needed. No symptomatic thrombosis or infections occurred. CONCLUSION:: The placement of the tunnelled midline catheter is shown to be a safe and effective way to ensure vascular access for almost 2 months.

A risk factor analysis for in-hospital mortality after surgery for infective endocarditis and a proposal of a new predictive scoring system.

PURPOSE: Risk stratification is of utmost importance for patients with infective endocarditis (IE) who need surgery. However, for these critically ill patients, aspecific scoring systems are used to predict the risk of death after surgery. The aim of this study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE and to create a mortality risk score based on the results of this analysis. METHODS: Outcomes of 138 consecutive patients (mean age 60.6 ± 8.5 years) who had undergone surgery for IE in an Italian cardiac surgery center between 1999 and 2015 were reviewed retrospectively and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver-operating characteristic (ROC) curve analysis. RESULTS: Twenty-eight (20.3%) patients died in hospital following surgery. Anemia [odds ratio (OR) 11.0, p = 0.035), New York Heart Association class IV (OR 2.61, p = 0.09), critical state (OR 4.97, p = 0.016), large intracardiac destruction (OR 6.45, p = 0.0014), and surgery of the thoracic aorta (OR 7.51, p = 0.041) were independent predictors of hospital death. A new scoring system was devised to predict in-hospital death after surgery for IE (area under ROC curve, 0.828, 95% confidence interval, 0.754-0.887). The score outperformed six of seven scoring systems, for early death after cardiac surgery, that were considered. CONCLUSIONS: A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk after surgery for IE. Prospective studies are needed for the score validation.

Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes.

BACKGROUND: Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting in women. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender. METHODS: Of 786 consecutive women with multivessel coronary disease who underwent isolated coronary bypass surgery at the authors' institution from 1999 throughout 2014, 477 (60.7%; mean age: 70±7.7years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models. RESULTS: There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2±6.1%); glomerular filtration rate<50ml/min was an independent risk factor (p=0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index >35kg/m2 (p=0.0094), diabetes (p=0.005), non-elective surgical priority (p=0.0087) and multiple blood transfusions (p=0.016). The mean follow-up was 6.8±4.5years. The non-parametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1-79.1], 59.5 (95% CI: 55.9-63.1) and 91.9% (95% CI: 90.1-93.7), respectively. Preoperative congestive heart failure (p=0.04) and left main coronary artery disease (p=0.0095) were predictors of major adverse cardiac and cerebrovascular events. CONCLUSIONS: BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes.

Urgent Coronary Revascularization with Bilateral Internal Thoracic Artery Grafting: Is the Risk Justified?

Background The frequent need of immediate institution of cardiopulmonary bypass because of ischemia and increased risk of bleeding and longer duration of surgery limit the use of bilateral internal thoracic artery (BITA) grafting in urgency. Patients and Methods Of 4,525 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution (1999-September 2015), 121 (2.7%) patients had an operation before the beginning of the next working day after decision to operate, which is the definition for emergency according to the European System for Cardiac Operative Risk Evaluation II. BITA and single internal thoracic artery (SITA) grafting were used in 52 and 46 of these patients, respectively; venous grafts alone were used in the remaining cases. BITA and SITA patients were compared as risk profiles, operative data, and outcomes. A propensity score (PS)-matched analysis was also performed. Results Between BITA and SITA patients, there was no significant difference as hospital mortality, both in the overall (3.8 vs. 6.5%; p = 0.66) and the PS-matched series (0 vs. 4.3%; p = 1). Among the postoperative complications, only bleeding (but not blood transfusion nor mediastinal re-exploration) was increased both in the overall (p = 0.037) and the PS-matched series of BITA patients (p = 0.092); duration of surgery was increased but not quite significantly (p = 0.12). Freedom from cardiac and cerebrovascular deaths, and major adverse cardiac and cerebrovascular events were higher in PS-matched BITA patients, even though not quite significantly (p = 0.11 for both). Conclusion BITA grafting may be performed even in urgency. With respect to SITA grafting, hospital mortality and postoperative complications other than bleeding are not increased; late outcomes seem to be better.

Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery.

OBJECTIVES: To analyze success rate, dwell-time, and complications of long peripheral venous catheters (L-PVCs) inserted under ultrasound guidance. BACKGROUND: In difficult venous access (DVA) patients, L-PVC can represent an alternative to central or midline catheters. METHODS: Prospective observational study. L-PVCs were positioned in DVA patients. The outcome of the cannulation procedure and the times and reasons for catheters removal were analyzed. RESULTS: A 100% placement success rate was documented. The catheter dwell-time was 14.7 ± 11.1 days. Most catheters were removed at end-use in the absence of complications. The rate of catheters appropriately or inappropriately removed before completing the intravenous therapies was 27.7/1000 catheter-days. Two thrombophlebitis (1.91/1000 catheter-days) and 1 catheter-related bloodstream infection (0.96/1000 catheter-days) occurred. CONCLUSIONS: L-PVC could be a viable solution in DVA patients, as it may reduce the need for multiple vein punctures, patients' discomfort, and nursing workload. A better adherence to catheter management recommendations should further reduce complications.

Bilateral internal thoracic artery grafting in octogenarians: where are the benefits?

The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization is usually discouraged in the very elderly because of increased risk of perioperative complications. The aim of the study was to analyze early and late outcomes of BITA grafting in octogenarians. From January 1999 throughout February 2014, 236 consecutive octogenarians with multivessel coronary artery disease underwent primary isolated coronary bypass surgery at the authors' institution. Six of these patients underwent emergency surgery and were excluded from this retrospective study; consequently, 135 BITA patients were compared with 95 single internal thoracic artery (SITA) patients according to early and late outcomes. Between BITA and SITA patients, there was no significant difference in the operative risk (EuroSCORE II: 8 ± 7.7 vs. 7.6 ± 6.1 %, p = 0.65). There was a lower aortic manipulation in BITA patients. Hospital mortality (3 vs. 4.2 %, p = 0.44) and perioperative complications were similar except that only BITA patients experienced sternal wound infection (5.2 %, p = 0.022). The mean follow-up was 4.7 ± 3.3 years. There were no differences between the two groups in overall survival (p = 0.79), freedom from cardiac and cerebrovascular deaths (p = 0.73), major adverse cardiac and cerebrovascular events (p = 0.63) and heart failure hospital readmission (p = 0.64). Predictors of decreased late survival were diabetes (p = 0.0062) and congestive heart failure (p = 0.0004). BITA grafting can be routinely used in octogenarians with atherosclerotic ascending aorta without an increase in hospital mortality or major adverse cardiac and cerebrovascular complications. However, there is an increased risk of sternal wound infection without a demonstrable long-term benefit.

Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction.

Despite encouraging improvements, outcomes of coronary artery bypass grafting (CABG) in the presence of left ventricular (LV) dysfunction remain poor. In the present study, the authors' experience on this subject was reviewed to establish the predictors of immediate and long-term results of surgery. Out of 4383 consecutive patients with multivessel coronary artery disease who underwent primary isolated CABG at the authors' institution from January 1999 throughout September 2014, 300 patients (mean age 66.1 ± 9.6 years) suffered preoperatively from LV dysfunction (defined as LV ejection fraction ≤35 %). The mean expected operative risk (EuroSCORE II) was 10.3 ± 13 %. Hospital deaths and perioperative complications were analyzed retrospectively. Outcomes were evaluated during a mean follow-up of 6.2 ± 4 years. None, one or both internal thoracic arteries (ITAs) were used in 6.3, 29 and 64.7 % of cases, respectively. There were 16 (5.3 %) hospital deaths. Prolonged invasive ventilation (17.7 %), acute kidney injury (14.7 %) and multiple blood transfusion (21.3 %) were the most frequent major postoperative complications. The 10-year non-parametric estimates of freedom from all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were 47.8 [95 % confidence interval (CI) 44.1-51.5], 65.3 (95 % CI 61.4-69.2), and 42.3 % (95 % CI 38.3-46.3), respectively. Shared predictors of decreased late survival and MACCEs were old age (P < 0.04), chronic lung disease (P < 0.01), chronic dialysis (P < 0.0001) and extracardiac arteriopathy (P < 0.045). After adjustment for corresponding risk factors, freedom from cardiac death was higher when both ITAs were used but only for patients with significant increase of LV ejection fraction early after surgery (P = 0.04). In patients with LV dysfunction, CABG may be performed with acceptable hospital mortality and long-term survival. Late outcomes depend mainly on preoperative characteristics of the patients. The use of both ITAs for myocardial revascularization may give long-term survival benefits but only for patients whose LV function improves significantly early after surgery.

Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes.

OBJECTIVES: Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal complications. In the present study, early and long-term outcomes of the routine use of left-sided BITA grafting in insulin-dependent diabetic patients were reviewed retrospectively. METHODS: Among the 2701 consecutive patients who underwent isolated BITA grafting at the authors' institution from 1999 throughout 2012, 188 (mean age: 67 ± 9 years) were insulin-dependent diabetic patients. The mean expected operative risk, calculated according to the European System for Cardiac Operative Risk Evaluation II, was 11 ± 10.8%. RESULTS: There were 6 (3.2%) hospital deaths. Prolonged invasive ventilation (17.6%), multiple transfusion (16.5%), deep sternal wound infection (DSWI, 11.7%) and acute kidney injury (10.6%) were the most frequent major postoperative complications. Chronic lung disease (P = 0.08), low cardiac output (P = 0.039), multiple transfusion (P = 0.034) and mediastinal re-exploration (P = 0.071) were risk factors for DSWI. The mean follow-up was 5.7 ± 3.6 years. The 10-year non-parametric estimates of overall survival, freedom from cardiac and cerebrovascular death, and major adverse cardiac and cerebrovascular events were 57.7 [95% confidence interval (CI): 45.1-66.2], 83.6 (95% CI: 76.6-90.7) and 55.4% (95% CI: 44.7-66.1), respectively. Predictors of decreased late survival were old age (P = 0.013), chronic lung disease (P = 0.004), renal impairment (P = 0.009) and left ventricular dysfunction (P = 0.035). CONCLUSIONS: Left-sided BITA grafting may be performed routinely even in insulin-dependent diabetic patients. The increased rates of postoperative complications do not prevent low early mortality and good long-term outcomes.

Circulating cardiac biomarkers and postoperative atrial fibrillation in the OPERA trial.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and predicts increased morbidity and mortality. Identification of patients at high risk of POAF with the help of circulating biomarkers may enable early preventive treatment but data are limited, especially in contemporary surgical patients. METHODS: Plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) were measured at enrollment, on the morning of cardiac surgery, at end surgery, and 2 days postsurgery in 562 patients undergoing cardiac surgery, randomized to perioperative supplementation with oral fish oil or placebo in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation trial (OPERA). The primary endpoint was incident POAF lasting ≥ 30 s, centrally adjudicated and confirmed electrocardiographically. RESULTS: Higher levels of NT-proBNP and hs-cTnT before surgery were associated with older age, renal or cardiac dysfunction and EuroSCORE. NT-proBNP peaked on postoperative day 2 (2172 [1238-3758] ng/L, median [Q1-Q3]), while hs-cTnT peaked at the end of surgery (373 [188-660] ng/L). Fish oil supplementation did not alter the time course of the cardiac biomarkers (P > 0.05). Concentrations of NT-proBNP or hs-cTnT, on the morning of surgery, or changes in their level between morning of surgery and postsurgery, were not significantly associated with POAF after adjustment for clinical and surgical characteristics. CONCLUSION: Among patients undergoing cardiac surgery, NT-proBNP and hs-cTnT are related to clinical and surgical characteristics, have different perioperative time courses but are not independently associated with risk of POAF.

Idiopathic dilated cardiomyopathy and persistent viral infection: lack of association in a controlled study using a quantitative assay.

BACKGROUND: It remains unclear whether idiopathic dilated cardiomyopathy (DCM) might ensue as the consequence of viral myocarditis, due to viral persistence in cardiomyocytes. To address this issue, we quantified the levels of enterovirus, Epstein-Barr virus (EBV), Herpes Simplex Virus-1 (HSV-1), Herpes Simplex Virus-2 (HSV-2), adenovirus and parvovirus B19 genomes in endomyocardial biopsies (EMBs) from patients with DCM, active myocarditis and controls. METHODS: Real-time polymerase chain reaction (PCR)-based methods using TaqMan probes were developed for the quantitative detection of viral genomes in EMBs from 35 patients with DCM and 17 with active myocarditis. A control group included 20 surgical patients with valve or coronary artery disease. RESULTS: None of the 72 samples tested positive for enteroviruses, EBV, HSV-1 or -2. One DCM patient tested positive for adenovirus. Of notice, 20/52 (38%) of patients with cardiomyopathy and 8/20 (40%) of controls were positive for parvovirus B19; no significant differences in viral titre were detected between groups. CONCLUSIONS: Our preliminary results disfavour the hypothesis that persistent myocardial viral infection might be a frequent cause of DCM. The detection of parvovirus B19 from both cardiomyopathy and non-cardiomyopathy patients supports the notion that this virus is widely spread in the population.

Methylprednisolone infusion for life-threatening H1N1-virus infection.

BACKGROUND: During winter 2009 we treated with prolonged corticosteroid infusion eight consecutive patients affected by H1N1-virus infection and severe pneumonia. The most severe patient was a previously healthy 30-year-old man admitted to hospital because of bilateral pneumonia and severe acute respiratory failure. METHOD: H1N1-virus infection was detected by broncho-alveolar lavage performed on day 1. After some days following admission the patient was still in a life-threatening state, not responding to oseltamivir, protective mechanical ventilation and veno-arterial extracorporeal membrane oxygenation (ECMO). RESULTS: The addition of methylprednisolone infusion at a stress dose (1 mg/kg/24 h) as rescue therapy significantly and rapidly improved the clinical condition. Weaning from ECMO and invasive mechanical ventilation was possible within a relatively few days. CONCLUSION: According to the literature reports more than 34% of H1N1-virus severe infections were treated with corticosteroids. This report and our experience may suggest a possible life-saving use of corticosteroids at a stress dose in severely ill patients with an H1N1-virus infection that is not responding to the most advanced treatments.

Increased expression and secretion of resistin in epicardial adipose tissue of patients with acute coronary syndrome.

The purpose of this study was to test the hypothesis that specific epicardial adipose tissue (EAT) proinflammatory adipokines might be implicated in acute coronary syndrome (ACS). We compared expression and protein secretion of several EAT adipokines of male ACS with those of matched stable coronary artery disease (CAD) patients and controls with angiographically normal coronary arteries. The effect of supernatant of cultured EAT on endothelial cell permeability in vitro was also evaluated in the three study groups. EAT of ACS patients showed significantly higher gene expression and protein secretion of resistin than patients with stable CAD. Interleukin-6, plasminogen activator inhibitor-1, and monocyte chemoattractant protein-1 genes were also significantly overexpressed in ACS compared with the control group but not when compared with stable CAD. Immunofluorescence of EAT sections revealed a significantly greater number of CD68(+) cells in ACS patients than stable CAD and control groups. The permeability of endothelial cells in vitro was significantly increased after exposure to supernatant of cultured EAT from ACS, but not control or stable CAD groups, and this effect was normalized by anti-resistin antiserum. We found that EAT of patients with ACS is characterized by increased expression and secretion of resistin and associated with increased in vitro endothelial cell permeability.

Current role and outcomes of ascending aortic replacement for severe nonaneurysmal aortic atherosclerosis.

BACKGROUND: Severe atherosclerosis of the ascending aorta is a challenging issue potentially affecting indications for surgery, operative choices, and patients' outcome. No standard treatment has emerged to date, and uncertainties persist about criteria for selecting patients and procedures. METHODS: Replacement of the atherosclerotic ascending aorta was performed in 64 patients at time of either aortic (n = 49), mitral (n = 21), or tricuspid (n = 7) valve surgery. Coronary artery bypass grafting was performed in 53 patients, and the majority of patients underwent combined procedures (n = 49). Mean age was 72.0 +/- 7.6 years. The expected operative mortality, by logistic European System for Cardiac Operative Risk Evaluation, was 29.0% accounting for ascending aortic replacement and 13.1% disregarding it. Circulatory arrest under deep hypothermia, eventually combined with either retrograde or antegrade brain perfusion, was required in 61 cases. RESULTS: Early death, stroke, and myocardial infarction rates were 10.9%, 6.3%, and 7.8%, respectively. Factors univariately associated with early deaths were preoperative renal failure requiring dialysis (p = 0.001) and longer cardiopulmonary bypass (p = 0.001) and cardioplegia (p = 0.008) times. Cumulative survival at 1, 3, and 5 years was 86% +/- 4%, 74% +/- 6%, and 68% +/- 8%, respectively. CONCLUSIONS: Replacement of the atherosclerotic ascending aorta can be carried out at acceptable mortality rates despite the high rates of preoperative comorbidity and the significant incidence of postoperative complications.

Early and late outcomes of cardiac surgery in octogenarians.

BACKGROUND: Expanding demand for cardiac surgery in the elderly requires constant assessment of selection criteria and outcomes. METHODS: Records of consecutive patients 80 years old or greater (n = 355) having cardiac operations from September 1998 through May 2007 were reviewed. There were 172 isolated coronary bypass grafting (CABG), 73 isolated valve, 79 valve and CABG combined, and 31 other procedures. RESULTS: Thirty-three (9.3%) deaths and 13 (3.7%) strokes occurred during the index hospital stay. Intensive care unit and hospital length of stay lasted 6.3 +/- 14.3 and 15.5 +/- 20.8 days, respectively. Overall cumulative 5-year survival was 65.5 +/- 3.3%, varying among procedures as follows: 67.9 +/- 4.4% for isolated CABG, 64.6 +/- 8.9% for valve surgery, 60.3 +/- 7.3% for combined coronary and valve surgery, and 63 +/- 10.7% for other procedures (p = 0.23). Ninety-seven percent of survivors lived at home. Risk factors for hospital death were emergency status, preoperative renal dysfunction, and postoperative complications such as myocardial infarction, cardiac failure requiring intraaortic balloon pumping, acute renal failure requiring replacement therapy, stroke, and ventilator dependency exceeding 48 hours. Among hospital survivors, risk factors for late death were carotid artery disease, chronic lung disease, renal dysfunction, and the occurrence of postoperative complications. CONCLUSIONS: Long-term survival of octogenarians submitted to a wide variety of cardiac operations was satisfactory despite substantial rates of early complications and deaths. Most survivors were free from cardiac symptoms. Postoperative complications were stronger risk factors for hospital deaths than preoperative comorbidities and procedural variables. Their impact on long-term survival was also significant.

Mild inflammatory activation of mammary arteries in patients with acute coronary syndromes.

Acute coronary syndromes (ACS) are characterized by multiple unstable coronary plaques and elevated circulating levels of inflammatory biomarkers. The endothelium of internal mammary arteries (IMA), which are atherosclerosis resistant, is exposed to proinflammatory stimuli as vessels that develop atherosclerosis. Our study investigated the IMA endothelial expression of inflammatory molecules in patients with ACS or chronic stable angina (CSA). IMA demonstrated normal morphology, intact endothelial lining, and strong immunoreactivity for glucose transporter 1. E-selectin expression was observed more frequently in IMA of ACS patiention than CSA patients (ACS 61% vs. CSA 14%, P = 0.01). High fluorescence for major histocompatibility complex (MHC) was significantly more frequent on the luminal endothelium (ACS 66.7% vs. CSA 17.6%, P = 0.001 for class I; and ACS 66.7% vs. CSA 6.2%, P = 0.0003 for class II-DR) and on the vasa vasorum (ACS 92.9% vs. CSA 33.3% and 7.7%, P = 0.0007 and P < 0.0001 for class I and class II-DR, respectively) of ACS patients than CSA patients. ICAM-1, VCAM-1, Toll-like receptor 4, tissue factor, IL-6, inducible nitric oxide synthase, and TNF-alpha expression were not significantly different in ACS and CSA. Circulating C-reactive protein [ACS 4.8 (2.6-7.3) mg/l vs. CSA 1.8 (0.6-3.5) mg/l, P = 0.01] and IL-6 [ACS 4.0 (2.6-5.5) pg/ml vs. CSA 1.7 (1.4-4.0) pg/ml, P = 0.02] were higher in ACS than CSA, without a correlation with IMA inflammation. The higher E-selectin, MHC class I and MHC class II-DR on the endothelium and vasa vasorum of IMA from ACS patients suggests a mild, endothelial inflammatory activation in ACS, which can be unrelated to the presence of atherosclerotic coronary lesions. These findings indicated IMA as active vessels in coronary syndromes.