Short-Term Outcomes and Risk Factors of In-Hospital Mortality in Patients Suffering Acute Mesenteric Ischemia after Cardiac Surgery: Role of Opioids and Lactic Acid.

Acute mesenteric ischemia (AMI) is associated with poor clinical results after cardiac surgery. The aim of this study was to analyse the influence of AMI on short-term outcomes and all relevant risk factors of in-hospital mortality after cardiac surgery. Moreover, we aimed to investigate the role of opioids and lactic acid in the detection and prevention of AMI. Between August 2011 and September 2015, 176 consecutive patients with gastrointestinal complications after undergoing open-heart surgery were identified and included in this study. All patients were divided into two groups: AMI group (n = 39) and non-AMI group (n = 137). In terms of comorbidities, the groups were fairly equal and showed no significant differences. Dialysis was significantly higher (p < 0.001) in patients that suffered from AMI. Moreover, gastro-intestinal symptoms such as muscular defense (p = 0.004) and the laparotomy rate (p < 0.001) were significantly higher in the AMI group. Likewise, in-hospital mortality (p < 0.001) was significantly higher in patients with detected AMI. Univariate (p < 0.001) and multivariate analysis (p = 0.025) of both groups revealed that lactic acid value >2 mmol/L and present treatment with opioids are independent combined predictors of mesenteric ischemia in patients after undergoing cardiac surgery. Moreover, multivariate analysis showed peripheral vascular disease (p = 0.004), dialysis (p = 0.010), and septic shock (p = 0.003) as relevant predictors of in-hospital mortality. Prolonged analgetic treatment with opioids and sudden increase of lactic acid levels are independent combined predictors of mesenteric ischemia in patients after undergoing cardiac surgery. Furthermore, peripheral vascular disease, dialysis, and septic shock are relevant predictors for in-hospital mortality.

High Incidence of Transient Permanent Pacemaker Rate After Rapid Deployment Valve Replacement: Insights of a 9-Year Single-Centre Experience.

INTRODUCTION: The incidence of new permanent pacemaker implantation (PPI) after rapid deployment aortic valve replacement (RDAVR) remains debated. Expertise in this field has significantly increased over the last decade. This study aimed to investigate the need for PPI following implantation of a rapid deployment (RD) valve. METHODS: Analysis of n=372 patients who underwent Edwards INTUITY (Edwards Lifesciences, Irvine, CA, USA) (n=251) and Perceval (Sorin/LivaNova Group, Saluggia, Italy) (n=121) valve replacement at the current institution between May 2012 and August 2018 was performed. Coronary artery bypass graft procedures were additionally performed in patients with coronary artery disease. Baseline, preoperative and postoperative outcomes were examined regarding correctness and completeness of the procedure. Statistical analysis was performed using SPSS Version 23.0.0 (IBM Corp, Armonk, NY, USA). RESULTS: A total of 372 patients (aged 75±6.3 yrs) with a high grade of aortic valve stenosis underwent either Edwards INTUITY (67%) or Perceval (33%) valve replacement. Seventy-six (76) patients (20%) presented with preoperative conduction disorders. Sixty (60) patients (16%) underwent PPI, which in most cases was performed during the first month after the initial operation. Follow-up was performed up to 9 years, presenting a persistent pacemaker dependency rate of 50% among all patients who underwent PPI. Twenty (20) (40%) PPI recipients showed no dependency on pacemaker, while 10 (10%) required temporary pacemaker support. Mean length of ICU stay was 4±5.1 days and in-hospital stay was 8.2±7.6 days. CONCLUSIONS: The incidence of PPI after RD valve implantation still remains high compared with conventional aortic valve replacement. However, this study shows that this phenomenon appears to be transient in a significant proportion of the patients undergoing RD valve replacement. These findings might contribute to the scientific discussion and should be taken into consideration for the indication of RD valve replacement.

"A Stab in the Heart" Caused by a Cement Fragment After Kyphoplasty.

Kyphoplasty is a well-established method to treat symptomatic vertebral compression fractures. Reported local cement leakage rates are high, but clinically relevant leakages are rare. A fatal complication is the extravasation of cement to the venous system with cardiopulmonary manifestation. We report a case with right ventricular perforation caused by leaked cement fragments. (Level of Difficulty: Beginner.).

Impact of Obesity on In-Hospital Outcomes in Veno-Arterial ECMO Patients.

BACKGROUND: Obesity is known to impact outcomes of patients undergoing in-patient care in general. The association between veno-arterial extracorporeal membrane oxygenation (VA ECMO) and obesity-related outcomes remains unclear. Therefore, we sought to investigate weight-associated differences of patients treated with VA ECMO. METHOD: A retrospective study was performed for patients who required veno-arterial (VA) ECMO support at our tertiary ECMO centre between 1 March 2006 and 28 February 2017. Patients were categorised according to Body-Mass-Index (BMI) associated values in six groups (underweight, normal range, overweight, obese class I-III). Further, patients were divided into non-obese (18.5-29-9 kg/m2) and obese (≥30 kg/m2) groups and analysed concerning baseline, ECMO-related, and general outcome parameters. RESULTS: A total of 244 patients required VA ECMO support during the study period. Subgroup-analysis of BMI-category associated impact on in-hospital mortality showed the highest incidence of mortality in obese class II patients (93%) with a significant difference between overweighted patients. Non-obesity was present in 179, whereas 59 patients suffered obesity. Obese patients were significantly older (p=0.022) and suffered significantly more diabetes (21% non-obese vs 48% obese; p<0.001). Indication for support, laboratory parameters prior to ECMO, and ECMO-related outcomes did not differ between the groups. Obese patients showed a trend towards higher in-hospital mortality (70% non-obese vs 81% obese; p=0.085). CONCLUSIONS: Obesity is associated with comparable outcomes to non-obese patients, showing a tendency of higher mortality. Obese class II patients presented the highest risk of death compared to all BMI categories.

VEGF Contributes to Mesenchymal Stem Cell-Mediated Reversion of Nor1-Dependent Hypertrophy in iPS Cell-Derived Cardiomyocytes.

Myocardial hypertrophy is present in many heart diseases, representing a strong predictor of adverse cardiovascular outcomes. Regarding therapeutic intervention, mesenchymal stem cells (MSCs) have been suggested to significantly reduce cardiac hypertrophy and progression to heart failure. Preconditioning of MSCs was previously demonstrated to highly improve their paracrine activity resulting in modulation of immune responses and the progression of diseases. Here, we studied the effects of bone marrow-derived preconditioned MSCs on hypertrophied induced pluripotent stem cell-derived cardiomyocytes (iPS-CM) and also sought to identify MSC-derived antihypertrophic molecules. Phenylephrine (PE) was used to induce hypertrophy in murine iPS-CM, and markers of hypertrophy were identified by microarray analysis. Murine MSCs were treated with IFN-γ and IL-1ß to enhance their paracrine activity, and transcriptional profiling was performed by microarray analysis. Hypertrophied iPS-CM were subsequently cocultured with preconditioned MSCs or MSC-conditioned medium (CM), respectively. Effects on hypertrophied iPS-CM were studied by cell area quantification, real-time PCR, and western blot. In some experiments, cells were incubated with fractions of MSC-CM obtained by ultrafiltration or by MSC-CM supplemented with inhibitory antibodies. Intracellular and extracellular levels of vascular endothelial growth factor (VEGF) were evaluated by western blot and ELISA. PE-induced hypertrophy in iPS-CM was associated with an upregulation of neuron-derived orphan receptor (Nor1) expression, activation of Akt, and inhibition of both strongly prevented hypertrophy induction in iPS-CM. VEGF secreted by preconditioned MSCs provoked hypertrophy regression in iPS-CM, and a negative correlation between Nor1 expression and hypertrophic growth could be evidenced. Our results demonstrate that Nor1 expression strongly supports hypertrophy in iPS-CM. Moreover, the secretome of preconditioned MSCs triggered regression of hypertrophy in iPS-CM in a VEGF-dependent manner. We suggest that the delivery of the MSC-derived secretome may represent a therapeutic strategy to limit cardiac hypertrophy. However, additional in vivo studies are needed to prove this hypothesis.

Gender-related differences in treatment and outcome of extracorporeal cardiopulmonary resuscitation-patients.

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to significant improvement in selected patients' survival rates. Gender-related differences might impact the outcome of therapeutic measures. Therefore, we sought to investigate patients with eCPR at our interdisciplinary extracorporeal membrane oxygenation center regarding sex-related differences with the view to potentially adjusting current selection criteria. From January 2016 to December 2019, 71 patients underwent eCPR at our institution. Data before eCPR and early outcome parameters were analyzed comparing male and female patients. The cohort analyzed consisted of 60 male (84%) and 11 female (15%) patients. Comparing both groups, male patients significantly more frequently suffered out-of-hospital cardiac arrest (68% male vs. 36% female, P = .04), whereas female patients were associated with more in-hospital cardiac arrest (32% male vs. 64% female, P = .04). Creatinine levels differed significantly (1.5 (1.1;2.1) mg/dL in male vs. 1.0 (0.7;1.5) mg/dL in female patients, P = .03). Also, several hepatic parameters showed a significant difference between the groups: aspartate aminotransferase 423 (249;804) U/L in male vs. 115 (61;408) U/L in female patients, P = .01; alanine aminotransferase 174 (102;446) U/L in male vs. 86 (36;118) U/L in female patients, P = .01). Renal failure requiring hemodialysis occurred more frequently in men than in women (P < .01). There is a significant effect of male sex regarding renal failure with subsequent continuous venovenous hemodialysis (CVVH) (R2  = 0.11, ANOVA P = .01, 95% CI = -0.79--0.079). However, in-hospital mortality was comparable between the groups (78% in male vs. 72% in female patients, P = .68). Our retrospective study showed several gender-related differences associated with different cardiac arrest scenarios. Male sex was associated with a significantly higher risk for renal failure requiring CVVH. Survival rates were comparable between the groups. Further investigations should include gender in the evaluation of risk stratification for eCPR-related complications to further improve selection criteria for this demanding therapy.

Minimally invasive resection of a giant left atrial myxoma: a case report.

Cardiac tumors are a rarity. Most diagnosed primary tumors of the heart are benign, with an incidence ranging between 0.001% and 0.03%. Cardiac myxoma is one of these benign entities. A 44-year-old Caucasian woman who presented with symptoms of a common cold was diagnosed with a massive obstructing myxoma of the left atrium. Despite its large size, the tumor was completely removed using minimally invasive access through right anterior thoracotomy. However, the myxoma was adherent to the left atrial septum and was excised in toto. Pathological examinations confirmed the diagnosis of a primary cardiac myxoma. Total resection of obstructive cardiac myxomas is the therapy of choice, whereas minimally invasive surgical approach might be feasible despite large size and septal localization, but is technically challenging.

Preconditioning of bone marrow-derived mesenchymal stem cells highly strengthens their potential to promote IL-6-dependent M2b polarization.

BACKGROUND: During the last decade, mesenchymal stem cells (MSCs) have gained much attention in the field of regenerative medicine due to their capacity to differentiate into different cell types and to promote immunosuppressive effects. However, the underlying mechanism of MSC-mediated immunoregulation is not fully understood so far. Macrophages are distinguished in classical activated, pro-inflammatory M1 and alternatively activated M2 cells, which possess different functions and transcriptional profiles with respect to inflammatory responses. As polarization is not fixed, macrophage functional plasticity might be modulated by the microenvironment allowing them to rapidly react to danger signals and maintaining tissue homeostasis. METHODS: Murine MSCs were preconditioned with IL-1ß and IFN-É£ to enhance their immunosuppressive capacity regarding macrophage polarization under M1- and M2a-polarizing conditions. Macrophage polarization was analyzed by real-time PCR, flow cytometry, and cytokine detection in culture supernatants. The role of MSC-derived nitric oxide (NO), prostaglandin E2 (PGE2), and IL-6 in this process has been evaluated using siRNA transfection and IL-6 receptor-deficient macrophages, respectively. RESULTS: Preconditioned, but not unprimed, MSCs secreted high levels of NO, IL-6, and PGE2. Co-culture with macrophages (M0) in the presence of M1 inducers (LPS + IFN-É£) led to significant reduction of CD86 and iNOS protein in macrophages and diminished TNF-α secretion. Additionally, CD86 and iNOS protein expression as well as NO and IL-10 secretion were markedly increased under M2a-polarizing culture conditions (IL-4). MSC-dependent macrophage polarization did not depend on direct cell-cell contact. Co-culturing in the presence of LPS and IFN-É£ resulted in the upregulation of M2a, M2b, and M2c marker genes, whereas in the presence of IL-4 only M2b markers were significantly increased. In turn, IL-10-producing regulatory M2b cells significantly inhibited IFN-É£ expression in CD4+ T lymphocytes. Finally, we show that MSC-mediated macrophage polarization strongly depends on IL-6, whereas a minor role for NO and PGE2 was found. CONCLUSIONS: Preconditioning of MSCs highly strengthens their capacity to regulate macrophage features and to promote immunosuppression. Repression of M1 polarization during inflammation and M2b polarization under anti-inflammatory conditions strongly depend on functional IL-6 signaling in macrophages. The potential benefit of preconditioned MSCs and IL-6 should be considered for future clinical treatment.

Implicit attitudes toward violence among male perpetrators of intimate partner violence: a preliminary investigation.

Whereas cognitive variables are hypothesized to play an important role in intimate partner violence (IPV) etiology and intervention, cognitive assessment methods have largely targeted offenders' explicit, controlled cognitive processing using paper-and-pencil questionnaires prone to social desirability biases. Using an implicit measure of attitudes (the Implicit Association Test [IAT]), we assessed attitudes toward gender, violence, and the association between gender and violence among 50 men enrolled in an IPV treatment program and a comparison sample of 40 nonviolent (NV) men. Although no group differences were noted on explicit attitudinal measures, men in the IPV group showed more positive implicit attitudes regarding violence, and a more rapid association between women and violence. Among men in treatment for IPV, the attitudes toward violence IAT was significantly correlated with self/partner-reported IPV frequency. In accordance with social information processing models of aggression, these results suggest that aggressogenic attitudes are likely to operate automatically and with little conscious deliberation. As a result, clinicians and researchers must adapt assessment and intervention strategies to capture both implicit and explicit aspects of cognitive processing.

Intervention programs for perpetrators of intimate partner violence: conclusions from a clinical research perspective.

In this article, the authors consider the empirical status of batterer intervention programs (BIPs) for male perpetrators of intimate partner violence (IPV). Recent reviews have reported only small average effect sizes for BIPs, with the small number of randomized trials showing little benefit of BIP attendance in preventing future abuse. The most widely adopted BIP intervention model has little empirical justification to support this dominance, yet states with standards governing the content of BIPs often mandate this approach as a contingency for state funding. Little data exist concerning the moderators and mediators of BIP effects on IPV recidivism, and a variety of factors threaten to impede future design advancements, including "turf" battles regarding the causes of IPV and limited funding outlets. Given this discouraging summary, the authors argue that research efforts concerning BIP effectiveness should borrow the design strategies and programmatic research efforts that have proven successful in psychotherapy research, in which significant advances have been made with regard to the evaluation and validation of empirically supported treatments for a wide variety of mental health problems. They conclude by calling for a new generation of IPV researchers to work across professional boundaries in a multidisciplinary manner to design the sophisticated evaluation studies that funding agencies would readily support, and that would provide the substantive answers to the many IPV-related public health questions that remain.