Extracorporeal Membrane Oxygenation for Graft Dysfunction Early After Heart Transplantation: A Systematic Review and Meta-analysis

Introduction: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a prevailing option for the management of severe early graft dysfunction. This systematic review and individual patient data (IPD) meta-analysis aims to evaluate (1) mortality, (2) rates of major complications, (3) prognostic factors, and (4) the effect of different VA-ECMO strategies on outcomes in adult heart transplant (HT) recipients supported with VA-ECMO. Methods and Results: We conducted a systematic search and included studies of adults (≥18 years) who received VA-ECMO during their index hospitalization after HT and reported on mortality at any timepoint. We pooled data using random effects models. To identify prognostic factors, we analysed IPD using mixed effects logistic regression. We assessed the certainty in the evidence using the GRADE framework. We included 49 observational studies of 1477 patients who received VA-ECMO after HT, of which 15 studies provided IPD for 448 patients. There were no differences in mortality estimates between IPD and non-IPD studies. The short-term (30-day/in-hospital) mortality estimate was 33% (moderate certainty, 95% confidence interval [CI] 28%–39%) and 1-year mortality estimate 50% (moderate certainty, 95% CI 43%–57%). Recipient age (odds ratio 1.02, 95% CI 1.01–1.04) and prior sternotomy (OR 1.57, 95% CI 0.99–2.49) are associated with increased short-term mortality. There is low certainty evidence that early intraoperative cannulation and peripheral cannulation reduce the risk of short-term death. Conclusions: One-third of patients who receive VA-ECMO for early graft dysfunction do not survive 30 days or to hospital discharge, and one-half do not survive to 1 year after HT. Improving outcomes will require ongoing research focused on optimizing VA-ECMO strategies and care in the first year after HT

Intraoperative Neuromonitoring of the External Branch of the Superior Laryngeal Nerve During Thyroid Surgery

Thyroid gland surgeries are among the most common surgical interventions worldwide and are considered by many surgeons as a relatively easy and safe procedure. But the number of complications still remains significant with unacceptable and unpleasant consequences for the patients. Among them, the most significant are postoperative hypoparathyroidism and the injuries of the laryngeal nerves - the recurrent laryngeal nerve (RLN) and the external branch of the superior laryngeal nerve (EBSLN). Nowadays, the surgical anatomy of the recurrent laryngeal nerves and the surgical approach to them are described in detail in the medical literature and their damages are perhaps the most known and discussed complications. EBSLN injury leads to paralysis of the cricothyroid muscle (CTM) and often remains unseen due to a lack of clear laryngoscopic markers. The main postoperative symptoms are accompanied mostly by qualitative voice disturbances of the patients. A relatively new method for timely assessment of the risk of iatrogenic lesions of the laryngeal nerves in thyroid surgery is the intraoperative neuromonitoring (IONM). The method emerged as the gold standard of care for prevention of RLN, and lately its application on EBSLN is subject of detailed analysis. This creates a need to assess the method and develop a friendly practice system for its clinical application

Persistence of vitamin D deficiency among Italian patients with acute myocardial infarction

Background and aims: Vitamin D deficiency is a common cardiovascular risk factor associated with the development of atherosclerosis. We evaluated changes in 25(OH)D concentrations in 1510 patients with acute myocardial infarction (AMI) over a long observation period, including the COVID-19 pandemic. Methods and results: Patients were separated into four groups according to the year of enrolment, group 1 (2009–2010), group 2 (2014–2016), group 3 (2017–2019), and group 4 (2020–2022). The median 25(OH)D concentration in the overall cohort was 17.15 (10.3–24.7) ng/mL. The median plasma concentrations of 25(OH)D for groups 1, 2, 3, and 4 were 14.45 (7.73–22.58) ng/mL, 17.3 ng/mL (10.33–24.2), 18.95 (11.6–26.73) ng/mL and 19.05 (12.5–27.3) ng/mL, respectively. Although 25(OH)D levels increased over the years, the prevalence of vitamin D deficiency remained high in each group (68.4%, 61.4%, 53.8%, and 52% respectively). Hypovitaminosis D was predicted by the season influence (OR:2.03, p < 0.0001), higher body mass index (OR:1.25; p = 0.001), diabetes mellitus (OR:1.54; p = 0.001), smoking (OR:1.47; p = 0.001), older age (OR:1.07; p = 0.008), higher triglycerides levels (OR:1.02; p = 0.01), and female gender (OR:1.3; p = 0.038). After multivariable adjustment, vitamin D ≤ 20 ng/mL was an independent predictor of mortality. Conclusion: Vitamin D deficiency is highly prevalent and persistent in patients with AMI despite a trend towards increasing 25(OH)D concentrations over the years. The frequent lockdowns did not reduce the levels of 25(OH)D in the fourth group. Low levels of 25(OH)D are an independent predictor of mortality

Heart failure impairs the mechanotransduction properties of human cardiac pericytes

The prominent impact that coronary microcirculation disease (CMD) exerts on heart failure symptoms and prognosis, even in the presence of macrovascular atherosclerosis, has been recently acknowledged. Experimental delivery of pericytes in non-revascularized myocardial infarction improves cardiac function by stimulating angiogenesis and myocardial perfusion. Aim of this work is to verify if pericytes (Pc) residing in ischemic failing human hearts display altered mechano-transduction properties and to assess which alterations of the mechano-sensing machinery are associated with the observed impaired response to mechanical cues. Results: Microvascular rarefaction and defects of YAP/TAZ activation characterize failing human hearts. Although both donor (D-) and explanted (E-) heart derived cardiac Pc support angiogenesis, D-Pc exert this effect significantly better than E-Pc. The latter are characterized by reduced focal adhesion density, decreased activation of the focal adhesion kinase (FAK)/ Crk-associated substrate (CAS) pathway, low expression of caveolin-1, and defective transduction of extracellular stiffness into cytoskeletal stiffening, together with an impaired response to both fibronectin and lysophosphatidic acid. Importantly, Mitogen-activated protein kinase kinase inhibition restores YAP/TAZ nuclear translocation. Conclusion: Heart failure impairs Pc mechano-transduction properties, but this defect could be reversed pharmacologically

Predicting atrial fibrillation recurrence with circulating inflammatory markers in patients in sinus rhythm at high risk for atrial fibrillation: data from the GISSI atrial fibrillation trial.

Background Inflammation may play a significant role in the pathogenesis of atrial fibrillation (AF). Objectives To examine the roles of three systemic inflammatory markers in predicting recurrent AF. Methods The association between the plasma concentrations of high-sensitivity C reactive protein (hsCRP), interleukin-6 (IL-6) and pentraxin-3 (PTX3) with echocardiographic parameters and with the time to first recurrence of AF was tested in 382 patients with a history of AF but in sinus rhythm at randomisation, enrolled in the GISSI-AF biohumoral study. Results Baseline PTX3 was related to left atrial, but not to left ventricular chamber volume. During one year of follow-up, 204 patients (53.1%) had a recurrent AF. There were no significant differences in baseline median [Q1eQ3] plasma concentrations of IL-6, hsCRP and PTX3 among patients with (2.11 [1.47e3.74] pg/ml, 3.30 [1.40e6.80] mg/l and 4.66 [3.27e6.97] ng/ml, respectively) or without recurrent AF (2.09 [1.37e2.90] pg/ml, p\ubc0.182; 3.00 [1.10e6.20] mg/l, p\ubc0.333; 5.09 [3.22e7.98] ng/ml, p\ubc0.637). At 6 and 12 months follow-up, AF patients had significantly higher concentrations of IL-6 and PTX3 than those in sinus rhythm, and those with most recent episodes of AF had higher hsCRP. Baseline levels of IL-6, hsCRP or PTX3 were not significantly associated with a higher risk of recurrence of AF. Conclusion In patients with a history of AF, but without significant left ventricular dysfunction or heart failure, inflammatory biomarkers may be raised but are, at best, weak predictors of the risk for first recurrence of AF

Prenatal Diagnosis and Preimplantation Genetic Testing for Inherited Cardiac Diseases

Inherited cardiac diseases (cardiomyopathies and channelopathies) are associated with an increased risk of sudden cardiac death (SCD). A common hallmark is the variable disease expression and incomplete penetrance. Therefore the phenotype varies widely between and within families. Carriers of a severe genetic disease have several reproductive options to fulfill their child wish due to progress in molecular genomics and assisted reproductive technology (Prenatal Diagnosis or Preimplantation Genetic Testing (PGT)). In this chapter, we describe the different reproductive techniques and evaluate the number of prenatal diagnoses and referrals for PGT for inherited cardiac diseases in literature and in the Netherlands in the past years. Although inherited cardiac diseases can exhibit a severe phenotype or a severe family history of sudden cardiac death, the number of patients with inherited cardiac diseases opting for and continuing with PND and PGT is small

Predicting atrial fibrillation recurrence with circulating inflammatory markers in patients in sinus rhythm at high risk for atrial fibrillation : data from the GISSI atrial fibrillation trial

Background: Inflammation may play a significant role in the pathogenesis of atrial fibrillation (AF). Objectives: To examine the roles of three systemic inflammatory markers in predicting recurrent AF. Methods: The association between the plasma concentrations of high-sensitivity C reactive protein (hsCRP), interleukin-6 (IL-6) and pentraxin-3 (PTX3) with echocardiographic parameters and with the time to first recurrence of AF was tested in 382 patients with a history of AF but in sinus rhythm at randomisation, enrolled in the GISSI-AF biohumoral study. Results: Baseline PTX3 was related to left atrial, but not to left ventricular chamber volume. During one year of follow-up, 204 patients (53.1%) had a recurrent AF. There were no significant differences in baseline median [Q1-Q3] plasma concentrations of IL-6, hsCRP and PTX3 among patients with (2.11 [1.47-3.74] pg/ml, 3.30 [1.40-6.80] mg/l and 4.66 [3.27-6.97] ng/ml, respectively) or without recurrent AF (2.09 [1.37-2.90] pg/ml, p=0.182; 3.00 [1.10-6.20] mg/l, p=0.333; 5.09 [3.22-7.98] ng/ml, p=0.637). At 6 and 12 months follow-up, AF patients had significantly higher concentrations of IL-6 and PTX3 than those in sinus rhythm, and those with most recent episodes of AF had higher hsCRP. Baseline levels of IL-6, hsCRP or PTX3 were not significantly associated with a higher risk of recurrence of AF. Conclusion: In patients with a history of AF, but without significant left ventricular dysfunction or heart failure, inflammatory biomarkers may be raised but are, at best, weak predictors of the risk for first recurrence of AF