Hypothermic cardiac arrest far away from the center providing rewarming with extracorporeal circulation

A 41-year-old man suffered hypothermic cardiac arrest after water immersion and was transported to our university hospital by ambulance helicopter for rewarming on cardiopulmonary bypass. He resumed spontaneous cardiac activity 6 h 52 min after cardiac arrest and recovered completely

Alpha-2-adrenergic receptor agonists for the prevention of delirium and cognitive decline after open heart surgery (ALPHA2PREVENT): protocol for a multicentre randomised controlled trial

INTRODUCTION: Postoperative delirium is common in older cardiac surgery patients and associated with negative short-term and long-term outcomes. The alpha-2-adrenergic receptor agonist dexmedetomidine shows promise as prophylaxis and treatment for delirium in intensive care units (ICU) and postoperative settings. Clonidine has similar pharmacological properties and can be administered both parenterally and orally. We aim to study whether repurposing of clonidine can represent a novel treatment option for delirium, and the possible effects of dexmedetomidine and clonidine on long-term cognitive trajectories, motor activity patterns and biomarkers of neuronal injury, and whether these effects are associated with frailty status. METHODS AND ANALYSIS: This five-centre, double-blind randomised controlled trial will include 900 cardiac surgery patients aged 70+ years. Participants will be randomised 1:1:1 to dexmedetomidine or clonidine or placebo. The study drug will be given as a continuous intravenous infusion from the start of cardiopulmonary bypass, at a rate of 0.4 µg/kg/hour. The infusion rate will be decreased to 0.2 µg/kg/hour postoperatively and be continued until discharge from the ICU or 24 hours postoperatively, whichever happens first.Primary end point is the 7-day cumulative incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Secondary end points include the composite end point of coma, delirium or death, in addition to delirium severity and motor activity patterns, levels of circulating biomarkers of neuronal injury, cognitive function and frailty status 1 and 6 months after surgery. ETHICS AND DISSEMINATION: This trial is approved by the Regional Committee for Ethics in Medical Research in Norway (South-East Norway) and by the Norwegian Medicines Agency. Dissemination plans include publication in peer-reviewed medical journals and presentation at scientific meetings. TRIAL REGISTRATION NUMBER: NCT05029050

Transcatheter aortic valve implantation (from inception to standard treatment): a single-center observational study

Background: Treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) was introduced in 2002. Since then, TAVI has become the primary treatment approach worldwide for advanced-age patients and younger patients with severe comorbidities. We aimed to evaluate the changes in patient demographics, complications, and mortality rates within 13 years. Methods: This retrospective observational study included 867 patients who underwent TAVI at the University Hospital of North Norway in Tromsø from 2008 to 2021. The 13-year period was divided into period 1 (2008–2012), period 2 (2013–2017), and period 3 (2018–2021). The primary objective was to evaluate the changes in periprocedural (30 days), early (30–365 days), and late mortality rates (>365 days) between the periods. The secondary objective was to evaluate late mortality rates by sex and age groups: Results: The periprocedural mortality rates for periods 1, 2, and 3 were 10.3%, 2.9%, and 1.2%, respectively (P  Conclusion: Our findings indicate that most patients are octogenarians, and the burden of their comorbidities should be highly considered compared to their age when evaluating the procedural outcomes. As the incidence of most complications related to TAVI has decreased, the rates of permanent pacemaker implantation remain high. Important advancements in diagnostics, valve technology, and procedural techniques have improved the periprocedural mortality rates; however, early mortality remains unchanged and poses a clinical challenge that needs to be addressed in the future

Peak longitudinal strain most accurately reflects myocardial segmental viability following acute myocardial infarction - an experimental study in open-chest pigs

BACKGROUND: The extension and the transmurality of the myocardial infarction are of high predictive value for clinical outcome. The aim of the study was to characterize the ability of longitudinal, circumferential and radial strain measured by 2-dimensional speckle tracking echocardiography (2D-STE) to predict the extent of necrosis in myocardial segments following acute myocardial infarction and to separate transmural necrotic segments from non-transmural necrotic segments in a full 18-segment porcine model. METHODS: 2D-STE strain was assessed in long- and short-axis following myocardial infarction in ten open-chest anesthetized pigs. Strain was defined according to systolic peak values. In segments displaying both negative and positive peaks, only the peak with the highest absolute value was utilized. Necrosis was measured by 2,3,5-triphenyltetrazolium chloride (TTC) staining and expressed as percent of each myocardial segment. RESULTS: Significant correlations were found between the extension of necrosis and all measured parameters of myocardial deformation (p < 0.001), but was stronger for longitudinal strain (r(2) = 0.52) than circumferential strain (r(2) = 0.38) and radial strain (r(2) = 0.23). The area under the receiver operator characteristic curve (AUC) for separating transmural necrotic segments (>50% necrosis) from predominantly viable segments (0–50% necrosis) was significantly larger for longitudinal strain (AUC = 0.98, CI = 0.97–1.00) when compared with circumferential strain (AUC = 0.91, CI = 0.84–0.97, p < 0.05) and radial strain (AUC = 0.90, CI = 0.83 – 0.96, p < 0.01), indicating a stronger ability of longitudinal strain to identify segments with transmural necrosis. CONCLUSION: Peak strain values derived from 2D-STE correlate well with the extent of necrosis in myocardial segments following acute myocardial infarction. Longitudinal strain most accurately reflects myocardial segmental viability in this setting

Plasmapheresis in severe sepsis and septic shock: a prospective, randomised, controlled trial

Objective: To determine the therapeutic efficacy and safety of plasmapheresis in the treatment of patients with severe sepsis and septic shock. Design: Prospective, randomised, clinical trial with a planned, midstudy, interim analysis. Setting: Intensive care unit in a university hospital in Archangels, Russia. Patients: Consecutive patients with severe sepsis or septic shock. Interventions: One hundred and six patients were randomised to receive either standard therapy or an add-on treatment with plasmapheresis. Measurements and results: The primary endpoint was 28-day survival. Septic shock was diagnosed in 57% of the plasmapheresis-treated patients and 54% of the control patients. Mean APACHE III score at entry was 56.4 in the plasmapheresis group and 53.5 in the control group. The 28-day, all-cause mortality rate was 33.3% (18/54) in the plasmapheresis group and 53.8% (28/52) in the control group. This represents a relative risk for fatal outcome in the plasmapheresis group of 0.61, an absolute risk reduction of 20.5% and a number of patients needed to treat of 4.9. Apart from six transient episodes of hypotension and one allergic reaction to fresh frozen plasma, no adverse reactions were attributable to the plasmapheresis treatment in this study. Conclusions: Plasmapheresis may be an important adjuvant to conventional treatment to reduce mortality in patients with severe sepsis or septic shock. Plasmapheresis is a safe procedure in the treatment of septic patients. A prospective randomised multicentre trial is warranted to confirm our results and to determine which subgroups of septic patients will benefit most from this treatment modality

Increased Risk of Transmission of Hepatitis C in Open Heart Surgery Compared With Vascular and Pulmonary Surgery

Background. We report a case of patient-to-surgeon transmission of hepatitis C virus (HCV), and the subsequent transmission of HCV to surgical patients. Methods. In 2007, a cardiac surgeon tested positive for hepatitis C. A complete look-back investigation was initiated that involved screening of all patients on the surgeon's operating lists between September 2004 and April 2007. Genotyping and phylogenetic analyses were performed where HCV RNA was detected. Results. Of the 499 patients invited to HCV testing, 431 responded, 13 of whom were found anti-HCV positive. One patient, who had surgery in August 2005, was found most likely to be the source of transmission to the surgeon. Of the 270 patients who had surgery after this incident, 10 became infected, giving an estimated rate of transmission of 3.7%. The HCV polymerase chain reaction positive samples were found to be the same genotype 1a strain by phylogenetic analyses. All the 10 subsequently infected patients had undergone open heart surgery, whereas none of the 103 noncardiac patients became infected, giving an estimated risk of transmission during open heart surgery of 6.0% (95% confidence interval [3.3% to 10.7%]). Conclusions. The transmission rate from an HCV positive surgeon to patients in a cardiothoracic setting was higher than previously reported and significantly higher during open heart surgery compared with vascular and pulmonary surgery. These results indicate the need for unequivocal routines for testing and handling of HCV positive health care workers and patients. (Ann Thorac Surg 2010; 90: 1425-31) (C) 2010 by The Society of Thoracic Surgeon

Clinical and echocardiographic parameters predicting 1- and 2-year mortality after transcatheter aortic valve implantation

Background: Transcatheter aortic valve implantation (TAVI) has become a standard treatment option for patients with symptomatic aortic stenosis. Elderly high-risk patients treated with TAVI have a high residual mortality due to preexisting comorbidities. Knowledge of factors predicting futility after TAVI is sparse and clinical tools to aid the preoperative evaluation are lacking. The aim of this study was to evaluate if echocardiographic measures, including speckle-tracking analysis, in addition to clinical parameters, could aid in the prediction of mortality beyond 30 days after TAVI. Methods: This prospective observational cohort study included 227 patients treated with TAVI at the University Hospital of North Norway, Tromsø and Oslo University Hospital, Rikshospitalet from February 2010 to June 2013. All the patients underwent preoperative echocardiographic evaluation with retrospective speckle-tracking analysis. Primary endpoints were 1- and 2-year mortality beyond 30 days after TAVI. Results: All-cause 1- and 2-year mortality beyond 30 days after TAVI was 12.1 and 19.5%, respectively. Predictors of 1-year mortality beyond 30 days were body mass index [hazard ratio (HR): 0.88, 95% CI: 0.80–0.98, p = 0.018], previous myocardial infarction (HR: 2.69, 95% CI: 1.14–6.32, p = 0.023), and systolic pulmonary artery pressure ≥ 60 mm Hg (HR: 5.93, 95% CI: 1.67–21.1, p = 0.006). Moderate-to-severe mitral regurgitation (HR: 2.93, 95% CI: 1.53–5.63, p = 0.001), estimated glomerular filtration rate (HR: 0.98, 95% CI: 0.96–0.99, p = 0.002), and chronic obstructive pulmonary disease (HR: 1.9, 95% CI: 1.01–3.58, p = 0.046) were predictors of 2-year mortality. Conclusion: Both the clinical and echocardiographic parameters should be considered when evaluating high-risk patients for TAVI, as both are predictive of 1-and 2-year mortality. Our results support the importance of individual risk assessment using a multidisciplinary, multimodal, and individual approach

Clinical and echocardiographic parameters predicting 1- and 2-year mortality after transcatheter aortic valve implantation

Background: Transcatheter aortic valve implantation (TAVI) has become a standard treatment option for patients with symptomatic aortic stenosis. Elderly high-risk patients treated with TAVI have a high residual mortality due to preexisting comorbidities. Knowledge of factors predicting futility after TAVI is sparse and clinical tools to aid the preoperative evaluation are lacking. The aim of this study was to evaluate if echocardiographic measures, including speckle-tracking analysis, in addition to clinical parameters, could aid in the prediction of mortality beyond 30 days after TAVI. Methods: This prospective observational cohort study included 227 patients treated with TAVI at the University Hospital of North Norway, Tromsø and Oslo University Hospital, Rikshospitalet from February 2010 to June 2013. All the patients underwent preoperative echocardiographic evaluation with retrospective speckle-tracking analysis. Primary endpoints were 1- and 2-year mortality beyond 30 days after TAVI. Results: All-cause 1- and 2-year mortality beyond 30 days after TAVI was 12.1 and 19.5%, respectively. Predictors of 1-year mortality beyond 30 days were body mass index [hazard ratio (HR): 0.88, 95% CI: 0.80–0.98, p = 0.018], previous myocardial infarction (HR: 2.69, 95% CI: 1.14–6.32, p = 0.023), and systolic pulmonary artery pressure ≥ 60 mm Hg (HR: 5.93, 95% CI: 1.67–21.1, p = 0.006). Moderate-to-severe mitral regurgitation (HR: 2.93, 95% CI: 1.53–5.63, p = 0.001), estimated glomerular filtration rate (HR: 0.98, 95% CI: 0.96–0.99, p = 0.002), and chronic obstructive pulmonary disease (HR: 1.9, 95% CI: 1.01–3.58, p = 0.046) were predictors of 2-year mortality. Conclusion: Both the clinical and echocardiographic parameters should be considered when evaluating high-risk patients for TAVI, as both are predictive of 1-and 2-year mortality. Our results support the importance of individual risk assessment using a multidisciplinary, multimodal, and individual approach

Predictors of early mortality after transcatheter aortic valve implantation

Objectives To investigate whether preoperative echocardiographic evaluation of ventricular function, especially right ventricular systolic and diastolic parameters including speckle-tracking analysis, could aid in the prediction of 30-day mortality after transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis. Methods This is a prospective observational cohort study including 227 patients accepted for TAVI at the University Hospital of North Norway and Oslo University Hospital from February 2010 through June 2013. All patients underwent preoperative transthoracic echocardiography with retrospective speckle-tracking analysis. Primary endpoint was all-cause 30-day mortality. Results All-cause 30-day mortality was 8.7 % (n = 19). Independent predictors of 30-day mortality were systolic pulmonary arterial pressure (SPAP) > 60 mm Hg (HR: 7.7, 95% CI: 1.90 to 31.3), heart failure (HR: 2.9, 95% CI: 1.1 to 7.78), transapical access (HR: 3.8, 95% CI: 1.3 to 11.2), peripheral artery disease (HR: 6.0, 95% CI: 2.0 to 18.0) and body mass index (HR: 0.73, 95% CI: 0.61 to 0.87). C-statistic for the model generated was 0.91 (95% CI: 0.85 to 0.98). Besides elevated SPAP, no other echocardiographic measurements were found to be an independent predictor of early mortality. Conclusion Except for elevated systolic pulmonary artery pressure, our data suggests that clinical rather than echocardiographic parameters are useful predictors of 30-day mortality after TAVI

Predictors of early mortality after transcatheter aortic valve implantation

To investigate whether preoperative echocardiographic evaluation of ventricular function, especially right ventricular systolic and diastolic parameters including speckle-tracking analysis, could aid in the prediction of 30-day mortality after transcatheter aortic valve implantation (TAVI) in patients with aortic stenosis.This is a prospective observational cohort study including 227 patients accepted for TAVI at the University Hospital of North Norway and Oslo University Hospital from February 2010 through June 2013. All patients underwent preoperative transthoracic echocardiography with retrospective speckle-tracking analysis. Primary endpoint was all-cause 30-day mortality.All-cause 30-day mortality was 8.7 % (n = 19). Independent predictors of 30-day mortality were systolic pulmonary arterial pressure (SPAP) &gt; 60 mm Hg (HR: 7.7, 95% CI: 1.90 to 31.3), heart failure (HR: 2.9, 95% CI: 1.1 to 7.78), transapical access (HR: 3.8, 95% CI: 1.3 to 11.2), peripheral artery disease (HR: 6.0, 95% CI: 2.0 to 18.0) and body mass index (HR: 0.73, 95% CI: 0.61 to 0.87). C-statistic for the model generated was 0.91 (95% CI: 0.85 to 0.98). Besides elevated SPAP, no other echocardiographic measurements were found to be an independent predictor of early mortality.Except for elevated systolic pulmonary artery pressure, our data suggests that clinical rather than echocardiographic parameters are useful predictors of 30-day mortality after TAVI