Central versus Peripheral Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Systematic Review and Individual Patient Data Meta-Analysis

Background: It is unclear whether peripheral arterial cannulation is superior to central arterial cannulation for postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Methods: A systematic review was conducted using PubMed, Scopus, and Google Scholar to identify studies on postcardiotomy VA-ECMO for the present individual patient data (IPD) meta-analysis. Analysis was performed according to the intention-to-treat principle. Results: The investigators of 10 studies agreed to participate in the present IPD meta-analysis. Overall, 1269 patients were included in the analysis. Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA-ECMO were 70.7% vs. 63.7%, respectively (adjusted OR 1.38, 95% CI 1.08–1.75). Propensity score matching yielded 538 pairs of patients with balanced baseline characteristics and operative variables. Among these matched cohorts, central arterial cannulation VA-ECMO was associated with significantly higher in-hospital mortality compared to peripheral arterial cannulation VA-ECMO (64.5% vs. 70.8%, p = 0.027). These findings were confirmed by aggregate data meta-analysis, which showed that central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation (OR 1.35, 95% CI 1.04–1.76, I2 21%). Conclusions: Among patients requiring postcardiotomy VA-ECMO, central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation. This increased risk is of limited magnitude, and further studies are needed to confirm the present findings and to identify the mechanisms underlying the potential beneficial effects of peripheral VA-ECMO

Outcomes of tricuspid valve regurgitation after heart transplantation; a single center retrospective cohort study

Abstract Background Tricuspid valve regurgitation (TR) of the donor's heart is a common problem that can develop immediately after cardiac transplantation. There is still little data about its impact on clinical outcomes. We aimed to evaluate the short-term and 1-year effects of significant TR after heart transplantation. We retrospectively analyzed 120 patients who underwent elective orthotopic heart transplantation between 2011 and 2022. According to the postoperative TR, the patients were divided into insignificant (n= 106) and significant (n= 14) TR groups. Results Patients with significant TR were younger [median age: 38 (Q1- Q3: 36- 39) vs. 49 (35- 55) years, p=0.037] and had a higher prevalence of nonischemic cardiomyopathy (85.71% vs. 42.45%, p=0.003) and donor female gender (35.7% vs. 19.8%,p=0.021). The patients with significant TR had a longer ICU stay [19 (14-27) vs. 11 (9-14) days, p=0.001], more frequent acute kidney injury (57.14% vs. 32.08%, p=0.023), and continuous renal replacement therapy (14.3% vs. 5.66%, p=0.031), with higher 30-day mortality (7.14% vs. 1.9%, p=0.046) and 1-year mortality (14.3% vs. 2.8%, p=0.022) compared to patients with insignificant TR. The degree of TR significantly decreased during the follow-up [β: -0.18 (95% CI: -0.25 to -0.10); p<0.001]. All patients with TR were managed medically without surgical interventions. Logistic multivariable regression revealed that nonischemic heart disease (OR: 3.41,95% CI: 1.31-41.2, p=0.024) and female donor (OR:1.56, 95%CI: 1.13-25.3, p=0.013) independently predicted significant postoperative TR. Conclusions Significant TR was associated with early mortality and morbidities with prolonged hospitalization. The degree of TR significantly decreased during the first year after transplantation

The Validity of SOFA Score to Predict Mortality in Adult Patients with Cardiogenic Shock on Venoarterial Extracorporeal Membrane Oxygenation

Background. Venoarterial ECMO is increasingly used in resuscitation of adult patients with cardiogenic shock with variable mortality reports worldwide. Our objectives were to study the variables associated with hospital mortality in adult patients supported with VA-ECMO and to determine the validity of repeated assessments of those patients by the Sequential Organ Failure Assessment (SOFA) score for prediction of hospital mortality. We retrospectively studied adult patients admitted to the cardiac surgical critical care unit with cardiogenic shock supported with VA-ECMO from January 2015 to August 2019 in our tertiary care hospital. Results. One hundred and six patients supported with VA-ECMO were included in our study with in-hospital mortality of 56.6%. The mean age of studied patients was 40.2 ± 14.4 years, and the patients were mostly males (69.8%) with a mean BMI of 26.5 ± 7 without statistically significant differences between survivors and nonsurvivors. Presence of CKD, chronic atrial fibrillation, and cardiac surgeries was significantly more frequent in the nonsurvivors group. The nonsurvivors had more frequent AKI (p<0.001), more haemodialysis use (p<0.001), more gastrointestinal bleeding (p=0.039), more ICH (p=0.006), and fewer ICU days (p=0.002) compared to the survivors group. The mean peak blood lactate level was 11 ± 3 vs 16.7 ± 3.3, p<0.001, and the mean lactate level after 24 hours of ECMO initiation was 2.2 ± 0.9 vs 7.9 ± 5.7, p<0.001, in the survivors and nonsurvivors, respectively. Initial SOFA score ≥13 measured upon ICU admission had a 85% sensitivity and 73.9% specificity for predicting hospital mortality [AUROC = 0.862, 95% CI: 0.791–0.932; p<0.001] with 81% PPV, 79.1% NPV, and 80.2% accuracy while SOFA score ≥13 at day 3 had 100% sensitivity and 91.3% specificity for predicting mortality with 93.8% PPV, 100% NPV, and 96.2% accuracy [AUROC = 0.995, 95% CI: 0.986–1; p<0.001]. The ∆1 SOFA (3-1) ≥2 had 95% sensitivity and 93.5% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.913–1; p<0.001] with 95% PPV, 93.5% NPV, and 94.3% accuracy. SOFA score ≥15 at day 5 had 98% sensitivity and 100% specificity for predicting mortality with 99% accuracy [AUROC = 0.994, 95% CI: 0.982–1; p<0.001]. The ∆2 SOFA (5-1) ≥2 had 90% sensitivity and 97.8% specificity for predicting hospital mortality [AUROC = 0.958, 95% CI: 0.909–1; p<0.001] with 97.8% PPV, 90% NPV, and 94.8% accuracy. Multivariable regression analysis revealed that increasing ∆1 SOFA score (OR = 2.506, 95% CI: 1.681–3.735, p<0.001) and increasing blood lactate level (OR = 1.388, 95% CI: 1.015–1.898, p=0.04) were significantly associated with hospital mortality after VA-ECMO support for adults with cardiogenic shock. Conclusion. The use of VA-ECMO in adult patients with cardiogenic shock is still associated with high mortality. Serial evaluation of those patients with SOFA score during the first few days of ECMO support is a good predictor of hospital mortality. Increase in SOFA score after 48 hours and hyperlactataemia are significantly associated with increased hospital mortality

Outcome of Postcardiac Surgery Acute Myocardial Infarction and Role of Emergency Percutaneous Coronary Interventions

Background. Cardiac surgery carries a well-known risk of perioperative myocardial infarction (MI), which is associated with high morbidity and both in-hospital and late mortality. The rapid haemodynamics deterioration and presence of myocardial ischemia early after cardiac surgical operations is a complex life-threatening condition where rapid diagnosis and management is of fundamental importance. Objective. To analyse the factors associated with mortality of patients with postcardiotomy MI and to study the role of emergency coronary angiography in management and outcome. Methods. We retrospectively enrolled adult patients diagnosed to have postcardiotomy MI and underwent emergency coronary angiography at our tertiary care hospital between January 2016 and August 2019. Results. Sixty-one patients from consecutive 1869 adult patients who underwent cardiac surgeries were enrolled in our study. The studied patients had a mean age of 49 ± 16.2 years with a mean BMI of 29.5 ± 6.6 and 65.6% of them were males. As compared to the survivors group, the nonsurvivors of perioperative MI had significant preoperative CKD, postoperative AKI, longer CPB time, frequent histories of previous PCI, previous cardiotomies, pre and postoperative ECMO use, higher median troponin I levels, higher peak and 24 hours median lactate levels. Regression analysis revealed that reoperation for revascularization (OR: 23; 95% CI: 8.27–217.06; P=0.034) and hyperlactataemia (OR: 3.21; 95% CI: 1.14–9.04; P=0.027) were independent factors associated with hospital mortality after perioperative MI. Hospital mortality occurred in 25.7% vs 86.7% (P<0.001), AKI occurred in 37.1% vs 93.3% (P<0.001), haemodialysis was used in 28.6% vs 80% (P=0.002), and mediastinal exploration for bleeding was performed in 31.4% vs 80% (P=0.006) in the PCI and reoperation groups, respectively, while there were no significant differences regarding gastrointestinal bleeding, cerebral strokes, or intracerebral bleeding. The median peak troponin level was 795 (IQR 630–1200) vs 4190 (IQR 3700–6300) (P<0.001) in the PCI and reoperation groups, respectively. Absence of significant angiographic findings occurred in 18% of patients. Conclusions. Perioperative MI is associated with significant morbidities and hospital mortality. Reoperation for revascularization and progressive hyperlactataemia are independent predictors of hospital mortality. Emergency coronary angiography is helpful in diagnosis and management of perioperative MI

Coronary Atherosclerotic Plaque Vulnerability Rather than Stenosis Predisposes to Non-ST Elevation Acute Coronary Syndromes

Background. Non-ST elevation acute coronary syndromes (NSTE-ACS) may arise from moderately stenosed atherosclerotic lesions that suddenly undergo transformation to vulnerable plaques complicated by rupture and thrombosis. Objective. Assessment and tissue characterization of the coronary atherosclerotic lesions among NSTE-ACS patients compared to those with stable angina. Methodology. Evaluation of IVUS studies of 312 coronary lesions was done by 2 different experienced IVUS readers, 216 lesions in 66 patients with NSTE-ACS (group I) versus 96 lesions in 50 patients with stable angina (group II). Characterization of coronary plaques structure was done using colored-coded iMap technique. Results. The Syntax score was significantly higher in group I compared to group II (18.7 ± 7.8 vs. 8.07 ± 2.5, p=0.001). Body mass index (BMI) was significantly higher in group II while triglycerides levels were higher in group I (P=0.01 & P=0.04, respectively). History of previous MI and PCI was significantly higher in group I (P=0.016 & P=0.001, respectively). The coronary lesions of NSTE-ACS patients had less vessel area (9.86 ± 3.8 vs 11.36 ± 2.9, p=0.001), stenosis percentage (54.7 ± 14.9% vs 68.6 ± 8.7%, p=0.001), and plaque burden (54.4 ± 14.7 vs 67.8 ± 9.8, p=0.001) with negative remodeling index (0.95 ± 20 vs 1.02 ± 0.14, p=0.008) compared to the stable angina group. On the other hand, they had more lipid content (21.8 ± 7.03% vs 7.26 ± 3.47%, p=0.001), necrotic core (18.08 ± 10.19% vs 15.83 ± 4.9%, p=0.02), and calcifications (10.4 ± 5.2% vs 4.19 ± 3.29%, p=0.001) while less fibrosis (51.67 ± 7.07% vs 70.37 ± 11.7%, p=0.001) compared to the stable angina patients. Syntax score and core composition especially calcification and lipid content were significant predictors to NSTE-ACS. Conclusions. The vulnerability rather than the stenotic severity is the most important factor that predisposes to non-ST segment elevation acute coronary syndromes. The vulnerability is related to the lesion characteristics especially lipidic core and calcification while lesion fibrosis favours lesion stability

Intravascular evaluation of coronary atherosclerotic lesions among Egyptian diabetic patients with acute coronary syndromes

Background: Coronary artery disease is one of the main causes of death in diabetes mellitus (DM). Egypt was listed among the world top 10 countries regarding the number of diabetic patients by the International Diabetes Federation (IDF). Aim of work: Assessment of the extent of coronary atherosclerotic disease and lesion tissue characterization among diabetic compared to non-diabetic Egyptian patients. Methodology: IVUS studies of 272 coronary lesions in 116 patients presented with unstable angina were examined. The patients were divided into two groups: diabetic group (50 patients with 117 lesions) and non-diabetic group (66 patients with 155 lesions). Results: As compared to the non-diabetic group, the diabetic patients were more dyslipidemic (84% vs 39.4%, p = 0.001) with higher total cholesterol level (194.6 ± 35.3 vs 174.4 ± 28.5 mg/dl, p = 0.001) and higher LDL-C (145.3 ± 27.1 vs 123.2 ± 31.4, p = 0.001). Regarding lesions characteristics, the diabetic group had longer lesions (19.4 ± 7.4 vs 16.3 ± 7.9 mm, p = 0.002) with higher plaque burden (60.8 ± 15.3 vs 54.8 ± 14.0, p 0.002) and more area stenosis percentage (60.8 ± 15.6 vs 55.6 ± 14.1, p = 0.008). Structurally, the diabetic group lesions had more lipid content (19.8 ± 8.8 vs 16.8 ± 8.7, p = 0.008) and more necrotic core (17.6 ± 7.4 vs 14.7 ± 4.8, p = 0.008) but less calcification (6.9 ± 3.6 vs 11.8 ± 6.3, p = 0.001). The RI was negative in both groups, 0.95 ± 0.13 in the diabetic group vs 0.98 ± 0.19 in non-diabetic group (p = 0.5). Within the diabetic group lesions, the dyslipidaemic subgroup had more lipid content (23. ± 5.2 vs 14.6 ± 8.6, p = 0.01) but less fibrotic component (48.6 ± 4.7 vs 59.1 ± 13.6%, p = 0.01) and less calcification (10.9 ± 6.8% vs 14.07 ± 3.8%, p = 0.02) as compared to the nondyslipidaemic subgroup. Conclusions: Diabetic patients with coronary atherosclerosis in Egypt have longer lesions with higher plaque burden and more percent area stenosis with negative remodeling index. The diabetic lesions had more lipid content and more necrotic core but less calcification. Keywords: Diabetes mellitus (DM), Intravascular ultrasound (IVUS), Plaque burden, Remodeling index (RI), Dyslipidemi

Impact of diastolic pulmonary gradient and pulmonary vascular remodeling on survival after left ventricular assist device implantation and heart transplantation

Abstract Background The left ventricular assist devices (LVADs) are increasingly used for advanced heart failure as a bridge to heart transplantation or as a destination therapy. The aim of this study was to investigate the changes of diastolic pulmonary gradient (DPG), pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG) after LVAD implantation and their impact on survival after LVAD and heart transplantation. Results A total of 73 patients who underwent LVAD (HeartMate III) implantation between 2016 and 2022 were retrospectively studied. According to pre-LVAD catheterization, 49 (67.1%) patients had DPG < 7 mmHg and 24 (32.9%) patients had DPG ≥ 7 mmHg. The patients with a pre-VAD DPG ≥ 7 mmHg had higher frequencies of right ventricular (RV) failure (p < 0.001), RVAD insertion (p < 0.001), need for renal replacement therapy (p = 0.002), total mortality (p = 0.036) and on-VAD mortality (p = 0.04) with a longer ICU stay (p = 0.001) compared to the patients with DPG < 7 mmHg. During the follow-up period of 38 (12–60) months, 24 (32.9%) patients died. Pre-LVAD DPG ≥ 7 mmHg (adjusted HR 1.83, 95% CI 1.21–6.341, p = 0.039) and post-LVAD DPG ≥ 7 mmHg (adjusted HR 3.824, 95% CI 1.482–14.648, p = 0.002) were associated with increased risks of mortality. Neither pre-LVAD TPG ≥ 12 (p = 0.505) nor post-LVAD TPG ≥ 12 mmHg (p = 0.122) was associated with an increased risk of death. Pre-LVAD PVR ≥ 3 WU had a statistically insignificant risk of mortality (HR 2.35, 95% CI 0.803–6.848, p = 0.119) while post-LVAD PVR ≥ 3 WU had an increased risk of death (adjusted HR 2.37, 95% CI 1.241–7.254, p = 0.038). For post-transplantation mortality, post-LVAD DPG ≥ 7 mmHg (p = 0.55), post-LVAD TPG ≥ 12 mmHg (p = 0.85) and PVR ≥ 3 WU (p = 0.54) did not have statistically increased risks. The logistic multivariable regression showed that post-LVAD PVR ≥ 3 WU (p = 0.013), post-LVAD DPG ≥ 7 mmHg (p = 0.026) and RVF (p = 0.018) were the predictors of mortality after LVAD implantation. Pre-LVAD DPG ≥ 7 mmHg (p < 0.001) and pre-LVAD PVR ≥ 3 WU (p = 0.036) were the predictors of RVF after LVAD implantation. Conclusions Persistently high DPG was associated with right ventricular failure and mortality after LVAD implantation rather than after heart transplantation. DPG is a better predictor of pulmonary vascular remodeling compared to TPG and PVR. Further larger prospective studies are required in this field due to the growing numbers of patients with advanced heart failure, as possible candidates for LVAD implantation, and limitations of heart transplantation

Stent boost enhancement compared to intravascular ultrasound in the evaluation of stent expansion in elective percutaneous coronary interventions

Background: Stent underexpansion is a major risk factor for in-stent restenosis and acute in-stent thrombosis1Intravascular ultrasound (IVUS) is one of the standards for detection of stent underexpansion (de Feyter et al. 1999; Mintz et al., 2001). StentBoost (SB) enhancement allows an improved angiographic visualization of the stent (Koolen et al., 2005). Aim of work: Comparison of stent expansion by IVUS and SB enhancement and detection of value of SB to guide dilatation post stent deployment. Methodology: IVUS, SB enhancement and QCA were done in 30 patients admitted for elective stenting procedures .We compared measurements of mean ±standard deviations of (Max SD, Min SD, Mean SD, stent symmetry index) using IVUS, SB and QCA after stent deployment and after postdilatation whenever necessary to optimize stent deployment. The Stent symmetry index was calculated [(maximum stent diameter minus minimum stent diameter) divided by maximum stent diameter]. Results: The Max SD was (3.45 ± 0.62 vs 3.55 ± 0.56 vs 2.97 ± 0.59) by IVUS vs SB vs QCA respectively. Max SD was significantly higher by IVUS vs QCA (p .009) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .53). The Min SD was (2.77 ± 0.53 vs 2.58 ± 0.56 vs 1.88 ± 0.60) by IVUS vs SB vs QCA respectively. Min SD was significantly higher by IVUS vs QCA (p .001) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .07). The stent symmetry index was (0.24 ±0.09 vs 0.34 ± 0.09 vs 0.14 ±0.27) by IVUS vs SB vs QCA respectively. It was significantly higher by IVUS vs QCA (p .001) and between SB vs QCA (p .001) while there was nonsignificant difference between IVUS vs SB (p .32). SB was positively correlated with IVUS measurements of Max SD (p < .0001 & r 0.74) and Min SD (p < .0001 & r 0.68). QCA was positively correlated with IVUS measurements of Max SD correlation (p < .0001 & r 0.69) and Min SD (p < .0001 & r 0.63). QCA was positively correlated with SB measurements of Max SD (p < .0001 & r 0.61) and Min SD (p .003 & r 0.49). Conclusions: StentBoost enhancement has superior correlations for stent expansion measured by IVUS when compared with QCA. SB enhancement improved stent visualization and identification of stent underexpansion to guide stent postdilatation. Keywords: Quantitative coronary angiography (QCA), Intravascular ultrasound (IVUS), Stent Boost (SB) enhancement, Maximal stent diameter (Max SD), Minimal stent diameter (Min SD