Repair of Penetrating Pericardial and Diaphragmatic Injury with Cormatrix® Patch in a Case of Suicide Attempt

Abstract The authors report the case of a suicide attempt. A 59-year-old man with self-inflicted penetrating chest trauma underwent emergency cardiothoracic surgery. Pre-operative computed tomography scan showed critical proximity between the blade and the right ventricle. Intraoperative findings showed a pericardial laceration and a huge diaphragmatic lesion with heart and abdominal organs integrity. The diaphragm muscle was repaired with a CorMatrix® patch, an acceptable alternative to the traditional synthetic mesh avoiding infection and repeated herniation

Intraoperative bypass graft flow in intra-aortic balloon pump-supported patients: differences in arterial and venous sequential conduits

BACKGROUND: The intra-aortic balloon pump is used worldwide as an anti-ischemic strategy. However, little is known about the modifications of the graft flowmetry during use of intra-aortic balloon pump. METHODS: An observational study aimed at analyzing transit-time flow measurements during 1:1 intra-aortic balloon pump use and during its cessation in 138 consecutive patients using intra-aortic balloon pump before coronary artery bypass grafting (n = 442 graft segments) was reported. RESULTS: In normally functioning grafts, the mean diastolic and mean blood flow improved significantly during 1:1 intra-aortic balloon pump use compared with during intra-aortic balloon pump cessation (P 1) during 1:1 intra-aortic balloon pump use in all normally functioning grafts, with higher values in single arterial or sequential saphenous vein grafts versus single venous grafts (both P < .001). In the 9 cases of graft failure, the mean diastolic, mean systolic, and mean flow were significantly lower and the pulsatility index greater, compared with normally functioning grafts (all P <or= .001). Blood flow did not change appreciably during 1:1 intra-aortic balloon pump use in failed bypass grafts; thus the surplus graft flow approached 1. CONCLUSION: In this analysis, use of intra-aortic balloon pump was associated with improved diastolic and mean blood flow in bypass grafts. Arterial and sequential grafts were associated with greater improvements in blood flow and surplus graft flow. Graft failure was associated with poor transit-time flow results, high pulsatility index values, and absent surplus graft flow

Continuous coronary sinus perfusion reverses ongoing myocardial damage in acute ischemia

Acute cardiogenic shock or cardiac arrest (CS/CA) before cardiopulmonary bypass (CPB) installation are life-threatening events in acute coronary syndromes. We evaluated whether continuous retrograde warm-blood perfusion (CRWBP) before aortic cross-clamping (ACC), with immediate CPB installation may improve hospital results in these dreadful events. Hospital outcome of 18 coronary artery bypass grafting (CABG) (Group A) with CS/CA before CPB, with immediate CPB installation and CRWBP, has been compared with 24 CABG (Group B) with CS/CA undergoing only immediate CPB installation. No differences have been detected in the mean time to establish CPB (P = 0.655). Electrocardiography normalized in a significantly higher number of CRWBP (P = 0.0001). Group B showed longer CPB (116.2 +/- 21.2 min vs. 157.8 +/- 32.4; P = 0.0001) and postoperative intra-aortic balloon pumping time course (36.2 +/- 5.9 h vs. 77.8 +/- 13.2; P = 0.0001). CRWBP reduced postoperative acute myocardial infarction (P = 0.004) and damage (P = 0.033), death (P = 0.026), and need for high inotropic support (0% vs. 37.5%; P = 0.003). Troponin I was significantly lower in Group A (P = 0.013 from coronary sinus; P &lt; 0.0001 at 12, 24, and 48 h postoperatively; P = 0.008 at 72 h), never reaching values suggestive of acute myocardial infarction. Group A had also lower lactate release from aortic declamping to 48 h postoperatively (P &lt; 0.0001). CRWBP improved postoperative left ventricular ejection fraction (EF) (P = 0.017) and wall motion score index (P = 0.041), whereas Group B showed a significant worsening of EF (P = 0.0001) and wall motion score index (P = 0.002). Patients in Group A had shorter intubation time (P = 0.0001), intensive therapy unit (ITU) stay (P = 0.001), and hospital stay (P = 0.0001). CRWBP reverses myocardial damage in patients with CS/CA during acute coronary syndromes, adding a straightforward benefit to hospital survival

In vivo functional flowmetric behavior of the radial artery graft: is the composite Y-graft configuration advantageous over conventional aorta-coronary bypass?

INTRODUCTION: Intraoperative flowmetric results of different configurations (Y-graft or aorta-coronary) of radial artery grafts have been poorly investigated. METHODS: We report the results of an observational study designed to analyze transit-time flow measurements at baseline and during 1:1 intra-aortic balloon pumping in 114 consecutive patients receiving the radial artery as a aorta-coronary bypass (group A, 72 patients) or as a Y-graft with the left internal thoracic artery (group B, 42 patients). Graft flow reserve, recruited by 1:1 intra-aortic balloon pumping) greater than 1 indicated recruitment of surplus graft flow. Results were stratified by grafted territory and surgical technique. RESULTS: Hospital outcome was comparable. Baseline transit-time flow results were similar between the 2 groups in terms of maximum diastolic flow, minimum systolic flow, mean flow, and pulsatility index. Graft flow reserve was not recruited by intra-aortic balloon pumping in 3 (2.7%) malfunctioning single aorta-oronary radial artery bypass grafts (P = .005 versus successful radial artery bypass grafts). Graft flow reserve was recruited (>1) by intra-aortic balloon pumping in the remaining 111 patent radial artery bypass grafts. Y-grafts showed higher maximum diastolic flow P < .0001), mean flow (P < .0001), graft flow reserve (P < .0001), percentage improvement of maximum diastolic flow (P < .0001), and of mean flow (P < .0001) compared with aorta-coronary radial artery bypass grafts. These results were confirmed for the right coronary (P < or = .004) and the circumflex territory (P < or = .001), for off-pump (P < or = .008) or cardiopulmonary bypass (P < .0001) and for patients undergoing isolated bypass grafting (P < .0001). CONCLUSIONS: Intraoperative flows of radial artery bypass grafts showed comparable baseline results in single aorta-coronary conduits and Y-grafts. Graft flow reserve recruited by intra-aortic balloon pumping was higher in Y-conduits, regardless of the grafted territory and the perfusion strategy chosen. Failed radial artery bypass grafts did not improve transit-time flow results during 1:1 intra-aortic balloong pumping nor showed any recruitment of graft flow reserve

Troponin I and lactate from coronary sinus predict cardiac complications after myocardial revascularization

Background. Postoperative troponin I and lactate elevation are related to cardiac complications after myocardial revascularization. We sought to evaluate earlier predictive value for acute myocardial infarction (AMI) and myocardial damage of troportin I and lactate after myocardial revascularization.Methods. In all, 183 consecutive isolated myocardial revascularizations were prospectively enrolled in the study. Troportin I and lactate were sampled preoperatively and intraoperatively from the coronary sinus, and at 12, 24, 48, and 72 hours. Hospital outcome was recorded. Receiver operating curves for coronary sinus troponin I and lactate were constructed to differentiate patients with or without AMI and myocardial damage.Results. Acute myocardial infarction developed in 6 patients (3.2%), with higher troponin I and lactate at all time points (p &lt; 0.05), longer intubation time (p = 0.003), intensive care unit stay (p = 0.001), hospital stay (p = 0.001), higher atrial fibrillation (p = 0.001), and worse ventricular function (p = 0.001). Myocardial damage developed in 6 patients (3.2%), showing higher troponin I at all time points (p &lt; 0.001), higher intraoperative lactate (P = 0.04), longer intubation time (p = 0.005), and intensive care unit stay (p = 0.03). Receiver operating characteristic curves demonstrated coronary sinus troponin I greater than 0.94 mu g/L (area under the curve [AUCI 0.820 +/- 0.075; sensitivity 90.0%, specificity 68.9%) as a better discriminator between patients with or without AMI than lactate level greater than 2.85 mmol/L (AUC 0.686 +/- 0.090; sensitivity 80.0%; specificity 72.9%); troponin I greater than 0.65 mu g/L was a better discriminator between patients with or without myocardial damage (AUC 0.834 +/- 0.061; sensitivity 93.8%, specificity 71.5%), than lactate greater than 2.05mmol/L (AUC 0.627 +/- 0.067; sensitivity 87.5%; specificity 70.7%).Conclusions. Coronary sinus troponin I and lactate are predictive for cardiac complications after myocardial revascularization. Intraoperative biochemical assays should be routinely performed to establish preventative strategies to reduce further myocardial damage

Social Determinants of Health and Vascular Diseases: A Systematic Review and Call for Action

Several factors that underlie health inequality have been studied and defined as the social determinants of health (SDHs). The main SDHs are gender, socioeconomic status (SES), and ethnicity. In this study, disparity was analyzed in the context of vascular diseases (VDs) such as Peripheral Artery Disease (PAD), Chronic Venous Disease (CVD), Abdominal Arterial Aneurysm (AAA), and Carotid Stenosis (CS). This article aims to provide a comprehensive overview of the published evidence of the SDHs in VDs. For this purpose, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Published articles using the Scopus and ScienceDirect databases were searched. The criteria for the articles’ inclusion/exclusion were decided using a modified PICOTS framework. For the selected articles, the data sheets were organized in such a way to extract all data of potential relevance. Our findings showed that in VDs, gender, SES, and ethnicity are very important, with some specific problems for VDs analyzed. In conclusion, having detected the presence of SDHs that act negatively on VDs, a model based on action items for the SDHs associated with VDs was proposed

Should we discontinue intraaortic balloon during cardioplegic arrest? Splanchnic function results of a prospective randomized trial

Background. Preoperative use of intraaortic ballon pumping (IABP) has increased in high-risk patients. Linear flow during cardiopulmonary bypass (CPB) can induce subclinical damage, whereas automatic IABP mode may maintain pulsatile flow. We sought to evaluate differences between suspending IABP and switching it to an automatic 80 bpm mode during cardioplegic arrest.Methods. Between January and November 2004, 40 patients undergoing preoperative IABP were randomized to receive either standard nonpulsatile CPB with IABP discontinued during cardioplegic arrest (20 patients; group A) or IABP-induced pulsatile (automatic 80 bpm) CPB (20 patients; group B). Hospital outcome was recorded. Urine output, blood urea nitrogen (BUN), creatine, creatinine clearance, peripheral lactate, recovery of gut motility, alanine-amino-transf erase (ALT), aspartateamino-transferase (AST), lactic dehydrogertase (LDH), bilirubin, and amylase (AMY) were compared.Results. There were no IABP-related complications, nor perioperative renal or liver failures, nor hospital deaths, nor myocardial infarctions. Intensive care and hospital stay, urine output, and recovery of gut motility were comparable. Group B showed lower creatine on the first (P = 0.01) and second (p = 0.005) postoperative days, higher creatinine clearance (first day: p = 0.01; second day: p = 0.03), lower lactate after CPB termination (p = 0.0001) and during the first day (p = 0.001). The ALT, AST, and AMY were lower in group B (first day ALT: p = 0.01; AST: p = 0.04; AMY: p = 0.017; second day ALT: p = 0.01; AST: p = 0.02; AMY: p = 0.027), as well as total bilirubin (first day: p = 0.05; second day: p = 0.02).Conclusions. Automatic 80 bpm IABP during cardioplegic arrest improves creatinine clearance and splanchnic enzymes. There is no reason to suspend preoperative IABP support during cardioplegic arrest

Intraaortic balloon pumping during cardioplegic arrest preserves lung function in patients with chronic obstructive pulmonary disease

Background. Linear flow during cardiopulmonary bypass is considered a potential mechanism of lung damage in patients with chronic obstructive pulmonary disease (COPD). We evaluated differences in lung function of patients with COPD undergoing preoperative intraaortic balloon pumping (IABP), between linear flow during cardiopulmonary bypass (IABP-off) and maintenance of pulsatile flow (IABP-on at automatic 80 bpm) during cardioplegic arrest.Methods. Fifty patients with COPD undergoing preoperative IABP were randomized between January 2004 and July 2005 to receive nonpulsatile cardiopulmonary bypass with IABP discontinued during cardioplegic arrest (25 patients; group A), or IABP-induced pulsatile cardiopulmonary bypass (25 patients; group B). Hospital outcome, need for noninvasive ventilation, oxygenation (partial pressure of oxygen, arterial to fraction of inspired oxygen [PaO2/FIO2]), respiratory system compliance, and scoring of chest radiographs were compared.Results. There were no hospital deaths, no IABP-related complications, and no differences in postoperative noninvasive ventilation (group A: 6 of 25, 24.0% vs group B: 5 of 25, 20%; p = not significant [NS]). One patient in both groups developed pneumonia (p = NS). intensive care and hospital stay were comparable (p = NS). Group B showed lower intubation time (8.3 +/- 5.1 hours versus group A: 13.2 +/- 6.0; p = 0.001), better PaO2/FIO2 at aortic declamping (369.5 +/- 93.7 mm Hg vs 225.7 +/- 99.3; p = 0.001) at admission in intensive care (321.3 +/- 96.9 vs 246.2 +/- 109.7; p = 0.003), and at 24 hours (349.8 +/- 100.4 vs 240.8 +/- 77.3; p = 0.003). The respiratory system compliance was better in group B at the end of surgery (56.4 +/- 8.2 mL/cm H2O vs 49.4 +/- 7.0; p = 0.004) and 8 hours postoperatively (76.4 +/- 8.2 vs 59.4 +/- 7.0; p = 0.0001), as well as scoring of chest radiograph at intensive care admission (0.20 +/- 0.41 vs 0.38 +/- 0.56; p = 0.05) and on the first day (0.26 +/- 0.45 vs 0.50 +/- 0.67; p = 0.025).Conclusions. Automatic 80 bpm IABP during cardioplegic arrest preserves lung function in patients with COPD

Ventricular assist device abdominal driveline infection: Treatment with platelet-rich plasma

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Neurohormonal and echocardiographic results after CorCap and mitral annuloplasty for dilated cardiomyopathy

BACKGROUND: Restrictive mitral annuloplasty (RMA) can be an effective treatment for functional mitral regurgitation in congestive heart failure (CHF). Passive cardiac restraint is another surgical approach, but the midterm results are not well characterized. METHODS: Thirty patients with functional mitral regurgitation were prospectively randomized to RMA alone or cardiac restraint with the CorCap Cardiac Support Device (Acorn Cardiovascular Inc, St. Paul, MN) and RMA. Clinical, echocardiographic, New York Heart Association (NYHA) functional class, Short Form 36-Item Health Survey (SF-36) quality of life scores, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) results were analyzed. RESULTS: No hospital deaths or device-related complications occurred. The two groups had comparable morbidity (p = 0.34). Echocardiography showed a trend towards a slightly better functional improvement during follow-up in CorCap plus RMA patients (between groups, p = 0.001). Both groups showed improved results for SF-36, NYHA, and NT-pro.BNP; however, CorCap plus RMA patients had significantly better SF-36 at discharge (p = 0.003), postoperative NYHA (p = 0.05), and NT-pro.BNP (p = 0.001). Survival (p = 0.46), freedom from CHF (p = 0.23), and rehospitalization (p = 0.28) were comparable. Patients in whom CHF developed after postoperative day 1 had higher NT-pro.BNP values (p = 0.001 at all time-points). CONCLUSIONS: Adjunctive application of CorCap with RMA correlated with better NT-pro.BNP at short-term follow-up together with slightly improved echocardiographic and functional results. This deserves further evaluation at midterm and long-term follow-up. Reduction of NT-pro.BNP at follow-up may be suggested as a prognostic index