Effects of body position on autonomic regulation of cardiovascular function in young, healthy adults

Background: Analysis of rhythmic patterns embedded within beat-to-beat variations in heart rate (heart rate variability) is a tool used to assess the balance of cardiac autonomic nervous activity and may be predictive for prognosis of some medical conditions, such as myocardial infarction. It has also been used to evaluate the impact of manipulative therapeutics and body position on autonomic regulation of the cardiovascular system. However, few have compared cardiac autonomic activity in supine and prone positions, postures commonly assumed by patients in manual therapy. We intend to redress this deficiency. Methods: Heart rate, heart rate variability, and beat-to-beat blood pressure were measured in young, healthy non-smokers, during prone, supine, and sitting postures and with breathing paced at 0.25 Hz. Data were recorded for 5 minutes in each posture: Day 1 - prone and supine; Day 2 - prone and sitting. Paired t-tests or Wilcoxon signed-rank tests were used to evaluate posture-related differences in blood pressure, heart rate, and heart rate variability. Results: Prone versus supine: blood pressure and heart rate were significantly higher in the prone posture (p < 0.001). Prone versus sitting: blood pressure was higher and heart rate was lower in the prone posture (p < 0.05) and significant differences were found in some components of heart rate variability. Conclusion: Cardiac autonomic activity was not measurably different in prone and supine postures, but heart rate and blood pressure were. Although heart rate variability parameters indicated sympathetic dominance during sitting (supporting work of others), blood pressure was higher in the prone posture. These differences should be considered when autonomic regulation of cardiovascular function is studied in different postures

Improving Mortality in Subclinical Acute Kidney Injury after Cardiac Surgery by Composite Biomarker Panel

We read with great interest the study of Bouma et al (1) demonstrating the increase in long-term mortality of patients experiencing cardiac surgery associated acute kidney injury (CSA-AKI) stage 1 or higher not only after coronary artery bypass but also after cardiac valve operations. Even more, the mortality risk increased already substantially far below the threshold of AKI definition for stage 1(1). By consistently showing increased mortality also in (combined) valve operations this study closes the missing gap and carries therewith several important implications. First, the study justifies the endeavors for improved AKI definition, very early AKI detection as well as targeted interventions limited to high-risk subgroups in the hope of reducing incidence and severity of CSA-AKI. Second, the present study invariably shows, that the abovementioned endeavors should not be based upon creatinine-derived definitions, because important proportion of patients with potentially deleterious short- and longer-term outcomes could be missed in this way. Essentially, the study of Bouma et al. supports the concept of subclinical CSA-AKI, defined as being not always clinically expressed as per standard creatinine-based criteria but nevertheless strongly predicting adverse acute and late clinical outcomes (1). With the purpose of timely detecting subclinical AKI and forms of its potential (ir-)reversible progression towards more severe forms, we recently proposed a combination of conventional creatinine, relative delta (post-preoperative) creatinine dynamic changes, Neutrophil gelatinase-associated lipocalin to depict acute tubular injury and Cystatin C as a Glomerular Filtration Rate marker (2). While acknowledging that also minimal (up to 10%) creatinine changes could identify patients at higher risk of CSA-AKI, it has been till now unknown that even subclinical increase of creatinine after cardiac surgery in the range of 10-25% translates into substantially higher long-term mortality (1). Mizuguchi et al have recently identified patients at increased risk of AKI to acute kidney disease (AKD) progression by acute kidney injury severity determination (3). On the other hand, it has been reported that applying care bundles could reverse the kidney disease progression, namely by reducing the frequency as well as severity of AKI after cardiac surgery compared to standard postoperative care (4). We strongly believe that a proposed composite biomarker panel, with respect to other available novel biomarkers also costly efficient, could help us overcoming the gap, presented in the current manuscript whereby 10-25% patients with initially subclinical and undetected AKI present with substantially higher mortality (1). Finally, we once again congratulate the authors for the carefully executed study, underlying the inadequacy of the present CSA-AKI creatinine-based definition to reliably assess long-term mortality after cardiac operations therewith further supporting the view that future development of evidence-based Composite Biomarker Panel with reference values for early detection of (ir-)reversible CSA-AKI and CSA-AKD corresponds to putting additional horse before the cart rather than putting a cart before the horse

Sutureless aortic valve and pacemaker rate: from surgical tricks to clinical outcomes

BACKGROUND: Several studies reported high rates of postoperative permanent pacemaker (PPM) implantation, which has been described as the "Achilles' heel" of sutureless aortic valve replacement (AVR). METHODS: From July 2010 to December 2017, 3158 patients with symptomatic, severe aortic valve stenosis were referred to our cardiac surgery center and 512 received a Perceval sutureless bioprosthesis. Thirty-nine patients who had been discharged with concomitant PPM implantation were re-evaluated. RESULTS: After a cumulative follow-up of 1534 months (100% complete, median 50, IQR 30, max 76, min 3 months), a total of 22 patients were still pacemaker-dependent. Kaplan-Meier analysis showed pacemaker-dependent rhythm in 92.0%, 80.0%, 49.4%, and 32.3% of patients at 1, 2, 4, and 5 years, respectively. At Cox regression analysis, pressure during valve deployment [hazard ratio (HR) 79.41; p=0.0003] and "late-onset" atrioventricular block were found to be independent predictors of sinus rhythm restoration (HR 0.16; p=0.0061). Log-rank test showed significantly lower pacemaker dependency rates in patients with "low-pressure" prosthesis implantation (p<0.0001). CONCLUSIONS: Our study shows that several technical measures, including appropriate annulus decalcification, precise positioning of guiding sutures, release of traction sutures applied to the valve commissures and ballooning with reduced pressure, all reduce the rate of PPM implantation after sutureless AVR. Furthermore, a high proportion of patients were found to be no longer pacemaker-dependent at follow-up

Aspectos morfológicos dos autotransplantes de tireóide da rata

Foram operadas cinqüenta ratas Wistar, adultas, separadas em seis grupos: 1, 2, 3, grupos isotado 1 e 2 e um grupo piloto. O lobo esquerdo da tireóide da rata foi dividido em três fragmentos similares e implantados no músculo esternoclidomastóideo, na raiz do mesentério e no ovário. Os tecidos implantados foram examinados histologicamente após dez, vinte e trinta dias. No grupo isolado I, depois de trinta dias a porção restante da tireóide in situ foi removida, passando a viver somente com os implantes. Para verificar aspectos funcionais, foram implantados três fragmentos da tireóide em um grupo isolado na raiz do mesentério. T3 T4 e TSH foram dosados no soro antes e após a retirada da tireóide. O exame histológico mostrou que o tecido tireóideo implantado sofria inicialmente discreta hipotrofia, retomando em seguida para os limites da normalidade. Os melhores resultados foram obtidos com o implante no mesentério. Os valores de T 3 e T 4 eram baixos e os de TSH altos. Apoiado nos resultados histológicos e hormonais, concluiu-se que no período estudado, a tireóide autotransplantada manteve sua arquitetura folicular, cumprindo a função de produzir os hormônios

Long-term survival after surgical treatment for post-infarction mechanical complications: results from the Caution study

International audienceBACKGROUND AND AIMS: Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study early and long-term results of patients undergoing surgical treatment for post-AMI MCs. METHODS: Patients undergone surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centers worldwide were retrieved from the database of CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality. RESULTS: The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5 and 10 years was 54.0%, 48.1% and 41.0%, respectively. Older age (p \textless 0.001) and postoperative LCOS (p \textless 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significant higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022). CONCLUSIONS: Contemporary data from a multicenter cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate postoperative period is encouraging.Trial registration number: NCT03848429

Impact of COVID-19 on incidence and outcomes of post-infarction mechanical complications in Europe

International audienceOBJECTIVES: Post-acute myocardial infarction mechanical complications (post-AMI MCs) represent rare but life-threatening conditions, including free-wall rupture, ventricular septal rupture and papillary muscle rupture. During the coronavirus disease-19 (COVID-19) pandemic, an overwhelming pressure on healthcare systems led to delayed and potentially suboptimal treatments for time-dependent conditions. As AMI-related hospitalizations decreased, limited information is available whether higher rates of post-AMI MCs and related deaths occurred in this setting. This study was aimed to assess how COVID-19 in Europe has impacted the incidence, treatment and outcome of MCs. METHODS: The CAUTION-COVID19 study is a multicentre retrospective study collecting 175 patients with post-AMI MCs in 18 centres from 6 European countries, aimed to compare the incidence of such events, related patients' characteristics, and outcomes, between the first year of pandemic and the 2 previous years. RESULTS: A non-significant increase in MCs was observed [odds ratio (OR) = 1.15, 95% confidence interval (CI) 0.85-1.57; P = 0.364], with stronger growth in ventricular septal rupture diagnoses (OR = 1.43, 95% CI 0.95-2.18; P = 0.090). No significant differences in treatment types and mortality were found between the 2 periods. In-hospital mortality was 50.9% and was higher for conservatively managed cases (90.9%) and lower for surgical patients (44.0%). Patients admitted during COVID-19 more frequently had late-presenting infarction (OR = 2.47, 95% CI 1.24-4.92; P = 0.010), more stable conditions (OR = 2.61, 95% CI 1.27-5.35; P = 0.009) and higher EuroSCORE II (OR = 1.04, 95% CI 1.01-1.06; P = 0.006). CONCLUSIONS: A non-significant increase in MCs incidence occurred during the first year of COVID-19, characterized by a significantly higher rate of late-presenting infarction, stable conditions and EuroSCORE-II if compared to pre-pandemic data, without affecting treatment and mortality

Surgical Treatment of Post-Infarction Left Ventricular Free-Wall Rupture: A Multicenter Study

Background: Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. Methods: Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post\u2013acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality. Results: The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P &lt;.001), cardiac arrest at presentation (P =.011), female sex (P =.044), and the need for preoperative extracorporeal life support (P =.003) were independent predictors for operative mortality. Conclusions: Surgical repair of post-infarction LVFWR carries a high operative mortality. Female sex, preoperative left ventricular ejection fraction, cardiac arrest, and extracorporeal life support are predictors of early mortality