Preoperative prediction of pediatric patients with effusions and edema following cardiopulmonary bypass surgery by serological and routine laboratory data

AIM: Postoperative effusions and edema and capillary leak syndrome in children after cardiac surgery with cardiopulmonary bypass constitute considerable clinical problems. Overshooting immune response is held to be the cause. In a prospective study we investigated whether preoperative immune status differences exist in patients at risk for postsurgical effusions and edema, and to what extent these differences permit prediction of the postoperative outcome. METHOD: One-day preoperative serum levels of immunoglobulins, complement, cytokines and chemokines, soluble adhesion molecules and receptors as well as clinical chemistry parameters such as differential counts, creatinine, blood coagulation status (altogether 56 parameters) were analyzed in peripheral blood samples of 75 children (aged 3–18 years) undergoing cardiopulmonary bypass surgery (29 with postoperative effusions and edema within the first postoperative week). RESULTS: Preoperative elevation of the serum level of C3 and C5 complement components, tumor necrosis factor-α, percentage of leukocytes that are neutrophils, body weight and decreased percentage of lymphocytes (all P < 0.03) occurred in children developing postoperative effusions and edema. While single parameters did not predict individual outcome, >86% of the patients with postoperative effusions and oedema were correctly predicted using two different classification algorithms. Data mining by both methods selected nine partially overlapping parameters. The prediction quality was independent of the congenital heart defect. CONCLUSION: Indicators of inflammation were selected as risk indicators by explorative data analysis. This suggests that preoperative differences in the immune system and capillary permeability status exist in patients at risk for postoperative effusions. These differences are suitable for preoperative risk assessment and may be used for the benefit of the patient and to improve cost effectiveness

A randomized comparison of HBP versus RVP: Effect on left ventricular function and biomarkers of collagen metabolism

Background: Right ventricular pacing (RVP) can result in pacing-induced cardiomyopathy (PICM). It is unknown whether specific biomarkers reflect differences between His bundle pacing (HBP) and RVP and predict a decrease in left ventricular function during RVP. Aims: To compare the effect of HBP and RVP on the LV ejection fraction (LVEF) and to study how they affect serum markers of collagen metabolism. Methods: Ninety-two high-risk PICM patients were randomized to HBP or RVP. Their clinical characteristics, echocardiography, and serum levels of TGF-β1, MMP-9, ST2-IL, TIMP-1, and Gal-3 were studied before and six months after pacemaker implantation. Results: Fifty-three patients were randomized to HBP and 39 patients to RVP. HBP failed in 10 patients, which crossed over to the RVP group. Patients with RVP had significantly lower LVEF compared to HBP after six months of pacing (−5% and −4% in as-treated and intention-to-treat analysis, respectively). Levels of TGF-β1 after 6 months were lower in HBP than RVP (mean difference −6 ng/ml; P = 0.009) and preimplant Gal-3 and ST2-IL levels were higher in RVP patients with a decline in the LVEF ≥ 5% compared to those with a decline of &lt; 5% (mean difference 3 ng/ml and 8 ng/ml; P = 0.02 for both). Conclusion: In high-risk PICM patients, HBP was superior to RVP in providing more physiological ventricular function, as reflected by higher LVEF and lower levels of TGF-β1. Among RVP patients, LVEF declined more in those with higher baseline Gal-3 and ST2-IL levels than those with lower levels

Catheter ablation for non-paroxysmal atrial fibrillation. A review

Atrial fibrillation (AF), the most common cardiac arrhythmia is associated with increased morbidity and mortality. The higher mortality is due to the risk of heart failure and cardioembolic events. This in-depth review focuses on the strategies and efficacy of catheter ablation for non-paroxysmal atrial fibrillation. The main medical databases were searched for contemporary studies on catheter ablation for non-paroxysmal AF. Catheter ablation is currently proven to be the most effective treatment for AF and consists of pulmonary vein isolation as the cornerstone plus additional ablations. In terms of SR maintenance, it is less effective in non-paroxysmal AF than in paroxysmal patients. but the clinical benefit in non-paroxysmal patients is substantially higher. Since pulmonary vein isolation is ineffective, a variety of techniques have been developed, e.g. linear ablations, ablation of complex atrial fractionated electrograms, etc. Another paradox consists in the technique of catheter ablation. Despite promising results in early observation studies, further randomized studies have not confirmed the initial enthusiasm. Recently, a new approach, pulsed-field ablation, appears promising. This is an in-depth summary of current technologies and techniques for the ablation of non-paroxysmal AF. We discuss the benefits, risks and implications in the treatment of patients with non-paroxysmal AF

Close Proximity of Left Anterior Descending Artery to the Right Ventricular Lead Apparently Implanted into the Mid-septum

Right ventricular (RV) mid-septal pacing should have fewer negative effects on left ventricular function compared to apical pacing. However, targeting the mid-septum may be technically challenging since it is usually done with two-dimensional fluoroscopy. The rotation of the heart and various shapes of the RV make it difficult to assess, whether the lead is really anchored in the septum. Many leads, apparently anchored in the septum, are in fact anchored in the anterior wall or anteroseptal groove, and some can get anchored in close proximity to the left anterior descending artery (LAD). We report three cases from our series of 51 patients, in whom the RV lead thought to be implanted in the mid-septum was in fact anchored in close proximity of LAD when assessed using computed tomography

Double-gap-in-roof reentrant tachycardia following surgical thoracoscopic atrial fibrillation ablation

A case of macro-reentrant tachycardia associated with a box lesion after thoracoscopis left atrial surgical atrial fibrillation (AF) ablation yet to be described. The goal was to clarify the mechanisms and electrophysiological characteristics of this type of tachycardia. A patient was admitted for an EP study following surgical thoracoscopic AF ablation (box lexion formation by right-sided Cobra thoracoscopic ablation). Thoracoscopic ablation was done as the first step of the hybrid ablation approach to the persistent AF; the second step was the EP study. At the EP study, he presented with incessant regular tachycardia (cycle length of 226 ms). An EP study with conventional, 3D activation and entrainment mapping was done to assess the tachycardia mechanism. Two conduction gaps in the superior line (roofline) between the superior pulmonary veins were discovered. The tachycardia was successfully treated with a radiofrequency application near the gap close to the left superior pulmonary vein; however, following tachycardia termination, pulmonary vein isolation was absent. A second radiofrequency application, close to the roof of the right superior pulmonary, vein closed the gap in the box and led to the isolation of all 4 pulmonary veins. No atrial tachycardia recurred during the 6-month follow-up. Conduction gaps in box lesion created by thoracospcopic ablation can present as a novel type of man-made tachycardia after surgical ablation of atrial fibrillation. Activation and entrainment mapping is necessary for an accurate diagnosis

Prognostic value of TNF-related apoptosis inducing ligand (TRAIL) in acute coronary syndrome patients.

BACKGROUND: Apoptosis plays an important role in the development of heart failure. The aim of the prospectively designed study was to assess whether the concentration of apoptotic markers apoptosis-stimulating fragment (Fas, CD95/APO-1) and tumor necrosis factor-related apoptosis inducing ligand (TRAIL) can predict prognosis in patients with acute coronary syndromes. METHODS: The concentrations of soluble Fas and TRAIL were determined in 295 patients with acute coronary syndromes. The status of all patients was evaluated at 6 months. The primary goal was a composite end-point of death and hospitalization for heart failure. The secondary end-points were re-MI, death alone and stroke alone. RESULTS: During the median follow-up of 6 months, 26 patients experienced the composite end-point. Using multivariate logistic regression, the concentration of TRAIL was the strongest significant and independent predictor of composite end-point (OR 0.11 (95% CI 0.03-0.45), p = 0.002). Low concentration was associated with poor prognosis of patients. Other significant predictors of composite end-point were serum creatinine (OR 7.7 (95% CI 1.1-54.5, p = 0.041) and complete revascularization (OR 0.19 (95% CI 0.05-0.78, p = 0.02). Independent significant predictors of death in the multivariate analysis were the concentration of TRAIL (OR 0.053 (95% CI 0.004-0.744), p = 0.029), older age (OR 1.20 (95% CI 1.02-1.41, p = 0.026) and serum creatinine (OR 15.1 (95% CI 1.56-145.2), p = 0.0193). Re-MI or stroke could not be predicted by any combination of obtained parameters. CONCLUSIONS: Low concentrations of soluble TRAIL represent a strong predictor of a poor prognosis in patients with acute coronary syndrome. The predictive value of TRAIL concentration is independent of age, ejection fraction, index peak troponin level, concentration of BNP or serum creatinine