Extrinsic outflow graft flow obstruction in patients with HeartMate3 LVAD

Blood flow obstruction at the level of the outflow graft is a rare but severe complication of LVAD support. We present a series of five patients supported with HeartMate3 LVAD (Abbott Labs, Chicago, IL) that developed an outflow graft obstruction after 607–1250 days of support, during prolonged antithrombotic therapy. Three patients presented with severe symptoms of heart failure, were treated with endovascular stenting and experienced full recovery. Preoperative computed tomography angiography and intraoperative angiography together with intravascular ultrasound provided diagnosis and guided treatment. In two patients, outflow obstruction was an occasional finding at imaging without heart failure symptoms and a “watchful waiting” approach was adopted: delayed treatment in one of them was futile. This late adverse event is peculiar for its pathophysiology and not yet discussed among the mechanical circulatory support community

Innovative Helicopter In-Flight Noise Monitoring Systems Enabled by Rotor-State Measurements

The present contribution aims at providing a comprehensive illustration of a new approach to rotorcraft noise abatement, especially during terminal procedures, when the vehicle approaches the ground and the acoustic impact is higher. This approach pursues the development of technologies and tools for real-time, in-flight monitoring of the emitted noise. The effect of the acoustic radiation is presented to the pilot in a condensed, practical form on a new cockpit instrumentation, the Pilot Acoustic Indicator (PAI), to be used for performing quieter maneuvers. The PAI is based on the synergetic composition of pre-calculated acoustic data, which are used in a noise estimation algorithm together with the data gathered by an innovative contactless measurement system, capable of acquiring the main rotor blade motion. The paper reports on the current studies in unsteady and quasi-steady aeroacoustic prediction and tip-path-plane angle of attack and thrust coefficient observation. Results on novel methodologies are discussed, together with the main features of the PAI design and development process

Cold-to-warm flow regime transition in snow avalanches

Large avalanches usually encounter different snow conditions along their track. When they release as slab avalanches comprising cold snow, they can subsequently develop into powder snow avalanches entraining snow as they move down the mountain. Typically, this entrained snow will be cold (T‾&lt;-1&thinsp;∘C) at high elevations near the surface, but warm (T‾&gt;-1&thinsp;∘C) at lower elevations or deeper in the snowpack. The intake of warm snow is believed to be of major importance to increase the temperature of the snow composition in the avalanche and eventually cause a flow regime transition. Measurements of flow regime transitions are performed at the Vallée de la Sionne avalanche test site in Switzerland using two different radar systems. The data are then combined with snow temperatures calculated with the snow cover model SNOWPACK. We define transitions as complete when the deposit at runout is characterized only by warm snow or as partial if there is a warm flow regime, but the farthest deposit is characterized by cold snow. We introduce a transition index Ft, based on the runout of cold and warm flow regimes, as a measure to quantify the transition type. Finally, we parameterize the snow cover temperature along the avalanche track by the altitude Hs, which represents the point where the average temperature of the uppermost 0.5&thinsp;m changes from cold to warm. We find that Ft is related to the snow cover properties, i.e. approximately proportional to Hs. Thus, the flow regime in the runout area and the type of transition can be predicted by knowing the snow cover temperature distribution. We find that, if Hs is more than 500&thinsp;m above the valley floor for the path geometry of Vallée de la Sionne, entrainment of warm surface snow leads to a complete flow regime transition and the runout area is reached by only warm flow regimes. Such knowledge is of great importance since the impact pressure and the effectiveness of protection measures are greatly dependent on the flow regime.</p

Assessment of surgeon communication skills from the patient perspective: A national evaluation using the Communication Assessment Tool

Objective: The Communication Assessment Tool (CAT) has previously been translated and adapted to the Italian context. This national study aimed to validate the CAT and evaluate communication skills of practicing surgeons from the patient perspective. Methods: CAT consists of 14 items associated with a 5-point scale (5 = excellent); results are reported as the percent of ‘‘excellent’’ scores. It was administered to 920 consenting outpatients aged 18–84 in 26 Italian surgical departments. Results: The largest age group was 45–64 (43.8%); 52.2% of the sample was male. Scores ranged from 44.6% to 66.6% excellent. The highest-scoring items were “Treated me with respect” (66.6%), “Gave me as much information as I wanted” (66.3%) and “Talked in terms I could understand” (66.0%); the lowest was “Encouraged me to ask questions” (44.6%). Significant differences were associated with age (18–24 year old patients exhibited the lowest scores) and geographical location (Northern Italy had the highest scores). Conclusion: CAT is a valid tool for measuring communication in surgical settings. Practice Implications: Results suggest that expectations of young people for communication in surgical settings are not being met. While there is room to improve communication skills of surgeons across Italy, patients highlighted the greatest need in the Central and Southern regions

A Randomized Trial of Intravenous Amino Acids for Kidney Protection

Background Acute kidney injury (AKI) is a serious and common complication of cardiac surgery, for which reduced kidney perfusion is a key contributing factor. Intravenous amino acids increase kidney perfusion and recruit renal functional reserve. However, the efficacy of amino acids in reducing the occurrence of AKI after cardiac surgery is uncertain. Methods In a multinational, double-blind trial, we randomly assigned adult patients who were scheduled to undergo cardiac surgery with cardiopulmonary bypass to receive an intravenous infusion of either a balanced mixture of amino acids, at a dose of 2 g per kilogram of ideal body weight per day, or placebo (Ringer's solution) for up to 3 days. The primary outcome was the occurrence of AKI, defined according to the Kidney Disease: Improving Global Outcomes creatinine criteria. Secondary outcomes included the severity of AKI, the use and duration of kidney-replacement therapy, and all-cause 30-day mortality. Results We recruited 3511 patients at 22 centers in three countries and assigned 1759 patients to the amino acid group and 1752 to the placebo group. AKI occurred in 474 patients (26.9%) in the amino acid group and in 555 (31.7%) in the placebo group (relative risk, 0.85; 95% confidence interval [CI], 0.77 to 0.94; P=0.002). Stage 3 AKI occurred in 29 patients (1.6%) and 52 patients (3.0%), respectively (relative risk, 0.56; 95% CI, 0.35 to 0.87). Kidney-replacement therapy was used in 24 patients (1.4%) in the amino acid group and in 33 patients (1.9%) in the placebo group. There were no substantial differences between the two groups in other secondary outcomes or in adverse events. Conclusions Among adult patients undergoing cardiac surgery, infusion of amino acids reduced the occurrence of AKI

Management of Bleeding and Hemolysis During Percutaneous Microaxial Flow Pump Support A Practical Approach

© 2023 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY), https://creativecommons.org/licenses/by/4.0/Percutaneous ventricular assist devices (pVADs) are increasingly being used because of improved experience and availability. The Impella (Abiomed), a percutaneous microaxial, continuous-flow, short-term ventricular assist device, requires meticulous postimplantation management to avoid the 2 most frequent complications, namely, bleeding and hemolysis. A standardized approach to the prevention, detection, and treatment of these complications is mandatory to improve outcomes. The risk for hemolysis is mostly influenced by pump instability, resulting from patient- or device-related factors. Upfront echocardiographic assessment, frequent monitoring, and prompt intervention are essential. The precarious hemostatic balance during pVAD support results from the combination of a procoagulant state, due to critical illness and contact pathway activation, together with a variety of factors aggravating bleeding risk. Preventive strategies and appropriate management, adapted to the impact of the bleeding, are crucial. This review offers a guide to physicians to tackle these device-related complications in this critically ill pVAD-supported patient population.Peer reviewe

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device

Impedance Responses Reveal β2-Adrenergic Receptor Signaling Pluridimensionality and Allow Classification of Ligands with Distinct Signaling Profiles

The discovery that drugs targeting a single G protein-coupled receptor (GPCR) can differentially modulate distinct subsets of the receptor signaling repertoire has created a challenge for drug discovery at these important therapeutic targets. Here, we demonstrate that a single label-free assay based on cellular impedance provides a real-time integration of multiple signaling events engaged upon GPCR activation. Stimulation of the β2-adrenergic receptor (β2AR) in living cells with the prototypical agonist isoproterenol generated a complex, multi-featured impedance response over time. Selective pharmacological inhibition of specific arms of the β2AR signaling network revealed the differential contribution of Gs-, Gi- and Gβγ-dependent signaling events, including activation of the canonical cAMP and ERK1/2 pathways, to specific components of the impedance response. Further dissection revealed the essential role of intracellular Ca2+ in the impedance response and led to the discovery of a novel β2AR-promoted Ca2+ mobilization event. Recognizing that impedance responses provide an integrative assessment of ligand activity, we screened a collection of β-adrenergic ligands to determine if differences in the signaling repertoire engaged by compounds would lead to distinct impedance signatures. An unsupervised clustering analysis of the impedance responses revealed the existence of 5 distinct compound classes, revealing a richer signaling texture than previously recognized for this receptor. Taken together, these data indicate that the pluridimensionality of GPCR signaling can be captured using integrative approaches to provide a comprehensive readout of drug activity