Echocardiographic evaluation of paravalvular aortic regurgitation of a patient with recurrent aortic valve replacements.

Paravalvular regurgitation (PVR) is a serious complication after surgical valve replacement. Echocardiography is the gold standard technique to assess the severity of PVR with an integrated approach.A 48-year-old male underwent aortic valve replacement due to infective endocarditis (IE). During in-hospital cardiac rehabilitation after a redo surgery for a new IE three years later, an echo-free anterior space around the valve with several PVRs through transthoracic echocardiography (TTE) was identified. On transesophageal echocardiography (TOE) a double PVR (anterior and posterior) with abscessual cavity was detected. The patient's conditions worsened within six months with hemodynamic instability: a massive PVR due to a large abscess cavity next to the right cusp was confirmed by TTE and TOE and a third surgery was carried out. On the third admission at our Rehabilitation Unit the echo features were normal. Patient did not report any cardiovascular symptoms at 1 year follow-up

Left atrial strain predicts exercise capacity in heart failure independently of left ventricular ejection fraction

Aims: We hypothesized that left atrial (LA) remodelling and function are associated with poor exercise capacity as prognostic marker in chronic heart failure (CHF) across a broad range of left ventricular ejection fraction (LVEF). Methods and results: One hundred seventy-one patients with CHF were analysed [age 65 +/- 11 years, 136 males (80%); 86 heart failure with reduced ejection fraction (HFrEF), 27 heart failure with mid-range ejection fraction (HFmrEF), 58 heart failure with preserved ejection fraction (HFpEF)]. All patients underwent echocardiography and maximal cardiopulmonary exercise testing and were classified according to a prognostic cut-off of peak VO2 (pVO(2); 14 mL/kg/min). Seventy-seven (45%) patients reached pVO(2) = 14 mL/kg/min. Between the two groups, there was a considerable difference in both left atrial volume (LAVi, 53 +/- 24 vs. 44 +/- 18 mL/m(2), P = 0.005) and function (LA reservoir strain 12 +/- 5 vs. 20 +/- 10%, P < 0.0001). Receiver-operating characteristic curves identified LA reservoir strain (area under the curve: 0.73 [0.65-0.80], P < 0.0001) as strong predictor for impaired pVO(2) among all echocardiographic variables; LA reservoir strain < 23% had 37% specificity but a very high sensitivity (96%) in identifying a severely reduced pVO(2). In logistic regression analysis, LA reservoir strain < 23% was associated with a highly increased risk of pVO(2) < 14 mL/kg/min (odds ratio 16.0 [4.7-54.6]; P < 0.0001). The multivariate analysis showed that a reduced LA reservoir strain was associated with pVO(2) < 14 mL/kg/min after adjustment for age, body mass index (BMI), and clinical variables, that is, New York Heart Association class, atrial fibrillation, haemoglobin, and creatinine (b 0.22 [95% confidence interval, CI, 0.12-0.31]; P < 0.0001), and after adjustment for echocardiographic variables, that is, LVEF or left ventricular global longitudinal strain (LVGLS) and tricuspid annular plane systolic excursion (TAPSE) (b 0.16 [95% CI 0.08-0.24]; P < 0.0001). Patients with HFrEF, HFmrEF, and HFpEF were separately analysed. Among LA reservoir strain, LAVi, LVEF, LVGLS, and TAPSE, LA reservoir strain was the only one significantly associated with pVO(2) in all subgroups (after adjustment for sex and BMI, P = 0.003, 0.04, and 0.01, respectively). Conclusions: In patients with CHF, an impaired LA reservoir function is independently associated with a severely reduced pVO(2). LA dysfunction represents a marker of poor prognosis across LVEF borders in the CHF population

Malt in Combination with Lactobacillus rhamnosus Increases Concentrations of Butyric Acid in the Distal Colon and Serum in Rats Compared with Other Barley Products but Decreases Viable Counts of Cecal Bifidobacteria123

Several substances, including glutamine and propionic acid but in particular butyric acid, have been proposed to be important for colonic health. β-Glucans lead to the formation of comparatively high amounts of butyric acid, and germinated barley foodstuff obtained from brewer’s spent grain (BSG), containing high amounts of β-glucans and glutamine, has been reported to reduce the inflammatory response in the colon of patients with ulcerative colitis. The present study examines how 3 barley products, whole grain barley, malt, and BSG, affect SCFA in the hindgut and serum of rats and whether the addition of Lactobacillus rhamnosus 271 to each of these diets would have further effects. Amino acids in plasma and the cecal composition of the microbiota were also analyzed. The butyric acid concentration in the distal colon and serum was higher in the malt groups than in the other groups as was the serum concentration of propionic acid. The concentrations of propionic and butyric acids were higher in the cecum and serum of rats given L. rhamnosus than in those not given this strain. The proportion of plasma glutamine and the cecal number of bifidobacteria were lower in the malt groups than in the other groups. L. rhamnosus decreased the number of cecal bifidobacteria, whereas plasma glutamine was unaffected. We conclude that malt together with L. rhamnosus 271 had greater effects on propionic and butyric acid concentrations in rats than the other barley products. This is interesting when developing food with effects on colonic health

The Open Abdomen for the Management of Critically Ill Patients with Abdominal Sepsis: Safe? Yes! Effective? Perhaps!

Background The use of Open Abdomen (OA) has been increasingly adopted in the last years to manage patients with severe abdominal sepsis. Several techniques for temporary abdominal closure (TAC) during OA, such as Negative Pressure Wound Therapy (NPWT), have been proposed. The aim of this study was to analyze the outcomes of patients with intra-abdominal infections treated with OA. Methods Ninety-six patients treated with OA for severe secondary peritonitis and/or septic shock from January 2010 to March 2018 were included in the study. Patients demographics with the clinical picture and the type of TACs adopted were the independent variables analyzed. Major outcomes were: DFC rate, morbidity, and mortality. Minor outcomes included the number of revisions and length of the period with OA. Results Patients population included 50 males and 46 females (M: F ratio 1.09:1). Mean age was 66.9 years, mean BMI was 26.3 Kg/m2. 89% of patients presented with an ASA score ≥ 3. Mean Mannheim Peritonitis Index (MPI) was 22.7 (SD ± 6.5). With regard to the negative pressure systems, this was used in 82 patients (85%) with the following distribution: Barker’s vacuum-pack in 41 patients (43%); NPWT system in 38 (39%) and NPWT with dynamic fascial tension system in 3 (3%). In 14 patients (15%), a skin-closure technique was adopted. Overall, the post-operative complications rate was 73%. According to Clavien and Dindo Classification, 25 patients (45%) presented a grade ≥ III complication (6 grade IIIa; 5 grade IIIb; 8 grade IVa and 6 grade IVb). Entero-atmospheric fistula was observed in 2 patients, one in the group treated with NPWT system and one in the group with Barker’s vacuum-pack. DFC was reached in 82 out of 83 patients (99%) who survived the initial operation. In 10 patients (12%), a prosthetic mesh was used. Overall mortality rate was 42%. Mortality rate during OA was 14% (13 patients): for these patients, the mean time from the first laparotomy to death was 6 days. The mortality rate after definitive fascial closure was 33% (27 patients) with an interval from DFC to death of 17.2 days. Meanly, the length of OA was 3.1 days and the number of revisions was 1.4. Conclusion OA appears to be a safe method to manage critically ill patients with abdominal sepsis. Negative pressure systems for temporary abdominal closure allow reaching a high rate of DFC with a low number of enteroatmospheric fistulas. However, morbidity and mortality remain severe suggesting that randomized studies are needed to prove the effectiveness of OA in severe abdominal sepsis