Introduction Extracorporeal membrane oxygenation (ECMO) is implemented as a rescue therapy in COVID-19 related acute distress respiratory syndrome (ARDS) and refractory hypoxemia. Google trends (GT) is an ongoing-developing web-kit providing feedback on specific population’s interests. This study uses GT to analyze the United States (US) general population interest in ECMO as COVD-19/ARDS salvage therapy. Methods GT was used to access data searched for the term ECMO and COVID-19. The gathered information included data from March 2020 through July 2021 within US territories. Search frequency, time intervals, sub-regions, frequent topics of interest, and related searches were analyzed. Data was reported as search frequency on means, and a value of 100 represented overall peak popularity. Results The number of Google searches related to the terms ECMO and COVID-19 has surged and sustained interest over time ever since the initial reports of COVID-19 in the US, from an initial mean of 34% in March 2020 to a 100% interest by April 2020, resulting in an up-to-date overall average of 40% interest. Over time West Virginia, Gainesville, and Houston, lead the frequency of searches in sub-region, metro and city areas, respectively. Top search terms by frequency include: ECMO machine, COVID ECMO, what is ECMO, ECMO treatment and VV ECMO. Parallel to this, the related rising terms are: COVID ECMO, ECMO machine COVID, ECMO for COVID, ECMO machine coronavirus, and ECMO vs ventilator. Seemingly, medical-relevant websites fail to adequately address these for patient therapeutic education (PTE) purposes. Conclusions GT complements the understanding of interest in ECMO for COVID-19. When properly interpreted, the use of these trends can potentially improve on PTE and therapy awareness via specific medical relevant websites.
Title Page:Title: Letter To The Editor: Gastrointestinal complications after cardiac surgery: Incidence, predictors, and impact on outcomesArticle Type: Letter To The EditorCorrespondence: 1. Sapna goindaniContact no: +971 54 344 9435. Email: [email protected]: Peoples University of Medical and Health Sciences For Women (PUMHSW)Address: Flat no 9, building no 10 bastakia building, Al hamriya bur dubai, dubaiORCID: 0000-0003-4906-8463Co-Authors: 2. Roomi rajaContact No: +92-3342946940. Email: [email protected]: Ziauddin University KarachiAddress: Hemilton Courts Block G-1 Flat 408 Near Teen Talwar Clifton KarachiORCID: 0000-0001-9104-3644Co-Authors: 3. Satesh KumarContact No: +92-3325252902. Email: [email protected]: Shaheed Mohtarma Benazir Bhutto Medical College Liyari, KarachiAddress: Parsa Citi Garden East, KarachiORCID: 0000-0001-7975-6297Word Count: 340Conflict of interest : NoneAcknowledgment : NoneDeclaration: NoneDisclosure : NoneFunding : None
The intra-aortic balloon pump (IABP) is used to prevent complications after coronary artery bypass grafting (CABG) surgery; although some results are controversial nowadays even contradictory. A new article on this field is published in this edition and shows that the risk factors for in-hospital mortality are the preoperative plasma creatinine level and cardiopulmonary bypass time in 177 patients. About the prophylactic use of the IABP regarding mortality the results reflected so far in meta-analyses have been highly contradictory between them, and the risk factors associated with it have been several and different. This lack of evidence has resulted in the continued variation of IABP use in these procedures. A large, multicenter RCT is certainly required to take the next step towards more definitive evidence, either for or against, the use of IABP in high-risk CABG. Until then, the unanswered questions regarding this topic will remain.
Background: Mitral valve apparatus is complex and involves the mitral annulus, the leaflets, the chordae tendinae, the papillary muscles as well as the left atrial and ventricular myocardium. Secondary mitral regurgitation is consequence of regional or global left ventricle remodeling due to an acute myocardial infarction (75% of cases) or idiopathic dilated cardiomyopathy (25% of cases). It is associated with an increase in mortality and poor outcome. There is a potential survival benefit deriving from the reduction in the degree of severity of mitral regurgitation. So the correction of the valve defect can change the clinical course and prognosis of the patient. The rationale for mitral valve treatment depends on the mitral regurgitation mechanism. Therefore, it is essential to identify and understand the pathophysiology of the mitral valve regurgitation. Aim of the study: The aim of this review is to describe the crucial role of transthoracic and trans-esophageal echocardiography, in particular with 3D echocardiography, for the assessment of the severity of secondary mitral regurgitation, anatomy and hemodynamic changes in the left ventricle. Moreover, the concept that the mitral valve has no organic lesions has been abandoned. The echocardiography must allow a complete anatomical and functional evaluation of each component of the mitral valve complex, also useful to the surgeon in choosing the best surgical approach to repair the valve. Conclusions: Echocardiography is the first-line imaging modality for a better selection of patients, according to geometrical modifications of mitral apparatus and left ventricle viability, especially in preoperative phase.
Objective: In this study, it was aimed to compare various parameters during surgery and postoperative cognitive functions in patients undergoing coronary artery bypass graft (CABG) surgery using different levels of perioperative oxygen. Methods: One hundred patients scheduled for elective CABG surgery were included in the study. The patients were divided into two groups according to arterial oxygen levels during surgery. In the normoxia group (NG) (n = 50), PaO2 was between ≥100mmHg and <180mmHg with at least 40% FiO2 mechanical ventilation (MV), and in the hyperoxia group (HG) (n = 50), PaO2 was ≥180 mmHg with 100% FiO2 MV. Hemodynamic parameters, peripheral oxygen saturation (SpO2), cerebral oxygen saturation (rSO2) measured from bilateral sensors, and blood gas values were recorded at the planned measurement times. Mini-mental state examination test (MMSE) was applied to the patients before and at the 12th, 24th hours; on the 1st, 3rd, 6th months after surgery. Results: Extubation time was found to be shorter in NG (p <0.05). Between the groups, rSO2 and mean arterial pressure (MAP) were found to be significantly lower in HG at the time of T4 measurement (p = 0.042, p = 0.038, respectively). MMSE values of the groups at the 1st, 3rd and 6th months were found to be significantly higher in NG (respectively p = 0.017, p = 0.014, p = 0.002). Conclusion: Hyperoxemia application during CABG may be associated with worse postoperative late-term cognitive functions. Keywords: cardiopulmonary bypass; hyperoxia; postoperative complications; cognitive function; spectroscopy, near-infrared.
For donation after circulatory death, procurement is performed after the heart has arrested. This technique has been employed and adopted by clinicians to overcome the shortage of available hearts for transplant. Warm ischemia time plays a pivotal role in the survival outcome of the heart recipients. We describe a fast and safe technique to flush the heart during recovery from circulatory death donors in order to shorten the warm ischemia time.
Purpose: Extracorporeal membrane oxygenation (ECMO) is a refractory treatment for acute respiratory distress syndrome (ARDS) due to influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, also referred to as COVID-19). We conducted this study to compare the outcomes of influenza patients treated with veno-venous-ECMO (VV-ECMO) to COVID-19 patients treated with VV-ECMO, during the first wave of COVID-19. Materials and Methods: Patients in our institution with ARDS due to COVID-19 or influenza who were placed on ECMO between August 1, 2010 and September 15, 2020 were included in this comparative, retrospective study. To improve homogeneity, only VV -ECMO patients were analyzed. The clinical characteristics and outcomes were extracted and analyzed. Results: 28 COVID-19 patients and 17 influenza patients were identified and included. ECMO survival rates were 68% (19/28) in COVID-19 patients and 94% (16/17) in influenza patients (p=0.04). 30-day survival rates after ECMO decannulation were 54% (15/28) in COVID-19 patients and 76% (13/17) in influenza patients (p=0.13). COVID-19 patients spent a longer time on ECMO compared to flu patients (21 days vs. 12 days, p=0.025), and more COVID-19 patients (26/28 vs. 2/17) were on immunomodulatory therapy prior to ECMO initiation (p<0.001). COVID-19 patients had higher rates of new infections during ECMO (50% vs. 18%, p=0.03) and bacterial pneumonia (36% vs 6%, p=0.024). Conclusions: COVID-19 patients who were treated in our institution with VV-ECMO had statistically lower ECMO survival rates than influenza patients. It is possible that COVID-19 immunomodulation therapies may increase the risk of other superimposed infections.
The use of radial artery (RA) grafts for coronary bypass surgery has recently gained newer attention since it has been associated with significant reduction in the risk of midterm cardiac events. Surprisingly the use on the RA graft as second ‘best’ conduit has been limited among the surgical community. There may be several explanations for the little popularity of the RA graft; one of the reasons that could prevent surgeons to include the RA in the daily surgical armamentarium it is that patients with RA grafts may require postoperative calcium-channel blocker (CB) therapy. Due to the thick muscular wall, it seems possible that the RA would needs CB in order to prevent spasm and ameliorate patency. CBs are, however, associated with important side effects; also they have hypotensive effect that can hamper the use of other therapy such as beta-blocker or angiotensin-converting enzyme inhibitors. The evidence supporting the use of CB after RA graft (either in the early phase or as chronic calcium-blocker (CCB)) is weak. A the post-hoc analysis from the ‘RADIAL’ (Radial Artery Database International ALliance), showed that in patients with RA, the use of CB for at least 12 months was associated with better clinical and angiographic outcomes at mid-term follow-up, but confounders and bias may be responsible for the reported findings (as healthier patients are more likely to tolerate CB) . This review aims to summarize current evidences available on the topic and to serve as benchmark for evidence-based decision-making for CB prescription after RA grafting.
Coronary artery and cerebrovascular disease represent a major cause of cardiovascular morbidity and mortality worldwide. Despite technological advancements in percutaneous interventions, surgical revascularization remains the preferred strategy in patients with left main or multivessel disease and in those with complex lesions with high SYNTAX score. As a result, an increasing number of older patients with diffuse atherosclerotic extracoronary disease are referred for coronary artery bypass grafting (CABG). Cerebrovascular complications after isolated coronary surgery occurs in 1-5% of patients; the magnitude of injury ranges from overt neurologic lesions with varying degree of permanent disability to “asymptomatic” cerebral events detected by dedicated neuro-imaging, nevertheless associated with significant long term cognitive and functional decline. Thromboembolic events due to manipulation of an atherosclerotic aorta are universally recognized as the leading etiology of early postoperative stroke following CABG. Coronary bypass surgery performed on an arrested heart relies on considerable aortic instrumentation associated with significant atheroembolic risk especially in older patients presenting with diffuse aortic calcifications. Surgical techniques to deal with a calcified ascending aorta during isolated coronary surgery have evolved over the last forty years. Moving away from aggressive aortic debridement or replacement, surgeons have developed strategies aimed to minimize aortic manipulation: from pump-assisted beating heart surgery with the use of composite grafts to complete avoidance of aortic manipulation with “anaortic” off-pump coronary artery bypass grafting, a safe and effective approach in significantly reducing the risk of intraoperative stroke.
Frozen elephant trunk (FET) has in recent times become a mainstay for total arch replacement (TAR) in aortovascular surgery and is indicated in order to treat a spectrum of complex aortic pathologies. However, despite associated excellent post-operative results it is incredibly important to recognise potential adverse complications such as negative aortic remodelling, endoleak and distal stent-graft induced new entry so that outcomes can be further improved. Below we provide commentary on a recent article in the Journal of Cardiac Surgery discussing the topic. Despite the fascinating outcomes of this systematic review and meta-analysis the heterogeneity of the literature regarding these adverse outcomes remains an issue which can only be solved with large multi-centre trials directly comparing graft types as well as indications for surgery.
Cytokine Filter Application in COVID-19 Patients; Island of Hope for Crash and Burn Patients or Future Solution for All Septic Acute Respiratory Distress Syndrome (ARDS) PatientsAli Ghodsizad MD, PhD, FACC, FETCS, FACSThe COVID-19 pandemic crisis certainly has challenged the scientific community as well as entire world. While incidence numbers have decreased following expedited vaccination and precautions, still some patients present with COVID 19 related pneumonia and ARDS requiring Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) support to survive.In COVID-19 patients a cytokine release syndrome concomitant with ARDS can lead to overwhelming clinical scenario. Geraci and colleagues report on their single center feasibility study looking at application of the CytosorbTM hemadsorption device which was used as a parallel circuit within the VV ECMO circuit.The authors give evidence for safety and feasibility of the CytosorbTM hemadsorption device use in 10 patients with COVID-19 related ARDS in combination with VV ECMO. They show a reduction of inflammatory markers and cytokines following hemadsorption treatment. The cytokine storm can cause a critical clinical picture of septic shock. Only under high vasopressor and inotropic support end organ perfusion can be maintained. The required invasive pressure ventilation with high PEEP and peak pressure can decrease the intrathoracic venous return further and contributes more to the shock physiology (1). We have to look at inspiring results from current single center experience carefully understanding the evolving nature of COVID-19 related ARDS. Other groups have used plasmapheresis and CVVH modifications in COVID-19 cases. Dominik et al have shown a significant benefit only using hemadsorption comparing to other used protocols (2).We have shown successful application of somatic stem cells in COVID-19 patients on VV ECMO at our center. We could observe a reduction of inflammatory markers following somatic stem cell application (3). COVID 19 ARDS patients who required VV ECMO support, underwent a Pulmonary Artery (PA)-catheter placement and allogenic human stem cell injection into the PA using the PA-catheter as part of our expanded access protocol (3,4).Brouwer and colleagues, another group working with hemadsorption, have actually shown reduced survival in patients undergoing hemadsorption therapy (5). Geraci and colleagues describe their overall VV ECMO survival for COVID 19 related respiratory failure to be > 90%. Others including our center have experienced a much lower survival in that patient population. So patient selection clearly is a key point. The results presented by Geraci and colleagues have to be taken as a pioneering step, which can help in ARDS and septic clinical scenarios with different pathology in future.
We describe two cases of favorable and unexpected recovery in positive patients with COVID-19, suffering from multiorgan comorbidity and already assisted with the left ventricular assist device. We have observed that, although in the presence of more comorbidities, when the maintenance of a valid support of the cardiovascular function is guaranteed, the possibility of successfully overcoming the SARS-CoV-2 infection is still alive.
COVID-19 has created challenges for society and the medical community. While the pandemic continues to unfold, the transplant community has had to pivot to keep recipients, donors, and transplant teams safe given these unprecedented times. This has resulted in a decrease in the number of transplants performed in the United States and an increased number of inactive patients on the UNOS waiting list.1 Waitlist and transplant recipients have an increased risk for acquiring COVID-19. It is speculated that this patient population is particularly vulnerable given their immunocompromised status and the high prevalence of comorbidities.2 Given the uncertainty surrounding the risk of transplant patients contracting COVID-19, there is interest in describing these cases in the literature.
Background: There is insufficient evidence regarding the comparison of Rapid Deployment aortic valve replacement(RDAVR) to TAVR in intermediate-risk patients with severe symptomatic aortic stenosis(AS) Aims: We compare the 2-years outcomes between RDAVR with INTUITY and TAVR with SAPIEN 3 in intermediate-risk patients with AS. Methods: Inclusion criteria: severe AS implanted with RDAVR or TAVR; EUROSCORE II ≥ 4% and clinical evaluation by Heart Team. Regression adjustment for the propensity score was used to compare RDAVR with TAVR(1:1). Primary endpoint: composite criterion of death, disabling stroke or rehospitalization. Secondary endpoints: occurrence of major bleeding post-operative complications, paravalvular regurgitation (PVR)≥2 and patient-prosthesis mismatch(PPM) at 1 month and pacemaker implantation at 2 years. Results: A total of 152 patients were included from 2012 to 2018: 48 in the RDAVR group and 104 in the TAVR group. Mean age was 82.7±6, 51.3% were female, mean Euroscore II was 6.03±1.6% and mean baseline LVEF was 56±13%,mean indexed iEOA was 0.41±0.1cm/m2, mean gradient was 51.7±14.7mmHg. Patients with RDAVR were younger(79.5±6vs82.6±6,p=0.01), at higher risk (EUROSCORE2 6,61±1,8%vs5,63±1,5%, p=0.005), combined surgery was performed in 28 patients(58.3%). Twenty-two patients(45.99%) met the primary outcome in the RDAVR group and 32 patients(66.67%) in the TAVR group. By 1:1propensity score matching analysis, there was a significant difference between both groups in favor of RDAVR(HR=0.58[95%CI:0.34;1.00],p=0.04). No difference were observed in PPM occurrence(0.83;[0.35-1.94];p=0.67),major bleeding events(1.33;[0.47-3.93];p=0.59),PVR≥2(0.33[0-6.28],p=0.46), and pacemaker implantation (0.84[0.25-2.84],p=0.77).Conclusion: RDAVR is associated with better 2-years outcomes than TAVR in intermediate-risk patients with severe symptomatic AS.
Background: This study compared outcomes of patients bridged with extracorporeal membrane oxygenation (ECMO) to orthotopic heart transplantation (OHT) following the recent heart allocation policy change. Methods: The United Network of Organ Sharing Registry (UNOS) database was queried to examine OHT patients between 2010-2020 that were bridged with ECMO. Waitlist outcomes and one-year posttransplant survival were compared between patients waitlisted and/or transplanted before and after the heart allocation policy change. Secondary outcomes included posttransplant stroke, renal failure, and one-year rejection. Results: 285 waitlisted patients were included, 173 (60.7%) waitlisted under the old policy and 112 (39.3%) under the new policy. New policy patients were more likely to receive OHT (82.2% vs 40.6%), and less likely to be removed from the waitlist due to death or clinical deterioration (15.0% vs 41.3%) (both P<0.001). 165 patients bridged from ECMO to OHT were analyzed, 72 (43.6%) transplanted during the old policy and 93 (56.3%) under the new. Median waitlist time was reduced under the new policy (4 days [IQR 2-6] vs 47 days [IQR 10-228]). Postoperative renal failure was higher in the new policy group (23% vs 6%; P=0.002), but rates of stroke and one-year acute rejection were equivalent. One-year survival was lower the new policy but was not significant (79.8% vs 90.3%; P=0.3917). Conclusions: The UNOS heart allocation policy change has resulted in decreased waitlist times and higher likelihood of transplant in patients supported with ECMO. Posttransplant one-year survival has remained comparable although absolute rates are lower.
Cardiothoracic surgery is facing a multitude of challenges in leadership and training on the global scale, these being a complex and aging patient population, shortage of cardiac surgeons, diminishing student interest and trainee enthusiasm, increasingly challenging training obstacles and work-life imbalances, suboptimal job prospects, reports of discrimination and bullying and lack of diversity as well as gap between innovation and technology, clinical application, and training of future surgeons. The survival of cardiac surgery hinges on the leadership attracting and retaining young surgeons into the specialty. Mentoring, leading through example, recognizing the work-life imbalances, adapting to diverse and modern training models and embracing diversity with respect to gender and race, will ultimately be required to create and cultivate a nurturing environment of training and preparing future leaders. The vision for training future generations of cardiothoracic surgeons must rely heavily on strengthening the unity of the heart team. In doing so we can provide the best possible care for our patients and a most fulfilling career for the future generation of cardiac surgeons.
In this article, the author provides synopses of the factors that have finally propelled healthcare education and practice to join, at times reluctantly, the overarching digital transformative process that has been swept other industries over the last few decades. The key contributors and driving forces that have energized the entry of healthcare education and practices are mentioned. The roles of major universities, large technology companies and the expanding roles of Artificial Intelligence and Machine Learning are described. The projected future developments are predicted to continue to be substantial, sweeping and forcing changes that are unprecedented. Thus, academicians and practitioners should be alerted to what the rapidly changing landscape is likely to become and accordingly take steps to manage and preserve their roles or risk be left behind or worse be forced out.