Decrease In Arterial Pressure Research Articles

Epidural analgesia in the perioperative period and mean arterial pressure as risk factors for postoperative complications after pancreaticoduodenectomy

Objective. To study the influence of epidural analgesia and mean arterial pressure as risk factors for the development of postoperative pancreatic fistula, delayed evacuation of gastric contents and postpancreatic bleeding after pancreaticoduodenectomy. Materials and Methods. The retrospective study included 234 patients who underwent pancreaticoduodenectomy at the National Research Center of Surgery and Transplantation named after O. O. Shalimov from January 2022 to November 2023. The surgical intervention included a standard pancreaticoduodenectomy according to the modified Child's technique. The objective was to evaluate the optimal approach to anesthesia and blood pressure management to minimize the risk of postoperative complications. Data were collected on the type of anesthesia (general anesthesia or a combination of general anesthesia and epidural analgesia), mean arterial pressure, use of vasopressors, and the incidence of postoperative complications. The analysis was performed using logistic–binomial regression to assess the risk of complications depending on the level of blood pressure and the use of epidural analgesia. Results. The combined use of epidural analgesia and general anesthesia was associated with a decrease in the incidence of clinically significant postoperative pancreatic fistula, delayed evacuation of gastric contents, and other complications. Epidural analgesia, although associated with an increased risk of hemodynamic instability, contributed to better pain control and a reduction in the incidence of postoperative complications. A decrease in mean arterial pressure by each 1 mm Hg increases the risk of postoperative pancreatic fistula by 15.8%, which confirms the importance of maintaining an adequate level of pressure to ensure optimal tissue perfusion. Despite the hypothesis of a possible negative effect of vasopressors, their use did not show a statistically significant association with the incidence of postoperative pancreatic fistula. Thus, further studies are needed to clarify the optimal parameters of patient management after pancreaticoduodenectomy.

Effects of dexamethasone on the EC50 of remifentanil combined with dexmedetomidine achieving analgesia during pancreatic extracorporeal shockwave lithotripsy: a prospective, randomized and controlled study

BackgroundIn addition to their classic genomic effects, glucocorticoids also manifest rapid non genomic effects. We speculate that dexamethasone has the potential prompt onset of analgesic effects. The objective of this study is to investigate the influence of a single preoperative dose of dexamethasone on the half maximal effective concentration (EC50) of remifentanil when combined with dexmedetomidine for pain relief during pancreatic extracorporeal shockwave lithotripsy (P-ESWL).MethodsA total of 60 patients undergoing P-ESWL were enrolled and randomized at 1:1 ratio into the dexamethasone (DXM) group and the placebo group. Before anesthesia induction, patients in DXM group received an intravenous injection of 8 mg dexamethasone, while subjects in placebo group received an equal dose of physiological saline. Monitored anesthesia care (MAC) was performed based on remifentanil in combination with dexmedetomidine. Remifentanil was administered by TCI with an initial target concentration of 2.5 µg/mL for both groups. A positive response was defined as that VAS score > 3 by the patient at any time during the procedure. Subsequent target concentrations were adjusted by Dixon up-down sequential method, where dose modifications were performed by 0.3 ng/mL intervals, based on the response of the previous patient. The EC50 of remifentanil for pain relief during P-ESWL treatment was calculated using Dixon’s up-and-down method. Hemodynamic variables, oxygen saturation and adverse events were also recorded.ResultsDixon up-and-down method revealed that the EC50 of remifentanil was significantly higher in placebo group (2.65 ± 0.28 ng/mL) than in DXM group (2.02 ± 0.23 ng/ml) (P < 0.001). Hemodynamic parameter exhibited a significant decrease in mean arterial pressure (MAP) and heart rate (HR) before and after induction in placebo group; however, data of the two groups were comparable (P>0.05). Less adverse events occurred in DXM group, including the incidence of postoperative nausea and vomiting (PONV) and analgesia requirement with in the first 24 h following the procedure at ward.ConclusionDexamethasone exerted analgesic effects with a rapid onset, and patients received dexamethasone 8 mg preoperative had a lower required EC50 of remifentanil during P-ESWL. It is also associated with reduced PONV in addition to reduced postoperative analgesic consumption in the first postoperative 24 h.Trial registrationRegistered in the Chinese Clinical Trial Registry (ChiCTR2300078171) on 30/11/2023.

Pulse oximetry-based perfusion index as a non-invasive indicator of systemic hemodynamics during spinal anesthesia in cesarean delivery

Background &amp; Objectives: Placental perfusion is not autoregulated and is susceptible to effects of spinal anesthesia (SA) induced hypotension. The perfusion index (PI) is a non-invasive marker of peripheral vascular tone, and a higher PI indicates increased risk of hypotension following SA. This study aims to establish preoperative baseline PI in our local population and its correlation with incidence of intraoperative hypotension. Methods: This prospective observational study recruited 35 parturients who underwent elective lower segment cesarean section (LSCS). Preoperatively, baseline heart rate (HR), systolic blood pressure (SBP), mean arterial pressure (MAP) and PI were documented. SA was performed with 8 to 10 mg of injection bupivacaine 0.5% (hyperbaric) at L3–L4 interspace followed by co-loading with 1 L Hartmann solution. Hypotension was defined as SBP less than 80% of baseline or less than 90 mmHg. A bolus of phenylephrine 50 µg was given as rescue medication to treat the hypotension. Intraoperatively, degree of decrease in SBP, MAP and HR, as well as the amount of phenylephrine required was recorded every minute until delivery of the baby and 3 min thereafter. Results: The correlations between parturients’ baseline PI with the degree of decreases in systolic and mean arterial pressure (r = 0.81, P &lt; 0.001 and r = 0.76, P &lt; 0.001, respectively) and phenylephrine requirement (r = 0.761, p &lt; 0.005) were recorded. This study identified that the patients with cut-off PI value of 3.2 were at higher risk for SA induced hypotension with a sensitivity of 85.9% and a specificity of 87.5% (P = 0.001). Conclusion: The patients with baseline cut-off perfusion index value of more than 3.2 were at higher risk for spinal anesthesia induced hypotension in elective cesarean section. Abbreviations: CO - cardiac output; LSCS - lower segment cesarean section MAP - mean arterial pressure; PI - perfusion index; SA - spinal anesthesia Keywords: Hypotension; Pulse Oximeter; Perfusion Index; Spinal Anesthesia; Cesarean section; Citation: Manap NSA, Zaini RHM, Shukeri WFWM, Omar SC, Abu Bakar MZ, Seevaunnamtum P. Pulse oximetry-based perfusion index as a non-invasive indicator of systemic hemodynamics during spinal anesthesia in cesarean delivery. Anaesth. pain intensive care 2024;28(5):927−932; DOI: 10.35975/apic.v28i5.2570 Received: July 23, 2024; Reviewed: September 02, 2024; Accepted: September 10, 2024

Comparison of intra and postoperative analgesia efficacy of intraperitoneal levobupivacaine alone or in combination with dexmedetomidine in cats undergoing ovariohysterectomy; a randomized, prospective, blinded, clinical trial

This study aimed to compare the analgesic and cardiopulmonary effects of levobupivacaine with or without dexmedetomidine, in cats undergoing ovariohysterectomy. In this prospective, randomized, and blinded clinical trial, 24 healthy cats were recruited. Animals received either saline (S group; 2 mL NaCl), levobupivacaine alone (Lev; 0.35 mg/kg), or levobupivacaine with dexmedetomidine (LevDex group; 0.004 mg/kg), which was infiltrated intraoperatively into the subcutaneous tissue at various incision sites, including the right and left ovarian pedicles and the caudal aspect of the uterine body. Intraoperative analgesia was evaluated using a cumulative pain scale, while postoperative analgesia was assessed at various time points: before surgery (Tb), and at 0 (T0), 1 (T1h), 2 (T2h), 4 (T4h), 8 (T8h), 12 (T12h), and 24 (T24h) hours after the procedure, using the UNESP-Botucatu multidimensional composite pain scale (MCPS). Significant decreases in heart rate, respiratory rate, and mean arterial pressure were observed in LevDex group as compared to S and Lev groups (p < 0.05). The S group required significantly more rescue morphine doses than the LevDex group (p = 0.029), but the difference was not significant when compared to the Lev group (p = 0.123). At T1h and T2h, the S group had significantly higher MCPS scores than both the Lev and LevDex groups (p = 0.029). However, at T8h, no significant difference was found between the S and LevDex groups (p = 0.741). While adding dexmedetomidine to levobupivacaine may slightly prolong postoperative analgesia, this combination does not provide significant additional benefit over levobupivacaine alone in terms of response to surgical stimulation.

Haemodynamic effects of intra-aortic balloon pumps stratified by baseline pulmonary artery pulsatility index.

Intra-aortic balloon pump (IABP) devices are commonly used in patients with heart failure related cardiogenic shock (HF-CS), including those with out-of-proportion right ventricular (RV) dysfunction. Pulmonary artery pulsatility index (PAPi) is a haemodynamic surrogate for RV performance. We aimed to assess short-term haemodynamic changes in patients with HF-CS following IABP support stratified by baseline PAPi. This is a single-centre study of 67 consecutive patients with HF-CS who underwent IABP placement between 2020 and 2022. The primary aim was haemodynamic changes of specific variables on pulmonary artery catheter monitoring over 72h following IABP placement. Secondary aims were clinically significant changes in diuretic regimens, changes in inotropes or vasopressors at 72h following IABP, along with clinical outcomes. Prior to IABP placement, 57% of the total cohort (median age 59years [48, 69], 31% female) had Society of Cardiovascular Angiography and Interventions Stage C HF-CS. Thirty-eight (56%) patients had a PAPi <2.0. Following 72h of IABP support, the PAPi <2.0 group had an observed significant decrease in central venous pressure (CVP; 20 to 12mmHg, P<0.001) and mean pulmonary artery pressure (mPAP; 37.5 to 28.5mmHg, P=0.001), and an increase in PAPi (1 to 1.6, P=0.001). No significant change in cardiac index (CI; 2 to 2.1L/min/m2, P=0.31) was observed. The PAPi ≥2.0 group (N=29) had no observed significant change in CVP (10 to 8mmHg, P=0.47), or PAPi (2.6 to 2.8, P=0.92), but there was a significant improvement in CI (1.9 to 2.5L/min/m2, P=0.004) along with reduction in mPA (37 to 29mmHg, P=0.03). The PAPi <2.0 group had a significant increase in diuretic requirement (52.6% vs. 20.7%, P=0.01) and numerically greater addition of inotropes/vasopressors (47.3% vs. 34.4%, P=0.07) compared with the PAPi ≥2.0 group at 72h following IABP placement. Significantly more patients in the PAPi ≥2.0 group underwent left ventricular assist device (55.2% vs. 26.3%, P=0.02), with no overall significant differences observed in escalation to veno-arterial extracorporeal membrane oxygenation, 30-day mortality, renal replacement therapy post-IABP, or rates of heart transplantation. IABP devices in those with HF-CS and low or abnormal PAPi may provide modest short-term haemodynamic benefits without significant improvement in CI, along with greater need for adjustment in medical therapeutics to achieve haemodynamic optimization.

Hemodynamic tolerability and efficacy of hemodialysis modalities in critically ill patients

IntroductionAcute kidney injury (AKI) is frequently seen in critically ill patients and is associated with high mortality and morbidity. However, the optimal dialysis modality in such patients remains controversial. We examined the hemodynamic tolerability of hemodialysis modalities in critically ill individuals with AKI.MethodologyCritically ill patients with AKI who underwent Continuous Renal Replacement Therapy (CRRT), Sustained Low-Efficiency Diafiltration (SLEDD-f), or Sustained Low-Efficiency Dialysis (SLED) dialysis were included in the study. In-hospital mortality, number of dialysis sessions, number of sessions terminated pre-maturely, change in blood pressure during dialysis, and hemodynamic instability during dialysis sessions were noted.ResultsA total of 264 patients were included, of which 78 received Continuous Renal Replacement Therapy (CRRT), 62 received Sustained Low-Efficiency Diafiltration (SLEDD-f), and 124 received Sustained Low-Efficiency Dialysis (SLED), with a total of 682 sessions among 264 patients. The commonest cause for AKI was septic shock (32.6%, n=43). All CRRT and SLEDD-f sessions were delivered without anticoagulation, and SLED was delivered without anticoagulation in 88.7% of sessions. There was a significant decrease in mean arterial pressure in CRRT compared to other modalities, with higher mortality. However, patients undergoing CRRT were more sicker. There was no significant difference between SLEDD-f and SLED in terms of outcomes.ConclusionSLEDD-f and SLED have good hemodynamic tolerability compared to CRRT. There was no significant difference in hemodynamic disturbances between SLEDD-f and SLED despite a higher proportion of patients on SLEDD-f being more critical.

Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study.

Pulmonary embolism (PE) embodies a large healthcare burden globally and is the third leading cause of morbidity and mortality worldwide. Submassive (intermediate-risk) PE accounts for 40% of this burden. However, the optimal treatment pathway for this population remains complex and ill-defined. Catheter-directed interventions (CDIs) have shown promise in directly impacting morbidity and mortality while demonstrating a favorable success rate, safety profile, and decreased length of stay (LOS) in the intensive care unit and hospital. This retrospective review included 22 patients (50% female) with submassive PE who underwent mechanical thrombectomy (MT). A total of 45% had a contraindication to thrombolytics, the mean pulmonary embolism severity index was 127, 36% had saddle PE, the average decrease in mean pulmonary artery pressure (PAP) was 7.2 mmHg following MT, the average LOS was 6.9 days, the 30-day mortality rate was 9%, the major adverse event (MAE) rate was 9%, and the readmission rate was 13.6%. A total of 82% had successful removal of thrombus during MT with no major bleeding complications, intracranial hemorrhage events, or device-related deaths. Acknowledging the limitation of our small sample size, our data indicate that MT in the intermediate-high-risk submassive pulmonary embolism (PE) cohort resulted in a decreased hospital length of stay (LOS) and in-hospital mortality compared to standard anticoagulation therapy alone.

Selective opioid agonist Taphalgin® as a component of postoperative analgesia in various surgical areas: “NIKITA” observational multicenter study

Introduction. The role of peptides in antinociceptive system regulation has became a subject of interest for scientists worldwide. The first registered peptide analgesic tyrosyl-D-arginyl-phenylalanyl-glycinamide acetate which currently can be used in clinical practice was developed in Russia under the name Taphalgin® (PharmFirma “Sotex”, Russia). The effectiveness and safety of this pharmaceutical in postoperative pain management was evaluated in the all-Russia multicenter prospective observation program NICITA (Non-interventional Clinical Trial of Taphalgin ®).Aim. To analyze the effectiveness and safety of Taphalgin® in postoperative pain management in various surgical fields.Materials and methods. The observational program NICITA included 887 patients including patients with malignant tumors of various locations from 15 study centers in different Russian cities. All patients underwent surgical interventions in various anatomical areas under general, regional and combination anesthesia. The principal scheme of postoperative pain management was based on the multimodal approach which included peptide opioid agonist alongside acetaminophen, cyclooxygenase inhibitors in combination with regional anesthesia or without it. The study also included patients who underwent small-volume surgeries, and pain was managed through Taphalgin® monotherapy with subsequent switch to cyclooxygenase inhibitors. The primary endpoint of the NICITA observational program was response to therapy after the first Taphalgin® administration. Decreased pain syndrome per the numerical rating scale 15–60 min after subcutaneous injection and maintenance of analgesic effect 3 h later were considered treatment response. The secondary endpoints included mean time to analgesia start after administration of the 1st single drug dose (in min), duration of effect, types and frequency of adverse reactions including serious in the central nervous system, pulmonary system, gastrointestinal tract developed during the observational program, as well as patient and research physician satisfaction with pain management. To evaluate the significance of pain intensity change at rest and in motion in time, analysis of variance with repeat measurements was used; for pairwise comparison of two time periods, Student’s t-test for dependent samples was used. The differences were considered significant at p = 0.05.Results. Statistically significant decrease in pain intensity in the total patient group was observed 15 minutes after Taphalgin® administration; it reached its minimum 40 min after the injection (р &lt;0.05). The percentage of patients responding to analgesic therapy with Taphalgin® was 96.5 %. During administration of the drug, insignificant decrease (10–15 mmHg) in arterial blood pressure (1.7 % of cases) and vertigo (1 % of cases) were observed. In some patients, several adverse reactions were observed. Satisfaction with analgesic effect of Taphalgin® was relatively high both in patients and research physicians.Conclusion. Taphalgin® has pronounced analgesic effect and is effective for pain management after surgical interventions of various volumes and injury level. The use of this drug is associated with low rate of adverse reactions and absence of pulmonary depression characterizing opioid agonists. Therefore, Taphalgin® can be recommended for clinical use for postoperative pain management after various types of surgical interventions.

The impact of electrical stimulation at the back-shu acupoint with an extrinsic diaphragmatic pacing mode on respiratory function and extubation success rate in tracheostomized stroke patients: An observational study.

To observe of the effect of electrical stimulation at the back-shu acupoint with extrinsic diaphragmatic pacing (EDP) mode on respiratory function and extubation success rate in tracheostomized stroke patients. A total of 200 patients who underwent tracheostomy after a stroke from January 2022 to February 2023 were included in this study. They were divided into 2 groups based on whether electroacupuncture was used: the EDP + electroacupuncture group and the EDP group. We assessed the differences in cough reflex scores and clinical lung infection scores between the 2 groups, and measured levels of blood gas analysis indicators, diaphragmatic function, lung function, maximum inspiratory pressure, and maximum expiratory pressure in both groups. The total effective rate in the EDP + electroacupuncture group was 91.00% (91/100), which was higher than the EDP group's 80.00% (80/100) (P < .05). After treatment, both groups showed a decrease in clinical lung infection scores and cough reflex scores compared to before treatment, with the EDP + electroacupuncture group having lower scores than the EDP group (P < .05). After treatment, the pH value, arterial oxygen pressure, and oxygenation index all increased compared to before treatment, with the EDP + electroacupuncture group showing higher values than the EDP group (P < .05). After treatment, both groups showed a decrease in arterial carbon dioxide pressure compared to before treatment, with the EDP + electroacupuncture group having lower PaCO2 levels than the EDP group (P < .05). After treatment, both groups showed an increase in forced vital capacity as a percentage of predicted value (FVC%), diaphragm thickness, diaphragm mobility, maximum inspiratory pressure, maximum expiratory pressure, forced expiratory volume in the first second as a percentage of predicted value (FEV1%), and diaphragm contraction speed compared to before treatment. Additionally, the EDP + electroacupuncture group had higher values in these parameters compared to the EDP group (P < .05). The EDP + electroacupuncture group had a shorter average extubation time and a higher extubation success rate compared to the EDP group (P < .05). The combination of EDP mode and electroacupuncture at the back-shu acupoint appears to be effective in improving lung function and diaphragmatic function in tracheostomized stroke patients. It also leads to a shorter extubation time and higher extubation success rates.

Effects of Continuous versus Single Dose Spinal Anesthesia in Octogenarians Undergoing Hip Surgery: Randomized Control Trial

Abstract Background Continuous spinal anesthesia (CSA) is an anesthetic technique that offers several clinical advantages for anesthesia and analgesia in elderly patients. The level of sensory blockade can be titrated to the desired dermatomal level with great precision with intrathecal (IT) catheters, allowing better control of the hemodynamic consequences of sympathetic blockade associated with spinal anesthesia compared to epidural or single shot spinal techniques. Octogenarians are expected to suffer more from hemodynamic instability with spinal anesthesia. Objective The primary outcome is to compare the incidence of hypotension (defined as decrease in mean arterial blood pressure &amp;gt; 20% from the base line) in continuous spinal anesthesia CSA versus single dose spinal anesthesia in octogenarians undergoing hip surgery. The secondary outcome is to determine the total use of vasopressor (Ephedrine) and the incidence of spinal complications as nausea, vomiting and post Dural puncture headache. Methods This is a randomized controlled clinical trial done at Ain-shams University Hospitals, Cairo, Egypt within a period of 6 months from approval of medical ethics committee. Twenty patients in CSA group received increments of (0.5 ml) of plain bupivacaine 0.5% until T10 level blockade is achieved. Twenty patients in SDA group received single shot of (2.5ml) of bupivacaine 0.5%. Results The main finding of this study is that while MAP was significantly lower between 5-35 minutes (&amp;lt;0.001), it was significantly higher between 40-75 minutes in SDA group than CSA group (0.05).Total bupivacaine dose was significantly higher in SDA (12.5±0.8) group than CSA group (7.6±1.3) (p &amp;lt; 0.001). The total ephedrine dose needed was significantly higher in the SDA group (19.5 ±11.3) than in CSA group (4.5±1.7) (p.0.006). Conclusion The main finding of this study is that for octogenarians undergoing hip surgery, while MAP was significantly lower between 5-35 minutes, it was significantly higher between 40-75 minutes in single dose spinal anesthesia group than continuous spinal anesthesia group. Episodes of bradycardia were similar in both groups. The bupivacaine dose as well as total ephedrine dose was significantly higher in SDA group than CSA group. Groups were similar in the incidence of postoperative complications related to the neuraxial blockade. The impact of these changes on the overall cardiovascular status and outcome in octogenarians undergoing hip surgery could not be determined from our study design.

Differences in Exercise Capacity, Ventilatory Efficiency, and Gas Exchange between Patients with Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension Residing at High Altitude.

Cardiopulmonary exercise testing (CPET) assesses exercise capacity and causes of exercise limitation in patients with pulmonary hypertension (PH). At altitude, changes occur in the ventilatory pattern and a decrease in arterial oxygen pressure in healthy; these changes are increased in patients with cardiopulmonary disease. Our objective was to compare the response to exercise and gas exchange between patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) residing at the altitude of Bogotá (2640 m). All patients performed an incremental CPET with measurement of oxygen consumption ( ), dead space (VD/VT), ventilatory equivalents (VE/ ), and alveolar-arterial oxygen gradient ( ). test and one-way analysis of variance were used for comparisons between PAH and CTEPH. We included 53 patients, 29 with PAH, 24 with CTEPH, and 102 controls as a reference of the normal response to exercise at altitude. CTEPH patients had a higher New York Health Association (NYHA) functional class than PAH (p = 0.037). There were no differences between patients with PAH and CTEPH in hemodynamics and % of predicted (67.8 18.7 vs. 66.0 19.8, p 0.05), but those with CTEPH had higher dyspnea, VD/VT (0.36 0.09 vs. 0.23 0.9, p 0.001), VE/ (45.8 7.1 vs. 39.3 5.6, p 0.001), and (19.9 7.6 vs. 13.5 7.6, p 0.001) than PAH patients. At altitude, patients with PH present severe alterations in gas exchange during exercise. There were no differences in exercise capacity between PAH and CTEPH, but patients with CTEPH had more dyspnea and greater alterations in gas exchange during exercise. CPET made it possible to identify alterations related to the pathophysiology of CTEPH that could explain the functional class and dyspnea in these patients.

Endovascular Treatment for Peripheral Pulmonary Arterial Stenosis in RNF213-Related Vasculopathy

This brief report reviews the clinical, procedural, and imaging data of 7 patients with p.Arg4810Lys variant of the ring finger protein 213 (RNF213) gene–related peripheral pulmonary arterial stenosis who underwent percutaneous transluminal pulmonary angioplasties (PTPAs) for demographics, clinical presentation, indications for angioplasty, and procedural and clinical outcomes. During median follow-up of 64.4 months since the first confirmed diagnosis, PTPA was performed for 62 segmental pulmonary arteries with 38 sessions of the procedure in 7 patients. Vascular stent placement because of resistance to balloon dilation and immediate elastic recoil was performed in 48 of 62 procedures (77%). Except for 1 death, 6 patients showed an improvement in dyspnea and 5 patients showed a decrease in mean pulmonary arterial pressure (mean, 55.5–42.7 mm Hg) and increase in 6-minute walk distance (mean, 415.5–484.3 m). Reperfusion edema occurred in 4 of 7 patients (57%), which was 6 of 38 sessions (16%).

Association between Transient-Continuous Hypotension during Mechanical Thrombectomy for Acute Ischemic Stroke and Final Infarct Volume in Patients with Proximal Anterior Circulation Large Vessel Occlusion.

Background/Objectives: Periprocedural blood pressure changes in stroke patients with a large vessel occlusion are a known modifiable risk factor of unfavorable treatment outcomes. We aimed to evaluate the association between pre-revascularization hypotension and the final infarct volume. Methods: In our retrospective analysis, we included 214 consecutive stroke patients with an anterior circulation large vessel occlusion that underwent mechanical thrombectomy under general anesthesia. Noninvasively obtained blood pressure values prior to symptomatic vessel recanalization were analyzed as a predictor of post-treatment infarct size. Linear logistic regression models adjusted for predefined factors were used to investigate the association between blood pressure parameters and the final infarct volume. Results: In our cohort, higher baseline systolic blood pressure (aβ = 8.32, 95% CI 0.93-15.7, p = 0.027), its maximal absolute drop (aβ = 6.98, 95% CI 0.42-13.55, p = 0.037), and >40% mean arterial pressure decrease (aβ = 41.77, CI 95% 1.93-81.61, p = 0.040) were independently associated with higher infarct volumes. Similarly, continuous hypotension measured as intraprocedural cumulative time spent below either 100 mmHg (aβ = 3.50 per 5 min, 95% CI 1.49-5.50, p = 0.001) or 90 mmHg mean arterial pressure (aβ = 2.91 per 5 min, 95% CI 0.74-5.10, p = 0.010) was independently associated with a larger ischemia size. In the subgroup analysis of 151 patients with an M1 middle cerebral artery occlusion, two additional factors were independently associated with a larger ischemia size: systolic blood pressure maximal relative drop and >40% drop from pretreatment value (aβ = 1.36 per 1% lower than baseline, 95% CI 0.04-2.67, p = 0.043, and aβ = 43.01, 95% CI 2.89-83.1, p = 0.036, respectively). No associations between hemodynamic parameters and post-treatment infarct size were observed in the cohort of intracranial internal carotid artery occlusion. Conclusions: In patients with ischemic stroke due to a proximal middle cerebral artery occlusion, higher pre-thrombectomy treatment systolic blood pressure is associated with a larger final infarct size. In patients treated under general anesthesia, hypotension prior to the M1 portion of middle cerebral artery recanalization is independently correlated with the post-treatment infarct volume. In this group, every 5 min spent below the mean arterial pressure threshold of 100 mmHg is associated with a 4 mL increase in ischemia volume on a post-treatment NCCT. No associations between blood pressure and final infarct volume were present in the subgroup of patients with an intracranial internal carotid artery occlusion.

Safety and Efficacy of Dapagliflozin in Patients with Heart Failure with Reduced Ejection Fraction: Multicentre Retrospective Study on Echocardiographic Parameters and Biomarkers of Heart Congestion.

Objectives: Dapagliflozin has shown efficacy in clinical trials in patients with heart failure and reduced ejection fraction (HFrEF). However, real-world data on its use and outcomes in routine clinical practice are limited. We aimed to evaluate the utilisation and safety profile of dapagliflozin in a real-world population of HFrEF patients within the Marche region. Methods: Nine cardiology departments within the Marche region retrospectively included HFrEF patients who were initiated on dapagliflozin therapy in an outpatient setting. Data on medical history, comorbidities, echocardiographic parameters, and laboratory tests were collected at baseline and after 6 months. Telephone follow-up interviews were conducted at 1 and 3 months to assess adverse events. We defined the composite endpoint score as meeting at least 50% of four objective measures of improvement among: weight loss, NYHA decrease, ≥50% Natriuretic peptides (NP) decrease, and guideline/directed medical therapy (GDMT) up titration. Results: We included 95 HFrEF patients aged 66 ± 12 years, 82% were men, 48% had ischemic heart disease, and 20% had diabetes. At six months, glomerular filtration rate declined (p = 0.03) and natriuretic peptides levels decreased, on average, by 23% (p < 0.001). Echocardiographic measurements revealed a decrease in pulmonary artery pressure (p < 0.001) and E/e' (p < 0.001). In terms of drug therapy, furosemide dosage decreased (p = 0.001), and the percentage of the target dose achieved for angiotensin receptor-neprilysin inhibitors increased (p = 0.003). By multivariable Cox regression, after adjustment for age, sex, the presence of diabetes/prediabetes, and HF duration, higher baseline Hb concentrations (HR 1.347, 95% CI 1.038-1.746, p = 0.025), and eGFR levels (HR 1.016, 95% CI 1.000-1.033, p = 0.46). Conclusions: In a real-life HFrEF population, dapagliflozin therapy is safe and well-tolerated, improves echocardiographic parameters and biomarkers of congestion, and can also facilitate the titration of drugs with a prognostic impact.

Oscillations of Hemodynamic Parameters Induced by Negative Pressure Breathing in Healthy Humans.

INTRODUCTION: Negative pressure breathing is breathing with decreased pressure in the respiratory tract without lowering pressure acting on the torso. We lowered air pressure only during inspiration (NPBin). NPBin, used to increase venous return to the heart, is considered a countermeasure against redistribution of body fluids toward the head during spaceflight. We studied NPBin effects on circulation in healthy humans with an emphasis on NPBin-induced oscillations of hemodynamic parameters synchronous with breathing. We propose an approach to analyze the oscillations based on coherent averaging.METHODS: Eight men ages 24-42 yr participated in the NPBin and control series. During the series, to reproduce fluids shift observed under microgravity, subjects were supine and head down (-8°). Duration of NPBin was 20 min, rarefaction -20 cm H₂O. Hemodynamic parameters were measured by Finometer. Electrical impedance measurements were used to estimate changes in blood filling of cerebral vessels.RESULTS: Mean values of hemodynamic parameters virtually did not change under NPBin, but NPBin induced oscillations of the parameters synchronous with respiration. Peak-to-peak amplitude under NPBin were: mean arterial pressure, 4 ± 1 (mmHg); stroke volume, 7 ± 3 (mL); and heart rate, 4 ± 1 (bpm). Electrical impedance of the head increased during inspiration. The increase under NPBin was three times greater than under normal breathing.DISCUSSION: Analysis of oscillations gives more information than analysis of mean values. NPBin induces short-term decrease in left ventricle stroke volume and arterial blood pressure during each inspiration; the decrease is compensated by increase after inspiration. NPBin facilitates redistribution of body fluids away from the head.Semenov YS, Melnikov IS, Luzhnov PV, Dyachenko AI. Oscillations of hemodynamic parameters induced by negative pressure breathing in healthy humans. Aerosp Med Hum Perform. 2024; 95(6):297-304.

Induction of cGMP-mediated migraine attacks is independent of CGRP receptor activation.

The cAMP and cGMP pathways are implicated in the initiation of migraine attacks, but their interactions remain unclear. Calcitonin gene-related peptide (CGRP) triggers migraine attacks via cAMP, whereas the phosphodiesterase-5 inhibitor sildenafil induces migraine attacks via cGMP. Our objective was to investigate whether sildenafil could induce migraine attacks in individuals with migraine pre-treated with the CGRP-receptor antibody erenumab. In this randomized, double-blind, placebo-controlled, cross-over study, adults with migraine without aura received a single subcutaneous injection of 140 mg erenumab on day 1. They were then randomized to receive sildenafil 100 mg or placebo on two experimental days, each separated by at least one week, between days 8 and 21. The primary endpoint was the difference in the incidence of migraine attacks between sildenafil and placebo during the 12-h observation period after administration. In total, 16 participants completed the study. Ten participants (63%) experienced a migraine attack within 12 h after sildenafil administration compared to three (19%) after placebo (p = 0.016). The median headache intensity was higher after sildenafil than after placebo (area under the curve (AUC) for the 12-h observation period, p = 0.026). Furthermore, sildenafil induced a significant decrease in mean arterial blood pressure (AUC, p = 0.026) and a simultaneous increase in heart rate (AUC, p < 0.001) during the first hour after administration compared to placebo. These findings provide evidence that migraine induction via the cGMP pathway can occur even under CGRP receptor blockade. ClinicalTrials.gov: Identifier NCT05889455.

The impact of right ventricular energy failure on the results of pulmonary endarterectomy and balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension

Objective: We aimed to investigate the effect of right ventricular energy failure (RVEF) on hemodynamic and clinical outcomes in patients diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary endarterectomy (PEA) surgery or balloon pulmonary angioplasty (BPA). Patients and Methods: A total of 100 CTEPH patients planned for PEA or BPA were included in the study. Based on the presence of RVEF during diagnosis, patients divided into two groups. Hemodynamic data from right heart catheterization (RHC) were compared before and after procedures in 3-6 months follow up period. Results: Patients with RVEF revealed a decrease in mean pulmonary artery pressure (mPAP) from 54.67±12.27 mmHg to 36.12±11.76 mmHg (p:&amp;lt;0.001), mean right atrial pressure (mRAP) from 13.40±4.08 mmHg to 9.76±4.56 mmHg (p:0.003), and pulmonary vascular resistance (PVR) from 11.36±5.15 Wood Units (WU) to 5.46±3.30 WU (p &amp;lt;0.001). In the non-RVEF group, mPAP decreased from 38.82±12.61 mmHg to 30.81±10.57 mmHg (p:&amp;lt;0.001), mRAP from 7.09±3.02mmHg to 7.15±3.07mmHg (p: 0.917), and PVR from 6.33±3.65 WU to 4.09±2.31 WU (p:&amp;lt;0.001). Conclusion:The presence of RVEF at the time of diagnosis in CTEPH patients does not have a negative impact on early perioperative and 3-month postoperative outcomes following PEA or BPA. This high-risk patient group demonstrated significant hemodynamic and clinical benefits from both PEA and BPA.

The hybrid (physical-computational) cardiovascular simulator to study valvular diseases

To better understand the impact of valvular heart disease (VHD) on the hemodynamics of the circulatory system, investigations can be carried out using a model of the cardiovascular system. In this study, a previously developed hybrid (hydro-numerical) simulator of the cardiovascular system (HCS) was adapted and used. In our HCS Björk-Shiley mechanical heart valves were used, playing the role of mitral and aortic ones. In order to simulate aortic stenosis (AS) and mitral regurgitation (MR), special mechanical devices have been developed and integrated with the HCS. The simulation results proved that the system works correctly. Namely, in the case of AS − the mean pulmonary arterial pressure was increased due to increased preload of the left ventricle and the decrease in right ventricular preload was caused by a decrease in systemic arterial pressure. The severity of AS was performed based on the transaortic pressure gradient as well as using the Gorlin and Aaslid equations. In the case of severe AS, when the mean gradient was above 40 mmHg, the aortic valve orifice area was 0.5 cm2, which is in line with ACC/AHA guidelines. For the case of MR − with increasing severity of MR, there was a decrease in the left ventricular pressure and an increase in left atrial pressure. Using mechanical heart valves to simulate VHD by the HCS can be a valuable tool for biomedical research, providing a safe and controlled environment to study and understand the pathophysiology of VHD.

Роль ацетилхолиновой системы и ее компонентов в формировании постковидных синдромов (обзор)

According to the latest data, COVID-19 is classified as a respiratory virus. However, it has been proven to cause a significant multi-organ dysfunction. Despite the increase in the effectiveness of treatment tactics, a post-COVID-19 symptom complex has been observed in patients after recovery, manifesting itself as cephalalgia, brain fog, high fever, muscle weakness and a decrease (or increase) in arterial pressure. To describe this condition, a clinical characteristic has been proposed: post-acute COVID-19 syndrome (PACS). Approximately 57 % of patients hospitalized with COVID-19 have symptoms of PACS even one year after initial infection with COVID-19. This pathological condition is being actively studied, but the question of the causes of PACS and its development mechanisms remains open. One of the possible reasons behind this symptomatology, in our opinion, is a disorder of the body’s acetylcholine system and its components. The acetylcholine system plays an integral role in various physiological and pathophysiological processes, such as the regulation of the muscular system, immune and inflammatory reactions, wound healing, as well as the development of cardiovascular, respiratory and other diseases. A key way of translating acetylcholine signals in the body is through the use of neurotransmission via a chemical synapse. Based on current literature data, there is reason to believe that viral invasion can significantly change the functional activity of the vagus nerve by disrupting signal transmission in a synapse. We believe that the hyperimmune response caused by COVID-19 triggers a chain of pathological mechanisms that are associated with disrupted nitric oxide production and imbalance in acetylcholine and its receptors. An understanding of these processes may open up prospects for improving the effectiveness of treatment and rehabilitation of patients with COVID-19.

Changes in the pulmonary circulation due to gravitational loads in high altitude conditions.

The impact of gravity on the existence of all living things has long been of interest to scientists. The force of the Earth's gravity combined with hypoxia significantly affects blood circulation and blood accumulation in various parts of the human and animal body. To date, the relationship between body position and blood circulation in pulmonary circulation under hypobaric hypoxia has not been sufficiently studied. Therefore, the research aims to determine the possibility of changing the body position in space on the reactions in the pulmonary circulation in the plains and highlands. For this purpose, research was conducted on male Wistar rats, 44 of whom spent 150 days at an altitude of 3200 m above sea level, and 25 representatives of the control group - at an altitude of 164 m. The study revealed that gravitational redistribution of blood in mountainous conditions is less pronounced compared to the control group. This is explained by the remodeling of the vascular wall and an increase in its stiffness. It was found that a change in pulmonary artery pressure at the time of a change in body position was recorded both on the plains and in the highlands. On the plains, when the body position of rats was changed to passive orthostatic, a decrease in systolic and diastolic pulmonary artery pressure was noted, and when the body position was changed to passive anti-orthostatic, an increase in pulmonary artery pressure was observed. The increase in pulmonary artery pressure was a compensatory mechanism due to the increased stiffness of the pulmonary vasculature. The practical significance of this research is to expand the understanding of the pathogenesis of pulmonary hypertension in high-altitude hypoxia.