Duration Of Arrest Research Articles

Abstract 18173: Spinal Cord Protective Strategy Before Extensive Surgical Procedure for Patients With Acute Type A Aortic Dissection

Introduction: Spinal cord injury (SCI) is a devastating complication following total arch replacement (TAR) with frozen elephant trunk (FET) procedure in acute type A aortic dissection (ATAAD). This study aims to evaluate the efficacy of spinal cord protective strategy (SCPS) implemented before this extensive procedure. Methods: Between January 2013 and December 2021, a total of 1105 ATAAD patients underwent TAR with FET procedure. SCPS included preoperative assessment of segment number of the false lumen closest to the spinal cord between T9-L3 level. If segment number exceeded 5, indicating high risk of postoperative SCI, prophylactic cerebrospinal fluid drainage would be conducted. SCPS was performed since June 2017 at our institution (703 patients). The remaining 402 patients were served as the control group. The two groups were compared to assess the efficacy of SCPS in preventing SCI. Results: The average age was significantly higher in the SCPS group (48.9±11.1 vs 46.6±10.0, P<0.001). The patients in SCPS group presented with higher percentage of coma (P<0.001). The mean duration of cardiopulmonary bypass was significantly longer in SCPS group (P<0.001), while the mean duration of hypothetical cardiac arrest was significantly lower (P<0.001). Propensity score matching was conducted, resulting in a matched sample of 186 patients from each group to adjust for differences in patient characteristics. The incidence of postoperative SCI was significantly lower in SCPS group (1.7% vs 7.2%, P<0.001). Propensity score matching demonstrated higher estimated incremental protective efficacy of SCPS (1.1% vs 9.7%, P<0.001). Multivariate logistic regression analysis revealed that preoperative SCPS was an independent protective factor for postoperative SCI (OR=0.226, 95% CI: 0.114-0.448, P<0.001). Conclusions: The implementation of preoperative SCPS is an effective strategy for reducing the incidence of SCI follow extensive surgical procedure in ATAAD.

Risk Factors for Acute Kidney Injury after Moderate Hypothermic Circulatory Arrest in Hemiarch Replacement

Background. The aim of this study was to clarify the incidence and risk factors for acute kidney injury (AKI) in patients undergoing hemiarch replacement (HAR) under moderate hypothermic circulatory arrest (MHCA) with retrograde cerebral perfusion (RCP). Methods. We retrospectively analyzed patients who underwent HAR under MHCA with RCP at our institution between April 2015 and July 2022. Exclusion criteria were preoperative dialysis, single kidney, and lack of preoperative plasma creatinine data. The study endpoint was the incidence of postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria. Multivariate logistic regression analysis was performed to identify the risk factors for postoperative AKI. Results. One hundred and seventy-nine patients were included in this study. The most common indications for HAR were thoracic aortic aneurysm (n = 107) and acute aortic dissection (n = 57). Concomitant procedures, most frequently aortic valve surgery, were performed in 104 (60.5%) patients. Median circulatory arrest time and minimum rectal temperature were 15 minutes (interquartile range, 11 to 19) and 27.4°C (interquartile range, 25.9 to 28.1), respectively. Operative mortality was 1.1%. The incidence of postoperative AKI was 37.8%. Multivariate analysis showed that acute aortic dissection (odds ratio, 4.57; 95% confidence interval (CI), 2.13–10.14; P < 0.001) and longer operating time (odds ratio, 1.01; 95% CI, 1.00-1.01; P = 0.001) were independent predictors for postoperative AKI. Conclusions. Acute aortic dissection and longer operating time were risk factors for postoperative AKI in patients undergoing HAR under MHCA with RCP. In contrast, neither circulatory arrest time nor minimum rectal temperature was a risk factor for AKI. This may be due to the short duration of circulatory arrest.

Predictors of the inability to achieve full oral feeding in postoperative infants with CHD.

Poor oral feeding is a known contributor to growth challenges in neonates with complex CHD who require early surgery. Almost 60% of these infants do not achieve full oral feeding by hospital discharge. This study's objective was to identify predictors of the inability to achieve full oral feeding by discharge in neonates with complex CHD following surgical intervention with cardiopulmonary bypass. A retrospective analysis of a prospective study of 192 full-term neonates with complex CHD was performed. A stepwise selection logistic regression model was developed to predict oral feeding status at hospital discharge. Univariate subgroup analysis was performed with groups determined based on a CHD classification system. 58% of neonates (112/192) failed to achieve full oral feeding by hospital discharge. A logistic regression model identified duration of deep hypothermic circulatory arrest and reintubation as predictors of the inability to achieve full oral feeding. Among neonates who achieved full oral feeding by discharge (42%), only 7.5% did so after postoperative day 10. Brain maturation, brain injury, and preoperative oral feeding were not predictors of full postoperative oral feeding. Many infants with CHD fail to achieve full oral feeding by time of hospital discharge. Longer duration of deep hypothermic circulatory arrest and increased number of intubations were predictive of poor feeding after surgery. Prolonging hospitalisation solely to achieve full oral feeding after postoperative day ten is of limited utility; earlier discharge should be promoted to avoid negative impacts on neonatal neurodevelopment as unintended consequences of lengthy hospitalisations.

Pulmonary thromboendarterectomy in hospitalized versus elective patients with chronic thromboembolic pulmonary hypertension

ObjectiveWe sought to characterize outcomes in patients undergoing pulmonary thromboendarterectomy electively versus after acute presentation. MethodsThis is a retrospective analysis of patients who underwent pulmonary thromboendarterectomy from October 2015 to April 2022. Patients were divided into 2 groups depending on elective surgery or surgery during the same hospitalization as their presentation. ResultsIn total, 69 patients were included: 45 in the hospitalized group and 24 in the elective group. Patients in the hospitalized group were less likely to have chronic lung disease, history of pulmonary embolism and hypertension, be on anticoagulation and medication for pulmonary hypertension, and present with >1 month of respiratory symptoms. They were more likely to have worse preoperative right ventricular function. Among other demographics, risk factors for venous thromboembolism were similar between both groups. Thirteen patients in the hospitalized group required preoperative extracorporeal membrane oxygenation. There was no difference in disease classification and operative, cardiopulmonary bypass, and hypothermic circulatory arrest durations between both groups. Postoperative complications were similar between both groups, except for greater frequency of deep vein thrombosis in the hospitalized group (26.7% vs 4.2%, P = .03). In-hospital and intensive care unit length of stay were similar between both groups. Overall, in-hospital mortality was 4.3% and was similar between both groups; P = .28. ConclusionsOur series shows that pulmonary thromboendarterectomy can be safely performed in patients presenting acutely, with comparable postoperative complications and in-hospital mortality to an elective setting. Such patients present with worse right ventricular function, sometimes requiring temporary mechanical support.

Mortality after cardiac arrest in children less than 2 years: relevant factors

BackgroundThere are only scant studies of predicting outcomes of pediatric resuscitation due to lack of population-based data. This study aimed to determine variable factors that may impact the survival of resuscitated children aged under 24 months.MethodsThis is a retrospective study of 66 children under 24 months. Cardiopulmonary resuscitation (CPR) with pediatric advanced life support guideline was performed uniformly for all children. Linear regression analysis with variable factors was conducted to determine impacts on mortality.ResultFactors with statistically significant increases in mortality were the number of administered epinephrine (p value < 0.001), total CPR duration (p value < 0.001), in-hospital CPR duration of out-hospital cardiac arrest (p value < 0.001), and changes in cardiac rhythm (p value < 0.040). However, there is no statistically significant association between patient outcomes and remaining factors such as age, sex, underlying disease, etiology, time between last normal to CPR, initial CPR location, initial cardiac rhythm, venous access time, or inotropic usage.ConclusionMore than 10 times of epinephrine administration and CPR duration longer than 30 minutes were associated with a higher mortality rate, while each epinephrine administration and prolonged CPR time increased mortality.Impact statementThis study analyzed various factors influencing mortality after cardiac arrest in patients under 24 months.Increased number of administered epinephrine and prolonged cardiopulmonary resuscitation duration do not increase survival rate in patients under 24 months.In patients with electrocardiogram rhythm changes during CPR, mortality increased when the rhythm changed into asystole in comparison to no changes occurring in the rhythm.

Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection-Single Centre Experience.

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1-2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25-28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/- 56.874 min, the mean aortic cross-clamp time was 114.775 +/- 34.602 min, and the mean cerebral perfusion time was 37.837 +/- 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418-9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25-28 °C.

Radiological properties of neurological injury following acute type A aortic dissection repair

ObjectiveThe study objective was to assess the radiological properties of acute type A aortic dissection–related neurological injuries and identify predictors of neurological injury. MethodsOur single-center, retrospective, observational study included all patients who underwent acute type A aortic dissection repair between January 1998 and December 2021. Multivariable analyses and Cox regression were performed to identify predictors of embolic lesions, watershed lesions, neurological injury, 30-day mortality, and late mortality. ResultsA total of 538 patients were included. Of these, 120 patients (22.3%) experienced postoperative neurological injury; 74 patients (13.8%) had postoperative stroke, and 36 patients (6.8%) had postoperative coma. The 30-day mortality was 22.7% in the neurological injury group versus 5.8% in the no neurological injury group (P < .001). We identified several independent predictors of neurological injury. Cerebral malperfusion (odds ratio, 2.77; 95% confidence interval, 1.53-5.00), systemic hypotensive shock (odds ratio, 1.97; 95% confidence interval, 1.13-3.43), and aortic arch replacement (odds ratio, 3.08; 95% confidence interval, 1.17-8.08) predicted embolic lesions. Diabetes mellitus (odds ratio, 5.35; 95% confidence interval, 1.85-15.42), previous cardiac surgery (odds ratio, 8.62; 95% confidence interval, 1.47-50.43), duration of hypothermic circulatory arrest (odds ratio, 1.05; 95% confidence interval, 1.01-1.08), cardiopulmonary bypass time (odds ratio, 1.01; 95% confidence interval, 1.00-1.01), ascending aortic/arch cannulation (odds ratio, 5.68; 95% confidence interval, 1.88-17.12), and left ventricular cannulation (odds ratio, 17.81; 95% confidence interval, 1.69-188.01) predicted watershed lesions. Retrograde cerebral perfusion (odds ratio, 0.28; 95% confidence interval, 0.01-0.84) had a protective effect against watershed lesions. ConclusionsIn this study, we demonstrated that the radiological features of neurological injury may be as important as clinical characteristics in understanding the pathophysiology and causality behind neurological injury related to acute type A aortic dissection repair.

Associations between clinical characteristics of cardiac arrest and early CT head findings of hypoxic ischaemic brain injury following out-of-hospital cardiac arrest

Background/ObjectivePost-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI. MethodsThis is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI. ResultsA total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01–1.11, p < 0.01). ConclusionSigns of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.

Robotic-assisted mitral valve surgery without aortic cross-clamping: a safe and feasible technique.

The primary objective of this study was to evaluate the safety and feasibility of robotic-assisted mitral valve surgery without aortic cross-clamping. From January 2010 to September 2022, 28 patients underwent robotic-assisted mitral valve surgery without aortic cross-clamping in our center using DaVinci Robotic Systems. Clinical data during the perioperative period and early outcomes of the patients were recorded. Most patients were in New York Heart Association (NYHA) class II and III. Mean age and EuroScore II of the patients were 71.5 ± 13.5 and 8.4 ± 3.7 respectively. The patients underwent either mitral valve replacement (n = 16, 57.1%) or mitral valve repair (n = 12, 42.9%). Concomitant procedures were performed including tricuspid valve repair, tricuspid valve replacement, PFO closure, left atrial appendage ligation, left atrial appendage thrombectomy and cryoablation for atrial fibrillation. Mean CPB times were 140.9 ± 44.6 and mean fibrillatory arrest duration was 76.6 ± 18.4. Mean duration of ICU stay was 32.5 ± 28.8 h and mean duration of hospital stay 9.8 ± 8.3 days. One patient (3.6%) underwent revision due to bleeding. New onset renal failure was observed in one (3.6%) patient and postoperative stroke in one (3.6%) patient. Postoperative early mortality was observed in two (7.1%) patients. Robotic-assisted mitral valve surgery without cross-clamping is a safe and feasible technique in high-risk patients undergoing redo mitral surgery with severe adhesions as well as in primary mitral valve cases that are complicated with ascending aortic calcification.

The Association of the Cerebral Protection Strategy with Early Mortality and Postoperative Stroke in Acute Type A Aortic Dissection: A Systematic Review and Meta-Analysis

Objective. The optimal cerebral protection strategy in acute type A aortic dissection (ATAAD) is still without a clear consensus. The purpose of this meta-analysis was to compare the outcome of different cerebral protection strategies on ATAAD patients. Materials and Methods. We conducted a systematic review including all studies concerning surgically managed ATAAD patients between 1.1.2010 and 28.2.2022 and reporting the use of cerebral protection strategies in three large databases (Pubmed, Cochrane library, and Scopus). The main outcome events were 30-day mortality and a postoperative stroke rate. The pooled event rates adjusted by age, gender, CPB duration, circulatory arrest duration, and total arch reconstruction rate were calculated. Results. Overall, 39 articles were included covering a total of 16, 876 ATAAD patients. The estimated adjusted pooled early mortality rate was 10.1% (95% confidence interval [CI] 9.1–11.3%) in the ACP group, 15.9% (13.3–18.9%) in the RCP group, and 11.6% (9.2–14.5%) in the HCA group. Compared to the RCP group, ACP and HCA demonstrated lower early mortality (RCP vs. ACP odds-ratio 1.66 [1.28–2.15],p &lt; 0.001; RCP vs. HCA odds-ratio 1.45 [1.02–2.07],p = 0.039). The adjusted pooled stroke rate was 9.0% (8.3–9.8%) in the ACP group, 10.5% (9.3–11.7%) in the RCP group, and 9.1% (8.1–10.2%) in the HCA group. Conclusion. Early mortality might be more common in ATAAD patients treated with RCP compared to ACP and HCA. With regards to postoperative stroke, the results were inconclusive despite the trending inferiority of RCP compared to the other strategies.

C52 GENDER DIFFERENCES IN AMPLITUDE SPECTRAL AREA (AMSA) OF VENTRICULAR FIBRILLATION IN PATIENTS WITH OUT–OF–HOSPITAL CARDIAC ARREST

Abstract Introduction Ventricular fibrillation (VF) Amplitude Spectral Area (AMSA) is a well–established predictor of successful defibrillation and return of spontaneous circulation (ROSC). Attending to the limited evidence on the topic, gender seems to affect AMSA, and higher values have been reported in females. The aim of this work was to investigate the effect of gender in AMSA values for patients suffering out–of–hospital cardiac arrest (OHCA). Methods We enrolled 4619 consecutive OHCA patients from January 2015 to December 2020 in the LombardiaCare Registry. We considered only those subjects with attempted cardio–pulmonary resuscitation (697 patients) and at least one shock delivered. A total of 250 patients were considered (40 F/ 210 M) with 830 shocks (100 F/ 730 M). AMSA values were computed for the ventricular fibrillation in the 2–s pre–shock interval of the ECG recorded by the Corpuls3 defibrillator (Corpuls, Kaufering, Germany). Results Female patients were older than male [median(IQR) 70.5 (62–72) vs 67 (55–75) years, p=0.01], with cardiac arrest more frequently at home (84% vs 76%, p=0.003), fewer shocks [2 (1–4) vs 4 (2–7), p=0.004] and higher percentage of success (53% vs 40%, p= 0.009). On the contrary, cardiac arrest duration [ 58.7 (31–69) vs 57.6 (41.4–77.3) min, p=0.366] and the rate of ROSC (32% vs 33%, p=0.88) were similar in both groups. Higher AMSA values were found in female patients [10.3 Hz–mV (6.6–13.5) vs 7.9 Hz–mV (5.2–12.1), p= 0.0007]. At a multivariable analysis, after correction for witnessed status, bystanders CPR, amiodarone administration, age and call–to shock time, male sex was found to be independently associated with the probability of having low values of AMSA, below the median value of 8.3 Hz–mV [OR 2.15 (95%CI1.35–3.43), p=0.001]. Despite gender stratification ROC curve analysis confirmed AMSA as a predictor of shock success [AUC–F: 0.75 (95%CI 0.65–0.83), p&amp;lt;0.001; AUC–M: 0.78 (95%CI 0.74–0.81)] and ROSC [AUC–F: 0.69 (95%CI 0.59–0.68), p=0.008; AUCM: 0.84 (95%CI 0.81–0.87)]. Conclusion Female sex is related to higher AMSA values. As AMSA reflects the energetical status and the ATP levels in the myocardial cells during cardiac arrest, this difference may be due to lower incidence and lower severity of cardiac ischemic disease in women. AMSA remains a valid predictor of both shock success and ROSC for female and male patients. Further investigations are needed to support and comprehend these conclusions.

Performance of APACHE, SOFA and SAPS-2 score in predicting good neurological outcome at discharge from ICU in patient admitted after an out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: None. Background Acute Physiologic and Chronic Health Evaluation (APACHE), Sequential (sepsis-related) Organ Failure Assessment (SOFA) and Simplified Acute Physiologic Score-2 (SAPS-2) are common predictive scoring systems in the intensive care unit (ICU) used all around the world to predict outcomes in general or specific population (eg. sepsis and septic shock). However, these scores were found to have mixed performance in several subgroups of critically ill patients. Purpose Few and conflicting data are available on patients admitted in the ICU after an out-of-hospital cardiac arrest (OHCA) regarding these prognostic scores. We sought to evaluate the performance of these scores obtained on admission in predicting good neurological outcome at ICU discharge. Methods We enrolled 171 consecutive patients admitted to ICU at our center after being resuscitated from an OHCA from September 2017 to April 2021. APACHE, SOFA and SAPS-2 were available for 133 patients [77% male, mean age 60 (18-90) years, 54% with first shockable rhythm, median number of shocks delivered 1 (0-14), median value of adrenaline administered 3 mg (0-12), 26% received amiodarone, median cardiac arrest duration 38 min (IQR 22-74)]. Worst values collected during the first 24 hours were considered for APACHE and SAPS-2 calculations, whereas SOFA was assessed at 24 hours from admission. The median values of each one of the three scores of patients with and without good neurological outcome (cognitive performance category 1-2) at ICU discharge were compared with Mann-Whitney U-test. For each one of the scores the Receiver Operating Characteristic (ROC) curve was analysed and the corresponding area under the curve AUC with its 95%CI was calculated, with the endpoint of survival with good neurological outcome at ICU discharge. Results patients with good neurological outcome had lower values of APACHE [22 (IQR 19-25) vs 24 (IQR 21-28)(p=0.01], SOFA [9 (IQR 7-10) vs 10 (IQR 8-12)(p&amp;lt;0.01] and SAPS-2 [56 (IQR 44-64) vs 72 (IQR 61-83)(p&amp;lt;0.01] . APACHE and SOFA scores showed similar AUC [0.616 (95% CI 0.528-0.699) vs 0.652 (95%CI 0,564-0,732), p=0.54]. SAPS-2 score performed significantly better than the other two [AUC 0.784 (95% CI 0.705-0.851, p&amp;lt;0.0001)]. Conclusion SAPS-2 score discriminates survival with good neurological outcome at ICU discharge significantly better than APACHE and SOFA in patients resuscitated from an OHCA and admitted to the ICU. These results could help clinicians in identifying which patients yield a better prognosis after 24 hours of clinical observation in the ICU and could therefore be safely and rapidly discharged to the ward.

Vasoactive inotropic score (VIS) at ICU admission predicts neurological outcome and survival in patients resuscitated from an out of hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: None. Background Since its proposal, Vasoactive Inotropic Score (VIS) was applied in different setting of acute critical care (e.g. pediatric population or post-cardiac surgery). It reflects the pharmacological support of the cardiovascular system and higher VIS values in the first 24 hours from ICU admission predict worse outcomes, both in pediatric and adult population. Few data are available regarding patients admitted for an Out of Hospital Cardiac Arrest (OHCA). The aim of this work is to investigate the prognostic role of VIS score in this population. Methods We enrolled 171 consecutive patients who were resuscitated after an OHCA and admitted to ICU at our center from September 2017 to April 2021. VIS score on admission was available for 144 patients. We divided the population in two groups (high vs low VIS score) according to VIS score median values. For every patient neurological outcome at discharge and survival at one year were available. Results Median VIS score was 10 so we considered low values ≤ 10 (group 1) and high values &amp;gt; 10 (group 2). There were 73 patients in low VIS group (Group 1) and 71 in high VIS group (Group 2). No differences were found in the two groups regarding sex (75% males vs 74%, p=0.88), age [64 (49-70) vs 61 (52-74), p=0.5], SAPS II score at admission [63.61 (53-70) vs 65.46 (61-86), p=0.54], shockable rhythm as first rhythm (60.2% vs 51.51%, p=0.3) and number of shocks delivered [median value 1 (0-13) vs 1 (0-14), p=0.84]. On the contrary, patients with lower VIS values had a shorter arrest duration [26 mins (19-40) vs 41 mins (27-74), p=0.0002] and less adrenaline delivered [2 mg (0-6) vs 3 mg (0 -12), p=0.0012]. Moreover, patients with lower VIS score values on admission showed a better neurological outcome (defined as a CPC &amp;lt; 2) at ICU discharge (44% vs 21%, p=0.08). In addition, patients in group 1 showed a lower mortality rate as compared to group 2 [60% (44/73) vs 76% (54/71),p=0.0048]. Conclusion in adult patients resuscitated from an out-of-hospital cardiac arrest and admitted to an ICU, lower values of VIS score were associated with higher survival at 1 year. Moreover patients with low VIS showed better neurological outcome at ICU discharge. This could be explained by the fact that VIS express the need for cardiovascular support and is lower in patients with a more stable hemodynamic status after OHCA, reflecting a less compromised clinical condition.

Blood lactate levels, base excess values and lactic acidosis predict short-term and long-term survival in patients admitted to the ICU after and out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: None. Background Global hypoperfusion causes tissue hypoxia, resulting in overproduction of lactate because of impaired mitochondrial oxidation, causing lactic acidosis (LA). Base excess (BE) is defined as the amount of acid or base required to return the pH to 7.4 in the setting of a normal Paco2 and is therefore related to the degree of acid production following injury. Purpose Our hypothesis was that lactate levels, BE levels and occurrence of LA on admission could help in early risk stratification in patients admitted to the ICU after an out-of-hospital cardiac arrest (OHCA). Methods we enrolled 171 consecutive patients resuscitated from an OHCA and admitted to ICU at our center from September 2017 to April 2021. Blood gas analysis on admission was available for 140 patients [77%male, mean age 60 (18-90) years, 54% with first shockable rhythm, median number of shocks delivered 1 (0-14), median dose of adrenaline administered 3 mg (0-12), 26% received amiodarone, median cardiac arrest duration 38 min (IQR 22-74 min)]. Patients with low lactate levels were compared with patients with high lactate levels (cutoff 2 mmol/l as per standard practice), patients with low BE levels were compared with patients with high BE levels (cutoff -8.5 mmol/l, median value) and patients with LA were compared with patients without LA (defined as pH &amp;lt;7.36 and lactate&amp;gt;2mmol/). Survival with good neurological outcome (CPC 1-2) at ICU discharge and 30-day survival were investigated for each group with chi-squared test. Then, one-year survival was investigated for each group with Kaplan-Meier analysis. Results Patients with low BE (&amp;lt; -8.5 mmol/l) had a significantly lower survival with good neurological outcome at ICU discharge (p=0.0017), lower survival at 30 days (p &amp;lt; 0.0001) and 365 days (p&amp;lt;0.0001) compared to patients with high BE (&amp;gt; - 8.5 mmol/l). Low lactate levels (&amp;lt; 2 mmol/L) were associated with higher survival with good neurological outcome at ICU discharge (p&amp;lt; 0.0001), higher survival at 30 days (p &amp;lt; 0.0001) and 365 days (p = 0.0002) compared to higher lactate levels (&amp;gt; 2 mmol/l). The occurrence of LA on admission was significantly associated with lower survival with good neurological outcome at ICU discharge (p=0.001), lower 30-days survival (p=0.001) and 365-days survival (p&amp;lt;0.0001). Conclusion high blood lactate levels, low base excess and lactic acidosis predict short-term and long-term survival in patients admitted to the ICU after an OHCA. These results could help clinician in the identification of populations with different risk profile with the first blood gas analysis obtained at ICU admission.

Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest: Analysis Using the CAse REport Guideline.

Extracorporeal membrane oxygenation (ECMO) is recommended in adults with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA). Our experience of managing a drowned 2-year-old girl with hypothermia (23°C) and cardiac arrest (58 min) prompted this summary using the CAse REport (CARE) guideline to address the question of optimal rewarming procedure in such patients. Following the CARE guideline, we identified 24 reports in the "PubMed database" describing children less than or equal to 6 years old with a temperature less than or equal to 28°C who had been rewarmed using conventional intensive care ± ECMO. Adding our patient, we were able to analyze a total of 57 cases. The two groups (ECMO vs non-ECMO) differed with respect to submersion time, pH and potassium but not age, temperature or duration of cardiac arrest. However, 44 of 44 in the ECMO group were pulseless on arrival versus eight of 13 in the non-ECMO group. Regarding survival, 12 of 13 children (92%) undergoing conventional rewarming survived compared with 18 of 44 children (41%) undergoing ECMO. Among survivors, 11 of 12 children (91%) in the conventional group and 14 of 18 (77%) in the ECMO group had favorable outcome. We failed to identify any correlation between "rewarming rate" and "outcome." In this summary analysis, we conclude that conventional therapy should be initiated for drowned children with OHCA. However, if this therapy does not result in return of spontaneous circulation, a discussion of withdrawal of intensive care might be prudent when core temperature has reached 34°C. We suggest further work is needed using an international registry.

Alternative CDC20 translational isoforms tune mitotic arrest duration.

Mitotic defects activate the spindle-assembly checkpoint, which inhibits the anaphase-promoting complex co-activator CDC20 to induce a prolonged cell cycle arrest1,2. Once errors are corrected, the spindle-assembly checkpoint is silenced, allowing anaphase onset to occur. However, in the presence of persistent unresolvable errors, cells can undergo 'mitotic slippage', exiting mitosis into a tetraploid G1 state and escaping the cell death that results from a prolonged arrest. The molecular logic that enables cells to balance these duelling mitotic arrest and slippage behaviours remains unclear. Here we demonstrate that human cells modulate the duration of their mitotic arrest through the presence of conserved, alternative CDC20 translational isoforms. Downstream translation initiation results in a truncated CDC20 isoform that is resistant to spindle-assembly-checkpoint-mediated inhibition and promotes mitotic exit even in the presence of mitotic perturbations. Our study supports a model in which the relative levels of CDC20 translational isoforms control the duration of mitotic arrest. During a prolonged mitotic arrest, new protein synthesis and differential CDC20 isoform turnover create a timer, with mitotic exit occurring once the truncated Met43 isoform achieves sufficient levels. Targeted molecular changes or naturally occurring cancer mutations that alter CDC20 isoform ratios or its translational control modulate mitotic arrest duration and anti-mitotic drug sensitivity, with potential implications for the diagnosis and treatment of human cancers.

Genetic dissection of the Mastl-Arpp19/Ensa-PP2A-B55δ pathway in mammalian cells

Abstract Objectives Mastl is an essential kinase required for inhibition of the phosphatase activity directed toward Cdk1/cyclin B substrates during mitosis. Mastl phosphorylates two small evolutionarily conserved proteins, Arpp19 and Ensa converting them into strong inhibitors of PP2A-B55δ. Mastl-Arpp19/Ensa-PP2A regulatory pathway has been mainly studied in Xenopus egg extracts and Drosophila using biochemical and genetic approaches. Studies in mammalian cells and genetically modified mouse models have suggested distinct but important functions for Arpp19 and Ensa, in mitosis and S-phase, respectively. A detailed comparative analysis of the Arpp19 and Ensa functions in mammalian cells has not been performed. Methods We utilized Mastl conditional knockout (CKO) mouse embryonic fibroblasts (MEF), to investigate the roles of Mastl-Arpp19/Ensa-PP2A pathway components in mitosis and cellular proliferation. We used viral transduction for overexpression or silencing of these genes in conjunction with inducible genetic Mastl knockout to assess their roles in relation to each other. Results We show that, Arpp19 is expressed at significantly higher levels in MEFs in comparison to Ensa. Silencing of Arpp19, but not Ensa, results in reduced cellular proliferation. Overexpression of WT Arpp19 or its phosphomimetic mutant (S67D) partially restores mitosis arrest duration in Mastl knockout MEFs, however cellular proliferation block cannot be rescued. Silencing of B55δ expression has a similar outcome as Arpp19 overexpression, underscoring the opposite roles of these genes in mitosis. Conclusions Our results show that Arpp19 is the major Mastl substrate during mitotic division of MEFs. Ensa expression is low and it is not essential for cell cycle.

Intestinal injury in cardiac arrest is associated with multiple organ dysfunction: A prospective cohort study

BackgroundThe impact of intestinal injury in cardiac arrest is not established. The first aim of this study was to assess associations between clinical characteristics in out-of-hospital cardiac arrest (OHCA) and a biomarker for intestinal injury, Intestinal Fatty Acid Binding Protein (IFABP). The second aim was to assess associations between IFABP and multiple organ dysfunction and 30-day mortality. MethodsWe measured plasma IFABP in 50 patients at admission to intensive care unit (ICU) after OHCA. Demographic and clinical variables were analysed by stratifying patients on median IFABP, and by linear regression. We compared Sequential Organ Failure Assessment (SOFA) score, haemodynamic variables, and clinical-chemistry tests at day two between the “high” and “low” IFABP groups. Logistic regression was applied to assess factors associated with 30-day mortality. ResultsSeveral markers of whole body ischaemia correlated with intestinal injury. Duration of arrest and lactate serum concentrations contributed to elevated IFABP in a multivariable model (p < 0.01 and p = 0.04, respectively). At day two, all seven patients who had died were in the “high” IFABP group, and all six patients who had been transferred to ward were in the “low” group. Of patients still treated in the ICU, the “high” group had higher total, renal and respiratory SOFA score (p < 0.01) and included all patients receiving inotropic drugs. IFABP predicted mortality (OR 16.9 per standard deviation increase, p = 0.04). ConclusionCardiac arrest duration and lactate serum concentrations were risk factors for intestinal injury. High levels of IFABP at admission were associated with multiple organ dysfunction and mortality.Trial registration: ClinicalTrials.gov: NCT02648061.

Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection.

This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection. From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta. Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed. The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134). No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.

Multicentric validation of a prognostic tool for predicting brain death following out-of-hospital cardiac arrest in children

AimOut-of-hospital cardiac arrest (OHCA) in pediatric patients is associated with high rates of mortality and neurologic injury, with no definitive evidence-based method to predict outcomes available. A prognostic scoring tool for adults, The Brain Death After Cardiac Arrest (BDCA) score, was recently developed and validated. We aimed to validate this score in pediatric patients. MethodsRetrospective cohort study of pediatric patients admitted to 5 PICUs after OHCA between 2011 and 2021. We extracted BDCA score elements for those who survived at least 24 hours but died as a result of their OHCA. We assessed score discrimination for the definitive outcome of brain death. Subgroup analysis was performed for infants < 12mo versus children ≥ 12mo, those who likely had brain death but had withdrawal of life sustaining therapy (WLST) prior to declaration, and by etiology and duration of arrest. Results389 subjects were identified across 5 institutions, with 282 meeting inclusion criteria. 169 (59.9%) were formally declared brain dead; 58 (20.6%) had findings consistent with brain death but had withdrawal of life sustaining therapies prior to completion of formal declaration. Area under the receiver operating characteristic curve for the age ≥ 12mo cohort was 0.82 [95% CI 0.75, 0.90], which mirrored the adult subject AUCs of 0.82 [0.77, 0.86] and 0.81 [0.76, 0.86] in the development and validation cohorts. Scores demonstrated worse discrimination in the infant cohort (AUC = 0.61). ConclusionsThe BDCA score shows promise in children ≥ 12mo following OHCA and may be considered in conjunction with existing multimodal prognostication approaches.