Hemodynamic Complications Research Articles

Update on the use of ultrasound in the diagnosis and monitoring of the critical patient.

Hemodynamic and respiratory complications are the main causes of morbidity and mortality in in critical care units (CCU). Imaging techniques are a key tool in differential diagnosis and treatment. In the last decade, ultrasound has shown great potential for bedside diagnosis of respiratory disease, as well as for the hemodynamic assessment of critically ill patients. Ultrasound has proven to be a useful guide for identifying the type of shock, estimating cardiac output, guiding fluid therapy and vasoactive drugs, providing security in the performance of percutaneous techniques (thoracentesis, pericardiocentesis, evacuation of abscesses/hematomas), detecting dynamically in real time pulmonary atelectasis and its response to alveolar recruitment maneuvers, and predicting weaning failure from mechanical ventilation. Due to its dynamic nature, simple learning curve and absence of ionizing radiation, it has been incorporated as an essential tool in daily clinical practice in CCUs. The objective of this review is to offer a global vision of the role of ultrasound and its applications in the critically ill patient.

Delayed biventricular repair of interrupted aortic arch with left ventricular outflow tract obstruction in 22q11.2 deletion syndrome: a case report.

In patients with critical left ventricular outflow tract obstruction but adequately sized ventricles, the treatment of choice is biventricular repair. Several options have been proposed, including neonatal Yasui or Ross-Konno operation. However, each of these procedures carries a high mortality risk, especially in syndromic neonates. Here, we report the case of a patient with 22q11.2 deletion syndrome and a diagnosis of interrupted aortic arch type B2, ventricular septal defect and left ventricular outflow tract obstruction. As a means to avoid high-risk neonatal surgery in this patient, we pursued a strategy of delayed biventricular repair involving initial hybrid Norwood palliation followed by a Yasui-type operation at 3months. Although this strategy turned out to be successful, proactive monitoring for the development of ductal stent stenosis during follow-up after the hybrid procedure remains crucial to prevent hemodynamic complications such as cardiac failure and systemic hypoperfusion.

Prenatal Diagnosis and Outcome of Intrapericardial Teratoma: Report of Two Clinical Scenarios.

Intrapericardial teratoma is a rare tumor composed of tissue from the three germ cell layers with a rapid growth that may cause severe hemodynamic complications due to compressive effects. We present two clinical cases: the first case had severe fetal heart failure with fatal outcome, and the second underwent surgical treatment during the immediate postnatal period with a favorable evolution. Although teratomas are histologically benign tumors, rapid growth can cause serious hemodynamic complications. The importance of prenatal diagnosis is to allow appropriate monitoring of tumor growth and establish a prompt therapeutic plan. Opportune surgical treatment can prevent death and improve the prognosis of these patients.

The CHA2DS2-VASc Score Predicts New-Onset Atrial Fibrillation and Hemodynamic Complications in Patients with ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention.

Arrhythmic and hemodynamic complications related to ST-segment elevation myocardial infarction (STEMI) represent a major clinical challenge. Several scores have been developed to predict mortality in STEMI. However, those scores almost exclusively include factors related to the acute phase of STEMI, and no score has been evaluated to date for its ability to specifically predict arrhythmic and hemodynamic complications. We, thus, aimed to assess the ability of chronic risk factors burden, as expressed by the CHA2DS2-VASc score, to predict STEMI-related arrhythmic and hemodynamic complications. Data were collected from 839 consecutive STEMI patients treated by primary percutaneous coronary interventions (pPCI). CHA2DS2-VASc and GRACE scores were calculated for all patients, and their ability to predict STEMI-related arrhythmic (i.e., new-onset atrial fibrillation (AF), ventricular tachycardia/fibrillation) and hemodynamic (i.e., cardiogenic shock, asystole) complications was assessed in univariate and multiple regression analysis. Arrhythmic and hemodynamic complications occurred in 14.8% and 10.2% of patients, respectively. Although the GRACE score outweighed the CHA2DS2-VASc score in the ability to predict STEMI-related hemodynamic complications (p < 0.0001), both scores had a similar predictive value for STEMI-related new-onset AF (p = 0.20), and both remained independent predictors of new-onset AF and of hemodynamic complications in the multiple regression analyses. A CHA2DS2-VASc score > 2 points independently predicted new-onset AF (p < 0.01) and hemodynamic complications (p = 0.04). Alongside the GRACE score, the CHA2DS2-VASc score independently predicted new-onset AF and hemodynamic complications in STEMI patients treated by pPCI. These data suggest that a combination of acute and chronic risk factors could provide additional benefit in identifying patients at risk of STEMI-related complications, who could benefit from closer follow-up and more intensive prophylactic and therapeutic strategies.

IMPACT OF PULMONARY EMBOLISM RESPONSE TEAM (PERT) ON TIME TO ANTICOAGULATION AND INTERVENTION IN HIGH- AND INTERMEDIATE-RISK PULMONARY EMBOLISM

SESSION TITLE: Expanding Considerations in Management of Pulmonary EmbolismSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/19/2022 11:15 am - 12:15 pmPURPOSE: Pulmonary embolism response teams (PERT) are being formed in many hospitals for rapid risk-stratification and treatment-initiation in patients with high and intermediate-risk pulmonary embolism (PE). Prompt diagnosis and treatment improves outcomes in PE. Limited data exists on whether institution of PERT changes outcomes. The goal of this study was to determine whether starting PERT in our institution improved time to (i) initiation of anticoagulation (AC), (ii) achieving therapeutic AC and (iii) starting advance treatments like catheter-directed thrombolysis (CDT) in high/intermediate-risk PEs.METHODS: Records of patients hospitalized in our institution with high and intermediate-risk PE, before and after starting PERT, were reviewed. Intermediate-risk (submassive) pulmonary embolism (PE) was defined as PE with presence of right ventricle (RV) dysfunction and/or elevated troponin levels and normal blood pressure, while high-risk (massive) PE was defined as patients with hypotension. 42 patients were studied before PERT was started and 93 patients after PERT. Patient demographics, time to initiation of AC and achieving therapeutic PTT, time to CDT was noted 2-years before and 2-yrs after PERT was formed. Independent t-test was performed to determine if outcomes studied were significantly impacted after the formation of PERT. p ≤ 0.05 was deemed statistically significant.RESULTS: Mean age of patients was 64 ± 15.7 years; 49% were females. Mean time to AC pre-PERT was 91.3 ± 90.3 min vs.111±114m post-PERT (p = 0.40). Time- to- CDT also did not change significantly( 1486.5±1346m pre- PERT vs.2290±1683 post-PERT (p = 0.29). There was a significant reduction in time to therapeutic PTT (925.3±636min, pre-PERT vs. 507 +264min post-PERT, p= 0.0007.CONCLUSIONS: PERT significantly reduced time to therapeutic anticoagulation in high and intermediate-risk PEs, but not on time to initiation of AC and CDT. Whether this translates to reduced hemodynamic complications and mortality needs to be further studied. Further studies are needed to assess whether mortality and other outcomes that are improved with PERT.CLINICAL IMPLICATIONS: PERT may improve outcomes in PE by enabling quicker achievement of therapeutic AC. Further studies on impact of PERT on mortality and hemodynamic complications are needed.DISCLOSURES: No relevant relationships by Soontharee CongreteNo relevant relationships by Debapriya DattaNo relevant relationships by Michelle Zur SESSION TITLE: Expanding Considerations in Management of Pulmonary Embolism SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Pulmonary embolism response teams (PERT) are being formed in many hospitals for rapid risk-stratification and treatment-initiation in patients with high and intermediate-risk pulmonary embolism (PE). Prompt diagnosis and treatment improves outcomes in PE. Limited data exists on whether institution of PERT changes outcomes. The goal of this study was to determine whether starting PERT in our institution improved time to (i) initiation of anticoagulation (AC), (ii) achieving therapeutic AC and (iii) starting advance treatments like catheter-directed thrombolysis (CDT) in high/intermediate-risk PEs. METHODS: Records of patients hospitalized in our institution with high and intermediate-risk PE, before and after starting PERT, were reviewed. Intermediate-risk (submassive) pulmonary embolism (PE) was defined as PE with presence of right ventricle (RV) dysfunction and/or elevated troponin levels and normal blood pressure, while high-risk (massive) PE was defined as patients with hypotension. 42 patients were studied before PERT was started and 93 patients after PERT. Patient demographics, time to initiation of AC and achieving therapeutic PTT, time to CDT was noted 2-years before and 2-yrs after PERT was formed. Independent t-test was performed to determine if outcomes studied were significantly impacted after the formation of PERT. p ≤ 0.05 was deemed statistically significant. RESULTS: Mean age of patients was 64 ± 15.7 years; 49% were females. Mean time to AC pre-PERT was 91.3 ± 90.3 min vs.111±114m post-PERT (p = 0.40). Time- to- CDT also did not change significantly( 1486.5±1346m pre- PERT vs.2290±1683 post-PERT (p = 0.29). There was a significant reduction in time to therapeutic PTT (925.3±636min, pre-PERT vs. 507 +264min post-PERT, p= 0.0007. CONCLUSIONS: PERT significantly reduced time to therapeutic anticoagulation in high and intermediate-risk PEs, but not on time to initiation of AC and CDT. Whether this translates to reduced hemodynamic complications and mortality needs to be further studied. Further studies are needed to assess whether mortality and other outcomes that are improved with PERT. CLINICAL IMPLICATIONS: PERT may improve outcomes in PE by enabling quicker achievement of therapeutic AC. Further studies on impact of PERT on mortality and hemodynamic complications are needed. DISCLOSURES: No relevant relationships by Soontharee Congrete No relevant relationships by Debapriya Datta No relevant relationships by Michelle Zur

Comparison of Hand-Held Doppler and Indocyanine Green Angiography in Preoperative Design of Expanded Forehead Flaps for Nasal Reconstruction.

Despite the different approaches for detection of perforators, methods of vascular mapping of the expanded forehead flap for nasal reconstruction are rarely described. This article aimed to present our experience in the preoperative design of the expanded forehead flap for nasal reconstruction and to compare the clinical practice of hand-held Doppler and indocyanine green angiography (ICGA) in vascular mapping for nasal reconstruction with the expanded forehead flap. From October 2019 to April 2022, 26 patients underwent nasal reconstruction using expanded forehead flap. The authors performed preoperative vascular mapping on 16 patients by hand-held Doppler alone, and on 10 patients by hand-held Doppler and ICGA primary outcomes considered were the visualization of the main vascular course of the flap obtained by hand-held Doppler or ICGA, intraoperative observation of the flap, and its postoperative complications. Indocyanine green angiography provides a better detection in distal flap and the branches of the supratrochlear artery. Vein detection by ICGA generally corresponds to the results obtained by the combination of hand-held Doppler and transillumination test. In the group that only used hand-held Doppler, 2 patients presented hemodynamic complications in the margin of the flap and 1 patient presented partial necrosis postoperatively. No complication was found in the group that used ICGA. It is recommended to use the ICGA for preoperative planning, as it yields highly accurate vascular courses. As an alternative to other methods, hand-held Doppler is also an effective tool. IV.

Echocardiographic Screening for Rheumatic Heart Disease in a Ugandan Orphanage: Feasibility and Outcomes.

Background: Rheumatic heart disease (RHD) is a major cause of cardiovascular disease in developing nations, leading to more than 230,000 deaths annually. Most patients seek medical care only when long-term structural and hemodynamic complications have already occurred. Echocardiographic screenings ensure the early detection of asymptomatic subjects who could benefit from prophylaxis, monitoring and intervention, when appropriate. The aim of this study is to assess the feasibility of a screening program and the prevalence of RHD in a Ugandan orphanage. Methods: We performed an RHD-focused echocardiogram on all the children (5–14 years old) living in a north Ugandan orphanage. Exams were performed with a portable machine (GE Vivid-I). All the time intervals were recorded (minutes). Results: A total of 163 asymptomatic children were screened over 8 days (medium age 9.1; 46% male; 17% affected by severe motor impairment). The feasibility rate was 99.4%. An average of 20.4 exams were performed per day, with an average of 15.5 images collected per subject. Pathological mitral regurgitation (MR) was found in 5.5% of subjects, while at least two morphological features of RHD were found in 4.3%, leading to 1 “definite RHD” (0.6%) case and 13 “borderline RHD” cases (8.1%). Six congenital heart defects were also noted (3.7%): four atrial septal defects, one coronary artery fistula and one Patent Ductus Arteriosus. Conclusions: We demonstrated the feasibility of an echocardiographic screening for RHD in an orphanage in Uganda. A few factors, such as good clinical and hygienic care, the availability of antibiotics and closeness to a big hospital, may account for the low prevalence of the disease in our population.

Addition of lumbar intrathecal morphine along with standard thoracic epidural anesthesia for abdomino thoracic esophagectomy

Introduction: Thoracic epidural anaesthesia (TEA) has been the standard of care for postoperative pain management for patients undergoing abdomino-thoracic esophagectomy. The study aims to observe whether addition of lumbar intrathecal morphine along with TEA reduces the post operative pain scores, post operative opioid consumption and total epidural drug requirement. Materials and methods:50 patients divided into two groups, one group was given standard TEA at level T5-T7, other group was receiving intrathecal morphine along with TEA. General anaesthesia will be provided as per standard protocol and one lung isolation will be achieved using Robertsons double lumen tube of proper size. Pain scores will be monitored using Numerical rating Scale. Total requirement of epidural drug in both the groups , requirement of rescue analgesia, complications in both the groups will be observed. Results and observations: In our study we found that VAS score were better in the combined intrathecal morphine plus thoracic intrathecal morphine plus thoracic epidural approach group and there were less need of rescue analgesia and good recovery compared to conventional thoracic epidural approach. Haemodynamic parameters and complications were almost comparable in both the groups except for heart rate.

Caspofungin-Induced Cardiotoxicity in Patients Treating for Candidemia.

Echinocandins selectively inhibit fungal cell wall synthesis and, therefore, have few side effects. However, there are reports of hemodynamic and cardiac complications. We conducted this study to investigate the effects of caspofungin both on the noninvasive echocardiographic indices of myocardial function and myocardial injury based on serum high-sensitivity cardiac troponin I (hs-cTnI) levels. This study was conducted on patients treated for candidemia. The hs-cTnI level and echocardiographic parameters were measured before and 1 h after the infusion of the induction dose of caspofungin. Data were compared between central and peripheral venous drug administration routes. Fifteen patients were enrolled in the study. There were no significant differences in the echocardiographic parameters between the baseline and post-treatment period. The mean hs-cTnI level exhibited a significant rise following drug administration (0.24 ± 0.2 ng/mL vs 0.32 ± 0.3 ng/mL; p = 0.006). There was also a significant difference concerning the hs-cTnI level between central and peripheral venous drug administration routes (p = 0.034). Due to differences in the hs-cTnI level, it appears that the administration of caspofungin may be associated with myocardial injury. Our findings also showed a higher possibility of cardiotoxicity via the central venous administration route.

Effect of probiotics on hemodynamic changes and complications associated with cirrhosis: A pilot randomized controlled trial.

BACKGROUNDBacterial translocation exacerbates the hyperdynamic circulation observed in cirrhosis and contributes to a more severe disease course. Probiotics may reduce bacterial translocation and may therefore be useful to redress the circulatory imbalance.AIMTo investigate the effect of probiotics on hemodynamic parameters, systemic inflammation, and complications of cirrhosis in this randomized placebo-controlled trial.METHODSThis single-blind randomized placebo-controlled study included 40 patients with Child-Pugh class B and C cirrhosis; 24 patients received probiotics (Saccharomyces boulardii) for 3 mo, and 16 patients received a placebo over the same period. Liver function and the systemic hemodynamic status were evaluated pre- and post-intervention. Echocardiography and simultaneous blood pressure and heart rate monitoring were performed to evaluate systemic hemodynamic indicators. Cardiac output and systemic vascular resistance were calculated.RESULTSFollowing a 3-mo course of probiotics in comparison to the control group, we observed amelioration of hyperdynamic circulation [a decrease in cardiac output (P = 0.026) and an increase in systemic vascular resistance (P = 0.026)] and systemic inflammation [a decrease in serum C-reactive protein levels (P = 0.044)], with improved liver function [an increase in serum albumin (P = 0.001) and a decrease in the value of Child-Pugh score (P = 0.001)] as well as a reduction in the severity of ascites (P = 0.022), hepatic encephalopathy (P = 0.048), and cholestasis [a decrease in serum alkaline phosphatase (P = 0.016) and serum gamma-glutamyl transpeptidase (P = 0.039) activity] and an increase in platelet counts (P < 0.001) and serum sodium level (P = 0.048).CONCLUSIONProbiotic administration was associated with amelioration of hyperdynamic circulation and the associated complications of cirrhosis.

Management of an Intra-Operative Rupture of a Huge Aortic Root and Ascending Aortic Aneurysm: A Case Report

Introduction: Intraoperative rupture of an aortic root and ascending aortic aneurysm is rare. However rupture of the aneurysm in this group of patients is challenging and associated with fatal outcomes. Case Report: we report the case of a 31-year-old Marfan syndrome patient with a huge aortic root and ascending aortic aneurysm. Median sternotomy and vertical opening of the pericardium were performed. Aneurysm rupture occurred before cannulation on its anterior surface. Intra-operative and postoperative management were successful. There were no neurological, hemodynamic or hemorrhagic complications. Conclusion: Intra-operative aneurysm rupture is rare and challenging. However, fast bleeding control and cannulation is compulsory in the management in this situation.

Wellens syndrome as an independent predictor of in-hospital cardiovascular complications

Introduction Wellens Syndrome was described for the first time in the eighties, as an equivalent pattern of a critical lesion of the anterior descending artery. Different risk factors have been associated with a worse prognosis during hospitalisation in patients with non-ST segment elevation acute coronary syndrome. However, it is unknown whether the presence of Wellens Syndrome alone contributes to an increase in in-hospital cardiovascular complications. Material and method Analytical prospective cohort study in 141 patients with the diagnosis of acute coronary syndrome without ST segment elevation who underwent coronary angiography between 2016 and 2020. Results Wellens syndrome was diagnosed in 64 patients with a mean age of 66.31 ± 12.54, of which 21 patients had a cardiac event during hospitalisation: hemodynamic complication 14 (21.9%), refractory or recurrent angina 4 (6.3%) and Acute myocardial infarction 3 (4.7%) confirming a relative risk (RR): 4.88 (95% confidence interval (CI) 1.92–12.45) p = 0.001. Conclusions The presence of Wellens Syndrome is independently associated with the appearance of cardiac complications during hospitalisation. Key points SW is now known to be a relatively frequent presentation of ACS, not addressed in depth in clinical practice guidelines for NSTEACS. This syndrome is generally caused by a severe ADA occlusion that, if not adequately treated, could evolve into a large infarction. According to the results of the different series published, the incidence of cardiovascular risk factors in SW is similar to other forms of presentation of ischaemic heart disease. At present, the exact relationship between the main cardiovascular risk factors and SW is unknown; in addition to the possible associations of this syndrome with in-hospital cardiovascular complications and its value as a predictor of the occurrence of cardiac complications, elements that are included in the results of the present study.

Intraoperative Circulatory Support in Lung Transplantation: Current Trend and Its Evidence.

Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.

Intrinsic Differences in Immune Checkpoint Inhibitor-Induced Myocarditis: A Retrospective Analysis of Real World Data.

Immune-related myocarditis is a severe and even life-threatening immune-related adverse event (irAE) which may also be underestimated due to the challenge in diagnosis. The inherent difference between individuals with immune-associated myocarditis has received little attention. Our study aimed to identify which baseline characteristics could contribute to distinguishing mild from severe ICI myocarditis. A retrospective analysis was conducted between March 2019 and June 2020 in West China Hospital, and 18 patients with immune-related myocarditis were studied. Patients were classified as having mild (n = 12) or severe myocarditis (n = 6), according to the clinical manifestations and hemodynamic complications. Factors associated with severe myocarditis were identified by comparing covariates derived from medical records in various groups. In this retrospective analysis, the median age of the 18 patients was 60 years old. Most myocarditis cases occur early and approximately after the first or second ICI infusion. The severity of myocarditis may be correlated with lactate dehydrogenase (LDH) (p = 0.04) and troponin levels (p = 0.0057). The relationship between troponin and myocarditis was further confirmed in another cohort, which included 30 patients. In addition, patients are more likely to develop multi-irAEs, and myositis was the most common second irAE. Those who experience multi-irAEs usually had significantly higher LDH (p = 0.02) and myoglobin levels (p = 0.02) than those who did not experience them. All patients were treated with steroids timely, and the mortality rate was 5.6% in our study. In this study, we explored risk factors for severe myocarditis and emphasized the importance of a multidisciplinary team in assisting diagnosis and treatment options. It is critical to initiate corticosteroid therapy, regardless of the severity of the myocarditis.

Perioperative Outcomes of Open Surgical Repair for Juxtarenal and Infrarenal Aortoiliac Occlusive Disease in Patients with Poor Cardiac Status

Purpose: The most common cause of mortality in patients undergoing open surgical repair for aortoiliac disease is from cardiac complications. As there is a paucity of literature about the surgical outcomes in patients with compromised cardiac status, this study was undertaken to study the perioperative outcomes of open surgical repair for aortoiliac occlusive disease in patients with poor cardiac status. Methodology: A retrospective study was carried out from January 2017 to December 2020. Patients with aortoiliac occlusive disease based on computed tomography angiographic findings with poor cardiac reserve (ejection fraction ≤40% on echocardiography) were included in the study. The primary endpoints were perioperative complications which included intraoperative hemodynamic complications and early postoperative complications. Results: During 2017–2020, a total of 44 patients with aortoiliac occlusive disease (AIOD) with erectile function ≤40% underwent open surgical repair. Of these, 25 (57%) patients had infrarenal aortoiliac involvement and 19 (43%) had juxtarenal aortoiliac involvement. In our study of open surgical repair for juxtarenal and infrarenal aortoiliac occlusive disease in patients with poor cardiac status, intraoperative hemodynamic complications were noted in 26 (59%) patients, early postoperative complications were noted in 11 (25%), and mortality rate was 4.5%. Conclusion: Even though AIOD patients with poor cardiac status are at high operative risk than patients with normal cardiac status, open surgical repair with in-line bypass can be considered as a suitable option in these patients, especially where facilities for appropriate intraoperative monitoring and management are available.

Surgical Approaches to Pediatric Moyamoya Disease

Moyamoya disease(MMD)is a chronic, occlusive cerebrovascular disease with unknown etiology, characterized by progressive stenosis of the internal carotid artery terminus and abnormal vascular network formation at the base of the brain. MMD has bimodal age distribution, with peaks in children and young adults, and surgical revascularization is a reasonable management choice for pediatric and adult patients with ischemic MMD. The superficial temporal artery-middle cerebral artery anastomosis with indirect pial synangiosis(combined revascularization)is a preferred surgical procedure for adult and pediatric MMD patients, providing early cerebral hemodynamic improvement and long-term favorable outcomes. Pediatric patients with MMD can present intrinsic postoperative hemodynamic complications, such as watershed shift ischemia and transient global hypoperfusion, even after successful revascularization. Therefore, perioperative management based on the early hemodynamic study is critical to avoid surgical complications, including perioperative cerebral infarction.

Blunted cardiovascular effects of beta-blockers in patients with cirrhosis: Relation to severity?

AimsPatients with cirrhosis and portal hypertension are at high risk of developing complications such as variceal hemorrhage, ascites, and cardiac dysfunction, the latter of which is known as cirrhotic cardiomyopathy. Since non-selective beta-blockers (NSBB) may aggravate hemodynamic complications we investigated the effect of real-time propranolol infusion on cardiac function in patients with varying degrees of cirrhosis.MethodsThirty-eight patients with Child-Pugh A (n = 17), B (n = 17) and C (n = 4) underwent liver vein catheterization and cardiac magnetic resonance imaging. We assessed the effect of real-time propranolol infusion on the hepatic venous pressure gradient, cardiac index, stroke volume, ejection fraction, heart rate, and contractility.ResultsNineteen patients were classified as responders to beta-blocker therapy. In pooling Child-Pugh B and C patients, the reduction in cardiac index by beta-blockade was weaker than in Child-Pugh A patients (-8.5% vs. -20.5%, p = 0.043). The effect of NSBB on portal pressure was inversely correlated to changes in the left atrium where the left atrial volume changed by 4 mL±18 in responders compared to 15 mL±11 in non-responders (p = 0.03). Finally, the baseline ejection fraction correlated inversely with the reduction in portal pressure (r = -0.39, p = 0.02).ConclusionWe found the effect of beta-blockade on cardiac index in patients with advanced cirrhosis to be less potent than in patients with early cirrhosis, indicating that underlying cirrhotic cardiomyopathy increases, and the cardiac compensatory reserve becomes more compromised, with disease progression. The differential effects of beta-blockade in the left atrium may be used to predict the effect of beta-blockers on portal pressure, but further studies are needed to investigate this possibility.

The Efficacy and Complications of Deep Sedation in Pediatric Dental Patients: A Retrospective Cohort Study.

Background Dental anxiety in children is a common problem. Currently, many of dental procedures are performed under sedation. Different methods of sedation have been employed for this purpose. Compared to adults, children usually need a deeper sedation level. The aim of this retrospective study is to assess the efficacy and complication of deep sedation in pediatric dental patients. Method This study was performed on 250 ASA (American Society of Anesthesiologists) I, II children undergoing deep sedation during the dental procedures. After the administration of oral midazolam as premedication, the monitoring process started. The patients that received the sedation dose of propofol and oxygen through nasal cannula during the procedure were carefully monitored for the purpose of evaluating hemodynamic and respiratory complications. The mean procedure and recovery time, postoperative nausea and vomiting (PONV), and success rate were further studied. Result The average age of the patients was 3.7. 32% of the patients were females, and 68% of them were males. Laryngospasm that occurred in 5 cases was resolved immediately by using positive pressure ventilation. Mild hypoxia was observed in 17 cases which were immediately managed by a bag-valve-mask ventilation. No cases of hemodynamic complications and PONV were reported. The mean length of the procedure was 57 minutes, and the mean length of recovery was 16 minutes. The success rate of this method was estimated to be 99.6%. Conclusion Deep sedation with propofol is a suitable technique with a high success rate for dental procedures in children. It was also concluded that in pediatric dental procedures, the presence of a skilled anesthetist and the implementation of a close monitoring process are required.

Abstract 2581: IL-15 expressing MSCs for NK cell-mediatedcancer immunotherapy

Abstract Mesenchymal stem cells (MSCs) offer the possibility of achieving highly selective, tumor-targeted drug delivery because of their ability to home to malignant tissues. IL-15 is currently in clinical trial either alone or as an adjuvant for certain types of metastatic solid tumors. Systemic administration of IL-15 is associated with severe toxicities including hemodynamic imbalance, lymphopenia, and other cytokine-related complications. We hypothesized that tumor targeted delivery of IL-15 using MSCs can improve efficacy and reduce toxicity associated with IL-15. MSCs were engineered to express IL-15 using a lentiviral system (pLenti-C-Myc-DDK-P2A-Puro vector; Invitrogen) tagged with C-terminal MYC/DDK tag for easy detection and purification with anti-DDK antibody. We achieved stable transfection of IL-15 in MSCs (5.7 ng/106 MSCs in 24 hrs; ELISA). Bioactivity of secreted IL-15 was confirmed by splenocyte proliferation assay. We then tested the anticancer activity of IL-15 secreting MSCs in a syngeneic LL/2 lung cancer model. Animals treated with IL-15 secreting MSCs demonstrated significant inhibition of tumor growth and prolonged survival compared to mice treated with IL-15 alone. It was further demonstrated that IL-15 expressing MSCs enhance tumor infiltration of various immune cells. These studies demonstrate the potential of developing novel MSC-based immunotherapy constructs with reduced toxicity. Citation Format: Drishti Sehgal, No'ad Shanas, Swayam Prabha. IL-15 expressing MSCs for NK cell-mediatedcancer immunotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2581.

Cardiac and Hemodynamic Manifestations of Hereditary Hemorrhagic Telangiectasia.

The autosomal dominant trait hereditary hemorrhagic telangiectasia (HHT) causes multiorgan dysplastic lesions of the vasculature that can activate multiple physiological cascades leading to a broad array of cardiovascular diseases. Up to 78% of patients with HHT develop hepatic arteriovenous malformations (AVMs), which cause a hyperdynamic circulatory state secondary to hepatic/portal shunting. This condition can eventually progress to high-output cardiac failure (HOCF) with continued peripheral tissue hypoxemia. Treatment for HOCF is often limited to supportive measures (diuretics and treatment of anemia); however, recent studies using systemic bevacizumab have shown promise by substantially reducing the cardiac index. In the context of liver AVMs and high cardiac output, the pulmonary vasculature can also experience high flow. Without adequate dilation of pulmonary vessels, post-capillary pulmonary hypertension can develop. Another form of pulmonary hypertension observed in HHT, pulmonary arterial hypertension, is caused by HHT-related mutations in ENG and ACVRL1 causing congestive arteriopathy. Post-capillary pathogenesis is addressed by reducing the high-output state, whereas the pre-capillary state is treated with supportive mechanisms (diuretics, oxygen) and agents targeting pulmonary vasoreactivity: endothelin-1 receptor antagonists and phosphodiesterase-5 inhibitors. If either form of pulmonary hypertension is left untreated or proves refractory and progresses, the common hemodynamic complication is right heart failure. Targeted right heart therapies involve similar strategies to those of pulmonary arterial hypertension, with several experimental approaches under study. In this review, we describe in detail the mechanisms of pathogenesis, diagnosis, and treatment of the hemodynamic complications and associated cardiovascular diseases that may arise in patients with HHT.