Duration Of Ischemia Research Articles

Anti-apoptotic treatment of warm ischemic male rat livers in machine perfusion improves symptoms of ischemia-reperfusion injury

BackgroundLiver donation after cardiac death (DCD) makes up a small percentage of the organs used in transplantation and poses a higher risk of graft loss compared to donation after brain death (DBD); this is a result of ischemia reperfusion for which the exact injury mechanisms are currently not fully understood. However, reperfusion injury has been shown to lead to necrosis as well as apoptosis through oxidative stress and mitochondrial dysfunction. In this work, we propose that use of the pro-survival, anti-apoptotic CEPT cocktail in post-ischemia normothermic machine perfusion (NMP) may improve recovery in rat livers subjected to extended durations of warm ischemia. Materials and MethodsLivers procured from male Lewis rats were subjected to 90 min of warm ischemia, followed by 6 h of NMP where they were treated either with the survival-enhancing anti-apoptotic cocktail (CEPT), the vehicle (DMSO) or the base media with no additives. ResultsThe CEPT-treated group exhibited lower expression of hepatic injury biomarkers, and improvement in a range of hepatocellular symptoms associated with the hepatic parenchyma, biliary epithelium and the sinusoidal endothelium, including recovery of bile secretion and lowered vascular resistance. ConclusionsThis study's findings suggest apoptosis plays a more significant role in ischemia-reperfusion injury than previously understood, and provide useful insight for further investigation of the specific underlying mechanisms and development of novel treatment methods.

Real-time monitoring of mitochondrial oxygenation during machine perfusion using resonance Raman spectroscopy predicts organ function

Organ transplantation is a life-saving procedure affecting over 100,000 people on the transplant waitlist. Ischemia reperfusion injury (IRI) is a major challenge in the field as it can cause post-transplantation complications and limit the use of organs from extended criteria donors. Machine perfusion technology has the potential to mitigate IRI; however, it currently fails to achieve its full potential due to a lack of highly sensitive and specific assays to assess organ quality during perfusion. We developed a real-time and non-invasive method of assessing organs during perfusion based on mitochondrial function and injury using resonance Raman spectroscopy. It uses a 441 nm laser and a high-resolution spectrometer to quantify the oxidation state of mitochondrial cytochromes during perfusion. This index of mitochondrial oxidation, or 3RMR, was used to understand differences in mitochondrial recovery of cold ischemic rodent livers during machine perfusion at normothermic temperatures with an acellular versus cellular perfusate. Measurement of the mitochondrial oxidation revealed that there was no difference in 3RMR of fresh livers as a function of normothermic perfusion when comparing acellular versus cellular-based perfusates. However, following 24 h of static cold storage, 3RMR returned to baseline faster with a cellular-based perfusate, yet 3RMR progressively increased during perfusion, indicating injury may develop over time. Thus, this study emphasizes the need for further refinement of a reoxygenation strategy during normothermic machine perfusion that considers cold ischemia durations, gradual recovery/rewarming, and risk of hemolysis.

Coronary angiographic scoring systems to predict prognosis of ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide, contributing to nearly 1.8 million deaths annually. Quantifying the severity of CAD is essential for risk stratification and managing CAD patients. The degree of CAD can affect a patient's chances of receiving medical care or going straight for revascularization. Revascularization may be more beneficial for patients with more severe CAD, but they also have a worse prognosis. There is a correlation between the severity of CAD and a higher risk of complications during revascularization treatment. Clinical outcomes after acute ST-segment elevation myocardial infarction (STEMI) can be predicted by the final infarct size, determined by the complex interplay of several factors, including the duration of myocardial ischemia, the presence of collateral blood supply, reperfusion injury, and the jeopardized left ventricular myocardium. Therapies aimed at restoring myocardial perfusion and/or limiting damage, either mechanically or pharmacologically, can be assessed by measuring the absolute final infarct size. Coronary angiography is still the preferred method for diagnosing and treating CAD; therefore, various angiographic scoring systems have been suggested to quantify the severity of CAD. However, the existing angiographic scores vary in their ease of use, applicability, and level of predictive validity, thus warranting further studies in the future.

Determination of Maximum Tolerable Cold Ischemia Time in a Mouse Model of Cervical Heterotopic Uterus Transplantation.

Uterus transplantation (UTx) is an emerging treatment for uterine factor infertility. Determining the maximum tolerable cold ischemia time is crucial for successful UTx. However, the limit for cold ischemia in the uterus is unclear. This study aimed to examine cold ischemia's effects on mouse uteri and identify the maximum cold ischemia duration that uteri can endure. We systematically assessed the tolerance of mouse uteri to extended cold ischemia, 24 h, 36 h, and 48 h, using the cervical heterotopic UTx model. Multiple indicators were used to evaluate ischemia-reperfusion injury, including reperfusion duration, macroscopic examination, oxidative stress, inflammation, and histopathology. The function of transplants was evaluated through estrous cycle monitoring and embryo transfer. Mouse uteri subjected to 48 h of cold ischemia exhibited significant delays and insufficiencies in reperfusion, substantial tissue necrosis, and loss of the estrous cycle. Conversely, uteri that underwent cold ischemia within 36 h showed long survival, regular estrous cycles, and fertility. Our study demonstrated that mouse uteri can endure at least 36 h of cold ischemia, extending the known limits for cold ischemia and providing a pivotal reference for research on the prevention and treatment of cold ischemic injury in UTx.

Ischemic preconditioning affects phosphosites and accentuates myocardial stunning while reducing infarction size in rats.

Ischemic preconditioning (IPC), i.e., brief periods of ischemia, protect the heart from subsequent prolonged ischemic injury, and reduces infarction size. Myocardial stunning refers to transient loss of contractility in the heart after myocardial ischemia that recovers without permanent damage. The relationship between IPC and myocardial stunning remains incompletely understood. This study aimed primarily to examine the effects of IPC on the relationship between ischemia duration, stunning, and infarct size in an ischemia-reperfusion injury model. Secondarily, this study aimed to examine to which extent the phosphoproteomic changes induced by IPC relate to myocardial contractile function. Rats were subjected to different durations of left anterior descending artery (LAD) occlusion, with or without preceding IPC. Echocardiograms were acquired to assess cardiac contraction in the affected myocardial segment. Infarction size was evaluated using triphenyl tetrazolium chloride staining. Phosphoproteomic analysis was performed in heart tissue from preconditioned and non-preconditioned animals. In contrast to rats without IPC, reversible akinesia was observed in a majority of the rats that were subjected to IPC and subsequently exposed to ischemia of 13.5 or 15 min of ischemia. Phosphoproteomic analysis revealed significant differential regulation of 786 phosphopeptides between IPC and non-IPC groups, with significant associations with the sarcomere, Z-disc, and actin binding. IPC induces changes in phosphosites of proteins involved in myocardial contraction; and both accentuates post-ischemic myocardial stunning and reduces infarct size.

The Role of Microvascular Obstruction and Intra-Myocardial Hemorrhage in Reperfusion Cardiac Injury. Analysis of Clinical Data.

Microvascular obstruction (MVO) of coronary arteries promotes an increase in mortality and major adverse cardiac events in patients with acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI). Intramyocardial hemorrhage (IMH) is observed in 41-50% of patients with ST-segment elevation myocardial infarction and PCI. The occurrence of IMH is accompanied by inflammation. There is evidence that microthrombi are not involved in the development of MVO. The appearance of MVO is associated with infarct size, the duration of ischemia of the heart, and myocardial edema. However, there is no conclusive evidence that myocardial edema plays an important role in the development of MVO. There is evidence that platelets, inflammation, overload, neuropeptide Y, and endothelin-1 could be involved in the pathogenesis of MVO. The role of endothelial cell damage in MVO formation remains unclear in patients with AMI and PCI. It is unclear whether nitric oxide production is reduced in patients with MVO. Only indirect evidence on the involvement of inflammation in the development of MVO has been obtained. The role of reactive oxygen species (ROS) in the pathogenesis of MVO is not studied. The role of necroptosis and pyroptosis in the pathogenesis of MVO in patients with AMI and PCI is also not studied. The significance of the balance of thromboxane A2, vasopressin, angiotensin II, and prostacyclin in the formation of MVO is currently unknown. Conclusive evidence regarding the role of coronary artery spasm in the development of MVhasn't been established. Correlation analysis of the neuropeptide Y, endothelin-1 levels and the MVO size in patients with AMI and PCI has not previously been performed. It is unclear whether epinephrine aggravates reperfusion necrosis of cardiomyocytes. Dual antiplatelet therapy improves the efficacy of PCI in prevention of MVO. It is unknown whether epinephrine or L-type channel blockers result in the long-term improvement of coronary blood flow in patients with MVO.

Heterotopic Auxiliary Whole Liver Rat Transplant Model Utilizing a Hepaticoureterostomy for Allograft Rejection Studies.

Small animal transplant models are indispensable for organ tolerance studies investigating feasible therapeutic interventions in preclinical studies. Rat liver transplantation (LTx) protocols typically use an orthotopic model where the recipients' native liver is removed and replaced with a donor liver. This technically demanding surgical procedure requires advanced micro-surgical skills and is further complicated by lengthy anhepatic and lower body ischemia times. This prompted the development of a less complicated heterotopic method that can be performed faster with no anhepatic or lower body ischemia time, reducing post-surgery stress for the recipient animal. This heterotopic LTx protocol includes two main steps: excising the liver from the donor rat and transplanting the whole liver into the recipient rat. During the excision of the donor liver, the surgeon ligates the supra-hepatic vena cava (SHVC) and hepatic artery (HA). On the recipient side, the surgeon removes the left kidney and positions the donor liver with the portal vein (PV), infra-hepatic vena cava (IHVC), and bile duct facing the renal vessels. Further, the surgeon anastomoses the recipient's renal vein end to end with the IHVC of the liver and arterializes the PV with the renal artery using a stent. A hepaticoureterostomy is utilized for biliary drainage by anastomosing the bile duct to the recipient's ureter, permitting the discharge of bile via the bladder. The average duration of the transplantation was 130 min, cold ischemia duration was around 35 min, and warm ischemia duration was less than 25 min. Hematoxylin and eosin histology of the auxiliary liver from syngeneic transplants showed normal hepatocyte structure with no significant parenchymal alterations 30 days post-transplant. In contrast, 8-day post-transplant allogeneic graft specimens demonstrated extensive lymphocytic infiltration with a Banff Schema rejection activity index score of 9. Therefore, this LTx method facilitates a low morbidity rejection model alternative to orthotopic LTx.

(128) Penile Replantation in Patient with Klingsor Syndrome; Case Report and Review of Literature

Abstract Introduction Penile amputation has multiple etiologies including self-mutilation, work-related accidents, circumcision, assault motivated by jealousy, rage and feelings of betrayal and animal attacks. By far self –mutilation due to underlying psychiatric disorders (Klingsor Syndrome) are the commonest cause. Re-implantation is the gold standard for management, however it may always not be possible to achieve because of significant local ischemia, tissue damage and prolonged duration post trauma. Objective We are reporting our experience with one case of Klingsor Syndrome and its stepwise management. Methods A 31 years old male Schizophrenic patient self-mutilated his penile shaft due to fixed illusion (get rid of devil in his penis). He also attempted to remove his entire scrotum. His father brought his son with the amputated penile part put in ice. Immediate application of wet saline towel to penile stump and putting of amputated penile part into cold iced saline. Anti-tetanic serum was given together with i.v. antibiotics. Urology team, Plastic microsurgery team together with Psychiatry treating consultant all were emergently called at once. Amputated penile shaft was prepared by the microsurgeon to identify the dorsal artery, vein and nerves and marked by micro-bulldogs. Urology team started by fixation of s.p. cath and preparing, cleaning penile stump. End-to end anastomosis of the urethra was done. Next, the corporal bodies, were reattached using interrupted sutures. Dorsal vein and artery were re-anastomosed microsurgically Results Few days post-operatively skin necrosis started inspite of positive needle brick to the glans indicating healthy underlying glans. Second stage debridement of necrotic skin with later skin grafting resulted in cosmetically and functionally excellent penis regarding erectile and voiding functions Conclusions Penile amputation is a rare surgical emergency mostly found in the literature as isolated case reports. Klingsor syndrome is well known etiology for this type of penile injury and warrants psychiatric control. A multidisciplinary approach involving a urologist, micro-vascular surgeons as well as a psychiatrist ensures good outcome. Microvascular re-implantation remains the treatment of choice with the highest probability of adequate cosmetic as well as functional outcomes Disclosure No.

Prevalence and risk factors analysis of early postoperative arrhythmia after congenital heart surgery in pediatric patients.

Arrhythmia is one of the most common complications after cardiac surgery. The objectives of this study were to determine the prevalence and analyze the risk factors of postoperative arrhythmia in pediatric patients after cardiac surgery for congenital heart defects (CHD) at a single center in Bali, Indonesia over 2 years period. A cross-sectional study, among 120 pediatric patients with CHD who underwent cardiac surgery, 92 patients met inclusion criteria in this study. The data were taken from medical records included demographic data, anthropometry, electrocardiography, surgical procedures, perioperative parameters, electrolyte levels, and management of postoperative arrhythmias. Among 92 patients, 14 (15.2%) developed postoperative arrhythmias. Complete heart block (CHB) the most common arrhythmia, observed in five patients (35.7%), followed by supraventricular tachycardia three patients (21.4%). There were statistically significant differences between arrhythmia and nonarrhythmia groups for cardiopulmonary bypass (CPB) duration (171.23 vs. 108.01 min), aortic cross-clamp duration (115.58 vs. 73.59 min), ischemia duration (106.33 vs. 65.43 min), and potassium level (3.33 vs. 3.88 mmol/L) with p < .05. Based on multivariate linear regression analysis, CPB time and potassium level were found to be independent risk factor. Early postoperative arrhythmia observed 15.2% in this study, dominated by CHB. CPB duration, aortic cross-clamping, ischemia time, and potassium level were statistically significantly different between arrhythmia and nonarrhythmia groups.

Development and external validation of a prediction model for digit replantation failure after traumatic amputations based on a prospective multicenter cohort.

Failure of digit replantation after traumatic amputation is difficult to predict. The authors aimed to develop a prognostic model to better identify factors that better predict replantation failure following traumatic digit amputation. In this multicenter prospective cohort, the authors identified patients who had received digit replantation between 1 January 2015 and 1 January 2019. Univariable and multivariable analyses were performed successively to identify independently predictive factors for failure of replanted digit. To reduce overfitting, the Bayesian information criterion was used to reduce variables in the original model. Nomograms were created with the reduced model after model selection. This model was then internally validated with bootstrap resampling and further externally validated in validation cohort. Digit replantation was failed in 101 of 1062 (9.5%) digits and 146 of 1156 digits (12.6%) in the training and validation cohorts, respectively. The authors found that six independent prognostic variables were associated with digit replantation failure: age, mechanism of injury, ischemia duration, smoking status, amputation pattern (complete or incomplete), and surgeon's experience. The prediction model achieved good discrimination, with concordance indexes of 0.81 (95% CI: 0.76-0.85) and 0.70 (95% CI: 0.65-0.74) in predicting digit failure in the training and validation cohorts, respectively. Calibration curves were well-fitted for both training and validation cohorts. The proposed prediction model effectively predicted the failure rate of digit replantation for individual digits of all patients. It could assist in selecting the most suitable surgical plan for the patient.

Impact of minimally invasive lung transplantation on early outcomes and analgesia use: A matched cohort study

IntroductionMinimally invasive (MI) approaches to lung transplantation (LTx) offer the prospect of faster recovery compared to traditional incisions, however, little data exist describing the impact of surgical technique on early outcomes and analgesia use. MethodsA prospectively maintained institutional registry identified 170 patients who underwent LTx between 01/2017 and 06/2022. Post-COVID acute respiratory distress syndrome, repeat, and multiorgan transplants were excluded (n=27) leaving 37 MILTx and 106 traditional LTx patients. Propensity score matching by age, sex, body mass index, diagnosis, lung allocation score, double vs. single lung, hypertension, diabetes, and hospitalization status created 37 pairs. ResultsBefore matching, MILTx patients were more often male (70% vs 43%) and more likely to receive grafts from younger (31 vs 42 years), circulatory death donors (19% vs 6%) compared with traditional LTx patients (all p<0.05). After matching, there were no differences in graft warm ischemia or operative duration (both p>0.05). Postoperatively, MILTx experienced shorter ICU (4.3 [IQR 3.1-5.5] vs 8.2 [IQR 3.7-10.8] days) and hospital lengths of stay (LOS) (13 [IQR 11-15] vs 17 [IQR 12-25] days) (both p<0.05). Among patients surviving to discharge, MILTx patients required fewer opioid prescriptions at discharge (38% vs 66%, p=0.008) and had improved pulmonary function at 3-months (FEV1 82 [IQR 72-102] vs 77 [IQR 52-88] % predicted; FVC 78 [IQR 65-92] vs 70 [IQR 62-80] % predicted] (both p<0.05). ConclusionMinimally invasive LTx techniques demonstrate potential advantages over traditional approaches, including reduced ICU and hospital LOS, lower opioid use on discharge, and improved early pulmonary function. Word count: 250/250

Abstract TP283: Histone Lactylation and Neuronal Autophagy: Insights Into the Penumbra-Core Transition and Potential Biomarker in Ischemic Stroke

Objectives: The dynamic evolution of ischemic penumbra to core has implications for stroke outcomes. Optimizing outcomes remains challenging despite advanced recanalization. We examined the intricate molecular interplay between lactylation and RNA m6A modifications, to unravel the H3K18la-Tfeb m6A-autophagy-neuron-injury pathway, understanding mechanisms underlying penumbra-core transition and investigating potential biomarkers indicative of injury severity. Method: Adult SD rats underwent 2, 6, and 24 h of middle cerebral artery occlusion (MCAO) and subsequent reperfusion. The penumbra-core transition-induced brain damage was quantified by infarct volume post 48 h of reperfusion. Employing CUT&amp;Tag and ChIP, H3K18la enrichment in promoter regions was identified. The mRNA and protein levels of lactylation, methyltransferase like 3 (METTL3), transcription factor EB (TFEB) and autophagy-related molecules (LC3, P62, LAMP1) were examined. METTL3 and TFEB localization was determined using immunofluorescence, while serum H3K18la levels were analyzed. Result: Ischemia duration was directly linked to elevated neuronal lactylation, particularly H3K18la, and autophagy. Increased H3K18la enrichment was observed in Mettl3 promoter regions, promoting Mettl3 gene transcription. This leads to METTL3-induced tfeb m6A modifications, enhancing TFEB expression and its nuclear translocation. Administering C646 (lactylation writer inhibitor) suppressed METTL3, TFEB, LC3, P62, and LAMP1 expressions, which mitigated brain injuries, underlining lactylation's key role in excessive neuronal autophagy initiation. All molecular alterations were strongly tied to the penumbra-core transition. Markedly, ischemic rats presented elevated serum H3K18la levels, which correlated with dynamic neurological damage. Conclusion: Our study elucidates molecular dynamics driving the penumbra-core transition in ischemic stroke. H3K18la initiatives METTL3-associated tfeb m6A modifications, activating the autophagy-lysosome pathway, thus enhancing autophagy and neuronal death. Serum H3K18la variations emerge as potential indicators of neuronal damage severity, suggesting effective biomarkers for assessing post-stroke prognosis.

Evidence-Based Complementary Benefit of the Vascular Surgeon Among the Team of Renal Transplantation; a Single Center Experience

In a kidney transplant tertiary referral center; we compared 3 operating team configurations of different surgical specialties to highlight the effect of the operating surgeon's specialty on various operative details and procedural outcome. A total of 50 cases of living donor transplantations were divided into 3 main groups according to the operating surgeons' specialty, the first group (A) includes 12 patients exclusively operated on by urologists with advanced training in transplantation, the second group (B) includes 35 patients operated by combined surgical specialties; a urologist and a vascular surgeon both with advanced transplantation training, and a third group (C) includes 3 cases where the transplant operation commenced with operating urologists as in group (A) but required intraoperative urgent notification of a vascular surgeon to manage unexpected intraoperative technical difficulties or major complications. Cases were studied according to operative details, anastomosis techniques, ischemia times, total procedure time, recovery of urinary output, intensive care unit (ICU) stay, postoperative surgical complications and serum creatinine level for up to 3years of follow-up. Study of operative details revealed that total duration of graft ischemia was significantly shorter in group (B) and significantly longer in group (C) (P value 0.001), Total procedural duration also varied significantly between the 3 groups, group (B) being the shortest while group (C) was the longest (P value less than 0.001). Technically; group (A) used only end to end arterial anastomosis as a standard technique, while group (B) used both end-to-end and end-to-side anastomoses as required per each case. End to side anastomosis in group (B) yielded better immediate graft response in the form of change in color, texture, earlier and more profuse postoperative urine volumes (P value 0.025). Furthermore, anastomosis to common and external iliac arteries (group B) yielded earlier and higher urine volumes than the internal iliac artery (P values 0.024 and 0.031 respectively). Group (B) recorded significantly less postoperative perigraft hematomas and lymphoceles compared to the other 2 groups. Equal rates of urine leaks, ICU stay, creatinine levels, patient and grafts survival rates among groups (A) and (B), while postoperative recovery and ICU stay duration were more lengthy in the complicated group (C). A vascular surgeon operating in a transplantation team would deal comfortably and efficiently with various vascular related challenges and complications, thus avoiding unnecessary time waste, complications and costs.

Prevalence of "Ghost Infarct Core" after Endovascular Thrombectomy.

Baseline CTP sometimes overestimates the size of the infarct core ("ghost core" phenomenon). We investigated how often CTP overestimates infarct core compared with 24-hour imaging, and aimed to characterize the patient subgroup in whom a ghost core is most likely to occur. Data are from the randomized controlled ESCAPE-NA1 trial, in which patients with acute ischemic stroke undergoing endovascular treatment were randomized to intravenous nerinetide or placebo. Patients with available baseline CTP and 24-hour follow-up imaging were included in the analysis. Ghost infarct core was defined as CTP core volume minus 24-hour infarct volume > 10 mL). Clinical characteristics of patients with versus without ghost core were compared. Associations of ghost core and clinical characteristics were assessed by using multivariable logistic regression. A total of 421 of 1105 patients (38.1%) were included in the analysis. Forty-seven (11.2%) had a ghost core > 10 mL, with a median ghost infarct volume of 13.4 mL (interquartile range 7.6-26.8). Young patient age, complete recanalization, short last known well to CT times, and possibly male sex were associated with ghost infarct core. CTP ghost core occurred in ∼1 of 10 patients, indicating that CTP frequently overestimates the infarct core size at baseline, particularly in young patients with complete recanalization and short ischemia duration.

SimLivA–Modeling ischemia‐reperfusion injury in the liver: A first step towards a clinical decision support tool

SummaryThe SIMulation supported LIVer Assessment for donor organs (SimLivA) project aims to develop a mathematical model to accurately simulate the influence of mechanical alterations in marginal liver grafts (specifically steatotic ones) and cold ischemia on early ischemia‐reperfusion injury (IRI) during liver transplantation. Our project tackles significant research challenges, including the co‐development of computational methodologies, experimental studies, clinical processes, and technical workflows. We aim to refine a continuum‐biomechanical model for enhanced IRI prediction, collect pivotal experimental and clinical data, and assess the clinical applicability of our model. Our efforts involve augmenting and tailoring a coupled continuum‐biomechanical, multiphase, and multi‐scale partial differential equation‐ordinary differential equation (PDE‐ODE) model of the liver lobule, allowing us to numerically simulate IRI depending on the degree of steatosis and the duration of ischemia. The envisaged model will intertwine the structure, perfusion, and function of the liver, serving as a crucial aid in clinical decision‐making processes. We view this as the initial step towards an in‐silico clinical decision support tool aimed at enhancing the outcomes of liver transplantation. In this paper, we provide an overview of the SimLivA project and our preliminary findings, which include: a cellular model that delineates critical processes in the context of IRI during transplantation; and the integration of this model into a multi‐scale PDE‐ODE model using a homogenized, multi‐scale, multi‐component approach within the Theory of Porous Media (TPM) framework. The model has successfully simulated the interconnected relationship between structure, perfusion, and function—all of which are integral to IRI. Initial results show simulations at the cellular scale that describe critical processes related to IRI during transplantation. After integrating this model into a multiscale PDE‐ODE model, first simulations were performed on the spatial distribution of key functions during warm and cold ischaemia. In addition, we were able to study the effect of tissue perfusion and temperature, two critical parameters in the context of liver transplantation and IRI.

Appropriate timing of veno-arterial extracorporeal membrane oxygenation initiation after cardiac surgery

BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be initiated during cardiac surgery or later in ICU according to the hemodynamic profile and organ perfusion. Our aim was to study the appropriate timing of post-cardiotomy ECMO (PC-ECMO) initiation. We retrospectively analyzed 152 adult patients supported with PC-ECMO in our cardiac center between 2016 and 2022. The patients were divided into two groups: the intra-operative ECMO and the postoperative ECMO groups. The primary outcome was all-and-on-ECMO hospital mortality. The secondary outcomes included ECMO duration, new need for dialysis, cerebrovascular stroke, and length of ICU stay.ResultsOur cohort analysis revealed that 81(53.3%) patients were intra-operatively supported with VA-ECMO while 71(46.7%) patients were postoperatively supported in ICU. The postoperative ECMO group had significantly lesser SAVE score (p = 0.001), higher SAVE risk classes (p < 0.001), and higher SOFA score (p = 0.008) compared to the intra-operative ECMO group. The postoperative ECMO group had significantly more frequent hospital mortality (p = 0.003), on-ECMO mortality (p = 0.006), cerebrovascular stroke (p = 0.034), acute renal failure requiring dialysis (p < 0.001), and lesser lactate clearance at 12 h (p = 0.016) and at 24 h (p = 0.023) compared to the intra-operative group. There were statistically insignificant differences between the two groups regarding post-ECMO hospital mortality, cerebral bleeding, limb ischemia, ECMO, and ICU duration. Postponed postoperative ECMO insertion was associated with an increased risk of death (HR 1.628, 95%CI 1.102–2.403, p =0.014) with cox-proportional hazard regression. Logistic multivariable regression showed that atrial fibrillation (OR 6.2, 95% CI 2.71–61.84, p = 0.002), initial SOFA score (OR 1.46, 95% CI 1.041–3.83, p = 0.001), and postoperative ECMO insertion (OR 1.93, 95% CI 1.04–8.73, p = 0.031) were the predictors of hospital mortality.ConclusionsPostponed ECMO insertion in critically sick patients was associated with increased mortality after cardiac surgery. Early intra-operative initiation of PC-ECMO may have the potential to improve outcomes after cardiac surgeries.

The progress of assessment methods and treatments of neovascular glaucoma secondary to central retinal vein occlusion.

Neovascular glaucoma is a condition that results from central retinal vein occlusion and often leads to blindness. Accurate evaluation and appropriate treatment are crucial for patients. However, there is currently no uniform and clear standard to differentiate between ischemic and non-ischemic central retinal vein occlusion. Also, the assessment of neovascular glaucoma progression is uncertain. Meanwhile, although pan-retinal photocoagulation is a standard treatment to prevent the onset of neovascular glaucoma, its actual efficacy and the timing of intervention remain highly controversial. It is still challenging to balance the risks of side effects in the visual field against the uncertain effectiveness of the treatment. This paper delves into the pathogenesis of neovascular glaucoma to understand the development of therapeutic approaches. By taking into account various assessment criteria of central retinal vein occlusion and neovascular glaucoma over the years, combining functional tests and morphological tests provides the most accurate and rigorous solution. The age of patients, the extent, location, and duration of retinal ischemia are the primary factors that affect the severity and extent of ischemic central retinal vein occlusion and induce serious complications. From the perspective of prevention and treatment, the ischemic index is closely related to the development of neovascularization. The paper provides essential insights into the mechanism, efficacy, complications, and optimal timing of pan-retinal photocoagulation. Comparing the treatment effects of pan-retinal photocoagulation and intravitreal anti-VEGF injections, we suggest a combination of both treatments to explore effective treatment with fewer side effects in the long term. This article details the debate on the above issues and explores ideas for the clinical diagnosis and preventive treatment of neovascular glaucoma that results from ischemic central retinal vein occlusion.

Evaluation of intestinal necrosis with laser Doppler in experimental mesenteric ischemia model.

Acute mesenteric ischemia (AMI) is responsible for one in a thousand emergency hospital admissions in America and Europe and is associated with high morbidity and mortality rates. Current diagnostic and treatment methods fall short of desired outcomes, often resulting in delayed diagnoses and difficulties in detecting ischemic bowel tissue during treatment. This study evaluates the diagnostic value of commonly used biochemical markers in clinical practice-creatine kinase, C-reactive protein (CRP), and lactate dehydrogenase (LDH)-alongside blood flow measurements using laser Doppler in a rat model of experimental mesenteric ischemia. We also compare these markers with pathological ischemia scoring. Rats were divided into five groups: control, 1 hour, 2 hours, 3 hours, and 4 hours. Mesenteric ischemia was induced for the respective durations in each group. After these periods, we measured blood flow using laser Doppler. We also collected blood samples and intestinal biopsies for biochemical parameter analysis. These values were assessed in relation to intestinal viability using the Chiu ischemia scoring system. Blood flow measurement with laser Doppler correlated with both the duration and severity of bowel ischemia. No significant relationship was found between CRP levels and the duration of ischemia. However, creatine kinase and lactate dehydrogenase (LDH) levels were significantly higher in ischemia lasting into the third and fourth hours. Creatine kinase and lactate dehydrogenase (LDH) levels may be useful biomarkers in patients with suspected acute mesenteric ischemia (AMI). Blood flow measurements using laser Doppler can accurately identify intestinal loops for resection during surgery.

Free Flap Perfusion in Microvascular Head and Neck Reconstruction: Influence of the Number of Ischemia Intervals and Ischemia Duration-A Retrospective Study.

In microvascular head and neck reconstruction, ischemia of the free flap tissue is inevitable during microsurgical anastomosis and may affect microvascular free flap perfusion, which is a prerequisite for flap viability and a parameter commonly used for flap monitoring. The aim of this study was to investigate the influence of the number of ischemia intervals and ischemia duration on flap perfusion. Intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 2 and 8 mm tissue depths, as measured with the O2C tissue oxygen analysis system, were retrospectively analyzed for 330 patients who underwent microvascular head and neck reconstruction between 2011 and 2020. Perfusion values were compared between patients without (control patients) and with a second ischemia interval (early or late) and examined with regard to ischemia duration. Intraoperative and postoperative flap blood flow at 8 mm tissue depth were lower in patients with early second ischemia intervals than in control patients [102.0 arbitrary units (AU) vs 122.0 AU, P = .030; 107.0 AU vs 128.0 AU, P = .023]. Both differences persisted in multivariable analysis. Intraoperative and postoperative flap blood flow at 8 mm tissue depth correlated weakly negatively with ischemia duration in control patients (r = -.145, P = .020; r = -.124, P = .048). Both associations did not persist in multivariable analysis. The observed decrease in microvascular flap blood flow after early second ischemia intervals may reflect ischemia-related vascular flap tissue damage and should be considered as a confounding variable in flap perfusion monitoring.

ORGANIZATION OF TRANSPLANTATION ASSISTANCE THROUGH TRANSPORTATION OF THE RECIPIENT TO THE REGIONAL EXPLANTATION BASE FOR HEART TRANSPLANTATION

Introduction. To date, heart transplantation remains the only effective method of treatment for patients with end-stage chronic heart failure. Due to the short time of ischemia of the donor heart and the lack of an alternative to deliver the organ on time over long distances, the strategy in organizing transplantation was changed. The aim of this study was to analyze the effectiveness of transporting the recipient to the donor to reduce the ischemia time of the donor organ during martial law. Materials and methods. This retrospective study includes all cases of heart transplantation carried out by specialists of the State Institution "Heart Institute of the Ministry of Health of Ukraine" during 2022–2024. Heart transplantations were performed directly in our center and on-site. Outpatient surgery involved heart transplantation in the medical facility where the donor was located or in the nearest hospital. The results. The study included 55 patients who underwent orthotopic heart transplantation, of which 20.0% were women and 80.0% were men. Depending on the place of heart transplantation, all patients were divided into two groups: the first group (32 patients) – heart transplantation in the State Institution "Heart Institute of the Ministry of Health of Ukraine" and the second group (23 patients) – heart transplantation elsewhere. The duration of donor heart ischemia was not significantly different between the study groups (95.4±15.3 min vs. 90.3±10.8 min, p=0.167), although there was a tendency to decrease in the patients of the second group. Hospital survival was 93.8±4.28% among patients of the first group and 91.3±5.87% among patients of the second group (p=0.408). 12-month survival in the study groups was 87.5±5.84% versus 86.9±7.02% (p=0.375). Conclusions. The use of recipient-to-donor transportation not only made it possible to reduce the duration of ischemia of the donor heart, but also presented with a similar level of hospital and 12-month survival, which makes it possible to effectively apply this method in wartime conditions when there is no possibility of helicopter transportation.