Need For Inotropic Support Research Articles

Levosimendan in Patients with Low Cardiac Output Syndrome After Cardiac Surgery: A Substudy of the Multicenter Randomized CHEETAH Trial

ObjectiveTo test the hypothesis that levosimendan administration to patients with low-cardiac-output syndrome after cardiac surgery is associated with improved long-term (5-year follow-up) outcome. DesignSingle-center subanalysis of the multicenter randomized CHEETAH trial. SettingCardiac surgery department of a tertiary hospital. ParticipantsA total of 134 adult patients requiring hemodynamic support for cardiac index <2.5 L/min/m2 after cardiac surgery with cardiopulmonary bypass (CPB). InterventionsPatients were randomized (1:1 ratio) to receive levosimendan (continuous infusion with starting dose of 0.05 μg/kg/min) or placebo, in addition to standard inotropic care. Measurements and Main ResultsThe primary endpoint was long-term mortality (1-5 years) after randomization. Secondary outcomes were the following: hemodynamic parameters, need for inotropic support (VIS), acute kidney injury (AKI), need for renal-replacement therapy, duration of mechanical ventilation, ICU and hospital stay, 30-day mortality. No significant between-group difference in long-term mortality (5-year) was observed (hazard ratio, 1.59; 95% CI, 0.81 to 3.11; P = 0.17). There were no significant differences in secondary outcomes, except for the difference in the mean pulmonary artery pressure at 4-6 hours after randomization, which was lower in the levosimendan group (24 [21.8, 28] mmHg versus placebo 26 [22.2, 33] mmHg, p = 0.019). ConclusionsAmong patients requiring hemodynamic support after cardiac surgery with CPB, perioperative levosimendan infusion does not affect long-term survival (1-5 years) compared with placebo. Levosimendan also had no effect on major clinical outcomes such as AKI, ICU stay, hospital stay, 30-day mortality.

The illness severity scores can predict the need for respiratory and inotropic support in newborns with critical congenital heart malformations

Background and objectives. The illness severity scoring systems have been developed and validated to assess mortality risks based on clinical conditions and aid critical patient decision-making. Dextro-transposition of the great arteries (D-TGA) and coarctation of the aorta (CoA) are critical congenital heart defects that require medical treatment from birth and surgical repair in the neonatal period. The study aimed to compare the values of three scoring systems in predicting the need for respiratory and inotropic support for newborns with D-TGA and CoA. Materials and methods. An observational study was conducted on inborn infants diagnosed with D-TGA and CoA admitted to the newborn intensive care unit (NICU) within 12 hours of birth at a referral unit for congenital heart disease between January 2018 and December 2020. Newborns with D-TGA and CoA who died within the first 24 hours of birth, outborn infants, and those with a late diagnosis were excluded. For each patient, the Clinical Risk Index of Babies (CRIB-II), Score for Neonatal Acute Physiology-II (SNAP-II), and Score for Neonatal Acute Physiology-Perinatal Extension-II (SNAPPE-II) were calculated. Results. A total of 69 newborns were included in the current study, 30 (43.48 %) of whom were infants with D-TGA (D-TGA Group) and 39 (56.52 %) with CoA (CoA group). Newborns who required respiratory support had significantly higher CRIBII scores (3.03 ± 0.63 vs. 1.34 ± 0.19; p = 0.001), SNAP-II scores (26.61 ± 13.96 vs. 12.43 ± 9.98; p = 0.001), and SNAPPE-II scores (33.04 ± 2.91 vs. 14.47 ± 12.35; p = 0.001) compared to those who did not require it. Significantly higher CRIB-II (3.22 ± 0.67 vs. 1.56 ± 0.23; p = 0.003), SNAP-II (22.91 ±14.57 vs. 14.28 ± 1.58; p = 0.003), and SNAPPE-II (28.82 ± 17.95 vs. 16.58 ± 13.85; p = 0.003) scores were also associated with the need for inotropic support. When comparing the predictive efficiency of illness severity scores for detecting the risk of needing respiratory and inotropic support, they are more effective at predicting the need for ventilation and less effective at predicting the need for inotropes. Conclusions. The illness severity scores can effectively predict the need for pre-surgery interventions. Their simplicity makes them suitable for routine use.

Predictors of mortality and severe illness from Escherichia coli sepsis in neonates

Neonatal Escherichia coli (E. coli) sepsis is increasing. There is limited data on the factors contributing to increased mortality and severity of illness in neonatal E. coli sepsis. A retrospective review of neonates (<30 days) admitted to a Level IV NICU in the United States from 2008 to 2022 diagnosed with E. coli bloodstream or cerebrospinal fluid infection was conducted. Primary outcome was defined as mortality from or severe illness during E. coli infection (defined as a need for inotropic support or metabolic acidosis). E. coli neonatal sepsis rate increased from 2008 to 2022 (average of 1.12 per 1000 live births). The primary outcome, which occurred in 57.4% of cases, was independently associated with prematurity, neutropenia, and thrombocytopenia. Ampicillin resistance was not associated with the primary outcome. GA, neutropenia, and thrombocytopenia but not ampicillin resistance, are associated with mortality or severe illness from E. coli sepsis.

Left atrial appendage emptying velocity and left ventricular function as predictors of inotropic support in patients undergoing elective off-pump coronary artery bypass grafting

Abstract Background: Patients undergoing elective off-pump coronary artery bypass grafting (CABG) are at risk of hemodynamic instability, ischemia, arrhythmia, and dysfunction. These events need to be managed by pharmacological supports or relieving of mechanical obstruction (octopus) of the heart to maintain the hemodynamic stability. There is a paucity of data on the effect of left ventricular (LV) dysfunction on left atrial appendage (LAA) emptying velocity. We evaluated the relationship between LV function and LAA emptying velocity and requirement of inotropic support perioperatively. Materials and Methods: In this prospective open-label all-comer study, fifty patients undergoing elective off-pump CABG under general anesthesia, we measured LAA emptying velocity by pulsed wave Doppler and evaluated if it could predict the need for inotropes perioperatively. It is a case series of 50 patients without a comparator arm. We measured pulsed wave Doppler across the mitral valve leaflet and early mitral inflow velocity (Evel) and late mitral inflow velocity, tissue Doppler at the lateral annulus of the mitral valve (e’) and also calculated the ratio of Evel and e’. Need for inotrope in the intraoperative and postoperative period was captured perioperatively. Vasoactive-inotropic score (VIS) was calculated for all the patients. Results: The VIS was significant (P &lt; 0.0001, with odds ratio of 131.6 and confidence interval of 95% (0.9–1). However, there was no significant correlation between ejection fraction (EF) and VIS (P = 0.87). In patients with the need of inotropes, LAA emptying velocity was significantly increased in the postgrafting period as compared to the pregrafting period (75.64 cm/s vs. 57.9 cm/s, P &lt; 0.001). Conclusion: The assessment of LAA emptying velocity value was a useful predictor of the need of inotropic support during off-pump surgery, especially during Obtuse marginal and Ramus grafting. This study paves the need of larger case–control studies to validate the findings.

Multicenter registry of multisystem inflammatory syndrome in children (MIS-C) and Paired comparison with Kawasaki disease

ObjectivesThis study aimed to identify clinical characteristics to differentiate multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease (KD) in Taiwan, an island with a delayed cluster of MIS-C and a high incidence of KD. Additionally, we studied risk factors for developing severe complications in patients with MIS-C. MethodsWe conducted a retrospective, multicenter, cohort, and observational study that linked data on patients with MIS-C between May and December 2022 and patients with KD between 2019 and 2021 from 12 medical centers. Hemodynamic compromise, defined as the need for inotropic support or fluid challenge, was recorded in patients with MIS-C. We also evaluated maximal coronary Z-scores before treatment and one month after disease onset. ResultsA total of 83 patients with MIS-C and 466 patients with KD were recruited. A 1:1 age and gender-matched comparison of 68 MIS-C and KD pairs showed that MIS-C patients had a lower percentage of positive BCG red halos, lower leukocyte/platelet counts, more gastrointestinal symptoms, and a higher risk of hemodynamic compromise. In Taiwan, 38.6% of MIS-C patients experienced hemodynamic compromise, with presence of conjunctivitis and elevated levels of procalcitonin (>1.62 ng/mL) identified as independent risk factors. ConclusionWe identified two independent risk factors associated with hemodynamic compromise in MIS-C patients. The comparison between matched MIS-C and KD patients highlighted significant differences in clinical presentations, like BCG red halos, which may aid in the differential diagnosis of the two disease entities, especially in regions with a high incidence rate of KD.

The role of urine chloride in acute heart failure

In our retrospective study, we aimed to investigate the relationship between urinary chloride (uCl−) and selected clinical and laboratory biomarkers, renal function, and patient outcomes in the acute heart failure (AHF) population. We divided 248 adult patients (≥ 18 years) with AHF into two groups: low uCl− (< 115 mmol/L) and high uCl−. The mean age of the patient group was 70.2 ± 12.6, and 182 patients were male (73.4%). Clinical endpoints included in-hospital mortality, one-year mortality, and a composite endpoint of one-year mortality and rehospitalization for heart failure. Patients were followed up for at least one year. Relevant clinical and baseline biomarker data were collected, including markers concerning inflammation, liver and kidney function, perfusion and congestion, iron status, cardiac remodeling, gasometry, renin and aldosterone. Low uCl− was associated with worse in-hospital outcomes, including higher in-hospital mortality (7.7% vs. 1.4%, p = 0.014), the need for inotropic support (20.19% vs. 2.08%, p ≤ 0.001), worsening of HF during therapy (17.31% vs. 4.86%, p ≤ 0.001), and the need for treatment in an intensive cardiac care unit (33.65% vs. 15.28%, p ≤ 0.001). Low uCl− was a significant predictor of one-year mortality (40.4% vs. 16.7%, p < 0.05) and the composite outcome (HR 2.42, 95% CI 1.43–4.08, p < 0.001). In the multivariable analysis, uCl− was independently associated with the risk of one-year mortality (HR 0.92, 95% CI 0.87–0.98, p < 0.05) and the composite outcome (HR 0.95, 95% CI 0.92–0.99, p < 0.05). Our findings suggest that low uCl− is a marker of more advanced heart failure, activation of the renin–angiotensin–aldosterone system and is related to worse one-year outcomes.

Correlation between Post-operative Serum Lactate Levels and Low Cardiac Output Syndrome in Patients Undergoing Coronary Artery Bypass Grafting Surgery: A Prospective Study in a Tertiary Care Hospital

Objectives: This study aimed to assess the correlation between the development of low cardiac output syndrome (LCOS) and post-operative serum lactate levels in patients undergoing coronary artery bypass grafting (CABG) surgery at a tertiary care hospital. Methodology: A prospective cross-sectional study was conducted from January to June 2021, involving 50 patients undergoing CABG surgery with cardiopulmonary bypass. Arterial samples were obtained immediately post-surgery and at six, twelve, and twenty-four-hour intervals post-operatively. The association between lactate levels and the occurrence of LCOS, need for inotropic support, and intra-aortic balloon pump (IABP) utilization was evaluated. Results: The study comprised predominantly male patients (84%). Patients were categorized into two groups based on lactate levels: Group 1 (&gt; 4 mmol/L) and Group 2 (&lt; 4 mmol/L). In Group 1, 32% of patients developed LCOS, 10% required IABP, and 20% needed inotropic and vasopressor support. Immediately post-CABG, the mean lactate level was 7.5 mmol/L, with 3% requiring IABP and 20% needing double inotropic support. Lactate levels decreased over time, with mean levels at six, twelve, and twenty-four hours post-surgery being 6.3 mmol/L, 3.8 mmol/L, and 3.3 mmol/L, respectively. Correspondingly, the need for IABP and inotropic support decreased. LCOS occurrence within 24 hours post-surgery correlated significantly with elevated lactate levels (p &lt; 0.05). Conclusion: Elevated lactate levels were associated with the development of LCOS within 24 hours post-CABG surgery. Monitoring lactate levels postoperatively may serve as a valuable tool in predicting and managing LCOS in CABG patients.

Predictors of low cardiac output syndrome after combined mitral and tricuspid valve surgery.

Low cardiac output syndrome (LCOS) is a common complication in cardiac surgery, and we evaluated the incidence of its early occurrence after mitral and tricuspid combined cardiac surgery and its associated risk factors. Retrospective, single institution study. We included 88 consecutive adult patients with severe mitral insufficiency scheduled for elective mitral and tricuspid valve replacement surgery between January 2015 and November 2018. The primary endpoint was the occurrence of LCOS, defined as the need for inotropic support or circulatory assistance after surgery. The secondary endpoint was mortality at 30 days. LCOS occurred in 26 patients (29.5%) of the studied patients and its associated risk factors that appeared in the multivariate analysis were chronic kidney failure [adjusted odds ratio (OR) 3.1; 95% confidence interval (CI) 1.0-9.9, p = 0.05], pre-operative left ventricular heart failure (OR 5.3; 95% CI 1.3-10.9, p = 0.002), pre-operative right ventricular heart failure (OR 3.6; 95% CI 1.1-11.5, p = 0.02), and mitral valve replacement (OR 3.9; 95% CI 1.2-12.6, p = 0.03). LCOS affected the survival of patients (HR = 5.5; 95% CI 1.1-27.7 p = 0.04). LCOS is a frequent complication after mitral and tricuspid combined surgery and is associated with poor prognosis.

Severity of Exacerbation in Pneumococcal Vaccinated versus Unvaccinated Patients with Exacerbation of Chronic Obstructive Pulmonary Disease: A Post hoc Analysis of Presentation Status of the Subjects of HOPE Chronic Obstructive Pulmonary Disease Study

Background: Acute exacerbations occur with varying frequency and severity and impact the natural course of chronic obstructive pulmonary disease (COPD) patients. Pneumococcal vaccination has been shown to decrease the incidence of community-acquired pneumonia and exacerbation rate in COPD patients. There is a paucity of data on the influence of pneumococcal conjugate vaccination on the severity of COPD exacerbations. Objectives: The objectives of this study were to evaluate the severity of exacerbation in pneumococcal vaccinated (vaccinated with 13-valent conjugate vaccine) versus unvaccinated COPD subjects hospitalized with acute exacerbation. Materials and Methods: This was a post hoc analysis of the severity of exacerbation in the subjects of HOPE COPD study. This involved the collection of clinical, radiological, and laboratory data of 120 COPD patients who were hospitalized with an acute exacerbation, 60 of whom had prior pneumococcal vaccination and 60 were unvaccinated. Data of COPD patients at the time of presentation with acute exacerbation were analyzed. Comparison was made between severity parameters such as presence of fever, leukocytosis, respiratory failure, multilobar consolidation, hypotension needing inotropic support, and presence of sepsis between pneumococcal vaccinated and unvaccinated subjects. Results: The occurrence of multilobar consolidation was substantially less in the vaccinated group (60% vs. 6.7%; P = 0.0001). The incidence of fever, leukocytosis, and elevated C-reactive protein was significantly higher in the unvaccinated group. Need for intensive care unit care was higher in the unvaccinated group (58.3% vs. 30% with P = 0.019). The occurrence of new-onset respiratory failure was similar in both the groups although type 2 failure with respiratory acidosis was more in the unvaccinated group. Patients in the unvaccinated group had a higher incidence of sepsis and need for inotropic support as well as assisted ventilation. Conclusions: Prior immunization with 13-valent pneumococcal conjugate vaccine ameliorates the severity of exacerbation in COPD patients needing hospitalization. Pneumococcal vaccination may be recommended for all patients with COPD who are at risk of hospitalization with acute exacerbation.

An alternate technique of performing total cavopulmonary connection without cardiopulmonary bypass.

Total cavopulmonary connection (Fontan) without using cardiopulmonary bypass (CPB) may be superior to Fontan on CPB. In the experience of many, a Fontan operation without CPB may be associated with a reduced need for inotropic support, improved outcomes in the postoperative phase including faster time to termination of mechanical ventilatory support, reduced intensive care unit stay, lower volume of pleural and peritoneal effusions, and decreased hospital stay, thereby rendering it more cost-effective. However, the operation is technically more difficult to perform than Fontan on CPB and requires significant modifications of surgical technique and alteration in overall management strategy. In this article, an alternative technique of performing total cavopulmonary connection without CPB is described. Its advantages are briefly discussed.

Correlation between shock index and postoperative outcomes for patients undergoing on-pump coronary artery bypass graft surgery (an observational study)

ABSTRACT Introduction Shock index (SI) is defined as a ratio of heart rate and systolic blood pressure. It was originally employed to evaluate hemorrhage and acute circulatory failure. Recently, SI has been used as a morbidity and mortality predictor in various fields. An elevated SI was associated with higher morbidity. Objective To detect the sensitivity and specificity of SI in predicting major cardiac events. Methods We randomly enrolled 100 patients who were set to undergo on-pump coronary artery bypass graft (CABG) surgery in the study. The primary outcome was to detect the sensitivity and specificity of SI to predict the occurrence of major adverse cardiac events, occurrence of acute kidney injury (AKI) and the need for ventilator support for >48 h. The secondary outcome was to correlate between SI and need of inotropic support, length of hospital stay and in-hospital mortality. Results The main findings of our study were the presence of a good correlation between SI and occurrence of postoperative cardiovascular (CV) collapse, AKI and prolonged postoperative mechanical ventilation after on-pump CABG as primary outcomes as well as the presence of a significant correlation between the occurrence of in-hospital mortality and morbidities and high values of SI as secondary outcomes. Conclusions We believe that SI has a good prediction of postoperative CV collapse, AKI and prolonged postoperative mechanical ventilation >48 h.

Comparison of Postoperative Outcomes Between Intra-aortic Balloon Pump and Levosimendan in Patients Undergoing Coronary Artery Bypass Graft: A Systematic Review and Meta-Analysis.

This study was conducted to compare the postoperative outcomes between intra-aortic balloon pump (IABP) and levosimendan in patients undergoing coronary artery bypass graft(CABG) surgery.This meta-analysis was conducted following the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).For this meta-analysis, a literature search was performed on PubMed, Cochrane Central Register of Controlled Trials, and EMBASE from inception to July 15, 2023. Keywords used to search for relevant articles included "intra-aortic balloon," "levosimendan," and "cardiac surgery" along with their key terms and Medical Subject Headings (MeSH) terms. Outcomes assessed in this study included postoperative outcomeslike all-cause mortality, postoperative arrhythmias, need for inotropic support, length of intensive care unit stay (ICU) in days, and duration of mechanical ventilation in hours. Other outcomes included two-hour, six-hour, and 24-hourpostoperative central venous pressure (CVP), mean atrial pressure (MAP), and heart rate (HR). A total of eight studies were included in the pooled analysis.The pooled results found that the length of ICU stay and the duration of mechanical ventilation were significantly higher in patients receiving IABP. Additionally, the findings of this meta-analysis showed a higher need for inotropic support in patients receiving IABP compared to patients receiving levosimendan but the difference was statistically insignificant. However, no significant differences were found between the two groups in terms of mortality and arrhythmias. In conclusion, patients treated with levosimendan exhibited significant advantages, as they experienced shorter ICU stays and reduced duration of mechanical ventilation compared to the IABP group and less requirement for inotropic support.

Integrin α10β1-selected mesenchymal stem cells reduced hypercoagulopathy in a porcine model of acute respiratory distress syndrome

Mesenchymal stem cells (MSCs) have been studied for their potential benefits in treating acute respiratory distress syndrome (ARDS) and have reported mild effects when trialed within human clinical trials. MSCs have been investigated in preclinical models with efficacy when administered at the time of lung injury. Human integrin α10β1-selected adipose tissue-derived MSCs (integrin α10β1-MSCs) have shown immunomodulatory and regenerative effects in various disease models. We hypothesized that integrin α10β1 selected-MSCs can be used to treat a sepsis-induced ARDS in a porcine model when administering cells after established injury rather than simultaneously. This was hypothesized to reflect a clinical picture of treatment with MSCs in human ARDS. 12 pigs were randomized to the treated or placebo-controlled group prior to the induction of mild to moderate ARDS via lipopolysaccharide administration. The treated group received 5 × 106 cells/kg integrin α10β1-selected MSCs and both groups were followed for 12 h. ARDS was confirmed with blood gases and retrospectively with histological changes. After intervention, the treated group showed decreased need for inotropic support, fewer signs of histopathological lung injury including less alveolar wall thickening and reduction of the hypercoagulative disease state. The MSC treatment was not associated with adverse events over the monitoring period. This provides new opportunities to investigate integrin α10β1-selected MSCs as a treatment for a disease which does not yet have any definitive therapeutic options.

Medium-Term Outcomes in Pediatric Patients Undergoing Cardiac Catheterization Early After Congenital Cardiac Surgery.

Safety and acute outcomes for patients who need catheterization shortly after congenital cardiac surgery has been established; literature on mid-term outcomes is lacking. We sought to evaluate the mid-term outcomes of patients who undergo early postoperative cardiac catheterization. This is a retrospective cohort study of patients who underwent cardiac catheterization within 6weeks of congenital cardiac surgery with longitudinal follow-up and assessment of mid-term outcomes. Multivariable analysis was utilized to relate variables of interest to outcomes. 99 patients underwent cardiac catheterizations within 6weeks of cardiac surgery between January 2008 and September 2016. Forty-six (45.5%) interventional procedures were performed at a median age of 41days (IQR 21-192) and a median weight of 3.9kg (3.3-6.6). During a median follow-up duration of 4.24years (1.6-5.6) in study survivors, 61% of patients remained free from the primary endpoint (death and/or transplant). Sixty-nine patients (69.7%) underwent an unplanned surgical or catheter procedure. Renal failure at catheterization (OR 280.5, p 0.0199), inotropic medication at catheterization (OR 14.8, p 0.002), and younger age were all significantly associated with meeting the primary endpoint. Patients requiring surgical intervention as an initial additional intervention underwent more unplanned re-interventions, while patients who survived to hospital discharge demonstrated favorable mortality, though with frequent need for re-intervention. In patients requiring early postoperative cardiac catheterization, renal failure, younger age, and need for inotropic support at catheterization are significantly associated with meeting the primary endpoint.

Factors associated with the need for inotropic support following pulmonary artery banding surgery for CHD.

We aimed to identify factors independently associated with the need for inotropic support for low cardiac output or haemodynamic instability after pulmonary artery banding surgery for CHD. We performed a retrospective chart review of all neonates and infants who underwent pulmonary banding between January 2016 and June 2019 at our institution. Bivariate and multivariable analyses were performed to identify factors independently associated with the use of post-operative inotropic support, defined as the initiation of inotropic infusion(s) for depressed myocardial function, hypotension, or compromised perfusion within 24 hours of pulmonary artery banding. We reviewed 61 patients. Median age at surgery was 10 days (25%,75%:7,30). Cardiac anatomy was biventricular in 38 patients (62%), hypoplastic right ventricle in 14 patients (23%), and hypoplastic left ventricle in 9 patients (15%). Inotropic support was implemented in 30 patients (49%). Baseline characteristics of patients who received inotropic support, including ventricular anatomy and pre-operative ventricular function, were not statistically different from the rest of the cohort. Patients who received inotropic support, however, were exposed to larger cumulative doses of ketamine intraoperatively - median 4.0 mg/kg (25%,75%:2.8,5.9) versus 1.8 mg/kg (25%,75%:0.9,4.5), p < 0.001. In a multivariable model, cumulative ketamine dose greater than 2.5mg/kg was associated with post-operative inotropic support(odds ratio 5.5; 95% confidence interval: 1.7,17.8), independent of total surgery time. Inotropic support was administered in approximately half of patients who underwent pulmonary artery banding and more commonly occurred in patients who received higher cumulative doses of ketamine intraoperatively, independent of the duration of surgery.

Ex-situ oxygenated hypothermic machine perfusion in donation after circulatory death heart transplantation following either direct procurement or in-situ normothermic regional perfusion

Heart transplantation in donation after circulatory death (DCD) relies on warm perfusion using either in situ normothermic regional perfusion (NRP) or ex situ normothermic machine perfusion. In this study, we explore an alternative: oxygenated hypothermic machine perfusion (HMP) using a novel clinically applicable perfusion system, which is compared to NRP with static cold storage (SCS). In a porcine model, a DCD setting was simulated, followed by either (1) NRP and SCS (2) NRP and HMP with the XVIVO Heart preservation system or (3) direct procurement (DPP) and HMP. After preservation, heart transplantation (HTX) was performed. After weaning from cardiopulmonary bypass (CPB), biventricular function was assessed by admittance and Swan-Ganz catheters. Only transplanted hearts in the HMP groups showed significantly increased biventricular contractility (end-systole elastance) 2 hour post-CPB (left ventricle absolute change: NRP HMP: +1.8 ± 0.56, p=0.047, DPP HMP: +1.5 ± 0.43, p=0.045 and NRP SCS: +0.97 ± 0.47 mmHg/ml, p=0.21; right ventricle absolute change: NRP HMP: +0.50 ± 0.12, p=0.025, DPP HMP: +0.82 ± 0.23, p=0.039 and NRP SCS: +0.28 ± 0.26, p=0.52) while receiving significantly less dobutamine to maintain a cardiac output >4l/min compared to SCS. Diastolic function was preserved in all groups. Post-HTX, both HMP groups showed significantly less increments in plasma troponin T compared to SCS. In DCD HTX, increased biventricular contractility post-HTX was only observed in hearts preserved with HMP. In addition, the need for inotropic support and signs of myocardial damage were lower in the HMP groups. DCD HTX can be successfully performed using DPP followed by preservation with HMP in a preclinical setting.

High frequency jet ventilation for congenital diaphragmatic hernia

BackgroundThe optimal role of high frequency jet ventilation (HFJV) in lung protective stabilization of congenital diaphragmatic hernia (CDH) remains uncertain. We aimed to describe our center's experience with HFJV as both a rescue (following failed stabilization with CMV) and primary ventilation mode in the management of CDH. MethodsLiveborn CDH patients treated from 2013 to 2021 in a single institution were reviewed.We compared 3 groups based on their primary and last ventilation mode prior to surgery: CMV (Group 1); HFJV (Group 2); and CMV/HFJV (Group 3). Outcomes included a composite primary outcome (≥1 of mortality, need for ECMO or need for supplemental O2 at discharge), total invasive ventilation days and development of pneumothorax. A descriptive analysis including univariate group comparisons was performed. Multivariate logistic regression models investigating the relationship between mode of ventilation and the primary outcome adjusted by potentially confounding covariates were constructed. Results56 patients (32 Group 1, 18 Group 2, 6 Group 3) were analyzed. Group 2 and 3 patients had more severe disease based on liver position, SNAP-II score, pulmonary hypertension severity, need for inotropic support, CDHSG defect size and need for patch repair. There were no group differences in survival, need for ECMO, or pneumothorax occurrence, although infants receiving HFJV required longer invasive ventilation and had a greater need for O2 at discharge. Multivariate logistic regression revealed no associations between mode of ventilation and outcome. ConclusionsHFJV appears effective, both for CMV rescue and as a primary ventilation strategy in high risk CDH.Level of evidence: Level IV.

Role of Inflammatory Markers and Clinical Correlate in Children Infected with the Novel SARS-CoV-2: A Prospective Observational Study

Introduction: Inflammatory markers have been used as predictors of adverse outcomes in adults with Coronavirus Disease-2019 (COVID-19) infection. Children mostly have mild infections and raised inflammatory markers have been reported only with severe COVID-19 or Multisystem Inflammatory Disorder (MIS-C). Studies in children showing the role of inflammatory markers in disease prognosis are few, and findings are not conclusive. Aim: To find out correlation, if any, between the inflammatory markers {Interleukin-6 (IL-6), C-reactive Protein (CRP), procalcitonin, Pro-B-type natriuretic Peptide (Pro-BNP), ferritin, D-dimer} with clinical presentation, prognosis, and outcome in children with acute COVID-19. Materials and Methods: The prospective, observational study was conducted at a tertiary care COVID-19 Paediatric Intensive Care Unit {PICU (Vardhaman Medical College and Hospital, New Delhi)}, Northern India, between September 2020 and December 2020. All children aged less than 12 years, with a positive COVID19 report were enrolled and investigated. Data was collected for clinical presentation, severity, treatment and outcome. The following variables were recorded: Complete Blood Count (CBC), Kidney Function Test (KFT) and Liver function Test (LFT), Absolute Lymphocyte Count (ALC), Absolute Neutrophil Count (ANC), Neutrophil-lymphocyte Ratio (NLR), Platelet Count (PLT), C-reactive Protein (CRP), Procalcitonin (PCT), serum ferritin, Lactate Dehydrogenase (LDH), fibrinogen, and Erythrocyte Sedimentation Rate (ESR) and ProBNP. Coagulation parameters like Prothrombin Time (PT), Activated Partial Thromboplastin Time (APTT), International Normalised Ration (INR), D-dimer were taken. Data was analysed using Statistical Package for the Social Sciences (SPSS) software version 21.0. Results: A total of 35 children were admitted during the study period. Seventeen children met the criteria for severe disease. Seven children met the criteria for MIS-C. Children presenting with conjunctivitis (n=3) were more likely to have signs of peripheral inflammation hypotension (n=4), tachycardia (n=6), and raised IL-6 levels (pg/mL) as well as the need for inotropic support. IL-6 values were higher in children (Mean±SD= 182.47±149.83). Median IL-6 value 199.8 (96.17-275.24) was highest in children with CRP &lt;10 mg/dL (p-value&lt;0.01). Children with raised D-dimer (Mean±SD=1881.94±1265.66 mg/dL) had a longer duration of stay (p-value=0.031). Conclusion: The study didn’t find any correlation between inflammatory markers with clinical presentation and the outcome of COVID-19 infection in children.

Early Administration of Sacubitril/Valsartan is Associated with more Rapid NT-proBNP Recovery in High-Risk Patients Hospitalized for Acute Heart Failure

BACKGROUND: in patients hospitalized for heart failure with reduced ejection fraction (HFrEF), randomized controlled trials have demonstrated some advantages in starting sacubitril/valsartan before discharge. However, information about the effects of sacubitril/valsartan use in the acute phase of HfrEF hospitalizations is limited. AIM: To evaluate clinical, biomarker, and echocardiographic effects of starting sacubitril/valsartan in real-world HFrEF patients before discharge. METHODS: retrospective analysis of 124 consecutive patients (58.9% males, 75.6±11.4 years) hospitalized for HFrEF. In 36, sacubitril/valsartan was started before discharge (Group A); in the remaining 88, at the 1-month follow-up visit (Group B). The primary endpoint was time-averaged NT-proBNP level reduction from admission to discharge. RESULTS: Group A showed a worse baseline clinical risk profile (diabetes: 47.2 vs. 20.7%, p=0.007; coronary artery disease: 66.7 vs. 22.7%, p&lt;0.001; systolic blood pressure: 118.0±20.8 vs. 132.9±22.9 mmHg, p=0.001; left ventricular ejection fraction: 28.5±5.5 vs. 32.1±7.6%, p&lt;0.0004). Nevertheless, the time-averaged mean NT-proBNP reduction was significantly higher in group A patients (ratio of change -0.30, 95% CI -0.40 to -0.21, &lt;0.0001 vs. group B). Creatinine and K+ levels did not change significantly during the hospital stay. Multivariate analysis suggested diabetes, coronary artery disease, higher systolic blood pressure, and the need for inotropic support as independent predictors for in-hospital sacubitril/valsartan treatment. CONCLUSIONS: in real-world patients, starting sacubitril/valsartan in-hospital rather than waiting for further stabilization was associated with a more considerable reduction of NT-proBNP levels at discharge, with an excellent safety profile. These data confirm randomized trials results, extending them to higher-risk real-world HFrEF patients.

Study of Inflammatory Markers in Chronic Obstructive Pulmonary Disease.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is the sudden worsening of symptoms of COPD like shortness of breath, increased quantity and color of sputum, and systemic inflammation, and has a significant impact on survival. Biomarkers such as high-sensitivity C-reactive protein (hsCRP) and procalcitonin have been studied in AECOPD patients as prognostic markers. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are two new inflammatory markers and play a significant role in prognosis in patients with AECOPD. NLR and PLR are easily available and cost-effective markers and have the potential for helping in the risk stratification of hospitalized AECOPD patients. Study of inflammatory markers in COPD and their correlation with clinical outcome. A prospective observational comparative study was conducted on 100 patients of COPD at the Department of General Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, and all necessary investigations were done. A total of 100 patients of COPD were taken, 50 patients were in a stable state (controls) and the same number of patients were in an acute exacerbation state (cases). Mean levels of NLR, hsCRP, and procalcitonin in cases were significantly higher as compared to controls whereas levels of PLR in cases and controls were comparable with no significant difference between them. Levels of both of these inflammatory markers (NLR and PLR) were positively correlated with levels of hsCRP and levels of procalcitonin. Of the total 50 patients, 23 (56.00%) patients needed mechanical ventilation and 11 (22%) needed inotropic support. Only 6 out of 50 patients (12.00%) died. Levels of NLR and PLR were positively correlated with the duration of hospitalization. Levels of NLR and PLR were not significantly associated with the need of inotropic support and mortality, levels of NLR were also not significantly associated with the need of mechanical ventilation whereas levels of PLR were significantly higher in patients who required mechanical ventilation. Levels of NLR were raised in patients with AECOPD (cases) than stable state COPD patients (controls). So levels of NLR can be used as a marker to predict acute exacerbation and there was a positive correlation of NLR and PLR with levels of hsCRP and procalcitonin.