Arterial Pressure Research Articles

Nitroglycerin challenge identifies microcirculatory target for improved resuscitation in patients with circulatory shock.

Circulatory shock and multi-organ failure remain major contributors to morbidity and mortality in critically ill patients and are associated with insufficient oxygen availability in the tissue. Intrinsic mechanisms to improve tissue perfusion, such as up-regulation of functional capillary density (FCD) and red blood cell velocity (RBCv), have been identified as maneuvers to improve oxygen extraction by the tissues; however, their role in circulatory shock and potential use as resuscitation targets remains unknown. To fill this gap, we examined the baseline and maximum recruitable FCD and RBCv in response to a topical nitroglycerin stimulus (FCDNG, RBCvNG) in patients with and without circulatory shock to test whether this may be a method to identify the presence and magnitude of a microcirculatory reserve capacity important for identifying a resuscitation target. Sublingual handheld vital microscopy was performed after initial resuscitation in mechanically ventilated patients consecutively admitted to a tertiary medical ICU. FCD and RBCv were quantified using an automated computer vision algorithm (MicroTools). Patients with circulatory shock were retrospectively identified via standardized hemodynamic and clinical criteria and compared to patients without circulatory shock. 54 patients (57 ± 14y, BMI 26.3 ± 4.9kg/m2, SAPS 56 ± 19, 65% male) were included, 13 of whom presented with circulatory shock. Both groups had similar cardiac index, mean arterial pressure, RBCv, and RBCvNG. Heart rate (p < 0.001), central venous pressure (p = 0.02), lactate (p < 0.001), capillary refill time (p < 0.01), and Mottling score (p < 0.001) were higher in circulatory shock after initial resuscitation, while FCD and FCDNG were 10% lower (16.9 ± 4.2 and 18.9 ± 3.2, p < 0.01; 19.3 ± 3.1 and 21.3 ± 2.9, p = 0.03). Nitroglycerin response was similar in both groups, and circulatory shock patients reached FCDNG similar to baseline FCD found in patients without shock. Critically ill patients suffering from circulatory shock were found to present with a lower sublingual FCD. The preserved nitroglycerin response suggests a dysfunction of intrinsic regulation mechanisms to increase the microcirculatory oxygen extraction capacity associated with circulatory shock and identifies a potential resuscitation target. These differences in microcirculatory hemodynamic function between patients with and without circulatory shock were not reflected in blood pressure or cardiac index.

Neuraxial anesthesia for patients with severe pulmonary arterial hypertension undergoing urgent open abdominal surgeries: two case reports.

There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH. Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors. Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery.

The association of blood pressure, body mass index and carotid intima-media thickness as childhood predictors of cardiovascular disease risk: A systematic review and meta-analysis.

Blood pressure, body mass index (BMI), and carotid intima-media thickness (CIMT) are well-known independent predictors of cardiovascular disease especially in adulthood. However, there is insufficient evidence regarding the statistical significance of the relationship between childhood CIMT, blood pressure and BMI. This systematic review and meta-analysis was therefore conducted to ascertain the relationship. This systematic review and meta-analysis was reported in accordance with the PRISMA statement. Three electronic databases were searched, namely EMBASE, MEDLINE and the Cochrane Library. Data were extracted independently by two review authors. Quantitative data were analyzed using Review Manager. The meta-analysis was conducted using a random effects model and standard mean difference. The results of the meta-analysis indicated a statistically significant difference in CIMT of 0.86 (95% CI: 0.41-1.31) between normotensive versus hypertensive children. Again, overweight and moderately obese children had higher CIMT values as compared to normal weight children with a pooled standard mean difference of 0.72 (95% CI: 0.24-1.20) and 2.75 (95% CI: 0.73-4.77) respectively. The pooled standard mean difference of systolic and diastolic blood pressures was found to be 2.44 (95% CI: 1.69-3.19) and 1.28 (95% CI: 0.65-1.92) respectively between normal weight and overweight/obese children. The meta-analysis found a significant difference in CIMT between normotensive and hypertensive children, with overweight and moderately obese children having higher CIMT values. Thus, conducting CIMT screening for obese or overweight children and children with increased blood pressure can provide valuable information about their cardiovascular disease risk.

Sleeve Gastrectomy Protects Against Hypertension in Rats due to Changes in the Gut Microbiome

IntroductionSleeve gastrectomy (SG), results in improvement in hypertension. We have previously published that rodent SG improves hypertension independent of weight loss associated with unique shifts in the gut microbiome. We tested if the gut microbiome directly improves blood pressure by performing fecal material transfer (FMT) from post-SG rats to surgery-naïve animals. MethodsWe performed SG or Sham surgery in male, Zucker rats (n = 6-7) with obesity. Stool was collected postop from surgical donors for treatment of recipient rats. Three nonsurgical groups received daily, oral consumption of SG stool, sham stool, or vehicle alone (Nutella) for 10 wk (n = 7-8). FMT treatment was assessed for effects on body weight, food intake, oral glucose tolerance, and blood pressure. Genomic DNA of stool from donor and recipient groups were sequenced by 16S ribosomal RNA and analyzed for diversity, abundance, and importance. ResultsTen weeks of SG-FMT treatment significantly lowered systolic blood pressures in surgery-naïve, recipient rats compared to vehicle treatment alone (126.8 ± 13.3 mmHg versus 151.8 ± 12.2 mmHg, P = 0.001). SG-FMT treatment also significantly altered beta diversity metrics compared to Sham-FMT and vehicle treatment. In random forest analysis, amplicon sequence variant level significantly predicted FMT group, P = 0.01. ConclusionsWe have found a direct link between gut microbial changes after SG and regulation of blood pressure. Future mechanistic studies are required to learn what specific gut microbial changes are required to induce improvements in obesity-associated hypertension and translation to clinical, metabolic surgery.

Feasibility of aging in place clinics in low income senior housing

The purpose of this study was to describe the feasibility of implementing interdisciplinary senior housing clinics. Feasibility was based on evidence of resident participation, services provided, improvement in clinical outcomes and sustaining clinics over time. Data were collected prospectively in four senior housing communities which included approximately 375 residents 60 years of age and older. Over the 12-month implementation period, 228 residents were seen, 61 % of all residents. We gave 131 immunizations, checked 576 blood pressures, completed 92 foot care treatments, 69 hearing evaluations and cerumen removal, completed 16 advance directives, 119 Annual Wellness Visits, and 13 assessments for acute medical problems. Overall, 87 individuals (38 %) had a decrease in their blood pressures, 121 (54 %) maintained their pressures and 19 (8 %) had increases in blood pressures. We reached over half of the residents living in these communities and estimated we could financially maintain the clinics with reimbursement based on billing.

Role of GABAA receptors of the dorsomedial periaqueductal grey on blood pressure and heart rate in the anesthetized rat.

The midbrain dorsomedial periaqueductal grey column (dmPAG) is involved in the regulation of cardiovascular responses. Due to the presence of Gamma-Aminobutyric acid (GABA) receptors in the dmPAG, this study aimed to investigate the role of GABAA receptors in the dmPAG on cardiovascular parameters and its possible peripheral mechanisms. The left femoral artery was cannulated, and systolic arterial pressure (SAP), mean arterial pressure (MAP) and heart rate (HR) were recorded using a Power lab system. Microinjection of saline, muscimol and bicuculline (BIC) was done using a stereotaxic device. Also, the peripheral mechanisms dependent on GABAA receptors in the dmPAG were evaluated by intravenous (i.v.) injection of hexamethonium (Hexa) and atropine (Atr) 5min before the BIC. Results showed that BIC significantly increased ∆SAP, ∆MAP and ∆HR than the control group, but muscimol had no significant effect. Injection of Hex significantly attenuates the effect of BIC on ∆SAP and ∆MAP. Atr (i.v) significantly increased the ∆HR, and when injected before BIC microinjection, it did not affect the cardiovascular responses induced by BIC. These findings show that GABAA receptors of the dmPAG have inhibitory effects on the cardiovascular system, which are mostly mediated by the sympathetic system.

Feasibility of a 4 French resuscitative endovascular balloon occlusion of the aorta (REBOA) device for nontraumatic cardiac arrest in a randomized controlled study using a large porcine model

AimThe objectives of this study were to assess the return of spontaneous circulation rates and hemodynamic response of large swine (>65Kg) during cardiopulmonary resuscitation after nontraumatic cardiac arrest using the COBRA-OS® aortic occlusion balloon and to address limitations of large swine closed-chest cardiopulmonary resuscitation by comparing closed-chest vs. open-chest cardiopulmonary resuscitation. MethodsYorkshire pigs (n = 10) weighing >65 kg were anesthetized and ventilated. After 7 min of untreated ventricular fibrillation (VF), animals were randomized to receive mechanical closed-chest cardiopulmonary resuscitation or open-chest cardiac massage. Following a 5-minute low-flow state, advanced cardiac life support algorithms were started and the COBRA-OS® was inflated in the thoracic aorta. Animals that achieved return of spontaneous circulation were re-started on mechanical ventilation and medications, CPR, defibrillation, and aortic occlusion were discontinued. The primary outcome was return of spontaneous circulation and secondary outcomes were mean arterial pressures generated in the low flow and aortic occlusion states before return of spontaneous circulation. Groups were compared with a t-test or Mann-Whitney U test for normal and non-parametric data, respectively, while categorical data was compared with the chi square test. ResultsReturn of spontaneous circulation was obtained in 4 animals (80%) in the open cardiac massage group and none in the mechanical closed-chest CPR group (p < 0.05). The COBRA-OS® successfully occluded all aortas and animals experienced higher mean arterial pressures in both groups with aortic occlusion (median 15 mm Hg, IQR 13–23 mm Hg), but with a higher MAP difference in the open cardiac massage group (−12.2 mm Hg, [−2.581, −21.819]). ConclusionsConsideration should be given to intra-thoracic cardiac massage to increase cardiopulmonary resuscitation effectiveness and therefore return of spontaneous circulation rates in large (>65 kg) swine models of nontraumatic cardiac arrest. The COBRA-OS® demonstrated feasibility for use in this model.The Keenan Research Center, Li Ka Shing Knowledge Institute of St. Michael’s Hospital Animal Care Committee: ACC Protocol #726.

Differing associations of PM2.5 exposure with systolic and diastolic blood pressures across exposure durations in a predominantly non-Hispanic Black cohort.

Environmental health research has suggested that fine particulate matter (PM2.5) exposure can lead to high blood pressures, but it is unclear whether the impacts remain the same for systolic and diastolic blood pressures (SBP and DBP). This study aimed to examine whether the effects of PM2.5 exposure on SBP and DBP differ using data from a predominantly non-Hispanic Black cohort collected between 2013 and 2019 in the US. PM2.5 exposure was assessed based on a satellite-derived model across exposure durations from 1 to 36months. The average PM2.5 exposure level was between 9.5 and 9.8μg/m3 from 1 through 36months. Mixed effects models were used to estimate the association of PM2.5 with SBP, DBP, and related hypertension types, adjusted for potential confounders. A total of 6381 participants were included. PM2.5 exposure was positively associated with both SBP and DBP. The association magnitudes depended on exposure durations. The association with SBP was null at the 1-month duration (β = 0.05, 95% CI: - 0.23, 0.33), strengthened as duration increased, and plateaued at the 24-month duration (β = 1.14, 95% CI: 0.54, 1.73). The association with DBP started with β = 0.29 (95% CI: 0.11, 0.47) at the 1-month duration, and plateaued at the 12-month duration (β = 1.61, 95% CI: 1.23, 1.99). PM2.5 was associated with isolated diastolic hypertension (12-month duration: odds ratio = 1.20, 95% CI: 1.07, 1.34) and systolic-diastolic hypertension (12-month duration: odds ratio = 1.18, 95% CI: 1.10, 1.26), but not with isolated systolic hypertension. The findings suggest DBP is more sensitive to PM2.5 exposure and support differing effects of PM2.5 exposure on SBP and DBP. As elevation of SBP and DBP differentially predict CVD outcomes, this finding is relevant for prevention and treatment.

Placental ischemia-upregulated angiotensin II type 1 receptor in hypothalamic paraventricular nucleus contributes to hypertension in rat.

Preeclampsia (PE) is associated with increased angiotensin II sensitivity and poor neurological outcomes marked by temporal loss of neural control of blood pressure. Yet the role of centrally expressed angiotensin II type 1 receptor (AT1R) within the paraventricular nucleus of the hypothalamus (PVN) in the PE model is not understood. In a PE rat model with reduced placental perfusion pressure (RUPP) induced on gestational day 14 (GD14), the PVN expression and cellular localization of AT1R were assessed using immunofluorescence and western blotting. The sensitivity of RUPP to acute angiotensin II infusion was assessed. AT1R was antagonized by losartan (100µg/kg/day) for 5days intracerebroventricularly (ICV). Hemodynamic data and samples were collected on GD19 for further analysis. RUPP upregulated (p < 0.05) mRNA and protein of AT1R within the PVN and lowered (p < 0.05) circulating angiotensin II in rats. RUPP increased neural and microglial activation. Cellular localization assessment revealed that AT1R was primarily expressed in neurons and slightly in microglia and astrocytes. Infusion of 100ng/kg as bolus increased the mean arterial pressure (MAP in mmHg) in both RUPP and Sham. ICV losartan infusion attenuated RUPP-increased MAP (113.6 ± 6.22 in RUPP vs. 92.16 ± 5.30 in RUPP + Los, p = 0.021) and the expression of nuclear transcription factor NF-κB, tyrosine hydroxylase (TH), NADPH oxidase 4 (NOX4) and reactive oxygen species (ROS) in the PVN. Our data suggest that centrally expressed AT1R, within the PVN, contributes to placental ischemia-induced hypertension in RUPP rats highlighting its therapeutic potential in PE.

Effects of exercise on autonomic cardiovascular control in individuals with chronic, motor-complete spinal cord injury: an exploratory randomised clinical trial.

Secondary analysis of a clinical trial. To assess the impact of 6 months of armcycle ergometry training (ACET), or body weight-supported treadmill training (BWSTT), on autonomic cardiovascular responses to a laboratory sit-up test (SUT) in individuals with chronic (≥1-year post-injury) spinal cord injury (SCI). Tertiary Rehabilitation Centre, Vancouver, Canada. Sixteen individuals with motor-complete (American Spinal Injury Association Impairment Scale A-B) SCI between the fourth cervical and sixth thoracic spinal cord segments, aged 39 ± 11 years, were assessed. Participants were randomized to receive 72 sessions of moderate-to-vigorous intensity ACET (n = 8) or passive BWSTT (n = 8). Changes in mean arterial pressure (finger plethysmography), hemodynamics (Modelflow® method), and heart rate/heart rate variability (HR/HRV; electrocardiography) were measured in response toa SUT before and after 6 months of exercise training. Spontaneous cardiovagal baroreflex sensitivity (cvBRS) was assessed using the sequence method. Neither ACET nor BWSTT impacted hemodynamic responses to SUT or the incidence of orthostatic hypotension (all P > 0.36). ACET increased HR (P < 0.01, ηp2 = 0.34) and high frequency (HF) power HRV responses (P < 0.01, ηp2 = 0.42) to SUT following 6 months of training while BWSTT did not. Consistent with this, cvBRS improved (P < 0.05, ηp2 = 0.16) only following ACET. Improvements in cvBRS were correlated with both the HR (r = 0.726, P < 0.0001) and HF power (r = -0.484, P < 0.01) responses to SUT. Six months of ACET, but not BWSTT, improved cardiovagal baroreflex control of HR but had no effect on BP responses to SUT in individuals with chronic, motor-complete SCI. Canadian Institutes of Health Research (CIHR) CLINICAL TRIAL REGISTRATION: NCT01718977.

A decade of follow-up: atrial fibrillation, pulmonary pressure, and the progression of tricuspid regurgitation.

Long-term data on atrial fibrillation (AF) impact on tricuspid regurgitation (TR) progression and its relation to pulmonary pressure are scant. We investigated this association in a study spanning over a decade. Adults with echocardiographic evaluation before 2014, free of significant TR, were included. Patients were dichotomized by baseline AF, followed by stratification according to systolic pulmonary artery pressure (sPAP). The development of new significant TR and its impact on mortality were studied. Study population included 21502 patients (median age 65, 40% female), 13% had baseline AF. During a median follow-up of 12 years, 11% developed significant TR. Compared with patients free of AF, patients with baseline AF were 3.5 and 1.3 times more likely to develop significant TR in a univariate and multivariate models, respectively (95% CI 3.27-3.91, 1.18-1.44, p<0.001 for both). The risk of TR progression was higher in patients with permanent AF and those treated with rate control strategy (HR 1.95 and 2.01, respectively; p<0.001 for both). The association of AF with TR progression was sPAP-related, being more pronounced among patients with normal sPAP than among those with elevated sPAP (HR 1.5vs. 1.18; p for interaction<0.001). TR progression was independently linked to a two-fold higher mortality risk, consistent regardless of baseline AF (p<0.001). AF is an independent predictor of TR progression, especially in patients with normal sPAP. Subsequent research on strategies to prevent TR progression in this patient population are warranted.This analysis investigated the association of AF with TR progression, and the interaction of pulmonary arterial pressure with this link. Among patients with AF (Left), progression to significant TR is highly prevalent, with higher risk among patients with permanent AF and lower risk in those treated with rhythm control strategy. Pulmonary arterial pressure interacts with this association (Right), such that among patients with normal sPAP, the link between AF and TR progression is stronger, suggesting that the importance of proactive AF management in this sugroup of patients. TR has important implications on mortality, regardless of AF status (Middle).AF=Atrial Fibrillation; A-STR=Atrial Secondary TR; CIED=cardiac implantable electronic device; TR=Tricuspid Regurgitation; V-STR=Ventricular Secondary TR.

Expedited versus standard postpartum discharge in patients with hypertensive disorders of pregnancy and its effect on the postpartum course.

Hospital stay after an uncomplicated delivery is typically 2 days for vaginal birth and 3 days for cesarean birth. Health maintenance organizations and third-party payers have encouraged shorter maternity stays. The safety of earlier discharge is unclear particularly when it comes to patients diagnosed with hypertensive disorders of pregnancy (HDP). To examine whether expedited discharge amongst patients with HDP will have a negative effect on postpartum readmission rate and blood pressure related complications. This was a single academic center retrospective cohort study of patients with HDP (gestational hypertension, preeclampsia, or chronic hypertension) during 2 epochs: 2015-2018, prior to implementation of an expedited discharge policy, and 2019-2020 after hospital wide implementation of expedited postpartum discharge. The expedited discharge policy entailed patients being discharged home as soon as day 1 after a vaginal delivery and day 2 after a cesarean delivery. The primary outcome was unplanned health care utilization postpartum, defined as Emergency Department (ED) visits, unscheduled clinic visits, and hospital readmission. Secondary outcomes were planned postpartum visits attendance, antihypertensive medication initiation after discharge, and blood pressure control throughout the first year. Bivariable and multivariable logistic regression analyses were run to evaluate the association between expedited discharge and primary and secondary outcomes. A total of 1,441 patients were included in the analysis. There were no statistically significant differences in the rate of unplanned health care utilization (11.3% in the standard postpartum discharge group vs. 13.8% in the expedited discharge group, p=0.17). Systolic and diastolic blood pressures did not differ between the groups at 1-2 weeks, six weeks, and one year postpartum. Patients in the expedited discharge group were more likely to attend the 1-2-week postpartum blood pressure check (58.7% vs. 51.7%, p=0.02, adjusted OR 1.33, 95% CI 1.08-1.77). Other secondary outcomes did not differ between the two cohort groups. In this single academic center study, expedited discharge after delivery in patients with HDP was not associated with a higher rate of unplanned healthcare utilization postpartum.

Hypercapnia during transcatheter aortic valve replacement under monitored anaesthesia care: a retrospective cohort study

BackgroundAcute intraoperative hypercapnia and respiratory acidosis, which can occur during monitored anaesthesia care (MAC), pose significant cardiopulmonary risks for patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The...

Effects of sour cherry fruits on platelet aggregation and arterialblood pressure

Effects of sour cherry fruits on platelet aggregation and arterialblood pressure

Right-Ventricle Heart Failure in PAH vs. HFrEF with Secondary PH: Hemodynamic, Ergospirometric, and Organ Function Correlations.

The goal of the study was to identify markers of organ function used in daily routines that could potentially aid in the overall evaluation of the cardiovascular system in patients with right-ventricle heart failure due to pulmonary arterial hypertension (PAH) and left-ventricle heart failure. We analyzed correlations between parameters from right heart catheterization (RHC), cardiopulmonary exercise test (CPET), and selected laboratory parameters of thyroid, liver, kidneys function and iron homeostasis. A retrospective analysis included 107 patients (mean age 57.6±16.2; 34.6% women), comprising 57 patients with PAH (mean age 54.0±18.2; 49.1% women) and 50 patients with heart failure with reduced ejection fraction (HFrEF) <40% (mean age 61.6±12.7; 18% women). All patients underwent CPET. Each patient in the PAH group had RHC performed. Fifteen patients from the HFrEF group underwent RHC, which confirmed the suspicion of pulmonary hypertension (HFrEF-SPH). CPET and laboratory parameters' analysis showed strong correlations between ventilation/carbon dioxide production (VE/VCO2) slope and NT-proBNP in HFrEF without secondary PH and HFrEF-SPH groups. In the PAH group, VE/VCO2 slope correlated with liver and thyroid function but also with morphological parameters of red-cell system. Analysis of correlations between laboratory and hemodynamic parameters revealed significant correlations between pulmonary arterial pressure, pulmonary vascular resistance (PVR) and red-cell parameters, especially strong with fT4 in the PAH group. In HFrEF-SPH patients, laboratory parameters strongly correlated with pulmonary pressures and pulmonary capillary wedge pressure (PCWP).

The Respiratory Rate, Age, and Mean Arterial Pressure (RAM) Index: A Novel Prognostic Tool to Predict Mortality among Adult Patients with Acute Heart Failure in the Emergency Department

The Respiratory Rate, Age, and Mean Arterial Pressure (RAM) Index: A Novel Prognostic Tool to Predict Mortality among Adult Patients with Acute Heart Failure in the Emergency Department

Predicting stroke volume variation using central venous pressure waveform: a deep learning approach.

&#xD;This study evaluated the predictive performance of a deep learning approach to predict stroke volume variation (SVV) from central venous pressure (CVP) waveforms. Long short-term memory and the feed-forward neural network were sequenced to predict SVV using CVP waveforms obtained from the VitalDB database, an open-source registry. The input for the long short-term memory consisted of 10 sec CVP waveforms sampled at 2 sec intervals throughout the anesthesia duration. Inputs of the feed-forward network were the outputs of long short-term memory and demographic data such as age, sex, weight, and height. The final output of the feed-forward network was the SVV. The performance of SVV predicted by the deep learning model was compared to SVV estimated derived from arterial pulse waveform analysis using a commercialized model, EV1000.&#xD;Main results.&#xD;The model hyperparameters consisted of 12 memory cells in the long short-term memory layer and 32 nodes in the hidden layer of the feed-forward network. A total of 224 cases comprising 1717978 CVP waveforms and EV1000/SVV data were used to construct and test the deep learning models. The concordance correlation coefficient between estimated SVV from the deep learning model were 0.993 (95% confidence interval [CI], 0.992-0.993) for SVV measured by EV1000.&#xD;Significance. &#xD;Using a deep learning approach, CVP waveforms can accurately approximate SVV values close to those estimated using commercial arterial pulse waveform analysis.&#xD.

Orthotopic heart transplantation in patient with situs inversus and pectus excavatum: a case report.

Heart transplantation in patients with situs inversus is challenging, especially in terms of reconstruction of the systemic venous return. Several rerouting techniques have been presented but are associated with vulnerability to external compression, which might cause hemodynamic instability, especially in the presence of chest deformity. In this study, we report a rare case of successful heart transplantation in the presence of situs inversus and pectus excavatum. A 55-year-old man, with a history of surgeries for corrected transposition of the great arteries with ventricular septal defect, was registered for heart transplantation owing to progression of heart failure. Subsequently, he had undergone a left ventricular assist device implantation; 14years after registration, he underwent transplantation of the heart with normal anatomy. The inferior vena cava was reconstructed by anastomosing the left atria with a counterclockwise rotation of the donor heart and by lengthening the recipient inferior vena cava with a conduit made of the residual right atrial tissue. The superior vena cava was reconstructed using a donor innominate vein harvested with sufficient length. After successful weaning from cardiopulmonary bypass, the chest could not be closed because the heart was compressed owing to chest deformity, resulting in hemodynamic instability. Therefore, to exclude the left lung, a left pericardial screen was created using a bovine pericardium, allowing the chest to be closed with acceptable hemodynamics. The patient suffered postoperatively from a higher venous pressure, suggesting an obstruction of venous return early after surgery. The obstruction gradually resolved, and the patient was transferred for rehabilitation. Heart transplantation in the presence of situs inversus is challenging; moreover, the presence of pectus excavatum further complicates the procedure. The paradoxically larger left lung and chest deformity compressed and impaired reconstructed systemic venous return. Although intrathoracic exclusion of the left lung was effective, an intraoperative or early postoperative thoracoplasty for pectus excavatum was also a viable option. Patient-specific management is mandatory, depending on the anatomy.

Association between wait time of central venous pressure and 28-day mortality in critically patients with acute pancreatitis: A restrospective cohort study.

Hemodynamic management is crucial in patients with acute pancreatitis. Central venous pressure (CVP) is widely used to assess volume status. Our aim was to determine the optimal time window for obtaining CVP measurements to prevent adverse outcomes in patients. This study utilized data from the Medical Information Mart for Intensive Care (MIMIC) IV database. The primary outcome under investigation was the 28-day mortality, while secondary outcomes included 90-day mortality and 1-year mortality. To categorize the study population, a CVP waiting time of 12 hours was employed as the grouping criterion, followed by the utilization of Cox regression analysis to compare the outcomes between the 2 groups. Our study included a total of 233 patients, among whom 154 cases (66.1%) underwent CVP measurements within 12 hours after admission to the Intensive Care Unit (ICU). Univariate and multivariate Cox regression analyses revealed a significantly increased risk of 28-day mortality in patients from the delayed CVP monitoring group compared to those who underwent early CVP measurements (HR = 2.87; 95% CI: 1.35-6.13; P = .006). Additionally, consistent results were observed for the risks of 90-day mortality (HR = 1.91; 95% CI: 1.09-3.35; P = .023) and 1-year mortality (HR = 1.84; 95% CI: 1.09-3.10; P = .023). In the ICU, an extended waiting time for CVP measurements in patients with acute pancreatitis was associated with an increased risk of 28-day mortality.

Occurrence of Low Cardiac Index During Normotensive Periods in Cardiac Surgery: A Prospective Cohort Study Using Continuous Noninvasive Cardiac Output Monitoring.

Continuous cardiac output monitoring is not standard practice during cardiac surgery, even though patients are at substantial risk for systemic hypoperfusion. Thus, the frequency of low cardiac output during cardiac surgery is unknown. We conducted a prospective cohort study at a tertiary medical center from July 2021 to November 2023. Eligible patients were ≥18 undergoing isolated coronary bypass (CAB) surgery with the use of cardiopulmonary bypass (CPB). Cardiac output indexed to body surface area (CI) was continuously recorded at 5-second intervals throughout surgery using a US Food and Drug Administration (FDA)-approved noninvasive monitor from the arterial blood pressure waveform. Mean arterial blood pressure (MAP) and central venous pressure (CVP) were also analyzed. Low CI was defined as <2 L/min/m2 and low MAP as <65 mm Hg. We calculated time with low CI for each patient for the entire surgery, pre-CPB and post-CPB periods, and the proportion of time with low CI and normal MAP. We used Pearson correlation to evaluate the relationship between CI and MAP and paired Wilcoxon rank sum tests to assess the difference in correlations of CI with MAP before and after CPB. In total, 101 patients were analyzed (age [standard deviation, SD] 64.8 [9.8] years, 25% female). Total intraoperative time (mean [SD]) with low CI was 86.4 (62) minutes, with 61.2 (42) minutes of low CI pre-CPB and 25.2 (31) minutes post-CPB. Total intraoperative time with low CI and normal MAP was 66.5 (56) minutes, representing mean (SD) 69% (23%) of the total time with low CI; 45.8 (38) minutes occurred pre-CPB and 20.6 (27) minutes occurred post-CPB. Overall, the correlation (mean [SD]) between CI and MAP was 0.33 (0.31), and the correlation was significantly higher pre-CPB (0.53 [0.32]) than post-CPB (0.29 [0.28], 95% confidence interval [CI] for difference [0.18-0.34], P < .001); however, there was substantial heterogeneity among participants in correlations of CI with MAP before and after CPB. Secondary analyses that accounted for CVP did not alter the correlation between CI and MAP. Exploratory analyses suggested duration of low CI (C <2 L/min/m2) was associated with increased risk of postoperative acute kidney injury (odds ratios [ORs] = 1.09; 95% CI; 1.01-1.13; P = .018). In a prospective cohort of patients undergoing CAB surgery, low CI was common even when blood pressure was normal. CI and MAP were correlated modestly. Correlation was higher before than after CPB with substantial heterogeneity among individuals. Future studies are needed to examine the independent relation of low CI to postoperative kidney injury and other adverse outcomes related to hypoperfusion.