Persistent Failure Research Articles

The value of using left ventricular pressure-strain loops to evaluate myocardial work in predicting heart failure with improved ejection fraction

BackgroundThe ultrasound left ventricular pressure-strain loop (LV PSL) was applied to evaluate myocardial work in heart failure with improved ejection fraction (HFimpEF) versus patients with persistent heart failure with reduced ejection fraction (HFrEF) to investigate the value of myocardial work parameters in predicting HFimpEF. MethodsWe collected 120 patients with HFrEF and recorded clinical characteristics and echocardiographic parameters (PSL technique) of patients. Patients were divided into HFimpEF group or persistent HFrEF group according to the outcome of follow-up.Furthermore, differential clinical and echocardiographic parameters were determined by Student's t-test. We recognized the important echocardiographic parameters to predict whether patients would recover to HFimpEF using the univariate logistic regression analysis and ROC curves. In addition, the multivariate logistic regression models were constructed and evaluated using Delong test and decision curve analysis. ResultsFirstly, the HFimpEF group had a higher prevalence of hypertension and higher systolic blood pressure (P-values <0.05). In terms of echocardiographic parameters, HFimpEF group also had higher LVEF, LV GLS, GCW, GWE, and GWI and lower LVEDD (P-values <0.01). In particular, LVEF, LVEDD, GLS, GWI, and GCW were robust predictors of the conversion of HFrEF patients to HFimpEF (AUC >0.70, P-values <0.05). Finally, we determined that the predictive Model 4 (LVEF, LVEDD, GLS, and GCW) had the optimal diagnostic power. ConclusionThe model constructed by GCW with LVEF, LVEDD, and GLS has important predictive value for HFimpEF, which is an effective clinical decision-making tool for providing disease assessment.

Relation between triglycerides and the severity of acute pancreatitis combined with nonalcoholic fatty liver disease: a retrospective study

BackgroundNonalcoholic fatty liver disease (NAFLD) can exacerbate the severity of acute pancreatitis (AP), and this severity is worsened with increased severity of NAFLD. This study aimed to investigate the relation between serum triglyceride (TG) and the severity of AP with NAFLD by collecting clinical data from AP patients with NAFLD.MethodsAP patients with NAFLD were divided into 2 groups according to TG levels: hypertriglyceridemia (HTG) group and non-hypertriglyceridemia (NHTG) group.ResultsIn total, 598 AP patients with NAFLD were enrolled in this study, including 433 in the HTG group and 165 in the NHTG group. Compared with the NHTG group, AP patients in the HTG group were more serious (P < 0.05). The incidence of persistent organ failure (POF), especially persistent respiratory failure, and the ratio of acute peripancreatic fluid collection (APFC) were higher in the HTG group (P < 0.05). Higher TG levels were associated with a higher incidence of APFC (P < 0.05). Logistic regression analysis showed that the risk of APFC was significantly higher in moderate and severe NAFLD than in mild NAFLD.ConclusionHTG may aggravate the severity and local complications of AP combined with NAFLD.

Modified Lemaire Lateral Extra-Articular Tenodesis Using an Inlay Technique and All-Suture Knotless Anchor Fixation

Appreciation of persistent anterolateral rotatory instability and graft failure after anterior cruciate ligament (ACL) reconstruction procedures has led surgeons to adopt the addition of lateral extra-articular tenodesis (LET) in both the revision and primary setting. Multiple techniques have been shown to eliminate anterolateral rotatory instability and reduce forces on the ACL graft, which has translated to lower re-rupture rates and improved patient outcomes. The risk of ACL/LET tunnel convergence can potentially compromise the fixation of one or both graft reconstructions. This article describes a technique for LET fixation which minimizes the depth of the LET femoral bone socket and utilizes low-profile implants thus mitigating this risk.

Carotid artery dissections from transcarotid artery revascularization as reported by the Food and Drug Administration.

Transcarotid artery revascularization (TCAR) is a hybrid procedure that allows reversal of blood flow away from the brain while placing a stent through direct surgical access of the common carotid artery. It has been shown to have a lower risk of perioperative stroke compared with any prospective trial of transfemoral carotid artery stenting. However, intraoperative injuries related to the procedure and its management are not well characterized. One of the intraoperative complications seen in TCAR is iatrogenic carotid artery dissection (CD). We aim to add qualitative insight in further characterizing CDs and its management in this emerging technology. The Food and Drug Administration (FDA) maintains the Manufacturer and User Facility Device Experience (MAUDE) database for surveillance of all medical devices approved for use. This database was queried for all cases associated with Silk Road Medical's ENROUTE Transcarotid Neuroprotection System from September 2016 to October 2020. Case narratives related to CD were individually analyzed to determine time of injury (intraoperative, recovery, and post-discharge follow-up). CD reporting was further analyzed for the associated procedural event at the time of injury, number of access attempts to CD repair, and type of CD repair. Reports associated with CD repair were further categorized into endovascular repair and open surgical repair. Of the 115 unique adverse events in the database, there were 58 CDs. Most were identified intraoperatively (n = 55), while three were incidentally found postoperatively. Overall, sheath placement was the most common procedural event attributed to CD (N = 34). There was adequate narrative information about CD repair in 54 patients. Intraoperative repair was performed in 52 cases and two were repaired after post-discharge follow-up imaging was performed.Among CDs that did not require additional access to engage the true lumen, the proportion of endovascular repair (62.5%) was significantly higher (p = .044) compared to the proportion of open surgical repair (37.5%). However, the proportion of open surgical repair (75%) was significantly higher than the proportion of endovascular repair (25%) in CDs with persistent failure to engage the true lumen despite ≥2 access attempts (p = .039). CD is the most common injury related to TCAR as reported on MAUDE. The most commonly reported procedural event associated with CD was sheath placement. The rate of intraoperative endovascular and open surgical CD repair was associated with whether the access to the true lumen of the carotid artery required additional access attempts or not. This should add qualitative insight among the vascular surgery community regarding intraoperative management of CDs from a TCAR procedure.

On-Support and Postweaning Mortality in Postcardiotomy Extracorporeal Membrane Oxygenation

BackgroundPostcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated. MethodsThe retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year. ResultsIn 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality. ConclusionsA discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.

A Real-Life Study of Combined Treatment with Long-Term Non-Invasive Ventilation and High Flow Nasal Cannula in Patients with End-Stage Chronic Obstructive Lung Disease.

Patients with end-stage chronic obstructive pulmonary disease (COPD) often develop persistent hypoxic or hypercapnic respiratory failure, or a combination of both. Ventilatory support, in terms of a long-term high-flow nasal cannula (LT-HFNC) and long-term non-invasive ventilation (LT-NIV), may be indicated. Often, clinicians choose either one or the other. This paper explores combined treatment with LT-HFNC and LT-NIV in a real-life setting. In total, 33 patients with COPD and persistent respiratory failure were included in this study. Of those, 17 were initiated on LT-HFNC and used it for 595 (374) days and 16 were initiated on LT-NIV and used it for 558 (479) days. On average, patients used respiratory support continuously for 908 (586) days. Baseline characteristics were comparable, apart from PaCO2 at first ventilatory support initiation (LT-HFNC/LT-NIV 7.1 (1.1) kPa/8.8 (0.9) kPa respectively (p = 0.002)). Both groups experienced a reduction in hospitalizations in the first twelve months after treatment initiation, compared to the twelve months before (LT-HFNC p = 0.022 and LT-NIV p = 0.014). In total, 25% of LT-NIV patients stopped treatment after HFNC initiation due to intolerance and 59% stopped LT-HFNC treatment 126 (36) days after LT-NIV initiation as monotherapy was sufficient. In 44% of these patients, LT-HFNC was re-initiated at the end of life. At the time of analysis, 70% of patients had died. In the last three months of life, patients stopped using LT-NIV, whereas 91% used LT-HFNC. In conclusion, the combined use of LT-NIV and LT-HFNC reduced hospitalizations in patients with COPD and persistent respiratory failure. The study indicates that LT-HFNC is well tolerated, and better tolerated than LT-NIV at the very end stages of COPD.

Suicide and attempted suicide of the victim: distinction of crimes under articles 120 and 166 of the Criminal Code of Ukraine

The article focuses on the issue of recognizing suicide as a social dangerous consequence of persistent failure to perform duties related to the care of a child or a person under guardianship or in the custody (Article 166 of the Criminal Code of Ukraine). Court practice of application of Article 166 of the Criminal Code of Ukraine for 2010-2023 (688 verdicts), as well as the legal opinions of the cassation court on the application of a number of legal provisions were studied. Taking into account the doctrine of criminal law and law enforcement practice, recognition not only the victim’s suicide, but also attempted suicide as a as a social dangerous consequence of this crime was proposed. As a result of the analysis of objective and subjective features of the crimes under Articles 120 «Driving a person into suicide» and 166 «Persistent failure to perform duties related to the care of a child or a person under guardianship or in the custody» of the Criminal Code of Ukraine, their differentiation was carried out. It is emphasized that systematic nature, as a mandatory feature of the act in both crimes, does not give grounds to conclude that the crime under Article 166 of the Criminal Code of Ukraine may be expressed in physical and psychological violence, cruel treatment. Options for qualifying the act depending on the perpetrator’s different psychological attitude to the consequences in the form of driving to suicide or attempted suicide were provided. In order to cover cases of intentional inaction of a person, which may consist, in particular, in failure to perform duties related to the care of a child or a person under guardianship or in the custody, it is proposed to replace the phrase “other actions” with “other act” in Part 1 of Article 120 of the Criminal Code of Ukraine.

Persistent mortality and heart failure burden of anterior ST-segment elevation myocardial infarction following primary percutaneous coronary intervention: real-world evidence from the US Medicare Data Set

ObjectivesWe sought to compare the temporal trends in the incidence of death and rehospitalisation for congestive heart failure (CHF) following anterior ST-elevation myocardial infarction (STEMI) in a Medicare cohort of...

Phenotypic and Genotypic Antimicrobial Susceptibility Testing of Chlamydia trachomatis Isolates from Patients with Persistent or Clinical Treatment Failure in Spain

The aim of this multicentre project (seven hospitals across the Spanish National Health Service) was to study the phenotypic and genotypic susceptibility of C. trachomatis to the main antimicrobials used (macrolides, doxycycline, and quinolones) in isolates from patients with clinical treatment failure in whom reinfection had been ruled out. During 2018–2019, 73 clinical isolates were selected. Sixty-nine clinical specimens were inoculated onto confluent McCoy cell monolayers for phenotypic susceptibility testing. The minimum inhibitory concentration for azithromycin and doxycycline was defined as the lowest concentration associated with an at least 95% reduction in inclusion-forming units after one passage in the presence of the antibiotic compared to the initial inoculum for each strain (control). Sequencing analysis was performed for the genotypic detection of resistance to macrolides, analysing mutations in the 23S rRNA gene (at positions 2057, 2058, 2059, and 2611), and quinolones, analysing a fragment of the gyrA gene, and searching for the G248T mutation (Ser83-&gt;Ile). For tetracyclines, in-house RT-PCR was used to test for the tet(C) gene. The phenotypic susceptibility testing was successful for 10 isolates. All the isolates had minimum inhibitory concentrations for azithromycin ≤ 0.125 mg/L and for doxycycline ≤ 0.064 mg/L and were considered sensitive. Of the 73 strains studied, no mutations were found at positions T2611C or G248T of the gyrA gene. We successfully sequenced 66 isolates. No macrolide resistance-associated mutations were found at positions 2057, 2058, 2059, or T2611C. None of the isolates carried the tet(C) gene. We found no evidence for genomic resistance in this large, clinically relevant dataset.

Heart failure, female sex and atrial fibrillation are the main drivers of atrial cardiomyopathy in cardiac surgery patients: results from the CATCH ME consortium

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): CATCH ME: Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly Background Atrial cardiomyopathy is emerging as independent prognostic factor in cardiovascular disease. Fibrotic remodeling, cardiomyocyte hypertrophy and a reduction in capillary density are histological hallmarks of atrial cardiomyopathy. The contribution of etiological factors to atrial cardiomyopathy has not been robustly quantified. Purpose To quantify the relation between histological features of atrial cardiomyopathy and the clinical profile of patients. Methods We examined left (LA, n=91) and right (RA, n=75) atrial appendages sampled from a European cohort of patients undergoing cardiac surgery. Quantification of histological cardiomyopathy features was performed a recently developed and validated imaging analysis algorithm following myocardial triple staining with wheat germ agglutinin (WGA), CD31 and vimentin. The contributions of AF, heart failure (HF), sex, age, and 4 principal components accounting for confounding clinical characteristics to over-all and endomysial fibrosis were determined in a multivariate model. K-means clustering of 6 atrial histological features was performed to identify different types of remodeling. Results LA samples showed less fibrosis (p&amp;lt;0.001), a higher capillary density (p&amp;lt;0.05), a smaller capillary size (p&amp;lt;0.05), and larger cardiomyocytes (p&amp;lt;0.01) than RA samples. In both LA and RA, persistent AF was associated with endomysial fibrosis, while over-all fibrosis was not. Men had larger cardiomyocytes (LAA), while women had a higher degree of endomysial fibrosis (LA). Heart failure patients had more endomysial and over-all fibrosis (LA), a higher capillary density (LA) and capillary size (LA/RA). Samples clustered into 2 distinct clusters. One cluster showed fibrotic cardiomyopathy, with more endomysial (p&amp;lt;0.001) and overall fibrosis (p&amp;lt;0.001), more fibroblasts (p&amp;lt;0,001) and a higher capillary density (p&amp;lt;0.001). The other cluster showed hypertrophic cardiomyopathy, with hypertrophic cardiomyocytes (p&amp;lt;0.001). Patients with fibrotic cardiomyopathy were more often female (LA and RA, p&amp;lt;0.003) and had more often persistent AF (LA, p=0.031) or heart failure (LA, p&amp;lt;0.001). Patients with hypertrophic cardiomyopathy were more often male (LA and RA, p&amp;lt;0.003). Conclusions Fibrotic cardiomyopathy is associated with female sex, persistent AF and heart failure while hypertrophic cardiomyopathy more often occurs in men. More research is needed to establish whether treatment of AF and heart failure prevents the development of atrial cardiomyopathy.

Effect of early pulmonary vein isolation in patients with heart failure and reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) and heart failure (HF) often coexist leading to worse outcomes compared to AF or HF alone. According to the current guidelines, PVI as first-line therapy should be considered, however, the optimal timing of the procedure is still unknown. Purpose We aimed to investigate the effect of early PVI on all-cause mortality and AF recurrence in patients with HFrEF. Methods We analyzed the data of 162 patients with symptomatic paroxysmal or persistent AF and heart failure with LVEF &amp;lt; 50% who underwent pulmonary vein isolation between 2010 and 2022. The patients’ medical history, laboratory results, echocardiographic and periprocedural parameters were collected in a structured registry. Early PVI was defined as catheter ablation performed within 12 months of AF diagnosis. The median follow-up was 59.7 months, the minimum follow-up was 12 months. Our primary endpoints were AF recurrence after a 3 months blanking period and all-cause mortality at any time during follow-up. Results Among the 162 patients, 77 experienced AF recurrence and 39 patients died during the follow-up period. The median age was 63.2 years. The median LVEF was 40% for early PVI and 37% for deferred PVI. Out of the 63 patients who underwent early PVI, 33 (52%) were taking amiodarone. Patients who underwent early PVI had longer freedom from recurrence (median 833 days until recurrence for early PVI, median 696 days for deferred PVI). Early PVI was a predictor of AF recurrence (HR: 0.58 [0.32-0.94], p=0.029).Early ablation was not associated with mortality benefit. However, among those who experienced AF recurrence, repeated ablation was associated with better survival during univariate Cox regression (p=0.01). Furthermore, in multivariate model, reablation was shown to be protective of mortality (HR: 0.312 [0.113-0.865], p=0.025) in the whole cohort. Conclusions Our study shows that early rhythm control therapy with catheter ablation is more successful compared to deferred PVI in patients with AF and HFrEF. A redo-PVI was associated with better survival, thus a repeat ablation should be considered in case of arrhythmia recurrence in patients with AF and HF to reduce mortality.

Management of Visceral Artery Patch Aneurysms and Segmental Artery Patch Aneurysms Following Open Thoracoabdominal Aortic Aneurysm Repair

Segmental intercostal/lumbar and visceral arteries are often reimplanted as a patch with surrounding native aortic tissue during open thoracoabdominal aortic aneurysm (TAAA) repair to preserve perfusion of the spinal cord and expedite visceral revascularization. However, late aneurysmal degeneration of the aortic tissue in the patch is a known, albeit infrequent, complication of this technique. The objective of this study was to describe our experience with management of visceral artery patch (VAP) aneurysms and segmental artery patch (SAP) aneurysms following TAAA repair. We retrospectively identified 57 patients (median age, 62 years; range, 50-73 years) who underwent VAP aneurysm and/or SAP aneurysm repair in our single practice (1986-2021). Median time from initial TAAA repair to patch aneurysm repair was 9 years (range, 5-12 years). Of these 57 repairs, 37 were for VAP aneurysm, 13 were for SAP aneurysm, and 7 were for both (Table). All 37 VAP aneurysms were repaired with open TAAA reoperations, while SAP aneurysms were addressed with either open repair (n = 13) or endovascular exclusion with thoracic aortic endografts (n = 7). Twenty-three patients (40%) had heritable thoracic aortic disease, of whom 17 had Marfan syndrome (30%). Crawford extent II repair was the most common preceding TAAA repair (n = 35, 61%). Patients presenting with patch aneurysm were often symptomatic (n = 41; 72%). Additionally, eight patients (14%) presented with patch aneurysm rupture. Early outcomes included operative mortality and adverse event, a composite variable comprised of operative death or persistent renal failure necessitating dialysis, paraplegia, paraparesis, or stroke. Operative mortality was 9% (n = 5); however, no operative deaths occurred in those treated with endovascular repair. The adverse event rate was 11% (n = 6), including four patients (7%) who developed persistent renal failure requiring dialysis following their repair. Only one patient (2%) experienced a stroke postoperatively. No patients experienced persistent paraplegia, including those who had endograft coverage of their intercostal patch without intercostal revascularization. Of 13 open SAP aneurysm repairs, 7 were performed with subsequent intercostal artery reimplantation. Left heart bypass was not used in any repairs; however, other adjuncts such as cerebrospinal fluid drainage (n = 27; 47%) and cold renal perfusion (n = 38; 67%) were used frequently. Most patients were discharged home (n = 49; 86%) (median length of hospital stay, 10 days; range, 9-14 days). Reoperative open VAP and SAP aneurysm repair is technically challenging; however, it can be performed with reasonable outcomes. Isolated SAP aneurysms can be safely managed with endovascular exclusion with promising results.TablePreoperative characteristics, operative details, and early outcomes in 57 visceral artery patch (VAP) aneurysm and segmental artery patch (SAP) aneurysm repairsVariablePatch aneurysm (n = 57)Age, years62 [50-73]Male sex30 (53)Time from initial TAAA repair to patch aneurysm repair, years9 [5-12]Heritable thoracic aortic disease23 (40)Tobacco use39 (68)Symptomatic41 (72)Rupture8 (14)Prior extent II repair35 (61)Urgent or emergency repair13 (23)Pseudoaneurysm at site of patch aneurysm15 (26)Open repaira50 (88) VAP aneurysm only37 (74) SAP aneurysm only6 (12) Both7 (14)Endovascular repair7 (12) VAP aneurysm0 SAP aneurysm7 (100)Cerebrospinal fluid drainage27 (47)Left heart bypass0Adverse event6 (11)Operative death5 (9)Persistent paraplegia0Persistent renal failure4 (7)Length of intensive care unit stay, days4 [3-6]Length of hospital stay, days10 [9-14]Discharged home49 (86)Values are number (%) or median (quartile 1-quartile3 [Q1-Q3]). Variables with missing data are clarified by available sample size.aPercentages in the open and endovascular repair subgroups are expressed as percentage of total open or endovascular repairs, respectively. Seven open repairs were performed in patients who had both VAP and SAP aneurysms repaired simultaneously. Open table in a new tab

Echocardiographic pattern of left ventricular function recovery in tachycardia-induced cardiomyopathy patients.

Tachycardia-induced cardiomyopathy (TCM) represents a partially reversible type of cardiomyopathy (CM) that is often underdiagnosed and cardiac chamber remodelling in TCM remains incompletely understood. We aim to explore differences in the dimensions of the left ventricle and functional recovery in patients with TCM compared with patients with other forms of CM. We identified patients with reduced ejection fraction (≤50%) and/or atrial fibrillation or flutter with a left ventricular ejection fraction that improved from baseline (≥15% in left ventricular ejection fraction at follow-up or normalization of cardiac function with at least 10% improvement). Patients were then divided into two groups: (A) TCM patients and (B) patients with other forms of CM (controls). Two hundred thirty-eight patients were included (31% female, 70years median age), 127 patients had TCM, and 111 had other forms of CM. Patients with TCM did not significantly improve indexed left ventricular volume (LVEDVI) after treatment (60 [45, 84] mL/m2 versus 56 [45, 70] mL/m2 , P=ns) compared with controls (67 [54, 81] mL/m2 versus 52 [42, 69] mL/m2 , P<0.001). Patients with TCM patients had significantly worse fractional shortening at baseline than controls (15.5 [12, 23] vs. 20 [13, 30], P=0.01) and higher indexed left atrial volume (LAVI) at baseline than controls (48 [37, 58] vs. 41 [33, 51], P=0.01) that remained dilated at follow-up (follow-up LAVI 41 [33, 52] mL/m2 ). Good predictors of TCM were: normal LVEDVI (LVEDVI < 58mL/m2 (M) and < 52mL/m2 (F)) (odds ratio [OR] 5.2; 95% confidence interval [CI] 2.2-13.3, P<0.001), fractional shortening<30% (OR 3.5; 95% CI 1.4-9.2, P=0.009), LAVI >40mL/m2 (OR 3.4; 95% CI 1.6-7.3, P=0.001) and normal wall thickness left ventricle (OR 3.2; 95% CI 1.4-7.8, P=0.008). 54% of patients with TCM demonstrated diastolic dysfunction at follow-up, without differences from controls (54% vs. 43%, P=ns). 21% of patients with TCM showed persistent heart failure symptoms at follow-up compared with 4.5% of controls, P=0.004. TCM patients have a specific pattern of functional recovery with persistent remodelling of the left atria and left ventricle. Several echocardiographic parameters might help identify TCM before treatment.

The Immunoadsorption Effect of Veno-arterial Extracorporeal Membrane Oxygenation in Refractory Septic Shock, Ventilator-associated Pneumonia, and Acute Respiratory Distress Syndrome Following Severe Pulmonary Contusions

Background: The utilization of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for immunoadsorption has proven efficacious in reducing mortality rates among neonatal and pediatric patients afflicted with severe sepsis and septic shock. However, the effectiveness of this treatment in adult patients with septic shock remains controversial. Objective: This study was designed to assess the potential of VA-ECMO as an immunoadsorption therapy in patients with severe sepsis and septic shock. The primary objective of this study is to evaluate the efficacy of VA-ECMO in improving clinical outcomes, including acute respiratory distress syndrome (ARDS) and ventilator-associated pneumonia (VAP), weaning from mechanical ventilation, the length of intensive care unit (ICU) stay, and mortality rates in patients with concurrent severe pulmonary contusions, septic shock, and respiratory failure resulting from ARDS and VAP. Methods: This study enrolled a cohort of 100 adult patients with severe pulmonary contusions resulting in persistent respiratory failure despite ten days of mechanical ventilation. These patients subsequently developed severe sepsis, VAP with ARDS presentation, and high Murray score (&gt;3 points), Sequential Organ Failure Assessment (SOFA) score (&gt; 12 points), and Clinical Pulmonary Infection Score (CPIS) (&gt; 6 points). The patients were then divided into two groups: group A (n = 50) received conventional management, while group B (n = 50) underwent VA-ECMO. Moreover, the outcomes, including improvement in ARDS and VAP, successful weaning from mechanical ventilation, length of ICU stay, improvement of one or all parameters of Murray, SOFA, and CPIS scores, morbidity rate, and mortality rate were compared between the two groups and recorded after 14 days of treatment. Results: This study revealed that patients in group B showed significant improvement in Murray, SOFA, and CPIS scores. Furthermore, a large percentage of patients in group B were successfully weaned from both inotropic support and mechanical ventilation and were discharged from ICU. However, no significant difference in the mortality rate was observed between the two groups. Conclusion: VA-ECMO notably impedes the progression of sepsis, shortens ICU stay, and expedites the weaning from inotropic support and mechanical ventilation. However, it has no impact on the mortality rate of adult patients with septic shock.

A novel stepwise approach incorporating ethanol infusion in the vein of Marshall for the ablation of persistent atrial fibrillation.

Apart from pulmonary vein isolation (PVI), several step-by-step procedures that aim to modify left atrial substrate have been proposed for the ablation of persistent atrial fibrillation (AF), yet the optimal strategy remains elusive. There are cumulative data suggesting an incremental benefit of adding vein of Marshall (VOM) ethanol infusion to PVI in patients with persistent AF. We sought to evaluate the feasibility and efficacy of a novel stepwise ablation approach, incorporating a VOM alcoholization step, for persistent AF. In this single-center study, we prospectively enrolled 66 consecutive patients with symptomatic persistent AF and failure of at least one antiarrhythmic drug (ADD). The ablation procedure consisted of (i) PVI, (ii) left atrial segmentation with VOM ethanol infusion and the deployment of linear radiofrequency lesions across the roof and the mitral isthmus and (iii) electrogram-based ablation of dispersion zones. The first two steps were performed in all patients, whereas the third step was carried out only in those still in AF at the end of the second step. Atrial tachycardias during the procedure were mapped and ablated. At the end of the procedure, cavotricuspid isthmus ablation was additionally performed in all patients. The primary endpoint was 12-month freedom from AF and atrial tachycardia after a single procedure and an initial three-month blanking period. Total procedure time was 153 ± 38.5 min. Fluoroscopy time was 16 ± 6.5 min and the radiofrequency ablation time was 26.14 ± 0.26 min. The primary endpoint occurred in 54 patients (82%). At 12 months, 65% of patients were off any AAD. In the univariate Cox regression analysis, left ventricular ejection fraction < 40% was the only predictor of arrhythmia recurrence (HR 3.56; 95% CI, 1.04-12.19; p = 0.04). One patient developed a pericardial tamponade and another a minor groin hematoma. A novel stepwise approach, including a step of ethanol infusion in the VOM, is feasible, safe and provides a high rate of sinus rhythm maintenance at 12 months in patients with persistent AF.

The monstruous and the miscount: a radical theory of accountability

ABSTRACT Can public inquiries and truth commissions provide a space for political transformation? This article investigates the field of transitional justice to address this question, focusing on pessimistic accounts of the persistent failure of truth-telling practices. It identifies three main narratives on why truth commissions fail to promote change, namely the failure of implementation, failure of design and failure by design narratives. This article contends that none of these narratives satisfactorily answer the question raised by this special issue due to their attachment to a referentialist ontology and a linear temporality of truth-seeking. Combining Rancière’s critique of political philosophy with insights from Lacanian psychoanalysis, the article advances a radical theory of accountability capable of circumventing these limitations and elucidating the links between truth-telling and political transformation. Based on an anti-foundationalist approach, this theory sees the work of truth commissions as situated in struggles that constitute the after-maths; the process of counting the parts of a conflict (victims, perpetrators, collaborators) and making suffering count (as violence) by attaching it to an object source (a cause). Seen in a radical light, truth-telling appears trespassed by two organizing principles: the management of monstrosity (as a regime of visibility that formalizes suffering and apportions blame and culpability) and the inevitable miscount of the identities that populate the victim-perpetrators spectrum. The article argues that investigative commissions are doomed to fail, but it is thanks to this failure that they can offer a space for political transformation.

MP-453085-5 ATRIAL FIBRILLATION, FEMALE SEX AND HEART HAILURE ARE THE MAIN DRIVERS OF ATRIAL CARDIOMYOPATHY IN CARDIAC SURGERY PATIENTS: RESULTS FROM THE CATCH ME CONSORTIUM

Atrial cardiomyopathy is emerging as independent prognostic factor in cardiovascular disease. Fibrotic remodeling, cardiomyocyte hypertrophy and a reduction in capillary density are histological hallmarks of atrial cardiomyopathy. The contribution of etiological factors to atrial cardiomyopathy has not been robustly quantified. To quantify the relation between histological features of atrial cardiomyopathy and the clinical profile of patients. We examined left (LAA, n=91) and right (RAA, n=75) atrial appendages sampled from a European cohort of patients undergoing cardiac surgery. Quantification of histological cardiomyopathy features was performed using a recently developed and validated imaging analysis algorithm following myocardial triple staining with wheat germ agglutinin (WGA), CD31 and vimentin. The contributions of AF, heart failure (HF), sex, age, and 4 principal components accounting for confounding clinical characteristics to over-all and endomysial fibrosis were determined in a multivariate model. K-means clustering of 6 atrial histological features was performed to identify different types of remodeling. LAA samples showed less fibrosis (p<0.001), a higher capillary density (p<0.05), a smaller capillary size (p<0.05), and larger cardiomyocytes (p<0.01) than RAA samples. In both LAA and RAA, persistent AF was associated with endomysial fibrosis, while over-all fibrosis was not. Men had larger cardiomyocytes (LAA), while women had a higher degree of endomysial fibrosis (LAA). Heart failure patients had more endomysial and over-all fibrosis (LAA), a higher capillary density (LAA) and capillary size (LAA/RAA). Samples clustered into 2 distinct clusters. One cluster showed fibrotic cardiomyopathy, with more endomysial (p<0.001) and overall fibrosis (p<0.001), more fibroblasts (p<0,001) and a higher capillary density (p<0.001). The other cluster showed hypertrophic cardiomyopathy, with hypertrophic cardiomyocytes (p<0.001). Patients with fibrotic cardiomyopathy were more often female (LAA and RA, p<0.003) and had more often persistent AF (LAA, p=0.031) or heart failure (LAA, p<0.001). Patients with hypertrophic cardiomyopathy were more often male (LAA and RAA, p<0.003). Fibrotic cardiomyopathy is associated with female sex, persistent AF and heart failure while hypertrophic cardiomyopathy more often occurs in men. More research is needed to establish whether treatment of AF and heart failure prevents the development of atrial cardiomyopathy.

Massive Left Ventricular Aneurysm After Inferior Infarction

True ventricular aneurysm is a rare complication of myocardial infarction. After a 53-year-old man presented late with an inferior ST-segment elevation myocardial infarction, he was found to have a massive posterobasal left ventricular aneurysm. Cardiac magnetic resonance imaging volumetric analysis highlighted the hemodynamic significance of the aneurysm. As the result of persistent symptomatic heart failure, the patient underwent surgical resection of the aneurysm and placement of a pericardial patch with excellent results at follow-up.

Effects of Gender and Baseline CD4 Count on Post-Treatment CD4 Count Recovery and Outcomes in Patients with Advanced HIV Disease: A Retrospective Cohort Study.

Presentation to care with advanced HIV disease (AHD) is a significant problem in sub-Saharan Africa. We evaluated factors associated with immune recovery among individuals presenting to care with AHD in Zimbabwe. We conducted a retrospective evaluation of outcomes among adult (>18 years old) individuals with AHD (CD4 count ≤200 cells/mm3) receiving care at 18 outpatient primary care clinics in Harare, Zimbabwe. Baseline and 12-month CD4 count data were extracted from medical records. CD4 count recovery (defined as CD4 count >200 cells/mm3) after 12 months on non-nucleotide reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy (ART) regimen was determined and factors associated with CD4 count recovery were established using logistic regression. All statistical analysis was performed on SPSS v23. A total of 1,338 participant records were included in the analysis. The median interquartile range (IQR) age was 37 (30-43) years and 52% were females. The baseline median (IQR) CD4 count was 50 (28-75) cells/mm3 and was significantly lower among patients with history of cryptococcal meningitis compared to those without [25 (10-52) vs. 52 (32-77), respectively; p = .0009]. The median (IQR) CD4 count at 12 months after ART initiation increased from 50 (28-75) at baseline to 180 (92-290) cells/mm3. Immune recovery with a CD4 count >200 cells/mm3 was observed in 181/417 (43%). Male gender and low baseline CD4 count were strong predictors of poor immunological recovery on ART. Immunological recovery following ART initiation was 43% among individuals with AHD. Male patients are most vulnerable to persistent immunological failure. Clinical Trial Registration number: NCT02434172.

Preservation of thalamocortical circuitry is essential for good recovery after cardiac arrest.

Continuous electroencephalographam (EEG) monitoring contributes to prediction of neurological outcome in comatose cardiac arrest survivors. While the phenomenology of EEG abnormalities in postanoxic encephalopathy is well known, the pathophysiology, especially the presumed role of selective synaptic failure, is less understood. To further this understanding, we estimate biophysical model parameters from the EEG power spectra from individual patients with a good or poor recovery from a postanoxic encephalopathy. This biophysical model includes intracortical, intrathalamic, and corticothalamic synaptic strengths, as well as synaptic time constants and axonal conduction delays. We used continuous EEG measurements from hundred comatose patients recorded during the first 48 h postcardiac arrest, 50 with a poor neurological outcome [cerebral performance category ] and 50 with a good neurological outcome ( ). We only included patients that developed (dis-)continuous EEG activity within 48 h postcardiac arrest. For patients with a good outcome, we observed an initial relative excitation in the corticothalamic loop and corticothalamic propagation that subsequently evolved towards values observed in healthy controls. For patients with a poor outcome, we observed an initial increase in the cortical excitation-inhibition ratio, increased relative inhibition in the corticothalamic loop, delayed corticothalamic propagation of neuronal activity, and severely prolonged synaptic time constants that did not return to physiological values. We conclude that the abnormal EEG evolution in patients with a poor neurological recovery after cardiac arrest may result from persistent and selective synaptic failure that includes corticothalamic circuitry and also delayed corticothalamic propagation.