Jurgen Passage

Custodiol for myocardial protection and preservation: a systematic review

INTRODUCTIONnCustodiol cardioplegia is attractive for minimally invasive cardiac surgery, as a single dose provides a long period of myocardial protection. Despite widespread use in Europe, there is little data confirming its efficacy compared with conventional (blood or crystalloid) cardioplegia. There is similar enthusiasm for its use in organ preservation for transplant, but also a lack of data. This systematic review aimed to assess the evidence for the efficacy of Custodiol in myocardial protection and as a preservation solution in heart transplant.nnnMETHODSnElectronic searches were performed of six databases from inception to October 2013. Reviewers independently identified studies that compared Custodiol with conventional cardioplegia (blood or extracellular crystalloid) in adult patients for meta-analysis; large case series that reported results using Custodiol were analyzed. Next, we identified studies that compared Custodiol with other organ preservation solutions for organ preservation in heart transplant.nnnRESULTSnFourteen studies compared Custodiol with conventional cardioplegia for myocardial protection in adult cardiac surgery. No difference was identified in mortality; there was a trend for increased incidence of ventricular fibrillation in the Custodiol group that did not reach statistical significance. No difference was identified in studies that compared Custodiol with other solutions for heart transplant.nnnCONCLUSIONSnDespite widespread clinical use, the evidence supporting the superiority of Custodiol over other solutions for myocardial protection or organ preservation is limited. Large randomised trials are required.

Remote ischaemic preconditioning down-regulates kinin receptor expression in neutrophils of patients undergoing heart surgery

OBJECTIVESnRemote ischaemic preconditioning (RIPC) may protect distant organs against ischaemia-reperfusion injury. We investigated the impact of RIPC on kinin receptor expression in neutrophils following RIPC in patients undergoing coronary artery bypass grafting (CABG).nnnMETHODSnPatients undergoing elective CABG with cardiopulmonary bypass (CPB) were randomized to RIPC (n = 15) or control (n = 15) groups. The study group underwent RIPC by inflation of a blood pressure cuff on the arm. Expression of kinin receptors, plasma concentrations of IL-6, IL-8, IL-10, TNF-α and neutrophil elastase were determined at baseline (before RIPC/sham), immediately before surgery (after RIPC/sham) and 30 min and 24 h after surgery. Plasma bradykinin levels were assessed before and after RIPC/sham, and at 30 min, 6, 12 and 24 h after surgery. Serum creatine kinase (CK), troponin I, C-reactive protein (CRP) and lactate levels were measured immediately prior to surgery and 30 min, 6, 12, 24 and 48 h after surgery.nnnRESULTSnKinin B2 receptor expression did not differ between the groups at baseline (pre-RIPC), but was significantly lower in the RIPC group than in the control group after RIPC/sham (P < 0.05). Expressions of both kinin B1 and B2 receptors were significantly down-regulated in the RIPC group, and this persisted to 24 h after surgery (P < 0.001). Neutrophil elastase levels were significantly increased after surgery. There were no differences in CK, CRP, cytokine, lactate or troponin I levels between the groups.nnnCONCLUSIONSnRIPC down-regulated the expression of kinin B1 and B2 receptors in neutrophils of patients undergoing CABG.

Percutaneous Mitral Valve Repair in a High-risk Australian Series

BACKGROUNDnThe prognosis for patients with symptomatic, severe mitral regurgitation (MR) who have comorbidities precluding mitral valve surgery is poor. Treatment of MR using a percutaneous edge-to-edge technique may improve survival, quality of life and reduce hospitalisations. To date, there are few studies reporting outcomes after percutaneous mitral valve repair in high-risk patients and none reported from Australia.nnnMETHODSnThe first 25 patients undergoing percutaneous mitral valve repair using the MitraClip in our Institution had follow-up to six months. These patients had severe, symptomatic MR and were deemed too high-risk for mitral valve surgery by a multidisciplinary heart team, including an interventional cardiologist and cardiothoracic surgeon.nnnRESULTSnThere were no peri-procedural deaths; the only peri-procedural morbidity was blood transfusion in three patients. Three patients had died at six months and there were six readmissions to hospital. There was a significant improvement in heart failure symptoms, 6-minute walk test and quality of life at six months. There was a significant improvement in the proportion of patients with MR ≤2+, but no significant change in other echocardiographic parameters.nnnCONCLUSIONSnPercutaneous mitral valve repair is safe in patients at high-risk for surgery, and improves symptoms and quality of life.

The Healthy Heart-Mind trial: melatonin for prevention of delirium following cardiac surgery: study protocol for a randomized controlled trial.

BackgroundDelirium is a common occurrence in patients undergoing major cardiac surgery and is associated with a number of adverse consequences for the individual, their family and the health system. Current approaches to the prevention of delirium include identifying those at risk together with various non-pharmacological and pharmacological strategies, although the efficacy of these is often modest. Emerging evidence suggests that melatonin may be biologically implicated in the development of delirium and that melatonin supplementation may be beneficial in reducing the incidence of delirium in medical and surgical patients. We designed this trial to determine whether melatonin reduces the incidence of delirium following cardiac surgery compared with placebo.Methods/DesignThe Healthy Heart-Mind trial is a randomized, double-blind, placebo-controlled clinical trial of 3xa0mg melatonin or matching placebo administered on seven consecutive days for the prevention of delirium following cardiac surgery. We will recruit 210 adult participants, aged 50 and older, undergoing elective or semi-elective cardiac surgery with the primary outcome of interest for this study being the difference in the incidence of delirium between the groups within 7xa0days of surgery. Secondary outcomes of interest include the difference between groups in the severity and duration of delirious episodes, hospital length of stay and referrals to mental health services during admission. In addition, we will assess differences in depressive and anxiety symptoms, as well as cognitive performance, at discharge and 3xa0months after surgery.DiscussionThe results of this trial will clarify whether melatonin reduces the incidence of delirium following cardiac surgery.Trial registrationThe trial is registered with the Australian Clinical Trials Registry, trial number ACTRN12615000819527 (10 August 2015).

The MitraClip Asia‐Pacific registry: Differences in outcomes between functional and degenerative mitral regurgitation

The objective of this study is to describe and compare the use of the MitraClip therapy in mitral regurgitation (MR) patients with degenerative MR (DMR) and functional MR (FMR).

Extensive clot propagation involving the aorta and brachiocephalic artery: unusual consequence of paradoxical embolism.

A 73-year old woman with factor V Leiden deficiency and a history of deep venous thrombosis ceased taking oral warfarin. She sustained a massive cerebral infarct following extensive paradoxical embolism involving the brachiocephalic artery and the aorta (Fig. 1A and B). Transoesophageal echo findings (Fig. 2A and B) can be viewed in Supplementary Videos 1 and 2. Supplementary material (Videos 1 and 2) is available at EJCTS online. Video 1: Transoesophageal echocardiogram showing a large free-floating luminal thrombus within the aortic arch. Video 2: Transoesophageal echocardiogram demonstrating a large patent foramen ovale and an aneurysmal interatrial septum with a right-to-left shunt.

Right Ventricular Perforation during Femoral Venous Cannulation – Lessons Learned

Peripheral cannulation for cardiopulmonary bypass is increasingly used for minimally invasive and re-operative cardiac surgery. Transoesophageal echo (TOE) is used routinely to guide placement of the peripheral venous cannula in the right atrium/superior vena cava (SVC). We here present a case where despite use of TOE, placement of the venous cannula led to perforation of the right ventricular apex. We describe the surgical management of the problem and highlight strategies to avoid this complication.

Transient occlusion of the right coronary artery by a calcific bicuspid aortic valve mass - An interesting case of inferior STEMI

Calcified bicuspid aortic valves are a commonly encountered clinical problem. Less common and possibly underreported, however, are embolic events secondary to a calcified valve. Events, including stroke and myocardial infarction, have been documented in the literature. We report the case of a myocardial infarction caused by transient occlusion of the right coronary artery, secondary to a mobile calcified lesion attached to a bicuspid aortic valve. <Learning objective: The purpose of this article is to demonstrate the importance of echocardiography in patients presenting with an acute myocardial infarction, without significant coronary artery disease. Urgent echocardiography in this case ensured identification of a calcified bicuspid valve and mobile lesion that had transiently occluded the right coronary artery. Subsequent urgent surgery ensured an excellent outcome.>.

Refractory ascites - a rare presentation of severe aortic regurgitation.

A 47 year-old male with a history of refractory ascites presented to our centre complaining of dyspnoea, abdominal distention, and weight gain. He was admitted under a medical team for investigation and management. Work-up excluded all common aetiologies of ascites. Echocardiography revealed severe aortic regurgitation (AR) with a dilated left ventricle but no right heart pathology or pulmonary hypertension. He underwent mechanical aortic valve replacement. Intra-operatively, a prolapsing left coronary leaflet of the aortic valve with frayed edges raised suspicion of resolved infective endocarditis. Postoperative course was uneventful. Following replacement of the aortic valve, the patient was completely free of ascites. This case demonstrates that ascites can be an unusual clinical presentation of severe aortic regurgitation, which may respond to aortic valve replacement.

Resection of Left Ventricular Rhabdomyosarcoma

![Figure][1] nn[![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5]nnnnA 24-year-old woman, a Jehovahs Witness, presented to the Emergency Department with a 4-day history of palpitations and found to be in fascicular ventricular tachycardia (A) . This proved difficult to