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The COVID-19 pandemic has required reorganization of the cardiac surgery system in the Italian region of Lombardy during early 2020. As a consequence, the hub-and-spoke (H&S) model was introduced to manage emergent/urgent cardiac surgery cases. In this challenging scenario, in which thousands of people were affected by the novel coronavirus, we present the case of a successful treatment of a middle-aged patient affected by both COVID-19 pneumonia and subacute aortic endocarditis. Learning objective: How to treat endocarditis during the COVID-19 pandemic.

ObjectiveTo assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19).MethodsThis single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion ResultsA total of 200 patients were included in the final analysis (median age 62 (IQR 52–74) years, 65.5% men). The prevalence of PH and RVD was 12.0% (24/200) and 14.5% (29/200), respectively. Patients with PH were older and had a higher burden of pre-existing cardiac comorbidities and signs of more severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (radiological lung involvement, laboratory findings and oxygenation status) compared with those without PH. Conversely, patients with RVD had a higher burden of pre-existing cardiac comorbidities but no evidence of more severe SARS-CoV-2 infection compared with those without RVD. The presence of PH was associated with a higher rate of in-hospital death or ICU admission (41.7 vs 8.5%, pConclusionsAmong hospitalised non-ICU patients with COVID-19, PH (and not RVD) was associated with signs of more severe COVID-19 and with worse in-hospital clinical outcome.Trial registration numberNCT04318366

CytoSorb is a promising tool to treat severe inflammatory status with multiple mechanisms in the acute care setting. Its effect on drugs is, however, poorly documented in vivo, although removal of small molecules might translate into decreased blood levels of life-saving medications. The aim of this study was to assess the impact of CytoSorb on vancomycin and bivalirudin clearance in a large population of critically ill patients. We performed a single-center analysis of CytoSorb treatments performed between January 2018 and March 2019 in critically ill patients admitted to our intensive care unit. A total of 109 CytoSorb treatments were performed in 89 patients. A decrease in lactate dehydrogenase (P = .007), troponin T (P = .022), and creatine phosphokinase (P = .013) was reported during treatment. Vancomycin dose required significant adjustments during treatment (P < .001), but no significant change was necessary after the first 3 days. Similarly, the requirements of bivalirudin significantly changed over days (P < .001), but no dose adjustment was needed after the first 3 days of treatment. No differences in terms of vancomycin and bivalirudin dose need was observed between patients on extracorporeal membrane oxygenation and those who were not (P = .6 and P = .6, respectively), between patients with and without continuous veno-venous hemofiltration (P = .9 and P = .9, respectively), and between CytoSorb responders or not (P = .4 and P = .7, respectively). CytoSorb is effective in mitigating the systemic inflammatory response and safe with respect to vancomycin and bivalirudin administration. These preliminary data further support the use of CytoSorb as adjunct therapy in critically ill patients.

SARS-CoV-2 outbreak has rapidly reached a pandemic proportion and has become a major threaten to global health. Although the predominant clinical feature of COVID-19 is an acute respiratory syndrome of varying severity, ranging from mild symptomatic interstitial pneumonia to acute respiratory distress syndrome, the cardiovascular system can be involved with several facets. As many as 40% hospitalized patients presenting with COVID-19 have pre-existing history of cardiovascular disease and current estimates report a proportion of myocardial injury in COVID-19 patients ranging up to 12%. Multiple pathways have been advocated to explain this finding and the related clinical scenarios, encompassing local and systemic inflammatory response and oxygen supply-demand imbalance. From a clinical point of view, cardiac involvement during COVID-19 may present a wide spectrum of severity ranging from subclinical myocardial injury to well-defined clinical entities (myocarditis, myocardial infarction, pulmonary embolism and heart failure), whose incidence and prognostic implications are currently largely unknown due to a significant lack of imaging data. The use of integrated heart and lung multimodality imaging plays a central role in different clinical settings and is essential in diagnosis, risk stratification and management of COVID-19 patients. Aim of this review is to summarize imaging-oriented pathophysiological mechanisms of lung and cardiac involvement in COVID-19 and to provide a guide for an integrated imaging assessment in these patients., Graphical abstract, Highlights • Although lung injury is predominant, cardiac involvement is present in up to 12% of COVID-19 patients. • Heart and lung multimodality imaging plays an essential role in different clinical settings in COVID-19 patients. • Multimodality imaging findings are useful in diagnosis, risk stratification and management of COVID-19 patients. • Strategies for preventing SARS-CoV-2 transmission during examinations in Imaging Departments must be adopted.

During the last decades, the use of mechanical circulatory support devices (MCS) has increased exponentially. In this scenario, a fully percutaneous approach to biventricular cardiogenic shock has ...

Background: Coronavirus disease 2019 (COVID-19) pandemic has led to a fast and radical transformation in social, economic, and healthcare networks. COVID-19 outbreak may thus have profound indirect consequences on clinical presentation and management of patients with ST-segment–elevation myocardial infarction (STEMI). Aim of this study was to assess clinical features of patients with STEMI during COVID-19 pandemic. Methods: This single-center, prospective study from a regional public service healthcare hub in Milan included all consecutive patients with STEMI admitted to our institute from February 21 to April 1, 2020 (during COVID-19 pandemic). These patients were compared with a historical cohort of patients admitted for STEMI during the analogous time period (February 21 to April 1) in 2018 and 2019, in terms of time from symptoms onset to hospital admission, clinical characteristics, and in-hospital outcomes. Results: A total of 26 patients were admitted for STEMI during the study period, and 7 (26.9%) of these patients tested positive for severe acute respiratory syndrome coronavirus 2. On admission, medical therapy, including angiotensin-converting enzyme inhibitors and angiotensin receptor blockers use, was similar between cohorts. Median (interquartile range) time from symptoms onset to hospital admission was significantly longer in 2020 as compared to the historical cohort (15.0 [2.0–48.0] versus 2.0 [1.0–3.0] hours; P P P =0.06). In-hospital death, thromboembolism, mechanical ventilation, or hemodynamic decompensation needing inotropic or mechanical support were similar between years. Conclusions: These preliminary results from a cardiovascular regional public service healthcare hub demonstrate a significantly longer time from symptoms onset to hospital admission among patients with STEMI during COVID-19 pandemic compared with the same time period in the previous 2 years.

Left ventricle (LV) unloading during VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) reduces the risk of LV distention, stagnation and pulmonary congestion resulting from the increased afterload. Lacking direct comparisons between unloading strategies we used network meta-analysis to indirectly compare different unloading approaches.A literature research was performed to include all studies on VA-ECMO reporting data on mechanical LV unloading. The pre-specified outcome was in-hospital death.Literature search identified 389 studies: 16 were included in the analysis (3930 patients). Two strategies of mechanical LV unloading were compared: afterload reduction (IABP) and preload reduction (Impella pump, right upper pulmonary/trans-septal catheters, LV surgical vents). Any LV unloading strategy was associated with mortality reduction with overall OR = 0.54; 95% CI 0.42-0.70; p .001. Targeting afterload was associated with reduced mortality (OR = 0.61 95% CI 0.46-0.81; p .001; IAny unloading strategy in VA-ECMO patients was associated with lower mortality as compared to no-unloading. Preload reduction strategies resulted superior to afterload reduction.

Objective To assess the prevalence, characteristics and prognostic value of pulmonary hypertension (PH) and right ventricular dysfunction (RVD) in hospitalised, non-intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19). Methods This single-centre, observational, cross-sectional study included 211 patients with COVID-19 admitted to non-ICU departments who underwent a single transthoracic echocardiography (TTE). Patients with poor acoustic window (n=11) were excluded. Clinical, imaging, laboratory and TTE findings were compared in patients with versus without PH (estimated systolic pulmonary artery pressure >35 mm Hg) and with versus without RVD (tricuspid annular plane systolic excursion

Introduction: Despite significant technical advancements in the design and manufacture of Left Ventricular Assist Devices, post-implant thrombotic and thromboembolic complications continue to affect long-term outcomes. Previous efforts, aimed at optimizing pump design as a means of reducing supraphysiologic shear stresses generated within the pump and associated prothrombotic shear-mediated platelet injury, have only partially altered the device hemocompatibility. Methods: We examined hemodynamic mechanisms that synergize with hypershear within the pump to contribute to the thrombogenic potential of the overall Left Ventricular Assist Device system. Results: Numerical simulations of blood flow in differing regions of the Left Ventricular Assist Device system, that is the diseased native left ventricle, the pump inflow cannula, the impeller, the outflow graft and the anastomosed downstream aorta, reveal that prothrombotic hemodynamic conditions might occur at these specific sites. Furthermore, we show that beyond hypershear, additional hemodynamic abnormalities exist within the pump, which may elicit platelet activation, such as recirculation zones and stagnant platelet trajectories. We also provide evidences that particular Left Ventricular Assist Device implantation configurations and specific post-implant patient management strategies, such as those allowing aortic valve opening, are more hemodynamically favorable and reduce the thrombotic risk. Conclusion: We extend the perspective of pump thrombosis secondary to the supraphysiologic shear stress environment of the pump to one of Left Ventricular Assist Device system thrombosis, raising the importance of comprehensive characterization of the different prothrombotic risk factors of the total system as the target to achieve enhanced hemocompatibility and improved clinical outcomes.

Purpose CytoSorb treatment is a promising tool to treat severe inflammatory status in the acute care setting. Its effect on drugs is, however, poorly documented in vivo, although unselective and unpredictable removal of small molecules might translate into decreased blood levels of potentially life-saving medications. The aim of this study was to assess the impact of Cytosorb treatment on clereance of small drug molecules, measured as dose adjustements need, in a large population of critically ill patients. Methods Single-center analysis of Cytosorb treatments performed between 01-2018 and 03-2019 in patients with cardiogenic shock of several origins. Results 109 Cytosorb treatments were performed in 86 patients. A decrease in LDH (p=0.007), troponin T (p=0.022) and CPK (p=0.013), together with a trend toward lower need of inotropes, was reported during treatment, supporting its clinical efficacy in the study population. Vancomycin dose was significantly changed during the days of treatment (p Conclusion Cytosorb therapy was effective in improving shock parameters in a large population of cardiogenic shock patients, without affecting the dose need of vancomycin and bivalirudin after reaching target concentration. The results of this study further support the role of Cytosorb in the treatment of critically ill.

Objectives: Aim of the study was to assess in-hospital survival rate and the degree of myocardial recovery after MCS treatment (IABP or IMPELLA) at discharge and at 6 months in patients with AMI-CS and planned early percutaneous revascularization. Background: All studies on MCS for acute myocardial infarction related cardiogenic shock (AMI-CS) focused on its impact on in-hospital mortality; however, few data about its role on myocardial recovery are available. Methods: Retrospective study on 64 patients: 36 patients (56%) received IABP and 28 (44%) Impella 2.5/CP. Results: Patients treated with Impella were sicker compared to those treated with IABP as shown by a higher need of catecholamines (93% Impella vs 57% IABP, P = 0.002) and higher inotropic score before procedure: 8 (5-15) versus 4.5 (0-9), P = 0.02. In-hospital survival and MCS-related complications were comparable; hemolysis was more frequent in the Impella group (32% vs 0%, P < 0.0001). Myocardial damage was lower in those patients who were implanted with IMPELLA before PCI: lower troponin peak [3831 ng/dL (1441-8436) vs 16 581 (7802-23 675), P = 0.004] and lower CPK peak [893 UI/L (584-4082) vs 5797 (2483-9292) P = 0.04]. Impella patients had higher LVEF at 6 months [45 (38-52) vs 40 (33-45)%, P = 0.04]. LVEF increase at 6 months was statistically significant in both groups (P < 0.0001), with higher myocardial recovery in patients supported with Impella (absolute delta-LVEF increase 20% vs 10% P = 0.005). Conclusions: Cardiac unloading with IMPELLA in ACS-CS, especially if implanted before PCI, might provide lower myocardial damage and improved myocardial recovery which translates into significantly higher LVEF at 6 months.

OBJECTIVE:Weaning from venoarterial extracorporeal membrane oxygenation (VA ECMO) usually is performed without clear guidelines; yet, patients still die after removal of extracorporeal circulation because of inadequate heart or end-organ recovery. The aim of the study was to address the weaning procedure, analyzing the hemodynamic and echocardiographic picture of patients weaned and to identify predictors of poor outcome among this population.DESIGN:Observational study.SETTING:University hospital.PARTICIPANTS:One hundred twenty-nine VA ECMO cases.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Forty-nine patients (38%) were weaned, 7 (5.4%) were bridged to a ventricular assist device, and 6 (5.2%) were listed for heart transplantation. Weaned patients showed a significant increase of pulse pressure (35 [0-50] mmHg before ECMO, 59 [53-67] mmHg at weaning, 61 [51-76] mmHg after ECMO (p

Management of acute decompensated heart failure patients presenting with cardiogenic shock (CS) is not straightforward, as few data are available from clinical trials. Stabilization before left ventricle assist device (LVAD) or heart transplantation (HTx) is strongly advocated, as patients undergoing LVAD implant or HTx in critical status have worse outcomes. This was a multicenter phase II study with a Simon 2-stage design, including 24 consecutive patients treated with low-moderate epinephrine doses, whose refractory CS prompted implantation of intra-aortic balloon pump (IABP) which was subsequently upgraded with peripheral venoarterial extracorporeal membrane oxygenation. At admission, patients had severe left ventricular dysfunction and overt CS, 7 patients could be managed only with inotropic therapy, and 16 patients were transitioned to IABP and 1 to IABP and venoarterial extracorporeal membrane oxygenation; the median duration of epinephrine therapy was 7 days (interquartile range 6-15), and the median dose was 0.08 μg/kg/min (interquartile range 0.05-0.1); 21 patients (87.5%) survived at 60 days (primary outcome); among them, 13 (61.9%) underwent LVAD implantation, 2 (9.5%) underwent HTx, and 6 (28.6%) improved on medical treatment, indicating that early and intensive treatment of CS in chronic advanced heart failure patients with low-dose epinephrine and timely short-term mechanical circulatory support leads to satisfactory outcomes.

Left ventricle (LV) unloading during VA-ECMO reduces the detrimental effect of increased afterload. Lacking direct comparisons between unloading strategies we used network metanalysis to indirectly compare different unloading approaches. A literature research was performed to include all studies on

Afterload mismatch, defined as acute impairment of left ventricular function after mitral surgery, is a major issue in patients with low ejection fraction and functional mitral regurgitation (FMR). Safety and efficacy of MitraClip therapy have been assessed in randomized trials, but limited data on its acute hemodynamic effects are available. This study aimed to investigate the incidence and prognostic role of afterload mismatch in patients affected by FMR treated with MitraClip therapy. We retrospectively analyzed patients affected by FMR and submitted to MitraClip therapy from October 2008 to December 2012. Patients were assigned to 2 groups according to the occurrence of the afterload mismatch: patients with afterload mismatch (AM+) and without afterload mismatch (AM-). Of 73 patients, 19 (26%) experienced afterload mismatch in the early postoperative period. Among preoperative variables, end-diastolic diameter (71 ± 8 vs 67 ± 7 mm, p = 0.02) and end-systolic diameter (57 ± 9 vs 53 ± 7 mm, p = 0.04) were both significantly larger in AM+ group. An increased incidence of right ventricular dysfunction (68% vs 31%, p = 0.049) and pulmonary hypertension (49 ± 10 vs 40 ± 10 mm Hg, p = 0.0009) was found in AM+ group. Before hospital discharge, left ventricular ejection fraction (LVEF) became similar in both groups (31 ± 9% vs 33 ± 11%, p = 0.65). Long-term survival was comparable between the 2 groups (p = 0.44). A low LVEF in the early postoperative period (LVEF

PATIENTS UNDERGOING LEFT VENTRICULAR assist device (LVAD) implantation often are supported preoperatively with an intra-aortic balloon pump (IABP), but no clear guideline addresses the management of this device after surgery. The 3 major aims of IABP use are to increase coronary perfusion, reduce left ventricular afterload, and increase cardiac output. The precise hemodynamic changes during LVAD support and IABP have not been described clearly. The case description of the management of an IABP after HeartWare LVAD centrifugal flow pump implantation is reported here.

"Abstract. OBJECTIVE: Most-Care (powered by the pressure-recording analytic method [PRAM]; Vytech HealthTM, Padova, Italy) is a minimally invasive cardiac output monitoring. This system already has been studied and validated in cardiac surgery and in children. It already showed a correlation with thermodilution methods in hemodynamically unstable patients. The purpose of this study was to confirm the reliability of cardiac index determinations by Most-Care in unstable patients with atrial fibrillation.. . DESIGN: A prospective study.. . SETTING: A teaching hospital.. . PARTICIPANTS: Forty-nine patients.. . INTERVENTIONS: Simultaneous cardiac index measurements by bolus thermodilution and by PRAM from a standard arterial access (radial and femoral) were obtained. The thermodilution cardiac index was calculated as the mean of 3 separate measurements. Because PRAM is a beat-to-beat monitoring system, the mean cardiac index of 12 consecutive beats was considered for the analysis. Correlations were calculated and differences compared by Bland-Altman analysis.. . MEASUREMENTS: Eight patients were excluded because the signal was altered by the arterial catheter resonance so that the study described the remaining 41 patients. The overall estimates of cardiac index measured by PRAM did not show agreement with the reference cardiac index by thermodilution (mean difference = 0.136 L\/min\/m(2) [0,43 L\/min\/m(2)-0.15 L\/min\/m(2)], with an upper limit of agreement of 1.94 L\/min\/m(2) and a lower limit of agreement of -1.665 L\/min\/m(2), respectively). The median (interquartile) value of cardiac index assessed by thermodilution was 2.42 L\/min\/m(2) (2.21-2.98 L\/min\/m(2)), and by PRAM it was 2.48 L\/min\/m(2) (1.80-3.00 L\/min\/m(2), p = 0.6).. . CONCLUSIONS: The authors concluded that PRAM did not compare well with thermodilution in unstable patients with atrial fibrillation.. . "

Contrast-Enhanced Ultrasound Imaging of Intraplaque Neovascularization in Carotid Arteries: Correlation With Histology and Plaque EchogenicityStefano Coli, Marco Magnoni, Giuseppe Sangiorgi, Massim...

a Anesthesia and Intensive Care Department, San Raffaele University Hospital, Milan, Italy b Invasive Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy c Non-invasive Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy d Arrhythmia Unit, Cardiology Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy e Cardiac Surgery Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy

Background Doppler of mitral and pulmonary vein flows are used to estimate left ventricular (LV) filling pressure. Mitral regurgitation (MR) makes unreliable these parameters by inducing changes of both mitral inflow and pulmonary vein flow. Objectives To evaluate whether Doppler tissue imaging (DTI) diastolic indices obtained at the level of LV lateral mitral annulus can provide accurate estimation of LV filling pressure in patients with MR. Methods Forty-three patients (age 55 +/- 11 years) with severe MR and mean LV ejection fraction (EF) 58 +/- 13 were enrolled, 10 (23%) with LV EF 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and DTI indices of the lateral mitral annulus were obtained. LV end-diastolic pressure (LVEDP) was measured invasively with fluid-filled catheter. Results In the overall population, the majority of standard Doppler and DTI indices correlated with LVEDP, but the multivariate analysis showed that the ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/Em ratio) (beta = .87, P = .0001) was independent predictor of LVEDP (R-2 = 0.74, SE = 4, P = .0001). An E/Em ratio >10 predicted an LVEDP >15 mm Hg (sensitivity 90%, specificity 83%). In both groups with LV EF >50% (beta = .77, P = .005; cumulative R-2 = 0.73, SE = 2.5, P = .0001) and 50% and

We assessed whether the presence of latent myocardial dysfunction, evaluated by echocardiographic derived force-frequency relationship (FFR) during exercise, predicts the appearance of stress-induced pulmonary hypertension in minimally symptomatic patients with severe mitral regurgitation (MR). Two groups of patients were identified: group I with normal (/=40 mm Hg) and group II with abnormal (40 mm Hg) peak stress systemic pulmonary artery pressure. Group I had normal and upsloping FFR and group II had abnormal flat or biphasic FFR. Therefore, in patients with severe MR and apparently normal left ventricular function, the stress-induced pulmonary hypertension seems to be related to the presence of latent left ventricular dysfunction.

The Levitronix CentriMag is approved in Europe for 30 days as uni- or biventricular support in acute heart failure as a bridge to recovery, bridge to heart transplantation or to a long-term left ventricular assist device (LVAD). We report the case of a patient who was supported with the same Levitronix CentriMag pump for 119 days without changing any components of the circuit or the pump head because of an anatomical condition which precluded the feasibility of pump exchange and who did not experience any mechanical failure of the impeller but eventually died due to the rupture of the cannulae. This is the first report of failure of paracorporeal short-term LVAD due to disruption of one cannula with a properly functioning pump. doi: 10.1111/jocs.12149 (J Card Surg 2013;28:472–474)

Although the mechanism of ischemic mitral regurgitation (MR) is understood, the echocardiographic picture of ischemic MR is not homogeneous. Ninety-two consecutive patients with chronic ischemic MR due to restricted motion were divided into two groups according to tethering pattern: the asymmetric group with predominant posterior tethering of both leaflets (54 patients) and the symmetric one with predominant apical tethering of both leaflets (38 patients). The mitral deformation indexes, LV global (volume, function and sphericity) and local (papillary muscle displacements and regional wall motion score index) remodeling were evaluated. All indexes of global LV remodeling were significantly higher in the symmetric than asymmetric group (all p

Transesophageal echocardiography has been widely used as a diagnostic tool during the past two decades to detect cardiac abnormalities that are not visible or poorly visible with transthoracic echocardiography. At present, transesophageal echocardiography is a cornerstone of modern diagnosis of several cardiac diseases, providing diagnostic, prognostic and therapeutic information. In this review, the present status of transesophageal echocardiography not only as a diagnostic tool, underlining its effects on clinical decision making, but also as a monitoring adjunct for many interventional cardiac procedures is examined.

All studies on Mechanical Circulatory Support MCS for acute myocardial infarction related cardiogenic shock AMICS focused on its impact on in-hospital mortality; however, few data about its role on myocardial recovery are available. Retrospective study on 64 selected patients with AMI-CS and

A 72-year-old man presented to the emergency department in cardiogenic shock; 4-days before he was diagnosed with right femoro-popliteal deep vein thrombosis after trauma. During routine monitoring and diagnostic workup, cardiac arrest with pulseless electric activity rapidly ensued and cardiopulmonary resuscitation was initiated. A transthoracic echocardiogram showed severe right ventricular dilatation and acute pulmonary embolism was suspected. No Return of Spontaneous Circulation was obtained after 10 minutes of cardiopulmonary resuscitation. The patient was transferred to the cardiac catheterization laboratory under resuscitation with autopulse (ZOLL, Chelmsford, MA) and femoro-femoral veno-arterial extracorporeal membrane oxygenation (ECMO; PLS Maquet GmbH, Rastett, Germany) was percutaneously initiated with a 23 French (Fr) venous cannula and 17 Fr arterial cannula with restoration of systemic blood flow and oxygen delivery (5 L/min, 4000 rpm). Baseline pulmonary angiography demonstrated a large amount of thrombus in both the right (Movie I in the online-only Data Supplement) and the left pulmonary arteries …

Objective The authors conducted a review of randomized studies to show whether there are any increases or decreases in survival when using milrinone in patients undergoing cardiac surgery. Design A meta-analysis. Setting Hospitals. Participants Five hundred eighteen patients from 13 randomized trials. Interventions None. Measurements and Main Results BioMedCentral, PubMed EMBASE, the Cochrane central register of clinical trials, and conference proceedings were searched for randomized trials that compared milrinone versus placebo or any other control in the setting of cardiac surgery that reported data on mortality. Overall analysis showed that milrinone increased perioperative mortality (13/249 [5.2%] in the milrinone group v 6/269 [2.2%] in the control arm, odds ratio [OR] = 2.67 [1.05-6.79], p for effect = 0.04, p for heterogeneity = 0.23, I2 = 25% with 518 patients and 13 studies included). Subanalyses confirmed increased mortality with milrinone (9/84 deaths [10.7%] v 3/105 deaths [2.9%] with other drugs as control, OR = 4.19 [1.27-13.84], p = 0.02) with 189 patients and 5 studies included) but did not confirm a difference in mortality (4/165 [2.4%] in the milrinone group v 3/164 [1.8%] with placebo or nothing as control, OR = 1.27 [0.28-5.84], p = 0.76 with 329 patients and 8 studies included). Conclusions This analysis suggests that milrinone might increase mortality in adult patients undergoing cardiac surgery. The effect was seen only in patients having an active inotropic drug for comparison and not in the placebo subgroup. Therefore, the question remains whether milrinone increased mortality or if the control inotropic drugs were more protective.

Cardiac complications (perioperative myocardial infarction and cardiac death) are the leading cause of morbidity and mortality in patients undergoing major vascular surgery. The incidence of these complications has been reported to be up to 25%. Compared with open surgery, endovascular procedures are associated with fewer perioperative complications. However, long-term outcome is similar for both open and endovascular procedures, suggesting that long-term outcome is primarily related to the presence and extent of underlying coronary artery disease and not to the treatment modality. Patients requiring major aortic reconstruction need a thorough cardiovascular evaluation and risk stratification in order to assess the feasibility of surgery, the opportunity for preoperative myocardial revascularization or treatment of valvulopathies, the optimization of medical therapy, and the surgical approach. In particular, preoperative cardiac evaluation may help to identify high-risk patients in whom coronary angiography may be planned with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes.

This case report describes a case of acute right ventricular failure caused by aortopulmonary fistula post ascending aorta surgery. © 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Arterial vasa vasorum (VV) are known to be involved in the atherosclerotic process. The aim of the present study was to explore whether ultrasound imaging with contrast agent is able to visualize adventitial VV in human carotid atherosclerosis. We studied with standard ultrasound 25 patients with carotid stenosis > 50% (ATS group) and 15 patients without carotid artery plaques and an intima-media thickness (IMT) < 1.0 mm (CTRL group). All patients underwent contrast ultrasound to evaluate periadventitial VV and B-flow imaging (BFI) modality was used to improve and measure periadventitial flow signal. On contrast-enhanced images, a fast microbubble flow and a homogeneous and linear periadventitial contrast signal using BFI were detectable in the adventitial area in all patients of both groups. Periadventitial signal thickness by BFI was higher in patients with atherosclerosis than in the control group (mean +/- SD: CTRL 0.80 +/- 0.06 mm; ATS 1.10 +/- 0.11 mm; P < 0.001). Moreover, considering the whole study population, the adventitial signal thickness significantly correlated with IMT values (r= 0.88, r(2)= 0.77; P < 0.0001). Periadventitial contrast signal was detected in all patients and BFI thickness was higher in patient with carotid atherosclerosis and correlated with IMT.

Two previous reports have reported myocardial infarction during ovarian hyperstimulation syndrome, a complication of controlled ovarian stimulation characterized by ascites, pleural effusion, hemoconcentration and an increased thromboembolic risk, but no association with the initial phase (before treatment with human chorionic gonadotropin) of a normal ovarian stimulation protocol for infertility has ever been described. We report the first case, to our knowledge, of acute myocardial infarction occurring during the initial phase of an otherwise uncomplicated ovarian stimulation protocol. A young woman with infertility associated to polycystic ovary syndrome was treated with leuprolide acetate and recombinant follicle stimulating hormone to induce ovarian stimulation for in vitro fertilization and embryo transfer. After 12 days the patient presented a non-ST elevation myocardial infarction, which was treated with aspirin, clopidogrel, enoxaparin, intravenous nitrates and beta blockers. Cardiac catheterization showed angiographically normal coronary arteries. Echocardiography showed a circumscribed akinesis of the inferior apical segment of the left ventricle and right ventricular apex, which was confirmed by cardiac magnetic resonance. A screening for thrombophilic diathesis was negative. The patient was discharged and remained asymptomatic at 1 and 3 months follow up. Further ovarian stimulations were excluded and a trial of oocyte retrieval on spontaneous cycle was planned. Myocardial infarction can complicate ovarian stimulation protocols for infertility even in their early phase without any sign of ovarian hyperstimulation syndrome.