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We describe a 69-year-old dialysis-dependent patient who developed intractable ascites after zone 2 aortic reconstruction for a type IA thoracic endovascular aneurysm repair endoleak. Investigation as to the cause of ascites revealed a unique set of clinical circumstances leading to intractable bloody ascites. Investigation included imaging and invasive testing to diagnose the culprit mechanism. Ultimately, interventional catherization of the left subclavian vein illustrated an abnormally elevated pressure in the left subclavian vein. It was thus determined that, owing to the combination of a left brachiocephalic (innominate) vein occlusion after surgical ligation and in situ left brachiobasilic arteriovenous dialysis graft, there was overcirculation through the thoracic duct. Retrograde flow through the pop-off thoracic duct led to hematogenous ascites. Ligation of the left brachiobasilic arteriovenous dialysis graft resulted in near instantaneous and complete resolution of the ascites.

This dataset contains individual subject data for microcirculatory parameters assessed in the present study. Demographic and macrocirculatory parameters are not included at this time due to the present study being part of a larger, partially unpublished project., PMID: 32505603 doi: 10.1053/j.jvca.2020.04.045

Patients undergoing cardiovascular surgery may be exposed to heparin before surgery, during cardiopulmonary bypass (CPB), or in the immediate postoperative period. For this reason, cardiovascular surgery patients are at increased risk for heparin-induced thrombocytopenia (HIT), occurring in 1 to 3% of patients. The diagnosis of HIT can be difficult, if based solely on the development of thrombocytopenia, because cardiac surgical patients have multiple reasons to be thrombocytopenic. Several clinical scoring systems have been developed to reduce unnecessary testing and better define the pretest probability of HIT, which we will review in detail with a diagnostic algorithm. In addition, we will cover the prevention and treatment HIT.

INTRODUCTION: Lactic acidosis after cardiac surgery with cardiopulmonary bypass is common and associated with an increase in postoperative morbidity and mortality. A number of potential causes for an elevated lactate after cardiopulmonary bypass include cellular hypoxia, impaired tissue perfusion, ischemic-reperfusion injury, aerobic glycolysis, catecholamine infusions, and systemic inflammatory response after exposure to the artificial cardiopulmonary bypass circuit. Our goal was to examine the relationship between early abnormalities in microcirculatory convective blood flow and diffusive capacity and lactate kinetics during early resuscitation in the intensive care unit. We hypothesized that patients with impaired microcirculation after cardiac surgery would have a more severe postoperative hyperlactatemia, represented by the lactate time-integral of an arterial blood lactate concentration greater than 2.0 mmol/L. METHODS: We measured sublingual microcirculation using incident darkfield video microscopy in 50 subjects on intensive care unit admission after cardiac surgery. Serial measurements of systemic hemodynamics, blood gas, lactate, and catecholamine infusions were recorded each hour for the first 6 h after surgery. Lactate area under the curve (AUC) was calculated over the first 6 h. The lactate AUC was compared between subjects with normal and low perfused vessel density (PVD 0.4), and low vessel-by-vessel microvascular flow index (MFIv

Web services support the integration and interoperability of Web-based applications and enable machine-to-machine interaction. The concepts of web services and open distributed architecture were applied to the development of T-DSS, the prototype customised for web based hydro-information systems. T-DSS provides mapping services, database related services and access to remote components, with special emphasis placed on output flexibility (e.g. multilingualism), where SOAP web services are mainly used for communication. The remote components are represented above all by distant data and mapping services (e.g. eteorological predictions), modelling and analytical systems (currently HEC-HMS, Modflow and additional utilities), which support decision making in water management.

ACUTE RESPIRATORY FAILURE is a rare but possible initial presentation of an autoimmune disease such as systemic lupus erythematosus. The diffuse alveolar edema that typically is a feature of this life-threatening presentation may prove refractory to multimodal aggressive medical management in the intensive care unit. This case conference explores the application of extracorporeal membrane oxygenation in this setting as a life-saving bridge to clinical recovery.

Background Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. Objective We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge. Methods Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014. Results During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months. Conclusion ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.

THE INFERIOR VENA CAVA (IVC) is responsible for about two thirds of the total venous return to the right atrium (RA). Obstruction of the IVC can be due to chronic disease or an acute insult. The etiology of chronic IVC obstruction includes congenital abnormalities, indirect compression of the IVC (retroperitoneal tumors, hepatic tumors, giant left atrium), or intravascular tumor extension (metastatic renal tumors). Chronic obstruction of the IVC is associated with findings of hepatic congestion, ascites, lower extremity edema, and venous thrombosis. The slow progression of disease results in collateral venous return to the superior vena cava (SVC) via the azygos, intrathoracic, and vertebral veins. In contrast, acute stenosis of the IVC can result in hepatic and renal dysfunction, severe hemodynamic instability, and cardiovascular collapse if left untreated. Acute IVC obstruction is rare and has been reported as a complication of operative procedures, including bicaval heart transplantation, orthotopic liver transplantation, mitral valve replacement, and extrinsic compression from implantation of a Nuss bar for repair of pectum excavatum. The authors describe a case of acute IVC stenosis at the RA junction that was diagnosed by intraoperative transesophageal echocardiography after cardiopulmonary bypass (CPB). The intraoperative echocardiographic findings included a localized area of narrowing at the IVC-RA cannulation site, turbulent flow into the RA, underfilled cardiac chambers with hyperdynamic biventricular activity, and dilated hepatic veins. The echocardiographic findings were correlated with invasive hemodynamic measurements, and a therapeutic intervention with return to CPB was performed. The authors recommend the routine examination of the IVC at the IVC-RA junction with color-flow Doppler and spectral Doppler interrogation of flow after cardiac surgery cases, especially in the case of a bicaval venous cannulation technique.

From the *Cardiovascular and Thoracic Section, Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; †Division of Cardiac Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; ‡Division of Cardiothoracic Surgery, Department of Surgery, Aristotle University, Thessaloniki, Greece; §Division of Cardiac Surgery, Department of Surgery Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada. Address reprint requests to John G. Augoustides MD, FASE, FAHA, Anesthesiology and Critical Care, 680 Dulles, HUP, 3400 Spruce Street, Philadelphia, PA 19104-4283. E-mail: yiandoc@hotmail.com © 2014 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2013.10.020 CARDIOPULMONARY BYPASS (CPB) first was applied successfully in cardiac surgery by John H. Gibbon in 1953. Since that clinical milestone more than 60 years ago, CPB has evolved into a mainstream technique in contemporary cardiac surgery to facilitate openand closed-chamber procedures of all types, including specialized perfusion approaches such as deep hypothermic circulatory arrest. The safe conduct of CPB requires a vigilant and experienced team approach to minimize serious errors and to solve critical events when they occur. This conference presents a challenging case of major retroperitoneal hemorrhage that presented during CPB. The successful detection and management of this rare but serious complication is outlined, highlighting the principles of a team approach, vigilance, and creative applications of transesophageal echocardiography. The case conference begins with a description and discussion of the case, followed by 2 expert commentaries, the first from the cardiac surgeon’s perspective and the second from the cardiac anesthesiologist’s perspective.

Background— The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results— We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P =0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P =0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions— Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality.

Patients with alcoholic liver disease (ALD) often display disturbed iron indices. Hepcidin, a key regulator of iron metabolism, has been shown to be down-regulated by alcohol in cell lines and animal models. This down-regulation led to increased duodenal iron transport and absorption in animals. In this study, we investigated gene expression of duodenal iron transport molecules and hepcidin in three groups of patients with ALD (with anaemia, with iron overload and without iron overload) and controls. Expression of DMT1, FPN1, DCYTB, HEPH, HFE and TFR1 was measured in duodenal biopsies by using real-time PCR and Western blot. Serum hepcidin levels were measured by using ELISA. Serum hepcidin was decreased in patients with ALD. At the mRNA level, expressions of DMT1, FPN1 and TFR1 genes were significantly increased in ALD. This pattern was even more pronounced in the subgroups of patients without iron overload and with anaemia. Protein expression of FPN1 paralleled the increase at the mRNA level in the group of patients with ALD. Serum ferritin was negatively correlated with DMT1 mRNA. The down-regulation of hepcidin expression leading to up-regulation of iron transporters expression in the duodenum seems to explain iron metabolism disturbances in ALD. Alcohol consumption very probably causes suppression of hepcidin expression in patients with ALD.

Aims. The non-invasive 13 C-methacetin ( 13 C-MBT) breath test has been proposed as a measure of metabolic liver function that improves the diagnostic efficacy of serologic and biochemical tests in assessing hepatic functional capacity and liver disease severity, The goal of this study was to establish the clinical utility of this test in quantifying hepatic metabolic function in patients with liver cirrhosis of varying severity and to compare 13 C-MBT measurements with the AST/ALT ratio, APRI score, and other routine liver tests. Methods. Routine liver function tests including serum bilirubin, aspartate aminotransferase activity (AST), alanine aminotransferase (ALT), AST/ALT ratio, the APRI score, the percentage of dose rate (PDR) and cumulative percentage of dose rate (CPDR) of the 13 C-MBT were evaluated in 52 cirrhotic patients of alcohol etiology (Child-Pugh A/B/C 10/28/14) and 37 healthy controls. Results. The 13 C-MBT differed significantly between healthy controls and cirrhotic patients at all time intervals measured. It also proved the ability to differentiate patients with liver cirrhosis based on severity of hepatic impairment corresponding to the Child-Pugh classification A vs. B vs. C. The ROC curve analysis suggested that the best prediction is provided by time intervals between the 10 th - 20 th or 10 th - 40 th minute of PDR. Conclusions. The 13 C-MBT offers a reliable means for quantification of hepatic metabolic function over the complete

Objective To evaluate the accuracy of Doppler-derived transmitral valve gradients immediately after mitral valve repair by comparing them with near simultaneously obtained direct catheter gradients. Design A prospective study. Setting A tertiary care medical center. Participants Twenty elective adult surgical patients presenting for mitral valve repair surgery. Methods Mitral valve surgery proceeded in standard fashion except for the use of a smaller than usual left ventricular vent catheter (Medtronic DLP 10 French left heart vent catheter). After completion of the mitral valve repair and subsequent cardiac de-airing, the patient was weaned from cardiopulmonary bypass. Immediately after separation, the study period began. Near simultaneous transmitral Doppler gradients were obtained with directly measured catheter gradients via the vent catheter. Results While the mean peak gradient difference of 1.1 mmHg was small (p-value 0.18, 95% CI: −0.54 to 2.73 mmHg), the correlation between Doppler and catheter gradient measurements (Pearson correlation coefficient r = 0.54, p = 0.055) only approached statistical significance due to the large variance associated with the small sample size. In all patients with a peak gradient greater than 10 mmHg (4 of the 20 patients), overestimation of catheter gradients by Doppler occurred, with two showing a 62% to 73% discrepancy. In these two cases, there was also evidence for elevated left ventricular end-diastolic pressure (LVEDP) along with high transmitral blood flow velocities. Conclusion Doppler-derived transmitral gradients provide a simple, safe, and reliable measure of the true physiologic transmitral valve gradient. At the same time, it is important to recognize that significant Doppler over-estimation of catheter gradients may occur in patients with elevated Doppler transmitral velocities. The causes of these overestimations are unknown. They may be related to technical recording errors. They may also be related to an inherent weakness in Doppler technology—its inability to account for any distal recovery of pressure, which in a select group of patients could be significant. doi: 10.1111/jocs.12125 (J Card Surg 2013;28:329–335)

PURPOSE: We investigated whether the pharmacokinetics and tolerability of gefitinib were altered in patients with hepatic impairment due to cirrhosis or hepatic metastases in two open, parallel-group, multicenter studies. METHODS: In Study 1, subjects with normal hepatic function or mild, moderate, or severe hepatic impairment (Child-Pugh criteria) due to cirrhosis received single-dose gefitinib 250 mg (n = 10 per group). In Study 2, patients with solid malignant tumors with normal liver biochemistry (n = 18), moderate (n = 16), or severe (n = 7) hepatic impairment (liver biochemistry tests) due to metastases received gefitinib 250 mg daily for 28 days. RESULTS: In Study 1, the geometric mean area under the plasma concentration-time curve (AUC) for gefitinib was significantly higher in patients with hepatic impairment compared with healthy subjects; hepatic impairment was associated with reduced gefitinib plasma clearance, longer half-life, and reduced plasma metabolite levels. In Study 2, the geometric mean gefitinib steady-state AUC during the 24-h dosing interval was slightly, but not significantly, higher in patients with moderate hepatic impairment; there were, however, no significant differences between groups in gefitinib and metabolite pharmacokinetic parameters. In both studies, gefitinib was well tolerated across all cohorts. CONCLUSIONS: We conclude that the effect of hepatic impairment on gefitinib pharmacokinetics depends on the underlying etiology of that impairment and its classification.

Disturbances of iron metabolism are observed in chronic liver diseases. In the present study, we examined gene expression of duodenal iron transport molecules and hepcidin in patients with hereditary hemochromatosis (HHC) (treated and untreated), involving various genotypes (genotypes which represent risk for HHC were examined), and in patients with iron deficiency anaemia (IDA). Gene expressions of DMT1, ferroportin, Dcytb, hephaestin, HFE and TFR1 were measured in duodenal biopsies using real-time PCR and Western blot. Serum hepcidin levels were measured using ELISA. DMT1, ferroportin and TFR1 mRNA levels were significantly increased in post-phlebotomized hemochromatics relative to controls. mRNAs of all tested molecules were significantly increased in patients with IDA compared to controls. The protein expression of ferroportin was increased in both groups of patients but not significantly. Spearman rank correlations showed that DMT1 versus ferroportin, Dcytb versus hephaestin and DMT1 versus TFR1 mRNAs were positively correlated regardless of the underlying cause, similarly to protein levels of ferroportin versus Dcytb and ferroportin versus hephaestin. Serum ferritin was negatively correlated with DMT1 mRNA in investigated groups of patients, except for HHC group. A decrease of serum hepcidin was observed in IDA patients, but this was not statistically significant. Our data showed that although untreated HHC patients do not have increased mRNA levels of iron transport molecules when compared to normal subjects, the expression is relatively increased in relation to body iron stores. On the other hand, post-phlebotomized HHC patients had increased DMT1 and ferroportin mRNA levels possibly due to stimulated erythropoiesis after phlebotomy.

Takotsubo cardiomyopathy is increasingly being recognized in the perioperative period. To date, there have been only three previous cases involving cardiac surgery reported and this represents the fourth case. The precise mechanism remains elusive, and there is no definitive management strategy. It appears that the syndromes course in cardiac surgical patients is self-limited. This syndrome must now be considered in the differential diagnosis of postcardiotomy cardiac failure. (J Card Surg 2010;25:679-683)

We tested the effect of iron deprivation on the uptake of iron from ferric citrate by human erythroleukemia K562 cells. The iron uptake after 24-h preincubation in defined iron-free medium was approximately 2–3× higher than after the preincubation in control transferrin-containing medium. The preincubation of K562 cells in iron-free medium together with the inhibitor of protein synthesis cycloheximide completely abrogated the stimulation of the iron uptake. The preincubation in iron-free medium resulted in a slight decrease (20%) of DMT1 mRNA level. The level of Dcytb, ferroportin and hephaestin mRNA did not exert any significant change. We also did not find any significant effect on the protein level of DMT1, Dcytb, ferroportin and hephaestin. We conclude that iron deprivation stimulates the uptake of non-transferrin iron in K562 cells and that this stimulation depends on protein synthesis. It seems that the expression of an unknown or seemingly unrelated protein(s) is involved.

This study was designed to evaluate the effect of hepatic impairment on the pharmacokinetics of lamivudine.Sixteen patients not infected with hepatitis B virus or human immunodeficiency virus who had hepatic impairment due to liver cirrhosis were assigned to moderately or severely impaired groups by clinical signs/symptoms, 14C-aminopyrine metabolic activity and caffeine clearance and compared with eight healthy controls. Following a 300-mg dose of lamivudine, blood and urine samples were taken for drug assay.Lamivudine was well tolerated in patients with hepatic impairment. There were no statistical differences in overall lamivudine exposure (in terms of AUC or Cmax) or other major pharmacokinetic parameters i.e. CLR, tmax and t1/2, between healthy control subjects and patients with moderate or severe hepatic impairment.Hepatic impairment does not warrant dose modification of lamivudine based on this single-dose pharmacokinetic study.

Noncardiogenic pulmonary edema can be fatal without adequate resuscitation. We report, for the first time, the use of prone positioning in the immediate post-cardiac surgical period to treat a patient with profound hypoxemia secondary to massive (noncardiogenic) pulmonary edema. Prone positioning corrects ventilation-perfusion mismatch and allows gravity-dependent drainage of capillary leak-mediated endobronchial pulmonary fluid.

Transcatheter aortic valve replacement (TAVR) is rapidly gaining popularity as a technique to surgically manage aortic stenosis (AS) in high risk patients. TAVR is significantly less invasive than the traditional approach to aortic valve replacement via median sternotomy. Patients undergoing TAVR often suffer from multiple comorbidities, and their postoperative course may be complicated by a unique set of complications that may become evident in the intensive care unit (ICU). In this article, we review the common complications of TAVR that may be observed in the ICU, and different strategies for their management.

The management of a patient who had previously undergone surgical palliation of tricuspid atresia at the age of two, and who required right parietal craniotomy for resection of seizure focus, is presented. The anesthetic considerations in patients with Fontan physiology are also presented, as well as the impact on patients undergoing neurosurgical procedures, specifically, craniotomy for seizure focus resection. The physiologic demands of modern surgical practice requires that there is a thorough understanding of the complex circulations that exist in patients with congenital heart disease.

Transesophageal echocardiography (TEE) assists in the intraoperative decision-making process during cardiac anesthesia and cardiac surgery. Mechanical ventricular support may be necessary to support the circulatory system temporarily or serve as a bridge to heart transplantation. A left ventricular assist device (LVAD) is most commonly used.1 Biventricular failure necessitates the use of an LVAD along with a right ventricular assist device (RVAD) to form a biventricular assist device (BIVAD) (Fig 1). TEE plays a vital role in evaluating effective mechanical assistance of the circulation.1-3 This case describes a BIVAD placement in a patient and shows the roles and limitations of TEE in this scenario.

To the editor: We read with interest the report by Lausten-Thomsen et al in this issue of Blood .[1][1] The study challenges the previous report by Mori et al describing ∼ 1% frequency of TEL/AML1 ( ETV6/RUNX1 )–positive cord blood in healthy newborns and questions the hypothesis of TEL/AML1

Introduction: Despite the extensive literature on the resuscitation of patients in shock, there currently are no published guidelines or algorithms to direct practitioners on how to effectively wean inotropes and vasopressors. In the case of septic shock, for example, optimal resuscitation involves

Ventricular assist device support for heart failure has gained popularity as both a bridge to heart transplantation and as destination therapy. Early device malfunction is unusual and can be caused by several distinct mechanisms. We present the first reported case of echocardiographic diagnosis of extracardiac cannula obstruction leading to biventricular assist device failure.