Ivancarmine Gambardella

Background and purpose: The conceptualization of brain death (BD) was pivotal in the shaping of judicial and medical practices. Nonetheless, media reports of alleged recovery from BD reinforced the criticism that this construct is a self‐fulfilling prophecy (by treatment withdrawal or organ donation). We meta‐analyzed the natural history of BD when somatic support (SS) is maintained.Methods: Publications on BD were eligible if the following were reported: aggregated data on its natural history with SS; and patient‐level data that allowed censoring at the time of treatment withdrawal or organ donation. Endpoints were as follows: rate of somatic expiration after BD with SS; BD misdiagnosis, including “functionally brain‐dead” patients (FBD; i.e. after the pronouncement of brain‐death, ≥1 findings were incongruent with guidelines for its diagnosis, albeit the lethal prognosis was not altered); and length and predictors of somatic survival.Results: Forty‐seven articles were selected (1610 patients, years: 1969–2021). In BD patients with SS, median age was 32.9 years (range = newborn–85 years). Somatic expiration followed BD in 99.9% (95% confidence interval = 89.8–100). Mean somatic survival was 8.0 days (range = 1.6 h–19.5 years). Only age at BD diagnosis was an independent predictor of somatic survival length (coefficient = −11.8, SE = 4, p < 0.01). Nine BD misdiagnoses were detected; eight were FBD, and one newborn fully recovered. No patient ever recovered from chronic BD (≥1 week somatic survival).Conclusions: BD diagnosis is reliable. Diagnostic criteria should be fine‐tuned to avoid the small incidence of misdiagnosis, which nonetheless does not alter the prognosis of FBD patients. Age at BD diagnosis is inversely proportional to somatic survival.

Objective: The lung is a target organ of diabetes mellitus (DM) via glycation of pulmonary elastin and collagen. In addition, hyperglycemia facilitates hypercapnic respiratory failure, which is instead mitigated by low‐carbohydrate high‐lipid (LC‐HL) nutrition. We sought to determine the association between diabetes and severe respiratory failure (SRF, i.e., need of reintubation\tracheostomy) after open aortic arch replacement (AAR).Methods: Machine learning algorithms were evaluated for precision and recall (F2 score) and for clinical applicability to predict SRF. Conditional regression evaluated independent predictors of SRF after 1:2 propensity‐score matching.Results: Information on diabetic status was available in 1275 patients undergoing AAR (1997–2023). Although support vector machine presented the highest F2 score (F2 = 0.337), conditional inference trees provided the most clinically applicable algorithm: diabetes was the best predictor of SRF, which occurred in 20/150 diabetics (13.3%) vs. 40/1125 nondiabetics (3.6%) (p < 0.01). In diabetics, left ventricular ejection fraction (LVEF) was the next best predictor of SRF, which occurred in 8/20 diabetics with LVEF ≤ 30% (40%) vs. 12/130 diabetics with LVEF >30% (9.2%) (p = 0.02). In nondiabetics, chronic obstructive pulmonary disease (COPD) was the next best predictor of respiratory failure, which occurred in 14/177 nondiabetics with COPD (7.9%) vs. 26/948 nondiabetics without COPD (2.7%) (p = 0.01). In the matched sample, diabetes was independently able to predict SRF (OR 2.20, 95% CI 1.10 | 4.42).Conclusions: DM was the best predictor of SRF after AAR. Strict glycemic control and LC‐HL nutrition should be evaluated as measures to reduce postoperative SRF in diabetic patients.

Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. Methods: All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. Results: A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. Conclusion: The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.

Type A acute aortic dissection is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. Methods: All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilized predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimize potential collinearity of over-fitting variables and variables measured from the same patient. Results: 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs 62/318 (19.5%), p<0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥ 2.6 mmol/L. Conclusion: The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 hours after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.

Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, “intubated/sedated” status on arrival, and “emergency or salvage” status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.

Background: Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition. Methods: A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score. Results: 633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491–1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561–1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133–1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361–319.017) were significantly associated with increased operative mortality. Conclusions: The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.

The coronavirus 2019 pandemic has affected many healthcare systems worldwide. While acute respiratory distress syndrome (ARDS) has been well-documented in COVID-19, there are several cardiovascular complications, such as myocardial infarction, ischaemic stroke, and pulmonary embolism, leading to disability and death. The link between COVID-19 and increasing thrombogenicity potentially occurs due to numerous different metabolic mechanisms, ranging from endothelial damage for direct virus infection, associated excessive formation of neutrophil extracellular traps (NETs), pathogenic activation of the renin-angiotensin-aldosterone system (RAAS), direct myocardial injury, and ischemia induced by respiratory failure, all of which have measurable biomarkers. A search was performed by interrogating three databases (MEDLINE; MEDLINE In-Process and Other Non-Indexed Citations, and EMBASE). Evidence from randomized controlled trials (RCT), prospective series, meta-analyses, and unmatched observational studies were evaluated for the processing of the algorithm and treatment of thromboembolic disease and cardiac thrombotic complications related to COVID-19 during SARS-CoV-2 infection. Studies out with the SARS-Cov-2 infection period and case reports were excluded. A total of 58 studies were included in this analysis. The role of the acute inflammatory response in the propagation of the systemic inflammatory sequelae of the disease plays a major part in determining thromboembolic disease and cardiac thrombotic complication in COVID-19. Some of the mechanisms of activation of these pathways, alongside the involved biomarkers noted in previous studies, are highlighted. Inflammatory response led to thromboembolic disease and cardiac thrombotic complications in COVID-19. NETs play a pivotal role in the pathogenesis of the inflammatory response. Despite moving into the endemic phase of the disease in most countries, thromboembolic complications in COVID-19 remain an entity that substantially impacts the health care system, with long-term effects that remain uncertain. Continuous monitoring and research are required.

Objective: To discern the impact of diabetes mellitus (DM) on spinal cord injury (SCI) after open descending thoracic and thoracoabdominal aneurysm repair (DTAAAR). Background: Compared with euglycemia, hyperglycemia, and ketosis make neurons respectively more vulnerable and more resilient to ischemia. Methods: During the study period (1997–2021), patient who underwent DTAAAR were dichotomized according to the presence/absence of DM. The latter was investigated as predictor of our primary (SCI) and secondary [operative mortality (OM), myocardial infarction, stroke, need for tracheostomy, de novo dialysis, and survival] endpoints. Two-level risk-adjustment employed maximum likelihood conditional regression after 1:2 propensity-score matching. Results: DTAAAR was performed in 934 patients. Ninety-two diabetics were matched to 184 nondiabetics. All preoperative variables had a standardized mean difference P 0.03) and OM (14.1% vs. 6.0%, P=0.01), while the other secondary endpoints were similar between groups in the matched sample. DM was an independent predictor for SCI in the matched sample (odds ratio: 5.05, 95% confidence interval: 1.17–21.71). Matched patients with DM presented decreased survival at 1 (70.2% vs. 86.2%), 5 (50.4% vas 67.5%), 10 years (31.7% vs. 36.7%) (P=0.03). The results are summarized in the graphical Conclusion: DM is associated to increased OM and decreased survival, and it is an independent predictor of SCI after open DTAAAR. Strict perioperative glycemic control should be implemented, and exogenous ketones should be investigated as neuroprotective agents to reduce such adverse events.