A pilot study investigating the effects of remote ischemic preconditioning in high-risk cardiac surgery using a randomised controlled double-blind protocol

The efficacy of remote ischemic preconditioning (RIPC) in high-risk cardiac surgery is uncertain. In this study, 96 adults undergoing high-risk cardiac surgery were randomised to RIPC (3 cycles of 5 min of upper-limb ischemia induced by inflating a blood pressure cuff to 200 mmHg with 5 min of reperfusion) or control. Main endpoints were plasma high-sensitivity troponin T (hsTNT) levels at 6 and 12 h, worst post-operative acute kidney injury (AKI) based on RIFLE criteria, and noradrenaline duration. hsTNT levels were log-normally distributed and higher with RIPC than control at 6-h post cross-clamp removal [810 ng/ml (IQR 527-1,724) vs. 634 ng/ml (429-1,012); ratio of means 1.41 (99.17% CI 0.92-2.17); P=0.04] and 12 h [742 ng/ml (IQR 427-1,700) vs. 514 ng/ml (IQR 356-833); ratio of means 1.56 (99.17% CI 0.97-2.53); P=0.01]. After adjustment for baseline confounders, the ratio of means of hsTNT at 6 h was 1.23 (99.17% CI 0.88-1.72; P=0.10) and at 12 h was 1.30 (99.17% CI 0.92-1.84; P=0.05). In the RIPC group, 35/48 (72.9%) had no AKI, 5/48 (10.4%) had AKI risk, and 8/48 (16.7%) had either renal injury or failure compared to the control group where 34/48 (70.8%) had no AKI, 7/48 (14.6%) had AKI risk, and 7/48 (14.6%) had renal injury or failure (Chi-squared 0.41; two degrees of freedom; P = 0.82). RIPC increased post-operative duration of noradrenaline support [21 h (IQR 7-45) vs. 9 h (IQR 3-19); ratio of means 1.70 (99.17% CI 0.86-3.34); P=0.04]. RIPC does not reduce hsTNT, AKI, or ICU-support requirements in high-risk cardiac surgery.     

Pharmacologic Preconditioning Therapy Prior to Atrial Septal Defect Closure in Patients at High Risk for Acute Pulmonary Edema

Objectives: The aim of this study was to assess whether transient atrial septal defect (ASD) occlusion and, if required, vasodilator therapy would improve the safety of percutaneous ASD closure in high-risk subsets. Background: While percutaneous ASD closure is generally considered a low risk intervention, hypertensive and elderly patients may develop pulmonary edema following the procedure because of underlying left ventricular (LV) diastolic dysfunction. Methods: Fifty-two consecutive patients who underwent successful percutaneous ASD closures were enrolled into a single-center prospective registry. Patients with arterial hypertension and/or >60 years of age (n = 15) were considered at risk for periprocedural pulmonary edema. Those patients were tested for an increase of LV filling pressures during transient ASD occlusion and, if this was the case, treated according to a prespecified algorithm. Clinical and echocardiography data were collected in-hospital and at 6 months follow-up. Results: Shunt size was comparable in high and standard-risk patients (Qp:Qs 2.1 ± 0.8 vs. 2.1 ± 0.7, P = 0.82). High-risk patients had more often pulmonary hypertension (58% vs. 14%, P < 0.05) and were more frequently symptomatic. Among them, 4/15 (27%) demonstrated a significant rise of left-sided filling pressures during transient ASD balloon occlusion and underwent pharmacologic preconditioning prior to ASD closure. None of them developed periprocedural pulmonary edema. At follow-up, patients were less symptomatic (Pre: NYHA II n = 15, NYHA III n = 9; Post: NYHA II n = 15, NYHA III n = 0; P = 0.02) and right ventricular size decreased from 23 ± 5 cm(2) to 17 ± 5 cm(2) , P < 0.05. Conclusion: Transient ASD occlusion and, if required, pharmacologic preconditioning prior to percutaneous closure may prevent periprocedural pulmonary edema in high-risk patients. (J Interven Cardiol 2012;25:505-512).     

The Global Lung Initiative 2012 reference values reflect contemporary Australasian spirometry

We aimed to ascertain the fit of the European Respiratory Society Global Lung Initiative 2012 reference ranges to contemporary Australasian spirometric data. Z‐scores for spirometry from Caucasian subjects aged 4–80 years were calculated. The mean (SD) Z‐scores were 0.23 (1.00) for forced expirtory volume in 1 s (FEV₁), 0.23 (1.00) for forced vital capacity (FVC), ?0.03 (0.87) for FEV₁/FVC and 0.07 (0.95) for forced expiratory flows between 25% and 75% of FVC. These results support the use of the Global Lung Initiative 2012 reference ranges to interpret spirometry in Caucasian Australasians.     

Minimally invasive insertion of an equine stented pulmonary valve with a built-in sinus portion in a sheep model

Objectives : This study evaluated the feasibility of inserting a new equine stented‐valve with a sinus portion in a lamb survival model, through a minimally invasive thoracotomy with right ventricular access without cardiopulmonary bypass. Background : Extant surgical or percutaneous methods for inserting biological valves in the right outflow tract have drawbacks and limitations. Methods : A decellularized equine valved jugular vein, sutured to a self‐expanding stent with a sinus portion, was placed through a minimal right thoracotomy using a newly developed flexible hydraulic release device in seven lambs. The approach through the right ventricle into the pulmonary valve position is achieved on a beating heart. Results : The stented valves were correctly positioned in the right outflow tract, were competent up to 6 months as confirmed by angiography and echocardiography, and were well‐tolerated by the animals, with endothelialization of the valve demonstrated at 6 months. Conclusions : The newly developed hydraulic release system allowed for safe and reliable insertion of an equine stented‐valve with a sinus portion, through a right transventricular approach on a beating heart, in a sheep survival model. © 2011 Wiley Periodicals, Inc.     

Lowered vision as a risk factor for injurious accidents in older people

BACKGROUND AND AIMS: Poor vision in older people is often related to increased fall risk. However, the association of the severity between visual deficit and risk for all kind of injurious accidents has not been widely studied. The aim of this study was to examine whether visual loss is associated with higher incidence of injurious accidents and whether walking speed or physical activity play a mediating role in the association. METHODS: 416 persons aged 75 and 80 years at baseline underwent visual acuity measurements. Visual acuity (VA) <0.3 in the better eye, with spectacle correction when necessary, was defined as visual impairment, VA >or=0.3 but 0.5 as normal VA. Hospital records of accidents resulting in injury were monitored for 10 years after baseline. RESULTS: During the 10-year follow-up, 239 (58%) participants suffered at least one injurious accident. The risk for injurious accidents in a multivariate model adjusted for age, gender, eye-related diseases, diabetes and cardiovascular diseases among participants with lowered vision was 1.45 (95% CI 1.08- 1.94), compared with that for people with normal visual acuity. Participants with visual impairment did not have an increased risk for injurious accidents (HR 1.20, 95% CI 0.82-1.75). Furthermore, neither walking speed nor physical activity had a mediating effect on the relationship between visual loss and accidents. CONCLUSIONS: Lowered vision is a risk factor for injurious accidents in older people independent of mobility and physical activity. Interestingly, more severe visual impairment did not increase the risk. Early intervention strategies, for example, proper correction of refractive errors or cataract extraction, may potentially prevent injurious accidents in older people.