Contemporary Use of Venoarterial Extracorporeal Membrane Oxygenation: Insights from the Multicenter RESCUE Registry

BackgroundVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a life-saving therapy for patients with cardiovascular collapse, but identifying patients unlikely to benefit remains a challenge.Methods and ResultsWe created the RESCUE registry, a retrospective, observational registry of adult patients treated with VA-ECMO between January 2007 and June 2017 at 3 high-volume centers (Columbia University, Duke University, and Washington University) to describe short-term patient outcomes. In 723 patients treated with VA-ECMO, the most common indications for deployment were postcardiotomy shock (31%), cardiomyopathy (including acute heart failure) (26%), and myocardial infarction (17%). Patients frequently suffered in-hospital complications, including acute renal dysfunction (45%), major bleeding (41%), and infection (33%). Only 40% of patients (n = 290) survived to discharge, with a minority receiving durable cardiac support (left ventricular assist device [n = 48] or heart transplantation [n = 7]). Multivariable regression analysis identified risk factors for mortality on ECMO as older age (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.12–1.42) and female sex (OR, 1.44; 95% CI, 1.02–2.02) and risk factors for mortality after decannulation as higher body mass index (OR 1.17; 95% CI, 1.01-1.35) and major bleeding while on ECMO support (OR, 1.92; 95% CI, 1.23–2.99).ConclusionsDespite contemporary care at high-volume centers, patients treated with VA-ECMO continue to have significant in-hospital morbidity and mortality. The optimization of outcomes will require refinements in patient selection and improvement of care delivery.     

Prevalence of non-alcoholic fatty liver disease and liver fibrosis in a general population cohort from Argentina

Introduction and ObjectivesSouth America is one of the regions with the highest rates of non-alcoholic fatty liver disease (NAFLD). This study aimed to assess the prevalence and severity of NAFLD in suburban Argentina.Patients and MethodsThe study involved a general community cohort of 993 subjects evaluated sequentially with a comprehensive lifestyle questionnaire, laboratory testing, abdominal ultrasound (US) and transient elastography with XL probe. NAFLD was diagnosed according to standard criteria.ResultsThe prevalence of NAFLD by the US was 37.2% (326/875) overall, 50.3% in subjects with overweight/obesity, 58.6% with hypertriglyceridemia, 62.3% with diabetes/hyperglycemia and 72.1% with all three risk factors. Male gender (OR 1.42, 95% CI 1.03–1.47, p = 0.029), age (50–59 years: OR 1.98, 95 CI 1.16–3.39, p = 0.013 and ≥60 years: OR 1.86, 95% CI 1.13–3.09, p = 0.015), BMI (25–29: OR 2.87, 95% CI 1.86–4.51, p<0.001 and ≥30: OR 9.57, 95% CI 6.14–15.20, p<0.001), diabetes/hyperglycemia (OR 1.65, 95% CI 1.05–2.61, p = 0.029) and hypertriglyceridemia (OR 1.73, 95% CI 1.20–2.48, p = 0.002) were independent predictors of NAFLD. Among patients with steatosis, 22.2% (69/311) had ≥F2 fibrosis (overweight 25%, hypertriglyceridemia 32%, diabetes/hyperglycemia 34%). BMI (OR 5.22, 95% CI 2.64–11.74, p<0.001), diabetes/hyperglycemia (OR 2.12, 95% CI 1.05–4.29, p = 0.04) and hypertriglyceridemia (OR 1.94, 95% CI 1.03–3.68, p = 0.040) were independent predictors of liver fibrosis.ConclusionsThis general population study from Argentina showed a high prevalence of NAFLD. Significant liver fibrosis was present in 22% of subjects with NAFLD. This information adds to the existing knowledge of NAFLD epidemiology in Latin America.     

Incidence, 30-day readmission rates and predictors of readmission after new onset atrial fibrillation who underwent transcatheter aortic valve replacement

IntroductionNew onset Atrial Fibrillation (NOAF) is frequently seen post transcatheter aortic valve replacement (TAVR). NOAF in the setting of TAVR has also been recognized as predictor of worse outcomes, including higher readmission rates. Data assessing the effect and predictors of NOAF on 30-day readmission rates post TAVR is limited.ObjectiveTo assess the incidence, 30-day readmission rate and predictors of NOAF in patients who underwent TAVR.MethodsNationwide Readmissions Database was used to identify patients who developed NOAF post-TAVR between 2012 and 2015.ResultsA total of 24,076 patients were included in this study, of which 54% were males, and the mean age was 82.4 ± 7.2. NOAF was developed in 10,847 (45%) patients. Overall readmission rates with NOAF was 19.7% and trend in the readmissions reduced during the course of the study (21.9% to 18.7%, P_trend < 0.001). Thirty-day readmission rate in patients who developed NOAF post-TAVR was significantly higher compared to TAVR patients without NOAF (OR 1.39; 95% CI, 1.28–1.51; p < 0.001). Similarly, rate of ischemic stroke was significantly higher among patients who developed NOAF (OR 1.22; 95% CI, 1.07–1.4; p = 0.004). Predictors of readmissions in NOAF group were mostly non-cardiac, and included age, and comorbidities with chronic liver disease, renal failure and chronic lung disease been the most common comorbidities, in that order.ConclusionsIncidence of NOAF is associated with increased risk of readmissions and ischemic stroke. Future research should focus on interventions to prevent avoidable readmissions and associated morbidity and mortality.     

Prognostic factors of critical acute pancreatitis: A prospective cohort study

BackgroundPatients with critical acute pancreatitis (CAP) have the highest risk of mortality. However, there have been no studies specifically designed to evaluate the prognostic factors of CAP.Aims & methodsThis was a prospective observational cohort study involving patients with CAP. Three aspects including organ failure, (peri)pancreatic necrotic fluid cultures and surgical interventions were analyzed specifically to identify prognostic factors.ResultsOf the 102 consecutive patients with CAP, 83 patients (81.4%) received step-up surgical treatment, the mortality of the step-up group was 25.3% (21/83). 19 patients (18.6%) underwent step-down surgical treatment, the mortality of the step-down group was 57.9% (11/19). Overall mortality in the whole cohort was 31.4% (32/102). Multivariate analysis of death predictors indicated that multiple organ failure (MOF) (OR = 5.3; 95% CI, 1.5–18.2; p = 0.008), long duration (≥5 days) of organ failure (OR = 6.4; 95% CI, 1.2–54.3; p = 0.029), multidrug-resistant organisms (MDROs) infection (OR = 4.6; 95% CI, 1.3–15.8; p = 0.013), OPN (OR = 3.7; 95% CI, 1.5–8.8; p = 0.004) and step-down surgical treatment (OR = 3.5; 95% CI, 1.2–10.1; p = 0.019) were significant factors.ConclusionAmong patients with CAP, MOF, long duration (≥5 days) of organ failure, MDROs infection, OPN and step-down surgical treatment were identified as the predictors of mortality.     

Early left ventricular systolic dysfunction in asymptomatic patients with type 1 diabetes: a single-center,pilot study

AimsPrevalence and risk factors of pre-symptomatic left ventricular systolic dysfunction (LVSD) in individuals with type 1 diabetes (T1D) have not been adequately studied. The present cross-sectional study assessed the prevalence of early LVSD in asymptomatic patients with type 1 diabetes and investigated potential risk factors.MethodsConsecutive patients with T1D, free of cardiovascular disease and significant evident microvascular complications were examined. LVSD was assessed by speckle-tracking echocardiography and calculation of global longitudinal strain (GLS). Abnormal GLS was defined as a value>-18.7%. We looked for possible associations between the presence of LVSD and patient demographic, clinical and laboratory characteristics, as well as with autonomic nervous system (ANS) function and arterial stiffness.ResultsWe enrolled 155 T1D patients (29.7% men, age 36.7 ± 13.1 years, diabetes duration 19.1 ± 10.0 years, HbA1c 7.5 ± 1.4% [58 ± 15 mmol/mol]). Early LVSD was prevalent in 53 (34.2%) patients. Multivariable analysis identified male gender (OR:4.14; 95% CI:1.39–12.31, p = 0.011), HbA1c (OR:1.59 per 1% increase; 95% CI:1.11–2.28, p = 0.011), glomerular filtration rate (GFR, OR:0.97; 95% CI:0.95–0.99, p = 0.010) and BMI (OR:1.19; 95% CI:1.06–1.34, p = 0.003) as independent predictors of LVSD presence.ConclusionsEarly subclinical LVSD is a common finding in asymptomatic patients with T1D, free of macrovascular and significant microvascular complications. Apart from chronic hyperglycemia, increased adiposity may be implicated in its etiology. Further investigation is warranted to identify patients at high risk for whom early screening is required and to determine possible associations between risk markers identified in the present analysis and long-term outcomes.     

Efficacy of Mechanical Circulatory Support Used Before Versus After Primary Percutaneous Coronary Intervention in Patients with Cardiogenic Shock From ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis

BackgroundOptimal timing to initiate mechanical circulatory support (MCS) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) remains unclear with studies showing conflicting results on whether to start before or after primary percutaneous coronary intervention (PPCI). This study aims to examine the association between mortality and MCS initiated before vs after PPCI in patients with STEMI complicated by CS.MethodsWe systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to October 2021. Studies were included if they evaluated the association of mortality in patients who initiated MCS (specifically intra-aortic balloon pump (IABP), Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO)) before PPCI versus after PPCI, specifically in patients with STEMI complicated by CS. Data were integrated using the random-effects models.ResultsTen studies involving 1,352 patients (956, 203, and 193 patients underwent IABP, Impella, and VA-ECMO respectively) with STEMI complicated by CS were included. There was no difference in mortality using IABP before or after PPCI ([OR] 1.77, 95% CI 0.77–1.61, I2 = 27%, p = 0.57). Nevertheless, Impella and VA-ECMO started before PPCI were significantly associated with a reduced risk of mortality compared to that started after PPCI ([OR] 0.49, 95% CI 0.26–0.92, I2 = 0%, p = 0.03 and [OR] 0.29, 95% CI 0.14–0.62, I2 = 0%, p = 0.001, respectively).ConclusionsIn patients with STEMI complicated by CS undergoing PPCI, the use of IMPELLA or VA-ECMO prior to PPCI significantly decreased mortality, in contrast to IABP, in which no difference in mortality was found between using it before or after PPCI. More rigorous studies are needed to clarify this association.     

Successfully Managed Access-Site Complication Was Not Associated With Worse Outcome After Percutaneous Transfemoral Transcatheter Aortic Valve Implantation: Up-to-Date Insights From the OCEAN-TAVI Registry

BackgroundAccess-site complications during transfemoral transcatheter aortic valve implantation (TF-TAVI) cause serious issues in the future, if unresolved, but the best strategies to manage these complications remains unclear. This study aimed to comprehensively assess access-site complications during percutaneous TF-TAVI in terms of their management.MethodsUsing the prospective, multicentre, observational registry OCEAN (Optimized Transcatheter Valvular Intervention), 1497 patients who underwent percutaneous TF-TAVI between October 2013 and May 2017 were identified. The incidence, predictors, temporal changes, and prognosis of access-site complications along with its treatment strategy and re-intervention rate were evaluated.ResultsAccess-site complications occurred in 105 patients (7.0%) and was predicted with lower body-mass-index (OR, 0.94; 95% CI; 0.89–0.99; p = 0.03) and higher sheath-to-femoral-artery-ratio (OR, 1.12; 95% CI, 1.03–1.24; p < 0.002). The incidence of access-site complications declined over time, irrespective of the increasing number of percutaneous TF-TAVI cases. Access-site complications were treated by conservative therapy (n = 19, 18%), interventional procedures (n = 42, 40%), rescue surgical repair (SR) (n = 10, 10%), and primary SR (n = 34, 32%). The severity of complications differed but the re-intervention rate was similar among 4 groups (p = 0.46). Re-intervention was not needed, except for a case of common femoral artery stenosis/occlusion induced by ProGlide. The need for all SRs decreased annually. Access-site complications were not associated with 30 days- and 1 year-survival rate.ConclusionsThe incidence of access-site complications was not low but has declined annually. Access-site complications are not related to worse outcomes after successful management. Interventional procedure is acceptable as the first-line strategy to treat access-site complications.     

Association of non-alcoholic fatty liver disease with microvascular complications of type 2 diabetes

IntroductionNon-alcoholic fatty liver disease (NAFLD) affects risks of type 2 diabetes (T2D), diabetes-related complications, and cardiovascular disease in a complex manner. This study is designed to clarify associations of sonographically-detected NAFLD and serum liver enzymes with diabetes-related microvascular complications.MethodsA matched case-contorl study was designed for 440 patients with T2D and at least one of the chronic diabetes-related microvascular complications and 495 age- and gender-matched control patients with T2D.ResultsConsidering pre-existing and newly developed chronic microvascular complications, diabetic peripheral neuropathy was found in 347 out of 935 (37.1%) study patients, diabetic retinopathy in 141/935 (15.1%), and diabetic nephropathy in 103/935 (11.0%). Diagnosis of diabetic retinopathy and diabetic nephropathy were inversely associated with the presence of NAFLD in the crude logistic regressions (OR [95% CI] = 0.18 [0.05–0.63], p value = 0.007; OR [95% CI] = 0.17 [0.04–0.59], p value = 0.011, respectively). The subgroup of NAFLD with elevated liver enzymes had lower odds of having diabetic peripheral neuropathy in the fully adjusted model (OR [95% CI] = 0.34 [0.12–0.98], p value = 0.048).ConclusionDiagnosis of NAFLD with or without elevated serum liver enzymes was inversely correlated with certain chronic diabetes microvascular complications. Possible explanations for this counter-intuitive and unexpected finding are discussed and center on reverse-causality, wherein sicker patients may develop beneficial compensatory physiological and behavioral adaptations. Diversity of studied patients, in particular with regards to the ethnic and racial differences among the Western and Asian populations may also partly account for contrasting findings of the relationship between NAFLD and microvascular complications of diabetes.     

The importance of sarcopenia as a prognostic predictor of the clinical course in acute severe ulcerative colitis patients

Background and aimAcute severe ulcerative colitis (ASUC) is a life-threatening condition that requires timely referral for therapy. Sarcopenia has been associated with clinical outcomes of inflammatory bowel disease (IBD). This study investigated the role of sarcopenia in predicting the clinical course of ASUC.MethodsThis retrospective cohort study included ASUC patients with abdominal CT scans. Univariate and multivariable regression analyses were performed to identify a practical predictive index for the clinical course of ASUC.ResultsOf 233 included patients, 151 had intravenous corticosteroid (IVS) failure, among whom 32 received surgery without medical rescue therapy. Fifty patients underwent colectomy after medical rescue therapy failure. Of these 82 surgical patients, 42 suffered postoperative complications. Multivariable regression analysis showed that sarcopenia remained an independent risk factor for IVS failure (OR=2.969; 95% CI, 1.547–5.701; p = 0.001), colectomy after medical rescue therapy failure (OR=3.411; 95% CI, 1.147–10.141; p = 0.027), and postoperative complications after colectomy (OR=4.157; 95% CI, 1.364–12.667; p = 0.012). During follow-up, patients with colectomy after first-line treatment had a lower comprehensive complication index and better health-related quality of life.ConclusionSarcopenia is useful in predicting the clinical course and postoperative outcomes of ASUC.     

Outcomes With Drug-Coated Balloons vs. Drug-Eluting Stents in Small-Vessel Coronary Artery Disease

BackgroundThe use of drug-coated balloons (DCBs) in small-vessel coronary artery disease (SVD) remains controversial.MethodsWe performed a meta-analysis of all randomized controlled trials (RCTs) reporting the outcomes of DCB vs. DES in de-novo SVD. We included a total of 5 RCTs (1459 patients), with (DCB n = 734 and DES n = 725).ResultsOver a median follow-up duration of 6 months, DCB was associated with smaller late lumen loss (LLL) compared with DES (mean difference −0.12 mm) (95% confidence intervals (CI) [−0.21, −0.03 mm], p = 0.01). Over a median follow-up of 12 months, both modalities had similar risk of major adverse cardiovascular events (MACE) (8.7% vs. 10.2%; odds ratio (OR): 0.94, 95% CI [0.49–1.79], p = 084), all-cause mortality (1.17% vs. 2.38%; OR: 0.53, 95% CI [0.16–1.75], p = 0.30), target lesion revascularization (TLR) (7.9% vs. 3.9%; OR: 1.26, 95% CI [0.51–3.14], p = 0.62), and target vessel revascularization (TVR) (8.2% vs. 7.8%; OR: 1.06, 95% CI [0.40–2.82], p = 0.91). DCBs were associated with lower risk of myocardial infarction (MI) compared with DES (1.55% vs. 3.31%; OR: 0.48, 95% CI [0.23–1.00], p = 0.05, I2 = 0%).ConclusionPCI of SVD with DCBs is associated with smaller LLL, lower risk of MI, and similar risk of MACE, death, TLR, and TVR compared with DES over one year. DCB appears as an attractive alternative to DES in patients with de-novo SVD, but long-term clinical data are still needed.     

Extracorporeal Membrane Oxygenation for Graft Dysfunction Early After Heart Transplantation: A Systematic Review and Meta-analysis

IntroductionVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is a prevailing option for the management of severe early graft dysfunction. This systematic review and individual patient data (IPD) meta-analysis aims to evaluate (1) mortality, (2) rates of major complications, (3) prognostic factors, and (4) the effect of different VA-ECMO strategies on outcomes in adult heart transplant (HT) recipients supported with VA-ECMO.Methods and ResultsWe conducted a systematic search and included studies of adults (≥18 years) who received VA-ECMO during their index hospitalization after HT and reported on mortality at any timepoint. We pooled data using random effects models. To identify prognostic factors, we analysed IPD using mixed effects logistic regression. We assessed the certainty in the evidence using the GRADE framework. We included 49 observational studies of 1477 patients who received VA-ECMO after HT, of which 15 studies provided IPD for 448 patients. There were no differences in mortality estimates between IPD and non-IPD studies. The short-term (30-day/in-hospital) mortality estimate was 33% (moderate certainty, 95% confidence interval [CI] 28%–39%) and 1-year mortality estimate 50% (moderate certainty, 95% CI 43%–57%). Recipient age (odds ratio 1.02, 95% CI 1.01–1.04) and prior sternotomy (OR 1.57, 95% CI 0.99–2.49) are associated with increased short-term mortality. There is low certainty evidence that early intraoperative cannulation and peripheral cannulation reduce the risk of short-term death.ConclusionsOne-third of patients who receive VA-ECMO for early graft dysfunction do not survive 30 days or to hospital discharge, and one-half do not survive to 1 year after HT. Improving outcomes will require ongoing research focused on optimizing VA-ECMO strategies and care in the first year after HT.     

Predictors of discharge timing and unplanned readmission after laparoscopic liver resection

BackgroundThe aim of the study was to determine the predictors of discharge timing and 90-day unplanned readmission after laparoscopic liver resection (LLR).MethodsConsecutive LLR performed at the “Institut Mutualiste Montsouris” between 2000 and 2019 were retrieved from a prospectively maintained database. Length of stay (LOS) was stratified according to surgical difficulty and was categorized as early (LOS<25th percentile), routine (25th percentile<75th percentile), and delayed discharge otherwise. Uni-and-multivariate analyses were conducted to determine the factors associated with the time of discharge and 90-day unplanned readmission.ResultsEarly discharge occurred in 15.7% patients whereas delayed discharge occurred in 20.6% patients. Concomitant pancreatic resections (OR 26.8, 95% CI 5.75–125, p < 0.0001) and removal of colorectal primary tumors (OR 7.14, 95% CI 3.98–12.8, p < 0.0001) were the strongest predictors of delayed discharge whereas ERP implementation was the strongest predictor of early discharge (OR 7.4, 95% CI 4.60–11.9, p < 0.0001). Unplanned readmission rate was lower among early discharged patients (7.4% vs. 23.8%, p < 0.0001). Bile leakage was the strongest predictor of 90-day unplanned readmission (OR 3.8, 95% CI 1.12–15.8, p = 0.045).ConclusionConcomitant colorectal or pancreatic resections were the strongest predictors of delayed discharge. Postoperative bile leakage was the strongest predictor of 90-day unplanned readmission following LLR.     

Home Health Care Utilization Trend,Predictors, and Association With Early Rehospitalization Following Endovascular Transcatheter Aortic Valve Replacement

Background/purposeHome healthcare (HHC) utilization is associated with higher rates of rehospitalization in patients with heart failure and transcatheter mitral valve repair. This study sought to assess the utilization, predictors, and the association of HHC with 30-day readmission in patients undergoing transcatheter aortic valve replacement (TAVR).Methods/materialsWe queried the Nationwide Readmission Database from January 2012 to December 2017 for TAVR discharges with and without HHC referral. Using multivariate analysis, we identified predictors of HHC utilization, and its association with outcomes.ResultsOf 60,950 TAVR discharges, 21,724 (35.7%) had HHC referral. On multivariable analysis, female sex (OR, 1.34; 95% CI, 1.29–1.40), non-elective admission (OR, 1.49; 95% CI, 1.42–1.56), diabetes mellitus (OR, 1.09; 95% CI, 1.05–1.13), prior stroke (OR, 1.06; 95% CI, 1.01–1.12), anemia (OR, 1.16; 95% CI, 1.11–1.21), and in-hospital complications including cardiogenic shock (OR, 1.37; 95% CI, 1.16–1.50), cardiac arrest (OR, 1.22; 95% CI, 1.00–1.50), stroke (OR, 2.62; 95% CI, 2.20–3.18), and new Permanent pacemaker (OR, 1.49; 95% CI, 1.41–1.58) were identified as independent predictors of HHC referral. HHC utilization was associated with longer median length of stay (4 days vs. 2 days, P < 0.001), higher rate of 30-day all-cause (15.5% vs. 10.6%, P < 0.001) and heart failure (2.1%vs. 1.1%, P < 0.001) readmission rates compared to those without HHC.ConclusionsOur study identified a vulnerable group of TAVR patients that are at higher risk of 30-day readmission. Evidence-based interventions proven effective in reducing the burden of readmissions should be pursed in these patients to improve outcomes and quality of life.     

Clinical Impact of Atrial Fibrillation on Short-Term Outcomes and In-Hospital Mortality in Patients with Takotsubo Syndrome: A Propensity-Matched National Study

IntroductionTakotsubo Syndrome (TS) patients are at high risk of developing atrial fibrillation. We sought to investigate the outcomes and economic impact of atrial fibrillation on TS patients utilizing the National Inpatient Sample.MethodsPatients with TS were identified in the National Inpatient Sample (NIS) database between 2010 and 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and subsequently were divided into two groups, those with and without atrial fibrillation. The primary outcome was all-cause in-hospital mortality in the two groups. Secondary outcomes were in-hospital complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding factors.ResultsAmong the study population, the prevalence of atrial fibrillation was 17.57%. After matching, the atrial fibrillation group had no significant increase of in-hospital mortality (OR: 1.13; 95% CI: 0.94–1.35, p = 0.211). However, atrial fibrillation patients were more likely to develop cardiac arrest and ventricular arrhythmias (OR: 1.51, 95% CI: 1.26–1.80, p < 0.0001), have higher rate of major cardiac complications when combined as a single endpoint in-hospital complication (OR: 1.16, 95% CI: 1.04–1.29, p: 0.006), also they were more likely to stay longer in hospital (OR: 1.13, 95% CI: 1.08–1.19, p < 0.0001), and have increased cost of hospitalization (OR: 1.13, 95% CI 1.07–1.20, p < 0.0001).ConclusionAtrial fibrillation does not increase in-hospital mortality in patients presenting with TS. However atrial fibrillation is associated with an increased risk of ventricular arrhythmias, length of stay, non-routine discharges and cost of hospitalization.     

Complications of a lung biopsy for severe respiratory failure: A systematic review and meta-analysis

BackgroundThis systematic review and meta-analysis aimed to evaluate the complications of lung biopsy in patients with acute respiratory failure (ARF), including acute respiratory distress syndrome (ARDS).MethodsWe searched the MEDLINE and Cochrane Central Register of Controlled Trials. The primary outcomes were biopsy-related death, respiratory failure, cardiac complications, bleeding, and other major complications. We used the McMaster Quality Assessment Scale of Harms (McHarm) to evaluate the risk of bias. A random-effects model was used to calculate the pooled frequencies.ResultsThirteen studies (consisting of 574 patients) were included in the meta-analysis. Furthermore, most of the included studies had a high or unclear risk of bias in half of the items in McHarm. All included studies evaluated surgical lung biopsies. The median overall hospital mortality was 53% (range: 17%–90%). The pooled frequencies of biopsy-related death, respiratory failure, cardiac complication, bleeding, and other major complications were 0.00% (95% confidence interval [CI]: 0.00%–0.21%), 1.30% (95% CI: 0.00%–5.69%), 1.03% (95% CI: 0.00%–3.73%), 1.46% (95% CI: 0.16%–3.56%), and 4.26% (95% CI: 0.00%–13.0%), respectively.ConclusionsThe results of this study will be valuable information in considering the indications of lung biopsy in patients with ARF, including ARDS.Trial registrationThe protocol was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN 000040650).     

Predictive Value of Inflammation Biomarkers in Patients with Portal Vein Thrombosis

Background and AimsTo investigate the usefulness of inflammation biomarkers to serve as a predictors of portal vein thrombosis (PVT) postoperatively (post) in patients with portal hypertension after splenectomy and periesophagogastric devascularization.MethodsA total of 177 liver cirrhosis patients were recruited from January 2013 to December 2017. They were divided into a PVT group (n=71) and a non-PVT group (n=106), according to ultrasound examination findings at 7-day post. Inflammation biomarkers involving platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), red blood cell distribution width-to-platelet ratio(RPR), mean platelet volume-to-platelet ratio (MPR) preoperatively (pre) and at 1, 3, 7-days post were recorded.ResultsThe univariate logistic regression analysis indicated that PLR (pre) (odds ratio (OR)=3.963, 95% confidence interval (CI)=2.070–7.587, p<0.000), MLR (pre) (OR=2.760, 95% CI=1.386–5.497, p=0.004), PLR (post-day 7) (OR=3.345, 95% CI=1.767–6.332, p=0.000) were significantly associated with the presence of PVT. The multivariate logistic regression analysis results indicated that PLR (pre) (OR=3.037, 95% CI=1.463–6.305, p=0.003), MLR (pre) (OR=2.188, 95% CI=1.003–4.772, p=0.049), PLR(post-day 7) (OR=2.166, 95% CI=1.053–4.454, p=0.036) were independent factors for predicting PVT.ConclusionsThe PLR (pre), MLR (pre), and PLR (post-day 7) are predictors of portal vein thrombosis post in patients with portal hypertension after splenectomy and periesophagogastric devascularization.     

Predictive risk factors of early onset left ventricular aneurysm formation in patients with acute ST-elevation myocardial infarction

BackgroundLeft ventricular aneurysm (LVA) is a severe complication of ST-elevation myocardial infarction (STEMI) and is associated with poor prognosis due to high mortality. However, predictors of LVA formation in early period are inadequately defined.ObjectivesThe purpose of this study is to determine potential predictors of LVA formation in early period (<15 days after admission) after acute STEMI.MethodsThe present study was retrospectively conducted involving 1823 STEMI patients based on the AMI database of our clinic between January 2013 and April 2019. Among STEMI patients with regional wall motion abnormality (RWMA), the baseline, angiographic, procedural characteristics of patients with early-onset LVA and controls without LVA were compared. The controls were matched 2:1 with LVA cases for the admission date. Patients with prior myocardial infarction, non-ischemic cardiomyopathy, severe heart valve disease, and patients without coronary angiography were excluded. The odds ratio (OR) and confidence interval (CI) were obtained by logistic regression analysis and all statistical analysis were performed by SPSS 25.0.ResultsAmong 1823 STEMI patients who underwent coronary angiography, 103 eligible patients (median age 67 years) had LVA and were compared to 206 patients without LVA (median age 60 years). In multivariate analysis, RWMA in the left ventricular anterior wall (OR 13.17, 95%CI 2.21–78.57, p=0.005) was found to be the most striking predictor of LVA, followed by RWMA in the apex (OR 7.93, 95%CI 2.22–28.30, p=0.001). Female sex (OR 3.91, 95%CI 1.54–9.93, p=0.004), peak N-terminal pro brain natriuretic peptide (NT-pro BNP,OR 1.08, 95%CI 1.01–1.16, p=0.031), time between onset of pain and balloon time (OR 1.01, 95%CI 1.00–1.01, P=0.016), and presence of QS-waves on initial electrocardiogram (OR 3.06, 95%CI 1.49–6.27, P=0.016) were independently associated with LVA formation.ConclusionThis study indicated that female sex, peak NT-pro BNP, the time between the onset of pain and balloon time, presence of QS-waves on initial electrocardiogram, RWMA of left ventricular anterior wall and apex were the independent predictors of early-onset LVA in patients with acute STEMI.     

The impact of admission red cell distribution width on the development of poor myocardial perfusion after primary percutaneous intervention

BackgroundThe purpose of this study was to evaluate the predictive value of red cell distribution width (RDW) on the electrocardiographic no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention (PCI).MethodsOne-hundred consecutive patients (mean age 61.3 ± 12.8 years and male 77%) with ST-elevation myocardial infarction, who were treated with primary PCI, were analyzed prospectively. RDW and high sensitive C reactive protein (hs-CRP) were measured. The sum of ST-segment elevation was obtained immediately before and 60 min after the restoration of coronary flow. The difference between two measurements was accepted as the amount of ST-segment resolution and was expressed as ∑STR. ∑STR < 50% was accepted as electrocardiographic sign of no-reflow phenomenon.ResultsThere were 30 patients in the no-reflow group (Group 1) and 70 patients in the normal re-flow group (Group 2). RDW and hs-CRP levels on admission were higher in Group 1. An RDW level ≥14% measured on admission had 70% sensitivity and 64% specificity in predicting no-reflow on ROC curve analysis. Mid-term cardiovascular events were significantly higher in Group 1. In multivariate analyses, RDW (OR 2.93, <95% CI 1.42–6.04; p = 0.004), and tirofiban (OR 0.16, <95% CI 0.05–0.48; p = 0.001) were independent predictors of no-reflow, and RDW (OR 5.89, <95% CI 1.63–21.24; p = 0.007), and creatine kinase-MB (CK-MB) on admission (OR 1.01, <95% CI 1.00–1.02; p = 0.006) were independent predictors of mid-term mortality.ConclusionsA greater baseline RDW value was independently associated with the presence of electrocardiographic no-reflow.     

Vanishing bile duct syndrome after drug-induced liver injury

BackgroundVanishing bile duct syndrome (VBDS) is a serious cholestatic liver disease that can be a complication of drug-induced liver injury (DILI). While journals have published case reports of this condition, large studies on a cohort of these patients are lacking. We aimed to compile published case reports and case series of patients with VBDS and DILI to describe the clinical and laboratory characteristics of the disease and identify factors associated with good and poor outcomes.MethodsWe included case reports and case series of VBDS secondary only to DILI. We extracted demographic, clinical, laboratory, treatment, and exposure data from each case report and categorized cases by outcome, good versus poor. We defined poor outcomes as cases with severe long-term complications or death. We analyzed risk factors for poor outcomes using logistic regression.ResultsWe identified a total of 59 eligible cases. Of those, 39 (59%) were female, the median age was 36 (IQR:12–58), and 18 (31%) were pediatric cases (≤18 years). The most common offending drug class was antibiotics, especially beta-lactams. Patients with increased total bilirubin (OR=4.69; 95% CI=1.55–15.49; p = 0.008), increased direct bilirubin (OR=6.50; 95% CI=1.34–48.91; p = 0.034), lower liver synthetic activity (OR=0.11; 95% CI=0.02–0.55; p = 0.013), and older age (OR=3.31; 95% CI=1.15–10.04; p = 0.029) were more likely to develop poor outcomes.ConclusionsIn patients with VBDS and DILI, antibiotics were the most common offending agents. Higher total and direct bilirubin levels were associated with poor outcomes.     

Hepatocellular liver injury in hospitalized patients affected by COVID-19: Presence of different risk factors at different time points

BackgroundPrevalence and clinical impact of increased liver function tests in patients affected by Coronavirus disease 2019 (COVID-19) is controversial.AimsThis observational study evaluates the prevalence of transaminases elevation in hospitalized patients affected by COVID-19 and investigates the presence of factors associated with hepatocellular injury and with mortality.MethodsData of 292 adult patients with confirmed COVID-19 admitted to the Ente Ospedaliero Cantonale (Switzerland) were retrospectively analyzed.ResultsTransaminases were increased in about one-third of patients on hospital admission and two-thirds of patients during the hospital stay. On hospital admission, transaminases were more commonly elevated in younger patients, who also reported elevated C reactive protein and a higher degree of respiratory failure. Independent factors associated with abnormal transaminases during hospitalization were drugs, in particular paracetamol (OR=2.67; 95% CI=1.38–5.18; p = 0.004) and remdesivir (OR=5.16; 95% CI=1.10–24.26; p = 0.04). Mortality was independently associated to age (OR = 1.09; 95% CI=1.05–1.13; p<0.001), admission to intensive care unit (OR=5.22; 95% CI=2.28–11.90; p<0.001) and alkaline phosphatase peak (OR=1.01; 95% CI=1.00- 1.01; p = 0.01).ConclusionsOn hospital admission, factors associated with liver damage were linked to demographic and clinical characteristics (age, inflammation and hypoxia) while, during hospitalization, drug treatment was related to development and progression of hepatocellular damage. Mortality was associated with alkaline phosphate peak value.