Increasing role of post-intensive care syndrome in quality of life of intensive care unit survivors

In this editorial we comment on the detrimental consequences that post-intensive care syndrome(PICS)has in the quality of life of intensive care unit(ICU)survivors,highlighting the importance of early onset of multidisciplinary rehabilitation from within the ICU.Although,the syndrome was identified and well described early in 2012,more awareness has been raised on the long-term PICS related health problems by the increased number of coronavirus disease 2019 ICU survivors.It is well outlined that the syndrome affects both the patient and the family and is described as the appearance or worsening of impairment in physical,cognitive,or mental health as consequence of critical illness.PICS was described in order:(1)To raise awareness among clinicians,researchers,even the society;(2)to highlight the need for a multilevel screening of these patients that starts from within the ICU and continues after discharge;(3)to present preventive strategies;and(4)to offer guidelines in terms of rehabilitation.An early multidisci-plinary approach is the key element form minimizing the incidence of PICS and its consequences in health related quality of life of both survivors and their families.

Cardiac rehabilitation after cardiac surgery:An important underutilized treatment strategy

Physical inactivity remains in high levels after cardiac surgery,reaching up to 50%.Patients present a significant loss of functional capacity,with prominent muscle weakness after cardiac surgery due to anesthesia,surgical incision,duration of cardiopulmonary bypass,and mechanical ventilation that affects their quality of life.These complications,along with pulmonary complications after surgery,lead to extended intensive care unit(ICU)and hospital length of stay and significant mortality rates.Despite the well-known beneficial effects of cardiac rehabilitation,this treatment strategy still remains broadly underutilized in patients after cardiac surgery.Prehabilitation and ICU early mobilization have been both showed to be valid methods to improve exercise tolerance and muscle strength.Early mobilization should be adjusted to each patient’s functional capacity with progressive exercise training,from passive mobilization to more active range of motion and resistance exercises.Cardiopulmonary exercise testing remains the gold standard for exercise capacity assessment and optimal prescription of aerobic exercise intensity.During the last decade,recent advances in healthcare technology have changed cardiac rehabilitation perspectives,leading to the future of cardiac rehabilitation.By incorporating artificial intelligence,simulation,telemedicine and virtual cardiac rehabilitation,cardiac surgery patients may improve adherence and compliance,targeting to reduced hospital readmissions and decreased healthcare costs.

Quality of life and functional capacity in patients after cardiac surgery intensive care unit

Coronary heart disease and aortic stenosis are prevalent cardiovascular diseases worldwide,leading to morbidity and mortality.Coronary artery bypass grafting(CABG)and surgical aortic valve replacement(SAVR)have therapeutic benefits,including improved postoperative quality of life(QoL)and enhanced patient functional capacity which are key indicators of cardiac surgery outcome.In this article,we review the latest studies of QoL outcomes and functional capacity in patients who underwent cardiac surgery.Many standardized instruments are used to evaluate QoL and functional conditions.Preoperative health status,age,length of intensive care unit stay,operative risk,type of procedure,and other pre-,intra-,and postoperative factors affect postoperative QoL.Elderly patients experience impaired physical status soon after cardiac surgery,but it improves in the following period.CABG and SAVR are associated with increases of physical and mental health and functional capacity in the immediate postoperative and the long long-term.Cardiac rehabilitation improves patient functional capacity,QoL,and frailty following cardiac surgery.

Incidence and peri-operative risk factors for development of acute kidney injury in patients after cardiac surgery:A prospective observational study

BACKGROUND Patients admitted to intensive care unit(ICU) after cardiac surgery develop acute kidney injury(AKI) immediately post-operation. We hypothesized that AKI occurs mainly due to perioperative risk factors and may affect outcome.AIM To assess peri-operative risk factors for AKI post cardiac surgery and its relationship with clinical outcome.METHODS This was an observational single center, tertiary care setting study, which enrolled 206 consecutive patients, admitted to ICU after cardiac surgery. Patients were followed-up until ICU discharge or death, in order to determine the incidence of AKI, perioperative risk factors for AKI and its association with outcome.Univariate and multivariate logistic regression analysis was performed to assess predictor variables for AKI development.RESULTS After ICU admission, 55 patients(26.7%) developed AKI within 48 h. From the logistic regression analysis performed, high EuroScore Ⅱ(OR: 1.18;95%CI: 1.06-1.31, P = 0.003), white blood cells(WBC) pre-operatively(OR: 1.0;95%CI: 1.0-1.0, P = 0.002) and history of chronic kidney disease(OR: 2.82;95%CI: 1.195-6.65, P = 0.018) emerged as independent predictors of AKI among univariate predictors. AKI that developed AKI had longer duration of mechanical ventilation [1113(777–2195) vs 714(511–1020) min, P = 0.0001] and ICU length of stay [70(28–129) vs 26(21–51) h, P = 0.0001], higher rate of ICU-acquired weakness(16.4% vs 5.3%, P =0.015), reintubation(10.9% vs 1.3%, P = 0.005), dialysis(7% vs 0%, P = 0.005), delirium(36.4% vs 23.8%, P = 0.001) and mortality(3.6% vs 0.7%, P = 0.046).CONCLUSION Patients present frequently with AKI after cardiac surgery. EuroScore Ⅱ, WBC count and chronic kidney disease are independent predictors of AKI development. The occurrence of AKI is associated with poor outcome.

Incidence, risk factors and clinical outcome of multidrug-resistant organisms after heart transplantation

BACKGROUND Transplant recipients commonly harbor multidrug-resistant organisms(MDROs),as a result of frequent hospital admissions and increased exposure to antimi-crobials and invasive procedures.AIM To investigate the impact of patient demographic and clinical characteristics on MDRO acquisition,as well as the impact of MDRO acquisition on intensive care unit(ICU)and hospital length of stay,and on ICU mortality and 1-year mortality post heart transplantation.METHODS This retrospective cohort study analyzed 98 consecutive heart transplant patients over a ten-year period(2013-2022)in a single transplantation center.Data was collected regarding MDROs commonly encountered in critical care.RESULTS Among the 98 transplanted patients(70%male),about a third(32%)acquired or already harbored MDROs upon transplantation(MDRO group),while two thirds did not(MDRO-free group).The prevalent MDROs were Acinetobacter baumannii(14%),Pseudomonas aeruginosa(12%)and Klebsiella pneumoniae(11%).Compared to MDRO-free patients,the MDRO group was characterized by higher body mass index(P=0.002),higher rates of renal failure(P=0.017),primary graft dysfunction(10%vs 4.5%,P=0.001),surgical re-exploration(34%vs 14%,P=0.017),mechanical circulatory support(47%vs 26%P=0.037)and renal replacement therapy(28%vs 9%,P=0.014),as well as longer extracorporeal circulation time(median 210 vs 161 min,P=0.003).The median length of stay was longer in the MDRO group,namely ICU stay was 16 vs 9 d in the MDRO-free group(P=0.001),and hospital stay was 38 vs 28 d(P=0.006),while 1-year mortality was higher(28%vs 7.6%,log-rank-χ2:7.34).CONCLUSION Following heart transplantation,a predominance of Gram-negative MDROs was noted.MDRO acquisition was associated with higher complication rates,prolonged ICU and total hospital stay,and higher post-transplantation mortality.

Effects of combined aerobic,resistance and inspiratory training in patients with pulmonary hypertension:A systematic review

BACKGROUND Pulmonary hypertension(PH)is a serious progressive disorder of the modern world,characterized by endothelial dysfunction and impaired vasoreactivity.Patients with PH usually present exercise intolerance from the very early stages and reduced exercise capacity.Exercise training has been shown to have beneficial effects in patients with cardiovascular comorbidities.However,data regarding the effects of combined exercise training programs in patients with PH still remains limited.AIM To investigate the effects of combined exercise training programs on exercise capacity and quality of life in patients with PH.METHODS Our search included all available randomized controlled trials(RCTs)regarding combined aerobic,resistance and inspiratory training programs in patients with PH in 4 databases(Pubmed,PEDro,Embase,CINAHL)from 2012 to 2022.Five RCTs were included in the final analysis.Functional capacity,assessed by peak VO_(2)or 6-min walking test(6MWT),as well as quality of life,assessed by the SF-36 questionnaire,were set as the primary outcomes in our study.RESULTS Peak VO_(2)was measured in 4 out of the 5 RCTs while 6MWT was measured in all RCTs.Both indices of functional capacity were significantly increased in patients with PH who underwent combined exercise training compared to the controls in all of the included RCTs(P<0.05).Quality of life was measured in 4 out of 5 RCTs.Although patients improved their quality of life in each group,however,only 2 RCTs demonstrated further improvement in patients performing combined training compared to controls.CONCLUSION By this systematic review,we have demonstrated that combined aerobic,resistance and inspiratory exercise training is safe and has beneficial effects on aerobic capacity and quality of life in patients with PH.Such exercise training regimen may be part of the therapeutic strategy of the syndrome.

A systematic review of the effect of mobile health on cardiac rehabilitation among coronary heart disease patients

Objective： Mobile health （mHealth） provides an innovative and effective approach to promote prevention and management of coronary heart disease. However, the magnitude of its effects is unclear. The aim of this systematic review was to examine the impact of mHealth-based cardiac rehabilitation outcomes among coronary heart disease patients. Methods： Medline, CINAHL, Embase, PubMed, Google Scholar, NICE, and Cochrane library were searched for randomized controlled trials published between January 2002 and March 2017 which compared mHealth with conventional cardiac rehabilitation programs among coronary heart disease patients. Results： Eight articles were included in this review. The impact of mHealth interventions on physical activity, medicine adherence, smoking cessation, level of anxiety, and quality of life was inconsistent among the articles. Conclusions： Further research is needed to conclusively determine the impact of mHealth interventions on cardiac rehabilitation outcomes. The limitations of the included studies （e.g., inadequate sample size, failure to address the core components of cardiac rehabilitation programs, and lack of theory-based design） should be taken into account when designing future studies.

A case report of chylous ascites after cardiac surgery

Background:Chylous ascites(CA),an emulsion rich in triglycerides,is a rare type of ascites,especially after cardiac surgery.Also,there are few reports of the occurrence of CA after mitral valve replacement,aortic valve replacement,tricuspid valvuloplasty,and coronary artery bypass grafting.Case presentation:We report the case of a 53-year-old man who underwent surgery for a diagnosis of mitral incompetence,aortic incompetence,tricuspid incompetence,and coronary atherosclerotic heart disease.Fifteen days after surgery,3000 mL of milky-yellow ascites appeared in the abdominal cavity,diagnosed as CA by laboratory examination.The ascites gradually disappeared after being drained,and the patients improved.The curative was objective,but the exact cause is not clear.Conclusion:Although CA is rare,it may occur during the surgical intervention in cardiac surgery.

Extracorporeal blood purification strategies in sepsis and septic shock:An insight into recent advancements

BACKGROUND Despite various therapies to treat sepsis,it is one of the leading causes of mortality in the intensive care unit patients globally.Knowledge about the pathophysiology of sepsis has sparked interest in extracorporeal therapies(ECT)which are intended to balance the dysregulation of the immune system by removing excessive levels of inflammatory mediators.AIM To review recent data on the use of ECT in sepsis and to assess their effects on various inflammatory and clinical outcomes.METHODS In this review,an extensive English literature search was conducted from the last two decades to identify the use of ECT in sepsis.A total of 68 articles from peer-reviewed and indexed journals were selected excluding publications with only abstracts.RESULTS Results showed that ECT techniques such as high-volume hemofiltration,coupled plasma adsorption/filtration,resin or polymer adsorbers,and CytoSorb®are emerging as adjunct therapies to improve hemodynamic stability in sepsis.CytoSorb®has the most published data in regard to the use in the field of septic shock with reports on improved survival rates and lowered sequential organ failure assessment scores,lactate levels,total leucocyte count,platelet count,interleukin-IL-6,IL-10,and TNF levels.CONCLUSION Clinical acceptance of ECT in sepsis and septic shock is currently still limited due to a lack of large random clinical trials.In addition to patient-tailored therapies,future research developments with therapies targeting the cellular level of the immune response are expected.

Effectiveness of high intensity interval training on cardiorespiratory fitness and endothelial function in type 2 diabetes:A systematic review

BACKGROUND Type 2 diabetes mellitus(T2DM)is a chronic metabolic syndrome characterized by insulin resistance and hyperglycemia that may lead to endothelial dysfunction,reduced functional capacity and exercise intolerance.Regular aerobic exercise has been promoted as the most beneficial non-pharmacological treatment of cardiovascular diseases.High intensity interval training(HIIT)seems to be superior than moderate-intensity continuous training(MICT)in cardiovascular diseases by improving brachial artery flow-mediated dilation(FMD)and cardiorespiratory fitness to a greater extent.However,the beneficial effects of HIIT in patients with T2DM still remain under investigation and number of studies is limited.AIM To evaluate the effectiveness of high intensity interval training on cardiorespiratory fitness and endothelial function in patients with T2DM.METHODS We performed a search on PubMed,PEDro and CINAHL databases,selecting papers published between December 2012 and December 2022 and identified published randomized controlled trials(RCTs)in the English language that included community or outpatient exercise training programs in patients with T2DM.RCTs were assessed for methodological rigor and risk of bias via the Physiotherapy Evidence Database(PEDro).The primary outcome was peak VO_(2 ) and the secondary outcome was endothelial function assessed either by FMD or other indices of microcirculation.RESULTS Twelve studies were included in our systematic review.The 12 RCTs resulted in 661 participants in total.HIIT was performed in 310 patients(46.8%),MICT to 271 and the rest 80 belonged to the control group.Peak VO_(2 ) increased in 10 out of 12 studies after HIIT.Ten studies compared HIIT with other exercise regimens(MICT or strength endurance)and 4 of them demonstrated additional beneficial effects of HIIT over MICT or other exercise regimens.Moreover,4 studies explored the effects of HIIT on endothelial function and FMD in T2DM patients.In 2 of them,HIIT further improved endothelial function compared to MICT and/or the control group while in the rest 2 studies no differences between HIIT and MICT were observed.CONCLUSION Regular aerobic exercise training has beneficial effects on cardiorespiratory fitness and endothelial function in T2DM patients.HIIT may be superior by improving these parameters to a greater extent than MICT.

Expert Consensus on Nutritional Support for Children with Congenital Heart Disease(2023 Edition)

The second edition of the expert consensus on pediatric nutrition was formed based on a global update of pedia-tric nutrition guidelines or consensus worldwide,the management of congenital heart disease,and the results of multi-center clinical nutrition research for congenital heart disease following thefirst Chinese consensus edition of 2016.The consensus was also shaped by the results of three discussion sessions and two questionnaires con-ducted by the 13-member collaboration group.This process was informed by both clinical guidelines and expert consensus.The quality of literature,both in English and Chinese,and the level of recommendations were evaluated using the Grading of Recommendations Assessment,Development,and Evaluations(GRADE)system.

Myalgia may not be associated with severity of coronavirus disease 2019 (COVID-19)

Dear editor,A recent study based on the use of experimental artificial intelligence(AI)tool showed 70%–80%accuracy in predicting development of severe disease in coronavirus disease 2019(COVID-19)based on predictive parameters alanine aminotransferase(ALT),myalgia and hemoglobin,whilst only 5 of 53 patients developed acute respiratory distress syndrome(ARDS),2 of whom reporting myalgia.

Diagnosis of myocardial infarction with nonobstructive coronary arteries in a young man in the setting of acute myocardial infarction after endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Acute myocardial infarction(AMI) is characterized by chest pain as well as cardiac troponin I(cTnI) and electrocardiography(ECG) changes. Recently,clinical researchers have used the term "MINOCA" to indicate myocardial infarction with nonobstructive coronary arteries. To the best of our knowledge,no report has documented MINOCA in a young patient after choledocholithiasis by endoscopic retrograde cholangiopancreatography(ERCP).CASE SUMMARY An 18-year-old Chinese man presented to the cardiac intensive care unit with chest pain radiating to the left shoulder for 1 h after choledocholithiasis by ERCP and the following treatment. ECG showed a sinus rhythm with ST-segment elevation in the Ⅱ,Ⅲ, and aVF leads compared with the baseline. Laboratory data revealed cTnI levels of 67.55 ng/mL and 80 ng/mL at the peak(relative index below 0.034 ng/mL) and creatine kinase-MB levels of 56 U/L and 543 U/L at the peak(relative index below 24 U/L). AMI was suspected, and coronary angiography was performed the second day. The results revealed a smooth angiographic appearance of all arteries. The patient had been diagnosed with gallstones and cholecystitis for four years but had not accepted treatment. He had abdominal pain and bloating a week previously and underwent ERCP and subsequent treatments on the second day of admission;1.4 cm × 1.6 cm of stones were removed from his common bile duct during surgery. The results of his laboratory tests at admission revealed abnormal alanine aminotransferase,aspartate aminotransferase, glutamyl transpeptidase, total bile acid, total bilirubin, direct bilirubin, and indirect bilirubin levels. His temperature, heart rate, blood pressure, and body mass index were normal. His echocardiographic examination revealed no obvious abnormalities in the structure and movement of the ventricular wall and an estimated left ventricular ejection fraction of 57% after the heart attack. His cholesterol and triglycerides were within normal ranges, and his low-density lipoprotein cholesterol was 2.23 mmol/L(normal range 2.03-3.34 mmol). Further testing after AMI revealed nothing remarkable in his erythrocyte sedimentation rate, thyroid function, and tumour markers.CONCLUSION We ultimately made a diagnosis of MINOCA caused by coronary artery spasm,which seemed to be the most suitable diagnosis of this young patient. We are concerned that the heart attack may have been induced by the ERCP rather than occurred coincidentally afterward, so we should investigate the timing of the event further. Additional studies are needed to unravel the underlying pathophysiology.

Exercise training in heart transplantation

Heart transplantation remains the gold standard in the treatment of end-stage heart failure(HF).Heart transplantation patients present lower exercise capacity due to cardiovascular and musculoskeletal alterations leading thus to poor quality of life and reduction in the ability of daily self-service.Impaired vascular function and diastolic dysfunction cause lower cardiac output while decreased skeletal muscle oxidative fibers,enzymes and capillarity cause arteriovenous oxygen difference,leading thus to decreased peak oxygen uptake in heart transplant recipients.Exercise training improves exercise capacity,cardiac and vascular endothelial function in heart transplant recipients.Pre-rehabilitation regular aerobic or combined exercise is beneficial for patients with end-stage HF awaiting heart transplantation in order to maintain a higher fitness level and reduce complications afterwards like intensive care unit acquired weakness or cardiac cachexia.All hospitalized patients after heart transplantation should be referred to early mobilization of skeletal muscles through kinesiotherapy of the upper and lower limbs and respiratory physiotherapy in order to prevent infections of the respiratory system prior to hospital discharge.Moreover,all heart transplant recipients after hospital discharge who have not already participated in an early cardiac rehabilitation program should be referred to a rehabilitation center by their health care provider.Although high intensity interval training seems to have more benefits than moderate intensity continuous training,especially in stable transplant patients,individualized training based on the abilities and needs of each patient still remains the most appropriate approach.Cardiac rehabilitation appears to be safe in heart transplant patients.However,long-term follow-up data is incomplete and,therefore,further high quality and adequately-powered studies are needed to demonstrate the long-term benefits of exercise training in this population.

Endothelial progenitor cells mobilization after maximal exercise according to heart failure severity

BACKGROUND Vascular endothelial dysfunction is an underlying pathophysiological feature of chronic heart failure(CHF).Patients with CHF are characterized by impaired vasodilation and inflammation of the vascular endothelium.They also have low levels of endothelial progenitor cells(EPCs).EPCs are bone marrow derived cells involved in endothelium regeneration,homeostasis,and neovascularization.Exercise has been shown to improve vasodilation and stimulate the mobilization of EPCs in healthy people and patients with cardiovascular comorbidities.However,the effects of exercise on EPCs in different stages of CHF remain under investigation.AIM To evaluate the effect of a symptom-limited maximal cardiopulmonary exercise testing(CPET)on EPCs in CHF patients of different severity.METHODS Forty-nine consecutive patients(41 males)with stable CHF[mean age(years):56±10,ejection fraction(EF,%):32±8,peak oxygen uptake(VO2,mL/kg/min):18.1±4.4]underwent a CPET on a cycle ergometer.Venous blood was sampled before and after CPET.Five circulating endothelial populations were quantified by flow cytometry:Three subgroups of EPCs[CD34+/CD45-/CD133+,CD34+/CD45-/CD133+/VEGFR2 and CD34+/CD133+/vascular endothelial growth factor receptor 2(VEGFR2)]and two subgroups of circulating endothelial cells(CD34+/CD45-/CD133-and CD34+/CD45-/CD133-/VEGFR2).Patients were divided in two groups of severity according to the median value of peak VO2(18.0 mL/kg/min),predicted peak VO2(65.5%),ventilation/carbon dioxide output slope(32.5)and EF(reduced and mid-ranged EF).EPCs values are expressed as median(25th-75th percentiles)in cells/106 enucleated cells.RESULTS Patients with lower peak VO2 increased the mobilization of CD34+/CD45-/CD133+[pre CPET:60(25-76)vs post CPET:90(70-103)cells/106 enucleated cells,P<0.001],CD34+/CD45-/CD133+/VEGFR2[pre CPET:1(1-4)vs post CPET:5(3-8)cells/106 enucleated cells,P<0.001],CD34+/CD45-/CD133-[pre CPET:186(141-361)vs post CPET:488(247-658)cells/106 enucleated cells,P<0.001]and CD34+/CD45-/CD133-/VEGFR2[pre CPET:2(1-2)vs post CPET:3(2-5)cells/106 enucleated cells,P<0.001],while patients with higher VO2 increased the mobilization of CD34+/CD45-/CD133+[pre CPET:42(19-73)vs post CPET:90(39-118)cells/106 enucleated cells,P<0.001],CD34+/CD45-/CD133+/VEGFR2[pre CPET:2(1-3)vs post CPET:6(3-9)cells/106 enucleated cells,P<0.001],CD34+/CD133+/VEGFR2[pre CPET:10(7-18)vs post CPET:14(10-19)cells/106 enucleated cells,P<0.01],CD34+/CD45-/CD133-[pre CPET:218(158-247)vs post CPET:311(254-569)cells/106 enucleated cells,P<0.001]and CD34+/CD45-/CD133-/VEGFR2[pre CPET:1(1-2)vs post CPET:4(2-6)cells/106 enucleated cells,P<0.001].A similar increase in the mobilization of at least four out of five cellular populations was observed after maximal exercise within each severity group regarding predicted peak,ventilation/carbon dioxide output slope and EF as well(P<0.05).However,there were no statistically significant differences in the mobilization of endothelial cellular populations between severity groups in each comparison(P>0.05).CONCLUSION Our study has shown an increased EPCs and circulating endothelial cells mobilization after maximal exercise in CHF patients,but this increase was not associated with syndrome severity.Further investigation,however,is needed.

Intestinal microbiome changes in an infant with right atrial isomerism and recurrent necrotizing enterocolitis:A case report and review of literature

BACKGROUND Necrotizing enterocolitis(NEC)is a multifactorial disease that predominantly affects premature neonates.Intestinal dysbiosis plays a critical role in NEC pathogenesis in premature neonates.The main risk factor for NEC in term infants is mesenteric hypoperfusion associated with ductaldependent congenital heart disease(CHD)that eventually leads to intestinal ischemia.The incidence of NEC in neonates with critical CHD is 6.8%-13%.However,the role of the intestinal microbiome in NEC pathogenesis in infants with ductal-dependent CHD remains unclear.CASE SUMMARY A male term neonate with right atrial isomerism underwent modified Blalock-Taussig shunt placement on the 14^(th)day of life and had persistent mesenteric hypoperfusion after surgery.The patient had episodes of NEC stageⅡA on the 1^(st)and 28^(th)days after cardiac surgery.Fecal microbial composition was analyzed before and after cardiac surgery by sequencing region V4 of the 16S rRNA gene.Before surgery,species belonging to genera Veillonella and Clostridia and class Gammaproteobacteria were detected,Bifidobacteriaceae showed a low abundance.The first NEC episode was associated with postoperative hemodynamic instability,intestinal ischemiareperfusion injury during cardiopulmonary bypass,and a high abundance of Clostridium paraputrificum(Clostridium sensu stricto I)(56.1%).Antibacterial therapy after the first NEC episode resulted in increased abundance of Gammaproteobacteria,decreased abundance of Firmicutes,and low alpha diversity.These changes in the microbial composition promoted the growth of Clostridium sensu strictoⅠ(72.0%)before the second NEC episode.CONCLUSION A high abundance of Clostridium sensu strictoⅠand mesenteric hypoperfusion may have contributed to NEC in the present case.

Spontaneous coronary artery dissection:A review of diagnostic methods and management strategies

Spontaneous coronary artery dissection(SCAD)is a rare non-atherosclerotic cause of acute coronary syndromes defined as non-iatrogenic,non-traumatic separation of the coronary artery wall.The most common profile is a middle-aged woman between 44 and 53 years with few cardiovascular risk factors.SCAD is frequently linked with predisposing factors,such as postpartum,fibromuscular dysplasia or other vasculopathies,connective tissue disease and hormonal therapy,and it is often triggered by intense physical or emotional stress,sympathomimetic drugs,childbirth and activities increasing shear stress of the coronary artery walls.Patients with SCAD usually present at the emergency department with chest discomfort,chest pain,and rapid heartbeat or fluttery.During the last decades,the most common problem of SCAD was the lack of awareness about this condition which has led to significant underdiagnosis and misdiagnosis.However,modern imaging techniques such as optical coherence tomography,intravascular ultrasound,coronary angiography or magnetic resonance imaging have contributed to the early diagnosis of the disease.Treatment of SCAD remains controversial,especially during the last years,where invasive techniques are being used more often and in more emergent cardiac syndromes.Although conservative treatment combining aspirin and betablocker remains the recommended strategy in most cases,revascularization could also be suggested as a method of treatment in specific indications,but with a higher risk of complications.The prognosis of SCAD is usually good and long-term mortality seems to be low in these patients.Follow-up should be performed on a regular basis.

An unusual cause of cyanosis after intra-extra cardiac Fontan procedure: anastomotic leakage between conduit and inferior vena cava

A child aged 7 years was admitted to our hospital nearly 5 years after an intra-extra cardiac Fontan operation due to aggravated cyanosis.He was diagnosed with pulmonary atresia(PA),atrial septal defect,patent ductus arteriosus(PDA)and thickened tricuspid valve with severe regurgitation 1 month after being born,which was considered PA with intact ventricular septum(IVS)with severely hypoplastic right ventricle and was similar to functional single ventricle.

Red blood cell distribution width levels predict prolonged hospital stay for infants after cardiopulmonary bypass surgery

Background Thered cell distribution width(RDW)is a parameter that reflects the heterogeneity of red blood cell volume and size,and it is commonly used in the diagnosis of anemia in patients.RDW may serve as a predictor of the postoperative prognosis of surgical patients in the intensive care unit.This study evaluated the predictive capability of RDW for outcomes in infants after cardiopulmonary bypass surgery.Methods A retrospective cohort study was conducted at Guangdong Provincial People's Hospital enrolling infants(≤1 year)who underwent cardiac surgery between January 2019 and April 2019.The infants were divided into two groups based on their preoperative RDW levels(<14.5% and≥14.5%).The primary outcome measured was the prolonged hospital stay post-operation.The association between RDW levels and prolonged hospital length of stay was evaluated using multivariate Logistic regression,presenting the adjusted odds ratio with a 95%confidence interval(CI).Additionally,interaction and subgroup analyses were performed to assess the consistency of these correlations.Results A total of 186 infants were included in the study.After adjusting for potential confounders,multivariate logistic regression models demonstrated a significant association between RDW and prolonged length of stay(LOS)in hospital when treated as a continuous variable(change per 1SD,OR:1.50,95%CI:1.06-2.11,P=0.021).Categorizing RDW as a variable revealed that higher RDW levels(≥14.5%)were significantly associated with an increased risk of prolonged LOS compared to lower levels(<14.5%)(OR:9.72,95%CI:2.87-32.91,P<0.001).Receiver operating curves(ROC)analysis showed that RDW levels exhibited relatively higher diagnostic value for predicting prolonged LOS(AUC=0.697,95%CI:0.617-0.776,P<0.05).Stratified analyses further showed that depending on the variable testing,an association between higher RDW levels and prolonged hospital length of stay in different subgroups was observed.Conclusions Elevated RDW levels in infants undergoing cardiac surgery involving cardiopulmonary bypass may signify prolonged recovery periods.

Early prediction of acute kidney injury in neonates with cardiac surgery

Background Acute kidney injury(AKI)occurs in 42%-64%of the neonatal patients experiencing cardiac surgery,contributing to postoperative morbidity and mortality.Current diagnostic criteria,which are mainly based on serum creatinine and hourly urine output,are not sufficiently sensitive and precise to diagnose neonatal AKI promptly.The purpose of this review is to screen the recent literature,to summarize the novel and cost-effective biomarkers and approaches for neonatal AKI after cardiac surgery(CS-AKI),and to provide a possible research direction for future work.Data sources We searched PubMed for articles published before November 2019 with pertinent terms.Sixty-seven articles were found and screened.After excluding 48 records,19 articles were enrolled for final analysis.Results Nineteen articles were enrolled,and 18 possible urinary biomarkers were identified and evaluated for their ability to diagnose CS-AKI.Urinary neutrophil gelatinase-associated lipocalin(uNGAL),serum cystatin C(sCys),urinary human kidney injury molecule-1(uKIM-1),urinary liver fatty acid-binding protein(uL-FABP)and interleukin-18(uIL-18)were the most frequently described as the early predictors of neonatal CS-AKI.Conclusions Neonates are vulnerable to CS-AKI.UNGAL,sCys,uL-FABP,uKIM-1 and uIL-18 are potential biomarkers for early prediction of neonatal CS-AKI.Renal regional oxygen saturation by near-infrared spectroscopy is a non-invasive approach for early identification of neonatal AKI.Further work should focus on exploring a sensitive and specific combined diagnostic model that includes novel biomarkers and other complementary methods.