Citations

Introduction: Cardiopulmonary bypass time (CPBT) and aortic cross-clamp time (AXCT) are independently associated with postoperative morbidity and mortality. However, no universally accepted “optimal” duration exists, as these times are influenced by the complexity of cardiac surgery. ECMO is being increasingly used for cardiogenic shock in patients undergoing cardiotomy, but the impact of CPBT and AXCT on outcomes in this specific population remains unexplored. This study investigates how CPBT and AXCT influence outcomes in cardiotomy patients on ECMO support. Research Question: Do CPBT and AXCT influence mortality and complication rates in cardiotomy patients receiving ECMO support? Methods: We conducted a retrospective chart review (Jan 2020–Dec 2024) across a multidisciplinary North American practice, identifying 623 patients who required ECMO. Of these, 236 (37.8%) received ECMO in the preoperative, intraoperative, or postoperative period of cardiotomy. Patients were grouped by prolonged CPBT (>150 min) vs standard (≤150 min) and prolonged AXCT (>90 min) vs standard (≤90 min). We analyzed outcomes including 30-day mortality, ECMO characteristics, and postoperative complications. Results: Among the 236 patients, the average age was 60.8 years, BMI 37.43 kg/m 2 ; 63% were male, 85% White. Prolonged CPBT and AXCT were associated with higher BMI (p=0.02, 0.03), prior cardiac surgery (p<0.001, 0.006), and combined CABG+AVR procedures (p=0.01, 0.001). Patients with prolonged durations were more likely to require postoperative ECMO (p=0.001, 0.03). Complications such as mediastinal bleeding, AKI requiring CRRT, mediastinitis, bacteremia, and pneumonia, showed significant association with increased CPBT whereas prolonged AXCT was only linked with mediastinal bleeding. CPBT and AXCT durations did not significantly affect 30-day mortality, ICU/hospital stay, ECMO duration, or ventilation duration. Independent predictors of 30-day mortality included pre-/intraoperative IABP use (OR 2.19, 95% CI 1.11–4.30, p=0.023), Impella use (OR 0.20, 95% CI 0.03–0.75, p=0.040), post-op intracranial bleeding (OR 5.46, 95% CI 1.43–23.9, p=0.016), and CRRT-requiring AKI (OR 3.24, 95% CI 1.63–6.57, p<0.001). Conclusion: Prolonged CPBT and AXCT were significantly linked to higher rates of postoperative complications such as mediastinal bleeding, CRRT requiring AKI, mediastinitis, and pneumonia along with increased need for postoperative ECMO support, without significantly affecting mortality.

Environmental degradation due to industrial groundwater contamination is an emerging cardiovascular disease (CVD) risk factor. Our study examines the elevated CVD prevalence, including heart failure (HF) risk factors, in rural Punjab, India, near which a private distillery was linked to long-term groundwater contamination and environmental degradation. Our team primarily focused on CVD prevalence and its associations with environmental toxins. We also explored the role of socio-economic disparities on health outcomes. A cross-sectional study of 4,885 residents in three villages adjacent to the distillery (Mahianwala Kala, Ratol Rohi, Mansoorwaal Kalan) was conducted from October 2022 to August 2023. Health camps with follow-up door-to-door surveys by trained medical personnel collected medical histories, environmental exposure details, and socio-demographic data. Key outcomes included both communicable and non-communicable diseases, such as hypertension, ischemic heart disease, heart failure, and cancer. Logistic regression assessed associations between CVD prevalence, socio-economic status, and pollution exposure, with groundwater testing for heavy metals and chemical oxygen demand (COD). The cohort demonstrated a high CVD burden, with 39% having hypertension (exceeding national averages by more than 50%), 34% having diagnosed CVD, and 21.3% of households reporting an immediate family history of myocardial infarction. Adjusted models highlighted elevated odds of heart disease (OR 1.42; 95% CI 1.31–1.51) and stroke (OR 1.29; 95% CI 1.16–1.38), with higher clustering in low-income families. Concurrent systemic toxicity was also evident, as 60.5% reported dermatological conditions, 10.5% familial cancer, 20.8% with no history of smoking cited COPD-related dyspnea. We also observed elevated miscarriage rates and developmental disabilities in the studied population. Groundwater analysis confirmed contamination with cyanide (0.3 mg/L), lead (0.16 mg/L), and COD (320 mg/L), correlating with self-reported water discoloration and irregularities in taste. Families with polluted water access had a 1.5-fold increased CVD risk. Industrial contamination was linked to higher cardiovascular morbidity and multi-organ health effects in our study's cohort in rural India. The link was exacerbated by socio-economic inequities. These findings highlight the role of environmental degradation in rise in CVD, particularly in low-resource settings.

Abstract The incidence of venous thromboembolism (VTE) in patients with acute lymphoblastic leukemia (ALL) receiving asparaginase-based induction is high despite primary thromboprophylaxis. Our aim was to derive and externally validate a VTE risk prediction model in patients with ALL receiving asparaginase-based induction. We conducted a multicenter retrospective cohort study of patients (aged ≥18 years) with newly diagnosed ALL receiving asparaginase-based induction. The derivation and external validation cohorts included 306 and 94 patients, respectively. Primary outcome was VTE at any site. A cause-specific Cox proportional hazards model stratified by thromboprophylaxis and center was performed to identify VTE risk factors in the derivation cohort. A risk prediction model for VTE at 30 days was derived using variables with P value &lt; .05 in the multivariable model and was tested in the validation cohort. VTE risk factors on multivariable analysis in the derivation cohort included D-dimer ≥1 μg fibrinogen equivalent unit per mL (hazard ratio [HR], 2.64; 95% confidence interval [CI], 1.07-6.5) and hemoglobin (HR for each 1 g/dL increment, 1.19; 95% CI, 1.06-1.34) at ALL diagnosis. A VTE risk score based on these variables distinguished between a 4% (95% CI, 0.72-12) and 20% (95% CI, 14-27) 30-day cumulative incidence of VTE in the derivation cohort, with similar findings in the validation cohort (area under the curve, 0.56). The negative predictive value for VTE at 30 days was 96% and 93% in the derivation and validation cohorts, respectively, and the positive predictive value was 20% in both. We derived and validated a model using D-dimer and hemoglobin, which stratifies VTE risk in patients with ALL receiving asparaginase-based induction.

Background: Procalcitonin (PCT) is recognized as an inflammatory biomarker, often elevated in COVID-19 pneumonia alongside other biomarkers. Understanding its association with severe outcomes and comparing its predictive ability with other biomarkers is crucial for clinical management. Objectives: This retrospective multicenter observational study aimed to investigate the association between PCT levels and adverse outcomes in hospitalized COVID-19 patients. Additionally, it sought to compare the predictive performance of various biomarkers. Design: The study analyzed data from the Society of Critical Care Medicine (SCCM) Viral Infection and Respiratory Illness Universal Study (VIRUS) registry, comprising COVID-19 patients hospitalized across multiple Mayo Clinic sites between March 2020 and June 2022. Methods: A total of 7851 adult COVID-19 patients were included. Patients were categorized into 6 groups based on the worst WHO ordinal scale. Multivariate models were constructed using peak biomarker levels within 72 hours of admission, adjusted for confounders. Results: Elevated PCT levels were independently associated with increased odds of adverse outcomes, including ICU admission (adjusted odds ratio [aOR] 1.32, 95%CI 1.27-1.38), IMV requirement (aOR 1.35, 95%CI: 1.28-1.42), and in-hospital mortality (aOR 1.30, 95%CI: 1.22-1.37). A 3.48-fold increase in IMV requirement and 3.55 times increase in in-hospital mortality were noted with peak PCT ⩾ 0.25 ng/ml. Similar associations were observed with other biomarkers like NLR (AUC 0.730), CRP, IL-6, LDH (AUC 0.800), and D-dimer (AUC 0.719). Models incorporating NLR, LDH, D-dimer, and PCT demonstrated the highest predictive accuracy, with a combined model exhibiting an area under the curve (AUC) of 0.826 (95%CI 0.803-0.849). Conclusions: Higher PCT levels were significantly linked to worse outcomes in COVID-19 patients, emphasizing its potential as a prognostic marker. Biomarker-based predictive models, particularly those including PCT, showed promising utility for risk assessment and clinical decision-making. Further prospective studies are warranted to validate these findings on a larger scale.

Abstract Rationale: Mechanical ventilation is frequently required in heart transplant patients to support recovery, but prolonged ventilation may increase the risk of complications and mortality. This study is done to find the impact of pre-transplant ventilation duration on early post-transplant outcomes, including mortality, ICU stay, infection, and respiratory complications. Methods: This retrospective analysis includes 52 heart transplant recipients from Mayo Clinic (2019-2023) who required pre-transplant mechanical ventilation. We analyzed ventilation duration's relationship with ICU and hospital stay, infection rates, respiratory complications, mortality, and baseline demographics. Chi-squared and Mann-Whitney U tests were used to evaluate associations between co-morbidities, ventilation duration, and outcomes. Results: The mean age at transplant was 48.9±14 years. Average ventilation duration was 12.8±14.2 days (Median: 7 days), ICU stay was 24.8± 20.9 days (Median: 15.0 days), and hospital stay was 58±40.8 days (Median: 48 days). Of the patients, 5 (9.6%) did not survive. There was no statistically significant association between mortality and ventilation duration, with a mean duration of 12.7±14.6 days (Median: 7 days) for survivors and 13.6±11.5 days (Median: 21 days) for non-survivors (p&gt;0.05). Patients with infections 23 (44.2%) or respiratory complications 17 (32.7%) had longer ventilation durations (mean 16.3±17.8 days, Median: 9 and 10 days, respectively) compared to those without complications (mean 10±10.2 days, Median: 6 and 5 days, p&gt;0.05). Infection was associated with extended ICU stays (mean 27.5±22.3 days, Median: 18 days with infection vs. 22.7±19.9 days, Median: 15 days without infection). None of the individual co-morbidities (diabetes, hypertension, stroke, chronic kidney disease) significantly impacted mortality or ventilation duration (p &gt; 0.05). Conclusions: Prolonged ventilation is associated with increased rates of infections and respiratory complications but not with mortality in this cohort. Although co-morbidities did not significantly impact ventilation duration or mortality, infection remains a critical factor related to extended ICU stay. Future research should explore preventative strategies for infections in ventilated heart transplant recipients to improve outcomes.

Abstract Rationale: Early management after heart transplantation is essential for survival and quality of life, but we lack data on how initial clinical measures might predict patient outcomes. This study investigates whether early postoperative hemodynamic and clinical parameters can predict 1-year mortality and complications. Methods: We conducted a retrospective study of 550 heart transplant patients treated at the Mayo Clinic from 2019 to 2023. Demographic, hemodynamic, and clinical data, including Central Venous Pressure (CVP), Pulmonary Arterial Pressure (PAP), cardiac index, Pulmonary Artery Pulsatility Index (PaPi), blood pressure, heart rate, and Vasoactive-Inotropic Score (VIS), were collected. Key outcomes included 1-year mortality, Intensive Care Unit (ICU) and hospital stay durations, and complications such as respiratory issues and Acute Kidney Injury (AKI). Patients were divided into quartiles based on VIS scores to compare clinical outcomes. Logistic regression assessed how each parameter predicted 1-year mortality. Results: The patients’ mean age was 53.3±13.1 years, with 391 (71.1%) male and an average Body Mass Index (BMI) of 27.5±4.9. The median ICU stay was 9 days (Interquartile Range [IQR]: 4-22.8), and the median hospital stay was 35 days (IQR: 17-57.8). Within one year, 28 (5.1%) patients experienced mortality and ICU readmission occurred in 52 (9.5%) patients. Higher VIS quartiles were associated with worse outcomes. Logistic regression revealed three significant predictors of 1-year mortality: higher CVP (p=0.0305) and lower Systolic Blood Pressure (SBP) (p=0.0484) were linked to increased mortality risk, while each unit increase in VIS (p=0.0355) raised mortality odds by 6% (Odds Ratio [OR]: 1.06, 95% Confidence Interval [CI]: 1.004-1.113). Additionally, respiratory complications were seen in 177 (32.2%) patients, and AKI in 407 (74.0%) patients. AKI significantly predicted mortality (OR=2.50, p=0.044), while both ICU readmission (OR=2.98, p&lt;0.001) and AKI (OR=3.49, p&lt;0.001) predicted respiratory complications. Conclusions: Early postoperative hemodynamic and clinical parameters, especially higher VIS scores, are significant indicators of 1-year mortality in heart transplant patients. These findings highlight the importance of early assessment to identify high-risk patients and potentially guide post-transplant management strategies.

Objective The pattern and timing of palliative care utilisation and end-of-life characteristics in extracorporeal membrane oxygenation (ECMO)-supported patients remain underused. We wanted to share our centre’s experience. Methods This is an institutional review board-approved retrospective study of 45 patients who underwent ECMO at a large ECMO centre in North America between January 2013 and July 2018. Results Only 28.9% of the ECMO patients received in-hospital palliative care consultation at a median of 18 days (IQR 12–31) after hospitalisation and 10.5 days (IQR 1–28) from ECMO initiation. 1-year mortality was high, with 44% dying during hospitalisation and an additional 13% within the following year. Patients experienced prolonged hospitalisations (median hospital length of stay: 39 days, IQR 19–89) and exhibited high rates of tracheostomy (53%) and renal replacement therapy (60%). Most end-of-life cases involved the withdrawal of life-sustaining therapy during ECMO, yet only 53% had a completed living will. Conclusion Our study underscores the need for early initiation of palliative care consultation to enhance symptom management, advance care planning, caregiver support and quality of life for ECMO patients and their families.

Abstract Allogeneic hematopoietic stem cell transplant (alloHCT) is considered for all patients with myeloid neoplasms (MNs) harboring TP53 mutations (TP53mut). The aim of this international study across 7 transplant centers in the United States and Australia was to identify factors associated with improved post-alloHCT survival. Of 134 TP53mut MN cases who underwent alloHCT, 80% harbored complex karyotype; 94% of TP53 variants were localized to the DNA-binding domain (DBD). Most common comutations were ASXL1 (7%), TET2 (7%), and DNMT3A (6%). Median post-HCT survival was 1.03 years, and overall survival (OS) at 1 year, 2 years, and 3 years was 51.4%, 35.1%, and 25.1%, respectively. A total of 103 cases (76.9%) met the International Consensus Classification (ICC) criteria for MN with mutated TP53 (referred to as ICC-defined TP53mut MN hereafter). The 3-year OS of ICC-defined TP53mut was significantly shorter compared with that of other TP53mut MNs (3-year OS, 16.9% vs 54.9%; P = .002). ICC-defined TP53mut MNs was independently associated with inferior OS (hazard ratio [HR], 2.62; P = .019). The presence of non-DBD TP53mut only (HR, 3.40; P = .005), DNMT3A comutation (HR, 2.64; P = .016), and pre-alloHCT bone marrow blasts ≥5% (HR, 2.76; P = .006) was independently associated with inferior relapse-free survival (RFS), whereas melphalan-based conditioning was associated with superior RFS (HR, 0.52; P = .005). Combining these variables, we constructed a hierarchical model that stratified patients into low-, intermediate-, and high-risk categories with 1-year RFS of 81.3%, 31.3%, and 6.7%, respectively (P &lt; .001). In conclusion, a subset of MN harboring TP53mut who have low blasts pre-alloHCT and received melphalan-based conditioning derived long-term benefit from alloHCT.