1137A life support based comprehensive treatment regimen dramatically lowers the in-hospital mortality of patients with fulminant myocarditis —- a multiple center study

Background Fulminant myocarditis (FM) is characterized by rapid onset and progression to cardiac and circulatory failure. It has high mortality; however, patients may benefit from short-term circulatory support. This study evaluated the therapeutic efficacy of a life support–based comprehensive treatment regimen (LSBCTR) for FM and demonstrated that it saved the lives of FM patients. Methods One hundred and fourteen FM patients were recruited from January 2007 to October 2017 were divided into two groups: those who received LSBCTR (65 cases), including management of fluids and nutrients, use of antiviral drugs and large doses of glucocorticoids (methylprednisolone over 200 mg) and immunoglobulins, continuous renal replacement therapy (CRRT), and life support (artificial positive pressure respiration, intra-aortic balloon pump [IABP] with or without extracorporeal membrane oxygenation [ECMO]), and those who received traditional methods (74 cases). The primary endpoints were in-hospital death and length of hospital stay for survivors. Results Of the population, 41 patients (36.0%) died in the hospital. In-hospital mortality rates were 3.0% (2/65) for the LSBCTR group and 52.7% (39/74) for the traditional treatment group (P<0.001). Early life support (IABP with or without ECMO and a respirator) and early applications of CRRT, antiviral therapy, and sufficient doses of glucocorticoids and immunoglobulins individually contribute to the efficiency of reducing in-hospital mortality. Vasoactive agents did not improve prognosis, especially noradrenaline, which dramatically increased the incidence of death. Conclusion Our data described comprehensive treatment for patients with FM that can dramatically reduce in-hospital mortality. Its generalization and application in clinical practice will efficiently save lives. Clinical Trial: NCT03268642.

WAVELET ANALYSIS OF AORTIC PULSATIONS IN ANESTHETIZED DOGS: EFFECTS OF SPONTANEOUS AND POSITIVE-PRESSURE RESPIRATION

The wavelet transform (WT) analysis was applied to pressure and blood velocity pulsations in the aorta of anesthetized dogs. Each recording was submitted to Mallat’s algorithm and a multiresolution decomposition was obtained. Beside the different resolutions of the original recording (20 to 2–4), we obtained the corresponding details [Formula: see text]. The main purpose of the present study was to analyze the influence of normal respiration, positive-pressure respiration, double vagotomy, and of hyperventilation with the subsequent apneic period. At resolution 2–3 we observed regularly a low frequency amplitude modulation phenomenon with the exception of the apneic period after a prolonged hyperventilation. The applicability of the WT analysis in cardiovascular physiology is discussed.

Dural Sinus Pressure as Related to Neurosurgical Positions

Taking advantage of the exposure of dural sinuses during craniotomies, we measured confluens sinuum pressure by direct catheterization. The influence of various surgical positions and of other factors on confluens sinuum pressure was studied. When the upper half of the body was raised, the confluens sinuum pressure decreased to reach zero at + 25º when the angle was +90º, a marked negative pressure of −12.7 ± 3.0 cm H2O (mean ± SD) was observed in adults. In children under 6 years of age, however, such negative pressure was not observed even at an angle of +90º. The confluens sinuum pressure was 2.7 ± 0.6 cm H2O with the patient in the reverse jackknife position (supine position with the upper and lower halves of the body elevated ca. 20º), 3.0 ± 0.8 in the sea lion position (prone position with the upper and lower halves of the body elevated ca. 20º and with the neck hyperextended), 5.8 ± 0.9 in the prone position, and 5.9 ± 1.7 in the supine position. In the supine and the sitting positions, the confluens sinuum pressure was elevated well enough by jugular compression to prevent air embolism. Positive pressure respiration did not raise the confluens sinuum pressure. The pressure of the jugular bulb measured by percutaneous direct puncture did not always reflect the confluens sinuum pressure, probably because subcutaneous hematoma produced an effect similar to that of jugular compression.

Modulation of rabbit carotid baroreflex during positive end-expiratory pressure

Modification of carotid baroreflex heart and vascular responses during increased lung positive end-expiratory pressure (PEEP) were measured anesthetized aortic-denervated rabbits. Static carotid intrasinus pressure (ISP) was varied in increments of 12.5 mmHg over 25-140 mmHg during lung inflation conditions ranging from spontaneous breathing (SB) to positive-pressure respiration at 0.0-7.5 cmH2O PEEP. To distinguish cardiopulmonary vagally and nonvagally mediated influences, heart rate (HR), mean arterial pressure (MAP), cardiac output (CO), and total peripheral resistance (TPR) were measured and compared before and after sequential vagotomy and beta- and alpha-receptor blockade. When compared with responses of SB animals the HR-ISP relationship was not significantly altered during controlled respiration (CR) with PEEP before or after vagotomy. With CR and then PEEP, MAP-ISP relationship curves and linear slope values (ISP range 62-113 mmHg) were significantly depressed when compared with those of SB rabbits. Before vagotomy slope values were -1.61 (SB), -1.22 (CR + 0.0 cmH2O PEEP), and -0.82 (CR + 7.5 cmH2O PEEP); respective values after vagotomy were -2.26, -0.96, and -0.64. Results of CO and TPR responses during low ISP and PEEP demonstrated components of both vagally and nonvagally mediated influences from inflation sensitive cardiopulmonary receptors.U

Extracorporeal circulation system for coronary artery perfusion in the closed-chest dog

An adjustable constant-flow coronary artery perfusion system has been developed for use in the anesthetized closed-chest dog. Coronary flow and perfusion pressure measurements are obtained over the entire autoregulatory range. Coronary flow was briefly diverted to a bypass cannula and then returned to its original level. Coronary vasodilatation resulted in a fall of perfusion pressure below its preocclusion value, but recovery of vascular tone was complete in about twice the time required during unrestricted reactive hyperemia. It is concluded that no flow debt repayment is required for the restoration of vascular tone after brief occlusions. In the measurements made with this system, intramyocardial pressure distribution is not influenced by thoracotomy, pericardotomy, or positive-pressure respiration, and surgical trauma is minimal.

Shunt dynamics in experimental atrial septal defects

Inorder to study the hemodynamic variables involving the magnitude, direction, and timing of phasic shunt flow, both the interatrial pressure gradient and blood flow along with other pertinent hemodynamic variables were measured instantaneously across a surgically created atrial septal defect (ASD) in seven awake dogs. Atrial and ventricular pacing and infusion of phenylephrine and isoproterenol were used to alter hemodynamic conditions. The wave form of phasic ASD flow was similar both in configuration and timing to the interatrial pressure gradient. During the cardiac cycle, both left-to-right (L-R) and right-to-left (R-L) shunting occurred: atrial contraction augmented L-R flow; the onset of ventricular contraction was associated with R-L flow; during the latter part of ventricular contraction, flow returned to L-R with the maximum L-R shunting occurring in early diastole. Tachycardia, infusion of phenylephrine and isoproterenol did not alter the phasic flow pattern. Both spontaneous and positive pressure respiration decreased net L-R shunting.