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Objectives. Heart transplantation (HTx) has become an established treatment option in patients with end-stage heart failure. The aim of this study was to report on long-term outcome over the past three decades. Design. Consecutive adult patients receiving first-time and isolated HTx from October 3, 1990, to November 2, 2020, at Rigshospitalet, Copenhagen, Denmark, were retrospectively evaluated. Data were obtained from the Scandinavian Transplant Registry and patient medical records. Recipients were grouped by time of transplantation (early era: 1990–1999; mid era: 2000–2009; recent era: 2010–2020). Results. A total of 384 recipients (77% men, median age 50 [IQR: 40–57]) were included. Median number of HTx procedures per year was 12 (10–14). Overall, 22% of patients were bridged to HTx with a mechanical circulatory support device. Median survival for the whole cohort was 13.8 years and improved numerically from the early era (12.6 years) to the mid era (14.9 years). Median survival conditional on survival to 1-year follow-up after HTx was 16.1 years. Survival probability by Kaplan–Meier method improved significantly from the mid to the recent era (log-rank p =.02). Conclusions. Heart transplantation remains an excellent treatment for selected patients with end-stage heart failure and long-term outcome has improved significantly over the past decades.

Background: Lungs from donation after circulatory death (DCD) may be an underused resource for transplantation. The aim was to investigate, with a DCD pig model, if it was possible to recondition lungs exposed for up to 2 h of warm ischaemia with ex vivo lung perfusion (EVLP). Methods: Danish domestic pigs (N = 17) were randomized into three groups. In the two study groups, lungs were exposed to either 1 or 2 h of warm ischaemia. All lungs were reconditioned and evaluated after 83 ± 38 minutes of perfusion at FiO2 1.0 and 0.21 with EVLP. Outcome measures were gas exchange, pulmonary physiology, inflammatory markers, and histopathologic assessment score. Results: Lungs exposed for 2 h of warm ischaemia did not meet the criteria: PaO2 > 13 kPa required for donation compared with lungs subjected to 0 and 1 h of warm ischaemia (11.0 kPa vs. 14.2 kPa, P < 0.001). These lungs also developed an increased amount of foam and fluid in the airways. No differences in PaCO2, compliance, or pulmonary vascular resistance were observed. Conclusion: Results show that while lungs subjected to 0 or 1 h of warm ischaemia meet the criteria for transplantation based on EVLP evaluation, lungs subjected to 2 h of warm ischaemia did not.

Background: Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non-ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients. Method: We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy. Results: A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%–100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first-line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta-blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants. Conclusion: This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.

Background: Coronavirus disease 2019 (COVID-19) may be associated with cardiac arrhythmias in hospitalized patients, but data from the ICU setting are limited. We aimed to describe the epidemiology of cardiac arrhythmias in ICU patients with COVID-19. Methods: We conducted a multicenter, retrospective cohort study including all ICU patients with an airway sample positive for severe acute respiratory syndrome corona-virus 2 from March 1st to June 1st in the Capital Region of Denmark (1.8 million inhabitants). We registered cardiac arrhythmias in ICU, potential risk factors, interventions used in ICU and outcomes. Results: From the seven ICUs we included 155 patients with COVID-19. The incidence of cardiac arrhythmias in the ICU was 57/155 (37%, 95% confidence interval 30-45), and 39/57 (68%) of these patients had this as new-onset arrhythmia. Previous history of tachyarrhythmias and higher disease severity at ICU admission were associated with cardiac arrhythmias in the adjusted analysis. Fifty-four of the 57 (95%) patients had supraventricular origin of the arrhythmia, 39/57 (68%) received at least one intervention against arrhythmia (eg amiodarone, IV fluid or magnesium) and 38/57 (67%) had recurrent episodes of arrhythmia in ICU. Patients with arrhythmias in ICU had higher 60-day mortality (63%) as compared to those without arrhythmias (39%). Conclusion: New-onset supraventricular arrhythmias were frequent in ICU patients with COVID-19 and were related to previous history of tachyarrhythmias and severity of the acute disease. The mortality was high in these patients despite the frequent use of interventions against arrhythmias.

The COVID-19 pandemic has increased the need for an accessible, point-of-care and accurate imaging modality for pulmonary assessment. COVID-19 pneumonia is mainly monitored with chest X-ray, however, lung ultrasound (LUS) is an emerging tool for pulmonary evaluation. In this study, patients with verified COVID-19 disease hospitalized at the intensive care unit and treated with ventilator and extracorporal membrane oxygenation (ECMO) were evaluated with LUS for pulmonary changes. LUS findings were compared to C-reactive protein (CRP) and ventilator settings. Ten patients were included and scanned the day after initiation of ECMO and thereafter every second day until, if possible, weaned from ECMO. In total 38 scans adding up to 228 cineloops were recorded and analyzed off-line with the use of a constructed LUS score. The study indicated that patients with a trend of lower LUS scores over time were capable of being weaned from ECMO. LUS score was associated to CRP (R = 0.34; p < 0.03) and compliance (R = 0.60; p < 0.0001), with the strongest correlation to compliance. LUS may be used as a primary imaging modality for pulmonary assessment reducing the use of chest X-ray in COVID-19 patients treated with ventilator and ECMO.

OBJECTIVES: We reviewed our combined clinical outcome in patients who underwent lung transplantation after ex vivo lung perfusion (EVLP) and compared it to the contemporary control group.METHODS: At 2 Scandinavian centres, lungs from brain-dead donors, not accepted for donation but with potential for improvement, were subjected to EVLP (n = 61) and were transplanted if predefined criteria were met. Transplantation outcome was compared with that of the contemporary control group consisting of patients (n = 271) who were transplanted with conventional donor lungs.RESULTS: Fifty-four recipients from the regular waiting list underwent transplantation with lungs subjected to EVLP (1 bilateral lobar, 7 single and 46 double). In the EVLP and control groups, arterial oxygen tension/inspired oxygen fraction ratio at arrival in the intensive care unit (ICU) was 30 ± 14 kPa compared to 36 ± 14 (P = 0.005); median time to extubation was 18 h (range 2-912) compared to 7 (range 0-2280) (P = 0.002); median ICU length of stay was 4 days (range 2-65) compared to 3 days (range 1-156) (P = 0.002); Percentage of expected forced expiratory volume at 1s (FEV1.0%) at 1 year was 75 ± 29 compared to 81 ± 26 (P = 0.18); and the 1-year survival rate was 87% [confidence interval (CI) 82-92%] compared to 83% (CI 81-85), respectively. Follow-up to a maximum of 5 years did not show any significant difference in survival between groups (log rank, P = 0.63).CONCLUSIONS: Patients transplanted with lungs after EVLP showed outcomes comparable to patients who received conventional organs at medium-term follow-up. Although early outcome immediately after transplantation showed worse lung function in the EVLP group, no differences were observed at a later stage, and we consider EVLP to be a safe method for increasing the number of transplantable organs.

—Aortic valve stenosis (AS) is treated with biological prostheses (BPs) and mechanical prostheses (MPs). Vector flow imaging (VFI), an angle-independent ultrasound method, can quantify flow complexity (vector concentration (VC)) and secondary rotation (SR). Ten patients (mean age: 70.7 y) with tricuspid AS scheduled for BPs, 10 patients (mean age: 56.2 y) with bicuspid AS scheduled for MPs and 10 patients (mean age: 63.9 y) with normal aortic valves were scanned intra-operatively on the ascending aorta with VFI and conventional spectral Doppler. Bicuspid AS (peak systolic velocity (PSV): 380.9 cm/s, SR: 16.7 Hz, VC: 0.21) had more complex flow (p < 0.02) than tricuspid AS (PSV: 346.1 cm/s, SR: 17.1 Hz, VC: 0.33). Both groups had more complex and faster flow (p < 0.0001) than normal aortic valve patients (PSV: 124.0 cm/s, SR: 4.3 Hz, VC: 0.79). VC (r = 0.87) and SR (r = 0.89) correlated to PSV. After surgery, flow parameters changed (p < 0.0001) for patients with MPs (PSV: 250.4 cm/s, SR: 9.8 Hz, VC: 0.54) and BPs (PSV: 232.4 cm/s, SR: 12.5 Hz, VC: 0.61), with MPs having slower SR (p < 0.01). None of the implants had normal flow (p < 0.0001). In conclusion, VFI can provide new flow parameters for AS and implant assessment.

Objectives: Longitudinal shortening constitutes most of the right ventricle (RV) contraction in the normal heart. However, after even uncomplicated cardiac surgery with preserved RV function a significant and sustained decrease in longitudinal contraction expressed as a reduction in tricuspid annular plane systolic excursion (TAPSE) has been observed. Why and exactly when this happens remains unsettled. The aim of this study was to evaluate the magnitude and timing of changes in TAPSE in relation to sternotomy, pericardial opening, cardiopulmonary bypass (CPB), and chest closure. Methods: Fifty patients with normal preoperative ejection fraction and no valvulopathy, who underwent coronary artery bypass grafting with the use of CPB, were included. TAPSE was assessed using transthoracic echocardiography (TTE) at baseline and immediately after chest closure. Transesophageal echocardiography was performed at the following time points: after (1) anesthesia induction and transthoracic echocardiography; (2) sternotomy; (3) pericardiotomy; (4) completion of CPB; and (5) chest closure. Results: TAPSE was significantly reduced to approximately half of its initial value in all patients (from 22 [95% confidence interval, 21-23 mm] after anesthesia induction to 9 [95% confidence interval, 8-10 mm] after chest closure). No change was seen after pericardiotomy. The most prominent reduction (30%-40%) was observed after weaning from CPB. An additional significant decrease of 13% to 16% was seen after chest closure. Conclusions: TAPSE was consistently reduced to approximately half of its initial value after uncomplicated coronary artery bypass grafting surgery. The reduction happened mainly after weaning from CPB, possibly reflecting conformational change of the RV.

Purpose Conventional pediatric echocardiography is crucial for diagnosing congenital heart disease (CHD), but the technique is impaired by angle dependency. Vector flow imaging (VFI) is an angle-independent noninvasive ultrasound alternative for blood flow assessment and can assess complex flow patterns not visible on conventional Doppler ultrasound. Materials and Methods 12 healthy newborns and 3 infants with CHD were examined with transthoracic cardiac VFI using a conventional ultrasound scanner and a linear array. Results VFI examinations revealed common cardiac flow patterns among the healthy newborns, and flow changes among the infants with CHD not previously reported with conventional echocardiography. Conclusion For assessment of cardiac flow in the normal and diseased pediatric heart, VFI may provide additional information compared to conventional echocardiography and become a useful diagnostic tool.

Tricuspid annular plane systolic excursion (TAPSE) is a robust measure of RV function, but the performance of transesophageal echocardiography (TEE) measured TAPSE during surgery is not well established. We aim to evaluate feasibility of various TEE views before, during and after surgery. Furthermore, we compare performance of individual TEE measurements depending on view and method (AMM- and M-mode as well as 2D) as well as TAPSE measured using TEE with transthoracic echocardiography (TTE) TAPSE. The study was conducted from January 2015 through September 2016. In 47 patients with normal left ventricular ejection fraction, TEE was prospectively performed during coronary artery bypass grafting surgery. TAPSE and tricuspid annulus tissue Doppler imaging (TDI) were recorded in five different views at pre-specified time points during surgery. Data were analyzed for availability (obtainable/readable images) and reliability (intra-/inter-observer bias and precision). Finally, TEE TAPSE was compared to TTE TAPSE immediately before and after surgery. TAPSE and TDI with TEE was achievable in > 90% of patients in the transgastric view during surgery. The AM- and M-mode had the best reliability and the best correlation with TAPSE measured with TTE. The deep transgastric view was achievable in less than 50% after sternotomy, and TAPSE measured from 2D had a poorer performance compared to the AM- and M-mode. TDI demonstrated a high reliability throughout surgery. RV function can be evaluated by TAPSE and TDI using TEE during surgery. TEE values from the transgastric view demonstrated high performance throughout surgery and a good agreement with TTE TAPSE measurements.

OBJECTIVES: The optimal postoperative analgesic strategy after video-assisted thoracoscopic surgery lobectomy remains undetermined. We hypothesized that high-dose preoperative methylprednisolone (MP) would improve analgesia compared to placebo. METHODS: A total of 120 adult patients were randomized equally to 125mg MP or placebo before the start of their elective videoassisted thoracoscopic surgery lobectomy. Group allocation was blinded to patients, investigators and caregivers, and all patients received standardized multimodal, opioid-sparing analgesia. Our primary outcome was area under the curve on a numeric rating scale from 0 to 10, for pain scores on the day of surgery and on postoperative days 1 and 2. Clinical follow-up was 2-3 weeks, and telephone follow-up was 12 weeks after surgery. RESULTS: Ninety-six patients were included in the primary analysis. Methylprednisolone significantly decreased median pain scores on the day of surgery: at rest (numeric rating scale 1.6 vs 2.0, P = 0.019) and after mobilization to a sitting position (numeric rating scale 1.7 vs 2.5, P = 0.004) but not during arm abduction and coughing (P = 0.052 and P = 0.083, respectively). Nausea and fatigue were reduced on the day of surgery (P = 0.04 and 0.03), whereas no outcome was improved on postoperative Days 1 and 2. Methylprednisolone did not increase the risk of complications but increased blood glucose levels on the day of surgery (P < 0.0001). CONCLUSIONS: High-dose preoperative MP significantly reduced pain at rest and after mobilization to a sitting position on the day of surgery, without later analgesic effects. Nausea and fatigue were improved without side effects, except transient higher postoperative blood glucose levels.

BACKGROUND: Estimation of cardiac output (CO) is essential in the treatment of circulatory unstable patients. CO measured by pulmonary artery catheter thermodilution is considered the gold standard but carries a small risk of severe complications. Stroke volume and CO can be measured by transesophageal echocardiography (TEE), which is widely used during cardiac surgery. We hypothesized that Doppler-derived CO by 3-dimensional (3D) TEE would agree well with CO measured with pulmonary artery catheter thermodilution as a reference method based on accurate measurements of the cross-sectional area of the left ventricular outflow tract.METHODS: The primary aim was a systematic comparison of CO with Doppler-derived 3D TEE and CO by thermodilution in a broad population of patients undergoing cardiac surgery. A subanalysis was performed comparing cross-sectional area by TEE with cardiac computed tomography (CT) angiography. Sixty-two patients, scheduled for elective heart surgery, were included; 1 was subsequently excluded for logistic reasons. Inclusion criteria were coronary artery bypass surgery (N = 42) and aortic valve replacement (N = 19). Exclusion criteria were chronic atrial fibrillation, left ventricular ejection fraction below 0.40 and intracardiac shunts. Nineteen randomly selected patients had a cardiac CT the day before surgery. All images were stored for blinded post hoc analyses, and Bland-Altman plots were used to assess agreement between measurement methods, defined as the bias (mean difference between methods), limits of agreement (equal to bias ± 2 standard deviations of the bias), and percentage error (limits of agreement divided by the mean of the 2 methods). Precision was determined for the individual methods (equal to 2 standard deviations of the bias between replicate measurements) to determine the acceptable limits of agreement.RESULTS: We found a good precision for Doppler-derived CO measured by 3D TEE, but although the bias for Do

Aortic valve stenosis increases peak systolic velocity (PSV) and flow complexity in the ascending aorta, and is treated with either biological or mechanical implants. Vector flow imaging (VFI) is an angle independent ultrasound method for flow assessment. In contrast to conventional ultrasound, VFI can quantify complex flow patterns, e.g. the flow complexity called vector concentration (VC) in long axis and the secondary rotation (SR) in short axis view. Study aim was to evaluate flow changes only visible with VFI before and after valve implantation in patients with aortic valve stenosis. VFI on a commercial scanner (Pro Focus 2202 Ultra View, BK Medical) with a linear transducer (8670, BK Medical) was applied intraoperatively on the ascending aorta. Four patients scheduled for biological valve implants and 4 patients for mechanical valve implants were scanned before and after surgery. Four patients with normal aortic valve were scanned for comparison. VFI data of the ascending aorta were obtained in long and short axis view during the systolic phase for assessment of VC and SR. VC ranges from 0 to 1 (complex to laminar flow), and SR is measured in Hz. PSV was obtained with conventional spectral Doppler. Before surgery, patients with aortic valve stenosis scheduled for mechanical (PSV: 356.3 (64.3) cmls; SR: 15.3 (7.8) Hz; VC: 0.18 (0.03)) and biological implants (PSV: 350.0 (80.8) cmls; SR: 17.9 (2.6) Hz; VC: 0.26 (0.07)) had more complex flow with higher velocities compared with patients with normal aortic valve (PSV: 124.8 (16. 7) cmls; SR: 2.9 (1.1) Hz; VC: 0.83 (0.09)). After surgery, velocities were lower for mechanical (PSV: 214.5 (47.5) cmls; SR: 5.6 (3.0) Hz) compared with biological implants (PSV: 241.5 (39.1) cmls; SR: 13.2 (1.8) Hz). However, VC was higher for biological (0.68 (0.05)) compared with mechanical implants (0.56 (0.09)) indicating a more laminar and less complex flow despite higher systolic velocities in patients treated with biological impla

Out-of-hospital cardiac arrest is associated with high mortality and morbidity. Treatment options remain few in refractory cases, but extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly applied to improve the outcome. This article summarizes the use, experience and outcome of eCPR focussing on current knowledge of criteria for selection of relevant patients for treatment.

Aortic valve stenosis alters blood flow in the ascending aorta. Using intra-operative vector flow imaging on the ascending aorta, secondary helical flow during peak systole and diastole, as well as flow complexity of primary flow during systole, were investigated in patients with normal, stenotic and replaced aortic valves. Peak systolic helical flow, diastolic helical flow and flow complexity during systole differed between the groups (p < 0.0001), and correlated to peak systolic velocity (R = 0.94, 0.87 and 0.88, respectively). The study indicates that aortic valve stenosis increases helical flow and flow complexity, which are measurable with vector flow imaging. For assessment of aortic stenosis and optimization of valve surgery, vector flow imaging may be useful.

Objectives Outcome in patients with acute coronary syndrome (ACS) is improved with dual antiplatelet therapy (DAPT). Patients with acute aortic dissection type A (AAD) often present with similar symptoms and may therefore be prescribed DAPT before diagnosis. The aim of this study was to evaluate the use of antiplatelet therapy (APT) prior to AAD surgery and patient outcome, including indications according to the European Society of Cardiology's (ESC) recent guidelines. Design A retrospective, observational study. Setting A tertiary University Hospital, Rigshospitalet, Heart Centre, Copenhagen, Denmark. Participants The study included 171 patients operated for AAD during 2010 to 2014. Interventions The independent relationship of preoperative APT was explored on 30-day mortality, intraoperative bleeding and perioperative transfusion requirements. Furthermore, the indications for APT were obtained. Measurements and Main Results Patients receiving APT (n = 73) did not have an increased 30-day mortality (29% v 20%, p = 0.18). However, APT increased intraoperative bleeding by 45% (p<0.001) and increased perioperative transfusion of red blood cells by 71%, fresh frozen plasma by 52%, and platelets by 56% (p = 0.002). Among patients receiving APT preoperatively, 26 patients received acetylsalicylic acid (ASA) alone and 46 patients received DAPT. Bleeding was significantly more pronounced in patients receiving DAPT (5.6±4.1 L), compared to ASA alone (3.6±3.1 L) and no APT (3.3±4.8 L) (p<0.001). However, there was no significant difference in mortality between groups. DAPT, including ticagrelor, increased intraoperative bleeding by 62% compared to DAPT with clopidogrel (p = 0.004). Among patients receiving DAPT, only 30% of the patients fulfilled ESC criteria for ACS treatment. Conclusions The use of APT was associated with increased intraoperative bleeding and transfusion requirement; however, it was not associated with a statistically significant increased mortali

This paper presents a novel automatic method for detection of B-lines (comet-Tail artifacts) in lung ultrasound scans. B-lines are the most commonly used artifacts for analyzing the pulmonary edema. They appear as laser-like vertical beams, which arise from the pleural line and spread down without fading to the edge of the screen. An increase in their number is associated with presence of edema. All the scans used in this study were acquired using a BK3000 ultrasound scanner (BK Ultrasound, Denmark) driving a 192-element 5:5 MHz wide linear transducer (10L2W, BK Ultrasound). The dynamic received focus technique was employed to generate the sequences. Six subjects, among those three patients after major surgery and three normal subjects, were scanned once and Six ultrasound sequences each containing 50 frames were acquired. The proposed algorithm was applied to all 300 in-vivo lung ultrasound images. The pleural line is first segmented on each image and then the B-line artifacts spreading down from the pleural line are detected and overlayed on the image. The resulting 300 images showed that the mean lateral distance between B-lines detected on images acquired from patients decreased by 20% in compare with that of normal subjects. Therefore, the method can be used as the basis of a method of automatically and qualitatively characterizing the distribution of B-lines.

PURPOSE: Echocardiography is frequently used in the hemodynamic evaluation of critically ill patients, but inaccurate measurements may lead to wrong clinical decisions. The aim of our systematic review was to investigate the interchangeability of echocardiography with thermodilution technique in measuring cardiac output and its changes.METHODS: In August 2015 we systematically searched electronic databases and included studies investigating the echocardiographic measurement of cardiac output compared with thermodilution technique using the Bland-Altman method. Two authors independently reviewed the studies and extracted data on type of measurements, clinical setting and characteristics, and those of the Bland-Altman and trending ability analyses.RESULTS: We identified 13,834 citations and included 24 studies in the final analysis. The median number of participants was 32 (range 8-65). Most of the studies assessed left-sided heart structures and the majority had small bias, wide limits of agreement, and high percentage error between echocardiography and thermodilution. In only two of the 24 studies the precision of each technique (echocardiography and thermodilution) was assessed before comparing them. In the single study evaluating trending ability using valid methodology, agreement was observed between echocardiography and thermodilution in detecting the directional changes in cardiac output, but the magnitude of changes varied considerably.CONCLUSIONS: The majority of studies comparing echocardiography with thermodilution were difficult to interpret, but current evidence does not support interchangeability between these techniques in measuring cardiac output. The techniques may be interchangeable in tracking directional changes in cardiac output, but this has to be confirmed in large high-quality studies.

This paper presents a novel automatic method for detection of B-lines (comet-tail artifacts) in lung ultrasound scans. B-lines are the most commonly used artifacts for analyzing the pulmonary edema. They appear as laser-like vertical beams, which arise from the pleural line and spread down without fading to the edge of the screen. An increase in their number is associated with presence of edema. All the scans used in this study were acquired using a BK3000 ultrasound scanner (BK Ultrasound, Denmark) driving a 192-element 5.5 MHz wide linear transducer (10L2W, BK Ultrasound). The dynamic received focus technique was employed to generate the sequences. Six subjects, among those three patients after major surgery and three normal subjects, were scanned once and Six ultrasound sequences each containing 50 frames were acquired. The proposed algorithm was applied to all 300 in-vivo lung ultrasound images. The pleural line is first segmented on each image and then the B-line artifacts spreading down from the pleural line are detected and overlayed on the image. The resulting 300 images showed that the mean lateral distance between B-lines detected on images acquired from patients decreased by 20% in compare with that of normal subjects. Therefore, the method can be used as the basis of a method of automatically and qualitatively characterizing the distribution of B-lines.