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ObjectivesInstitutional studies suggest robotic mitral surgery may be associated with superior outcomes. The objective of this study was to compare the outcomes of robotic, minimally invasive (mini), and conventional mitral surgery.MethodsA total of 2300 patients undergoing non-emergent isolated mitral valve operations from 2011 to 2016 were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by approach: robotic (n=372), mini (n=576) and conventional sternotomy (n=1352). To account for preoperative differences, robotic cases were propensity score matched (1:1) to both conventional and mini approaches.ResultsThe robotic cases were well matched to the conventional (n=314) and mini (n=295) cases with no significant baseline differences. Rates of mitral repair were high in the robotic and mini cohorts (91%), but significantly lower with conventional (76%, P<0.0001) despite similar rates of degenerative disease. All procedural times were longest in the robotic cohort, including operative time (224 vs 168 min conventional, 222 vs 180 min mini; all P<0.0001). The robotic approach had comparable outcomes to the conventional approach except there were fewer discharges to a facility (7% vs 15%, P=0.001) and 1 less day in the hospital (P<0.0001). However, compared with the mini approach, the robotic approach had more transfusions (15% vs 5%, P<0.0001), higher atrial fibrillation rates (26% vs 18%, P=0.01), and 1 day longer average hospital stay (P=0.02).ConclusionDespite longer procedural times, robotic and mini patients had similar complication rates with higher repair rates and shorter length of stay metrics compared with conventional surgery. However, the robotic approach was associated with higher atrial fibrillation rates, more transfusions and longer postoperative stays compared with minimally invasive approach.

The ultimate treatment for patients with end-stage heart failure is heart transplantation. The number of donor hearts which are primarily procured from donation after brain death (DBD) donors is limited, but donation after circulatory death (DCD) donor hearts can increase the heart donor pool. However, ischemia and reperfusion injuries associated with the DCD process causes myocardial damage, limiting the use of DCD hearts in transplantation. Addressing this problem is critical in the exploration of DCD hearts as suitable donor hearts for transplantation. In this study, rat hearts were procured following the control beating-heart donor (CBD) or DCD donation process. Changes in mitochondria and cardiac function from DCD hearts subjected to 25 or 35 minutes of ischemia followed by 60 minutes of reperfusion were compared to CBD hearts. Following ischemia, rates of oxidative phosphorylation and calcium retention capacity were progressively impaired in DCD hearts compared to CBD hearts. Reperfusion caused additional mitochondrial dysfunction in DCD hearts. Developed pressure, inotropy and lusitropy, were significantly reduced in DCD hearts compared to CBD hearts. We, therefore, suggest that interventional strategies targeted before the onset of ischemia and at reperfusion could protect mitochondria, thus potentially making DCD hearts suitable for heart transplantation.

Two predominant pathways contribute to ischemia reperfusion injury (IRI) following donation after circulatory death (DCD): mitochondrial permeability transition pore (MPTP) opening and Calpain-1 (CPN1) activation. Each pathway has established inhibitors; Cyclosporine A (CyA) and MDL-28170 (MDL), respectively, which are effective in modulating IRI in a DCD heart with 25 min of warm ischemia time (WIT). We studied the effect of co-administering CyA and MDL during reperfusion on infarct size and graft function in DCD rat hearts with extended WIT of 35 min. Male rats were exposed to 35 min of warm ischemia followed by 90 min of reperfusion. During reperfusion, hearts were given either 0.5 mM of CyA, 10 mM of MDL, or mixed CyA and MDL. Cardiac function and coronary flow rates were monitored throughout reperfusion and infarct size at the end of reperfusion. Infarct size in hearts treated with mixed CyA + MDL (31.59 ± 7.1%) was less than that of MDL-treated hearts (33.26 ± 4.3%) but larger than CyA-treated hearts (25.49 ± 5.9%). Graft function and coronary flow rates were variable amongst groups. CyA-treated hearts had more profound infarct size reduction when compared to MDL, and no additional synergistic effect was seen with combination treatment. Our results indicate that MPTP opening contributes significantly to the development of IRI in DCD hearts.

Ventricular septal defect (VSD) is a life-threatening complication occurring after delayed presentation of acute myocardial infarction (AMI). We assessed clinical characteristics based on mortality following surgical repair of post-AMI VSD and evaluated trends of mortality, mechanical circulatory support (MCS) device use, and surgical approach. We included all patients who had surgical VSD repair following AMI who were included in a regional quality collaborative from May 2008 through January 2020. The primary outcome was in-hospital mortality. A univariate logistic regression model was utilized for each clinical variable on in-hospital mortality, while a multivariable model was used on age and variables that showed significant association (p <0.05) in the univariable model. Of the 79 patients who received repair, 32 (41%) were ≥70 years, 49 (62%) were male, and 28 (35%) died. The preoperative mean ejection fraction was 35%. Cardiogenic shock (CS) was observed in 53% (alive vs dead: 39% vs 79%, p = 0.001), while 6% required cardiopulmonary resuscitation (alive vs dead: 2% vs 14%, p = 0.05). MCS devices including extracorporeal membrane oxygenation were used in 22% (alive vs dead: 4% vs 54%, p <0.001). Emergent surgery was performed in 37% (alive vs dead: 18% vs 71%, p <0.001), concomitant aortic valve replacement in 10% (alive vs dead: 11% vs 9%, p = 0.029), and delayed intervention (beyond 7 days) in 44% (alive vs dead: 57% vs 21%, p = 0.002). Intraoperatively, blood products were used in 49% (alive vs dead: 45% vs 57%, p = 0.005). Following repair, 22% suffered from renal failure (alive vs dead: 19% vs 48%, p = 0.021). Patients who experienced delayed intervention had higher survival rates probably related to survival bias. Patients who suffered in-hospital mortality were more likely to have CS and to require MCS. Improvement in patient selection by a “Heart Team” approach and new therapeutic options are needed as part of advanced care for mechanical complications of AMI.

Heart transplantation (HTx) is the ultimate treatment for end-stage heart failure. The number of patients on waiting lists for heart transplants, however, is much higher than the number of available organs. The shortage of donor hearts is a serious concern since the population affected by heart failure is constantly increasing. Furthermore, the long-term success of HTx poses some challenges despite the improvement in the management of the short-term complications and in the methods to limit graft rejection. Myocardial injury occurs during transplantation. Injury initiated in the donor as result of brain or cardiac death is exacerbated by organ procurement and storage, and is ultimately amplified by reperfusion injury at the time of transplantation. The innate immune system is a mechanism of first-line defense against pathogens and cell injury. Innate immunity is activated during myocardial injury and produces deleterious effects on the heart structure and function. Here, we briefly discuss the role of the innate immunity in the initiation of myocardial injury, with particular focus on the Toll-like receptors and inflammasome, and how to potentially expand the donor population by targeting the innate immune response.

Donation after circulatory death (DCD) involves unavoidable ischemia–reperfusion injury (IRI). Mitochondrial permeability transition pore (MPTP) opening plays a critical role in DCD heart injury. Activation of ubiquitous calpains, including calpain-1 and calpain-2 (CPN1/2), increases MPTP opening in DCD hearts. Mitofilin, a mitochondrial inner membrane protein that regulates cristae morphology, is also involved in MPTP opening during ischemia–reperfusion. However, it remains unclear whether CPN1/2 activation contributes to mitofilin-mediated IRI in DCD hearts. We first incubated a mitofilin peptide with exogenous CPN1 in vitro to investigate the link between CPN1 activation and mitofilin degradation. Next, we tested whether CPN1/2 inhibition reduces cardiac injury in DCD hearts by preserving mitofilin and limiting MPTP opening. Sprague-Dawley (SD) rat hearts were subjected to 25 min of in vivo ischemia followed by ex vivo perfusion with or without the CPN1/2 inhibitor MDL-28170 (10 µM). In vitro incubation with CPN1 led to mitofilin degradation, confirming mitofilin as a CPN1 substrate. CPN1/2 inhibition significantly reduced infarct size compared with untreated DCD hearts, preserved mitofilin expression, and decreased MPTP opening. These findings indicate that CPN1/2 activation promotes MPTP opening in DCD hearts through mitofilin degradation. Timely inhibition of CPN1/2 represents a promising strategy to reduce cardiac injury and improve DCD heart function.

Introduction This case study reports on a suicide attempt involving indoxacarb and vitamin C. Indoxacarb is a neurotoxic insecticide used in agriculture and as a flea controller in pets. Cotton, vegetables, and fruits are treated with indoxacarb, an insecticide that can be applied both indoors and outdoors. It causes skin allergies, methemoglobinemia, and hemolytic anemia. It is also attributed to allergic reactions through ingestion, inhalation, physical contact, and translaminar action. This case report highlights use of vitamin C in methemoglobinemia caused by indoxacarb poisoning. Indoxacarb poisoning has the potential to be extremely serious and even lethal. In this instance, the patient initially had no symptoms after ingesting a substance containing indoxacarb in an attempt at suicide. However, further tests revealed methemoglobinemia and low oxygen levels. Case presentation A 28-year-old south-east Asian female patient ingested an insecticide containing 5.25% novaluron, 4.5% indoxacarb, and 25% thiamethoxam, and reported that she noticed muddy brown urine but presented with no active signs or symptoms of poisoning. Upon examination, the patient was fully conscious, alert, and hemodynamically stable, but had an oxygen saturation of 84%. Gastric lavage was performed, and blood investigations revealed a muddy-brown-colored blood sample and methemoglobin levels of 12%. The patient was treated with high-dose vitamin C and showed significant improvement, with a drop in methemoglobin levels to 1.2% and an increase in oxygen saturation to 97%. Discussion Indoxacarb poisoning can cause severe methemoglobinemia. Vitamin C may be a useful treatment option for methemoglobinemia caused by indoxacarb, particularly in cases in which traditional treatment with methylene blue is contraindicated or not tolerated. Hence high doses of ascorbic acid, that is, vitamin C, were administered to the patient, which lowered their methemoglobin levels and improved oxygen levels without much safety concerns. Conclusion This example emphasizes the significance of early indoxacarb poisoning detection and treatment as well as the possible advantages of utilizing ascorbic acid in the management of methemoglobinemia, and highlights the use of vitamin C in the treatment of methemoglobinemia caused by indoxacarb poisoning. Therefore, it is important for healthcare professionals to be aware of the potential for indoxacarb to cause methemoglobinemia and to consider vitamin C as a treatment option.

Background Ex-vivo heart perfusion can be utilized to study a variety of physiologic and molecular pathways in a controlled system outside of the body. It can also be used in clinical settings such as for organ preservation before transplantation. Myocardial oxygen consumption (MVO 2 ) correlates with energy production in the myocardium and can also be used to determine the balance between the oxygen supply and demand of the perfused heart. This study sought to determine an ex-vivo perfusion rate that matches the metabolic demands of the heart according to different temperatures and solution compositions (with and without the addition of erythrocytes), a flow below which the supply of oxygen is not sufficient to maintain an aerobic state of the perfused heart (“D CRIT ”). Methods Under general anesthesia, rat hearts were procured and preserved by perfusing with the University of Wisconsin Belzer machine perfusion system (UW Belzer MPS) solution saturated with 100% O 2 . The key elements of this solution include supraphysiological potassium (to stop the heartbeat and reduce the cellular metabolic demand), starch, gluconate and mannitol (to maintain cell wall integrity), glucose (to sustain basal metabolism), and glutathione (to scavenge free radicals). Three groups of rat hearts ( n  = 7) were randomly allocated to be perfused at 15 °C, 22 °C or 37 °C, at a varying flow index (FI) starting from a minimum of 380 mL/min/100 g to less than 50 mL/min/100 g, decreasing by 50 mL/min/100 g at 10 min intervals while measuring the MVO 2 at each FI. Lactate was measured from coronary sinus samples to determine the onset of tissue hypoxia/anaerobic state. Results The D CRIT at 15 °C was 99.9 ± 4.9 mL/min/100 g; however, at 22 °C and 37 °C we could not reach a D CRIT . The myocardial oxygen demand could not be met at 22 °C and 37 °C with the maximum FI above 380 mL/min/100 g even when erythrocytes (10% V/V) were added to the solution. At 15 °C, the production of lactate was evident only below the D CRIT , while at 22 °C lactate production was present at all flow indices. Conclusions Determining the D CRIT for optimal ex-vivo perfusion of the heart is necessary to ensure adequate tissue oxygenation and limit anaerobic state. Temperatures employed above 15 °C limit the efficient ex-vivo perfusion preservation of heart with the UW Belzer MPS solution.

Due to the COVID-19 epidemic, the tourism industry in Bangladesh has caused massive disruption in both inbound and outbound tourism, where all interdependent tourism supply chain activities (hotels, resorts, restaurants and transportation) have been forced to be bunged down. The fundamental aim of this qualitative study is to evaluate stakeholders' experiences and opinions about the impact of the COVID-19 pandemic on the tourism industry of Bangladesh. Reliable literature reviews and qualitative interviews with stakeholders in the tourist industry were utilized to generate the data for this study. This qualitative research was conducted in three phases, comprising a longitudinal approach from January 2021 to March 2022, focusing on the perspectives of multi-level stakeholders in the tourism and hospitality industry in four distinct tourist destinations in Bangladesh. Moreover, this research used a case study technique based on 36 semi-structured interviews with important stakeholders in the region. The findings indicate that the influence of COVID-19 on tourism has a substantial positive and negative impact on a number of stakeholders who contribute significantly to the region's sustainable development. Positive impacts are (a) improved air quality, (b) reduced water and noise pollution, (d) limited natural resources consumption and (e) favourable greenhouse atmosphere; on the other hand, negative impacts are (a) reduced rate of tourists arrival (b) unoccupied hotel accommodations (c) disruption of tourism activities (d) declining purchasing trends and (e)hampering socialization process. Based on the evaluation of stakeholders' views, an alternative re-engineering policy framework has been recommended for future strategic actions and control.

Purpose - The sustainable coastal and marine tourism can be regarded as a prerequisite for ensuring socioeconomic development and maintaining an ecological balance on the planet, and it has drawn keen attention among academicians, professionals, and stakeholders. This case-study-based qualitative research employed a multi-stakeholder approach, assessing the economic, sociocultural, and environmental impacts, both positive and negative, on coastal destinations. Methodology - Data have been primarily collected through direct observation and face-to-face interviews backed by secondary literature. Semi-structured questionnaires were employed to gather data from a variety of tourism-related stakeholders from Cox's Bazar and Saint Martin, considered as tourist hotspots in Bangladesh. Findings - The results revealed critical economic, social, and environmental interdependent strategic issues responsible for the sustainable CMT industry. Significance of the research - The study contributes to sustainability models through addressing how multi-stakeholder collaboration can boost sustainable practices in tourism, integrating actionable recommendations based on '10Ls' factors for execution by relevant authorities. Originality of the research - The originality of the study is placed on its evaluation of sustainable practices in a tourism industry vulnerable to climate change. It presents a strategic framework that provides theoretical and managerial understandings, aiding stakeholders make informed decisions to enhance sustainable tourism.