Ventilator associated pneumonia (VAP) is the commonest hospital acquired infection (HAI) in intensive care. In Asia, VAP is increasingly caused by resistant Gram-negative organisms. Despite the global antimicrobial resistance crisis, the epidemiology of VAP is poorly documented in Asia.We systematically reviewed literature published on Ovid MEDLINE, Embase Classic and Embase from 1st January 1990 to 17th Aug 2017 to estimate incidence, prevalence, and etiology of VAP. We performed meta-analysis of pooled data to give overall rates and rates by country income level.Pooled incidence density of VAP was high in low- and middle-income countries and lower in high-income countries (18.5, 15.2 and 9.0/1000 ventilator days respectively).Acinetobacter baumannii and Pseudomonas aeruginosa (26%, N=3687; 22%, N=3176) were leading causes of VAP, Staphylococcus aureus caused 14% (N=1999). Carbapenem resistance was common (57.1%).VAP remains a common cause of HAI, especially in low and middle income countries and antibiotic resistance is common.

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Background: Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon. Methods: We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration–maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality. Results: From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used ( P =0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04–0.40; P <0.001). Conclusions: From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.

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Aortic annular rupture is one of the most feared complications of transcatheter aortic valve replacement (TAVR). This complication often presents as sudden cardiac tamponade with hypotension and requires urgent intervention. The traditional rescue strategy for such cases is emergency surgical intervention, yet the mortality remains high considering most patients who undergo TAVR are not candidates for open heart surgery. As such, there is a need for percutaneous alternatives to treat this critical complication. Here, we describe a case of annular rupture during TAVR that was successfully treated with coil embolization at the rupture site. This case illustrates the use of coil embolization as a treatment strategy in patients with acute aortic annular rupture who are at high-risk for surgical intervention.

Background and Aim of Study The treatment of inoperable patients with concomitant complex coronary artery disease and severe aortic stenosis unsuitable for conventional transcatheter aortic valve replacement (TAVR) poses a significant challenge. Effective treatment is even more difficult in those patients with complex coronary anatomy unamenable to percutaneous revascularization. Our manuscript aims to enlighten clinicians on the management of this complex patient. Methods We conducted a contemporary review of the literature of combined off‐pump coronary artery bypass grafting and transaortic TAVR in this patient population and describe our own successful experience in an inoperable patient with a porcelain aorta. Results Including our report, 17 cases have been described in the literature. All patients had multiple comorbidities with elevated STS (range, 2.6‐25; 6%) and EuroScore I (range, 13.7‐83; 7%) and were not considered candidates for conventional CABG and SAVR. Most had severe, complex, multivessel CAD deemed unsuitable for PCI and structural findings precluding them from other standard percutaneous or alternative TAVR approaches (transfemoral/subclavian/transcaval/transapical). Out of the 17 cases, 5 (29%) had porcelain aortas. Most reports specify the decision‐making process is driven by a multidisciplinary team. Conclusion This report demonstrates that hybrid off‐pump CABG surgery and transaortic TAVR can be successfully performed in high‐risk patients with porcelain aortas who are not candidates for percutaneous methods, on‐pump revascularization, transfemoral, subclavian, or transcaval valve implantations. It also highlights that careful study of the CTA scan could predict adequate access for a transaortic approach even in the presence of porcelain aorta in selected patients.

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Aortic arch and hemiarch surgery necessitate the temporary interruption of blood perfusion to the brain. Despite its complexity, hemiarch and ascending aortic surgery can be performed via a minimally invasive approach. Due to the higher risk of neurological injury during a circulatory arrest, several techniques were developed to further protect the brain during this surgery. We searched the Embase, Medline, and Cochrane databases and identified articles reporting outcomes of antegrade and retrograde cerebral perfusion strategies. Herein, we outline surgical approaches, intra-operative technical considerations, and clinical outcomes of hemiarch and ascending aortic surgery. Hemiarch and ascending aortic surgery is associated with a higher risk of mortality and morbidity. Attention to the optimal approach and cerebral protection strategy has been shown to significantly affect outcomes and mitigate risk.