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Pubblicazioni recenti - cardiogenic
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Current and future trial design in refractory cardiogenic shock.
Eur J Heart Fail2023 Mar;():. doi: 10.1002/ejhf.2838.
Arrigo Mattia, Blet Alice, Morley-Smith Andrew, Aissaoui Balanant Nadia, Baran David A, Bayes-Genis Antoni, Chioncel Ovidiu, Desch Steffen, Karakas Mahir, Moller Jacob Eifer, Poess Janine, Price Susanna, Zeymer Uwe, Mebazaa Alexandre,
Abstract
Cardiogenic shock is a life-threatening syndrome of peripheral hypoperfusion and organ dysfunction due to primary cardiac disease. Few adequately designed randomized clinical trials provide guidance on the optimal management strategies, which frequently includes vasoactive drugs, circulatory and ventilatory support, and reversal of any underlying cause, including coronary revascularization in case of acute myocardial infarction. Management is largely based on experience rather than evidence-based recommendations and patient outcomes remain poor. Particular attention is currently given to refractory patients (i.e., not responding to medical treatment) with a growing number of studies investigating various modalities of mechanical circulatory support. This consensus document summarizes the output from the third Critical Care Clinical Trialists Workshop, where a group of experts convened to discuss, debate, and reflect on approaches related to trials in refractory cardiogenic shock, to provide recommendations for the design of future trials. Invited participants included clinical trialists, clinicians (including cardiologists, intensive care specialists, anaesthesiologists, and cardiac surgeons), epidemiologists, patient representatives, regulators from the United States and Europe, United States federal grant managers, and industry representatives. Special attention is given to current and future definitions of cardiogenic shock including refractory states, recent and ongoing clinical trials in refractory cardiogenic shock and future directions in light of the most recent literature.
This article is protected by copyright. All rights reserved.
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Life-Threatening Cardiogenic Shock Related to Venlafaxine Poisoning-A Case Report with Metabolomic Approach.
Metabolites2023 Feb;13(3):. doi: 353.
Magny Romain, Mégarbane Bruno, Guillaud Pauline, Chevillard Lucie, Auzeil Nicolas, Thiebot Pauline, Voicu Sebastian, Malissin Isabelle, Deye Nicolas, Labat Laurence, Houzé Pascal,
Abstract
Metabolomics in clinical toxicology aim at reliably identifying and semi-quantifying a broad array of endogenous and exogenous metabolites using dedicated analytical methods. Here, we developed a three-step-based workflow to investigate the metabolic impact of the antidepressant drug venlafaxine in a poisoned patient who developed life-threatening cardiac failure managed with extracorporeal membrane oxygenation. Both targeted quantitative and untargeted semi-quantitative metabolomic analyses using liquid chromatography hyphenated to high-resolution tandem mass spectrometry were performed to determine the plasma kinetics of venlafaxine, -desmethyl-venlafaxine, and -desmethyl-venlafaxine and to identify sixteen different venlafaxine-derived metabolites including one unknown (, venlafaxine conjugated to a hexosyl-radical), respectively. Correlations between the quantitative metabolomic data and annotated endogenous metabolites suggested impaired amino acid and lipid metabolism, Krebs cycle, and kynurenine pathway. This preliminary study represents a first step towards a more extensive application of toxicometabolomics in clinical toxicology and a useful workflow to identify the biomarkers of toxicity.
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The Prognostic Role of Spot Urinary Sodium and Chloride in a Cohort of Hospitalized Advanced Heart Failure Patients: A Pilot Study.
Life (Basel)2023 Mar;13(3):. doi: 698.
Xanthopoulos Andrew, Christofidis Charalambos, Pantsios Chris, Magouliotis Dimitrios, Bourazana Angeliki, Leventis Ioannis, Skopeliti Niki, Skoularigki Evangelia, Briasoulis Alexandros, Giamouzis Grigorios, Triposkiadis Filippos, Skoularigis John,
Abstract
Recent studies have demonstrated the prognostic value of spot urinary sodium (UNa) in acutely decompensated chronic HF (ADCHF) patients. However, data on the prognostic role of UNa and spot urinary chloride (UCl) in patients with advanced HF are limited. In the present prospective pilot study, we examined the predictive value of UNa and UCl concentration at baseline, at 2 h and at 24 h after admission for all-cause mortality and HF rehospitalization up to 3 months post-discharge. Consecutive advanced HF patients (n = 30) admitted with ADCHF and aged > 18 years were included in the study. Loop diuretics were administered based on the natriuresis-guided algorithm recommended by the recent HF guidelines. Exclusion criteria were cardiogenic shock, acute coronary syndrome, estimated glomerular filtration rate
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Gender-Related Discrepancies in Short-Term Outcomes in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery.
J Clin Med2023 Mar;12(6):. doi: 2202.
Krasivskyi Ihor, Djordjevic Ilija, Ivanov Borko, Eghbalzadeh Kaveh, Großmann Clara, Reichert Stefan, Radwan Medhat, Sandoval Boburg Rodrigo, Sabashnikov Anton, Schlensak Christian, Wahlers Thorsten, Rustenbach Christian Jörg,
Abstract
The sex differences in patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery are still unclear. Our aim was to investigate the impact of gender on short-term outcomes in males and females after off-pump bypass procedures. Our research was designed as a double-center retrospective analysis. Generally, 343 patients (men (n = 255) and women (n = 88)) who underwent an OPCAB procedure were included in our study. To provide a statistical analysis of unequal cohorts, we created a propensity score-based matching (PSM) analysis (men, n = 61; women, n = 61). The primary endpoint was all-cause in-hospital mortality. Dialysis, transient ischemic attack (TIA), low cardiac output syndrome (LCOS), reoperation due to postoperative bleeding, wound infection and duration of hospital stay were secondary outcomes in our analysis. No significant differences were detected within the male and female groups regarding age ( = 0.116), BMI ( = 0.221), diabetes ( = 0.853), cardiogenic shock (0.256), STEMI ( = 0.283), NSTEMI ( = 0.555) and dialysis ( = 0.496). Males underwent significantly more frequently ( = 0.005) total-arterial revascularization with T-graft technique ( = 0.005) than females. In contrast, temporary pacer use was significantly higher ( = 0.022) in females compared to males. The in-hospital mortality rate was not significantly higher ( = 0.496) in the female group compared to the male group. Likewise, secondary outcomes did not differ significantly between the non-adjusted and the adjusted groups. Based on our findings, gender has no impact on short-term outcomes after OPCAB surgery.
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Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction.
J Clin Med2023 Mar;12(6):. doi: 2184.
De Luca Leonardo, Mistrulli Raffaella, Scirpa Riccardo, Thiele Holger, De Luca Giuseppe,
Abstract
Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.
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Eptifibatide, an Older Therapeutic Peptide with New Indications: From Clinical Pharmacology to Everyday Clinical Practice.
Int J Mol Sci2023 Mar;24(6):. doi: 5446.
Tonin Ga?per, Klen Jasna,
Abstract
Therapeutic peptides are oligomers or short polymers of amino acids used for various medical purposes. Peptide-based treatments have evolved considerably due to new technologies, stimulating new research interests. They have been shown to be beneficial in a variety of therapeutic applications, notably in the treatment of cardiovascular disorders such as acute coronary syndrome (ACS). ACS is characterized by coronary artery wall damage and consequent formation of an intraluminal thrombus obstructing one or more coronary arteries, leading to unstable angina, non-ST elevated myocardial infarction, and ST-elevated myocardial infarction. One of the promising peptide drugs in the treatment of these pathologies is eptifibatide, a synthetic heptapeptide derived from rattlesnake venom. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that blocks different pathways in platelet activation and aggregation. In this narrative review, we summarized the current evidence on the mechanism of action, clinical pharmacology, and applications of eptifibatide in cardiology. Additionally, we illustrated its possible broader usage with new indications, including ischemic stroke, carotid stenting, intracranial aneurysm stenting, and septic shock. Further research is, however, required to fully evaluate the role of eptifibatide in these pathologies, independently and in comparison to other medications.
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The Prognostic Utility of Venous Blood Gas Analyses at Presentation in Cats with Cardiogenic Pulmonary Edema.
Vet Sci2023 Mar;10(3):. doi: 232.
Tani Akiyoshi, Suzuki Ryohei, Matsukata Satoshi, Nakamura Atsushi, Nuruki Takaomi,
Abstract
Cats urgently visit emergency hospitals due to respiratory distress, and the chief cause is cardiogenic pulmonary edema (CPE). Although cats with CPE were frequently encountered in clinics, the prognostic factors were poorly reported. The objective of this retrospective study was to investigate the association of physical examination and venous blood gas parameters with the survival of cats with CPE in an emergency hospital. Thirty-six cats with CPE were ultimately included in the present study, and eight of them died within 12 h after their presentation to our hospital. Statistical analyses of clinical parameters between cats that died within 12 h and those that survived for 12 h were conducted using Mann-Whitney U test with Bonferroni correction. Cats that died within 12 h had significantly lower rectal temperatures and higher PvCO than those that did not die within 12 h. Moreover, hypotension and vasoconstrictor use were related to death within 12 h of presentation and higher PvCO. These findings indicated the prognostic utility of body temperature and PvCO, and the association between hypercapnia and the severity of CPE or hypotension. A large number of prospective studies should be performed to validate these results.
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Acute coronary syndrome in very elderly patients-a real-world experience.
Heart Vessels2023 Mar;():. doi: 10.1007/s00380-023-02260-x.
Bianco Matteo, Mottola Filiberto Fausto, Cerrato Enrico, Giordana Francesca, Cinconze Sebastian, Baralis Giorgio, Verra Alison, Musumeci Giuseppe, Rossini Roberta,
Abstract
Very elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). Notably, age represents both a proxy of frailty and an exclusion criterion in clinical randomized trials, which probably contributes to lack of data and undertreatment of real-world elderly patients. The aim of the study is to describe patterns of treatment and outcome of very elderly patients with ACS. All consecutive patients aged???80 years old (yo) admitted between January 2017 and December 2019 with ACS were included. The primary endpoint was in-hospital occurrence of major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, new onset cardiogenic shock, definite/probable stent thrombosis, and ischemic stroke. The secondary endpoints were in-hospital incidence of Thrombolysis in Myocardial Infarction (TIMI) major/minor bleedings, contrast-induced nephropathy (CIN), six-month all-cause mortality, and unplanned readmission. One hundred ninety-three patients (mean age 84.1?±?3.5 yo, 46% females) were included, of whom 86 (44.6%), 79 (40.9%), and 28 (14.5%) presented with ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA), respectively. The vast majority of patients received an invasive strategy, with 92.7% undergoing coronary angiography and 84.4% to percutaneous coronary intervention (PCI). Aspirin was administered to 180 (93.3%) patients, clopidogrel to 89 (46.1%) patients, and ticagrelor to 85 (44%) patients. In-hospital MACE occurred in 29 patients (15.0%), whereas 3 (1.6%) and 12 patients (7.2%) experienced in-hospital TIMI major and TIMI minor bleeding, respectively. Of the overall population, 177 (91.7%) were discharged alive. After discharge, 11 patients (6.2%) died of all-cause death, whereas 42 patients (23.7%) required a new hospitalization within six months. Invasive strategy of ACS in elderly patients seems safe and effective. Six-month new hospitalization appears inevitably related to age.
© 2023. Springer Nature Japan KK, part of Springer Nature.
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Preclinical Studies on Pulsatile Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review.
ASAIO J2023 Mar;():. doi: 10.1097/MAT.0000000000001922.
Kanagarajan Dhayananth, Heinsar Silver, Gandini Lucia, Suen Jacky Y, Dau Van Thanh, Pauls Jo, Fraser John F,
Abstract
Refractory cardiogenic shock is increasingly being treated with veno-arterial extracorporeal membrane oxygenation (V-A ECMO), without definitive proof of improved clinical outcomes. Recently, pulsatile V-A ECMO has been developed to address some of the shortcomings of contemporary continuous-flow devices. To describe current pulsatile V-A ECMO studies, we conducted a systematic review of all preclinical studies in this area. We adhered to PRISMA and Cochrane guidelines for conducting systematic reviews. The literature search was performed using Science Direct, Web of Science, Scopus, and PubMed databases. All preclinical experimental studies investigating pulsatile V-A ECMO and published before July 26, 2022 were included. We extracted data relating to the 1) ECMO circuits, 2) pulsatile blood flow conditions, 3) key study outcomes, and 4) other relevant experimental conditions. Forty-five manuscripts of pulsatile V-A ECMO were included in this review detailing 26 in vitro, two in silico, and 17 in vivo experiments. Hemodynamic energy production was the most investigated outcome (69%). A total of 53% of studies used a diagonal pump to achieve pulsatile flow. Most literature on pulsatile V-A ECMO focuses on hemodynamic energy production, whereas its potential clinical effects such as favorable heart and brain function, end-organ microcirculation, and decreased inflammation remain inconclusive and limited.
Copyright © ASAIO 2023.
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Bridging with Surgically Placed Microaxial Left Ventricular Assist Devices: A High-Volume Center Experience.
Eur J Cardiothorac Surg2023 Mar;():. doi: ezad116.
Gill George, Rowe Georgina, Chen Qiudong, Malas Jad, Thomas Jason, Peiris Achille, Cole Robert, Chikwe Joanna, Megna Dominick, Emerson Dominic,
Abstract
OBJECTIVES:
The Impella 5.0 and 5.5 have largely superseded non-ambulatory temporary mechanical support devices, yet clinical outcomes are predominantly limited to small series: this study presents the experience of a high-volume center.
METHODS:
An institutional clinical registry was used to identify all patients with cardiogenic shock who underwent Impella 5.0 or 5.5 implantation from January 2014 through March 2022. The primary outcome was survival to device explantation.
RESULTS:
The study cohort comprised 221 patients, including 146 (66.1%) Impella 5.0 and 75 (33.9%) Impella 5.5 patients. The primary etiology was non-ischaemic cardiomyopathy (50.7%, n?=?112), ischaemic cardiomyopathy (23.1%, n?=?51), and acute myocardial infarction (26.2%, n?=?58). Patients were prospectively classified according to strategy as bridge to transplant (47.5%, n?=?105), bridge to durable device (13.6%, n?=?30) or bridge to recovery (38.9%, n?=?86). Patients were predominantly Interagency Registry for Mechanically Assisted Circulatory Support profile 1 or 2 (95.0%, n?=?210). The median bridging duration was 14 (range 0-137) days. Device exchange, Ischaemic stroke, and ipsilateral arm ischaemia occurred in 8.1% (n?=?18), 2.7% (n?=?6) and 1.8% (n?=?4) of patients, respectively. Compared to the 75 most recent Impella 5.0 patients, Impella 5.5 patients (n?=?75) had lower rates of device exchange (4.0%, n?=?3 versus 13.3%, n?=?10, p?=?0.04). Overall, 70.1% (n?=?155) of patients survived to Impella explantation.
CONCLUSIONS:
The Impella 5.0 and 5.5 provide safe and effective temporary mechanical support in appropriately selected patients with cardiogenic shock. The newer device generation may have a lower requirement for device exchange as compared to its predecessor.
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Research status and development trend of extracorporeal membrane oxygenation based on bibliometrics.
Front Cardiovasc Med2023 ;10():1048903. doi: 1048903.
Guan Cuizhong, Shen Hua, Dong Shiyong, Zhan Yuhua, Yang Jie, Zhang Qiu, Wang Rong,
Abstract
BACKGROUND:
Using bibliometric method to analyze the research status and development trend of extracorporeal membrane oxygenation (ECMO), we aim to provide clinicians, scientists, and stakeholders with the most up-to-date and comprehensive overview of ECMO research.
MATERIALS AND METHODS:
Using Excel and VOSviewer, the literature on ECMO was systematically analyzed regarding publication trends, journal source, foundation, countries, institutions, core authors, research hotspots, and market distribution.
RESULTS:
There were five important time nodes in the research process of ECMO, including the success of the first ECMO operation, the establishment of ELSO, and the outbreak of influenza A/H1N1 and COVID-19. The R&D centers of ECMO were the United States, Germany, Japan, and Italy, and the attention to ECMO was gradually increasing in China. The products most used in the literature were from Maquet, Medtronic, and LivaNova. Medicine enterprises attached great importance to the funding of ECMO research. In recent years, the literature has mainly focused on the following aspects: the treatment of ARDS, the prevention of coagulation system-related complications, the application in neonatal and pediatric patients, mechanical circulatory support for cardiogenic shock, and ECPR and ECMO during the COVID-19 pandemic.
CONCLUSION:
The frequent epidemic occurrence of viral pneumonia and the technical advancement of ECMO in recent years have caused an increase in clinical applications. The hot spots of ECMO research are shown in the treatment of ARDS, mechanical circulatory support for cardiogenic shock, and the application during the COVID-19 pandemic.
© 2023 Guan, Shen, Dong, Zhan, Yang, Zhang and Wang.
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CARDIOGENIC SHOCK ASSOCIATED WITH ACUTE NOROVIRUS GASTROENTERITIS: WHAT IS NEEDED TO PROVE CAUSALITY?
Eur J Case Rep Intern Med2023 ;10(2):003759. doi: 003759.
Evans Abbie, Benjanuwattra Juthipong, Mora Barbara, Abdelnabi Mahmoud,
Abstract
UNLABELLED:
Acute myocarditis is a well-recognized condition attributable to a variety of viral illnesses. Common viral aetiologies include enteroviruses including coxsackie, adenovirus, influenza, echovirus, parvovirus B19 and herpesvirus. A high index of suspicion, early diagnosis, and prompt management with supportive anti-failure measures, and in selected cases immunosuppressive therapies including high-dose steroids, might be considered for better outcomes. The authors report a case of sudden onset of acute heart failure complicated by cardiogenic shock caused by viral myocarditis in a patient who initially presented with norovirus gastroenteritis. She had no previous cardiac history or significant cardiovascular risk factors. Prompt medical management for cardiogenic shock for norovirus-induced myocarditis was started, her symptoms gradually improved, and she was discharged safely on regular follow-up.
LEARNING POINTS:
Viral myocarditis exhibits a wide spectrum of symptoms ranging from non-specific prodromes such as fatigue and myalgia to chest pain, life-threatening arrhythmias, fulminant heart failure, or even sudden cardiac death.Common viral aetiologies for myocarditis include enteroviruses including coxsackie, adenovirus, influenza, echovirus, parvovirus B19 and herpesvirus.A high index of suspicion, early diagnosis, and prompt management with supportive anti-failure measures, and in selected cases immunosuppressive therapies including high-dose steroids, might be considered for better outcomes in cases of acute myocarditis.
© EFIM 2023.
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Left atrial intramural haematoma: a fatal complication of cardiac amyloidosis-a case report.
Eur Heart J Case Rep2023 Mar;7(3):ytad116. doi: ytad116.
Terashima Rika, Nakagawa Takashi, Hara Hisao, Hiroi Yukio,
Abstract
BACKGROUND:
Spontaneous left atrial intramural hematoma (LAIH) is extremely rare and there are only two cases of spontaneous LAIH involving cardiac amyloidosis (CA) reported in literature. In both cases, LAIH rapidly compromised hemodynamic stability proving to be a rare yet fatal complication.
CASE SUMMARY:
An 83-year-old man presented with cardiogenic shock. Electrocardiogram showed complete atrioventricular block, and echocardiogram revealed severe hypokinesis and left ventricular hypertrophy. Coronary angiography revealed no significant coronary stenosis and tissue biopsy was taken from the left ventricle. The patient was intubated, placed on extracorporeal membrane oxygenation with intra-aortic balloon pump and temporary pacemaker, and admitted to ICU. Day 6 of admission, he became hemodynamically unstable, and presented with atrial fibrillation. Transesophageal echocardiography showed a newly formed large mass in the left atrium. Day 11 of admission, the patient passed away. Autopsy revealed cardiac amyloidosis and showed the mass to be a left atrial intramural hematoma. Diffuse amyloid deposits were found in the myocardium as well as the blood vessel walls of the region surrounding the LAIH.
CONCLUSION:
LAIH is a rare yet fatal complication of CA. Autopsy revealed diffuse amyloid deposits within the left atrium may lead to left atrial fragility and contribute to development of LAIH. LAIH should be considered as an important differential diagnosis in the setting of a rapidly growing left atrial mass, and in hemodynamic instability in patients with CA.
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Efficacy of inhaled hydrogen on neurological outcome following brain ischaemia during post-cardiac arrest care (HYBRID II): a multi-centre, randomised, double-blind, placebo-controlled trial.
EClinicalMedicine2023 Apr;58():101907. doi: 101907.
Tamura Tomoyoshi, Suzuki Masaru, Homma Koichiro, Sano Motoaki, ,
Abstract
BACKGROUND:
Inhaled molecular hydrogen gas (H) has been shown to improve outcomes in animal models of cardiac arrest (CA). H inhalation is safe and feasible in patients after CA. We investigated whether inhaled H would improve outcomes after out-of-hospital CA (OHCA).
METHODS:
HYBRID II is a prospective, multicentre, randomised, double-blind, placebo-controlled trial performed at 15 hospitals in Japan, between February 1, 2017, and September 30, 2021. Patients aged 20-80 years with coma following cardiogenic OHCA were randomly assigned (1:1) using blinded gas cylinders to receive supplementary oxygen with 2% H or oxygen (control) for 18 h. The primary outcome was the proportion of patients with a 90-day Cerebral Performance Category (CPC) of 1 or 2 assessed in a full-analysis set. Secondary outcomes included the 90-day score on a modified Rankin scale (mRS) and survival. HYBRID II was registered with the University Hospital Medical Information Network (registration number: UMIN000019820) and re-registered with the Japan Registry for Clinical Trials (registration number: jRCTs031180352).
FINDINGS:
The trial was terminated prematurely because of the restrictions imposed on enrolment during the COVID-19 pandemic. Between February 1, 2017, and September 30, 2021, 429 patients were screened for eligibility, of whom 73 were randomly assigned to H (n = 39) or control (n = 34) groups. The primary outcome, i.e., a CPC of 1 or 2 at 90 days, was achieved in 22 (56%) and 13 (39%) patients in the H and control groups (relative risk compared with the control group, 0.72; 95% CI, 0.46-1.13; P = 0.15), respectively. Regarding the secondary outcomes, median mRS was 1 (IQR: 0-5) and 5 (1-6) in the H and control groups, respectively (P = 0.01). An mRS score of 0 was achieved in 18 (46%) and 7 (21%) patients in the H and control groups, respectively (P = 0.03). The 90-day survival rate was 85% (33/39) and 61% (20/33) in the H and control groups, respectively (P = 0.02).
INTERPRETATION:
The increase in participants with good neurological outcomes following post-OHCA H inhalation in a selected population of patients was not statistically significant. However, the secondary outcomes suggest that H inhalation may increase 90-day survival without neurological deficits.
FUNDING:
Taiyo Nippon Sanso Corporation.
TRANSLATION:
For the Japanese translation of the abstract see Supplementary Materials section.
© 2023 The Author(s).
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Extracorporeal membrane oxygenation as a bridge to advanced heart failure therapies.
J Heart Lung Transplant2023 Mar;():. doi: S1053-2498(23)01545-0.
Acharya Deepak, Manandhar-Shrestha Nabin, Leacche Marzia, Rajapreyar Indranee, William Preethi, Kazui Toshinobu, Hooker Robert, Tonna Joseph, Jovinge Stefan, Loyaga-Rendon Renzo,
Abstract
BACKGROUND:
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a key support modality for cardiogenic shock. The 2018 United Network for Organ Sharing (UNOS) heart transplant allocation algorithm prioritizes VA-ECMO patients.
OBJECTIVE:
To evaluate the role of VA-ECMO in bridging to advanced heart failure therapies.
METHODS:
We analyzed adult patients from the multicenter Extracorporeal Life Support Organization registry receiving VA-ECMO for cardiac support or resuscitation between 2016 and 2021 in the United States, comparing bridge-to-transplant (BTT) and non-BTT intent patients, as well as pre- vs post-2018 patients, on a wide range of demographic and clinical outcome predictors.
RESULTS:
Of 17,087 patients, 797 received left ventricular assist device (LVAD)/heart transplant, 7,931 died or had poor prognosis, and 8,359 had expected recovery at ECMO discontinuation. Patients supported with BTT intent had lower clinical acuity than non-BTT candidates and were more likely to receive LVAD/transplant. The proportion of patients who received VA-ECMO as BTT and received LVAD/transplant increased after 2018. Post-2018 BTT patients had significantly lower clinical acuity and higher likelihood of transplant than both post-2018 non-BTT patients and pre-2018 BTT patients. ECMO complications were associated with lower likelihood of transplant but were significantly less common post-2018 than pre-2018.
CONCLUSIONS:
After implementation of the 2018 UNOS allocation system, ECMO utilization as BTT or LVAD has increased, and the acuity of BTT intent patients cannulated for ECMO has decreased. There has not yet been an increase in more acute ECMO patients getting transplanted. This may partially explain the post-transplant outcomes of ECMO patients in the current era reported in UNOS.
Copyright © 2023 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.
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Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study.
Ann Emerg Med2023 Mar;():. doi: S0196-0644(23)00117-8.
Yamamoto Ryo, Tamura Tomoyoshi, Haiden Akina, Yoshizawa Jo, Homma Koichiro, Kitamura Nobuya, Sugiyama Kazuhiro, Tagami Takashi, Yasunaga Hideo, Aso Shotaro, Takeda Munekazu, Sasaki Junichi, ,
Abstract
STUDY OBJECTIVE:
To elucidate the clinical utility of the Clinical Frailty Scale score for predicting poor neurologic functions in patients resuscitated from out-of-hospital cardiac arrest (OHCA).
METHODS:
This was a prospective, multicenter, observational study conducted between 2019 and 2021. The study included adults with nontraumatic OHCA admitted to the intensive care unit after return of spontaneous circulation (ROSC). Pre-arrest high Clinical Frailty Scale score was defined as 5 or more. Favorable neurologic outcomes defined as a Cerebral Performance Category score of 2 or less at 30 days after admission were compared between patients with and without high Clinical Frailty Scale scores. Multivariable logistic regression analyses fitted with generalized estimating equations were performed to adjust for patient characteristics, out-of-hospital information, and resuscitation content and account for within-institution clustering.
RESULTS:
Of 9,909 patients with OHCA during the study period, 1,216 were included, and 317 had a pre-arrest high Clinical Frailty Scale score. Favorable neurologic outcomes were fewer among patients with high Clinical Frailty Scale scores. The high Clinical Frailty Scale score group showed a lower percentage of favorable neurologic outcomes after OHCA than the low Clinical Frailty Scale score group (6.1% vs 24.4%; adjusted odds ratio, 0.45 [95% confidence interval 0.22 to 0.93]). This relationship remained in subgroups with cardiogenic OHCA, with ROSC after hospital arrival, and without a high risk of dying (Clinical Frailty Scale score of 7 or less), whereas the neurologic outcomes were comparable regardless of pre-arrest frailty in those with noncardiogenic OHCA and with ROSC before hospital arrival.
CONCLUSIONS:
Pre-arrest high Clinical Frailty Scale score was associated with unfavorable neurologic functions among patients resuscitated from OHCA. The Clinical Frailty Scale score would help predict clinical consequences following intensive care after ROSC.
Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
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The efficacy of venous-arterial membrane oxygenation for emergency extracorporeal life support: results from a single-center large series over 6 years.
Intern Emerg Med2023 Mar;():. doi: 10.1007/s11739-023-03198-8.
Ottolina Davide, Colombo Riccardo, Fossali Tommaso, Castelli Antonio, Rech Roberto, Borghi Beatrice, Ballone Elisabetta, Catena Emanuele,
Abstract
The efficacy of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in supporting cardio-pulmonary resuscitation for cardiac arrest is still debated. This study aimed to evaluate the outcome of patients treated with VA-ECMO positioned according to different clinical indications. The method is retrospective data analysis from patients admitted to a tertiary referral center for VA-ECMO in 6 years. The study population was divided into three groups based on the VA-ECMO indication: patients with refractory cardiac arrest (CA group), cardiogenic shock after return of spontaneous circulation (CS-ROSC group), and cardiogenic shock without cardiac arrest (CS group). Seventy-nine patients underwent emergency VA-ECMO, 49 patients (62.0%) were in the CA group, 14 (17.7%) in the CS-ROSC group, and 16 patients (20.3%) in the CS group. The overall survival at 28 days was different between the three groups (6.1% in the CA group, 64.2% in the CS-ROSC group, and 50.0% in the CS group, p?0.001) and remained significant at 12 months (p?0.001). Furthermore, the Cerebral Performance Category at 12 months differed between groups with good outcomes in 4.1% of patients in CA, 50.0% in CS-ROSC, and 31.2% in CS groups (p?0.001). In the studied population, emergency VA-ECMO had negligible efficacy in refractory cardiac arrest, while it was correlated with a good outcome in cardiogenic shock after cardiac arrest, such as in cardiogenic shock alone. Patients with ROSC appear to benefit from VA-ECMO in the setting of persistent shock at rates comparable to cardiogenic shock patients who never sustained cardiac arrest.
© 2023. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).
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Percutaneous versus surgical revascularization of unprotected left main coronary artery: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS).
Rev Port Cardiol2023 Mar;():. doi: S0870-2551(23)00171-3.
Pereira Ana Rita, Calé Rita, Briosa Alexandra, Santos João Grade, Sebaiti Daniel, Martinho Mariana, Ferreira Bárbara, Marques Ana, Alegria Sofia, Gomes Ana Catarina, Morgado Gonçalo, Martins Ana Cristina, Pereira Hélder, ,
Abstract
BACKGROUND:
In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary artery (ULMCA) culprit lesion has been under-investigated. Therefore, we compared clinical characteristics and short- and medium-term outcomes of percutaneous and surgical revascularization in ACS.
METHODS AND RESULTS:
Of 31 886 patients enrolled in a multicenter, national, prospective registry study between October 2010 and December 2020, 246 (0.8%) had ULMCA as a culprit lesion and underwent percutaneous coronary intervention (PCI) alone (n=133, 54%) or coronary artery bypass grafting (CABG) alone (n=113, 46%). Patients undergoing PCI presented more frequently ongoing chest pain (68% versus 41%, p
CONCLUSION:
Percutaneous coronary intervention was the most common revascularization strategy in the ACS with ULMCA culprit lesion. PCI was preferred in unstable patients and presented a high angiographic success. CABG was often delayed and preferred in low-risk patients. At one-year follow-up, PCI and CABG conferred a similar prognosis. The two approaches appear complementary in this high risk cohort.
Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.
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Clinical profile and prognosis of young patients with ST-elevation myocardial infarction managed by the emergency-intervention Codi IAM network.
Rev Esp Cardiol (Engl Ed)2023 Mar;():. doi: S1885-5857(23)00079-8.
Umanzor Eduardo Flores, Guillén Pedro Cepas, Freixa Xavier, Regueiro Ander, Marcos Helena Tizón, Brugaletta Salvatore, Solé Albert Ariza, Calvo Margarita, Forado Ilana, Carrillo Xavier, Cárdenas Mérida, Rojas Sergio Giovanny, Muñoz Juan Francisco, Picart Joan García, Lidón Rosa María, Sabaté Manel, Masotti Mónica, Roqué Mercè,
Abstract
INTRODUCTION AND OBJECTIVES:
Data on the clinical profile and outcomes of younger patients with ST-elevation myocardial infarction (STEMI) is scarce. This study compared clinical characteristics and outcomes between patients aged 45 years and those aged ? 45 years with STEMI managed by the acute myocardial infarction code (AMI Code) network. Sex-based differences in the younger cohort were also analyzed.
METHODS:
This multicenter study collected individual data from the Catalonian AMI Code network. Between 2015 and 2020, we enrolled patients with an admission diagnosis of STEMI. Primary endpoints were all-cause mortality within 30 days, 1 year, and 2 years.
RESULTS:
Overall, 18 933 patients (23% female) were enrolled. Of them, 1403 participants (7.4%) were aged?
CONCLUSIONS:
Despite showing high-risk features on admission, young patients exhibit better outcomes than older patients. Differences in ischemia times and treatment were observed between men and women.
Copyright © 2023. Published by Elsevier España, S.L.U.
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Beyond Stage C: Considerations in the Management of Patients with Heart Failure Progression and Gaps in Evidence.
J Card Fail2023 Mar;():. doi: S1071-9164(23)00078-7.
Carroll Aubrie M, Farr Maryjane, Russell Stuart D, Schlendorf Kelly H, Truby Lauren K, Gilotra Nisha A, Vader Justin M, Patel Chetan B, DeVore Adam D,
Abstract
Despite treatment with contemporary medical therapies for chronic heart failure (HF), there has been an increase in the prevalence of patients progressing to more advanced disease. Patients progressing to and living at the interface of severe Stage C and Stage D HF are underrepresented in clinical trials, and there is a lack of high-quality evidence to guide clinical decision making. For patients with a severe HF phenotype, the medical therapies used for patients with a less advanced stage of illness are often no longer tolerated nor provide adequate clinical stability. The limited data on these patients highlights the need to increase formal research characterizing this high-risk population. This review summarizes existing clinical trial data on and incorporates our considerations for approaches to the medical management of patients advanced "beyond Stage C" HF.
Copyright © 2023. Published by Elsevier Inc.
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