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Arnold JH, Perl L, Assali A, Codner P, Greenberg G, Samara A, Porter A, Orvin K, Kornowski R, Vaknin Assa H. The Impact of Sex on Cardiogenic Shock Outcomes Following ST Elevation Myocardial Infarction. J Clin Med 2023; 12:6259. [PMID: 37834902 PMCID: PMC10573491 DOI: 10.3390/jcm12196259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/13/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) remains the leading cause of ST elevation myocardial infarction (STEMI)-related mortality. Contemporary studies have shown no sex-related differences in mortality. METHODS STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) were included based on a dedicated prospective STEMI database. We compared sex-specific differences in CS characteristics at baseline, during hospitalization, and in subsequent clinical outcomes. Endpoints included all-cause mortality and major adverse cardiac events (MACE). RESULTS Of 3202 consecutive STEMI patients, 210 (6.5%) had CS, of which 63 (30.0%) were women. Women were older than men (73.2 vs. 65.5% y, p < 0.01), and more had hypertension (68.3 vs. 52.8%, p = 0.019) and diabetes (38.7 vs. 24.8%, p = 0.047). Fewer were smokers (13.3 vs. 41.2%, p < 0.01), had previous PCI (9.1 vs. 22.3% p = 0.016), or required IABP (35.3 vs. 51.1% p = 0.027). Women had higher rates of mortality (53.2 vs. 35.3% in-hospital, p = 0.01; 61.3 vs. 41.9% at 1 month, p = 0.01; and 73.8 vs. 52.6% at 3 years, p = 0.05) and MACE (60.6 vs. 41.6% in-hospital, p = 0.032; 66.1 vs. 45.6% at 1 month, p = 0.007; and 62.9 vs. 80.3% at 3 years, p = 0.015). After multivariate adjustment, female sex remained an independent factor for death (HR-2.42 [95% CI 1.014-5.033], p = 0.042) and MACE (HR-1.91 [95% CI 1.217-3.031], p = 0.01). CONCLUSIONS CS complicating STEMI is associated with greater short- and long-term mortality and MACE in women. Sex-focused measures to improve diagnosis and treatment are mandatory for CS patients.
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Affiliation(s)
- Joshua H. Arnold
- Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Leor Perl
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Abid Assali
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
- Department of Cardiology, Meir Medical Center, Kfar-Saba 4428164, Israel
| | - Pablo Codner
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Gabriel Greenberg
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Abid Samara
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Avital Porter
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Katia Orvin
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
| | - Hana Vaknin Assa
- Department of Cardiology, Rabin Medical Center, Petach-Tikva 4941492, Israel; (L.P.)
- School of Medicine, Tel Aviv University, Tel-Aviv 6997801, Israel
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Lamastra R, Abbott DM, Degani A, Pellegrini C, Veronesi R, Pelenghi S, Dezza C, Gazzaniga G, Belliato M. Left atrium veno-arterial extra corporeal membrane oxygenation as temporary mechanical support for cardiogenic shock: A case report. World J Clin Cases 2023; 11:6531-6536. [PMID: 37900254 PMCID: PMC10600982 DOI: 10.12998/wjcc.v11.i27.6531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Veno-arterial extra corporeal membrane oxygenation (VA-ECMO) support is commonly complicated with left ventricle (LV) distension in patients with cardiogenic shock. We resolved this problem by transeptally converting VA-ECMO to left atrium veno-arterial (LAVA)-ECMO that functioned as a temporary paracorporeal left ventricular assist device to resolve LV distension. In our case LAVA-ECMO was also functioning as a bridge-to-transplant device, a technique that has been scarcely reported in the literature. CASE SUMMARY A 65 year-old man suffered from acute myocardial injury that required percutaneous stents. Less than two weeks later, noncompliance to antiplatelet therapy led to stent thrombosis, cardiogenic shock, and cardiac arrest. Femoro-femoral VA-ECMO support was started, and the patient underwent a second coronary angiography with re-stenting and intra-aortic balloon pump placement. The VA-ECMO support was complicated by left ventricular distension which we resolved via LAVA-ECMO. Unfortunately, episodes of bleeding and sepsis complicated the clinical picture and the patient passed away 27 d after initiating VA-ECMO. CONCLUSION This clinical case demonstrates that LAVA-ECMO is a viable strategy to unload the LV without another invasive percutaneous or surgical procedure. We also demonstrate that LAVA-ECMO can also be weaned to a left ventricular assist device system. A benefit of this technique is that the procedure is potentially reversible, should the patient require VA-ECMO support again. A transeptal LV venting approach like LAVA-ECMO may be indicated over ImpellaTM in cases where less LV unloading is required and where a restrictive myocardium could cause LV suctioning. Left ventricular over-distention is a well-known complication of peripheral VA-ECMO in cardiogenic shock and LAVA ECMO through transeptal cannulation offers a novel and safe approach for treating LV overloading, without the need of an additional percutaneous access.
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Affiliation(s)
- Rossana Lamastra
- Department of Surgical, Pediatric and Diagnostic Sciences, University of Pavia, Pavia 27100, PV, Italy
| | - David Michael Abbott
- Department of Surgical, Pediatric and Diagnostic Sciences, University of Pavia, Pavia 27100, PV, Italy
| | - Antonella Degani
- Department of Cardiothoracic Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, PV, Italy
| | - Carlo Pellegrini
- Clinical, Surgical, Diagnostic and Pediatric Sciences Department, University of Pavia, Italy - Department of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo Foundation, Pavia 27100, PV, Italy
| | - Roberto Veronesi
- SC-AR2 Anestesia e Terapia Intensiva Cardiotoracica Fondazione IRCCS Policlinico San Matteo, Pavia 27100, PV, Italy
| | - Stefano Pelenghi
- Department of Cardiac Surgery 1, IRCCS University Hospital Foundation "San Matteo", Pavia 27100, Italy
| | - Chiara Dezza
- SC-AR2 Anestesia e Terapia Intensiva Cardiotoracica Fondazione IRCCS Policlinico San Matteo, Pavia 27100, PV, Italy
| | - Giulia Gazzaniga
- Department of Surgical, Pediatric and Diagnostic Sciences, University of Pavia, Pavia 27100, PV, Italy
| | - Mirko Belliato
- SC-AR2 Anestesia e Terapia Intensiva Cardiotoracica Fondazione IRCCS Policlinico San Matteo, Pavia 27100, PV, Italy
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Burrell A, Kim J, Alliegro P, Romero L, Serpa Neto A, Mariajoseph F, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev 2023; 9:CD010381. [PMID: 37750499 PMCID: PMC10521169 DOI: 10.1002/14651858.cd010381.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) may provide benefit in certain populations of adults, including those with severe cardiac failure, severe respiratory failure, and cardiac arrest. However, it is also associated with serious short- and long-term complications, and there remains a lack of high-quality evidence to guide practice. Recently several large randomized controlled trials (RCTs) have been published, therefore, we undertook an update of our previous systematic review published in 2014. OBJECTIVES To evaluate whether venovenous (VV), venoarterial (VA), or ECMO cardiopulmonary resuscitation (ECPR) improve mortality compared to conventional cardiopulmonary support in critically ill adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was March 2022. The search was limited to English language only. SELECTION CRITERIA We included RCTs, quasi-RCTs, and cluster-RCTs that compared VV ECMO, VA ECMO or ECPR to conventional support in critically ill adults. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was 1. all-cause mortality at day 90 to one year. Our secondary outcomes were 2. length of hospital stay, 3. survival to discharge, 4. disability, 5. adverse outcomes/safety events, 6. health-related quality of life, 7. longer-term health status, and 8. cost-effectiveness. We used GRADE to assess certainty of evidence. MAIN RESULTS Five RCTs met our inclusion criteria, with four new studies being added to the original review (total 757 participants). Two studies were of VV ECMO (429 participants), one VA ECMO (41 participants), and two ECPR (285 participants). Four RCTs had a low risk of bias and one was unclear, and the overall certainty of the results (GRADE score) was moderate, reduced primarily due to indirectness of the study populations and interventions. ECMO was associated with a reduction in 90-day to one-year mortality compared to conventional treatment (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.70 to 0.92; P = 0.002, I2 = 11%). This finding remained stable after performing a sensitivity analysis by removing the single trial with an uncertain risk of bias. Subgroup analyses did not reveal a significant subgroup effect across VV, VA, or ECPR modes (P = 0.73). Four studies reported an increased risk of major hemorrhage with ECMO (RR 3.32, 95% CI 1.90 to 5.82; P < 0.001), while two studies reported no difference in favorable neurologic outcome (RR 2.83, 95% CI 0.36 to 22.42; P = 0.32). Other secondary outcomes were not consistently reported across the studies. AUTHORS' CONCLUSIONS In this updated systematic review, which included four additional RCTs, we found that ECMO was associated with a reduction in day-90 to one-year all-cause mortality, as well as three times increased risk of bleeding. However, the certainty of this result was only low to moderate, limited by a low number of small trials, clinical heterogeneity, and indirectness across studies.
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Affiliation(s)
- Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Jiwon Kim
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Patricia Alliegro
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care, Austin Hospital, Melbourne, Australia
| | - Frederick Mariajoseph
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Australia
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Pei G, Liu R, Wang L, He C, Fu C, Wei Q. Monocyte to high-density lipoprotein ratio is associated with mortality in patients with coronary artery diseases. BMC Cardiovasc Disord 2023; 23:451. [PMID: 37697241 PMCID: PMC10496218 DOI: 10.1186/s12872-023-03461-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/19/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Whether the monocyte to high-density lipoprotein ratio (MHR) is associated with the prognosis of coronary artery disease (CAD) is inconclusive. METHODS Patients with CAD were enrolled and their data were collected. Blood was sampled within 24 h after admission. Multivariate Cox regression analysis was performed to determine the relationship between the MHR and all-cause mortality as well as complications during hospitalization. RESULTS We included 5371 patients in our cohort study. Among them, 114 (2.12%) patients died in hospital. MHR was independently associated with all-cause mortality (hazard ratio [HR], 1.81; 95% confidence interval [CI] 1.35, 2.42), cardiovascular mortality (1.69; 1.17, 2.45) and non-cardiovascular mortality (2.04; 1.27, 3.28). This association was only observed in patients with hypertension (P for interaction = 0.003). Patients with higher MHR levels also have a higher risk of complications, including infection, pneumonia, electrolyte disturbance, gastrointestinal bleeding, multiple organ dysfunction syndrome, and disturbance of consciousness. The receiver operating characteristic (ROC) analysis showed that the MHR had higher prognostic values than monocytes and high-density lipoprotein. CONCLUSION MHR was an independent predictor of all-cause mortality and in-hospital complications in patients with CAD, especially in patients with hypertension.
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Affiliation(s)
- Gaiqin Pei
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Rui Liu
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Lu Wang
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Chengqi He
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China
| | - Chenying Fu
- West China Hospital, National Clinical Research Center for Geriatrics, Sichuan University, Chengdu, Sichuan, China.
- Aging and Geriatric Mechanism Laboratory, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Quan Wei
- Department of Rehabilitation Medicine and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, PR China.
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, Chengdu, Sichuan, China.
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Asher E, Karameh H, Nassar H, Yosefy C, Marmor D, Perel N, Taha L, Tabi M, Braver O, Shuvy M, Wiener-Well Y, Glikson M, Bruoha S. Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study. J Clin Med 2023; 12:5734. [PMID: 37685801 PMCID: PMC10488618 DOI: 10.3390/jcm12175734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/23/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Vasopressors are frequently utilized for blood pressure stabilization in patients with cardiogenic shock (CS), although with a questionable benefit. Obtaining central venous access is time consuming and may be associated with serious complications. Hence, we thought to evaluate whether the administration of vasopressors through a peripheral venous catheter (PVC) is a safe and effective alternative for the management of patients with CS presenting to the intensive cardiovascular care unit (ICCU). METHODS A prospective single-center study was conducted to compare the safety and outcomes of vasopressors administered via a PVC vs. a central venous catheter (CVC) in patients presenting with CS over a 12-month period. RESULTS A total of 1100 patients were included; of them, 139 (12.6%) required a vasopressor treatment due to shock, with 108 (78%) treated via a PVC and 31 (22%) treated via a CVC according to the discretion of the treating physician. The duration of the vasopressor administration was shorter in the PVC group compared with the CVC group (2.5 days vs. 4.2 days, respectively, p < 0.05). Phlebitis and the extravasation of vasopressors occurred at similar rates in the PVC and CVC groups (5.7% vs. 3.3%, respectively, p = 0.33; 0.9% vs. 3.3%, respectively, p = 0.17). Nevertheless, the bleeding rate was higher in the CVC group compared with the PVC group (3% vs. 0%, p = 0.03). CONCLUSIONS The administration of vasopressor infusions via PVC for the management of patients with CS is feasible and safe in patients with cardiogenic shock. Further studies are needed to establish this method of treatment.
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Affiliation(s)
- Elad Asher
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hani Karameh
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hamed Nassar
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Chaim Yosefy
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - David Marmor
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Nimrod Perel
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Louay Taha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Meir Tabi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Omri Braver
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - Mony Shuvy
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Yonit Wiener-Well
- Infectious Diseases Unit, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel;
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Sharon Bruoha
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
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Argenti G, Ishikawa G, Fadel CB. The Direct Effects of Norepinephrine Administration on Pressure Injuries in Intensive Care Patients: A Retrospective Cohort Study. Adv Skin Wound Care 2023; 36:1-12. [PMID: 37603319 DOI: 10.1097/asw.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To estimate the direct effects of norepinephrine administration on pressure injury (PI) incidence in intensive care patients. METHODS This is a secondary and exploratory analysis of a retrospective cohort study of intensive care patients discharged in 2017 to 2018. Observational cases only included patients who received primary PI preventive care during intensive care (N = 479). As a first-choice vasopressor drug, norepinephrine administration was approximated with days of norepinephrine. Linear path models were examined from norepinephrine administration to PI development. The identification of confounding variables and instrumental variables was grounded on directed acyclic graph theory. Direct effects were estimated with instrumental variables to overcome bias from unobserved variables. As models were re-specified with data analysis, the robustness of path identification was improved by requiring graph invariance with sample split. RESULTS Norepinephrine caused PI development from one stage to another after 4.0 to 6.3 days of administration in this cohort as a total effect (90% CI). The direct effect was estimated to advance the stage of PI at a rate of 0.140 per day of norepinephrine administered (standard error, 0.029; P < .001). The direct effect accounted for about 70% of the total effect on PI development. CONCLUSIONS Estimations with instrumental variables and structural equation modeling showed that norepinephrine administration directly and substantially affected hospital-acquired PI incidence in intensive care patients in this cohort.
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Affiliation(s)
- Graziela Argenti
- Graziela Argenti, MSc, RN, is Professor, Department of Nursing, Universidade Estadual de Ponta Grossa, Brazil. Gerson Ishikawa, DEng, is Associate Professor, Department of Production Engineering, Universidade Tecnologica Federal do Parana, Ponta Grossa. Also at Universidade Estadual de Ponta Grossa, Cristina Berger Fadel, DMD, is Associate Professor, Department of Dentistry. Acknowledgment: This research project was submitted and registered as CAAE 21591719.7.0000.0105 in PlataformaBrasil of Conselho Nacional de Saude and approved by the research ethics committee of Universidade Estadual de Ponta Grossa (resolution 3.604.604). The authors have disclosed no financial relationships related to this article. Submitted May 2, 2022; accepted in revised form December 1, 2022
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Abstract
Cardiogenic shock is characterized by tissue hypoxia caused by circulatory failure arising from inadequate cardiac output. In addition to treating the pathologic process causing impaired cardiac function, prompt hemodynamic support is essential to reduce the risk of developing multiorgan dysfunction and to preserve cellular metabolism. Pharmacologic therapy with the use of vasopressors and inotropes is a key component of this treatment strategy, improving perfusion by increasing cardiac output, altering systemic vascular resistance, or both, while allowing time and hemodynamic stability to treat the underlying disease process implicated in the development of cardiogenic shock. Despite the use of mechanical circulatory support recently garnering significant interest, pharmacologic hemodynamic support remains a cornerstone of cardiogenic shock management, with over 90% of patients receiving at least 1 vasoactive agent. This review aims to describe the pharmacology and hemodynamic effects of current pharmacotherapies and provide a practical approach to their use, while highlighting important future research directions.
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Affiliation(s)
- Jason E. Bloom
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
| | - William Chan
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - David M. Kaye
- Department of CardiologyAlfred HealthMelbourneAustralia
- Baker Heart and Diabetes InstituteMelbourneAustralia
| | - Dion Stub
- Department of CardiologyAlfred HealthMelbourneAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneAustralia
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De Angelis E, Bochaton T, Ammirati E, Tedeschi A, Polito MV, Pieroni M, Merlo M, Gentile P, Van De Heyning CM, Bekelaar T, Cipriani A, Camilli M, Sanna T, Marra MP, Cabassi A, Piepoli MF, Sinagra G, Mewton N, Bonnefoy-Cudraz E, Ravera A, Hayek A. Pheochromocytoma-induced cardiogenic shock: A multicentre analysis of clinical profiles, management and outcomes. Int J Cardiol 2023; 383:82-88. [PMID: 37164293 DOI: 10.1016/j.ijcard.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE There is still uncertainty about the management of patients with pheochromocytoma-induced cardiogenic shock (PICS). This study aims to investigate the clinical presentation, management, and outcome of patients with PICS. METHODS We collected, retrospectively, the data of 18 patients without previously known pheochromocytoma admitted to 8 European hospitals with a diagnosis of PICS. RESULTS Among the 18 patients with a median age of 50 years (Q1-Q3: 40-61), 50% were men. The main clinical features at presentation were pulmonary congestion (83%) and cyclic fluctuation of hypertension peaks and hypotension (72%). Echocardiography showed a median left ventricular ejection fraction (LVEF) of 25% (Q1-Q3: 15-33.5) with an atypical- Takotsubo (TTS) pattern in 50%. Inotropes/vasopressors were started in all patients and temporary mechanical circulatory support (t-MCS) was required in 11 (61%) patients. All patients underwent surgical removal of the pheochromocytoma; 4 patients (22%) were operated on while under t-MCS. The median LVEF was estimated at 55% at discharge. Only one patient required heart transplantation (5.5%), and all patients were alive at a median follow-up of 679 days. CONCLUSIONS PICS should be suspected in case of a CS with severe cyclic blood pressure fluctuation and rapid hemodynamic deterioration, associated with increased inflammatory markers or in case of TTS progressing to CS, particularly if an atypical TTS echocardiographic pattern is revealed. T-MCS should be considered in the most severe cases. The main challenge is to stabilize the patient, with medical therapy or with t-MCS, since it remains a reversible cause of CS with a low mortality rate.
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Affiliation(s)
- Elena De Angelis
- Department of Cardiology and Intensive Care Unit, "S. Anna e SS. Madonna della Neve" Boscotrecase Hospital, Local Health Authority Naples 3 South, Naples, Italy; Intensive Cardiological Care Division, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France.
| | - Thomas Bochaton
- Intensive Cardiological Care Division, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
| | - Enrico Ammirati
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Tedeschi
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Cardiology Division, Parma University, Parma University Hospital, Parma, Italy
| | - Maria Vincenza Polito
- Cardiology Division, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Maurizio Pieroni
- Cardiovascular Department, ASL8 Arezzo, "San Donato Hospital", Arezzo, Italy
| | - Marco Merlo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria "Giuliano Isontina" (ASUGI), University of Trieste, Trieste, Italy
| | - Piero Gentile
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Thalia Bekelaar
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Massimiliano Camilli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Martina Perazzolo Marra
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Aderville Cabassi
- Cardiorenal and Hypertension Research Unit, Physiopathology Unit, Clinica Medica Generale e Terapia Medica, Department of Medicine and Surgery (DIMEC), University of Parma, Parma, Italy
| | - Massimo F Piepoli
- Cardiology Department, Guglielmo da Saliceto Hospital of Piacenza, Piacenza, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria "Giuliano Isontina" (ASUGI), University of Trieste, Trieste, Italy
| | - Nathan Mewton
- Clinical Investigation Centre and Heart Failure Department, Hôpital Cardiovasculaire Louis Pradel, Inserm 1407, France
| | - Eric Bonnefoy-Cudraz
- Intensive Cardiological Care Division, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
| | - Amelia Ravera
- Intensive Cardiac Care Unit, Cardiology Division, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Ahmad Hayek
- Intensive Cardiological Care Division, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France; Interventional Department, Montreal heart Institute, Quebec, Canada
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Valerianova A, Mlcek M, Kittnar O, Grus T, Tejkl L, Lejsek V, Malik J. A large arteriovenous fistula steals a considerable part of systemic blood flow during veno-arterial extracorporeal circulation support in a porcine model. Front Physiol 2023; 14:1109524. [PMID: 37497434 PMCID: PMC10366375 DOI: 10.3389/fphys.2023.1109524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/30/2023] [Indexed: 07/28/2023] Open
Abstract
Background: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is one of the most frequently used mechanical circulatory support devices. Distribution of extracorporeal membrane oxygenation flow depends (similarly as the cardiac output distribution) on regional vascular resistance. Arteriovenous fistulas (AVFs), used frequently as hemodialysis access, represent a low-resistant circuit which steals part of the systemic perfusion. We tested the hypothesis that the presence of a large Arteriovenous fistulas significantly changes organ perfusion during a partial and a full Veno-arterial extracorporeal membrane oxygenation support. Methods: The protocol was performed on domestic female pigs held under general anesthesia. Cannulas for Veno-arterial extracorporeal membrane oxygenation were inserted into femoral artery and vein. The Arteriovenous fistulas was created using another two high-diameter extracorporeal membrane oxygenation cannulas inserted in the contralateral femoral artery and vein. Catheters, flow probes, flow wires and other sensors were placed for continuous monitoring of haemodynamics and organ perfusion. A stepwise increase in extracorporeal membrane oxygenation flow was considered under beating heart and ventricular fibrillation (VF) with closed and opened Arteriovenous fistulas. Results: Opening of a large Arteriovenous fistulas (blood flow ranging from 1.1 to 2.2 L/min) resulted in decrease of effective systemic blood flow by 17%-30% (p < 0.01 for all steps). This led to a significant decrease of carotid artery flow (ranging from 13% to 25% after Arteriovenous fistulas opening) following VF and under partial extracorporeal membrane oxygenation support. Cerebral tissue oxygenation measured by near infrared spectroscopy also decreased significantly in all steps. These changes occurred even with maintained perfusion pressure. Changes in coronary artery flow were driven by changes in the native cardiac output. Conclusion: A large arteriovenous fistula can completely counteract Veno-arterial extracorporeal membrane oxygenation support unless maximal extracorporeal membrane oxygenation flow is applied. Cerebral blood flow and oxygenation are mainly compromised by the effect of the Arteriovenous fistulas. These effects could influence brain function in patients with Arteriovenous fistulas on Veno-arterial extracorporeal membrane oxygenation.
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Affiliation(s)
- A. Valerianova
- Third Department of Internal Medicine, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - M. Mlcek
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - O. Kittnar
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - T. Grus
- Second Surgical Clinic—Cardiovascular Surgery, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
| | - L. Tejkl
- First Faculty of Medicine, Institute of Physiology, Charles University in Prague, Prague, Czechia
| | - V. Lejsek
- Third Department of Internal Medicine, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
| | - J. Malik
- Third Department of Internal Medicine, First Faculty of Medicine, General University Hospital in Prague, Charles University in Prague, Prague, Czechia
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Valente T, Bocchini G, Massimo C, Rea G, Lieto R, Guarino S, Muto E, Abu-Omar A, Scaglione M, Sica G. Multidetector CT Imaging Biomarkers as Predictors of Prognosis in Shock: Updates and Future Directions. Diagnostics (Basel) 2023; 13:2304. [PMID: 37443697 PMCID: PMC10341185 DOI: 10.3390/diagnostics13132304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
A severe mismatch between the supply and demand of oxygen is the common sequela of all types of shock, which present a mortality of up to 80%. Various organs play a protective role in shock and contribute to whole-body homeostasis. The ever-increasing number of multidetector CT examinations in severely ill and sometimes unstable patients leads to more frequently encountered findings leading to imminent death, together called "hypovolemic shock complex". Features on CT include dense opacification of the right heart and major systemic veins, venous layering of contrast material and blood, densely opacified parenchyma in the right hepatic lobe, decreased enhancement of the abdominal organ, a dense pulmonary artery, contrast pooling in dependent lungs, and contrast stasis in pulmonary veins. These findings are biomarkers and prognostic indicators of paramount importance which stratify risk and improve patient outcomes. In this review, we illustrate the various CT patterns in shock and review the spectrum and prognostic significance of thoraco-abdominal vascular and visceral alarming signs of impending death with the intention of increasing awareness among radiologists and radiographers to prepare for immediate resuscitation when required.
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Affiliation(s)
- Tullio Valente
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Giorgio Bocchini
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Candida Massimo
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Gaetano Rea
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Roberta Lieto
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Salvatore Guarino
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Emanuele Muto
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
| | - Ahmad Abu-Omar
- Department of Radiology, Vancouver General Hospital, 899 W 12th Avenue, Vancouver, BC V5Z 1M9, Canada
| | - Mariano Scaglione
- Department of Radiology, James Cook University Hospital, Middlesbrough TS4 3BW, UK
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Giacomo Sica
- Department of Radiology, Monaldi Hospital, Azienda dei Colli, 80131 Naples, Italy (G.S.)
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Kirigaya J, Iwahashi N, Terasaka K, Takeuchi I. Prevention and management of critical care complications in cardiogenic shock: a narrative review. J Intensive Care 2023; 11:31. [PMID: 37408036 PMCID: PMC10324237 DOI: 10.1186/s40560-023-00675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is a common cause of morbidity and mortality in cardiac intensive care units (CICUs), even in the contemporary era. MAIN TEXT Although mechanical circulatory supports have recently become widely available and used in transforming the management of CS, their routine use to improve outcomes has not been established. Transportation to a high-volume center, early reperfusion, tailored mechanical circulatory supports, regionalized systems of care with multidisciplinary CS teams, a dedicated CICU, and a systemic approach, including preventing noncardiogenic complications, are the key components of CS treatment strategies. CONCLUSIONS This narrative review aimed to discuss the challenges of preventing patients from developing CS-related complications and provide a comprehensive practical approach for its management.
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Affiliation(s)
- Jin Kirigaya
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kengo Terasaka
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Takeuchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
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Fishkin T, Isath A, Naami E, Aronow WS, Levine A, Gass A. Impella devices: a comprehensive review of their development, use, and impact on cardiogenic shock and high-risk percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2023; 21:613-620. [PMID: 37539790 DOI: 10.1080/14779072.2023.2244874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/02/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Impella devices have emerged as a critical tool for temporary mechanical circulatory support (TMCS) in the management of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (PCI). The purpose of this review is to examine the history of the different Impella devices, their hemodynamic profiles, and how the data supports their use. AREAS COVERED This review covers the development and specifications of the Impella 2.5, Impella CP, Impella 5.0/Left Direct (LD), Impella RP, and Impella 5.5 devices. This review also covers the clinical trials that illuminate the Impella devices' use in their appropriate clinical contexts. These studies examine the effectiveness of Impella devices and have begun to yield promising results, demonstrating improved survival rates when compared to the historically high mortality rates associated with CS. It is important to weigh the benefits of Impella devices in light of their contraindications. A literature search was conducted by searching the PubMed database for reviews, meta-analyses, and clinical trials pertinent to Impella devices. EXPERT OPINION Impella devices are a crucial tool for management of patients undergoing high-risk PCI and those with CS. There is evidence that early Impella implantation is beneficial in the treatment of patients presenting with CS. Further randomized controlled trials are needed to better elucidate the benefits of Impella devices in various clinical settings.
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Affiliation(s)
- Tzvi Fishkin
- Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Edmund Naami
- Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Alan Gass
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Matassini MV, Marini M, Angelozzi A, Angelini L, Shkoza M, Compagnucci P, Falanga U, Battistoni I, Pongetti G, Francioni M, Piva T, Mucaj A, Nicolini E, Maolo A, Di Eusanio M, Munch C, Dello Russo A, Perna G. Clinical outcomes and predictors of success with Impella weaning in cardiogenic shock: a single-center experience. Front Cardiovasc Med 2023; 10:1171956. [PMID: 37416919 PMCID: PMC10321515 DOI: 10.3389/fcvm.2023.1171956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Cardiogenic shock (CS) is a severe syndrome with poor prognosis. Short-term mechanical circulatory support with Impella devices has emerged as an increasingly therapeutic option, unloading the failing left ventricle (LV) and improving hemodynamic status of affected patients. Impella devices should be used for the shortest time necessary to allow LV recovery because of time-dependent device-related adverse events. The weaning from Impella, however, is mostly performed in the absence of established guidelines, mainly based on the experience of the individual centres. Methods The aim of this single center study was to retrospectively evaluate whether a multiparametrical assessment before and during Impella weaning could predict successful weaning. The primary study outcome was death occurring during Impella weaning and secondary endpoints included assessment of in-hospital outcomes. Results Of a total of 45 patients (median age, 60 [51-66] years, 73% male) treated with an Impella device, 37 patients underwent impella weaning/removal and 9 patients (20%) died after the weaning. Non-survivors patients after impella weaning more commonly had a previous history of known heart failure (p = 0.054) and an implanted ICD-CRT (p = 0.01), and were more frequently treated with continuous renal replacement therapy (p = 0.02). In univariable logistic regression analysis, lactates variation (%) during the first 12-24 h of weaning, lactate value after 24 h of weaning, left ventricular ejection fraction (LVEF) at the beginning of weaning, and inotropic score after 24 h from weaning beginning were associated with death. Stepwise multivariable logistic regression identified LVEF at the beginning of weaning and lactates variation (%) in the first 12-24 h from weaning beginning as the most accurate predictors of death after weaning. The ROC analysis indicated 80% accuracy (95% confidence interval = 64%-96%) using the two variables in combination to predict death after weaning from Impella. Conclusions This single-center experience on Impella weaning in CS showed that two easily accessible parameters as LVEF at the beginning of weaning and lactates variation (%) in the first 12-24 h from weaning begin were the most accurate predictors of death after weaning.
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Affiliation(s)
- M. V. Matassini
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - M. Marini
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - A. Angelozzi
- Unit of Cardiology and Cardiac Intensive Therapy, Cardiovascular Department, G. Mazzini Hospital, Teramo, Italy
| | - L. Angelini
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - M. Shkoza
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - P. Compagnucci
- Cardiology and Arrhythmology Clinic and Department of Biomedical Sciences and Public Health, University Hospital Ospedali Riuniti di Ancona and Marche Polytechnic University, Ancona, Italy
| | - U. Falanga
- Cardiology and Arrhythmology Clinic and Department of Biomedical Sciences and Public Health, University Hospital Ospedali Riuniti di Ancona and Marche Polytechnic University, Ancona, Italy
| | - I. Battistoni
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - G. Pongetti
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - M. Francioni
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - T. Piva
- Interventional Cardiology-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - A. Mucaj
- Interventional Cardiology-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - E. Nicolini
- Interventional Cardiology-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - A. Maolo
- Interventional Cardiology-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - M. Di Eusanio
- Cardiac Surgery Unit, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
| | - C. Munch
- Anaesthesia and Cardiac Surgery Intensive Care, Ospedali Riuniti di Ancona, Ancona, Italy
| | - A. Dello Russo
- Cardiology and Arrhythmology Clinic and Department of Biomedical Sciences and Public Health, University Hospital Ospedali Riuniti di Ancona and Marche Polytechnic University, Ancona, Italy
| | - G. Perna
- Cardiac Intensive Care Unit-Cardiology Division, Cardiovascular Department, Ospedali Riuniti di Ancona, Ancona, Italy
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Hu T, Huang R. Urine output for predicting in-hospital mortality of intensive care patients with cardiogenic shock. Heliyon 2023; 9:e16295. [PMID: 37274659 PMCID: PMC10238887 DOI: 10.1016/j.heliyon.2023.e16295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 06/06/2023] Open
Abstract
Background The role of urine output (UO) in the first 24 h of admission in the clinical management of cardiogenic shock (CS) patients has not been elucidated. Methods This study retrospectively analyzed intensive care CS patients in the MIMIC-IV database. Binomial logistic regression analysis was conducted to evaluate whether UO was an independent risk factor for in-hospital mortality in CS patients. The performance of UO in predicting mortality was evaluated by the receiver operating characteristic (ROC) curve and compared with the Oxford Acute Severity of Illness Score (OASIS). The clinical net benefit of UO in predicting mortality was determined using the decision curve analysis (DCA). Survival analysis was performed with Kaplan-Meier curves. Results After adjusting for confounding factors including diuretic use and acute kidney injury (AKI), UO remained an independent risk factor for in-hospital mortality in CS patients. The areas under the ROC curves (AUCs) of UO for predicting in-hospital mortality were 0.712 (UO, ml/day) and 0.701 (UO, ml/kg/h), which were comparable to OASIS (AUC = 0.695). In terms of clinical net benefit, UO was comparable to OASIS, with different degrees of benefit at different threshold probabilities. Survival analysis showed that the risk of in-hospital death in the low-UO (≤857 ml/day) group was 3.0143 times that of the high-UO (>857 ml/day) group. Conclusions UO in the first 24 h of admission is an independent risk factor for in-hospital mortality in intensive care CS patients and has moderate predictive value in predicting in-hospital mortality.
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Affiliation(s)
- Tianyang Hu
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rongzhong Huang
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Municipality Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
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Shou BL, Wilcox C, Florissi I, Kalra A, Caturegli G, Zhang LQ, Bush E, Kim B, Keller SP, Whitman GJR, Cho SM. Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury. Neurocrit Care 2023; 38:612-621. [PMID: 36167950 PMCID: PMC10040467 DOI: 10.1007/s12028-022-01607-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pulse pressure is a dynamic marker of cardiovascular function and is often impaired in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Pulsatile blood flow also serves as a regulator of vascular endothelium, and continuous-flow mechanical circulatory support can lead to endothelial dysfunction. We explored the impact of early low pulse pressure on occurrence of acute brain injury (ABI) in VA-ECMO. METHODS We conducted a retrospective analysis of adults with VA-ECMO at a tertiary care center between July 2016 and January 2021. Patients underwent standardized multimodal neuromonitoring throughout ECMO support. ABI included intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, cerebral edema, seizure, and brain death. Blood pressures were recorded every 15 min. Low pulse pressure was defined as a median pulse pressure < 20 mm Hg in the first 12 h of ECMO. Multivariable logistic regression was performed to investigate the association between pulse pressure and ABI. RESULTS We analyzed 5138 blood pressure measurements from 123 (median age 63; 63% male) VA-ECMO patients (54% peripheral; 46% central cannulation), of whom 41 (33%) experienced ABI. Individual ABIs were as follows: ischemic stroke (n = 18, 15%), hypoxic ischemic brain injury (n = 14, 11%), seizure (n = 8, 7%), intracranial hemorrhage (n = 7, 6%), cerebral edema (n = 7, 6%), and brain death (n = 2, 2%). Fifty-eight (47%) patients had low pulse pressure. In a multivariable model adjusting for preselected covariates, including cannulation strategy (central vs. peripheral), lactate on ECMO day 1, and left ventricle venting strategy, low pulse pressure was independently associated with ABI (adjusted odds ratio 2.57, 95% confidence interval 1.05-6.24). In a model with the same covariates, every 10-mm Hg decrease in pulse pressure was associated with 31% increased odds of ABI (95% confidence interval 1.01-1.68). In a sensitivity analysis model adjusting for systolic pressure, pulse pressure remained significantly associated with ABI. CONCLUSIONS Early low pulse pressure (< 20 mm Hg) was associated with ABI in VA-ECMO patients. Low pulse pressure may serve as a marker of ABI risk, which necessitates close neuromonitoring for early detection.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
| | - Christopher Wilcox
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Isabella Florissi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lucy Q Zhang
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Errol Bush
- Division of General Thoracic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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Bichali S, Bonnet M, Lampin ME, Baudelet JB, Reumaux H, Domanski O, Rakza T, Delarue A, Recher M, Soquet J, Dubos F, Leteurtre S, Houeijeh A, Godart F. Impact of time to diagnosis on the occurrence of cardiogenic shock in MIS-C post-COVID-19 infection. World J Pediatr 2023; 19:595-604. [PMID: 36607546 PMCID: PMC9817434 DOI: 10.1007/s12519-022-00681-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND In multisystem inflammatory syndrome in children (MIS-C), diagnostic delay could be associated with severity. This study aims to measure the time to diagnosis in MIS-C, assess its impact on the occurrence of cardiogenic shock, and specify its determinants. METHODS A single-center prospective cohort observational study was conducted between May 2020 and July 2022 at a tertiary care hospital. Children meeting the World Health Organization MIS-C criteria were included. A long time to diagnosis was defined as six days or more. Data on time to diagnosis were collected by two independent physicians. The primary outcome was the occurrence of cardiogenic shock. Logistic regression and receiver operating characteristic curve analysis were used for outcomes, and a Cox proportional hazards model was used for determinants. RESULTS Totally 60 children were assessed for inclusion, and 31 were finally analyzed [52% males, median age 8.8 (5.7-10.7) years]. The median time to diagnosis was 5.3 (4.2-6.2) days. In univariable analysis, age above the median, time to diagnosis, high C-reactive protein, and high N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with cardiogenic shock [odds ratio (OR) 6.13 (1.02-36.9), 2.79 (1.15-6.74), 2.08 (1.05-4.12), and 1.70 (1.04-2.78), respectively]. In multivariable analysis, time to diagnosis ≥ 6 days was associated with cardiogenic shock [adjusted OR (aOR) 21.2 (1.98-227)]. Time to diagnosis ≥ 6 days had a sensitivity of 89% and a specificity of 77% in predicting cardiogenic shock; the addition of age > 8 years and NT-proBNP at diagnosis ≥ 11,254 ng/L increased the specificity to 91%. Independent determinants of short time to diagnosis were age < 8.8 years [aHR 0.34 (0.13-0.88)], short distance to tertiary care hospital [aHR 0.27 (0.08-0.92)], and the late period of the COVID-19 pandemic [aHR 2.48 (1.05-5.85)]. CONCLUSIONS Time to diagnosis ≥ 6 days was independently associated with cardiogenic shock in MIS-C. Early diagnosis and treatment are crucial to avoid the use of inotropes and limit morbidity, especially in older children.
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Affiliation(s)
- Saïd Bichali
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France.
| | - Mathilde Bonnet
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
| | - Marie-Emilie Lampin
- Pediatric Intensive Care, Univ. Lille, CHU Lille, 59000, Lille, France
- ULR 2694 - Metrics: Évaluation des Technologies de Santé et des Pratiques Médicales, Univ. Lille, 59000, Lille, France
| | - Jean-Benoit Baudelet
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
| | - Héloïse Reumaux
- Pediatric Rhumatology, Univ. Lille, CHU Lille, 59000, Lille, France
| | - Olivia Domanski
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
| | - Thameur Rakza
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
| | - Alexandre Delarue
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
| | - Morgan Recher
- Pediatric Intensive Care, Univ. Lille, CHU Lille, 59000, Lille, France
- ULR 2694 - Metrics: Évaluation des Technologies de Santé et des Pratiques Médicales, Univ. Lille, 59000, Lille, France
| | - Jérôme Soquet
- Cardiac Surgery, Univ. Lille, CHU Lille, 59000, Lille, France
| | - Francois Dubos
- Pediatric Emergency, Univ. Lille, CHU Lille, 59000, Lille, France
| | - Stéphane Leteurtre
- Pediatric Intensive Care, Univ. Lille, CHU Lille, 59000, Lille, France
- ULR 2694 - Metrics: Évaluation des Technologies de Santé et des Pratiques Médicales, Univ. Lille, 59000, Lille, France
| | - Ali Houeijeh
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
| | - Francois Godart
- Pediatric Cardiology, Univ. Lille, CHU Lille, 2 Avenue Oscar Lambret, 59000, Lille, France
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Wei D, Sun Y, Chen R, Meng Y, Wu W. Age‑adjusted Charlson comorbidity index and in‑hospital mortality in critically ill patients with cardiogenic shock: A retrospective cohort study. Exp Ther Med 2023; 25:299. [PMID: 37229315 PMCID: PMC10203756 DOI: 10.3892/etm.2023.11998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/13/2023] [Indexed: 05/27/2023] Open
Abstract
Evidence regarding the relationship between age-adjusted Charlson comorbidity index (ACCI) and in-hospital mortality is limited. Therefore, the present study investigated whether there was an independent association between ACCI and in-hospital mortality in critically ill patients with cardiogenic shock (CS) after adjusting for other covariates (age, sex, history of disease, scoring system, in-hospital management, vital signs at presentation, laboratory findings and vasopressors). ACCI, calculated retrospectively after hospitalization between 2008 and 2019, was derived from intensive care unit (ICU) admissions at the Beth Israel Deaconess Medical Center (Boston, MA, USA). Patients with CS were classified into two categories based on predefined ACCI scores (low, <8; high, ≥8). Based on baseline ACCI, the risk of in-hospital mortality in patients with CS was calculated using a multivariate Cox proportional risk model, and the threshold effect was calculated using a two-piece linear regression model. The in-hospital mortality rate was ~1.5 times greater in the ACCI high group compared with that in the ACCI low group [hazard ratio (HR)=1.45; 95% confidence interval (CI), 1.14-1.86]. Additional analysis showed that ACCI had a curvilinear association with in-hospital mortality risk in patients with CS, with a saturation effect predicted at 4.5. When ACCI was >4.5, the risk of in-hospital CS death increased significantly with increasing ACCI (HR=1.122; 95% CI, 1.054-1.194). Overall, ACCI was an independent predictor of in-hospital mortality in ICU patients with CS. A non-linear relationship was revealed between ACCI and in-hospital mortality, where in-hospital mortality increased significantly when ACCI was >4.5.
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Affiliation(s)
- Dongmei Wei
- Department of Cardiovascular Medicine, Liuzhou Traditional Chinese Medical Hospital, Liuzhou, Guangxi Zhuang Autonomous Region 545001, P.R. China
- Department of Cardiovascular Medicine, Guangzhou University of Chinese Medicine First Affiliated Hospital, Guangzhou, Guangdong 510405, P.R. China
| | - Yang Sun
- Department of Cardiovascular Medicine, Guangxi University of Chinese Medicine, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Rongtao Chen
- Department of Cardiovascular Medicine, Guangxi University of Chinese Medicine, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Yuanting Meng
- Department of Cardiovascular Medicine, Guangxi University of Chinese Medicine, Nanning, Guangxi Zhuang Autonomous Region 530000, P.R. China
| | - Wei Wu
- Department of Cardiovascular Medicine, Guangzhou University of Chinese Medicine First Affiliated Hospital, Guangzhou, Guangdong 510405, P.R. China
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Farahmand M, Bodwell E, D'Souza GA, Herbertson LH, Scully CG. Mock circulatory loop generated database for dynamic characterization of pressure-based cardiac output monitoring systems. Comput Biol Med 2023; 160:106979. [PMID: 37167657 DOI: 10.1016/j.compbiomed.2023.106979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/30/2023] [Accepted: 04/23/2023] [Indexed: 05/13/2023]
Abstract
Pulse contour cardiac output monitoring systems allow real-time and continuous estimation of hemodynamic variables such as cardiac output (CO) and stroke volume variation (SVV) by analysis of arterial blood pressure waveforms. However, evaluating the performance of CO monitoring systems to measure the small variations in these variables sometimes used to guide fluid therapy is a challenge due to limitations in clinical reference methods. We developed a non-clinical database as a tool for assessing the dynamic attributes of pressure-based CO monitoring systems, including CO response time and CO and SVV resolutions. We developed a mock circulation loop (MCL) that can simulate rapid changes in different parameters, such as CO and SVV. The MCL was configured to simulate three different states (normovolemic, cardiogenic shock, and hyperdynamic) representing a range of flow and pressure conditions. For each state, we simulated stepwise changes in the MCL flow and collected datasets for characterizing pressure-based CO systems. Nine datasets were generated that contain hours of peripheral pressure, central flow and pressure waveforms. The MCL-generated database is provided open access as a tool for evaluating dynamic characteristics of pressure-based CO algorithms and systems in detecting variations in CO and SVV indices. In an example application of the database, a CO response time of 10 s, CO and SVV resolutions with lower and upper limits of (-9.1%, 8.4%) and (-5.0%, 3.8%), respectively, were determined for a pressure-based CO benchtop system. This tool will support a more comprehensive assessment of pressure-based CO monitoring systems and algorithms.
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Affiliation(s)
- Masoud Farahmand
- Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, U.S. Food and Drug Administration, Silver Spring, MD, USA.
| | | | - Gavin A D'Souza
- Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Luke H Herbertson
- Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Christopher G Scully
- Center for Devices and Radiological Health, Office of Science and Engineering Laboratories, U.S. Food and Drug Administration, Silver Spring, MD, USA
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Kanagarajan D, Heinsar S, Gandini L, Suen JY, Dau VT, Pauls J, Fraser JF. Preclinical Studies on Pulsatile Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review. ASAIO J 2023; 69:e167-e180. [PMID: 36976324 DOI: 10.1097/mat.0000000000001922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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.
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Affiliation(s)
- Dhayananth Kanagarajan
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Queensland, Australia
| | - Silver Heinsar
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Lucia Gandini
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Jacky Y Suen
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Van Thanh Dau
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jo Pauls
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Queensland, Australia
| | - John F Fraser
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Gupta B, Singh Y, Bagaria D, Nagarajappa A. Comprehensive Management of the Patient With Traumatic Cardiac Injury. Anesth Analg 2023; 136:877-893. [PMID: 37058724 DOI: 10.1213/ane.0000000000006380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.
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Affiliation(s)
- Babita Gupta
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Yudhyavir Singh
- From the Department of Anaesthesiology, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Bagaria
- Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Abhishek Nagarajappa
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Gilliot S, Henry H, Carta N, Genay S, Barthélémy C, Décaudin B, Odou P. Long-term stability of 10 mg/mL dobutamine injectable solutions in 5% dextrose and normal saline solution stored in polypropylene syringes and cyclic-oleofin-copolymer vials. Eur J Hosp Pharm 2023; 30:153-159. [PMID: 34011556 PMCID: PMC10176992 DOI: 10.1136/ejhpharm-2021-002748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Dobutamine is an inotropic agent given to patients with low cardiac output or undergoing cardiac surgery in intensive care units. Routine clinical care protocols recommend a target dilution concentration of 10 mg/mL dobutamine from the 250 mg/20 mL commercial solution.This study aimed to assess the 1-year stability of ready-to-use 10 mg/mL diluted dobutamine solutions. Two types of 50 mL conditioning, polypropylene (PP) syringes or cyclic-oleofin-copolymer (COC) vials and two diluents (5% dextrose (D5W) and normal saline (NS)) were tested. METHODS Reversed-phase liquid chromatography coupled with an ultraviolet detection stability-indicating method was developed for dobutamine and validated according to selectivity, linearity, sensitivity, accuracy and precision. Chemical stability was considered to have been maintained if the measured concentrations were >90% of the initial concentration with no colour change. Physical stability was assessed through sterility tests, pH and osmolality monitoring, and subvisible particle counting. Containers were stored at -20±5°C, +5±3°C and +25±2°C with 60%±5% relative humidity in a dark, closed environment. RESULTS According to this study, the physicochemical stability of 10 mg/mL dobutamine solutions prepared with D5W or NS is constant throughout a 365-day period when stored in COC vials, at all the aforementioned temperatures, whereas solutions in PP syringes required a refrigerated temperature and should not be administered after 21 days or 3 months when prepared with D5W or NS, respectively, or after 1 month at ambient temperature whatever the diluent. CONCLUSION Our results argue in favour of adopting the compounding of ready-to-use 10 mg/mL dobutamine solutions in COC vials in centralised intravenous additive services.
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Affiliation(s)
- Sixtine Gilliot
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Univ. Lille, CHU Lille, Lille, France
| | - Héloïse Henry
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Univ. Lille, CHU Lille, Lille, France
| | - Natacha Carta
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Univ. Lille, CHU Lille, Lille, France
| | - Stéphanie Genay
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Univ. Lille, CHU Lille, Lille, France
- Institut of Pharmacy, CHRU Lille Pôle Spécialités Médicochirurgicales, Lille, France
| | - Christine Barthélémy
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Univ. Lille, CHU Lille, Lille, France
| | - Bertrand Décaudin
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Univ. Lille, CHU Lille, Lille, France
- Institut of Pharmacy, CHRU Lille Pôle Spécialités Médicochirurgicales, Lille, France
| | - Pascal Odou
- ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Univ. Lille, CHU Lille, Lille, France
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Hamzaoui O, Boissier F. Hemodynamic monitoring in cardiogenic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:104-113. [PMID: 37188114 PMCID: PMC10175734 DOI: 10.1016/j.jointm.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a life-threatening condition characterized by acute end-organ hypoperfusion due to inadequate cardiac output that can result in multiorgan failure, which may lead to death. The diminished cardiac output in CS leads to systemic hypoperfusion and maladaptive cycles of ischemia, inflammation, vasoconstriction, and volume overload. Obviously, the optimal management of CS needs to be readjusted in view of the predominant dysfunction, which may be guided by hemodynamic monitoring. Hemodynamic monitoring enables (1) characterization of the type of cardiac dysfunction and the degree of its severity, (2) very early detection of associated vasoplegia, (3) detection and monitoring of organ dysfunction and tissue oxygenation, and (4) guidance of the introduction and optimization of inotropes and vasopressors as well as the timing of mechanical support. It is now well documented that early recognition, classification, and precise phenotyping via early hemodynamic monitoring (e.g., echocardiography, invasive arterial pressure, and the evaluation of organ dysfunction and parameters derived from central venous catheterization) improve patient outcomes. In more severe disease, advanced hemodynamic monitoring with pulmonary artery catheterization and the use of transpulmonary thermodilution devices is useful to facilitate the right timing of the indication, weaning from mechanical cardiac support, and guidance on inotropic treatments, thus helping to reduce mortality. In this review, we detail the different parameters relevant to each monitoring approach and the way they can be used to support optimal management of these patients.
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Affiliation(s)
- Olfa Hamzaoui
- Service de Médecine Intensive Réanimation, Hôpital Robert Debré, Université de Reims, Reims 51092, France
- Unité HERVI, Hémostase et Remodelage Vasculaire Post-Ischémie, EA 3801, Reims 51092, France
| | - Florence Boissier
- Médecine Intensive Réanimation, Hôpital Universitaire de Poitiers, Poitiers 90577, France
- INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers 90577, France
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Samir A, Almahjori M, Zarif B, Elshinawi M, Yehia H, Elhafy M, Shehata A, Farrag A. Characterization of features and outcomes of young patients (< 45 years) presenting with ST-segment elevation myocardial infarction. Egypt Heart J 2023; 75:32. [PMID: 37097520 PMCID: PMC10127970 DOI: 10.1186/s43044-023-00357-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/14/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Coronary artery disease (CAD) is the commonest cause of death worldwide. ST-segment elevation myocardial infarction (STEMI) and its consequences can be devastating particularly at younger age for a bigger impact on the patient's psychology and ability to work. Little is known about the differential features and outcomes of young STEMI patients in Egypt. This study characterized young STEMI patients (≤ 45 years) compared to patients > 45 years and evaluated 1-year outcomes. RESULTS A total of 492 eligible STEMI patients who presented to the National Heart Institute and Cairo University Hospitals were recruited. Young STEMI patients (< 45 years old) represented 20% of all STEMI comers. Male gender was predominant in both groups, yet with a significantly higher proportion in the younger compared to older patients (87% vs. 73%, p = 0.004). Compared to older patients, young STEMI patients had characteristically higher rates of smoking (72.4% vs. 49.7%, p < 0.001) and family history (13.3% vs. 4.8%, p = 0.002), while significantly lower rate of other conventional CAD risk factors as diabetes, hypertension, and dyslipidemia (20.4% vs. 44.7%, 20.4% vs. 44.9% and 12.7% vs. 21.8%, respectively, p < 0.05 for all). Follow-up was continued for at least 12 months after the index event. Younger STEMI patients had fewer major adverse cardiovascular events and fewer heart failure hospitalizations compared to the older controls (10.2 vs. 23.9% and 18.4% vs. 34.8%, respectively, p < 0.005 for both), however, 1-year mortality was similar (3.1% vs. 4.1%, p = 0.64). CONCLUSIONS Younger STEMI patients (≤ 45 years) show peculiar characteristics, with significantly higher rates of smoking and family history of premature CAD, while less prevalence of other conventional CAD risk factors. Overall MACE occurred less in younger STEMI patients; however, the mortality rate was similar to the older controls.
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Affiliation(s)
- Ahmad Samir
- Faculty of Medicine, Cairo University, Cairo, Egypt.
| | | | | | | | - Hesham Yehia
- Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | - Azza Farrag
- Faculty of Medicine, Cairo University, Cairo, Egypt
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74
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Lukhna K, Hausenloy DJ, Ali AS, Bajaber A, Calver A, Mutyaba A, Mohamed AA, Kiggundu B, Chishala C, Variava E, Elmakki EA, Ogola E, Hamid E, Okello E, Gaafar I, Mwazo K, Makotoko M, Naidoo M, Abdelhameed ME, Badri M, van der Schyff N, Abozaid O, Xafis P, Giesz S, Gould T, Welgemoed W, Walker M, Ntsekhe M, Yellon DM. Remote Ischaemic Conditioning in STEMI Patients in Sub-Saharan AFRICA: Rationale and Study Design for the RIC-AFRICA Trial. Cardiovasc Drugs Ther 2023; 37:299-305. [PMID: 34739648 PMCID: PMC8569288 DOI: 10.1007/s10557-021-07283-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Despite evidence of myocardial infarct size reduction in animal studies, remote ischaemic conditioning (RIC) failed to improve clinical outcomes in the large CONDI-2/ERIC-PPCI trial. Potential reasons include that the predominantly low-risk study participants all received timely optimal reperfusion therapy by primary percutaneous coronary intervention (PPCI). Whether RIC can improve clinical outcomes in higher-risk STEMI patients in environments with poor access to early reperfusion or PPCI will be investigated in the RIC-AFRICA trial. METHODS The RIC-AFRICA study is a sub-Saharan African multi-centre, randomized, double-blind, sham-controlled clinical trial designed to test the impact of RIC on the composite endpoint of 30-day mortality and heart failure in 1200 adult STEMI patients without access to PPCI. Randomized participants will be stratified by whether or not they receive thrombolytic therapy within 12 h or arrive outside the thrombolytic window (12-24 h). Participants will receive either RIC (four 5-min cycles of inflation [20 mmHg above systolic blood pressure] and deflation of an automated blood pressure cuff placed on the upper arm) or sham control (similar protocol but with low-pressure inflation of 20 mmHg and deflation) within 1 h of thrombolysis and applied daily for the next 2 days. STEMI patients arriving greater than 24 h after chest pain but within 72 h will be recruited to participate in a concurrently running independent observational arm. CONCLUSION The RIC-AFRICA trial will determine whether RIC can reduce rates of death and heart failure in higher-risk sub-optimally reperfused STEMI patients, thereby providing a low-cost, non-invasive therapy for improving health outcomes.
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Affiliation(s)
- Kishal Lukhna
- Division of Cardiology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, London, UK
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
| | | | | | | | - Arthur Mutyaba
- Division of Cardiology, Charlotte Maxeke Johannesburg Academic Hospital and University of Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Awad Abdalla Mohamed
- Al Shaab Teaching Hospital, Khartoum, Sudan
- Royal Care International Hospital, Khartoum, Sudan
| | | | - Chishala Chishala
- Division of Cardiology, Greys Hospital and University of KwaZulu Natal, Pietermaritzburg, South Africa
| | | | | | | | | | | | - Isam Gaafar
- Omdurman Accident and Emergency Hospital, Khartoum, Sudan
| | | | - Makoali Makotoko
- Division of Cardiology, Universitas Academic Hospital, Bloemfontein, South Africa
| | - Mergan Naidoo
- Division of Family Medicine, Wentworth Hospital, University of KwaZulu Natal, Durban, South Africa
| | | | - Motasim Badri
- Department of Epidemiology and Biostatistics, King Saud Bin Abdulaziz University for Health Sciences, University of Riyadh, Riyadh, Saudi Arabia
| | | | | | - Paul Xafis
- Victoria Hospital, University of Cape Town, Cape Town, South Africa
| | - Sara Giesz
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Trevor Gould
- Department of Medicine, George Hospital, George, South Africa
| | - Waldo Welgemoed
- Department of Medicine, George Hospital, George, South Africa
| | - Malcolm Walker
- The Hatter Cardiovascular Institute, University College London, London, UK
| | - Mpiko Ntsekhe
- Division of Cardiology, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, UK.
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Polyzogopoulou E, Bezati S, Karamasis G, Boultadakis A, Parissis J. Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done. J Clin Med 2023; 12:2643. [PMID: 37048727 PMCID: PMC10095596 DOI: 10.3390/jcm12072643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Cardiogenic shock is a complex syndrome manifesting with distinct phenotypes depending on the severity of the primary cardiac insult and the underlying status. As long as therapeutic interventions fail to divert its unopposed rapid evolution, poor outcomes will continue challenging health care systems. Thus, early recognition in the emergency setting is a priority, in order to avoid delays in appropriate management and to ensure immediate initial stabilization. Since advanced therapeutic strategies and specialized shock centers may provide beneficial support, it seems that directing patients towards the recently described shock network may improve survival rates. A multidisciplinary approach strategy commands the interconnections between the strategic role of the ED in affiliation with cardiac shock centers. This review outlines critical features of early recognition and initial therapeutic management, as well as the utility of diagnostic tools and risk stratification models regarding the facilitation of patient trajectories through the shock network. Further, it proposes the implementation of precise criteria for shock team activation and the establishment of definite exclusion criteria for streaming the right patient to the right place at the right time.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sofia Bezati
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Grigoris Karamasis
- Second Department of Cardiology, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
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Abu Ghosh Z, Amir O, Carasso S, Planer D, Alcalai R, Golomb M, Dagan G, Kalmanovich E, Blatt A, Elbaz-Greener G. Outcomes of Acute Coronary Syndrome Patients Who Presented with Cardiogenic Shock versus Patients Who Developed Cardiogenic Shock during Hospitalization. J Clin Med 2023; 12:2603. [PMID: 37048686 PMCID: PMC10095064 DOI: 10.3390/jcm12072603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Cardiogenic shock (CS) continues to be a severe and fatal complication of acute coronary syndrome (ACS). CS patients have a high mortality rate despite significant progress in primary reperfusion, the management of heart failure and the expansion of mechanical circulatory support strategies. The present study addressed the clinical characteristics, management, and outcomes of ACS patients complicated with CS. Methods: We performed an observational study, using the 2000-2013 Acute Coronary Syndrome Israeli Surveys (ACSIS) database and identified hospitalizations of ACS patients complicated with CS. Patients' demographics and clinical characteristics, complications and outcomes were evaluated. We assessed the outcomes of ACS patients with CS at arrival (on the day of admission) compared with ACS patients who arrived without CS and developed CS during hospitalization. Results: The cohort included 13,434 patients with ACS diagnoses during the study period. Of these, 4.2% were complicated with CS; 224 patients were admitted with both ACS and CS; while 341 ACS patients developed CS only during the hospitalization period. The latter patients had significantly higher rates of MACEs compared with the group of ACS patients who presented with CS at arrival (73% vs. 51%; p < 0.0001). Similarly, the rates of in-hospital mortality (55% vs. 36%; p < 0.0001), 30-day mortality (64% vs. 50%; p = 0.0013) and 1-year mortality (73% vs. 59%; p = 0.0016) were higher in ACS patients who developed CS during hospitalization vs. ACS patients with CS at admission. There was a significant decrease in 1-year mortality trends during the 13 years of this study presented in ACS patients from both groups. Conclusions: Patients who developed CS during hospitalization had higher mortality and MACE rates compared with those who presented with CS at arrival. Further studies should focus on this subgroup of high-risk patients.
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Affiliation(s)
- Zahi Abu Ghosh
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 5290002, Israel
| | - Shemy Carasso
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 5290002, Israel
- The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - David Planer
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Ronny Alcalai
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Mordechai Golomb
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Gil Dagan
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
| | - Eran Kalmanovich
- Department of Cardiology, Shamir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo 6997801, Israel
| | - Alex Blatt
- Kaplan Heart Center, Hebrew University, Jerusalem 9190501, Israel
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center, The Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9190501, Israel
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78
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Glazier MM, Kaki A. Treatment of Cardiogenic Shock and Refractory Ventricular Fibrillation: Pulling Out All the Stops. Int J Angiol 2023. [DOI: 10.1055/s-0043-1764461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
AbstractWe report the case of a 62-year-old woman who presented with an acute inferior wall myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation. Following prolonged resuscitation in the emergency room, she was transferred to the cardiac catheterization laboratory where, as a first step, mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (ECMO) was established. Next, a right heart catheterization study was performed, followed by coronary angiography and angioplasty of the infarct-related artery. Promptly on transfer to the intensive care unit, a hypothermia protocol was initiated. By postprocedure day 1, the patient's ventricular fibrillation had resolved, mean arterial pressure was >65 mm Hg, and pulmonary artery diastolic pressure was 10 mm Hg. Echocardiography demonstrated complete recovery of left ventricular systolic function. Lactate levels had fallen from 11.0 mmol/L (pre-ECMO) to 1.2 mmol/L. The patient was successfully weaned off pressor and ECMO support within 24 hours of the percutaneous coronary intervention procedure. She was extubated on postprocedure day 2 and discharged home on day 6. At 26-month follow-up, she remains well, angina free, neurologically intact, and without evidence of heart failure. The treatment algorithm used in this case should be considered favorably in the management of patients presenting with acute myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation.
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Affiliation(s)
| | - Amir Kaki
- Division of Cardiology, St John University Hospital, Detroit, Michigan
- Department of Medicine, Wayne State University, Detroit, Michigan
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Dagher O, Noly PE, Ben Ali W, Bouabdallaoui N, Geicu L, Lamanna R, Malhi P, Romero E, Ducharme A, Demers P, Lamarche Y. Extracorporeal membrane oxygenation and microaxial left ventricular assist device in cardiogenic shock: Choosing the right mechanical circulatory support to improve outcomes. JTCVS OPEN 2023; 13:200-213. [PMID: 37063130 PMCID: PMC10091281 DOI: 10.1016/j.xjon.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/11/2022] [Accepted: 12/05/2022] [Indexed: 04/18/2023]
Abstract
Objective To evaluate the outcomes of patients supported with Impella (CP/5.0) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock according to shock phenotype. The primary end point was 30-day survival. Methods A retrospective study of patients supported with Impella (CP/5.0) or VA-ECMO between 2010 and 2020 was performed. Patients were grouped according to 1 of 2 shock phenotypes: isolated left ventricular (LV) dysfunction versus biventricular dysfunction or multiple organ failure (MOF). The local practice favors Impella for isolated LV dysfunction and VA-ECMO for biventricular dysfunction or MOF. Results Among the 75 patients included, 17 (23%) had isolated LV dysfunction. Patients with biventricular dysfunction or MOF had a greater median lactate level compared with those with isolated LV dysfunction (7.9 [2.9-11.8] vs 3.8 [1.1-5.8] mmol/L, respectively). Among patients with isolated LV dysfunction, 30-day survival was 46% for the Impella group (n = 13) and 75% for VA-ECMO (n = 4). Among patients with biventricular dysfunction or MOF, 30-day survival was 9% for the Impella group (n = 11) and 28% for VA-ECMO (n = 47). Patients supported with Impella 5.0 had better 30-day survival compared with those supported with Impella CP, for both shock phenotypes (83% vs 14% and 14% vs 0%, respectively). Conclusions In this small cohort, patients supported with Impella for isolated LV dysfunction and VA-ECMO for biventricular dysfunction or MOF had acceptable survival at 30 days. Patients with biventricular dysfunction or MOF who were supported by Impella had the lowest survival rates. Patients with isolated LV dysfunction who were supported with VA-ECMO had good 30-day survival.
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Affiliation(s)
- Olina Dagher
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | | | - Walid Ben Ali
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Nadia Bouabdallaoui
- Université de Montréal and Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Lucian Geicu
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Roxanne Lamanna
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Pavan Malhi
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Elizabeth Romero
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Anique Ducharme
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
- Université de Montréal and Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Philippe Demers
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
- Address for reprints: Yoan Lamarche, MD, MSc, 5000 rue Bélanger Est, Montréal, Quebec, H1T 1C8, Canada.
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Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock. Anesthesiol Clin 2023; 41:1-25. [PMID: 36871993 DOI: 10.1016/j.anclin.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.
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81
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Pathophysiology-Based Management of Acute Heart Failure. Clin Pract 2023; 13:206-218. [PMID: 36826161 PMCID: PMC9955619 DOI: 10.3390/clinpract13010019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/22/2023] [Accepted: 01/29/2023] [Indexed: 02/01/2023] Open
Abstract
Even though acute heart failure (AHF) is one of the most common admission diagnoses globally, its pathogenesis is poorly understood, and there are few effective treatments available. Despite an heterogenous onset, congestion is the leading contributor to hospitalization, making it a crucial therapeutic target. Complete decongestion, nevertheless, may be hard to achieve, especially in patients with reduced end organ perfusion. In order to promote a personalised pathophysiological-based therapy for patients with AHF, we will address in this review the pathophysiological principles that underlie the clinical symptoms of AHF as well as examine how to assess them in clinical practice, suggesting that gaining a deeper understanding of pathophysiology might result in significant improvements in HF therapy.
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83
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Management of Cardiogenic Shock Unrelated to Acute Myocardial Infarction. Can J Cardiol 2023; 39:406-419. [PMID: 36731605 DOI: 10.1016/j.cjca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/01/2023] Open
Abstract
Cardiogenic shock is an extreme manifestation of acute decompensated heart failure. Cardiogenic shock is often caused by-and has traditionally been studied in the setting of-acute myocardial infarction (AMI CS); however, there is increasing incidence and recognition of cardiogenic shock not associated with acute myocardial infarction (non-AMI CS) as a distinct entity. Despite decades of study and technologic advancements, cardiogenic shock mortality remains as high as 50%, regardless of etiology. New approaches to shock phenotyping and classification have emerged, with a focus on appropriately matching patient physiology to a growing list of available interventions. Further study is needed to determine whether these efforts will lead to more nuanced use of mechanical circulatory support and improved patient outcomes, especially in non-AMI CS. In the meantime, models of care incorporating multidisciplinary decision making, such as shock teams, may improve patient selection and outcomes.
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84
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Cherbi M, Roubille F, Lamblin N, Bonello L, Leurent G, Levy B, Elbaz M, Champion S, Lim P, Schneider F, Cariou A, Khachab H, Bourenne J, Seronde MF, Schurtz G, Harbaoui B, Vanzetto G, Quentin C, Delabranche X, Aissaoui N, Combaret N, Tomasevic D, Marchandot B, Lattuca B, Henry P, Gerbaud E, Bonnefoy E, Puymirat E, Maury P, Delmas C. One-year outcomes in cardiogenic shock triggered by ventricular arrhythmia: An analysis of the FRENSHOCK multicenter prospective registry. Front Cardiovasc Med 2023; 10:1092904. [PMID: 36776263 PMCID: PMC9909601 DOI: 10.3389/fcvm.2023.1092904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
Background Cardiogenic shock (CS) is a life-threatening condition carrying poor prognosis, potentially triggered by ventricular arrhythmia (VA). Whether the occurrence of VA as trigger of CS worsens the prognosis compared to non-VA triggers remains unclear. The aim of this study was to evaluate 1-year outcomes [mortality, heart transplantation, ventricular assist devices (VAD)] between VA-triggered and non-VA-triggered CS. Methods FRENSHOCK is a prospective multicenter registry including 772 CS patients from 49 centers. One to three triggers can be identified in the registry (ischemic, mechanical complications, ventricular/supraventricular arrhythmia, bradycardia, iatrogenesis, infection, non-compliance). Baseline characteristics, management and 1-year outcomes were analyzed according to the VA-trigger in the CS population. Results Within 769 CS patients included, 94 were VA-triggered (12.2%) and were compared to others. At 1 year, although there was no mortality difference [42.6 vs. 45.3%, HR 0.94 (0.67-1.30), p = 0.7], VA-triggered CS resulted in more heart transplantations and VAD (17 vs. 9%, p = 0.02). Into VA-triggered CS group, though there was no 1-year mortality difference between ischemic and non-ischemic cardiomyopathies [42.5 vs. 42.6%, HR 0.97 (0.52-1.81), p = 0.92], non-ischemic cardiomyopathy led to more heart transplantations and VAD (25.9 vs. 5%, p = 0.02). Conclusion VA-triggered CS did not show higher mortality compared to other triggers but resulted in more heart transplantation and VAD at 1 year, especially in non-ischemic cardiomyopathy, suggesting the need for earlier evaluation by advanced heart failure specialized team for a possible indication of mechanical circulatory support or heart transplantation. Clinical trial registration https://clinicaltrials.gov, identifier NCT02703038.
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Affiliation(s)
- Miloud Cherbi
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | - François Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, INI-CRT, CHU de Montpellier, Montpellier, France
| | - Nicolas Lamblin
- Department of Cardiology, Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, Lille, France
| | - Laurent Bonello
- Aix-Marseille Université, Marseille, France,Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France,Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
| | - Guillaume Leurent
- Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, Univ Rennes 1, Rennes, France
| | - Bruno Levy
- CHRU Nancy, Réanimation Médicale Brabois, Nancy, France
| | - Meyer Elbaz
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | | | - Pascal Lim
- Université Paris Est-Créteil, INSERM, IMRB, Créteil, France,AP-HP, Hôpital Universitaire Henri-Mondor, Service de Cardiologie, Créteil, France
| | - Francis Schneider
- Médecine Intensive-Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Centre–Université de Paris, Medical School, Paris, France
| | - Hadi Khachab
- Intensive Cardiac Care Unit, Department of Cardiology, CH d’Aix-en-Provence, Aix-en-Provence, France
| | - Jeremy Bourenne
- Aix-Marseille Université, Service de Réanimation des Urgences, CHU La Timone 2, Marseille, France
| | | | - Guillaume Schurtz
- Department of Cardiology, Urgences et Soins Intensifs de Cardiologie, CHU Lille, University of Lille, Inserm U1167, Lille, France
| | - Brahim Harbaoui
- Cardiology Department, Hôpital Croix-Rousse and Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France,Department of Cardiology, University of Lyon, CREATIS UMR5220, INSERM U1044, INSA-15, Lyon, France
| | - Gerald Vanzetto
- Department of Cardiology, Hôpital de Grenoble, Grenoble, France
| | - Charlotte Quentin
- Service de Réanimation Polyvalente, Centre Hospitalier Broussais, 1 Rue de la Marne, Saint-Malo, France
| | - Xavier Delabranche
- Réanimation Chirurgicale Polyvalente, Pôle Anesthésie–Réanimation Chirurgicale–Médecine Péri-opératoire, Les Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil 1, Porte de l’Hôpital, Strasbourg, France
| | - Nadia Aissaoui
- Intensive Cardiac Care Unit, Department of Cardiology, CH d’Aix-en-Provence, Aix-en-Provence, France
| | - Nicolas Combaret
- Department of Cardiology, CHU Clermont-Ferrand, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Danka Tomasevic
- Intensive Cardiac Care Unit, Lyon Brom University Hospital, Lyon, France
| | - Benjamin Marchandot
- Université de Strasbourg, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Benoit Lattuca
- Department of Cardiology, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Patrick Henry
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Lariboisière, Department of Cardiology, Paris, France
| | - Edouard Gerbaud
- Intensive Cardiac Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, Pessac, France,Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, Hôpital Xavier Arnozan, Pessac, France
| | - Eric Bonnefoy
- Intensive Cardiac Care Unit, Lyon Brom University Hospital, Lyon, France
| | - Etienne Puymirat
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, Paris, France,Université de Paris, Paris, France
| | - Philippe Maury
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France,Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France,REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France,*Correspondence: Clément Delmas, ,
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85
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Geevarghese M, Patel K, Gulati A, Ranjan AK. Role of adrenergic receptors in shock. Front Physiol 2023; 14:1094591. [PMID: 36726848 PMCID: PMC9885157 DOI: 10.3389/fphys.2023.1094591] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
Shock is a severe, life-threatening medical condition with a high mortality rate worldwide. All four major categories of shock (along with their various subtypes)-hypovolemic, distributive, cardiogenic, and obstructive, involve a dramatic mismatch between oxygen supply and demand, and share standard features of decreased cardiac output, reduced blood pressure, and overall hypoperfusion. Immediate and appropriate intervention is required regardless of shock type, as a delay can result in cellular dysfunction, irreversible multiple organ failure, and death. Studies have shown that dysfunction and downregulation of adrenergic receptors (ARs) are often implicated in these shock conditions; for example, their density is shown to be decreased in hypovolemic and cardiogenic shock, while their reduced signaling in the brain and vasculature decrease blood perfusion and oxygen supply. There are two main categories of ARs, α, and β, each with its subtypes and distributions. Our group has demonstrated that a dose of .02 mg/kg body wt of centhaquine (CQ) specifically activates α2B ARs on venous circulation along with the central α2A ARs after hypovolemic/hemorrhagic shock. Activating these receptors by CQ increases cardiac output (CO) and reduces systemic vascular resistance (SVR), with a net increase in blood pressure and tissue perfusion. The clinical trials of CQ conducted by Pharmazz Inc. in India have demonstrated significantly improved survival in shock patients. CQ improved blood pressure and shock index, indicating better blood circulation, and reduced lactate levels in the blood compared to in-use standard resuscitative agents. After successful clinical trials, CQ is being marketed as a drug (Lyfaquin®) for hypovolemic/hemorrhagic shock in India, and United States FDA has approved the phase III IND application. It is anticipated that the phase III trial in the United States will begin in 2023. Thus, we have demonstrated that α2 ARs could be suitable targets for treating or managing hypovolemic/hemorrhagic shock. Further understanding of ARs in shock would help find new potential pharmacological targets.
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Affiliation(s)
- Mathew Geevarghese
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Krishna Patel
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL, United States
| | - Anil Gulati
- Pharmazz Inc., Research and Development, Willowbrook, IL, United States,Department of Bioengineering, The University of Illinois at Chicago, Chicago, IL, United States,Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
| | - Amaresh K. Ranjan
- Midwestern University College of Pharmacy Downers Grove, Downers Grove, IL, United States,*Correspondence: Anil Gulati, ; Amaresh K. Ranjan,
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Involvement of Vasopressin in Tissue Hypoperfusion during Cardiogenic Shock Complicating Acute Myocardial Infarction in Rats. Int J Mol Sci 2023; 24:ijms24021325. [PMID: 36674841 PMCID: PMC9866678 DOI: 10.3390/ijms24021325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/04/2023] [Accepted: 01/08/2023] [Indexed: 01/11/2023] Open
Abstract
Acute heart failure (AHF) due to acute myocardial infarction (AMI) is likely to involve cardiogenic shock (CS), with neuro-hormonal activation. A relationship between AHF, CS and vasopressin response is suspected. This study aimed to investigate the implication of vasopressin on hemodynamic parameters and tissue perfusion at the early phase of CS complicating AMI. Experiments were performed on male Wistar rats submitted or not to left coronary artery ligation (AMI and Sham). Six groups were studied Sham and AMI treated or not with either a vasopressin antagonist SR-49059 (Sham-SR, AMI-SR) or agonist terlipressin (Sham-TLP, AMI-TLP). Animals were sacrificed one day after surgery (D1) and after hemodynamic parameters determination. Vascular responses to vasopressin were evaluated, ex vivo, on aorta. AHF was defined by a left ventricular ejection fraction below 40%. CS was defined by AHF plus tissue hypoperfusion evidenced by elevated serum lactate level or low mesenteric oxygen saturation (SmO2) at D1. Mortality rates were 40% in AMI, 0% in AMI-SR and 33% in AMI-TLP. Immediately after surgery, a sharp decrease in SmO2 was observed in all groups. At D1, SmO2 recovered in Sham and in SR-treated animals while it remained low in AMI and further decreased in TLP-treated groups. The incidence of CS among AHF animals was 72% in AMI or AMI-TLP while it was reduced to 25% in AMI-SR. Plasma copeptin level was increased by AMI. Maximal contractile response to vasopressin was decreased in AMI (32%) as in TLP- and SR- treated groups regardless of ligation. Increased vasopressin secretion occurring in the early phase of AMI may be responsible of mesenteric hypoperfusion resulting in tissue hypoxia. Treatment with a vasopressin antagonist enhanced mesenteric perfusion and improve survival. This could be an interesting therapeutic strategy to prevent progression to cardiogenic shock.
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87
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COVID-19: A Comprehensive Review on Cardiovascular Alterations, Immunity, and Therapeutics in Older Adults. J Clin Med 2023; 12:jcm12020488. [PMID: 36675416 PMCID: PMC9865642 DOI: 10.3390/jcm12020488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
Here, we present a review focusing on three relevant issues related to COVID-19 and its impact in older adults (60 years and older). SARS-CoV-2 infection starts in the respiratory system, but the development of systemic diseases accompanied by severe clinical manifestations has also been reported, with cardiovascular and immune system dysfunction being the major ones. Additionally, the presence of comorbidities and aging represent major risk factors for the severity and poor prognosis of the disease. Since aging-associated decline has been largely related to immune and cardiovascular alterations, we sought to investigate the consequences and the underlying mechanisms of these pathologies to understand the severity of the illness in this population. Understanding the effects of COVID-19 on both systems should translate into comprehensive and improved medical care for elderly COVID-19 patients, preventing cardiovascular as well as immunological alterations in this population. Approved therapies that contribute to the improvement of symptoms and a reduction in mortality, as well as new therapies in development, constitute an approach to managing these disorders. Among them, we describe antivirals, cytokine antagonists, cytokine signaling pathway inhibitors, and vaccines.
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88
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Morici N, Frea S, Bertaina M, Sacco A, Corrada E, Dini CS, Briani M, Tedeschi M, Saia F, Colombo C, Rota M, Oliva F, Iannaccone M, De Ferrari GM, Sionis A, Kapur NK, Tavazzi G, Pappalardo F. SCAI stage reclassification at 24 h predicts outcome of cardiogenic shock: Insights from the Altshock-2 registry. Catheter Cardiovasc Interv 2023; 101:22-32. [PMID: 36378673 PMCID: PMC10100478 DOI: 10.1002/ccd.30484] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/27/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) includes several phenotypes with heterogenous hemodynamic features. Timely prognostication is warranted to identify patients requiring treatment escalation. We explored the association of the updated Society for Cardiovascular Angiography and Interventions (SCAI) stages classification with in-hospital mortality using a prospective national registry. METHODS Between March 2020 and February 2022 the Altshock-2 Registry has included 237 patients with CS of all etiologies at 11 Italian Centers. Patients were classified according to their admission SCAI stage (assigned prospectively and independently updated according to the recently released version). In-hospital mortality was evaluated for association with both admission and 24-h SCAI stages. RESULTS The overall in-hospital mortality was 38%. Of the 237 patients included and staged according to the updated SCAI classification, 20 (8%) had SCAI shock stage B, 131 (55%) SCAI stage C, 61 (26%) SCAI stage D and 25 (11%) SCAI stage E. In-hospital mortality stratified according to the SCAI classification at 24 h was 18% for patients in SCAI stage B, 27% for SCAI stage C, 63% for SCAI stage D and 100% for SCAI stage E. Both the revised SCAI stages on admission and at 24 h were associated with in-hospital mortality, but the classification potential slightly increased at 24-h. After adjusting for age, sex, lactate level, eGFR, CVP, inotropic score and mechanical circulatory support [MCS], SCAI classification at 24 h was an independent predictor of in-hospital mortality. CONCLUSIONS In the Altshock-2 registry the utility of SCAI shock stages to identify risk of in-hospital mortality increased at 24 h after admission. Escalation of treatment (either pharmacological or with MCS) should be tailored to achieve prompt clinical improvement within the first 24 h after admission. Registration: http://www. CLINICALTRIALS gov; Unique identifier: NCT04295252.
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Affiliation(s)
- Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Simone Frea
- Intensive Cardiac Care Unit, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maurizio Bertaina
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Torino, Italy
| | - Alice Sacco
- Cardiology Department and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elena Corrada
- Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Carlotta Sorini Dini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Michele Tedeschi
- Cardiology Department, Intensive Care Unit, S. Giovanni Di Dio e Ruggi D'Aragona Hospital, Salerno, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Costanza Colombo
- Intensive Cardiac Care Unit, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, Units of Biostatistics and Biomathematics and Bioinformatics, University of Brescia, Brescia, Italy
| | - Fabrizio Oliva
- Cardiology Department and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Torino, Italy
| | - Gaetano M De Ferrari
- Intensive Cardiac Care Unit, Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Medical Sciences, University of Torino, Torino, Italy
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia Italy.,Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Anestesia e Rianimazione I, Pavia, Italy
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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89
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Funamoto M, Kunavarapu C, Kwan MD, Matsuzaki Y, Shah M, Ono M. Single center experience and early outcomes of Impella 5.5. Front Cardiovasc Med 2023; 10:1018203. [PMID: 36926047 PMCID: PMC10011692 DOI: 10.3389/fcvm.2023.1018203] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/13/2023] [Indexed: 03/08/2023] Open
Abstract
Background Acute decompensated heart failure (HF) and cardiogenic shock (CS) frequently are refractory to conservative treatment and require mechanical circulatory support (MCS). We report our early clinical experience and evaluate patient outcomes with the newer generation surgical Impella 5.5. Methods Seventy patients that underwent Impella 5.5 implantation between October 2019 and December 2021 at a single center were enrolled in this study. Pre-operative characteristics, peri-operative clinical course information, and post-operative outcomes were retrospectively collected. Results Fifty-seven (81%) patients survived to discharge, and 51 (76%) patients survived at the time of the first 30 days post-discharge visit. Thirty-one patients (44%) received Impella support for a bridge to advanced surgical heart failure therapy (transplant or durable left ventricular assist device [LVAD]), 27 (39%) cases were used for a bridge to recovery/decision and 12 (17.1%) cases was used for planned perioperative support for high-risk cardiac surgery procedure. Conclusion Our results suggest that Impella 5.5 provides favorable survival in the management of HF and CS, particularly used for a bridge to heart transplant or LVAD. Early extubation and mobilization with high flow circulatory support allowed effective tailoring of MCS approaches from peri-operative support for high-risk cardiac surgery, bridge to recovery, and to advanced surgical heart failure therapy.
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Affiliation(s)
- Masaki Funamoto
- Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, TX, United States
| | - Chandra Kunavarapu
- Advanced Heart Failure and Transplant Cardiology, Methodist Hospital, San Antonio, TX, United States
| | - Michael D Kwan
- Advanced Heart Failure and Transplant Cardiology, Methodist Hospital, San Antonio, TX, United States
| | - Yuichi Matsuzaki
- Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, TX, United States
| | - Mahek Shah
- Advanced Heart Failure and Transplant Cardiology, Methodist Hospital, San Antonio, TX, United States
| | - Masahiro Ono
- Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, TX, United States
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90
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Sandhyavenu H, Ullah W, Badu I, Taha A, Polam AR, Mir T, Brailovsky Y, Rajapreyar IN, Vallabhajosyula S, Alraies MC. Trends and outcomes of cardiogenic shock in Asian populations compared with non-Asian populations in the US: NIS Analysis (2002-2019). Expert Rev Cardiovasc Ther 2023; 21:67-74. [PMID: 36597921 DOI: 10.1080/14779072.2023.2162040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Current understanding of outcomes of cardiogenic shock (CS) in Asian populations is limited. We aim to study the clinical outcomes of CS in Asian population compared with non-Asians in the US. METHODS The National Inpatient Sample (NIS) database was queried between 2002-2019 to identify hospitalizations with CS. Race was classified as Asians and non-Asians. The adjusted odds ratios (aOR) for in-hospital outcomes were calculated using multivariate logistic regression analysis. RESULTS Results Of 1,573,285 CS hospitalizations, 48,398 (3%) were Asians and 1,524,887 (97%) were non-Asians between 2002-2019. Adjusted odds of in-hospital mortality (aOR 1.03, 95% CI 1.01-1.05), and use of intra-aortic balloon pump (IABP) (aOR 1.15, 95% CI 1.12-1.17) were significantly higher among Asians compared with non-Asians. The in-hospital mean cost of hospitalization was higher in Asian population ($63,787±$80,261) with CS compared with non-Asians ($56,207±$76,120, p < 0.001). The use of Impella (aOR 0.90, 95% CI 0.86-0.95) and left ventricular assist devices (LVAD) (aOR 0.71, 95% CI 0.65-0.77) were lower with no difference in the use of extracorporeal membrane oxygenation (ECMO) compared with non-Asians. CONCLUSION Asian populations with CS have higher in-hospital mortality, increased requirement of IABP and higher mean cost of hospitalization compared with non-Asians.
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Affiliation(s)
| | - Waqas Ullah
- Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Irisha Badu
- Internal Medicine, Onslow Memorial Hospital, Jacksonville, NC, USA
| | - Amro Taha
- Internal Medicine, Weiss Memorial Hospital, Chicago, IL, USA
| | | | - Tanveer Mir
- Internal Medicine, Wayne State University, Detroit, MI, USA
| | | | | | | | - M Chadi Alraies
- Cardiology, Wayne State University/Detroit Medical Center, Detroit, MI, USA
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91
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Impact of shock aetiology and hospital characteristics on the clinical profile, management and prognosis of patients with non ACS-related cardiogenic shock. Hellenic J Cardiol 2023; 69:16-23. [PMID: 36334704 DOI: 10.1016/j.hjc.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/08/2022] [Accepted: 11/01/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND A significant proportion of cases of cardiogenic shock (CS) are due aetiologies other than acute coronary syndromes (non ACS-CS). We assessed differences regarding clinical profile, management, and prognosis according to the cause of CS among nonselected patients with CS from a large nationwide database. METHODS We performed an observational study including patients admitted from the hospitals of the Spanish National Health System (SNHS) with a principal or secondary diagnosis code of CS (2016-2019). Data were obtained from the Minimum Basic Data Set (MBDS). Hospitals were classified according to the availability of cardiology related resources, as well as the availability of Intensive Cardiac Care Unit (ICCU). RESULTS A total of 10,826 episodes of CS were included, of whom 5,495 (50.8%) were non-ACS related. Non ACS-CS patients were younger (71.5 vs. 72.4 years) and had a lower burden of arteriosclerosis-related comorbidities. Non ACS-CS cases underwent less often invasive procedures and presented lower in-hospital mortality (57.1% vs. 61%,p < 0.001). The most common main diagnosis among non ACS-CS was acute decompensation of chronic heart failure (ADCHF) (35.4%). A lower risk-adjusted in-hospital mortality rate was observed in high volume hospitals (52.6% vs. 56.7%; p < 0.001), as well as in centers with ICCU (OR: 0.71; CI 95%: 0.58-0.87; p < 0.001). CONCLUSIONS More than a half of cases of CS were due to non-ACS causes. Non ACS-CS cases are a very heterogeneous group, with different clinical profile and management. Management at high-volume hospitals and availability of ICCU were associated with lower risk adjusted mortality among non ACS-CS patients.
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92
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Ahmed AOE, Mohammed N, Alzaeem HA, Jalil SMS, Maaly CA, Al-Hijji M. MitraClip to the Rescue in Cardiogenic Shock: Case Series from a Single Center. Heart Views 2023; 24:50-53. [PMID: 37124438 PMCID: PMC10144420 DOI: 10.4103/heartviews.heartviews_87_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/22/2023] [Indexed: 02/24/2023] Open
Abstract
Cardiogenic shock (CS) in the setting of acute coronary syndrome carries detrimental consequences and high levels of mortality and morbidity if not managed promptly. Acute mitral regurgitation (MR) as a complication of the myocardial infarction might superimpose refractory CS that warrants mitral valve repair. There has been growing use of Transcatheter edge-to-edge mitral valve repair (TEER) as a therapy for CS secondary to acute MR. In this cohort, we describe two cases of CS secondary to acute ischemic MR managed with a Mitraclip.
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Affiliation(s)
| | - Nazar Mohammed
- Department of Interventional Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Cheikh Abdoul Maaly
- Department of Echocardiography, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Al-Hijji
- Department of Interventional Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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93
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Aldujeli A, Haq A, Tecson KM, Kurnickaite Z, Lickunas K, Bailey S, Tatarunas V, Braukyliene R, Baksyte G, Aldujeili M, Khalifeh H, Briedis K, Ordiene R, Unikas R, Hamadeh A, Brilakis ES. A prospective observational study on impact of epinephrine administration route on acute myocardial infarction patients with cardiac arrest in the catheterization laboratory (iCPR study). Crit Care 2022; 26:393. [PMID: 36539907 PMCID: PMC9764590 DOI: 10.1186/s13054-022-04275-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Epinephrine is routinely utilized in cardiac arrest; however, it is unclear if the route of administration affects outcomes in acute myocardial infarction patients with cardiac arrest. OBJECTIVES To compare the efficacy of epinephrine administered via the peripheral intravenous (IV), central IV, and intracoronary (IC) routes. METHODS Prospective two-center pilot cohort study of acute myocardial infarction patients who suffered cardiac arrest in the cardiac catheterization laboratory during percutaneous coronary intervention. We compared the outcomes of patients who received epinephrine via peripheral IV, central IV, or IC. RESULTS 158 participants were enrolled, 48 (30.4%), 50 (31.6%), and 60 (38.0%) in the central IV, IC, and peripheral IV arms, respectively. Peripheral IV epinephrine administration route was associated with lower odds of achieving return of spontaneous circulation (ROSC, odds ratio = 0.14, 95% confidence interval = 0.05-0.36, p < 0.0001) compared with central IV and IC administration. (There was no difference between central IV and IC routes; p = 0.9343.) The odds of stent thrombosis were significantly higher with the IC route (IC vs. peripheral IV OR = 4.6, 95% CI = 1.5-14.3, p = 0.0094; IC vs. central IV OR = 6.0, 95% CI = 1.9-19.2, p = 0.0025). Post-ROSC neurologic outcomes were better for central IV and IC routes when compared with peripheral IV. CONCLUSION Epinephrine administration via central IV and IC routes was associated with a higher rate of ROSC and better neurologic outcomes compared with peripheral IV administration. IC administration was associated with a higher risk of stent thrombosis. Trial registration This trial is registered at NCT05253937 .
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Affiliation(s)
- Ali Aldujeli
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania ,grid.45083.3a0000 0004 0432 6841Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ayman Haq
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, MN USA
| | - Kristen M. Tecson
- grid.486749.00000 0004 4685 2620Baylor Scott & White Research Institute, Dallas, TX USA
| | - Zemyna Kurnickaite
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Karolis Lickunas
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Som Bailey
- Medical City Fort Worth, Fort Worth, TX USA
| | - Vacis Tatarunas
- grid.45083.3a0000 0004 0432 6841Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Giedre Baksyte
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | | | | | - Kasparas Briedis
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Rasa Ordiene
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Ramunas Unikas
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Anas Hamadeh
- Texas Cardiovascular Institute, Fort Worth, TX USA
| | - Emmanouil S. Brilakis
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, MN USA
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Lim HS. Phenotyping and Hemodynamic Assessment in Cardiogenic Shock: From Physiology to Clinical Application. Cardiol Ther 2022; 11:509-522. [PMID: 36335176 PMCID: PMC9652191 DOI: 10.1007/s40119-022-00286-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 11/08/2022] Open
Abstract
There is growing interest in invasive hemodynamic assessment in cardiogenic shock, primarily due to the widespread adoption of mechanical circulatory support (MCS). Invasive hemodynamic assessment is central to two aspects of cardiogenic shock management: (1) the phenotyping of cardiogenic shock, and (2) the assessment of response to therapy. Phenotyping of cardiogenic shock serves to guide timely therapeutic intervention, and the assessment of hemodynamic response to therapy directs the escalation or de-escalation of therapy, including MCS. This review aims to discuss these two aspects of hemodynamic assessment in cardiogenic shock. Firstly, the physiologic underpinnings of a phenotyping schema, and the implication of the cardiogenic shock phenotype on the MCS strategy in cardiogenic shock will be discussed. Secondly, the concept of cardiac power output and 'effective' oxygen delivery will be discussed in relation to hemodynamic response to therapy in cardiogenic shock.
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Affiliation(s)
- Hoong Sern Lim
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2TH, UK.
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Sattar Y, Faisaluddin M, Almas T, Alhajri N, Shah R, Zghouzi M, Zafrullah F, Sengodon PM, Zia Khan M, Ullah W, Alam M, Balla S, Lakkis N, Kawsara A, Daggubati R, Chadi Alraies M. Cardiovascular outcomes of transradial versus transfemoral percutaneous coronary intervention in End-Stage renal Disease: A Regression-Based comparison. IJC HEART & VASCULATURE 2022; 43:101110. [PMID: 36051245 PMCID: PMC9424587 DOI: 10.1016/j.ijcha.2022.101110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/14/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022]
Abstract
Background Limited data is available on the comparison of outcomes of transradial (TR) and transfemoral (TF) access for percutaneous coronary intervention (PCI) in patients with end-stage stage renal disease (ESRD). Methods Online databases were queried to compare cardiovascular outcomes among TR. and TF in ESRD patients. The outcomes assessed included differences in mortality, cerebrovascular accidents (CVA), periprocedural myocardial infarction (MI), bleeding, transfusion, and periprocedural cardiogenic shock (CS). Unadjusted odds ratios (OR) were calculated using a random-effect effect model. Results A total of 6 studies including 7,607 patients (TR-PCI = 1,288; TF-PCI = 6,319) were included. The overall mean age was 67.7 years, while the mean age for TR-PCI and TF-PCI was 69.7 years and 67.9 years, respectively. TR-PCI was associated with lower incidence of mortality (OR 0.46 95 % CI 0.30–0.70, p < 0.05, I2 0.00 %), bleeding (OR 0.45 95 % CI 0.29, 0.68, p < 0.05, I2 3.48 %), and transfusion requirement (OR 0.52 95 % CI 0.40, 0.67, p < 0.05, I2 0.00 %) (Fig. 1). There were no differences among TR-PCI and TF-PCI for periprocedural MI, periprocedural CS, and CVA outcomes. Conclusion TR access was associated with lower mortality, bleeding, and transfusion requirement as compared to TF access in patients with ESRD undergoing PCI.
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Affiliation(s)
| | | | - Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
- Corresponding authors at: RCSI University of Medicine and Health Sciences, 123 St. Stephen’s Green, Dublin 2, Ireland (T. Almas) and Detroit Medical Center, Detroit, MI, USA (M. Chadi Alraies).
| | - Noora Alhajri
- College of Medicine and Health Science, Khalifa University, Abu Dhabi, United Arab Emirates
| | | | | | | | | | | | - Waqas Ullah
- Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | | | | | | | - M. Chadi Alraies
- Detroit Medical Center, Detroit, MI, USA
- Corresponding authors at: RCSI University of Medicine and Health Sciences, 123 St. Stephen’s Green, Dublin 2, Ireland (T. Almas) and Detroit Medical Center, Detroit, MI, USA (M. Chadi Alraies).
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Montero S, Rivas‐Lasarte M, Huang F, Chommeloux J, Demondion P, Bréchot N, Hékimian G, Franchineau G, Persichini R, Luyt C, Garcia‐Garcia C, Bayes‐Genis A, Lebreton G, Cinca J, Leprince P, Combes A, Alvarez‐Garcia J, Schmidt M. Time course, factors related to, and prognostic impact of venoarterial extracorporeal membrane flow in cardiogenic shock. ESC Heart Fail 2022; 10:568-577. [PMID: 36369748 PMCID: PMC9871705 DOI: 10.1002/ehf2.14132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/06/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is currently one of the most used devices in refractory cardiogenic shock. However, there is a lack of evidence on how to set the 'optimal' flow. We aimed to describe the evolution of VA-ECMO flows in a cardiogenic shock population and determine the risk factors of 'high-ECMO flow'. METHODS AND RESULTS A 7 year database of patients supported with VA-ECMO was used. Based on the median flow during the first 48 h of the VA-ECMO run, patients were classified as 'high-flow' or 'low-flow', respectively, when median ECMO flow was ≥3.6 or <3.6 L/min. Outcomes included rates of ventilator-associated pneumonia, ECMO-related complications, days on ECMO, days on mechanical ventilation, intensive care unit and hospitalization lengths of stay, and in-hospital and 60 day mortality. Risk factors of high-ECMO flow were assessed using univariate and multivariate cox regression. The study population included 209 patients on VA-ECMO, median age was 51 (40-59) years, and 78% were males. The most frequent aetiology leading to cardiogenic shock was end-stage dilated cardiomyopathy (57%), followed by acute myocardial infarction (23%) and fulminant myocarditis (17%). Among the 209 patients, 105 (50%) were classified as 'high-flow'. This group had a higher rate of ischaemic aetiology (16% vs. 30%, P = 0.023) and was sicker at admission, in terms of worse Simplified Acute Physiology Score II score [40 (26-58) vs. 56 (42-74), P < 0.001], higher lactate [3.6 (2.2-5.8) mmol/L vs. 5.2 (3-9.7) mmol/L, P < 0.001], and higher aspartate aminotransferase [97 (41-375) U/L vs. 309 (85-939) U/L, P < 0.001], among others. The 'low-flow' group had less ventilator-associated pneumonia (40% vs. 59%, P = 0.007) and less days on mechanical ventilation [4 (1.5-7.5) vs. 6 (3-12) days, P = 0.009]. No differences were found in lengths of stay or survival according to the ECMO flow. The multivariate analysis showed that risk factors independently associated with 'high-flow' were mechanical ventilation at cannulation [odds ratio (OR) 3.9, 95% confidence interval (CI) 2.1-7.1] and pre-ECMO lactate (OR 1.1, 95% CI 1.0-1.2). CONCLUSIONS In patients with refractory cardiogenic shock supported with VA-ECMO, sicker patients had higher support since early phases, presenting thereafter higher rates of ventilator-associated pneumonia but similar survival compared with patients with lower flows.
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Affiliation(s)
- Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de MedicinaUniversitat Autònoma de BarcelonaBarcelonaSpain,Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France
| | - Mercedes Rivas‐Lasarte
- Advanced Heart Failure and Heart Transplant Unit, Cardiology DepartmentHospital Universitario Puerta de Hierro Majadahonda, CIBERCVMadridSpain
| | - Florent Huang
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France
| | - Juliette Chommeloux
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France
| | - Pierre Demondion
- Thoracic and Cardiovascular DepartmentAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Nicolas Bréchot
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Guillaume Hékimian
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Guillaume Franchineau
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Romain Persichini
- Medical–Surgical Intensive Care UnitCHU de La Réunion, Felix‐Guyon HospitalSaint DenisLa RéunionFrance
| | - Charles‐Édouard Luyt
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Cosme Garcia‐Garcia
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de MedicinaUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Antoni Bayes‐Genis
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de MedicinaUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Guillaume Lebreton
- Thoracic and Cardiovascular DepartmentAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Juan Cinca
- Cardiology DepartmentHospital de la Santa Creu i Sant Pau, Universitat Autònoma de BarcelonaBarcelonaSpain
| | - Pascal Leprince
- Thoracic and Cardiovascular DepartmentAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Alain Combes
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
| | - Jesus Alvarez‐Garcia
- Cardiology DepartmentHospital Ramón y Cajal, Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV)MadridSpain
| | - Matthieu Schmidt
- Medical Intensive Care UnitAssistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière HospitalParis Cedex 13France,Institute of Cardiometabolism and NutritionSorbonne Université, INSERM UMRS_1166‐iCAN75651Paris Cedex 13France
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97
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Hyun DY, Han X, Oh S, Ahn JH, Lee SH, Cho KH, Kim MC, Sim DS, Hong YJ, Kim JH, Ahn Y, Jeong MH. Long-term clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock according to the application and initiation time of extracorporeal membrane oxygenation in South Korea. Cardiol J 2022; 30:713-724. [PMID: 36342031 PMCID: PMC10635714 DOI: 10.5603/cj.a2022.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 09/18/2022] [Accepted: 09/29/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Limited data are available regarding the proper application time and long-term outcomes of extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock. This cohort study appraised the clinical outcomes according to ECMO application without or before cardiopulmonary resuscitation (CPR) in patients with acute myocardial infarction (AMI) combined with cardiogenic shock. METHODS Between 2011 and 2015, a total of 13,104 patients with AMI were enrolled in a nationwide AMI registry. Eligible patients with cardiogenic shock, who underwent percutaneous coronary intervention, with a 3-year clinical follow-up, were analyzed. The 949 included patients were divided into two groups: no ECMO (n = 845) and ECMO application (n = 104). The ECMO group was further divided into ECMO without or before CPR (n = 11) and ECMO after CPR (n = 93). RESULTS Significant differences were noted in major adverse cardiac events (MACEs) between the no ECMO and ECMO application groups during the 3-year follow-up (41.5% vs. 80.8%; p < 0.001). However, the ECMO without or before CPR group showed similar outcomes to the no ECMO group in 3-year MACEs (63.6% vs. 41.5%; p = 0.055). MACEs during 3 years of follow-up were significantly lower in the ECMO without or before CPR group than in the ECMO after CPR group (63.6% vs. 82.8%; p = 0.005). CONCLUSIONS A significantly lower risk of major cardiac events in ECMO without or before CPR suggests that early application of ECMO can be a reasonable strategy to improve outcomes in patients with AMI complicated by cardiogenic shock.
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Affiliation(s)
- Dae Young Hyun
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Xiongyi Han
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seok Oh
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Joon Ho Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seung Hun Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyung Hoon Cho
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Doo Sun Sim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Ju Han Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
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98
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Intra-aortic Balloon Pump Versus Impella in Managing Cardiogenic Shock After Myocardial Infarction: Literature Review. Dimens Crit Care Nurs 2022; 41:321-329. [PMID: 36179310 DOI: 10.1097/dcc.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite early revascularization and supportive medical therapies, acute myocardial infarction with cardiogenic shock (AMICS) remains the leading cause of death in patient's with myocardial infarction. Intra-aortic balloon pump (IABP) has been the device of choice for these patients but has failed to show mortality benefit over medical therapy alone. The Impella (AbioMed, Danvers, Massachusetts) is a more recently developed alternative in bridging patients to recovery. AIM The aim of this study was to evaluate available evidence comparing mortality with the use of Impella (2.0 or CP) versus IABP in patients with AMICS. METHODS PubMed, CINAHL, EMBASE, and Scopus were searched to find articles comparing the outcomes of IABP versus Impella in AMICS patients. A total of 7 articles met the inclusion criteria. RESULTS Thirty-day mortality was the primary outcome observed. Secondary outcomes included myocardial recovery and complications from device implantation. All studies support that there is no statistically significant reduction in mortality when utilizing the Impella over the IABP. DISCUSSION Further research in an adequately powered randomized clinical trial is needed to shed light on the clinical characteristics of patients after AMICS who would benefit from 1 type of mechanical circulatory support over another. The therapy chosen is determined by provider discretion and skill set, as well as device availability. It is important for all care team members, including the critical care nurse, to understand the implications and complications associated with each therapy, so care can be catered to the individual patient's needs.
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99
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Muacevic A, Adler JR, El Dirani M, Mathew S, Ogwu CI, Kholoki S. Steps To Prevent Mortality in a Patient with Coinciding Severe Sepsis and Cardiogenic Shock Post-Non-ST-Elevation Myocardial Infarction (NSTEMI): A Case Report. Cureus 2022; 14:e32086. [PMID: 36600844 PMCID: PMC9803867 DOI: 10.7759/cureus.32086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/02/2022] Open
Abstract
Severe sepsis is characterized by acute organ dysfunction secondary to an infective source, often requiring emergent medical intervention. The severity of sepsis is determined by a criterion that focuses on the presence of fever, tachycardia, tachypnea, leukocytosis, lactic acidosis, hypotension, evidence of organ failure, and the presence of an infective source. Management of sepsis in patients with a coinciding ischemic event such as a myocardial infarction (MI), is difficult, given the prognosis is poor and there is a high risk for mortality. This case report explores methodical medical measures taken to prevent mortality in an 81-year-old Hispanic male that developed severe sepsis in conjunction with a complicated presentation of a non-ST-elevation myocardial infarction (NSTEMI).
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100
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Tan SR, Low CJW, Ng WL, Ling RR, Tan CS, Lim SL, Cherian R, Lin W, Shekar K, Mitra S, MacLaren G, Ramanathan K. Microaxial Left Ventricular Assist Device in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12101629. [PMID: 36295065 PMCID: PMC9605512 DOI: 10.3390/life12101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Microaxial left ventricular assist devices (LVAD) are increasingly used to support patients with cardiogenic shock; however, outcome results are limited to single-center studies, registry data and select reviews. We conducted a systematic review and meta-analysis, searching three databases for relevant studies reporting on microaxial LVAD use in adults with cardiogenic shock. We conducted a random-effects meta-analysis (DerSimonian and Laird) based on short-term mortality (primary outcome), long-term mortality and device complications (secondary outcomes). We assessed the risk of bias and certainty of evidence using the Joanna Briggs Institute and the GRADE approaches, respectively. A total of 63 observational studies (3896 patients), 6 propensity-score matched (PSM) studies and 2 randomized controlled trials (RCTs) were included (384 patients). The pooled short-term mortality from observational studies was 46.5% (95%-CI: 42.7–50.3%); this was 48.9% (95%-CI: 43.8–54.1%) amongst PSM studies and RCTs. The pooled mortality at 90 days, 6 months and 1 year was 41.8%, 51.1% and 54.3%, respectively. Hemolysis and access-site bleeding were the most common complications, each with a pooled incidence of around 20%. The reported mortality rate of microaxial LVADs was not significantly lower than extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumps (IABP). Current evidence does not suggest any mortality benefit when compared to ECMO or IABP.
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Affiliation(s)
- Shien Ru Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Wei Lin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119228, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Robin Cherian
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD 4032, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
| | - Saikat Mitra
- Intensive Care Unit, Dandenong and Casey Hospital, Monash Health, Melbourne, VIC 3175, Australia
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
- Correspondence:
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