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Lim HS, González-Costello J, Belohlavek J, Zweck E, Blumer V, Schrage B, Hanff TC. Hemodynamic management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1059-1073. [PMID: 38518863 PMCID: PMC11148863 DOI: 10.1016/j.healun.2024.03.009] [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: 12/15/2023] [Revised: 03/01/2024] [Accepted: 03/11/2024] [Indexed: 03/24/2024] Open
Abstract
Hemodynamic derangements are defining features of cardiogenic shock. Randomized clinical trials have examined the efficacy of various therapeutic interventions, from percutaneous coronary intervention to inotropes and mechanical circulatory support (MCS). However, hemodynamic management in cardiogenic shock has not been well-studied. This State-of-the-Art review will provide a framework for hemodynamic management in cardiogenic shock, including a description of the 4 therapeutic phases from initial 'Rescue' to 'Optimization', 'Stabilization' and 'de-Escalation or Exit therapy' (R-O-S-E), phenotyping and phenotype-guided tailoring of pharmacological and MCS support, to achieve hemodynamic and therapeutic goals. Finally, the premises that form the basis for clinical management and the hypotheses for randomized controlled trials will be discussed, with a view to the future direction of cardiogenic shock.
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Affiliation(s)
- Hoong Sern Lim
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - José González-Costello
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, BIOHEART-Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain; Ciber Cardiovascular (CIBERCV), Instituto Salud Carlos III, Madrid, Spain
| | - Jan Belohlavek
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Elric Zweck
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Vanessa Blumer
- Inova Schar Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Benedikt Schrage
- University Heart and Vascular Centre Hamburg, German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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2
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Cyrille-Superville N, Rao SD, Feliberti JP, Patel PA, Swayampakala K, Sinha SS, Jeng EI, Goswami RM, Snipelisky DF, Carroll AM, Najjar SS, Belkin M, Grinstein J. PREDICT HF: Risk stratification in advanced heart failure using novel hemodynamic parameters. Clin Cardiol 2024; 47:e24277. [PMID: 38838029 DOI: 10.1002/clc.24277] [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: 10/25/2023] [Revised: 01/29/2024] [Accepted: 03/14/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Invasive hemodynamics are fundamental in assessing patients with advanced heart failure (HF). Several novel hemodynamic parameters have been studied; however, the relative prognostic potential remains ill-defined. HYPOTHESIS Advanced hemodynamic parameters provide additional prognostication beyond the standard hemodynamic assessment. METHODS Patients from the PRognostic Evaluation During Invasive CaTheterization for Heart Failure (PREDICT-HF) registry who underwent right heart catheterization (RHC) were included in the analysis. The primary endpoint was survival to orthotopic heart transplant (OHT) or durable left ventricular assist device (LVAD), or death within 6 months of RHC. RESULTS Of 846 patients included, 176 (21%) met the primary endpoint. In a multivariate model that included traditional hemodynamic variables, pulmonary capillary wedge pressure (PCWP) (OR: 1.10, 1.04-1.15, p < .001), and cardiac index (CI) (OR: 0.86, 0.81-0.92, p < .001) were shown to be predictive of adverse outcomes. In a separate multivariate model that incorporated advanced hemodynamic parameters, cardiac power output (CPO) (OR: 0.76, 0.71-0.83, p < .001), aortic pulsatility index (API) (OR: 0.94, 0.91-0.96, p < .001), and pulmonary artery pulsatility index (OR: 1.02, 1.00-1.03, p .027) were all significantly associated with the primary outcome. Positively concordant API and CPO afforded the best freedom from the endpoint (94.7%), whilst negatively concordant API and CPO had the worst freedom from the endpoint (61.5%, p < .001). Those with discordant API and CPO had similar freedom from the endpoint. CONCLUSION The advanced hemodynamic parameters API and CPO are independently associated with death or the need for OHT or LVAD within 6 months. Further prospective studies are needed to validate these parameters and elucidate their role in patients with advanced HF.
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Affiliation(s)
| | - Sriram D Rao
- Department of Medicine, Medstar Washington Hospital Center, Division of Cardiology, Georgetown University, Washington, District of Columbia, USA
| | - Jason P Feliberti
- University of South Florida Heart and Vascular Institute, Transplant Cardiology, Tampa, Florida, USA
| | - Priyesh A Patel
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Kamala Swayampakala
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Eric I Jeng
- Department of Surgery, Division of Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Rohan M Goswami
- Division of Transplant, Research and Innovation, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - David F Snipelisky
- Section of Heart Failure & Cardiac Transplant Medicine, Cleveland Clinic Florida, Weston, Florida, USA
| | - Aubrie M Carroll
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Samer S Najjar
- Medstar Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Mark Belkin
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois, USA
| | - Jonathan Grinstein
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois, USA
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Palazzuoli A, Dini FL, Agostoni P, Cartocci A, Morrone F, Tricarico L, Correale M, Mercurio V, Nodari S, Severino P, Badagliacca R, Barillà F, Paolillo S, Filardi PP. Right ventricular dysfunction in chronic heart failure: clinical laboratory and echocardiographic characteristics. (the RIVED-CHF registry). J Cardiovasc Med (Hagerstown) 2024; 25:457-465. [PMID: 38652523 DOI: 10.2459/jcm.0000000000001623] [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: 04/25/2024]
Abstract
BACKGROUND Right ventricular dysfunction (RVD) and pulmonary hypertension have been recognized as two important prognostic features in patients with left side heart failure. Current literature does not distinguish between right heart failure (RHF) and RVD, and the two terms are used indiscriminately to describe pulmonary hypertension and RVD as well as clinical sign of RHF. Therefore, the right ventricle (RV) adaptation across the whole spectrum of left ventricular ejection fraction (LVEF) values has been poorly investigated. METHODS This is a multicenter observational prospective study endorsed by the Italian Society of Cardiology aiming to analyze the concordance between the signs and symptoms of RHF and echocardiographic features of RVD. The protocol will assess patients affected by chronic heart failure in stable condition regardless of the LVEF threshold by clinical, laboratory, and detailed echocardiographic study. During the follow-up period, patients will be observed by direct check-up visit and/or virtual visits every 6 months for a mean period of 3 years. All clinical laboratory and echocardiographic data will be recorded in a web platform system accessible for all centers included in the study. RESULTS The main study goals are: to investigate the concordance and discordance between clinical signs of RHF and RVD measured by ultrasonographic examination; to evaluate prognostic impact (in terms of cardiovascular mortality and heart failure hospitalization) of RVD and RHF during a mean follow-up period of 3 years; to investigate the prevalence of different right ventricular maladaptation (isolated right ventricular dilatation, isolated pulmonary hypertension, combined pattern) and the related prognostic impact. CONCLUSIONS With this protocol, we would investigate the three main RVD patterns according to heart failure types and stages; we would clarify different RVD and pulmonary hypertension severity according to the heart failure types. Additionally, by a serial multiparametric analysis of RV, we would provide a better definition of RVD stage and how much is it related with clinical signs of RHF (ClinicalTrials.gov Identifier: NCT06002321).
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Affiliation(s)
| | | | - PierGiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan
| | | | - Francesco Morrone
- UOSA Malattie Cardiovascolari, Le Scotte Hospital University of Siena
| | - Lucia Tricarico
- UO Cardiologia Universitaria -UTIC Policlinico Riuniti, Foggia
| | | | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples
| | - Savina Nodari
- Cardiology Unit Spedali riuniti di Brescia University of Brescia
| | - Paolo Severino
- Policlinico Umberto I UOC Cardiologia Università La Sapienza
| | | | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Section of Cardiology, Federico II University, Naples, Italy
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Section of Cardiology, Federico II University, Naples, Italy
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Nomoto Y, Imamura T, Izumida T, Narang N, Kinugawa K. Clinical Implications of Remote Dielectric Sensing-Guided Management. J Clin Med 2024; 13:2906. [PMID: 38792447 PMCID: PMC11121768 DOI: 10.3390/jcm13102906] [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: 04/12/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Remote dielectric sensing (ReDS) systems can quantify the degree of pulmonary congestion rapidly and non-invasively. However, the clinical implications of ReDS-guided medication adjustment remain uncertain. Methods: Patients hospitalized to treat cardiovascular diseases, including heart failure, valvular disease, and coronary artery disease, and underwent ReDS measurement before index discharge between 2021 and 2022 were included. According to our institutional protocol, ReDS values were blinded to the attending clinicians until February 2022 (blind period). After the period, ReDS values were timely opened to the attending clinicians, and medications such as diuretics were adjusted according to the ReDS values (target value between 20% and 35%) before index discharge (open period). A composite primary outcome of all-cause death and heart failure readmissions was compared between the two groups. Results: A total of 183 patients were included (median 79 years old, 101 men), consisting of 138 patients in the blind period and 45 patients in the open period. During a median of 646 (401, 818) days after the index discharge, 33 patients experienced the primary outcome of interest. Management during the open period, where medications were adjusted according to ReDS values, was independently associated with a lower incidence of the primary outcome with an adjusted hazard ratio of 0.22 (95% confidence interval 0.05-0.94, p = 0.041), as compared with those of the blind period. Conclusions: According to the findings of the present retrospective study, ReDS-guided management may have the potential to reduce the risk of mortality and heart failure admission in individuals hospitalized for cardiovascular diagnoses. Further prospective randomized control trials involving those with a variety of background etiologies and clinical scenarios are warranted to validate our findings and establish optimal ReDS-guided management.
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Affiliation(s)
- Yu Nomoto
- Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Toshihide Izumida
- Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Nikhil Narang
- Advocate Christ Medical Center, Oak Lawn, IL 60453, USA
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
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Chau VQ, Imamura T, Narang N. Implementation of remote monitoring strategies to improve chronic heart failure management. Curr Opin Cardiol 2024; 39:210-217. [PMID: 38567948 DOI: 10.1097/hco.0000000000001119] [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: 04/05/2024]
Abstract
PURPOSE OF REVIEW The goal of this review is to describe the current evidence available for remote monitoring devices available for patients with chronic heart failure, and also detail practical clinical recommendations for implementing these tools in daily clinical practice. RECENT FINDINGS Several devices ranging from sophisticated multiparametric algorithms in defibrillators, implantable pulmonary artery pressure sensors, and wearable devices to measure thoracic impedance can be utilized as important adjunctive tools to reduce the risk of heart failure hospitalization in patients with chronic heart failure. Pulmonary artery pressure sensors provide the most granular data regarding hemodynamic status, while alerts from wearable devices for thoracic impedance and defibrillator-based algorithms increase the likelihood of worsening clinical status while also having high negative predictive value when values are within normal range. SUMMARY Multiple device-based monitoring strategies are available to reduce longitudinal risk in patients with chronic heart failure. Further studies are needed to best understand a practical pathway to integrate multiple signals of data for early clinical decompensation risk predictionVideo abstract: http://links.lww.com/HCO/A95.
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Affiliation(s)
- Vinh Q Chau
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
- Division of Cardiology, Department of Medicine, University of Illinois-Chicago, Chicago, Illinois, USA
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Grinstein J. Advanced hemodynamics for prognostication in heart failure: the pursuit of the patient-specific tipping point. Front Cardiovasc Med 2024; 11:1365696. [PMID: 38500751 PMCID: PMC10944906 DOI: 10.3389/fcvm.2024.1365696] [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: 01/04/2024] [Accepted: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
Background Objective tools to define the optimal time for referral for advanced therapies and to help guide escalation and de-escalation of support can improve management decisions and outcomes for patients with advanced heart failure. The current parameters have variable prognostic potential depending on the patient population being studied and often have arbitrary thresholds. Methods Here, a mathematical and physiological framework to define the patient-specific tipping point of myocardial energetics is defined. A novel hemodynamic parameter known as the myocardial performance score (MPS), a marker of power and efficiency, is introduced that allows for the objective assessment of the physiological tipping point. The performance of the MPS and other advanced hemodynamic parameters including aortic pulsatility index (API) and cardiac power output (CPO) in predicting myocardial energetics and the overall myocardial performance was evaluated using a validated computer simulation model of heart failure (Harvi) as well as a proof-of-concept clinical validation using a cohort of the Society for Cardiovascular Angiography and Interventions (SCAI) Stage C cardiogenic shock patients. Results Approximately 1010 discrete heart failure scenarios were modeled. API strongly correlated with the left ventricular coupling ratio (R2 = 0.81) and the strength of association became even stronger under loaded conditions where pulmonary capillary wedge pressure (PCWP) was >20 mmHg (R2 = 0.94). Under loaded conditions, there is a strong logarithmic relationship between MPS and mechanical efficiency (R2 = 0.93) with a precipitous rise in potential energy (PE) and drop in mechanical efficiency with an MPS <0.5. An MPS <0.5 was able to predict a CPO <0.6 W and coupling ratio of <0.7 with sensitivity (Sn) of 87%, specificity (Sp) of 91%, positive predictive value of 81%, and negative predictive value of 94%. In a cohort of 224 patients with SCAI Stage C shock requiring milrinone initiation, a baseline MPS score of <0.5 was associated with a 35% event rate of the composite endpoint of death, left ventricular assist device, or transplant at 30 days compared with 3% for those with an MPS >1 (p < 0.001). Patients who were able to augment their MPS to >1 after milrinone infusion had a lower event rate than those with insufficient reserve (40% vs. 16%, p = 0.01). Conclusions The MPS, which defines the patient-specific power-to-efficiency ratio and is inversely proportional to PE, represents an objective assessment of the myocardial energetic state of a patient and can be used to define the physiological tipping point for patients with advanced heart failure.
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Affiliation(s)
- Jonathan Grinstein
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL, United States
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Grant MC, Salenger R, Lobdell KW. Perioperative hemodynamic monitoring in cardiac surgery. Curr Opin Anaesthesiol 2024; 37:1-9. [PMID: 38085877 DOI: 10.1097/aco.0000000000001327] [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: 12/20/2023]
Abstract
PURPOSE OF REVIEW Cardiac surgery has traditionally relied upon invasive hemodynamic monitoring, including regular use of pulmonary artery catheters. More recently, there has been advancement in our understanding as well as broader adoption of less invasive alternatives. This review serves as an outline of the key perioperative hemodynamic monitoring options for cardiac surgery. RECENT FINDINGS Recent study has revealed that the use of invasive monitoring such as pulmonary artery catheters or transesophageal echocardiography in low-risk patients undergoing low-risk cardiac surgery is of questionable benefit. Lesser invasive approaches such a pulse contour analysis or ultrasound may provide a useful alternative to assess patient hemodynamics and guide resuscitation therapy. A number of recent studies have been published to support broader indication for these evolving technologies. SUMMARY More selective use of indwelling catheters for cardiac surgery has coincided with greater application of less invasive alternatives. Understanding the advantages and limitations of each tool allows the bedside clinician to identify which hemodynamic monitoring modality is most suitable for which patient.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kevin W Lobdell
- Sanger Heart & Vascular Institute, Advocate Health, Charlotte, North Carolina, USA
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Youmans QR, Lala A, Mentz RJ. JCF Heart Failure Year-In-Review 2023… Shaping the Future of Heart Failure. J Card Fail 2024; 30:1-3. [PMID: 38212089 DOI: 10.1016/j.cardfail.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Affiliation(s)
- Quentin R Youmans
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
| | - Robert J Mentz
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
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