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Fan TD, Bei DK, Wang Q. Relationship between admission blood urea nitrogen levels and postoperative length of stay in patients with hip fracture: A retrospective study. Medicine (Baltimore) 2024; 103:e38918. [PMID: 38996118 PMCID: PMC11245248 DOI: 10.1097/md.0000000000038918] [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: 01/16/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
To investigate the relationship between admission blood urea nitrogen (BUN) levels and postoperative length of stay (LOS) in hip fracture (HF) patients. This retrospective study retrieved related data from the MIMIC-IV database, of which the laboratory variables were taken preoperatively. The patients were divided into 4 groups according to the BUN quartile levels. After exploring the nonlinear relationship between BUN and LOS by generalized additive model, their connection was further analyzed using the generalized linear models, quantile regression models, and interaction analysis. Receiver operating characteristic curve analysis and decision curve analysis were performed to evaluate its value in predicting first intensive care unit admission and in-hospital mortality. Totally 1274 patients with HF were enrolled in the study. There was a nonlinear relationship between BUN and LOS (P < .05). Besides, BUN was an independent predictor for LOS after adjusting different covariates in 3 models (P < .05). Age served as a significant interactor in this relationship (P < .05). Moreover, receiver operating characteristic curve and decision curve analysis revealed the predictive value of BUN for intensive care unit admission and in-hospital mortality in HF. Admission BUN level as a cost-effective and easy-to-collect biomarker is significantly related to LOS in patients with HF. It helps clinicians to identify potential high-risk populations and take effective preventions before surgery to reduce postoperative LOS.
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Affiliation(s)
- Teng-di Fan
- Department of Orthopedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Di-kai Bei
- Department of Orthopedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
| | - Qi Wang
- Department of Medical Record Office, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China
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Brewer JM, Maybauer MO. Extracorporeal Membrane Oxygenation to Support the Circulation in Interventional Cardiac Procedures. Ann Card Anaesth 2024; 27:189-192. [PMID: 38963352 PMCID: PMC11315260 DOI: 10.4103/aca.aca_122_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 06/08/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Joseph M. Brewer
- Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support Service, INTEGRIS Health Baptist Medical Center, Oklahoma City, OK, USA
| | - Marc O. Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida, Gainesville, FL, USA
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, Australia
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Hao T, Jiang Y, Wu C, Li C, Chen C, Xie J, Pan C, Guo F, Huang Y, Liu L, Xie H, Du Z, Hou X, Liu S, Yang Y, Qiu H. Clinical outcome and risk factors for acute fulminant myocarditis supported by venoarterial extracorporeal membrane oxygenation: An analysis of nationwide CSECLS database in China. Int J Cardiol 2023; 371:229-235. [PMID: 36174824 DOI: 10.1016/j.ijcard.2022.09.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 08/04/2022] [Accepted: 09/21/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND To assess the outcomes and risk factors for adult patients with acute fulminant myocarditis (AFM) supported with venoarterial extracorporeal membrane oxygenation (VA ECMO) in China mainland. METHODS Data were extracted from Chinese Society of ExtraCorporeal Life Support (CSECLS) Registry database. Data from adult patients who were diagnosed with AFM and needed VA ECMO in the database were retrospectively analyzed. The primary outcome was 90-day mortality after ECMO initiation in patients with AFM supported with VA ECMO. Cox proportional hazard regression model was used to examine the risk factors associated with 90-day mortality. RESULTS Among 221 patients enrolled and followed up to 90 days, 186 (84.2%) patients weaned from ECMO and 159 (71.9%) patients survived and discharged home. The median age was 38 years (IQR 29-49) and males (n = 115) represented 52.0% of the total accounted patients. The median ECMO duration was 134 h (IQR 96-177 h). The main adverse event during ECMO course was bleeding (16.3%), followed by infection (15.4%). In the multivariate Cox model analysis, cardiac arrest prior to ECMO initiation (adjusted HR 2.529; 95%CI: 1.341-4.767, p = 0.004), lower pH value (adjusted HR 0.016; 95%CI: 0.010-0.059, p < 0.001) and higher lactate concentration at 24 h after ECMO initiation (adjusted HR 1.146; 95%CI: 1.075-1.221, p < 0.001) were associated with 90-day mortality. CONCLUSIONS 71.9% patients with AFM (clinical diagnosed) supported with VA ECMO survived. Cardiac arrest prior to ECMO, lower pH and higher lactate concentration at 24 h after ECMO initiation were correlated with 90-day mortality of AFM patients supported with VA ECMO.
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Affiliation(s)
- Tong Hao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Yu Jiang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Changde Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chuang Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Chun Pan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
| | - Haixiu Xie
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhongtao Du
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Songqiao Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China; Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, No. 86 Chongwen Road, Lishui District, Nanjing 211200, Jiangsu, People's Republic of China.
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China.
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu 210009, People's Republic of China
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Waskowski J, Michel MC, Steffen R, Messmer AS, Pfortmueller CA. Fluid overload and mortality in critically ill patients with severe heart failure and cardiogenic shock-An observational cohort study. Front Med (Lausanne) 2022; 9:1040055. [PMID: 36465945 PMCID: PMC9712448 DOI: 10.3389/fmed.2022.1040055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/03/2022] [Indexed: 06/03/2024] Open
Abstract
OBJECTIVE Patients with heart failure (HF) and cardiogenic shock are especially prone to the negative effects of fluid overload (FO); however, fluid resuscitation in respective patients is sometimes necessary resulting in FO. We aimed to study the association of FO at ICU discharge with 30-day mortality in patients admitted to the ICU due to severe heart failure and/or cardiogenic shock. METHODS Retrospective, single-center cohort study. Patients with admission diagnoses of severe HF and/or cardiogenic shock were eligible. The following exclusion criteria were applied: (I) patients younger than 16 years, (II) patients admitted to our intermediate care unit, and (III) patients with incomplete data to determine FO at ICU discharge. We used a cumulative weight-adjusted definition of fluid balance and defined more than 5% as FO. The data were analyzed by univariate and adjusted univariate logistic regression. RESULTS We included 2,158 patients in our analysis. 185 patients (8.6%) were fluid overloaded at ICU discharge. The mean FO in the FO group was 7.2% [interquartile range (IQR) 5.8-10%]. In patients with FO at ICU discharge, 30-day mortality was 22.7% compared to 11.7% in non-FO patients (p < 0.001). In adjusted univariate logistic regression, we did not observe any association of FO at discharge with 30-day mortality [odds ratio (OR) 1.48; 95% confidence interval (CI) 0.81-2.71, p = 0.2]. No association between FO and 30-day mortality was found in the subgroups with HF only or cardiogenic shock (all p > 0.05). Baseline lactate (adjusted OR 1.27; 95% CI 1.13-1.42; p < 0.001) and cardiac surgery at admission (adjusted OR 1.94; 95% CI 1.0-3.76; p = 0.05) were the main associated factors with FO at ICU discharge. CONCLUSION In patients admitted to the ICU due to severe HF and/or cardiogenic shock, FO at ICU discharge seems not to be associated with 30-day mortality.
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Affiliation(s)
- Jan Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Pang S, Miao G, Zhao X. Effects and safety of extracorporeal membrane oxygenation in the treatment of patients with ST-segment elevation myocardial infarction and cardiogenic shock: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:963002. [PMID: 36237911 PMCID: PMC9552800 DOI: 10.3389/fcvm.2022.963002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/05/2022] [Indexed: 11/27/2022] Open
Abstract
Background There is a lack of large randomized controlled trials (RCTs) that comprehensively evaluate the effects of venoarterial extracorporeal membrane oxygenation (V-A ECMO)- assisted treatment of patients with ST-segment elevation myocardial infarction (STEMI) combined with Cardiogenic shock (CS). This meta-analysis aims to identify predictors of short-term mortality, and the incidence of various complications in patients with STEMI and CS treated with V-A ECMO. Methods We searched PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and the Wanfang Database from 2008 to January 2022 for studies evaluating patients with STEMI and CS treated with V-A ECMO. Studies that reported on mortality in ≥ 10 adult (>18 years) patients were included. Newcastle-Ottawa Scale was used by two independent reviewers to assess methodological quality. Mantel-Haenszel models were used to pool the data for meta-analysis. Results Sixteen studies (1,162 patients) were included with a pooled mortality estimate of 50.9%. Age > 65 years, BMI > 25 kg/m2, lactate > 8 mmol/L, anterior wall infarction, longer CPR time, and longer time from arrest to extracorporeal cardiopulmonary resuscitation (ECPR) were risk predictors of mortality. Achieving TIMI-3 flow after percutaneous coronary intervention (PCI) was a protective factor of mortality. The prevalence of bleeding, cerebral infarction, leg ischemia, and renal failure were 22, 9.9, 7.4, and 49.4%, respectively. Conclusion Our study identified Age, BMI, lactate, anterior wall infarction, TIMI-3 flow after PCI, CPR time, and time from arrest to ECPR significantly influence mortality in STEMI patients with CS requiring V-A ECMO. These factors may help clinicians to detect patients with poor prognoses earlier and develop new mortality prediction models.
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A. Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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The effect of complete revascularization in patients with ST-segment elevation myocardial infarction with Killip class ≥ III. Coron Artery Dis 2021; 31:13-19. [PMID: 31658147 PMCID: PMC6903383 DOI: 10.1097/mca.0000000000000815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The effect of complete revascularization (CR) on high-risk patients with ST-segment elevation myocardial infarction (STEMI) has remains a controversial issue, especially on patients in a critical condition. The aim of this study was to explore the effect of CR on patients with STEMI with Killip class ≥ III. METHODS From January 2008 to December 2014, 185 patients diagnosed with STEMI with Killip class ≥ III and multiple vessel coronary artery disease received primary percutaneous coronary intervention (PCI). Eighty-nine patients underwent culprit-only PCI, and the remaining 96 patients underwent immediate or staged PCI for CR. Out of the 96 patients in the CR group, 51 patients underwent immediate CR, and 45 patients underwent CR during the same hospitalization. Thirty-day and 1-year clinical outcomes were compared between the culprit-only PCI group and the CR group as well as between the immediate CR group and staged CR group. RESULTS There was a trend toward a lower incidence of post-PCI acute kidney injury in the culprit-only PCI group when compared with the CR group (14.8% vs. 26.0%; P = 0.069). Thirty-day and 1-year cardiovascular mortality and all-cause mortality were similar between the culprit-only PCI group and CR group. Decreased 1-year cardiovascular mortality and all-cause mortality were noted in the staged CR group compared with the immediate CR group. CONCLUSION was associated a higher possibility of post-PCI acute kidney injury and did not seem to improve 30-day or 1-year clinical outcomes. Patients undergoing staged CR during the same hospitalization had better clinical outcomes.
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Semaan C, Charbonnier A, Pasco J, Darwiche W, Saint Etienne C, Bailleul X, Bourguignon T, Fauchier L, Angoulvant D, Ivanes F, Genet T. Risk Scores in ST-Segment Elevation Myocardial Infarction Patients with Refractory Cardiogenic Shock and Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2021; 10:jcm10050956. [PMID: 33804450 PMCID: PMC7957612 DOI: 10.3390/jcm10050956] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 12/14/2022] Open
Abstract
Although many risk models have been tested in patients implanted by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), few scores assessed patients’ prognosis in the setting of ST-segment elevation myocardial infarction (STEMI) with refractory cardiogenic shock. We aimed at assessing the performance of risk scores, notably the prEdictioN of Cardiogenic shock OUtcome foR AMI patients salvaGed by VA-ECMO (ENCOURAGE) score, for predicting mortality in this particular population. This retrospective observational study included patients admitted to Tours University Hospital for STEMI with cardiogenic shock and requiring hemodynamic support by VA-ECMO. Among the fifty-one patients, the 30-day and 6-month survival rates were 63% and 56% respectively. Thirty days after VA-ECMO therapy, probabilities of mortality were 12, 17, 33, 66, 80% according to the ENCOURAGE score classes 0–12, 13–18, 19–22, 23–27, and ≥28, respectively. The ENCOURAGE score (AUC of the Receiving Operating Characteristic curve = 0.83) was significantly better compared to other risk scores. The hazard ratio for survival at 30 days for each point of the ENCOURAGE score was 1.10 (CI 95% (1.06, 1.15); p < 0.001). Decision curve analysis indicated that the ENCOURAGE score had the best clinical usefulness of the tested risk scores and the Hosmer–Lemeshow test suggested an accurate calibration. Our data suggest that the ENCOURAGE score is valid and the most relevant score to predict 30-day mortality after VA-ECMO therapy in STEMI patients with refractory cardiogenic shock. It may help decision-making teams to better select STEMI patients with shock for VA-ECMO therapy.
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Affiliation(s)
- Carl Semaan
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Arthur Charbonnier
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
| | - Jeremy Pasco
- Service d’Informatique Médicale, Épidémiologie et Économie de la Santé, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France;
| | - Walid Darwiche
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Christophe Saint Etienne
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
| | - Xavier Bailleul
- Service de Chirurgie Cardiaque, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France;
| | - Thierry Bourguignon
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
- Service de Chirurgie Cardiaque, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France;
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Denis Angoulvant
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
| | - Fabrice Ivanes
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
- Faculté de Médecine, Université de Tours, 37032 Tours, France;
- Correspondence:
| | - Thibaud Genet
- Service de Cardiologie, Centre Hospitalier Régional, Universitaire de Tours, 37044 Tours, France; (C.S.); (A.C.); (W.D.); (C.S.E.); (L.F.); (D.A.); (T.G.)
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Blood Urea Nitrogen and In-Hospital Mortality in Critically Ill Patients with Cardiogenic Shock: Analysis of the MIMIC-III Database. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5948636. [PMID: 33604376 PMCID: PMC7870297 DOI: 10.1155/2021/5948636] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 11/27/2022]
Abstract
The association between blood urea nitrogen (BUN) and prognosis has been the focus of recent research. Therefore, the objective of this study was to investigate the association between BUN and hospital mortality in critically ill patients with cardiogenic shock (CS). This was a retrospective cohort study, in which data were obtained from the Medical Information Mart for Intensive Care III V1.4 database. Data from 697 patients with CS were analyzed. Logistic regression and subgroup analyses were used to assess the association between BUN and hospital mortality in patients with CS. The average age of the 697 participants was 71.14 years, and approximately 42.18% were men. In the multivariate logistic regression model, after adjusting for age, sex, diabetes, cardiac arrhythmias, urine output, simplified acute physiology score II, sequential organ failure assessment, creatinine, anion gap, and heart rate, high BUN demonstrated strong associations with increased in-hospital mortality (per standard deviation increase: odds ratio [OR] 1.47, 95% confidence interval [CI] 1.13–1.92). A similar result was observed in BUN tertile groups (BUN 23–37 mg/dL versus 6–22 mg/dL: OR [95% CI], 1.42 [0.86–2.34]; BUN 38–165 mg/dL versus 6–22 mg/dL: OR [95% CI], 1.99 [1.10–3.62]; P trend 0.0272). Subgroup analysis did not reveal any significant interactions among various subgroups, and higher BUN was associated with adverse clinical outcomes in patients with CS.
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Extracorporeal Membrane Oxygenation during Percutaneous Coronary Intervention in Patients with Coronary Heart Disease. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:196-202. [PMID: 32981957 DOI: 10.1182/ject-1900039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/16/2020] [Indexed: 12/23/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has become an effective method in the treatment of adults and children with severe cardiac and pulmonary dysfunction that is resistant to conventional therapy. The aim of this article was to summarize an experience of ECMO usage for cardiac dysfunction, which develops in patients with coronary heart disease (CHD) during percutaneous transluminal coronary angioplasty. The study comprised a retrospective, single-center analysis of 23 patients with CHD (19 men and four women, average age 65.7 ± 12.3 years), who undertook the ECMO technique during percutaneous transluminal coronary angioplasty. A total of 13 (56.52%) patients died directly in the hospital, or 30 days after a discharge. Independent predictors of fatal outcomes were diabetes mellitus (odds ratio [OR] = 17.58; 95% confidence interval [CI] = 6.47-47.48; p = .00125), chronic renal failure (CRF) (OR = 20.81; 95% CI = 5.95-72.21; p = .00014), and damage to the right coronary artery (RCA) (OR = 25.51; 95% CI = 8.27-79.12; p = .00013). For deceased patients, the "no reflow" phenomenon was indicated in a larger percentage of cases (23.1% in the group of deceased, vs. 10% in the group of survivors). A routine connection to ECMO before the occurrence of cardiac events was significantly more often used in the group of survived patients (90% of cases) than in the deceased (p = .0000001). Diabetes mellitus, CRF, and damage to the RCA were independent predictors of mortality during percutaneous transluminal coronary angioplasty in patients with CHD. The routine use of ECMO in high-risk patients with percutaneous transluminal coronary angioplasty was a positive prognostic factor of patient survival.
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Predictors of Survival for Patients with Acute Decompensated Heart Failure Requiring Extra-Corporeal Membrane Oxygenation Therapy. ASAIO J 2020; 65:781-787. [PMID: 30312208 DOI: 10.1097/mat.0000000000000898] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Chronic systolic heart failure (HF) with acute decompensation can result in cardiogenic shock (CS) requiring short-term mechanical circulatory support. We sought to identify predictors of survival for acute decompensated HF (ADHF) patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients >18 years old treated at our institution with VA-ECMO from 2009 to 2018 for ADHF with CS were studied. Demographic, hemodynamic, and echocardiographic data were collected. The primary outcome was survival to discharge. Fifty-two patients received VA-ECMO for ADHF with CS; 24 (46.2%) survived. Seventeen (32.7%) had suffered cardiac arrest, and 37 (71.2%) were mechanically ventilated. Mean lactate was 4.33 ± 3.45 mmol/L, and patients were receiving 2.7 ± 1.2 vasopressor/inotropic infusions at ECMO initiation; these did not differ significantly between survivors and nonsurvivors. Pre-ECMO cardiac index was 1.84 ± 0.56L/min/m and 1.94 ± 0.63L/min/m in survivors and nonsurvivors, respectively (p = 0.57). In multivariable analysis, only diabetes mellitus (DM; OR, 13.25; CI, 1.42-123.40; p = 0.02) and mineralocorticoid receptor antagonist use (OR, 0.12; CI, 0.02-0.78; p = 0.03) were independent predictors of mortality. Nineteen (79.2%) survivors required durable ventricular assist device. Among ADHF patients receiving VA-ECMO, DM is a powerful predictor of outcomes while markers of clinical acuity including hemodynamics, vasopressor/inotrope use, and lactate are not. The vast majority of survivors required durable left-ventricular assist devices.
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van den Brink FS, Meijers TA, Hofma SH, van Boven AJ, Nap A, Vonk A, Symersky P, Sjauw KD, Knaapen P. Prophylactic veno-arterial extracorporeal membrane oxygenation in patients undergoing high-risk percutaneous coronary intervention. Neth Heart J 2020; 28:139-144. [PMID: 31782108 PMCID: PMC7052097 DOI: 10.1007/s12471-019-01350-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Complex high-risk percutaneous coronary intervention (PCI) is challenging and frequently accompanied by haemodynamic instability. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide cardiopulmonary support in high-risk PCI. However, the outcome is unclear. METHODS A two-centre, retrospective study was performed of all patients undergoing high-risk PCI and receiving VA-ECMO for cardiopulmonary support. RESULTS A total of 14 patients (92% male, median age 69 (53-83) years), of whom 50% had previous coronary artery disease in the form of a coronary artery bypass graft (36%) and a PCI (14%) underwent high-risk PCI and received VA-ECMO support. The main target lesion was a left main coronary artery in 78%, a left anterior descending artery in 14%, a right coronary artery in 7%, and 71% underwent multi-vessel PCI in addition to main target vessel PCI. The median SYNTAX score was 27.2 (8-42.5) and in 64% (9/14) there was a chronic total occlusion. Left ventricular function was mildly impaired in 7% (1/14), moderately impaired in 14% (2/14) and severely impaired in 64% (9/14). Cannulation was femoral-femoral in all patients. Median ECMO run was 2.57 h (1-4). Survival was 93% (13/14). One patient died during hospitalisation due to refractory cardiac failure. All other patients survived to discharge. Complications occurred in 14% (2/14), with one patient developing a transient ischaemic attack post-ECMO and one patient developing a thrombus in the femoral vein used for ECMO cannulation. CONCLUSION VA-ECMO in high-risk PCI is feasible with a good outcome. It can be successfully used for cardiopulmonary support in selected patients.
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Affiliation(s)
- F S van den Brink
- Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands.
| | - T A Meijers
- Department of Cardiology, Location Vrije Universiteit Medisch Centrum, Amsterdam Universitair Medisch Centrum, Amsterdam, The Netherlands
| | - S H Hofma
- Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - A J van Boven
- Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - A Nap
- Department of Cardiology, Location Vrije Universiteit Medisch Centrum, Amsterdam Universitair Medisch Centrum, Amsterdam, The Netherlands
| | - A Vonk
- Department of Cardiology, Location Vrije Universiteit Medisch Centrum, Amsterdam Universitair Medisch Centrum, Amsterdam, The Netherlands
| | - P Symersky
- Department of Cardio-Thoracic Surgery, Location Vrije Universiteit Medisch Centrum, Amsterdam Universitair Medisch Centrum, Amsterdam, The Netherlands
| | - K D Sjauw
- Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - P Knaapen
- Department of Cardiology, Location Vrije Universiteit Medisch Centrum, Amsterdam Universitair Medisch Centrum, Amsterdam, The Netherlands
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Extracorporeal Membrane Oxygenation Use in Cardiogenic Shock: Impact of Age on In-Hospital Mortality, Length of Stay, and Costs. Crit Care Med 2020; 47:e214-e221. [PMID: 30585830 DOI: 10.1097/ccm.0000000000003631] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Increasing age is a well-recognized risk factor for in-hospital mortality in patients receiving extracorporeal membrane oxygenation for cardiogenic shock, but the shape of this relationship is unknown. In addition, the impact of age on hospital length of stay, patterns of patient disposition, and costs has been incompletely characterized. DESIGN Retrospective analysis of the National Inpatient Sample. SETTING U.S. nonfederal hospitals, years 2004-2016. PATIENTS Adults with cardiogenic shock treated with extracorporeal membrane oxygenation (3,094; weighted national estimate: 15,415). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The mean age of extracorporeal membrane oxygenation recipients was 54.8 ± 15.4 years (range, 18-90 yr). Crude in-hospital mortality was 57.7%. Median time-to-death was 8 days (interquartile range, 3-17 d). A linear relationship between age and in-hospital mortality was observed with a 14% increase in the adjusted odds of in-hospital mortality for every 10-year increase in age (adjusted odds ratio, 1.14; 95% CI, 1.08-1.21; p < 0.0001). Thirty-four percent of patients were discharged alive at a median time of 30 days (interquartile range, 19-48 d). The median length of stay and total hospitalization costs were 14 days (interquartile range, [5-29 d]) and $134,573 ($71,782-$239,439), respectively, both of which differed significantly by age group (length of stay range from 17 d [18-49 yr] to 9 d [80-90 yr]; p < 0.0001 and cost range $147,548 [18-49 yr] to $105,350 [80-90 yr]; p < 0.0001). CONCLUSIONS Age is linearly associated with increasing in-hospital mortality in individuals receiving extracorporeal membrane oxygenation for cardiogenic shock without evidence of a threshold effect. Median time-to-death is approximately 1 week. One third of patients are discharged from the hospital alive, but the median time-to-discharge is 1 month. Median length of stay ranges from 9 to 17 days depending on age. Hospitalization costs exceed $100,000 in all age groups.
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14
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Predicting Survival in Patients Treated With Extracorporeal Membrane Oxygenation After Myocardial Infarction. Crit Care Med 2019; 46:e359-e363. [PMID: 29373359 DOI: 10.1097/ccm.0000000000002995] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Acute myocardial infarction is the most common cause of cardiogenic shock. Although the number of patients with acute myocardial infarction complicated by cardiogenic shock who were treated with venoarterial extracorporeal membrane oxygenation increased during the last decade, detailed data on survival are lacking. We sought to analyze covariates that were independently associated with survival in this patient population and to externally validate the newly developed prEdictioN of Cardiogenic shock OUtcome foR Acute myocardial infarction patients salvaGed by venoarterial Extracorporeal membrane oxygenation (ENCOURAGE) score. DESIGN Retrospective clinical study. SETTING A single academic teaching hospital. PATIENTS Adult patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation from June 2008 to September 2016. INTERVENTIONS Fourteen individual variables were assessed for their association with the primary endpoint. These variables were prespecified by the study team as being the most likely to affect survival. A receiver operating characteristic analysis was also performed to test the ability of the ENCOURAGE score to predict survival in this patient cohort. MEASUREMENTS AND MAIN RESULTS The primary endpoint of the study was in-hospital survival. A total of 61 patients were included in the analysis. Thirty-seven (60.7%) could be weaned from venoarterial extracorporeal membrane oxygenation and 36 (59.0%) survived. Survival was significantly higher in patients less than 65 years old (odds ratio, 14.6 [CI, 2.5-84.0]; p = 0.003), whose body mass index was less than 32 kg/m (odds ratio, 5.5 [CI, 1.2-25.4]; p = 0.029) and international normalized ratio was less than 2 (odds ratio, 7.3 [CI, 1.3-40.1]; p = 0.022). In patients where the first lactate drawn was less than 3 mmol/L, the survival was not significantly higher (odds ratio, 4.4 [CI, 0.6-32.6]; p = 0.147). The C-statistic for predicting survival using a modified version of the ENCOURAGE score, which replaced prothrombin activity less than 50% with an international normalized ratio greater than 2, was 0.74 (95% CI, 0.61-0.87). CONCLUSIONS In this single-center study, several important covariates were associated with improved survival in patients with acute myocardial infarction complicated by cardiogenic shock who were supported by venoarterial extracorporeal membrane oxygenation and the ENCOURAGE score was found to be externally valid for predicting survival to hospital discharge.
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15
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Extracorporeal membrane oxygenation in patients with heart transplantation : A clinical prognosis analysis. Herz 2019; 45:739-744. [PMID: 31410515 DOI: 10.1007/s00059-019-04843-9] [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: 06/23/2019] [Revised: 07/07/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is indicated for bridging to heart transplantation, graft failure, and right heart failure after heart transplantation. This study explored risk factors affecting the clinical prognosis of cardiac transplantation patients treated with ECMO during the perioperative period. METHODS Data on 28 heart transplantation patients with ECMO obtained from January 2012 to January 2018 in the People's Hospital of Zhongshan City were retrospectively analyzed. RESULTS A total of 25 patients (20 male and 5 female) were finally included. Heart transplantation was performed mainly due to cardiomyopathy (77.8%). Of the treated patients, 18 (72%) survived and were discharged, 4 were treated with cardiopulmonary resuscitation (CPR) before ECMO, and 3 died in hospital. There were no differences between the surviving and death group donors (N-terminal pro b‑type natriuretic peptide [NT-proBNP], creatine kinase-muscle/brain [CK-MB], warm ischemia time of donated heart, cold ischemia time of donated heart, total ischemia time of donated heart, and donor type). In univariate analysis, body mass index (BMI), length of stay in the intensive care unit (ICU), and CPR were relevant prognostic factors for heart transplantation patients with ECMO. Multi-factor logistic regression showed that CPR before ECMO (odds ratio, OR, 49.45; 95% confidence interval, CI, [1.37, 1781.6]; P = 0.033) is an independent risk factor influencing prognosis. CONCLUSION ECMO is an important life support method for patients before and after heart transplantation surgery. Obesity, poor preoperative cardiac function, and considerable intraoperative red blood cell transfusion may influence prognosis. Extracardiac compression before ECMO is an independent risk factor for prognosis.
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16
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Asleh R, Resar JR. Utilization of Percutaneous Mechanical Circulatory Support Devices in Cardiogenic Shock Complicating Acute Myocardial Infarction and High-Risk Percutaneous Coronary Interventions. J Clin Med 2019; 8:E1209. [PMID: 31412669 PMCID: PMC6724052 DOI: 10.3390/jcm8081209] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/24/2019] [Accepted: 08/08/2019] [Indexed: 01/14/2023] Open
Abstract
Given the tremendous progress in interventional cardiology over the last decade, a growing number of older patients, who have more comorbidities and more complex coronary artery disease, are being considered for technically challenging and high-risk percutaneous coronary interventions (PCI). The success of performing such complex PCI is increasingly dependent on the availability and improvement of mechanical circulatory support (MCS) devices, which aim to provide hemodynamic support and left ventricular (LV) unloading to enable safe and successful coronary revascularization. MCS as an adjunct to high-risk PCI may, therefore, be an important component for improvement in clinical outcomes. MCS devices in this setting can be used for two main clinical conditions: patients who present with cardiogenic shock complicating acute myocardial infarction (AMI) and those undergoing technically complex and high-risk PCI without having overt cardiogenic shock. The current article reviews the advancement in the use of various devices in both AMI complicated by cardiogenic shock and complex high-risk PCI, highlights the available hemodynamic and clinical data associated with the use of MCS devices, and presents suggestive management strategies focusing on appropriate patient selection and optimal timing and support to potentially increase the clinical benefit from utilizing these devices during PCI in this high-risk group of patients.
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Affiliation(s)
- Rabea Asleh
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jon R Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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17
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Pozzi M, Flagiello M, Armoiry X, Generali T, Adamou Nouhou K, Koffel C, Schweizer R, Fellahi JL, Cuenin L, Cellier G, Green L, Derimay F, Rioufol G, Finet G, Obadia JF. Extracorporeal life support in the multidisciplinary management of cardiogenic shock complicating acute myocardial infarction. Catheter Cardiovasc Interv 2019; 95:E71-E77. [DOI: 10.1002/ccd.28316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 02/03/2019] [Accepted: 04/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Michele Flagiello
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Xavier Armoiry
- Division of Health SciencesUniversity of Warwick, Warwick Medical School Coventry England
| | - Tommaso Generali
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Kaled Adamou Nouhou
- Department of Cardiac Surgery“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Catherine Koffel
- Department of Anesthesia and ICU“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Remi Schweizer
- Department of Anesthesia and ICU“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Jean Luc Fellahi
- Department of Anesthesia and ICU“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Leo Cuenin
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Guillaume Cellier
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Lisa Green
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Francois Derimay
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Gilles Rioufol
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Gerard Finet
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
| | - Jean Francois Obadia
- Department of Cardiology“Louis Pradel” Cardiologic Hospital, “Claude Bernard” University Lyon France
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Lactate Clearance Predicts Good Neurological Outcomes in Cardiac Arrest Patients Treated with Extracorporeal Cardiopulmonary Resuscitation. J Clin Med 2019; 8:jcm8030374. [PMID: 30889788 PMCID: PMC6462911 DOI: 10.3390/jcm8030374] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background: We evaluated critically ill patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) due to cardiac arrest (CA) with respect to baseline characteristics and laboratory assessments, including lactate and lactate clearance for prognostic relevance. Methods: The primary endpoint was 30-day mortality. The impact on 30-day mortality was assessed by uni- and multivariable Cox regression analyses. Neurological outcome assessed by Glasgow Outcome Scale (GOS) was pooled into two groups: scores of 1–3 (bad GOS score) and scores of 4–5 (good GOS score). Results: A total of 93 patients were included in the study. Serum lactate concentration (hazard ratio (HR) 1.09; 95% confidence interval (CI) 1.04–1.13; p < 0.001), hemoglobin, (Hb; HR 0.87; 95% CI 0.79–0.96; p = 0.004), and catecholamine use were associated with 30-day-mortality. In a multivariable model, only lactate clearance (after 6 h; OR 0.97; 95% CI 0.94–0.997; p = 0.03) was associated with a good GOS score. The optimal cut-off of lactate clearance at 6 h for the prediction of a bad GOS score was at ≤13%. Patients with a lactate clearance at 6 h ≤13% evidenced higher rates of bad GOS scores (97% vs. 73%; p = 0.01). Conclusions: Whereas lactate clearance does not predict mortality, it was the sole predictor of good neurological outcomes and might therefore guide clinicians when to stop ECPR.
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19
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Predictors of mid-term outcomes in patients undergoing implantation of a ventricular assist device directly after extracorporeal life support. Eur J Cardiothorac Surg 2018; 55:773-779. [DOI: 10.1093/ejcts/ezy351] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/23/2018] [Accepted: 09/13/2018] [Indexed: 01/07/2023] Open
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20
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Abstract
Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.
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Affiliation(s)
- Deepak Acharya
- From the Section of Advanced Heart Failure, Mechanical Circulatory Support, and Pulmonary Vascular Disease, University of Alabama at Birmingham, Birmingham, AL
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21
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Lactate and microcirculation as suitable targets for hemodynamic optimization in resuscitation of circulatory shock. Curr Opin Crit Care 2018; 23:348-354. [PMID: 28537998 DOI: 10.1097/mcc.0000000000000423] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW A discussion of recent research exploring the feasibility of perfusion-guided resuscitation of acute circulatory failure with a focus on lactate and microcirculation. RECENT FINDINGS Upon diagnosis of shock, hyperlactemia is associated with poor outcome and, under appropriate clinical circumstances, may reflect inadequate tissue perfusion. Persistent hyperlactemia despite resuscitation is even more strongly correlated with morbidity and mortality. Importantly, there is minimal coherence between lactate trends and static hemodynamic measures such as blood pressure, especially after the initial, hypovolemic phase of shock. During this early period, lactate guided-resuscitation is effective and possibly superior to hemodynamic-guided resuscitation. Similar to hyperlactemia, impaired microcirculation is ubiquitous in shock and is evident even in the setting of hemodynamic compensation (i.e., occult shock). Moreover, persistent microcirculatory derangement is associated with poor outcome and may reflect ongoing shock and/or long-lasting damage. Although the wait continues for a microcirculation-guided resuscitation trial, there is progress toward this goal. SUMMARY Although questions remain, a multimodal perfusion-based approach to resuscitation is emerging with lactate and microcirculation as core measures. In this model, hyperlactemia and microcirculatory derangement support the diagnosis of shock, may help guide resuscitation during the initial period, and may reflect resuscitation efficacy and iatrogenic harm (e.g., fluid overload).
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22
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Veno-arterial extracorporeal membrane oxygenation in addition to primary PCI in patients presenting with ST-elevation myocardial infarction. Neth Heart J 2017; 26:76-84. [PMID: 29260464 PMCID: PMC5783893 DOI: 10.1007/s12471-017-1068-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction Primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI) can cause great haemodynamic instability. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide haemodynamic support in patients with STEMI but data on outcome and complications are scarce. Methods An in-hospital registry was conducted enrolling all patients receiving VA-ECMO. Patients were analysed for medical history, mortality, neurological outcome, complications and coronary artery disease. Results Between 2011 and 2016, 12 patients underwent pPCI for STEMI and received VA-ECMO for haemodynamic support. The majority of the patients were male (10/12) with a median age of 63 (47–75) years and 4 of the 12 patients had a history of coronary artery disease. A cardiac arrest was witnessed in 11 patients. The left coronary artery was compromised in 8 patients and 4 had right coronary artery disease. All patients were in Killip class IV. Survival to discharge was 67% (8/12), 1‑year survival was 42% (5/12), 2 patients have not yet reached the 1‑year survival point but are still alive and 1 patient died within a year after discharge. All-cause mortality was 42% (5/12) of which mortality on ECMO was 33% (4/12). Patient-related complications occurred in 6 of the 12 patients: 1 patient suffered major neurological impairment, 2 patients suffered haemorrhage at the cannula site, 2 patients had limb ischaemia and 1 patient had a haemorrhage elsewhere. There were no VA-ECMO hardware malfunctions. Conclusion VA-ECMO in pPCI for STEMI has a high survival rate and neurological outcome is good, even when the patient is admitted with a cardiac arrest.
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Hayıroğlu Mİ, Keskin M, Uzun AO, Yıldırım Dİ, Kaya A, Çinier G, Bozbeyoğlu E, Yıldırımtürk Ö, Kozan Ö, Pehlivanoğlu S. Predictors of In-Hospital Mortality in Patients With ST-Segment Elevation Myocardial Infarction Complicated With Cardiogenic Shock. Heart Lung Circ 2017; 28:237-244. [PMID: 29191504 DOI: 10.1016/j.hlc.2017.10.023] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 10/04/2017] [Accepted: 10/30/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) complicated with cardiogenic shock (CS) remains as an unresolved condition causing high morbidity and mortality despite advances in medical treatment and coronary intervention procedures. In the current study, we evaluated the predictors of in-hospital mortality of STEMI complicated with CS. METHODS In this retrospective study, we evaluated the predictive value of baseline characteristics, angiographic, echocardiographic and laboratory parameters on in-hospital mortality of 319 patients with STEMI complicated with CS who were treated with primary percutaneous coronary intervention. Patients were divided into two groups consisting of survivors and non-survivors during their index hospitalisation period. RESULTS The mortality rate was found to be 61.3% in the study population. At multivariate analysis after adjustment for the parameters detected in univariate analysis, chronic renal failure, Thrombolysis In Myocardial Infarction (TIMI) post percutaneous coronary intervention (PCI) ≤2, plasma glucose and lactate level, blood urea nitrogen level, Tricuspid Annular Plane Systolic Excursion (TAPSE) and ejection fraction were independent predictors of in-hospital mortality. CONCLUSIONS Apart from haemodynamic deterioration, angiographic, echocardiographic and laboratory parameters have an impact on in-hospital mortality in patients with STEMI complicated with CS.
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Affiliation(s)
- Mert İlker Hayıroğlu
- Department of Cardiology, Haydapasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey.
| | - Muhammed Keskin
- Department of Cardiology, Haydapasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Okan Uzun
- Department of Cardiology, Hatay Dortyol State Hospital, Dörtyol, Hatay, Turkey
| | - Duygu İlke Yıldırım
- Department of Family Medicine, Health Sciences University Konya Training and Research Hospital, Konya, Turkey
| | - Adnan Kaya
- Department of Cardiology, Düzce University Faculty of Medicine, Düzce, Turkey
| | - Göksel Çinier
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Emrah Bozbeyoğlu
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Özlem Yıldırımtürk
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ömer Kozan
- Department of Cardiology, Haydapasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Seçkin Pehlivanoğlu
- Department of Cardiology, Başkent University Faculty of Medicine, Istanbul, Turkey
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Garan AR, Eckhardt C, Takeda K, Topkara VK, Clerkin K, Fried J, Masoumi A, Demmer RT, Trinh P, Yuzefpolskaya M, Naka Y, Burkhoff D, Kirtane A, Colombo PC, Takayama H. Predictors of survival and ability to wean from short-term mechanical circulatory support device following acute myocardial infarction complicated by cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:755-765. [PMID: 29094607 DOI: 10.1177/2048872617740834] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Cardiogenic shock following acute myocardial infarction (AMI-CS) portends a poor prognosis. Short-term mechanical circulatory support devices (MCSDs) provide hemodynamic support for patients with cardiogenic shock but predictors of survival and the ability to wean from short-term MCSDs remain largely unknown. METHODS: All patients > 18 years old treated at our institution with extra-corporeal membrane oxygenation or short-term surgical ventricular assist device for AMI-CS were studied. We collected acute myocardial infarction details with demographic and hemodynamic variables. Primary outcomes were survival to discharge and recovery from MCSD (i.e. survival without heart replacement therapy including durable ventricular assist device or heart transplant). RESULTS: One hundred and twenty-four patients received extra-corporeal membrane oxygenation or short-term surgical ventricular assist device following acute myocardial infarction from 2007 to 2016; 89 received extra-corporeal membrane oxygenation and 35 short-term ventricular assist device. Fifty-five (44.4%) died in the hospital and 69 (55.6%) survived to discharge. Twenty-six (37.7%) required heart replacement therapy (four transplant, 22 durable ventricular assist device) and 43 (62.3%) were discharged without heart replacement therapy. Age and cardiac index at MCSD implantation were predictors of survival to discharge; patients over 60 years with cardiac index <1.5 l/min per m2 had a low likelihood of survival. The angiographic result after revascularization predicted recovery from MCSD (odds ratio 9.00, 95% confidence interval 2.45-32.99, p=0.001), but 50% of those optimally revascularized still required heart replacement therapy. Cardiac index predicted recovery from MCSD among this group (odds ratio 4.06, 95% confidence interval 1.45-11.55, p=0.009). CONCLUSION: Among AMI-CS patients requiring short-term MCSDs, age and cardiac index predict survival to discharge. Angiographic result and cardiac index predict ventricular recovery but 50% of those optimally revascularized still required heart replacement therapy.
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Affiliation(s)
- A Reshad Garan
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Christina Eckhardt
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Koji Takeda
- 2 Department of Surgery, Columbia University Medical Center, New York, USA
| | - Veli K Topkara
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Kevin Clerkin
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Justin Fried
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Amirali Masoumi
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Ryan T Demmer
- 3 Department of Epidemiology, Columbia University Mailman School of Public Health, New York, USA
| | - Pauline Trinh
- 3 Department of Epidemiology, Columbia University Mailman School of Public Health, New York, USA
| | - Melana Yuzefpolskaya
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Yoshifumi Naka
- 2 Department of Surgery, Columbia University Medical Center, New York, USA
| | - Dan Burkhoff
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Ajay Kirtane
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Paolo C Colombo
- 1 Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, USA
| | - Hiroo Takayama
- 2 Department of Surgery, Columbia University Medical Center, New York, USA
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Yonezu K, Sakakura K, Watanabe Y, Taniguchi Y, Yamamoto K, Wada H, Momomura SI, Fujita H. Determinants of survival and favorable neurologic outcomes in ischemic heart disease treated by veno-arterial extracorporeal membrane oxygenation. Heart Vessels 2017; 33:25-32. [DOI: 10.1007/s00380-017-1031-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/28/2017] [Indexed: 10/19/2022]
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