Cardiogenic shock

ECPELLA as a bridge-to-decision in refractory cardiogenic shock: a single-centre experience

BACKGROUND

In refractory cardiogenic shock, temporary mechanical support (tMCS) may be crucial for maintaining tissue perfusion and oxygen delivery. tMCS can serve as a bridge-to-decision to assess eligibility for left ventricular assist device (LVAD) implantation or heart transplantation, or as a bridge-to-recovery. ECPELLA is a novel tMCS configuration combining venoarterial extracorporeal membrane oxygenation with Impella. The present study presents the clinical parameters, outcomes, and complications of patients supported with ECPELLA.

METHODS

All patients supported with ECPELLA at University Medical Centre Utrecht between December 2020 and August 2023 were included. The primary outcome was 30-day mortality, and secondary outcomes were LVAD implantation/heart transplantation and safety outcomes.

RESULTS

Twenty patients with an average age of 51 years, and of whom 70% were males, were included. Causes of cardiogenic shock were acute heart failure (due to acute coronary syndrome, myocarditis, or after cardiac surgery) or chronic heart failure, respectively 70 and 30% of cases. The median duration of ECPELLA support was 164 h (interquartile range 98-210). In 50% of cases, a permanent LVAD was implanted. Cardiac recovery within 30 days was seen in 30% of cases and 30-day mortality rate was 20%. ECPELLA support was associated with major bleeding (40%), haemolysis (25%), vascular complications (30%), kidney failure requiring replacement therapy (50%), and Impella failure requiring extraction (15%).

CONCLUSION

ECPELLA can be successfully used as a bridge to LVAD implantation or as a bridge-to-recovery in patients with refractory cardiogenic shock. Despite a significant number of complications, 30-day mortality was lower than observed in previous cohorts.

Predicting the mortality of patients with cardiogenic shock after coronary artery bypass grafting

INTRODUCTION

Cardiogenic shock (CS) is a critical condition and the leading cause of mortality after coronary artery bypass grafting (CABG). To define the risk factors for CS in patients who undergo CABG and create a risk-predictive model is crucial.

METHODS

In this observational study, we retrospectively evaluated consecutive patients who underwent CABG between January 2018 and October 2022 at Beijing Anzhen Hospital. A total of 496 patients were enrolled and categorized into the training (396 cases) and internal test (100 cases) sets. The variables significantly associated with mortality (p < 0.05) were analyzed using logistic regression analyses.

RESULTS

The E/A ratio at admission, postoperative brain natriuretic peptide, postoperative arterial lactate, two or more arrhythmias at the same time after CABG, and carotid artery stenosis at admission were identified as independent prognostic factors for in-hospital mortality after multivariate logistic regression analysis. The CS after CABG score (ACCS) was established and three classes of ACCS, named classes I (ACCS, <20), II (ACCS, 20-30), and III (ACCS, >30), made up the risk model. The ACCS showed better discrimination with an AUROC of 0.937 (95% confidence interval, 0.982-0.892) and calibration with the Hosmer-Lemeshow test (X2 = 5.854 with 8 df; p = 0.664). In addition, tenfold cross-validation demonstrated that the mean misdiagnosis rate was 5.56% and the lowest misdiagnosis rate was 6.38%.

CONCLUSION

The ACCS score represents a risk-predictive model for in-hospital mortality of patients with CS after CABG in acute care settings. Patients identified as class III may have a worse prognosis.

Acute kidney injury in patients with acute decompensated heart failure-cardiogenic shock: Prevalence, risk factors and outcome

BACKGROUND

Acute Kidney Injury (AKI) represents a major complication of acute heart failure and cardiogenic shock (CS). There is a paucity of data on AKI complicating acutely decompensated heart failure patients presenting with CS (ADHF-CS). We aimed to investigate AKI prevalence, risk factors and outcomes in this subgroup of patients.

METHODS

Retrospective observational study on patients admitted for ADHF-CS to our 12-bed Intensive Care Unit (ICU), between January 2010 and December 2019. Demographic, clinical, and biochemical variables were collected at baseline and during hospital stay.

RESULTS

Eighty-eight patients were consecutively recruited. The predominant etiologies were idiopathic dilated cardiomyopathy (47%), followed by post-ischemic (24%). AKI was diagnosed in 70 (79.5%) of patients. Forty-three out of 70 patients met the criteria for AKI at ICU admission. On multivariate analysis, a central venous pressure (CVP) higher than 10 mmHg (OR 3.9; 95%CI 1.2-12.6; p = 0.025) and serum lactate higher than 3 mmol/L (OR 4.1; 95%CI 1.01-16.3; p = 0.048) were identified to be independently associated with AKI. Age and AKI stage were independent predictors of 90-day mortality.

CONCLUSION

AKI is a common and early complication of ADHF-CS. Venous congestion and severe hypoperfusion are risk factors for AKI development. Early detection and prevention of AKI could lead to better outcome in this clinical subgroup.

Keep the Right in Mind-A Focused Approach to Right Ventricle-Predominant Cardiogenic Shock

Cardiogenic shock (CS) remains a highly lethal condition despite many efforts and new interventions. Patients presenting with a rapid onset of hemodynamic instability and subsequent collapse require prompt and appropriate multimodality treatment. Multiple etiologies can lead to heart failure and subsequent shock. As the case prevalence of heart failure increases worldwide, it is of great importance to explore all manners and protocols of presentation and treatment present. With research primarily focusing on CS due to cardiac left-sided pathology, few assessments of right-sided pathology and the subsequent clinical state and treatment have been conducted. This review aims to present an in-depth assessment of the currently available literature, assessing the pathophysiology, presentation and management of CS patients due to right heart failure.

Extracellular Vesicles Are Associated With Outcome in Veno-Arterial Extracorporeal Membrane Oxygenation and Myocardial Infarction

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is being increasingly applied in patients with circulatory failure, but mortality remains high. An inflammatory response syndrome initiated by activation of blood components in the extracorporeal circuit may be an important contributing factor. Patients with ST-elevation myocardial infarction (STEMI) may also experience a systemic inflammatory response syndrome and are at risk of developing cardiogenic shock and cardiac arrest, both indications for VA-ECMO. Extracellular vesicles (EV) are released by activated cells as mediators of intercellular communication and may serve as prognostic biomarkers. Cardiomyocyte EV, released upon myocardial ischemia, hold strong potential for this purpose. The aim of this study was to assess the EV-profile in VA-ECMO and STEMI patients and the association with outcome.

Methods: In this prospective observational study, blood was sampled on day 1 after VA-ECMO initiation or myocardial reperfusion (STEMI patients). EV were isolated by differential centrifugation. Leukocyte, platelet, endothelial, erythrocyte and cardiomyocyte (caveolin-3⁺) Annexin V⁺ EV were identified by flow cytometry. EV were assessed in survivors vs. non-survivors of VA-ECMO and in STEMI patients with normal-lightly vs. moderately-severely reduced left ventricular function. Logistic regression was conducted to determine the predictive accuracy of EV. Pearson correlation analysis of EV with clinical parameters was performed.

Results: Eighteen VA-ECMO and 19 STEMI patients were recruited. Total Annexin V⁺, cardiomyocyte and erythrocyte EV concentrations were lower (p ≤ 0.005) while the percentage of platelet EV was increased in VA-ECMO compared to STEMI patients (p = 0.002). Total Annexin V⁺ EV were increased in non-survivors of VA-ECMO (p = 0.01), and higher levels were predictive of mortality (AUC = 0.79, p = 0.05). Cardiomyocyte EV were increased in STEMI patients with moderately-severely reduced left ventricular function (p = 0.03), correlated with CK-MB_max (r = 0.57, p = 0.02) and time from reperfusion to blood sampling (r = 0.58, p = 0.01). Leukocyte EV correlated with the number of coronary stents placed (r = 0.60, p = 0.02).

Conclusions: Elevated total Annexin V⁺ EV on day 1 of VA-ECMO are predictive of mortality. Increased cardiomyocyte EV on day 1 after STEMI correlate with infarct size and are associated with poor outcome. These EV may aid in the early identification of patients at risk of poor outcome, helping to guide clinical management.

"Assessing the hemodynamic impact of various inotropes combination in patients with cardiogenic shock with Non-ST elevation myocardial infarction -the ANAPHOR study"

BACKGROUND

Various inotropic agents/vasopressors combinations are used in patients of cardiogenic shock. We performed this study to observe hemodynamic effects of various inotrope/vasopressor combinations in patients with NSTEMI cardiogenic shock (CS) at tertiary cardiac centre METHODS AND MATERIALS: Of 3832 NSTEMI, we studied 59 consecutive such patients with CS who hadn't undergone revascularization in the first 24 h in a prospective, open label, observational study. Group 1 comprised of background Dopamine with Noradrenaline titration(N = 38), Group 2 had background Dobutamine and Noradrenaline titration(N = 15) and Group 3 comprised of triple combination of Dopamine, Noradrenaline & Adrenaline(N = 6).

RESULTS

The mean change in hemodynamic parameters between these groups from baseline to 24 h showed no statistical difference. Cardiac output(CO), mean arterial pressure(MAP), central venous pressure(CVP) and cardiac power output(CPO) in group 2 were favorable at 6 and 24 h compared to baseline but mean change was insignificant as compared to others. In group 3, the increase in MAP was significant. IABP use did not change CO, CPO or SVR in any group except lower dosages of Dobutamine (49%) in IABP group. Lower in-hospital mortality in group 2 compared to others (P = 0.004) may be reflective of sicker patients in group 1 and 3.

CONCLUSION

The mean changes in hemodynamic parameters were not significant between all groups. All regimes of inotropes when selected as per clinical indication in CS with ACS resulted in similar hemodynamic effects. The mortality difference may not truly be reflective of regimes rather reflect sicker patients in the higher mortality group.

Complete percutaneous angio-guided approach using preclosing for venoarterial extracorporeal membrane oxygenation implantation and explantation in patients with refractory cardiogenic shock or cardiac arrest

BACKGROUND

The approach for veno-arterial extracorporeal membrane oxygenation implantation (VA-ECMO) in patients with cardiogenic shock can be either surgical or percutaneous. Complete angio-guided percutaneous implantation and explantation could decrease vascular complications. We sought to describe the initial results of complete percutaneous angio-guided ECMO implantation and explantation using preclosing.

METHODS

All consecutive patients who underwent peripheral femoro-femoral VA-ECMO percutaneous implantation for refractory cardiogenic shock or cardiac arrest were enrolled in a prospective registry (03/2018-12/2020). Percutaneous preclosing using two closing devices (Perclose ProGlide, Abbott) inserted before cannulation was used in both femoral artery and vein. Explantation was performed using a crossover technique under angiographic guidance. The occurrence of vascular complication was recorded.

RESULTS

Among the 56 patients who underwent percutaneous VA-ECMO implantation for cardiogenic shock or refractory cardiac arrest, 41 underwent preclosing. Femoral vessel cannulation was successful in all patients and total cannulation time was 20 (10-40) min. Weaning from ECMO was possible in 22/41 patients (54%) and 12 (29%) patients were alive at day 30. Significant vascular complications occurred in 2/41 patients. Percutaneous decannulation was performed in 20 patients with 19/20 technical success rate. All femoral arteries and veins were properly closed using the pre-closing devices without bleeding on the angiographic control except for one patient in whom surgical closure of the artery was required. No patient required transfusion for access related significant bleeding and no other vascular complication occurred. Furthermore, no groin infection was observed after full percutaneous implantation and removal of ECMO.

CONCLUSION

Emergent complete percutaneous angio-guided VA-ECMO implantation and explantation using pre-closing technique can be an attractive strategy in patients referred for refractory cardiogenic shock.

Intraoperative Cardiac Arrest

Cardiac arrest in the operating room and in the immediate postoperative period is a potentially catastrophic event that is almost always witnessed and is frequently anticipated. Perioperative crises and perioperative cardiac arrest, although often catastrophic, are frequently managed in a timely and directed manner because practitioners have a deep knowledge of the patient's medical condition and details of recent procedures. It is hoped that the approaches described here, along with approaches for the rapid identification and management of specific high-stakes clinical scenarios, will help anesthesiologists continue to improve patient outcomes.

The prognostic value of pulmonary artery compliance in cardiogenic shock

The aim of this study was to evaluate the pathophysiological role and the prognostic significance of pulmonary artery compliance (C_PA), a measure of right ventricular pulsatile afterload, in cardiogenic shock. We retrospectively included 91 consecutive patients with cardiogenic shock due to primary left ventricular failure, monitored with a pulmonary artery catheter within the first 24 h. C_PA was calculated as the ratio of stroke volume to pulmonary artery pulse pressure, and we determined whether C_PA predicted mortality and whether it performed better than other pulmonary hemodynamic variables. The overall in-hospital mortality in our cohort was 27%. Survivors and nonsurvivors had comparable left ventricular ejection fraction, systolic, diastolic and mean pulmonary artery pressure, transpulmonary gradient, diastolic pressure gradient, and pulmonary vascular resistance at 24 h. In contrast, C_PA was the only pulmonary artery variable significantly associated with mortality in univariate and multivariate analyses. Mortality increased from 4.5% at the highest quartile of C_PA (3.6–6.5 mL/mmHg) to 43.5% at the lowest quartile (0.7–1.7 mL/mmHg). In 64 patients with a PAC inserted immediately upon admission, we calculated the trend of C_PA between admission and 24 h. This trend was positive in survivors (+0.8 ± 1.3 ml/mmHg) but negative in nonsurvivors (−0.1 ± 1.0 mL/mmHg). The lower C_PA in nonsurvivors was associated with more severe right ventricular systolic dysfunction. In conclusion, a reduced compliance of the pulmonary artery promotes right ventricular dysfunction and is independently associated with mortality in cardiogenic shock. Future studies should evaluate the impact on pulmonary arterial compliance and right ventricular afterload of therapies used in cardiogenic shock.

Management of Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock

OBJECTIVES

Cardiogenic shock is a highly morbid condition in which inadequate end-organ perfusion leads to death if untreated. Peripheral venoarterial extracorporeal membrane oxygenation is increasingly used to restore systemic perfusion despite limited understanding of how to optimally titrate support. This review provides insights into the physiologic basis of extracorporeal membrane oxygenation support and presents an approach to extracorporeal membrane oxygenation management in the cardiogenic shock patient.

DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION

Data were obtained from a PubMed search of the most recent medical literature identified from MeSH terms: extracorporeal membrane oxygenation, cardiogenic shock, percutaneous mechanical circulatory support, and heart failure. Articles included original articles, case reports, and review articles.

DATA SYNTHESIS

Current evidence detailing the use of extracorporeal membrane oxygenation to support patients in cardiogenic shock is limited to isolated case reports and single institution case series focused on patient outcomes but lacking in detailed approaches to extracorporeal membrane oxygenation management. Unlike medical therapy, in which dosages are either prescribed or carefully titrated to specific variables, extracorporeal membrane oxygenation is a mechanical support therapy requiring ongoing titration but without widely accepted variables to guide treatment. Similar to mechanical ventilation, extracorporeal membrane oxygenation can provide substantial benefit or induce significant harm. The widespread use and present lack of data to guide extracorporeal membrane oxygenation support demands that intensivists adopt a physiologically-based approach to management of the cardiogenic shock patient on extracorporeal membrane oxygenation.

CONCLUSIONS

Extracorporeal membrane oxygenation is a powerful mechanical circulatory support modality capable of rapidly restoring systemic perfusion yet lacking in defined approaches to management. Adopting a management approach based physiologic principles provides a basis for care.

Shock Index in Patients Presenting With Acute Heart Failure: A Multicenter Multinational Observational Study

Shock index (SI) has a prognostic role in coronary heart disease; however, data on acute heart failure (AHF) are lacking. We evaluated the predictive values of SI in patients with AHF. Data were retrospectively analyzed from the Gulf Acute Heart Failure Registry. Patients were categorized into low SI versus high SI based on the receiver operating characteristic curves. Primary outcomes included cardiogenic shock (CS) and mortality. Among 4818 patients with AHF, 1143 had an SI ≥0.9. Compared with SI <0.9, patients with high SI were more likely males, younger, and having advanced New York Heart Association class, fewer cardiovascular risk factors and less prehospital β-blockers and angiotensin-converting enzyme inhibitor use. Shock index had significant negative correlations with age, pulse pressure, mean arterial pressure, and left ventricle ejection fraction and had positive correlation with hospital length of stay. Shock index ≥0.9 was significantly associated with higher composite end points, in-hospital, and 3-month mortality. Shock index ≥0.9 had 96% negative predictive value (NPV) and 3.5 relative risk for mortality. Multivariate regression analysis showed that SI was independent predictor of mortality and CS. With a high NPV, SI is a simple reliable bedside tool for risk stratification of patients with AHF. However, this conclusion needs further support.

Venous oxygen saturation in critical illness

OBJECTIVE

To review clinically relevant features of systemic oxygen delivery and consumption and the technique and use of venous oxygenation monitoring in human and veterinary medicine.

DATA SOURCES

Veterinary and human peer-reviewed medical literature including scientific reviews, clinical and laboratory research articles, and authors' clinical research experience.

SUMMARY

Measurement of venous hemoglobin oxygen saturation (venous oxygenation) provides insight into the balance between oxygen supply and tissue demand. In people, measurement of venous oxygen saturation can reveal decompensation that is missed by physical examination and other routinely monitored parameters. Therefore, measurement of mixed or central venous oxygenation measurement may help guide therapy and predict outcome of critically ill patients. In dogs, low central venous oxygen saturation has been associated with impaired cardiopulmonary function and poor outcome in several small studies of experimental shock or severe clinical illness, suggesting that monitoring this variable may assist the treatment of severe illness in this species as well.

CONCLUSION

Venous oxygenation reflects systemic oxygenation status and can be used to guide treatment and estimate prognosis in critically ill patients. Measurement of venous oxygenation in veterinary patients is feasible and is a potentially valuable tool in the management of patients with severe disease. This review is intended to increase the understanding and awareness of the potential role of venous oxygen measurement in veterinary patients.

Clinical Characteristics and Current Interventions in Shock Patients in Chinese Emergency Departments: A Multicenter Prospective Cohort Study

Background:

Shock is a life-threatening condition in emergency departments (EDs) and is associated with a high mortality; however, its clinical characteristics and current interventions in China are seldom reported. This study investigated the clinical characteristics and current interventions of shock patients in Chinese EDs.

Methods:

This multicenter prospective cohort study was conducted in the EDs of 33 academic hospitals in 16 Chinese provinces. Adult shock patients were enrolled from December 2013 to April 2014. Age, sex, comorbidities, shock subtype, and vital signs were recorded on ED arrival; details of subsequent interventions and treatments were added. We compared those data between survivors and nonsurvivors. All patients were followed up for 3 days. The primary outcome was 3-day mortality. Binary logistic regression analysis identified the independent predictors of that mortality.

Results:

We enrolled 1095 shock patients. The 3-day mortality was 27.5%, 36.3%, and 29.0%, respectively, in the whole cohort and for cardiogenic and septic shock. Within the first 24 h, 1039 patients (94.9%) were admitted to the Intensive Care Unit. Use of bicarbonate, epinephrine, and dopamine is an independent predictor for mortality. Hemorrhage and trauma (39.1%), along with sepsis (40.4%) were the most commonly observed causes of shock in the ED. In nondiabetic patients with cardiogenic shock, 3-day mortality was 69.2% for patients needing glucose control — much higher than in those not needing glucose control (30.0%, P = 0.01). Hydroxyethyl starch (HES) was applied in 29.6% of septic shock patients, and the mortality of septic patients who received HES was much higher than those who did not (38.2% vs. 25.1%, P = 0.006).

Conclusions:

In China, short-term mortality of shock patients in EDs is still high, especially among those with cardiogenic and septic shock. HES application needs to be restricted — particularly in septic shock patients.

Long-term clinical outcomes in patients with cardiogenic shock according to left ventricular function: The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme

BACKGROUND

Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains a major concern. Failure of the left ventricular (LV) pump is the primary insult in most forms of CS, but other parts of the circulatory system and diastolic function contribute to shock. However, little is known of the clinical presentation, management and outcomes according to LV function in these patients.

OBJECTIVES

To assess the presentation, management and clinical outcomes in patients admitted for AMI with CS according to early LV ejection fraction (LVEF), using long-term data from the French registry of Acute ST-elevation or non-ST-elevation Myocardial Infarction (FAST-MI) 2010.

METHODS

We analysed baseline characteristics, management and 3-year mortality in patients with CS, according to LVEF (≤40% vs>40%). The analyses were replicated in the FAST-MI 2005 cohort.

RESULTS

Among 4169 patients with AMI included in the survey, the incidence of CS was 3.3%. LVEF was>40% in 43%. Early PCI (≤24hours) was used more often in patients with LV dysfunction (61% vs 42%), as was the use of optimal medical therapy at discharge (66% vs 40%). CS remained associated with a major increase in 3-year mortality, both in patients with LVEF ≤40% (55%) and in those with LVEF>40% (44%). Using Cox multivariable analysis, LVEF ≤40% was associated with higher 3-year mortality (hazard ratio 2.08, 95% confidence interval 1.15-3.78) in patients with AMI with CS. Consistent results were found in the replication cohort.

CONCLUSIONS

Despite the many circulatory system contributors to the physiopathology of CS in patients with AMI, the occurrence of early LV systolic dysfunction is associated with higher long-term mortality.

Frequency and Prognostic Significance of Abnormal Liver Function Tests in Patients With Cardiogenic Shock

Cardiogenic shock (CS) is a cardiac emergency often leading to multiple organ failure and death. Assessing organ dysfunction and appropriate risk stratification are central for the optimal management of these patients. The purpose of this study was to assess the prevalence of abnormal liver function tests (LFTs), as well as early changes of LFTs and their impact on outcome in CS. We measured LFTs in 178 patients in CS from serial blood samples taken at 0 hours, 12 hours, and 24 hours. The associations of LFT abnormalities and their early changes with all-cause 90-day mortality were estimated using Fisher's exact test and Cox proportional hazards regression analysis. Baseline alanine aminotransferase (ALT) was abnormal in 58% of the patients, more frequently in nonsurvivors. Abnormalities in other LFTs analyzed (alkaline phosphatase, gamma-glutamyl transferase, and total bilirubin) were not associated with short-term mortality. An increase in ALT of >20% within 24 hours (ΔALT>+20%) was observed in 24% of patients. ΔALT>+20% was associated with a more than 2-fold increase in mortality compared with those with stable or decreasing ALT (70% and 28%, p <0.001). Multivariable regression analysis showed that ΔALT>+20% was associated with increased 90-day mortality independent of other known risk factors. In conclusion, an increase in ALT in the initial phase was seen in 1/4 of patients in CS and was independently associated with 90-day mortality. This finding suggests that serial ALT measurements should be incorporated in the clinical assessment of patients in CS.

Clinical profiles and prognosis of acute heart failure in adult patients with dystrophinopathies on home mechanical ventilation

Aims

Duchenne muscular dystrophy (DMD) is characterized by respiratory and heart involvements. In the context of permanently wheelchair bound and on mechanical ventilation (MV) patients, the clinical presentation of acute heart failure (AHF) syndrome may be atypical. We sought to describe clinical and genetic profiles and to determine prognosis of DMD and Becker muscular dystrophy (BMD) patients on home MV (HMV), hospitalized for AHF.

Methods and results

We included genetically proven DMD and BMD patients on HMV admitted for AHF. A total of 13 patients (11 DMD and 2 BMD) fulfilled the inclusion criteria. Median age was 34.0 [interquartile range (IQR) 26.0; 40.0] years. Median pulmonary vital capacity was 9.0% (6.0; 15.0) of predicted value. Long‐term invasive ventilation was performed in 69% of patients. All the 11 DMD patients carried out‐of‐frame DMD gene mutations. At admission, dyspnoea was present in 46%, lipothymia in 23%, and abdominal discomfort in 38.4% of patients. A total of 53.8% of patients showed anasarca. Cardiogenic shock presentation was found in six patients (46%). Ejection fraction was severely altered [median 25% (IQR 20; 30)]. Intra‐hospital mortality rate was 30%, reaching 53.8 % after 1 year. Previous episodes of AHF ≥ 2 were associated with intra‐hospital mortality (P = 0.025). In patients with cardiogenic shock, intra‐hospital mortality rate was 66.6%, reaching 83.3% after 1 year.

Conclusions

In adult DMD and BMD patients with severe ejection fraction alteration and on HMV, admitted for AHF, right cardiac signs are frequent. The intra‐hospital and 1 year mortality rate was high and was associated with previous episodes of AHF ≥ 2.

Use of noninvasive and invasive mechanical ventilation in cardiogenic shock: A prospective multicenter study

BACKGROUND

Despite scarce data, invasive mechanical ventilation (MV) is widely recommended over non-invasive ventilation (NIV) for ventilatory support in cardiogenic shock (CS). We assessed the real-life use of different ventilation strategies in CS and their influence on outcome focusing on the use of NIV and MV.

METHODS

219 CS patients were categorized by the maximum intensity of ventilatory support they needed during the first 24h into MV (n=137; 63%) , NIV (n=26; 12%), and supplementary oxygen (n=56; 26%) groups. We compared the clinical characteristics and 90-day outcome between the MV and the NIV groups.

RESULTS

Mean age was 67years, 74% were men. The MV and NIV groups did not differ in age, medical history, etiology of CS, PaO₂/FiO₂ ratio, baseline hemodynamics or LVEF. MV patients predominantly presented with hypoperfusion, with more severe metabolic acidosis, higher lactate levels and greater need for vasoactive drugs, whereas NIV patients tended to be more often congestive. 90-day outcome was significantly worse in the MV group (50% vs. 27%), but after propensity score adjustment, mortality was equal in both groups. Confusion, prior CABG, ACS etiology, higher lactate level, and lower baseline PaO₂ were independent predictors of mortality, whereas ventilation strategy did not have any influence on outcome.

CONCLUSIONS

Although MV is generally recommended mode of ventilatory support in CS, a fair number of patients were successfully treated with NIV. Moreover, ventilation strategy was not associated with outcome. Thus, NIV seems a safe option for properly chosen CS patients.

Veno-arterial extracorporeal membrane oxygenation for adult cardiovascular failure

PURPOSE OF REVIEW

To examine the utility and technical challenges of applying veno-arterial extracorporeal membrane oxygenation for acute cardiovascular failure in adults with acute and chronic causes of heart failure.

RECENT FINDINGS

The role of mechanical circulatory support in acute cardiovascular continues to evolve as technology and clinical experience develop. There is increasing interest in the role of veno-arterial extracorporeal membrane oxygenation as a bridging therapy and as an adjunct to conventional cardiopulmonary resuscitation.

SUMMARY

Veno-arterial extracorporeal membrane oxygenation is an expensive, complex, resource intensive support. It is essential that its future use be guided by evidence obtained from centres that have demonstrated timely, safe support.

Water and sodium in heart failure: a spotlight on congestion

Despite all available therapies, the rates of hospitalization and death from heart failure (HF) remain unacceptably high. The most common reasons for hospital admission are symptoms related to congestion. During hospitalization, most patients respond well to standard therapy and are discharged with significantly improved symptoms. Post-discharge, many patients receive diligent and frequent follow-up. However, rehospitalization rates remain high. One potential explanation is a persistent failure by clinicians to adequately manage congestion in the outpatient setting. The failure to successfully manage these patients post-discharge may represent an unmet need to improve the way congestion is both recognized and treated. A primary aim of future HF management may be to improve clinical surveillance to prevent and manage chronic fluid overload while simultaneously maximizing the use of evidence-based therapies with proven long-term benefit. Improvement in cardiac function is the ultimate goal and maintenance of a "dry" clinical profile is important to prevent hospital admission and improve prognosis. This paper focuses on methods for monitoring congestion, and strategies for water and sodium management in the context of the complex interplay between the cardiac and renal systems. A rationale for improving recognition and treatment of congestion is also proposed.

Increasing mean arterial pressure in cardiogenic shock secondary to myocardial infarction: effects on hemodynamics and tissue oxygenation

There are very few data regarding the effects of norepinephrine uptitration on global and regional hemodynamics in cardiogenic shock. We studied 25 patients with shock secondary to myocardial infarction successfully treated with percutaneous coronary intervention. Before the inclusion, 16 of 25 patients presented a cardiac arrest in the presence of medical staff. Norepinephrine was titrated to increase mean arterial pressure (MAP) from 65 to 85 mmHg during 1 h. Swan-Ganz variables, arterial and mixed venous blood gases, lactate, and thenar near-infrared spectroscopy variables (muscle tissue oxygen saturation [StO2] and its changes during a vascular occlusion test) were measured before, 1 h after norepinephrine uptitration, and 1 h after norepinephrine downtitration. To obtain a MAP at 85 mmHg, norepinephrine was increased from 0.6 (0.28-1.2) to 1.53 µg · kg · min (0.76-2.6 µg · kg · min) (P < 0.00001) (median and interquartile range), with no change in heart rate. Norepinephrine uptitration significantly increased cardiac index (2.3 ± 0.5 to 2.8 ± 0.1 L · min · m), cardiac power index (0.40 ± 0.1 to 0.55 ± 0.1 W/m), mixed venous oxygen saturation (69% ± 9% to 73% ± 9%), and coronary perfusion pressure (32 ± 3 to 43 ± 4 mmHg). Lactate level decreased from 2.6 ± 1.7 to 1.6 ± 0.4 mmol/L (P < 0.05). Pulmonary artery occlusion pressure remained unchanged. Regarding near-infrared spectroscopy variables, all values except StO2 were significantly pathological when compared with healthy volunteers. The StO2 recovery slope and delta StO2, respectively, increased from 3.0% ± 1.3%/s to 3.6% ± 1.3%/s and 10% ± 3% to 14% ± 4%, whereas StO2 did not change (83% ± 6% to 83% ± 7%). After H1, norepinephrine was decreased to basal values, and all variables returned to baseline. In conclusion, a short-term increase in MAP with norepinephrine in resuscitated cardiogenic shock complicated by postreperfusion disease is associated with better cardiac performance and improved microcirculatory variables.

Ivabradine during cardiogenic shock: a clinical case and review of the literature

Although the introduction of novel medical and invasive therapies in recent years has led to a significant reduction in mortality from heart failure, the same cannot be said for mortality due to cardiogenic shock. Drug therapy with inotropic agents and catecholamines has the disadvantage of causing increased myocardial oxygen consumption resulting in increased heart rate which may lead to the widening of the ischemic area. A reduction in heart rate with the administration of β-blockers is contraindicated due to negative inotropic and blood pressure lowering effects, typical of this group of drugs. Thus the theoretical possibility of ivabradine administration for an isolated reduction in heart rate, associated with the absence of a negative inotropic effect, could favorably influence hemodynamics in patients with cardiogenic shock. We report a case of cardiogenic shock treated by adding ivabradine to the currently used therapy.

Hemodynamic effects of Ivabradine in addition to dobutamine in patients with severe systolic dysfunction

BACKGROUND

Dobutamine induced tachycardia increases myocardial oxygen consumption and impairs ventricular filling. We hypothesized that Ivabradine may be efficient to control dobutamine induced tachycardia.

METHODS

We assessed the effects of Ivabradine in addition to dobutamine in stable heart failure (HF) patients (LVEF < 35%, n = 22, test population) and validated its effects in refractory cardiogenic shock patients (n = 9, validation population) with contraindication to cardiac assistance or transplant. In the test population (62 ± 17 years, LVEF = 24 ± 8%), systolic and diastolic function were assessed at rest and under dobutamine [10 γ/min], before and after Ivabradine [5mg per os]. In the validation population (54 ± 11 years, LVEF = 22 ± 7%), Ivabradine [5mg twice a day] was added to the dobutamine infusion.

RESULTS

In the test population, Ivabradine decreased heart rate [HR] at rest and during dobutamine echocardiography (-9 ± 8 bpm, P = 0.0004). The decrease in HR was associated with a decrease in cardiac power output and an increase in diastolic duration at rest (+ 74 ± 67 ms, P = 0.0002), and during dobutamine infusion (+ 75 ± 67 ms, P < 0.0001). Change in LVEF during dobutamine was greater after Ivabradine treatment than before (+ 7.2 ± 4.7% vs. + 3.6 ± 4.2%, P = 0.002). In the validation population, Ivabradine decreased HR (-18 ± 11 bpm, P = 0.008) and improved diastolic filling time (+ 67 ± 42 ms, P = 0.012) without decreasing cardiac output. At 24h, Ivabradine improved systolic blood pressure (+ 9 ± 5 mmHg, P = 0.007), daily urine output (+ 0.7 ± 0.5L, P = 0.008), oxygen balance (ΔScv02 = + 13 ± 15%, P = 0.010), and NT-pro BNP (-2270 ± 1912 pg/mL, P = 0.017). Finally, only 2/9 (22%) patients died whereas expected mortality determined from a historical cohort was 78% (P = 0.017).

CONCLUSION

This pilot study demonstrates the safety and potential benefit of a HR lowering agent in cardiogenic shock.

Evaluation of cardiac function index as measured by transpulmonary thermodilution as an indicator of left ventricular ejection fraction in cardiogenic shock

Introduction. The PiCCO transpulmonary thermodilution technique provides two indices of cardiac systolic function, the cardiac function index (CFI) and the global ejection fraction (GEF). Both appear to be correlated with left ventricular ejection fraction (LVEF) measured by echocardiography in patients with circulatory failure, especially in septic shock. The aim of the present study was to test the reliability of CFI as an indicator of LVEF in patients with cardiogenic shock. Methods. In thirty-five patients with cardiogenic shock, we performed (i) simultaneous measurements of echocardiography LVEF and cardiac function index assessed by transpulmonary thermodilution (n = 72) and (ii) transpulmonary thermodilution before/after increasing inotropic agents (n = 18). Results. Mean LVEF was 31% (+/−11.7), CFI 3/min (+/−1), and GEF 14.2% (+/−6). CFI and GEF were both positively correlated with LVEF (P < 0.0001, r² = 0.27). CFI and GEF were significantly increased with inotropic infusion (resp., P = 0.005, P = 0.007). A cardiac function index <3.47/min predicted a left ventricular ejection fraction ≤35% (sensitivity 81.1% and specificity 63%). In patients with right ventricular dysfunction, CFI was not correlated with LVEF. Conclusion. CFI is correlated with LVEF provided that patient does not present severe right ventricular dysfunction. Thus, the PiCCO transpulmonary thermodilution technique is useful for the monitoring of inotropic therapy during cardiogenic shock.

Diagnosis of cardiogenic shock without the use of a pulmonary artery catheter

BACKGROUND

Current diagnostic criteria for cardiogenic shock (CS) require the use of a pulmonary artery catheter (PAC), which is time-consuming and may cause complications. A set of simple yet accurate noninvasive diagnostic criteria would be of significant utility.

METHODS

Candidate components for the Noninvasive Parameters for Assessment of Cardiogenic Shock (N-PACS) criteria were required to be objective, readily available, and noninvasive. Variables encompassing hypotension, hypoperfusion, predisposing conditions, and elevated intracardiac filling pressures were optimized versus a PAC-based standard in a retrospective developmental cohort of 122 patients with acute myocardial infarction (AMI). The finalized criteria were validated in a prospective cohort of coronary care unit patients in whom a PAC was placed for clinical indications.

RESULTS

According to invasive criteria, CS was present in 32 of 217 consecutive patients undergoing PAC. Compared to the PAC-based standard, the N-PACS criteria had a sensitivity of 96.9% (95% confidence interval (CI) 82.0-99.8), specificity of 90.8% (95% CI 85.5-94.4), positive predictive value of 64.6% (95% CI 49.4-77.4), negative predictive value of 99.4% (95% CI 96.2-100), positive likelihood ratio of 10.5 (95% CI 6.7-16.7), negative likelihood ratio of 0.03 (95% CI 0.00-0.24), and diagnostic odds ratio of 306.4. Results were similar among patients with and without AMI.

CONCLUSION

A simple, echocardiography-based set of noninvasive diagnostic criteria can be used to accurately diagnose CS.

Complement C5A antagonist treatment improves the acute circulatory and inflammatory consequences of experimental cardiac tamponade

OBJECTIVE

Cardiogenic shock often leads to splanchnic macro- and microcirculatory complications, and these events are linked to local and systemic inflammatory activation. Our aim was to investigate the consequences of complement C5a antagonist treatment on the early circulatory and inflammatory changes in a clinically relevant large animal model of cardiac tamponade.

DESIGN AND SETTING

A randomized, controlled in vivo animal study in a university research laboratory.

SUBJECTS

Anesthetized, ventilated, and thoracotomized Vietnamese mini pigs (24 ± 3 kg).

INTERVENTIONS

Group 1 (n = 6) served as sham-operated control. In group 2 (n = 7), cardiac tamponade was induced for 60 minutes by the administration of intrapericardial fluid, while the mean arterial pressure was kept in the interval 40 to 45 mm Hg. Group 3 (n = 6) was treated with a complement C5a antagonist compound (the peptide acetyl-peptide-A, 4 mg/kg) after 45 minutes of tamponade.

MEASUREMENTS AND MAIN RESULTS

The macrohemodynamics, including the superior mesenteric artery flow, was monitored; the average red blood cell velocity in the small intestinal mucosa was determined by an intravital orthogonal polarization imaging technique. The whole blood superoxide production, the plasma level of high-mobility group box protein-1 and big-endothelin and the small intestinal myeloperoxidase activity were measured. One hundred eighty minutes after the relief of tamponade, the mean arterial pressure was decreased, while the plasma levels of superoxide, high-mobility group box protein-1, and big-endothelin, and the intestinal myeloperoxidase activity were increased. The administration of acetyl-peptide-A normalized the mean arterial pressure and preserved the cardiac output, while the superior mesenteric artery flow and mucosal average red blood cell velocity were increased significantly, and the plasma superoxide, high-mobility group box protein-1, big-endothelin, and intestinal myeloperoxidase levels were reduced.

CONCLUSIONS

These results provide evidence that blockade of the C5a effects significantly influences the acute splanchnic macro- and microhemodynamic complications and decreases the potentially harmful inflammatory consequences of experimental cardiogenic shock.

Inflammatory activation after experimental cardiac tamponade

BACKGROUND/PURPOSE

Cardiac tamponade is a medical emergency situation associated with a high rate of life-threatening complications, even after immediate interventions. Our aim was to characterize the acute inflammatory consequences of this event in a clinically relevant large animal model.

METHODS

Cardiac tamponade was induced for 60 min in anesthetized, ventilated and thoracotomized minipigs by intrapericardial fluid administration, the mean arterial pressure (MAP) being maintained in the interval of 40-45 mm Hg (n = 8). A further group (n = 7) served as sham-operated control. The global macrohemodynamics, including the right- and left-heart end-diastolic volumes (RHEDV and LHEDV), the pulmonary vascular resistance index (PVRI) and the superior mesenteric artery (SMA) flow, were monitored for 240 min, and the intestinal microcirculatory changes (pCO2 gap) were evaluated by indirect tonometry. Blood samples were taken for the determination of cardiac troponin T and vasoactive inflammatory mediators, including histamine, nitrite/nitrate, big-endothelin, superoxide and high-mobility group box protein-1 levels in association with intestinal leukocyte and complement activation.

RESULTS

The cardiac tamponade induced significant decreases in MAP, cardiac output, LHEDV and SMA flow, while the PVRI and the pCO2 gap increased significantly. After the removal of fluid from the pericardial sac, the MAP and the LHEDV were decreased, while the PVRI and the pCO2 gap remained elevated when compared with those in the sham-operated group. In the posttamponade period, the abrupt release of inflammatory mediators was accompanied by a significant splanchnic leukocyte accumulation and complement activation.

CONCLUSIONS

The macrocirculatory and splanchnic microcirculatory disturbances were accompanied by a significant proinflammatory reaction; endothelin and the complement system may be significant components of the inflammatory cascade that is activated in this porcine model of pericardial tamponade.

Paradoxical heart failure precipitated by profound dehydration: intraventricular dynamic obstruction and significant mitral regurgitation in a volume-depleted heart

Occurrence of dynamic left ventricular outflow tract (LVOT) obstruction is not infrequent in critically ill patients, and it is associated with potential danger. Here, we report a case of transient heart failure with hemodynamic deterioration paradoxically induced by extreme dehydration. This article describes clinical features of the patient and echocardiographic findings of dynamic LVOT obstruction and significant mitral regurgitation caused by systolic anterior motion of the mitral valve in a volume-depleted heart.

Improved outcome of cardiogenic shock at the acute stage of myocardial infarction: a report from the USIK 1995, USIC 2000, and FAST-MI French nationwide registries

AIM

The historical evolution of incidence and outcome of cardiogenic shock (CS) in acute myocardial infarction (AMI) patients is debated. This study compared outcomes in AMI patients from 1995 to 2005, according to the presence of CS.

METHOD AND RESULTS

Three nationwide French registries were conducted 5 years apart, using a similar methodology in consecutive patients admitted over a 1-month period. All 7531 AMI patients presenting ≤48 h of symptom onset were included. The evolution of mortality was compared in the 486 patients with CS vs. those without CS. The incidence of CS tended to decrease over time (6.9% in 1995; 5.7% in 2005, P = 0.07). Thirty-day mortality was considerably higher in CS patients (60.9 vs. 5.2%). Over the 10-year period, mortality decreased for both patients with (70-51%, P = 0.003) and without CS (9-4%, P < 0.001). In CS patients, the use of percutaneous coronary intervention (PCI) increased from 20 to 50% (P < 0.001). Time period was an independent predictor of early mortality in CS patients (OR for death, 2005 vs. 1995 = 0.45; 95% CI: 0.27-0.75, P = 0.005), along with age, diabetes, and smoking status. When added to the multivariate model, PCI was associated with decreased mortality (OR = 0.38; 95% CI: 0.24-0.58, P < 0.001). In propensity-score-matched cohorts, CS patients with PCI had a significantly higher survival.

CONCLUSIONS

Cardiogenic shock remains a clinical concern, although early mortality has decreased. Improved survival is concomitant with a broader use of PCI and recommended medications at the acute stage. Beyond the acute stage, however, 1-year survival has remained unchanged.

[Cardiogenic shock]

Cardiogenic shock is most commonly a complication of acute myocardial infarction. The ischemic loss of functional myocardium triggers distinct cardiovascular responses which can deteriorate to global pump failure with a mortality rate of more than 50%. Causes of cardiogenic shock beyond myocardial ischemia are very diverse. Decisive management with rapid evaluation, identification of the underlying disease and urgent initiation of supportive measures as well as definitive therapy is of prognostic value. Causal treatment of the cardiac disease is crucial but has to be weighed against the specific surgical circumstances of perioperative patients, particularly concerning anticoagulation, platelet inhibition and bleeding risks. Hemodynamic stabilization is achieved by pharmacological support of myocardial function, control of arrhythmia and volume load. Prevention and intensive care of shock-related multiorgan failure is of pivotal importance in the successful management of cardiogenic shock.

Anesthesia advanced circulatory life support

PURPOSE

The constellation of advanced cardiac life support (ACLS) events, such as gas embolism, local anesthetic overdose, and spinal bradycardia, in the perioperative setting differs from events in the pre-hospital arena. As a result, modification of traditional ACLS protocols allows for more specific etiology-based resuscitation.

PRINCIPAL FINDINGS

Perioperative arrests are both uncommon and heterogeneous and have not been described or studied to the same extent as cardiac arrest in the community. These crises are usually witnessed, frequently anticipated, and involve a rescuer physician with knowledge of the patient's comorbidities and coexisting anesthetic or surgically related pathophysiology. When the health care provider identifies the probable cause of arrest, the practitioner has the ability to initiate medical management rapidly.

CONCLUSIONS

Recommendations for management must be predicated on expert opinion and physiological understanding rather than on the standards currently being used in the generation of ACLS protocols in the community. Adapting ACLS algorithms and considering the differential diagnoses of these perioperative events may prevent cardiac arrest.

[Heart rate and rate control : Prognostic value in cardiovascular diseases]

Resting heart rate represents a cardiovascular risk indicator and an important target of therapy in chronic heart failure and potentially in coronary artery disease. Clinical and experimental evidence suggests that sustained elevation of heart rate - independent of the underlying trigger - plays a causal role in the pathogenesis of vascular disease. Results of the SHIFT trial support the importance of heart-rate reduction with ivabradine for improvement of clinical outcomes in heart failure and confirm the role of heart rate as a risk factor for patients with severe left ventricular dysfunction. Results of the BEAUTIFUL trial show that patients with ischemic heart disease and a heart rate above 70 bpm exhibit an adverse prognosis concerning coronary events.

Prognosis value of central venous oxygen saturation in acute decompensated heart failure

BACKGROUND

Central venous oxygen saturation (ScvO2) provides an estimation of body oxygen consumption/delivery ratio. Its use has been suggested for monitoring treatment of patients admitted for acute decompensated heart failure (ADHF) but the optimal target value has never been clearly reported.

AIMS

We aimed to address the prognostic value of ScvO2 in ADHF requiring inotrope support.

METHODS

ScvO2 was prospectively assessed in 60 patients with ADHF requiring inotrope support (mean age 62±16 years; 45 men; left ventricular ejection fraction 25±7%) and was compared with major adverse cardiac events (MACE), defined as heart transplantation, cardiac assistance and death.

RESULTS

MACE occurred in 22 (35%) patients (14 deaths; eight referred for heart transplantation or cardiac assistance). Admission ScvO2 (mean 57±13%) did not differ between patients with and without MACE. At 24 hours ScvO2 (mean 62±7%) increased only in patients without MACE (65±6% vs. 58±7%; p<0.0001) and was associated with urine output, vena cava diameter and oxygen consumption reduction. No correlation was observed between ScvO2 and cardiac output or catecholamine rate. Multivariable analysis showed that ScvO2 at 24 hours remained an independent predictor of MACE. Using the optimal cut-off of 60% derived from receiver operating characteristic curves, MACE were observed in 81% of patients (17/21) with ScvO2≤60% at 24 hours vs. 13% (5/39) with ScvO2>60% at 24 hours.

CONCLUSION

In patients admitted for ADHF requiring inotrope support, ScvO2≤60% despite optimal treatment is a marker of poor outcome and might be an indicator for considering more aggressive therapy.