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Martin-Villen L, Adsuar-Gomez A, Garrido-Jimenez JM, Perez-Vela JL, Fuset-Cabanes MP. Mechanical circulatory support in cardiogenic shock patients. Med Intensiva 2024:S2173-5727(24)00230-3. [PMID: 39394008 DOI: 10.1016/j.medine.2024.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 10/13/2024]
Abstract
Cardiogenic shock (CS) is a highly complex clinical condition that requires a management strategy focused on early resolution of the underlying cause and the provision of circulatory support. In cases of refractory CS, mechanical circulatory support (MCS) is employed to replace the failed cardiocirculatory system, thereby preventing the development of multiorgan failure. There are various types of MCS, and patients with CS typically require devices that are either short-term (< 15 days) or intermediate-term (15-30 days). When choosing the device the underlying cause of CS, as well as the presence or absence of concomitant conditions such as failed ventricle, respiratory failure, and the intended purpose of the support should be taken into consideration. Patients with MCS require the comprehensive care indicated in complex critically ill patients with multiorgan dysfunction, with an emphasis on device monitoring and control. Different complications may arise during support management, and its withdrawal must be protocolized.
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Affiliation(s)
- Luis Martin-Villen
- Department of Intensive Care Medicine, Hospital Universitario Virgen del Rocío, Seville, Spain.
| | - Alejandro Adsuar-Gomez
- Department of Cardiovascular Surgery, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Jose Luis Perez-Vela
- Department of Intensive Care Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mari Paz Fuset-Cabanes
- Department of Intensive Care Medicine, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
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2
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Okuyama T, Nagoshi T, Hiraki N, Tanaka TD, Oi Y, Kimura H, Kashiwagi Y, Ogawa K, Minai K, Ogawa T, Kawai M, Yoshimura M. Blunted increase in plasma BNP during acute coronary syndrome attacks in obese patients. IJC HEART & VASCULATURE 2024; 54:101508. [PMID: 39314921 PMCID: PMC11417597 DOI: 10.1016/j.ijcha.2024.101508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/14/2024] [Accepted: 09/03/2024] [Indexed: 09/25/2024]
Abstract
Background Unexpectedly low natriuretic peptide (NP) levels in proportion to heart failure severity are often observed in obese individuals. However, the magnitude of NP elevation in response to acute cardiac stress in obesity has not yet been extensively studied. This study aimed to determine the impact of obesity on the increase in plasma NP in response to cardiac hemodynamic stress during acute coronary syndrome (ACS) attacks. Methods and Results The study population included 557 consecutive patients with ACS for whom data were collected during emergency cardiac catheterization. To determine the possible impact of body mass index (BMI) on the relationship between left ventricular ejection fraction (LVEF) and plasma B-type NP (BNP) levels, the study population was divided into two groups (Group 1: BMI <25, Group 2: BMI ≥25 [kg/m2]). Both BMI and LVEF were significantly and negatively correlated with BNP. Although a significant negative correlation between LVEF and BNP was observed in both groups, the regression line of Group 2 was significantly less steep than that of Group 1. Accordingly, BNP/LVEF ratio in Group 2, which indicates the extent of BNP increase in response to LVEF change, was significantly lower than that in Group 1. Conclusions Blunted increase in plasma BNP in response to cardiac hemodynamic stress during ACS attacks was observed in obese individuals. In addition to the relatively low plasma BNP levels at baseline in obese individuals, the blunted response of BNP elevation to ACS attacks may have important pathophysiological implications for hemodynamic regulation and myocardial energy metabolism.
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Affiliation(s)
| | | | - Nana Hiraki
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Toshikazu D. Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Yuhei Oi
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Haruka Kimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Yusuke Kashiwagi
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Kazuo Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Kosuke Minai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
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3
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Balgobind A, Pierce M, Alviar C, Barnett C, Barsness G, Chaudhry SP, Chonde M, Cooper H, Daniels L, Gidwani U, Fordyce C, Goldfarb M, Katz JN, Kontos M, Kwon Y, Liebner E, Liu S, Miller PE, Newby LK, O'Brien C, Papolos A, Pisani B, Potter B, Proudfoot A, Roswell RO, Sinha SS, Smith TD, Thompson AD, van Diepen S, Zakaria S, Morrow D, Villela MA. Current practices in the management of temporary mechanical circulatory support: A survey of CICU directors in North America. Am Heart J 2024; 276:115-119. [PMID: 39182940 DOI: 10.1016/j.ahj.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 08/27/2024]
Abstract
INTRODUCTION Despite the growing use of temporary mechanical circulatory support (tMCS), little data exists to inform management and weaning of these devices. METHODS We performed an online survey among cardiac intensive care unit directors in North America to examine current practices in the management of patients treated with intraaortic balloon pump and Impella. RESULTS We received responses from 84% of surveyed centers (n=37). Our survey focused on three key aspects of daily management: 1. Hemodynamic monitoring; 2. Hemocompatibility; and 3. Weaning and removal. We found substantial variability surrounding all three areas of care. CONCLUSION Our findings highlight the need for consensus around practices associated with improved outcomes in patients treated with tMCS.
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Affiliation(s)
- Amrita Balgobind
- Department of Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | | | - Carlos Alviar
- Department of Medicine at New York University Grossman School of Medicine, Bellevue Hospital, New York, New York, NY
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Gregory Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Meshe Chonde
- Department of Cardiology, Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA
| | - Howard Cooper
- Westchester Medical Center and New York Medical College, Valhalla
| | - Lori Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla
| | - Umesh Gidwani
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, NY
| | - Christopher Fordyce
- University of British Columbia, University of British Columbia Centre for Cardiovascular Innovation, Cardiovascular Health Program, University of British Columbia Centre for Health Evaluation and Outcomes Sciences, Vancouver, BC
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jason N Katz
- Department of Medicine at New York University Grossman School of Medicine, Bellevue Hospital, New York, New York, NY
| | - Michael Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Younghoon Kwon
- Division of Cardiology University of Washington Seattle, WA
| | - Evan Liebner
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, NY; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, NY
| | - Shuangbo Liu
- Max Rady College of Medicine, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - L K Newby
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Connor O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Alexander Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | | | - Brian Potter
- Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, Quebec, Canada
| | - Alastair Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London
| | - Robert O Roswell
- Northwell, New Hyde Park, Cardiovascular Institute, NY; Lenox Hospital, Northwell Health, New York, New York
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA
| | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH
| | - Andrea D Thompson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Miguel Alvarez Villela
- Northwell, New Hyde Park, Cardiovascular Institute, NY; Lenox Hospital, Northwell Health, New York, New York; Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY.
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4
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Gregory A, Ender J, Shaw AD, Denault A, Ibekwe S, Stoppe C, Alli A, Manning MW, Brodt JL, Galhardo C, Sander M, Zarbock A, Fletcher N, Ghadimi K, Grant MC. ERAS/STS 2024 Expert Consensus Statement on Perioperative Care in Cardiac Surgery: Continuing the Evolution of Optimized Patient Care and Recovery. J Cardiothorac Vasc Anesth 2024; 38:2155-2162. [PMID: 39004570 DOI: 10.1053/j.jvca.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Alexander Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heartcenter Leipzig GmbH, Leipzig, Germany
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH
| | - André Denault
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Stephanie Ibekwe
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | - Christian Stoppe
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Ahmad Alli
- Department of Anesthesiology & Pain Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Jessica L Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto CA
| | - Carlos Galhardo
- Department of Anesthesia, McMaster University, Ontario, Canada
| | - Michael Sander
- Anesthesiology and Intensive Care Medicine, Justus Liebig University Giessen, University Hospital Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Nick Fletcher
- Institute of Anaesthesia and Critical Care, Cleveland Clinic London, London, UK
| | | | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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5
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Yokoi M, Ito T, Shintani Y, Kawada Y, Mizoguchi T, Yamabe S, Mori K, Kikuchi S, Kitada S, Goto T, Seo Y. Clinical characteristics and short-term outcomes in patients with cardiogenic shock undergoing mechanical circulatory support escalation from intra-aortic balloon pump to impella: From the J-PVAD registry. J Cardiol 2024:S0914-5087(24)00181-3. [PMID: 39341372 DOI: 10.1016/j.jjcc.2024.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 09/01/2024] [Accepted: 09/20/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND An escalation strategy from intra-aortic balloon pump (IABP) to Impella (AbioMed, Danvers, MA, USA) is proposed in patients with cardiogenic shock (CS) refractory to IABP therapy, but its clinical data are lacking. This study aimed to elucidate the clinical characteristics and short-term outcomes in patients undergoing IABP-Impella escalation. METHODS AND RESULTS From the Japanese nationwide registry of Impella (J-PVAD), a total of 2578 patients with CS receiving Impella support were classified into the IABP-Impella group (n = 189) or the Primary Impella group (n = 2389). We applied 1:3 propensity score (PS) matching, selecting 185 patients and 555 patients, respectively. Before matching, the IABP-Impella group presented longer shock-to-Impella time, worse laboratory data, and more frequent inotropes and pulmonary artery catheter use than the Primary Impella group. After matching, the baseline characteristics were well-balanced. Regarding the 30-day clinical outcomes in the PS-matched cohort, there were no significant differences in the rates of mortality and major complications (a composite of bleeding, hemolysis, infection, stroke, myocardial infarction, limb ischemia, and vascular injury) between the groups. However, The IABP-Impella group showed a significantly higher rate of infection (10.3 % vs. 5.6 %, p = 0.042) and additional mechanical circulatory support use (34.1 % vs. 23.8 %, p = 0.008) than the Primary Impella group. CONCLUSIONS Compared to patients with primary Impella support, those undergoing IABP-Impella escalation showed similar 30-day mortality and major complications despite poorer clinical conditions before Impella support and a more complicated clinical course after Impella insertion.
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Affiliation(s)
- Masashi Yokoi
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tsuyoshi Ito
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Yasuhiro Shintani
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yu Kawada
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tatsuya Mizoguchi
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Sayuri Yamabe
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kento Mori
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shohei Kikuchi
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shuichi Kitada
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshihiko Goto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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6
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Kalapurakal G, Chau VQ, Imamura T, Tolia S, Sciamanna C, Macaluso GP, Joshi A, Pillarella J, Pauwaa S, Dia M, Kabbany T, Monaco J, Dela Cruz M, Cotts WG, Pappas P, Tatooles AJ, Narang N. Haemodynamic effects of intra-aortic balloon pumps stratified by baseline pulmonary artery pulsatility index. ESC Heart Fail 2024. [PMID: 39294848 DOI: 10.1002/ehf2.15083] [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: 06/06/2024] [Revised: 08/26/2024] [Accepted: 09/04/2024] [Indexed: 09/21/2024] Open
Abstract
AIMS Intra-aortic balloon pump (IABP) devices are commonly used in patients with heart failure related cardiogenic shock (HF-CS), including those with out-of-proportion right ventricular (RV) dysfunction. Pulmonary artery pulsatility index (PAPi) is a haemodynamic surrogate for RV performance. We aimed to assess short-term haemodynamic changes in patients with HF-CS following IABP support stratified by baseline PAPi. METHODS AND RESULTS This is a single-centre study of 67 consecutive patients with HF-CS who underwent IABP placement between 2020 and 2022. The primary aim was haemodynamic changes of specific variables on pulmonary artery catheter monitoring over 72 h following IABP placement. Secondary aims were clinically significant changes in diuretic regimens, changes in inotropes or vasopressors at 72 h following IABP, along with clinical outcomes. Prior to IABP placement, 57% of the total cohort (median age 59 years [48, 69], 31% female) had Society of Cardiovascular Angiography and Interventions Stage C HF-CS. Thirty-eight (56%) patients had a PAPi <2.0. Following 72 h of IABP support, the PAPi <2.0 group had an observed significant decrease in central venous pressure (CVP; 20 to 12 mmHg, P < 0.001) and mean pulmonary artery pressure (mPAP; 37.5 to 28.5 mmHg, P = 0.001), and an increase in PAPi (1 to 1.6, P = 0.001). No significant change in cardiac index (CI; 2 to 2.1 L/min/m2, P = 0.31) was observed. The PAPi ≥2.0 group (N = 29) had no observed significant change in CVP (10 to 8 mmHg, P = 0.47), or PAPi (2.6 to 2.8, P = 0.92), but there was a significant improvement in CI (1.9 to 2.5 L/min/m2, P = 0.004) along with reduction in mPA (37 to 29 mmHg, P = 0.03). The PAPi <2.0 group had a significant increase in diuretic requirement (52.6% vs. 20.7%, P = 0.01) and numerically greater addition of inotropes/vasopressors (47.3% vs. 34.4%, P = 0.07) compared with the PAPi ≥2.0 group at 72 h following IABP placement. Significantly more patients in the PAPi ≥2.0 group underwent left ventricular assist device (55.2% vs. 26.3%, P = 0.02), with no overall significant differences observed in escalation to veno-arterial extracorporeal membrane oxygenation, 30-day mortality, renal replacement therapy post-IABP, or rates of heart transplantation. CONCLUSIONS IABP devices in those with HF-CS and low or abnormal PAPi may provide modest short-term haemodynamic benefits without significant improvement in CI, along with greater need for adjustment in medical therapeutics to achieve haemodynamic optimization.
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Affiliation(s)
- George Kalapurakal
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Vinh Q Chau
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Sanika Tolia
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Chris Sciamanna
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Gregory P Macaluso
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Anjali Joshi
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Jessica Pillarella
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Sunil Pauwaa
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Muhyaldeen Dia
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Tarek Kabbany
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - James Monaco
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Mark Dela Cruz
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - William G Cotts
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Patroklos Pappas
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Antone J Tatooles
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USA
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7
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Nakamura M, Imamura T, Fujioka H, Nakagaito M, Ueno H, Kinugawa K. Impact of the spleen size on short-term prognosis in patients with cardiogenic shock receiving Impella-incorporated temporary mechanical circulatory support. J Artif Organs 2024:10.1007/s10047-024-01472-w. [PMID: 39277833 DOI: 10.1007/s10047-024-01472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 08/28/2024] [Indexed: 09/17/2024]
Abstract
The spleen size may be associated with mortality and morbidity in patients with heart failure, whereas its clinical implication in patients with cardiogenic shock receiving Impella-incorporated temporary mechanical circulatory support (MCS) remains unknown. Patients who received Impella-incorporated temporary MCS in our institute between March 2018 and August 2023 were eligible. The splenic volume index (SVI) was retrospectively calculated in all participants by measuring spleen size on the computed tomography obtained at the time of Impella placement. The impact of baseline SVI/central venous pressure (CVP) ratio on the 30-day mortality after Impella placement was evaluated. A total of 74 patients (70 years old, 62% men) were included. Median baseline SVI was 71.6 (50.3, 92.1) mL/m2. A lower SVI was associated with more decreased cardiac output and a higher SVI was associated with more elevated CVP (p < 0.05 for both). A lower SVI/CVP ratio was associated with higher 30-day mortality with an adjusted hazard ratio of 3.734 (95% confidence interval 1.397-9.981, p = 0.009). A baseline lower SVI/CVP ratio was associated with short-term mortality in patients receiving Impella-incorporated temporary MCS.
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Affiliation(s)
- Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-Shi, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-Shi, Toyama, 930-0194, Japan.
| | - Hayato Fujioka
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-Shi, Toyama, 930-0194, Japan
| | - Masaki Nakagaito
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-Shi, Toyama, 930-0194, Japan
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-Shi, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-Shi, Toyama, 930-0194, Japan
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8
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Nakamura M, Imamura T, Koichiro K. Contemporary optimal therapeutic strategy with escalation/de-escalation of temporary mechanical circulatory support in patients with cardiogenic shock and advanced heart failure in Japan. J Artif Organs 2024:10.1007/s10047-024-01471-x. [PMID: 39244693 DOI: 10.1007/s10047-024-01471-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 08/25/2024] [Indexed: 09/10/2024]
Abstract
The utilization of temporary mechanical circulatory support (MCS) in the management of cardiogenic shock is experiencing a notable surge. Acute myocardial infarction remains the predominant etiology of cardiogenic shock, followed by heart failure. Recent findings from the DanGer Shock trial indicate that the percutaneous micro-axial flow pump support, in conjunction with standard care, significantly reduced 6-month mortality in patients with acute myocardial infarction-related cardiogenic shock compared to those receiving standard care alone. However, real-world registry data reveal that the 30-day mortality among patients with acute myocardial infarction-related cardiogenic shock, who received concomitant veno-arterial extracorporeal membrane oxygenation support along with micro-axial flow pump, remain suboptimal. The persistent challenge in the field is how to incorporate, escalate, and de-escalate these temporary MCS to further improve clinical outcomes in such clinical scenarios. This review aims to elucidate the current practices surrounding the escalation and de-escalation of temporary MCS in real-world clinical settings and proposes considerations for future advancements in this critical area.
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Affiliation(s)
- Makiko Nakamura
- Second Department of Internal Medicine, Toyama University, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, Toyama University, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan.
| | - Kinugawa Koichiro
- Second Department of Internal Medicine, Toyama University, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 guideline focused update on indication and operation of PCPS/ECMO/IMPELLA. J Cardiol 2024; 84:208-238. [PMID: 39098794 DOI: 10.1016/j.jjcc.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
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10
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Zhao Z, Fang Z. Extracorporeal membrane oxygenation combined with hemoperfusion to assist in the rescue of aconitine poisoning: A case report. Perfusion 2024:2676591241280163. [PMID: 39196956 DOI: 10.1177/02676591241280163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been widely used as a clinical bridge for cardiopulmonary failure. We recently used combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and haemoperfusion to successfully treat a patient with acute aconitine poisoning. The patient was admitted to the Emergency Intensive Care Unit (EICU) in a state of coma and shock. Her received comprehensive treatment, including haemoperfusion and anti-shock therapy. 40 minutes after admission, the patient experienced sudden respiratory and cardiac arrest. After conventional defibrillation and cardiopulmonary resuscitation proved ineffective, veno-arterial ECMO was immediately initiated. One hour after initiation of VA-ECMO, the patient's heart rhythm stabilised to sinus rhythm. After 33 h of supportive care, the patient was awake, haemodynamically stable and the VA-ECMO was successfully removed. The patient made full recovery 7 days after admission.
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Affiliation(s)
- Zhiwen Zhao
- Department of Emergency Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Zhicheng Fang
- Department of Emergency Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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11
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Desai A, Sharma S, Luce C, Ruiz J, Goswami R. Case Report: Unmasking sustainable left ventricular recovery in chronic heart failure with axillary temporary mechanical circulatory support. Front Cardiovasc Med 2024; 11:1407552. [PMID: 39257842 PMCID: PMC11385610 DOI: 10.3389/fcvm.2024.1407552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 05/27/2024] [Indexed: 09/12/2024] Open
Abstract
Background Mechanical circulatory support (MCS), temporary or durable, is essential in patients with acute heart failure presenting in cardiogenic shock (CS). MCS is fundamental in patients with advanced heart failure when used as a bridge to decision, transplant or left ventricular recovery. Limited data on acute-on-chronic heart failure (HF) patients exists in the era of axillary mechanical circulatory support with the Impella 5.5. We describe a case of chronic ischemic cardiomyopathy, HF-CS, in a patient who underwent Impella placement, medical optimization, and explant, now with sustained normalization in ejection fraction. Case summary A Caucasian female in her 50 s was referred to our center for evaluation for advanced therapies, including transplantation or durable left ventricular assist device placement. Her initial ejection fraction was 30% with comorbidities including multivessel coronary artery disease revascularized with 3 vessel bypass grafting ten years prior, type 2 diabetes (A1c 8.6%), and peripheral vascular disease. During her evaluation, she had acute decompensation leading to cardiogenic shock and required hospitalization with inotrope initiation, which was unable to be weaned. She was approved for organ transplant and listed; however, she required escalation of support and eventual placement of right axillary Impella 5.5. While on Impella support, her vasoactive needs reduced, and she was found to have left ventricular recovery and tolerated the initiation of guideline medical therapy. After three weeks of support, the Impella was weaned and explanted, and the patient was discharged. She remains stable with a sustained ejection fraction of greater than 50% with NYHA class 1 functional status at follow-up. One year later, the patient showed sustained myocardial recovery with guideline-directed medical therapy (GDMT). Conclusion Our case highlights a unique approach in patients with long-standing (>5 years) heart failure who may benefit from early consideration for axillary support and concomitant optimization with guideline-directed medical therapy to assess for explant and native heart recovery.
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Affiliation(s)
- Aarti Desai
- Division of Advanced Heart Failure and Transplant Cardiology, Mayo Clinic, Jacksonville, FL, United States
| | - Shriya Sharma
- Division of Advanced Heart Failure and Transplant Cardiology, Mayo Clinic, Jacksonville, FL, United States
| | - Caitlyn Luce
- Division of Advanced Heart Failure and Transplant Cardiology, Mayo Clinic, Jacksonville, FL, United States
| | - Jose Ruiz
- Division of Advanced Heart Failure and Transplant Cardiology, Mayo Clinic, Jacksonville, FL, United States
| | - Rohan Goswami
- Division of Advanced Heart Failure and Transplant Cardiology, Mayo Clinic, Jacksonville, FL, United States
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12
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Martínez León A, Bazal Chacón P, Herrador Galindo L, Ugarriza Ortueta J, Plaza Martín M, Pastor Pueyo P, Alonso Salinas GL. Review of Advancements in Managing Cardiogenic Shock: From Emergency Care Protocols to Long-Term Therapeutic Strategies. J Clin Med 2024; 13:4841. [PMID: 39200983 PMCID: PMC11355768 DOI: 10.3390/jcm13164841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/08/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Cardiogenic shock (CS) is a complex multifactorial clinical syndrome of end-organ hypoperfusion that could be associated with multisystem organ failure, presenting a diverse range of causes and symptoms. Despite improving survival in recent years due to new advancements, CS still carries a high risk of severe morbidity and mortality. Recent research has focused on improving early detection and understanding of CS through standardized team approaches, detailed hemodynamic assessment, and selective use of temporary mechanical circulatory support devices, leading to better patient outcomes. This review examines CS pathophysiology, emerging classifications, current drug and device therapies, standardized team management strategies, and regionalized care systems aimed at optimizing shock outcomes. Furthermore, we identify gaps in knowledge and outline future research needs.
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Affiliation(s)
- Amaia Martínez León
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - Pablo Bazal Chacón
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Heath Sciences Department, Universidad Pública de Navarra (UPNA-NUP), 31006 Pamplona, Spain
| | - Lorena Herrador Galindo
- Advanced Heart Failure and Cardiology Department, Hospital Universitario de Bellvitge, Carrer de la Feixa Llarga s/n, 08907 L’Hospitalet de Llobregat, Spain;
| | - Julene Ugarriza Ortueta
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
| | - María Plaza Martín
- Cardiology Department, Hospital Clínico Universitario de Valladolid, Av Ramón y Cajal 3, 47003 Valladolid, Spain;
| | - Pablo Pastor Pueyo
- Cardiology Department, Hospital Universitari Arnau de Vilanova, Av Alcalde Rovira Roure, 80, 25198 Lleida, Spain;
| | - Gonzalo Luis Alonso Salinas
- Cardiology Department, Hospital Universitario de Navarra (HUN-NOU), Calle de Irunlarrea, 3, 31008 Pamplona, Spain; (A.M.L.); (P.B.C.); (J.U.O.)
- Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
- Heath Sciences Department, Universidad Pública de Navarra (UPNA-NUP), 31006 Pamplona, Spain
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13
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Augustin KJ, Wieruszewski PM, McLean L, Leiendecker E, Ramakrishna H. Analysis of the 2023 European Multidisciplinary Consensus Statement on the Management of Short-term Mechanical Circulatory Support of Cardiogenic Shock in Adults in the Intensive Cardiac Care Unit. J Cardiothorac Vasc Anesth 2024; 38:1786-1801. [PMID: 38862282 DOI: 10.1053/j.jvca.2024.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 06/13/2024]
Affiliation(s)
- Katrina Joy Augustin
- Division of Anesthesia and Critical Care Medicine, Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Lewis McLean
- Intensive Care Unit, John Hunter Hospital, Newcastle, Australia
| | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Vlachakis PK, Theofilis P, Leontsinis I, Drakopoulou M, Karakasis P, Oikonomou E, Chrysohoou C, Tsioufis K, Tousoulis D. Bridge to Life: Current Landscape of Temporary Mechanical Circulatory Support in Heart-Failure-Related Cardiogenic Shock. J Clin Med 2024; 13:4120. [PMID: 39064160 PMCID: PMC11277937 DOI: 10.3390/jcm13144120] [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: 06/01/2024] [Revised: 07/02/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Acute heart failure (HF) presents a significant mortality burden, necessitating continuous therapeutic advancements. Temporary mechanical circulatory support (MCS) is crucial in managing cardiogenic shock (CS) secondary to acute HF, serving as a bridge to recovery or durable support. Currently, MCS options include the Intra-Aortic Balloon Pump (IABP), TandemHeart (TH), Impella, and Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO), each offering unique benefits and risks tailored to patient-specific factors and clinical scenarios. This review examines the clinical implications of recent advancements in temporary MCS, identifies knowledge gaps, and explores promising avenues for future research and clinical application. Understanding each device's unique attributes is crucial for their efficient implementation in various clinical scenarios, ultimately advancing towards intelligent, personalized support strategies.
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Affiliation(s)
- Panayotis K. Vlachakis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.V.); (I.L.); (M.D.); (C.C.); (K.T.); (D.T.)
| | - Panagiotis Theofilis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.V.); (I.L.); (M.D.); (C.C.); (K.T.); (D.T.)
| | - Ioannis Leontsinis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.V.); (I.L.); (M.D.); (C.C.); (K.T.); (D.T.)
| | - Maria Drakopoulou
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.V.); (I.L.); (M.D.); (C.C.); (K.T.); (D.T.)
| | - Paschalis Karakasis
- 2nd Department of Cardiology, “Hippokration” General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Evangelos Oikonomou
- 3rd Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Christina Chrysohoou
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.V.); (I.L.); (M.D.); (C.C.); (K.T.); (D.T.)
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.V.); (I.L.); (M.D.); (C.C.); (K.T.); (D.T.)
| | - Dimitris Tousoulis
- 1st Department of Cardiology, “Hippokration” General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece; (P.K.V.); (I.L.); (M.D.); (C.C.); (K.T.); (D.T.)
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15
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Brewer JM, Maybauer MO. The ProtekDuo Cannula: A Comprehensive Review of Efficacy and Clinical Applications in Right Ventricular Failure. J Clin Med 2024; 13:4077. [PMID: 39064117 PMCID: PMC11278424 DOI: 10.3390/jcm13144077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Right ventricular failure (RVF) is a clinical challenge associated with various underlying acute and chronic medical conditions, necessitating diverse management strategies including mechanical circulatory support (MCS). The ProtekDuo cannula represents an important advancement in medical devices for MCS in the setting of RVF. When combined with an extracorporeal blood pump, the dual-lumen design allows for direct bypass of the RV using simultaneous drainage and return of blood using percutaneous, single-site access. Studies have reported favorable outcomes with the ProtekDuo cannula and low device-related complications, but comparative studies with other MCS devices are limited. Still, the ProtekDuo cannula has numerous advantages; however, it is not without challenges, and opportunities for further research exist. The ProtekDuo cannula holds significant potential for future advancements in the field of MCS, offering promising solutions for RVF management.
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Affiliation(s)
- Joseph M. Brewer
- Specialty Critical Care and Acute Circulatory Support Service, Nazih Zuhdi Transplant Institute, INTEGRIS Health Baptist Medical Center, Oklahoma City, OK 73112, USA
| | - Marc O. Maybauer
- Division of Critical Care Medicine, Department of Anesthesiology, University of Florida, Gainesville, FL 32610, USA
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, 35037 Marburg, Germany
- Critical Care Research Group, Prince Charles Hospital, University of Queensland, Brisbane, QLD 4072, Australia
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16
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de Roux Q, Disli Y, Bougouin W, Renaudier M, Jendoubi A, Merle JC, Delage M, Picard L, Sayagh F, Cherait C, Folliguet T, Quesnel C, Becq A, Mongardon N. Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support. Ann Intensive Care 2024; 14:104. [PMID: 38958791 PMCID: PMC11222359 DOI: 10.1186/s13613-024-01326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients. MATERIALS AND METHODS A retrospective single-center study (2013-2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation. RESULTS A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7-17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07-50.01], p = 0.042). CONCLUSION UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.
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Affiliation(s)
- Quentin de Roux
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France.
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France.
- Service d'Anesthésie-Réanimation et Médecine Péri-Opératoire, CHU Henri Mondor, 1 rue Gustave Eiffel, Créteil, 94000, France.
| | - Yekcan Disli
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Wulfran Bougouin
- Réanimation polyvalente, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
- AfterROSC research group, Paris, France
| | - Marie Renaudier
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Ali Jendoubi
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Jean-Claude Merle
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Mathilde Delage
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Lucile Picard
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Faiza Sayagh
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Chamsedine Cherait
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, Assistance Publique-Hôpitaux de Paris, DMU CARE, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Christophe Quesnel
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Aymeric Becq
- Service de gastro-entérologie, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation et médecine péri-opératoire, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé, Université Paris Est Créteil, Créteil, France
- U955-IMRB, Equipe 03 "Stratégies pharmacologiques et thérapeutiques expérimentales des insuffisances cardiaques et coronaires", Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
- AfterROSC research group, Paris, France
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Vallabhajosyula S, Abbott JD, Kapur NK. The Need to Define High-Dose Pharmacological Circulatory Support in Cardiogenic Shock. Mayo Clin Proc 2024; 99:1035-1037. [PMID: 38960493 DOI: 10.1016/j.mayocp.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 07/05/2024]
Affiliation(s)
- Saraschandra Vallabhajosyula
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI.
| | - J Dawn Abbott
- Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Navin K Kapur
- The CardioVascular Center, Division of Cardiovascular Medicine, Department of Medicine, Tufts University School of Medicine, Boston, MA
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18
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Huang X, Shen Y, Liu Y, Zhang H. Current status and future directions in pediatric ventricular assist device. Heart Fail Rev 2024; 29:769-784. [PMID: 38530587 DOI: 10.1007/s10741-024-10396-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
A ventricular assist device (VAD) is a form of mechanical circulatory support that uses a mechanical pump to partially or fully take over the function of a failed heart. In recent decades, the VAD has become a crucial option in the treatment of end-stage heart failure in adult patients. However, due to the lack of suitable devices and more complicated patient profiles, this therapeutic approach is still not widely used for pediatric populations. This article reviews the clinically available devices, adverse events, and future directions of design and implementation in pediatric VADs.
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Affiliation(s)
- Xu Huang
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
| | - Yi Shen
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
| | - Yiwei Liu
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
| | - Hao Zhang
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
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19
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Phillips JD, Spratt JR, Choi CY, Scali ST, Maybauer MO. Venoarterial Extracorporeal Membrane Oxygenation for "Protected" Percutaneous Coronary Intervention Secondary to Refractory Polymorphic Ventricular Tachycardia and Cardiac Arrest. Ann Card Anaesth 2024; 27:246-248. [PMID: 38963360 PMCID: PMC11315244 DOI: 10.4103/aca.aca_136_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/08/2023] [Accepted: 12/08/2023] [Indexed: 07/05/2024] Open
Abstract
ABSTRACT We present a case of cardiogenic shock secondary to refractory polymorphic ventricular tachycardia associated with coronary ischemia resulting in cardiac arrest. Following the return of spontaneous circulation, the patient was cannulated for peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) in anticipation of high-risk "protected" percutaneous coronary intervention (PCI). Under full V-A ECMO support, inotropes and vasopressors were weaned off, and the patient underwent uneventful PCI of left circumflex and obtuse marginal lesions. After 48 hours, the patient was decannulated and could be discharged home alive 16 days after his initial cardiac arrest.
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Affiliation(s)
- Jordan D. Phillips
- Department of Anesthesiology, Division of Critical Care Medicine, Gainesville, FL, USA
| | - John R. Spratt
- Department of Surgery, Division of Cardiovascular Surgery, Gainesville, FL, USA
| | - Calvin Y. Choi
- Department of Medicine, Division of Cardiovascular Medicine, Gainesville, FL, USA
| | - Salvatore T. Scali
- Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Marc O. Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, Gainesville, FL, USA
- Department of Anesthesiology and Intensive Care, Philipps University, Marburg, Germany
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, Australia
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20
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Shang L, Wei J, Liu K, Ao Y, Huang S, Hou J, Wu Z, Yao J. Predictors of short-term survival in cardiac valvular surgery patients with intra-aortic balloon pump implantation. Gen Thorac Cardiovasc Surg 2024; 72:447-454. [PMID: 38038878 DOI: 10.1007/s11748-023-01989-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Intro-aortic balloon pump (IABP) is widely used in cardiac surgery patients nowadays. This study aimed to analyze the predictor of short-term survival in cardiac valvular surgery patients with intra-aortic balloon pump implantation. METHODS This was a retrospective study and a total of 102 cardiac valvular surgery patients who received intra-aortic balloon pump implantation were consecutively included. We retrospectively collected the baseline characteristics and short-term outcomes. Baseline characteristics were compared between survivors with non-survivors, and logistic regression was performed to identify predictors for short-term mortality. RESULTS Among all the patients, there were 71 (69.6%) patients successfully weaned from IABP and survived to discharge, the other 31 (30.4%) patients failed to wean from IABP and died within the first 30 days after surgery. When compared with non-survivors, survivors had a higher proportion of males (62% vs 32.3%, p = 0.006), a lower rate of Atrial fibrillation (38% vs 62%, p < 0.03). After IABP implantation, vasoactive drug use was significantly lower in survivors compared with non-survivors, and survivors showed significant improvements in cardiac function and urine volume. Univariate and multivariate logistic regression analysis indicated that atrial fibrillation and combined use of continuous renal replacement therapy (CRRT) were significant independent predictors for short-term mortality. CONCLUSION Timely implantation of IABP can improve patients' cardiac and renal function and reduce the dosage of vasoactive drugs. Atrial fibrillation and combined use of CRRT are independent predictors for short-term mortality in patients who underwent cardiac valvular surgery with IABP implantation.
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Affiliation(s)
- Liqun Shang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Jinhui Wei
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Kaizheng Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Yuanhan Ao
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Jian Hou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China.
| | - Jianping Yao
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan II Rd, Guangzhou, 510080, China.
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21
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Kochar A, Vallabhajosyula S, John K, Sinha SS, Esposito M, Pahuja M, Hirst C, Li S, Kong Q, Li B, Natov P, Kanwar M, Hernandez-Montfort J, Garan AR, Walec K, Zazzali P, Sangal P, Ton VK, Zweck E, Kataria R, Guglin M, Vorovich E, Nathan S, Abraham J, Harwani NM, Fried JA, Farr M, Hall SA, Hickey GW, Wencker D, Schwartzman AD, Khalife W, Mahr C, Kim JH, Bhimaraj A, Blumer V, Faugno A, Burkhoff D, Kapur NK. Factors associated with acute limb ischemia in cardiogenic shock and downstream clinical outcomes: Insights from the Cardiogenic Shock Working Group. J Heart Lung Transplant 2024:S1053-2498(24)01705-4. [PMID: 38944132 DOI: 10.1016/j.healun.2024.06.012] [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: 01/31/2024] [Revised: 05/29/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND There are limited data depicting the prevalence and ramifications of acute limb ischemia (ALI) among cardiogenic shock (CS) patients. METHODS We employed data from the Cardiogenic Shock Working Group (CSWG), a consortium including 33 sites. We constructed a multi-variable logistic regression to examine the association between clinical factors and ALI, we generated another logistic regression model to ascertain the association of ALI with mortality. RESULTS There were 7,070 patients with CS and 399 (5.6%) developed ALI. Patients with ALI were more likely to be female (40.4% vs 29.4%) and have peripheral arterial disease (13.8% vs 8.3%). Stratified by maximum society for cardiovascular angiography & intervention (SCAI) shock stage, the rates of ALI were stage B 0.0%, stage C 1.8%, stage D 4.1%, and stage E 10.3%. Factors associated with higher risk for ALI included: peripheral vascular disease OR 2.24 (95% CI: 1.53-3.23; p < 0.01) and ≥2 mechanical circulatory support (MCS) devices OR 1.66 (95% CI: 1.24-2.21, p < 0.01). ALI was highest for venous-arterial extracorporeal membrane oxygenation (VA-ECMO) patients (11.6%) or VA-ECMO+ intra-aortic balloon pump (IABP)/Impella CP (16.6%) yet use of distal perfusion catheters was less than 50%. Mortality was 38.0% for CS patients without ALI but 57.4% for CS patients with ALI. ALI was significantly associated with mortality, adjusted OR 1.40 (95% CI 1.01-1.95, p < 0.01). CONCLUSIONS The rate of ALI was 6% among CS patients. Factors most associated with ALI include peripheral vascular disease and multiple MCS devices. The downstream ramifications of ALI were dire with a considerably higher risk of mortality.
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Affiliation(s)
- Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Saraschandra Vallabhajosyula
- Cardiovascular Institute, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Kevin John
- Internal Medicine, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Shashank S Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, Virginia
| | - Michele Esposito
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Mohit Pahuja
- Division of Cardiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Colin Hirst
- Division of Cardiology, St. Peter's Health Partners Medical Associates, Albany, New York
| | - Song Li
- Division of Cardiology, Institute for Advanced Cardiac Care, Medical City Healthcare, Dallas, Texas
| | - Qiuyue Kong
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Borui Li
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Peter Natov
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Manreet Kanwar
- McGinnis Cardiovascular Institute, Cardiovascular Instittue at Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jaime Hernandez-Montfort
- Division of Heart and Vascular Care, Baylor Scott & White Health, Advanced Heart Failure Program Clinic, Temple, Texas
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Karol Walec
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Peter Zazzali
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Paavni Sangal
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Van-Khue Ton
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Elric Zweck
- Division of Cardiology, Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rachna Kataria
- Division of Cardiology, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Maya Guglin
- Division of Heart and Vascular Care, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Esther Vorovich
- Heart and Vascular Center, Bluhm Cardiovascular Institute of Northwestern University, Chicago, Illinois
| | - Sandeep Nathan
- Division of Cardiology, University of Chicago, Chicago, Illinois
| | - Jacob Abraham
- Division of Cardiology, Providence Heart Institute, Portland, Oregon
| | - Neil M Harwani
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Justin A Fried
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Columbia University Irving Medical Center, New York, NY
| | - Maryjane Farr
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Gavin W Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Detlef Wencker
- Division of Heart and Vascular Care, Baylor Scott & White Health, Advanced Heart Failure Program Clinic, Temple, Texas
| | | | - Wissam Khalife
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Claudius Mahr
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington
| | - Ju H Kim
- Department of Cardiology, Houston Methodist Research Institute, Houston, Texas
| | - Arvind Bhimaraj
- Department of Cardiology, Houston Methodist Research Institute, Houston, Texas
| | - Vanessa Blumer
- Division of Cardiology, Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, Virginia
| | - Anthony Faugno
- Division of Pulmonology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | | | - Navin K Kapur
- Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts.
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22
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Movahed MR, Soltani Moghadam A, Hashemzadeh M. In Patients with Cardiogenic Shock, Extracorporeal Membrane Oxygenation Is Associated with Very High All-Cause Inpatient Mortality Rate. J Clin Med 2024; 13:3607. [PMID: 38930138 PMCID: PMC11204588 DOI: 10.3390/jcm13123607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Background: The goal of this study was to evaluate the effect of extracorporeal membrane oxygenation (ECMO) on mortality in patients with cardiogenic shock excluding Impella and IABP use. Method: The large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of ECMO in adults over the age of 18 and mortality and complications with a diagnosis of cardiogenic shocks. Results: ICD-10 codes for ECMO and cardiogenic shock for the available years 2016-2020 were utilized. A total of 796,585 (age 66.5 ± 14.4) patients had a diagnosis of cardiogenic shock excluding Impella. Of these patients, 13,160 (age 53.7 ± 15.4) were treated with ECMO without IABP use. Total inpatient mortality without any device was 32.7%. It was 47.9% with ECMO. In a multivariate analysis adjusting for 47 variables such as age, gender, race, lactic acidosis, three-vessel intervention, left main myocardial infarction, cardiomyopathy, systolic heart failure, acute ST-elevation myocardial infarction, peripheral vascular disease, chronic renal disease, etc., ECMO utilization remained highly associated with mortality (OR: 1.78, CI: 1.6-1.9, p < 0.001). Evaluating teaching hospitals only revealed similar findings. Major complications were also high in the ECMO cohort. Conclusions: In patients with cardiogenic shock, the use of ECMO was associated with the high in-hospital mortality regardless of comorbid condition, high-risk futures, or type of hospital.
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Affiliation(s)
- Mohammad Reza Movahed
- College of Medicine, University of Arizona Sarver Heart Center, 1501 North Campbell Avenue, Tucson, AZ 85724, USA
- College of Medicine, University of Arizona, Phoenix, AZ 85004, USA
| | - Arman Soltani Moghadam
- College of Medicine, University of Arizona Sarver Heart Center, 1501 North Campbell Avenue, Tucson, AZ 85724, USA
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23
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De Backer D, Donker DW, Combes A, Mebazaa A, Moller JE, Vincent JL. Mechanical circulatory support in cardiogenic shock: microaxial flow pumps for all and VA-ECMO consigned to the museum? Crit Care 2024; 28:203. [PMID: 38902801 PMCID: PMC11188205 DOI: 10.1186/s13054-024-04988-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 06/13/2024] [Indexed: 06/22/2024] Open
Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Boulevard du Triomphe 201, 1160, Brussels, Belgium.
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, The Netherlands
| | - Alain Combes
- Sorbonne Université, INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition and Service de Médecine Intensive-Réanimation, Hôpital Pitié-Salpêtrière, Sorbonne Université Assistance Publique-Hôpitaux de Paris, Sorbonne Université, INSERM, Paris, France
| | - Alexandre Mebazaa
- Université Paris Cité, Inserm 942 MASCOT, Hôpitaux Universitaires Saint-Louis and Lariboisière, Paris, France
| | - Jacob E Moller
- Heart Center, Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
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24
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Nakamura M, Imamura T, Hida Y, Izumida T, Nakagaito M, Nagura S, Doi T, Fukahara K, Kinugawa K. A case of destination therapy for post-fulminant myocarditis with myelodysplastic syndrome. J Artif Organs 2024:10.1007/s10047-024-01455-x. [PMID: 38862744 DOI: 10.1007/s10047-024-01455-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 06/02/2024] [Indexed: 06/13/2024]
Abstract
We encountered a 64-year-old woman who experienced fulminant myocarditis and underwent treatment with veno-arterial extracorporeal membrane oxygenation and Impella CP support. Subsequently, she underwent a device upgrade to Impella 5.5 and received continuous hemodiafiltration for 3 months. During mechanical circulatory support, she developed refractory anemia and thrombocytopenia, leading to a diagnosis of myelodysplastic syndrome. Following the removal of the devices, she no longer required blood transfusions. She received HeartMate 3 left ventricular assist device implantation as a destination therapy indication despite the presence of myelodysplastic syndrome. She was successfully managed by aspirin-free antithrombotic therapy without any hemocompatibility-related adverse events for 4 months after index discharge on foot. We present a patient with a unique and rare presentation, wherein HeartMate 3 was implanted and successfully managed without aspirin to prevent bleeding complications associated with myelodysplastic syndrome.
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Affiliation(s)
- Makiko Nakamura
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan.
| | - Yuki Hida
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Toshihide Izumida
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Masaki Nakagaito
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Saori Nagura
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Toyama, Japan
| | - Toshio Doi
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Toyama, Japan
| | - Kazuaki Fukahara
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
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25
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Alkhunaizi FA, Smith N, Brusca SB, Furfaro D. The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review. CHEST CRITICAL CARE 2024; 2:100071. [PMID: 38993934 PMCID: PMC11238736 DOI: 10.1016/j.chstcc.2024.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.
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Affiliation(s)
- Fatimah A Alkhunaizi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nikolhaus Smith
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Samuel B Brusca
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Furfaro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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26
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Ughetto A, Eliet J, Nagot N, David H, Bazalgette F, Marin G, Kollen S, Mourad M, Zeroual N, Muller L, Gaudard P, Colson P. Early temporary mechanical circulatory support for cardiogenic shock: Real-life data from a regional cardiac assistance network. J Heart Lung Transplant 2024; 43:911-919. [PMID: 38367739 DOI: 10.1016/j.healun.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Temporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network. METHODS Prospective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centers organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality. RESULTS Two hundred and forty-six patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95% CI:0.65-1.26). Patients with mechanical assistance had a higher rate of complications than others with longer Intensive Care Unit and hospital stays. CONCLUSIONS In the conditions of a cardiac assistance regional network, in-hospital mortality was not improved by early mechanical assistance implantation. A high incidence of complications of temporary mechanical circulatory support may have jeopardized its potential benefit.
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Affiliation(s)
- Aurore Ughetto
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Jacob Eliet
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Nicolas Nagot
- Clinical Research and Epidemiology Unit, CHU Montpellier, Univ Montpellier, Montpellier, France
| | - Hélène David
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France; University of Montpellier, CNRS, INSERM, PhyMedExp, Montpellier, France
| | - Florian Bazalgette
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Grégory Marin
- Clinical Research and Epidemiology Unit, CHU Montpellier, Univ Montpellier, Montpellier, France
| | - Sébastien Kollen
- Department of Critical Care Medicine, CH Perpignan, Perpignan, France
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Norddine Zeroual
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Laurent Muller
- Department of Critical Care Medicine, CHU Nîmes, University of Montpellier-Nîmes, Nîmes, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France; University of Montpellier, CNRS, INSERM, PhyMedExp, Montpellier, France
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France; University of Montpellier, CNRS, INSERM, Institut de Génomique Fonctionnelle, Montpellier, France.
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27
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Qu Z, Pang X, Mei Z, Li Y, Zhang Y, Huang C, Liu K, Yu S, Wang C, Sun Z, Liu Y, Li X, Jia Y, Dong Y, Lu M, Ju T, Wu F, Huang M, Li N, Dou S, Jiang J, Dong X, Zhang Y, Li W, Yang B, Du W. The positive feedback loop of the NAT10/Mybbp1a/p53 axis promotes cardiomyocyte ferroptosis to exacerbate cardiac I/R injury. Redox Biol 2024; 72:103145. [PMID: 38583415 PMCID: PMC11002668 DOI: 10.1016/j.redox.2024.103145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024] Open
Abstract
Ferroptosis is a nonapoptotic form of regulated cell death that has been reported to play a central role in cardiac ischemia‒reperfusion (I/R) injury. N-acetyltransferase 10 (NAT10) contributes to cardiomyocyte apoptosis by functioning as an RNA ac4c acetyltransferase, but its role in cardiomyocyte ferroptosis during I/R injury has not been determined. This study aimed to elucidate the role of NAT10 in cardiac ferroptosis as well as the underlying mechanism. The mRNA and protein levels of NAT10 were increased in mouse hearts after I/R and in cardiomyocytes that were exposed to hypoxia/reoxygenation. P53 acted as an endogenous activator of NAT10 during I/R in a transcription-dependent manner. Cardiac overexpression of NAT10 caused cardiomyocyte ferroptosis to exacerbate I/R injury, while cardiomyocyte-specific knockout of NAT10 or pharmacological inhibition of NAT10 with Remodelin had the opposite effects. The inhibition of cardiomyocyte ferroptosis by Fer-1 exerted superior cardioprotective effects against the NAT10-induced exacerbation of post-I/R cardiac damage than the inhibition of apoptosis by emricasan. Mechanistically, NAT10 induced the ac4C modification of Mybbp1a, increasing its stability, which in turn activated p53 and subsequently repressed the transcription of the anti-ferroptotic gene SLC7A11. Moreover, knockdown of Mybbp1a partially abolished the detrimental effects of NAT10 overexpression on cardiomyocyte ferroptosis and cardiac I/R injury. Collectively, our study revealed that p53 and NAT10 interdependently cooperate to form a positive feedback loop that promotes cardiomyocyte ferroptosis to exacerbate cardiac I/R injury, suggesting that targeting the NAT10/Mybbp1a/p53 axis may be a novel approach for treating cardiac I/R.
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Affiliation(s)
- Zhezhe Qu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Xiaochen Pang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Zhongting Mei
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Ying Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Yaozhi Zhang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Chuanhao Huang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Kuiwu Liu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Shuting Yu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Changhao Wang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Zhiyong Sun
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Yingqi Liu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Xin Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Yingqiong Jia
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Yuechao Dong
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Meixi Lu
- Traditional Chinese Medicine School, Beijing University of Chinese Medicine, Beijing, China
| | - Tiantian Ju
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Fan Wu
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Min Huang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Na Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Shunkang Dou
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Jianhao Jiang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Xianhui Dong
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Yi Zhang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Wanhong Li
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China
| | - Baofeng Yang
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China; Northern Translational Medicine Research and Cooperation Center, Heilongjiang Academy of Medical Sciences, Harbin Medical University, Harbin, China; Research Unit of Noninfectious Chronic Diseases in Frigid Zone, Chinese Academy of Medical Sciences, 2019RU070, Harbin, China.
| | - Weijie Du
- State Key Laboratory of Frigid Zone Cardiovascular Diseases (SKLFZCD), Department of Pharmacology (State-Province Key Laboratories of Biomedicine-Pharmaceutics of China, Key Laboratory of Cardiovascular Research, Ministry of Education), College of Pharmacy, Harbin Medical University, Harbin, China; Northern Translational Medicine Research and Cooperation Center, Heilongjiang Academy of Medical Sciences, Harbin Medical University, Harbin, China; Research Unit of Noninfectious Chronic Diseases in Frigid Zone, Chinese Academy of Medical Sciences, 2019RU070, Harbin, China; Eye Hospital, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China.
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 Guideline Focused Update on Indication and Operation of PCPS/ECMO/IMPELLA. Circ J 2024; 88:1010-1046. [PMID: 38583962 DOI: 10.1253/circj.cj-23-0698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Yasutaka Hirata
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | | | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | | | - Takeshi Kitai
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center
| | - Takayuki Ohno
- Division of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Kazuhiro Satomi
- Department of Cardiovascular Medicine, Tokyo Medical University Hospital
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Koichi Toda
- Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center
| | - Yasumasa Tsukamoto
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Faculty of Medical Sciences, Kyushu University
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | | | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hirotsugu Kurobe
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
| | - Tetsuya Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Shogo Shimada
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Shinya Unai
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Shunei Kyo
- Tokyo Metropolitan Institute for Geriatrics and Gerontology
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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Tsushima R, Maruhashi T, Kurihara Y, Hashikata T, Asari Y. Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit. CVIR Endovasc 2024; 7:48. [PMID: 38769160 PMCID: PMC11106222 DOI: 10.1186/s42155-024-00460-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/16/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Current guidelines recommend the use of mechanical circulatory support (MCS) for patients with cardiogenic shock that is refractory to medical therapy. Bleeding is the most common complication of MCS. Transarterial embolization (TAE) is often performed to treat this complication, because it is a less invasive hemostatic procedure. However, the TAE option needs to be carefully considered during MCS, as the access route may be limited during MCS. CASE PRESENTATION A man in his 70 s was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention via venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella. During treatment in the intensive care unit, he suffered damage to a branch of the internal thoracic artery during a cardiac drainage procedure, which was subsequently treated via emergency TAE. An ECMO return cannula and an Impella sheath were inserted into the patient's right and left femoral arteries, respectively. An approach from the left brachial artery was selected, and the left internal thoracic artery was embolized. Subsequently, the patient required re-intervention to treat re-bleeding from another artery. Because it was difficult to target the target artery from the brachial one, owing to interference from the Impella catheter, the ECMO circuit near the return cannula was punctured and a guiding sheath was inserted. The ECMO flow and the patient's blood pressure decreased following placement of this guiding sheath. We were thus able to maintain the patient's blood pressure by increasing the infusion fluids and Impella flow, and embolize the target artery using a gelatin sponge to achieve hemostasis. CONCLUSION When TAE is difficult to perform during MCS using an approach from the upper extremities, a lower extremity approach with a sheath inserted into the ECMO circuit may represent a viable alternative.
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Affiliation(s)
- Ryota Tsushima
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan.
| | - Yutaro Kurihara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Takehiro Hashikata
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
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30
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barsness GW, Chaudhry SP, Chonde MD, Cooper HA, Ginder C, Jentzer JC, Kontos MC, Miller PE, Newby LK, O'Brien CG, Park JG, Pierce MJ, Pisani BA, Potter BJ, Shah KS, Teuteberg JJ, Katz JN, van Diepen S, Morrow DA. Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights From the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2024; 17:e011736. [PMID: 38587438 DOI: 10.1161/circheartfailure.124.011736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. RESULTS Among 3665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10-point increase and decrease from 4 to 24 hours, respectively. The 4 and 24-hour VIS were each associated with cardiac intensive care unit mortality (13%-45% and 11%-73% for VIS <10 to ≥40, respectively; Ptrend <0.0001 for each). Stratifying by the 4-hour VIS, changes in VIS from 4 to 24 hours had a graded association with mortality, ranging from a 2- to >4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS (Ptrend <0.0001). The change in VIS alone provided good discrimination of cardiac intensive care unit mortality (C-statistic, 0.72 [95% CI, 0.70-0.75]) and improved discrimination of the 24-hour Sequential Organ Failure Assessment score (0.72 [95% CI, 0.69-0.74] to 0.76 [95% CI, 0.74-0.78]) and the clinician-assessed Society for Cardiovascular Angiography and Interventions shock stage (0.72 [95% CI, 0.70-0.74] to 0.77 [95% CI, 0.75-0.79]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with versus without mechanical circulatory support (odds ratio per 10-point higher 24-hour VIS, 1.36 [95% CI, 1.23-1.49] versus 1.84 [95% CI, 1.69-2.01]; Pinteraction <0.0001). CONCLUSIONS Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.
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Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | | | - Meshe D Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.D.C.)
| | - Howard A Cooper
- Department of Cardiology, Westchester Medical Center, Valhalla, NY (H.A.C.)
| | - Curtis Ginder
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.C.J.)
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond (M.C.K.)
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT (P.E.M.)
| | - L Kristin Newby
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N.)
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco (C.G.O.B.)
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
| | - Matthew J Pierce
- Department of Cardiology, Northwell Health, Zucker School of Medicine, New Hyde Park, NY (M.J.P.)
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC (B.A.P.)
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, Quebec, QC, Canada (B.J.P.)
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City (K.S.S.)
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (J.J.T.)
| | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York (J.N.K.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D.)
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.M.P., D.D.B., E.A.B., V.M.B.-Z., C.G., J.-G.P., D.A.M.)
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Gregers E, Frederiksen PH, Udesen NLJ, Linde L, Banke A, Povlsen AL, Larsen JP, Hassager C, Jensen LO, Lassen JF, Schmidt H, Ravn HB, Heegaard PMH, Møller JE. Immediate inflammatory response to mechanical circulatory support in a porcine model of severe cardiogenic shock. Intensive Care Med Exp 2024; 12:39. [PMID: 38647741 PMCID: PMC11035503 DOI: 10.1186/s40635-024-00625-8] [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: 01/16/2024] [Accepted: 04/14/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND In selected cases of cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is combined with trans valvular micro axial flow pumps (ECMELLA). Observational studies indicate that ECMELLA may reduce mortality but exposing the patient to two advanced mechanical support devices may affect the early inflammatory response. We aimed to explore inflammatory biomarkers in a porcine cardiogenic shock model managed with V-A ECMO or ECMELLA. METHODS Fourteen landrace pigs had acute myocardial infarction-induced cardiogenic shock with minimal arterial pulsatility by microsphere embolization and were afterwards managed 1:1 with either V-A ECMO or ECMELLA for 4 h. Serial blood samples were drawn hourly and analyzed for serum concentrations of interleukin 6 (IL-6), IL-8, tumor necrosis factor alpha, and serum amyloid A (SAA). RESULTS An increase in IL-6, IL-8, and SAA levels was observed during the experiment for both groups. At 2-4 h of support, IL-6 levels were higher in ECMELLA compared to V-A ECMO animals (difference: 1416 pg/ml, 1278 pg/ml, and 1030 pg/ml). SAA levels were higher in ECMELLA animals after 3 and 4 h of support (difference: 401 ng/ml and 524 ng/ml) and a significant treatment-by-time effect of ECMELLA on SAA was identified (p = 0.04). No statistical significant between-group differences were observed in carotid artery blood flow, urine output, and lactate levels. CONCLUSIONS Left ventricular unloading with Impella during V-A ECMO resulted in a more extensive inflammatory reaction despite similar end-organ perfusion.
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Affiliation(s)
- Emilie Gregers
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark.
| | | | - Nanna L J Udesen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Ann Banke
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Amalie L Povlsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jeppe P Larsen
- Department of Cardiothoracic Anesthesiology, Odense University Hospital, Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
| | - Lisette O Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Jens F Lassen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Henrik Schmidt
- Department of Cardiothoracic Anesthesiology, Odense University Hospital, Odense, Denmark
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesiology, Odense University Hospital, Odense, Denmark
| | - Peter M H Heegaard
- Department of Health Technology, Technical University of Denmark, Lyngby, Denmark
| | - Jacob E Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen O, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
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Williams S, Kalakoutas A, Olusanya S, Schrage B, Tavazzi G, Carnicelli AP, Montero S, Vandenbriele C, Luk A, Lim HS, Bhagra S, Ott SC, Farrero M, Samsky MD, Kennedy JLW, Sen S, Agrawal R, Rampersad P, Coniglio A, Pappalardo F, Barnett C, Proudfoot AG. The management of heart failure cardiogenic shock: an international RAND appropriateness panel. Crit Care 2024; 28:105. [PMID: 38566212 PMCID: PMC10988801 DOI: 10.1186/s13054-024-04884-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Observational data suggest that the subset of patients with heart failure related CS (HF-CS) now predominate critical care admissions for CS. There are no dedicated HF-CS randomised control trials completed to date which reliably inform clinical practice or clinical guidelines. We sought to identify aspects of HF-CS care where both consensus and uncertainty may exist to guide clinical practice and future clinical trial design, with a specific focus on HF-CS due to acute decompensated chronic HF. METHODS A 16-person multi-disciplinary panel comprising of international experts was assembled. A modified RAND/University of California, Los Angeles, appropriateness methodology was used. A survey comprising of 34 statements was completed. Participants anonymously rated the appropriateness of each statement on a scale of 1 to 9 (1-3 as inappropriate, 4-6 as uncertain and as 7-9 appropriate). RESULTS Of the 34 statements, 20 were rated as appropriate and 14 were rated as inappropriate. Uncertainty existed across all three domains: the initial assessment and management of HF-CS; escalation to temporary Mechanical Circulatory Support (tMCS); and weaning from tMCS in HF-CS. Significant disagreement between experts (deemed present when the disagreement index exceeded 1) was only identified when deliberating the utility of thoracic ultrasound in the immediate management of HF-CS. CONCLUSION This study has highlighted several areas of practice where large-scale prospective registries and clinical trials in the HF-CS population are urgently needed to reliably inform clinical practice and the synthesis of future societal HF-CS guidelines.
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Affiliation(s)
- Stefan Williams
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Antonis Kalakoutas
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Segun Olusanya
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Benedict Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Anthony P Carnicelli
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Santiago Montero
- Acute Cardiovascular Care Unit, Cardiology, Hospital Germans Trias i Pujol, Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Adriana Luk
- Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Hoong Sern Lim
- Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Sai Bhagra
- Advanced Heart Failure and Transplantation, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Sascha C Ott
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | | | - Marc D Samsky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jamie L W Kennedy
- Heart Failure / Transplant Program, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Richa Agrawal
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Amanda Coniglio
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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Bavishi C, Davies RE, Matsuno S, Kobayashi N, Katoh H, Obunai K, Maran A, Kearney K, Kohsaka S, Hirai T. Practice differences and knowledge gaps in complex and high-risk interventions between Japan and the USA: A case-based discussion. J Cardiol 2024; 83:272-279. [PMID: 37863185 DOI: 10.1016/j.jjcc.2023.10.005] [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: 07/20/2023] [Revised: 09/08/2023] [Accepted: 10/11/2023] [Indexed: 10/22/2023]
Abstract
Advances in percutaneous coronary intervention (PCI) devices and techniques have expanded the pool of eligible patients for revascularization, including those with comorbidities, reduced left ventricular function, or anatomical complexity (defined as CHIP: complex and high-risk interventions in indicated patients). CHIP interventions are typically performed by selected operators who specialize in complex PCI. This review presents two cases performed in the USA, to discuss the similarities and differences in practice patterns between CHIP operators in Japan and the USA. The first case involves a 58-year-old male presenting with myocardial infarction and cardiogenic shock, and the second case involves a 51-year-old female with a history of coronary artery bypass grafting presenting with a chronic total occlusion and PCI complicated by vessel perforation. The discussion focuses on appropriate patient selection, the role of the heart team approach for decision-making, the use of hemodynamic support devices, and other relevant factors. By comparing practices in Japan and the USA, this review highlights opportunities for knowledge exchange and potential areas for improving patient outcomes.
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Slack RJ, McGain F, Cox N, French C, Cheng V, Stub D, Zakhem B, Dade F, Bloom JE, Chan W, Yang Y. Structured Weaning From the Impella Left Ventricular Micro-Axial Pump in Acute Myocardial Infarction With Cardiogenic Shock and Protected Percutaneous Coronary Intervention: Experience From a Non-Cardiac Surgical Centre. Heart Lung Circ 2024; 33:460-469. [PMID: 38388259 DOI: 10.1016/j.hlc.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/08/2023] [Accepted: 12/10/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND The Impella (Abiomed, Danvers, MA, USA) temporary percutaneous left ventricular assist device is increasingly used as mechanical circulatory support in patients with acute myocardial infarction-cardiogenic shock (AMICS) or those undergoing high-risk protected percutaneous coronary intervention (PCI). The optimal weaning regimen remains to be defined. METHOD We implemented a structured weaning protocol in a series of 10 consecutive patients receiving Impella support for protected PCI or AMICS treated with PCI in a high volume non-cardiac surgery centre. Weaning after revascularisation was titrated to native heart recovery using both haemodynamic and echocardiographic parameters. RESULTS Ten patients (eight male, two female; aged 43-70 years) received Impella support for AMICS (80%) or protected PCI (20%). Cardiogenic shock was of Society for Cardiac Angiography & Interventions grade C-E of severity in 80%, and median left ventricular end-diastolic pressure was 31 mmHg. Protocol implementation allowed successful weaning in eight of 10 patients with a median support time of 29 hours (range, 4-48 hours). Explantation was associated with an increase in heart rate (81 vs 88 bpm; p=0.005), but no significant change in Cardiac Index (2.9 vs 2.9 L/min/m2), mean arterial pressure (79 vs 82 mmHg), vasopressor requirement (10% vs 10%), or serum lactate (1.0 vs 1.0). Median durations of intensive care and hospital stay were 3 and 6 days, respectively. At 30 days, the mortality rate was 20%, with median left ventricular ejection fraction of 40%. CONCLUSIONS A structured and dynamic weaning protocol for patients with AMICS and protected PCI supported by the Impella device is feasible in a non-cardiac surgery centre. Larger studies are needed to assess generalisability of such a weaning protocol.
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Affiliation(s)
- Ryan J Slack
- Intensive Care Unit Department, Western Health, Melbourne, Vic, Australia
| | - Forbes McGain
- Intensive Care Unit Department, Western Health, Melbourne, Vic, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - Craig French
- Intensive Care Unit Department, Western Health, Melbourne, Vic, Australia
| | - Victoria Cheng
- Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Brian Zakhem
- Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - Fabien Dade
- Intensive Care Unit Department, Western Health, Melbourne, Vic, Australia
| | - Jason E Bloom
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Yang Yang
- Intensive Care Unit Department, Western Health, Melbourne, Vic, Australia.
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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [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] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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Choi KH, Kang D, Lee J, Park H, Park TK, Lee JM, Song YB, Hahn JY, Choi SH, Gwon HC, Cho J, Yang JH. Association between intensive care unit nursing grade and mortality in patients with cardiogenic shock and its cost-effectiveness. Crit Care 2024; 28:99. [PMID: 38523296 PMCID: PMC10962168 DOI: 10.1186/s13054-024-04880-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Despite the high workload of cardiac intensive care unit (ICU), there is a paucity of evidence on the association between nurse workforce and mortality in patients with cardiogenic shock (CS). This study aimed to evaluate the prognostic impact of the ICU nursing grade on mortality and cost-effectiveness in CS. METHODS A nationwide analysis was performed using the K-NHIS database. Patients diagnosed with CS and admitted to the ICU at tertiary hospitals were enrolled. ICU nursing grade was defined according to the bed-to-nurse ratio: grade1 (bed-to-nurse ratio < 0.5), grade2 (0.5 ≤ bed-to-nurse ratio < 0.63), and grade3 (0.63 ≤ bed-to-nurse ratio < 0.77) or above. The primary endpoint was in-hospital mortality. Cost-effective analysis was also performed. RESULTS Of the 72,950 patients with CS, 27,216 (37.3%) were in ICU nursing grade 1, 29,710 (40.7%) in grade 2, and 16,024 (22.0%) in grade ≥ 3. The adjusted-OR for in-hospital mortality was significantly higher in patients with grade 2 (grade 1 vs. grade 2, 30.6% vs. 37.5%, adjusted-OR 1.14, 95% CI1.09-1.19) and grade ≥ 3 (40.6%) with an adjusted-OR of 1.29 (95% CI 1.23-1.36) than those with grade 1. The incremental cost-effectiveness ratio of grade1 compared with grade 2 and ≥ 3 was $25,047/year and $42,888/year for hospitalization and $5151/year and $5269/year for 1-year follow-up, suggesting that grade 1 was cost-effective. In subgroup analysis, the beneficial effects of the high-intensity nursing grade on mortality were more prominent in patients who received CPR or multiple vasopressors usage. CONCLUSIONS For patients with CS, ICU grade 1 with a high-intensity nursing staff was associated with reduced mortality and more cost-effectiveness during hospitalization compared to grade 2 and grade ≥ 3, and its beneficial effects were more pronounced in subjects at high risk of CS.
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Affiliation(s)
- Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Danbee Kang
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jin Lee
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyejeong Park
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Juhee Cho
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea.
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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Grinstein J. Advanced hemodynamics for prognostication in heart failure: the pursuit of the patient-specific tipping point. Front Cardiovasc Med 2024; 11:1365696. [PMID: 38500751 PMCID: PMC10944906 DOI: 10.3389/fcvm.2024.1365696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
Background Objective tools to define the optimal time for referral for advanced therapies and to help guide escalation and de-escalation of support can improve management decisions and outcomes for patients with advanced heart failure. The current parameters have variable prognostic potential depending on the patient population being studied and often have arbitrary thresholds. Methods Here, a mathematical and physiological framework to define the patient-specific tipping point of myocardial energetics is defined. A novel hemodynamic parameter known as the myocardial performance score (MPS), a marker of power and efficiency, is introduced that allows for the objective assessment of the physiological tipping point. The performance of the MPS and other advanced hemodynamic parameters including aortic pulsatility index (API) and cardiac power output (CPO) in predicting myocardial energetics and the overall myocardial performance was evaluated using a validated computer simulation model of heart failure (Harvi) as well as a proof-of-concept clinical validation using a cohort of the Society for Cardiovascular Angiography and Interventions (SCAI) Stage C cardiogenic shock patients. Results Approximately 1010 discrete heart failure scenarios were modeled. API strongly correlated with the left ventricular coupling ratio (R2 = 0.81) and the strength of association became even stronger under loaded conditions where pulmonary capillary wedge pressure (PCWP) was >20 mmHg (R2 = 0.94). Under loaded conditions, there is a strong logarithmic relationship between MPS and mechanical efficiency (R2 = 0.93) with a precipitous rise in potential energy (PE) and drop in mechanical efficiency with an MPS <0.5. An MPS <0.5 was able to predict a CPO <0.6 W and coupling ratio of <0.7 with sensitivity (Sn) of 87%, specificity (Sp) of 91%, positive predictive value of 81%, and negative predictive value of 94%. In a cohort of 224 patients with SCAI Stage C shock requiring milrinone initiation, a baseline MPS score of <0.5 was associated with a 35% event rate of the composite endpoint of death, left ventricular assist device, or transplant at 30 days compared with 3% for those with an MPS >1 (p < 0.001). Patients who were able to augment their MPS to >1 after milrinone infusion had a lower event rate than those with insufficient reserve (40% vs. 16%, p = 0.01). Conclusions The MPS, which defines the patient-specific power-to-efficiency ratio and is inversely proportional to PE, represents an objective assessment of the myocardial energetic state of a patient and can be used to define the physiological tipping point for patients with advanced heart failure.
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Affiliation(s)
- Jonathan Grinstein
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL, United States
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Fraser M, Barnes SG, Barsness C, Beavers C, Bither CJ, Boettger S, Hallman C, Keleman A, Leckliter L, McIlvennan CK, Ozemek C, Patel A, Pierson NW, Shakowski C, Thomas SC, Whitmire T, Anderson KM. Nursing care of the patient hospitalized with heart failure: A scientific statement from the American Association of Heart Failure Nurses. Heart Lung 2024; 64:e1-e16. [PMID: 38355358 DOI: 10.1016/j.hrtlng.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Meg Fraser
- University of Minnesota MHealth Physicians, Minneapolis, MN, USA.
| | | | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | | | | | | | - Anne Keleman
- MedStar Washington Section of Palliative Care, Washington, DC, USA
| | | | | | - Cemal Ozemek
- University of Illinois at Chicago, Cardiac Rehabilitation, College of Applied Health Sciences, Chicago, IL, USA
| | - Amit Patel
- Ascension St. Vincent Medical Group Cardiology, Indianapolis, IN, USA
| | - Natalie W Pierson
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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40
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Lamberti KK, Keller SP, Edelman ER. Dynamic load modulation predicts right heart tolerance of left ventricular cardiovascular assist in a porcine model of cardiogenic shock. Sci Transl Med 2024; 16:eadk4266. [PMID: 38354226 PMCID: PMC11461014 DOI: 10.1126/scitranslmed.adk4266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024]
Abstract
Ventricular assist devices (VADs) offer mechanical support for patients with cardiogenic shock by unloading the impaired ventricle and increasing cardiac outflow and subsequent tissue perfusion. Their ability to adjust ventricular assistance allows for rapid and safe dynamic changes in cardiac load, which can be used with direct measures of chamber pressures to quantify cardiac pathophysiologic state, predict response to interventions, and unmask vulnerabilities such as limitations of left-sided support efficacy due to intolerance of the right heart. We defined hemodynamic metrics in five pigs with dynamic peripheral transvalvular VAD (pVAD) support to the left ventricle. Metrics were obtained across a spectrum of disease states, including left ventricular ischemia induced by titrated microembolization of a coronary artery and right ventricular strain induced by titrated microembolization of the pulmonary arteries. A sweep of different pVAD speeds confirmed mechanisms of right heart decompensation after left-sided support and revealed intolerance. In contrast to the systemic circulation, pulmonary vascular compliance dominated in the right heart and defined the ability of the right heart to adapt to left-sided pVAD unloading. We developed a clinically accessible metric to measure pulmonary vascular compliance at different pVAD speeds that could predict right heart efficiency and tolerance to left-sided pVAD support. Findings in swine were validated with retrospective hemodynamic data from eight patients on pVAD support. This methodology and metric could be used to track right heart tolerance, predict decompensation before right heart failure, and guide titration of device speed and the need for biventricular support.
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Affiliation(s)
- Kimberly K. Lamberti
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Steven P. Keller
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MA 21205, USA
| | - Elazer R. Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Yeo I, Axman R, Lu DY, Feldman DN, Cheung JW, Minutello RM, Karas MG, Iannacone EM, Srivastava A, Girardi NI, Naka Y, Wong S, Kim LK. Impella Versus Intra-Aortic Balloon Pump in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation: An Observational Study. J Am Heart Assoc 2024; 13:e032607. [PMID: 38240236 PMCID: PMC11056174 DOI: 10.1161/jaha.123.032607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/19/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for patients with cardiogenic shock. Although Impella or intra-aortic balloon pump (IABP) is frequently used for left ventricular unloading (LVU) during VA-ECMO treatment, there are limited data on comparative outcomes. We compared outcomes of Impella and IABP for LVU during VA-ECMO. METHODS AND RESULTS Using the Nationwide Readmissions Database between 2016 and 2020, we analyzed outcomes in 3 groups of patients with cardiogenic shock requiring VA-ECMO based on LVU strategies: extracorporeal membrane oxygenation (ECMO) only, ECMO with IABP, and ECMO with Impella. Of 15 980 patients on VA-ECMO, IABP and Impella were used in 19.4% and 16.4%, respectively. The proportion of patients receiving Impella significantly increased from 2016 to 2020 (6.5% versus 25.8%; P-trend<0.001). In-hospital mortality was higher with ECMO with Impella (54.8%) compared with ECMO only (50.4%) and ECMO with IABP (48.4%). After adjustment, ECMO with IABP versus ECMO only was associated with lower in-hospital mortality (adjusted odds ratio [aOR], 0.83; P=0.02). ECMO with Impella versus ECMO only had similar in-hospital mortality (aOR, 1.09; P=0.695) but was associated with more bleeding (aOR, 1.21; P=0.007) and more acute kidney injury requiring hemodialysis (aOR, 1.42; P<0.001). ECMO with Impella versus ECMO with IABP was associated with greater risk of acute kidney injury requiring hemodialysis (aOR, 1.49; P=0.002), higher in-hospital mortality (aOR, 1.32; P=0.001), and higher 40-day mortality (hazard ratio, 1.25; P<0.001). CONCLUSIONS In patients with cardiogenic shock on VA-ECMO, LVU with Impella, particularly with 2.5/CP, was not associated with improved survival at 40 days but was associated with increased adverse events compared with IABP. More data are needed to assess Impella platform-specific comparative outcomes of LVU.
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Affiliation(s)
- Ilhwan Yeo
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Weill Cornell MedicineNew YorkNY
- Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterMN
| | - Rachel Axman
- Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
| | - Daniel Y. Lu
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Weill Cornell MedicineNew YorkNY
| | - Dmitriy N. Feldman
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Weill Cornell MedicineNew YorkNY
| | - Jim W. Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Weill Cornell MedicineNew YorkNY
| | - Robert M. Minutello
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
| | - Maria G. Karas
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
| | - Erin M. Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
| | - Ankur Srivastava
- Department of Anesthesiology, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
| | - Natalia I. Girardi
- Department of Anesthesiology, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
| | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
| | - Shing‐Chiu Wong
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Weill Cornell MedicineNew YorkNY
| | - Luke K. Kim
- Division of Cardiology, Department of Medicine, Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNY
- Weill Cornell Cardiovascular Outcomes Research Group (CORG)Weill Cornell MedicineNew YorkNY
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Riccardi M, Pagnesi M, Chioncel O, Mebazaa A, Cotter G, Gustafsson F, Tomasoni D, Latronico N, Adamo M, Metra M. Medical therapy of cardiogenic shock: Contemporary use of inotropes and vasopressors. Eur J Heart Fail 2024; 26:411-431. [PMID: 38391010 DOI: 10.1002/ejhf.3162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 02/24/2024] Open
Abstract
Cardiogenic shock is a primary cardiac disorder that results in both clinical and biochemical evidence of tissue hypoperfusion and can lead to multi-organ failure and death depending on its severity. Inadequate cardiac contractility or cardiac power secondary to acute myocardial infarction remains the most frequent cause of cardiogenic shock, although its contribution has declined over the past two decades, compared with other causes. Despite some advances in cardiogenic shock management, this clinical syndrome is still burdened by an extremely high mortality. Its management is based on immediate stabilization of haemodynamic parameters so that further treatment, including mechanical circulatory support and transfer to specialized tertiary care centres, can be accomplished. With these aims, medical therapy, consisting mainly of inotropic drugs and vasopressors, still has a major role. The purpose of this article is to review current evidence on the use of these medications in patients with cardiogenic shock and discuss specific clinical settings with indications to their use.
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Affiliation(s)
- Mauro Riccardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | - Alexandre Mebazaa
- Université Paris Cité, Inserm MASCOT, AP-HP Department of Anesthesia and Critical Care, Hôpital Lariboisière, Paris, France
| | | | - Finn Gustafsson
- Heart Centre, Department of Cardiology, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Brescia, Italy
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Baran DA, Billia F, Randhawa V, Cowger JA, Barnett CM, Chih S, Ensminger S, Hernandez-Montfort J, Sinha SS, Vorovich E, Proudfoot A, Lim HS, Blumer V, Jennings DL, Reshad Garan A, Renedo MF, Hanff TC, Kanwar MK. Consensus statements from the International Society for Heart and Lung Transplantation consensus conference: Heart failure-related cardiogenic shock. J Heart Lung Transplant 2024; 43:204-216. [PMID: 38069919 DOI: 10.1016/j.healun.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
The last decade has brought tremendous interest in the problem of cardiogenic shock. However, the mortality rate of this syndrome approaches 50%, and other than prompt myocardial revascularization, there have been no treatments proven to improve the survival of these patients. The bulk of studies have been in patients with acute myocardial infarction, and there is little evidence to guide the clinician in those patients with heart failure cardiogenic shock (HF-CS). An International Society for Heart and Lung Transplant consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals) with vast clinical and published experience in CS, representing 42 centers worldwide. This consensus report summarizes the results of a premeeting survey answered by participants and the breakout sessions where predefined clinical issues were discussed to achieve consensus in the absence of robust data. Key issues discussed include systems for CS management, including the "hub-and-spoke" model vs a tier-based network, minimum levels of data to communicate when considering transfer, disciplines that should be involved in a "shock team," goals for mechanical circulatory support device selection, and optimal flow on such devices. Overall, the document provides expert consensus on some important issues facing practitioners managing HF-CS. It is hoped that this will clarify areas where consensus has been reached and stimulate future research and registries to provide insight regarding other crucial knowledge gaps.
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Affiliation(s)
| | | | | | | | | | - Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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44
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Kanwar MK, Billia F, Randhawa V, Cowger JA, Barnett CM, Chih S, Ensminger S, Hernandez-Montfort J, Sinha SS, Vorovich E, Proudfoot A, Lim HS, Blumer V, Jennings DL, Reshad Garan A, Renedo MF, Hanff TC, Baran DA. Heart failure related cardiogenic shock: An ISHLT consensus conference content summary. J Heart Lung Transplant 2024; 43:189-203. [PMID: 38069920 DOI: 10.1016/j.healun.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 12/22/2023] Open
Abstract
In recent years, there have been significant advancements in the understanding, risk-stratification, and treatment of cardiogenic shock (CS). Despite improved pharmacologic and device-based therapies for CS, short-term mortality remains as high as 50%. Most recent efforts in research have focused on CS related to acute myocardial infarction, even though heart failure related CS (HF-CS) accounts for >50% of CS cases. There is a paucity of high-quality evidence to support standardized clinical practices in approach to HF-CS. In addition, there is an unmet need to identify disease-specific diagnostic and risk-stratification strategies upon admission, which might ultimately guide the choice of therapies, and thereby improve outcomes and optimize resource allocation. The heterogeneity in defining CS, patient phenotypes, treatment goals and therapies has resulted in difficulty comparing published reports and standardized treatment algorithms. An International Society for Heart and Lung Transplantation (ISHLT) consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals), with vast clinical and published experience in CS, representing 42 centers worldwide. State-of-the-art HF-CS presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues, including but not limited to models of CS care delivery, patient presentations in HF-CS, and strategies in HF-CS management. This consensus report summarizes the contemporary literature review on HF-CS presented in the first half of the conference (part 1), while the accompanying document (part 2) covers the breakout sessions where the previously agreed upon clinical issues were discussed with an aim to get to a consensus.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Filio Billia
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Varinder Randhawa
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer A Cowger
- Department of Cardiology, Henry Ford Health Heart and Vascular Institute, Detroit, Michigan
| | - Christopher M Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Jaime Hernandez-Montfort
- Advanced Heart Disease, Recovery and Replacement Program, Baylor Scott and White Health, Temple, Texas
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Esther Vorovich
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alastair Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Hoong S Lim
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Douglas L Jennings
- Department of Pharmacy, Columbia University Irving Medical Center, New York, New York
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | - Maria F Renedo
- Department of Heart Failure and Thoracic Transplantation, Fundacion Favaloro, Buenos Aires, Argentina
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - David A Baran
- Heart, Vascular Thoracic Institute, Cleveland Clinic Florida, Weston, Florida.
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45
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Min S, Basir MB, Lemor A, Zhou Z, Abu-Much A, Redfors B, Thompson JB, Truesdell AG, Bharadwaj AS, Li Y, Kaki A, Brott BC, Wohns DH, Meraj PM, Daggubati R, Grines CL, O'Neill WW, Moses JW. Clinical characteristics and outcomes of patients requiring prolonged mechanical circulatory support after high-risk percutaneous coronary intervention. EUROINTERVENTION 2024; 20:e135-e145. [PMID: 38224254 PMCID: PMC10786176 DOI: 10.4244/eij-d-23-00512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/12/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND There are limited data on the clinical characteristics and outcomes of patients who require prolonged mechanical circulatory support (MCS) after Impella-supported high-risk percutaneous coronary intervention (HR-PCI). AIMS The aim of this study is to describe the contemporary clinical characteristics, outcomes, and predictors associated with prolonged MCS support after assisted HR-PCI. METHODS Patients enrolled in the prospective, multicentre, clinical endpoint-adjudicated PROTECT III study who had undergone HR-PCI using Impella were evaluated. Patient and procedural characteristics and outcomes for those who received prolonged MCS beyond the duration of their index procedure were compared to those in whom MCS was successfully weaned and explanted at the conclusion of the index PCI. RESULTS Among 1,155 patients who underwent HR-PCI with Impella between 2017 and 2020 and had sufficient data to confirm the duration of Impella support, 16.5% received prolonged MCS (mean duration 25.2±31.1 hours compared with 1.8±5.8 hours for those who only received intraprocedural MCS). Patients receiving prolonged support presented with more urgent indications (e.g., acute coronary syndromes [ACS], lower ejection fraction [EF], elevated baseline heart rate and lower systolic blood pressure). Use of the Impella CP, intraprocedural complications, periprocedural complications and in-hospital mortality were all more common amongst the prolonged MCS group. Prolonged MCS was associated with increased rates of major adverse cardiovascular and cerebrovascular events, cardiovascular death, and all-cause mortality at 90-day follow-up. CONCLUSIONS Patients receiving prolonged MCS after Impella-supported HR-PCI presented with more ACS, reduced EF and less favourable haemodynamics. Additionally, they were more likely to experience intraprocedural and periprocedural complications as well as increased in-hospital and post-discharge mortality.
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Affiliation(s)
- Sugi Min
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Mir Babar Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, MI, USA
| | - Alejandro Lemor
- Department of Cardiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Zhipeng Zhou
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Arsalan Abu-Much
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Julia B Thompson
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Alexander G Truesdell
- Virginia Heart, Falls Church, VA, USA
- INOVA Heart and Vascular Institute, Falls Church, VA, USA
| | - Aditya S Bharadwaj
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Yanru Li
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Amir Kaki
- Interventional Cardiology Department, Ascension St. John Hospital and Center, Detroit, MI, USA
| | - Brigitta C Brott
- Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - David H Wohns
- Spectrum Health, Frederik Meijer Heart and Vascular Institute, Grand Rapids, MI, USA
| | - Perwaiz M Meraj
- Department of Cardiology, Zucker School of Medicine, Northwell Health, Manhasset, New York, NY, USA
| | - Ramesh Daggubati
- Division of Cardiology, West Virginia University, Morgantown, WV, USA
| | - Cindy L Grines
- Medical College of Georgia, Augusta, GA, USA
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA
| | - William W O'Neill
- Center for Structural Heart Disease, Department of Cardiology, Henry Ford Health Care System, Detroit, MI, USA
| | - Jeffrey W Moses
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
- St. Francis Heart Center, Roslyn, NY, USA
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46
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O'Kelly AC, Sarma A, Naoum E, Easter SR, Economy K, Ludmir J. Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy. J Intensive Care Med 2024:8850666231225606. [PMID: 38204193 DOI: 10.1177/08850666231225606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.
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Affiliation(s)
- Anna C O'Kelly
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Sarma
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Naoum
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katherine Economy
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Ludmir
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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47
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Tehrani BN, Epps KC, Batchelor WB. An Uneven Playing Field: Demographic and Regionalized Disparities in Access to Device-Based Therapies for Cardiogenic Shock. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101220. [PMID: 39131975 PMCID: PMC11307875 DOI: 10.1016/j.jscai.2023.101220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 08/13/2024]
Affiliation(s)
| | - Kelly C. Epps
- Inova Schar Heart and Vascular Institute, Falls Church, Virginia
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48
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Nathan AS, Reddy KP, Eberly LA, Fanaroff A, Julien HM, Fiorilli P, Wald J, Mutaawe S, Cevasco M, Bermudez C, Kapur NK, Basir MB, Roswell R, Groeneveld PW, Giri J. Racial, Ethnic, Socioeconomic, and Geographic Inequities in Access to Mechanical Circulatory Support. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101193. [PMID: 39131979 PMCID: PMC11307759 DOI: 10.1016/j.jscai.2023.101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Background Hospital admissions for cardiogenic shock have increased in the United States. Temporary mechanical circulatory support (tMCS) can be used to acutely stabilize patients. We sought to evaluate the presence of racial, ethnic, and socioeconomic inequities in access to MCS in the United States among patients with cardiogenic shock. Methods Medicare data were used to identify patients with cardiogenic shock admitted to hospitals with advanced tMCS (microaxial left ventricular assist device [mLVAD] or extracorporeal membranous oxygenation [ECMO]) capabilities within the 25 largest core-based statistical areas, all major metropolitan areas. We modeled the association between patient race, ethnicity, and socioeconomic status and use of mLVAD or ECMO. Results After adjusting for age and clinical comorbidities, dual eligibility for Medicaid was associated with a 19.9% (95% CI, 11.5%-27.4%) decrease in odds of receiving mLVAD in a patient with cardiogenic shock (P < .001). After adjusting for age, clinical comorbidities, and dual eligibility for Medicaid, Black race was associated with 36.7% (95% CI, 28.4%-44.2%) lower odds of receiving mLVAD in a patient with cardiogenic shock. Dual eligibility for Medicaid was associated with a 62.0% (95% CI, 60.8%-63.1%) decrease in odds of receiving ECMO in a patient with cardiogenic shock (P < .001). Black race was associated with 36.0% (95% CI, 16.6%-50.9%) lower odds of receiving ECMO in a patient with cardiogenic shock, after adjusting for Medicaid eligibility. Conclusions We identified large and significant racial, ethnic, and socioeconomic inequities in access to mLVAD and ECMO among patients presenting with cardiogenic shock to metropolitan hospitals with active advanced tMCS programs. These findings highlight systematic inequities in access to potentially lifesaving therapies.
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Affiliation(s)
- Ashwin S. Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Kriyana P. Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren A. Eberly
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Howard M. Julien
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Paul Fiorilli
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Joyce Wald
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shafik Mutaawe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Navin K. Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | | | - Robert Roswell
- Zucker School of Medicine, Northwell Health, Hofstra University, Hempstead, New York
| | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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49
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Kaur G, Berg DD. The Changing Epidemiology of the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:1-13. [PMID: 37973347 DOI: 10.1016/j.ccc.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Coronary care units (CCUs) were originally designed to monitor and treat peri-infarction ventricular arrhythmias but have evolved into highly specialized cardiac intensive care units (CICUs) that provide care to a patient population that is increasingly heterogeneous and complex. Paralleling broader epidemiologic trends, patients admitted to contemporary CICUs are older and have a greater burden of cardiovascular and non-cardiovascular comorbidities. Moreover, contemporary CICU patients have high illness severity and often present with acute noncardiac organ dysfunction. In addition to these shifting demographic patterns, there have been important epidemiologic changes in CICU technologies, multidisciplinary systems of care, and physician staffing and training.
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Affiliation(s)
- Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - David D Berg
- Department of Medicine, Levine Cardiac Intensive Care Unit, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, TIMI Study Group, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA.
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50
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Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
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Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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