ECMO in the Cardiac Catheterization Lab-Patient Selection Is Key

The use of extracorporeal membrane oxygenation (ECMO) has emerged as a rescue intervention for hemodynamically unstable patients and prophylactic intraprocedural hemodynamic support in the cardiac catheterization laboratory. The prompt initiation of ECMO provides immediate hemodynamic support and allows for the completion of bridging and/or life-saving interventions. However, there are no clinical practice guidelines for the use of extracorporeal support in this area. This review examines the role of patient selection and therapeutic intervention for extracorporeal support in the cardiac catheterization laboratory.

Sox9 Promotes Cardiomyocyte Apoptosis After Acute Myocardial Infarction by Promoting miR-223-3p and Inhibiting MEF2C

Acute myocardial infarction (AMI) is a severe and even fatal cardiovascular disease. The effect of transcription factors on AMI is intensively explored. Our experiment attempts to probe the role of Sox9 in cardiomyocyte apoptosis after AMI. AMI cell model was established in AC16 cells by hypoxia treatment. Cell viability and apoptosis were assessed. Then, the levels of BAX, Bcl-2, Sox9, miR-223-3p, and MEF2C were detected. The binding relation between Sox9 and miR-223-3p and between miR-223-3p and MEF2C was verified. The expression of miR-223-3p was upregulated using the miR-223-3p mimic, and collaborative experiments were conducted as si-Sox9 or si-MEF2C was transfected into cells to inhibit the expression of Sox9 or MEF2C. Sox9 was highly expressed in cardiomyocyte apoptosis after hypoxia, while Sox9 silencing protected hypoxia-treated cardiomyocytes from apoptosis by enhancing cell viability, quenching apoptosis, and reducing activity of caspase-3 and caspase-9. Essentially, Sox9 bound to the miR-223-3p promoter region to upregulate its expression. miR-223-3p targeted MEF2C transcription. miR-223-3p overexpression and MEF2C silencing could counteract the suppressive role of Sox9 silencing in hypoxia-treated cardiomyocyte apoptosis. Sox9 exacerbated hypoxia-induced cardiomyocyte apoptosis by promoting miR-223-3p expression and inhibiting MEF2C transcription.

Usefulness of severity scales for cardiogenic shock in-hospital mortality. Proposal for a new prognostic model

Cardiogenic shock (CS) is a condition comprising multiple etiologies, which associates high mortality rates. Some scoring systems have been shown to be good predictors of hospital mortality in patients admitted to Critical Care Units (CCU). The main objective of this study is to analyze their usefulness and validity in a cohort of CS patients.

METHODS

Observational unicentric study of a cohort of CS patients. SOFA, SAPS II and APACHE II scores were calculated in the first 24 h of CCU admission.

RESULTS

130 patients with CS were included. SOFA, SAPS II and APACHE II scores revealed good discrimination for hospital mortality: (AUC) ROC values (AUC: 0.711, 0.752 and 0.742 respectively; P = .6). Calibration, estimated by the Hosmer-Lemeshow test, was adequate in all cases. Acute coronary syndrome, lactate serum values, SAPS II score and vasoactive inotropic score (VIS) were found to be independent predictors for mortality, upon ICU admission. With these variables, a specific prognostic indicator was developed (SAPS-2-LIVE), which improved predictive capability for mortality in our series (AUC) ROC, 0.825 (95% CI 0.752-0.89).

CONCLUSION

In this contemporary CS cohort, the aforementioned scores have been shown to have good predictive ability for hospital mortality. These findings could contribute to a more accurate risk stratification in CS.

Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Heart Transplantation: A 7-Year Experience

Objective: Primary graft dysfunction (PGD) is the leading cause of early death after heart transplantation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support and time for functional recovery of the transplanted heart. The purpose of this study was to analyze the timing and prognoses of VA-ECMO in patients with severe PGD after heart transplantation. Methods: A total of 130 patients underwent heart transplantation at the Zhongshan Hospital Affiliated with Fudan University between January 2014 and December 2020. All patients received basiliximab immunoinduction and a classic double vena cava anastomosis orthotopic heart transplantation. Among them, 29 patients (22.3%) developed severe PGD in the early postoperative period. VA-ECMO was performed in patients with difficulty weaning from cardiopulmonary bypass (CPB) or postoperative refractory cardiogenic shock. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO (patients who survived for 48 h after weaning and did not need VA-ECMO assistance again). The perioperative clinical data were recorded, and all patients were followed up until discharge. Early outcomes were compared between groups. Results: A total of 29 patients with VA-ECMO support after heart transplantation were included in this study. The proportion of patients receiving VA-ECMO was 22.3% (29/130). Nineteen patients (65.5%) needed VA-ECMO due to difficulty with weaning from CPB, and 10 patients required VA-ECMO for postoperative cardiogenic shock. Nineteen patients (65.5%) were successfully weaned from VA-ECMO. Overall, in-hospital mortality of VA-ECMO support patients was 55.2%. The main causes of death were ventricular fibrillation (four cases), major bleeding (three cases), infection (four cases), and graft failure (five cases). Conclusion: Despite advances in heart transplantation, severe PGD remains a lethal complication after heart transplantation. At present, the treatment for severe PGD after heart transplantation is a challenge. VA-ECMO provides an effective treatment for severe PGD after heart transplantation, which can promote graft function recovery.

Circulatory Support with Extracorporeal Membrane Oxygenation and/or Impella for Cardiogenic Shock During Myocardial Infarction

Temporary mechanical circulatory support (TCS) is recommended for patients with profound cardiogenic shock (CS). Extracorporeal membrane oxygenation (ECMO) and Impella are possible TCS devices, but the device choice and the implantation timing are not definitely established, specifically during acute myocardial infarction. We have analyzed the respective use of ECMO or Impella (2.5, CP, or 5.0) for CS following acute myocardial infarction, from a cohort of patients who underwent TCS within 72 hours after admission for emergency percutaneous coronary intervention (PCI) from January 2009 to April 2015. Among 88 TCS-treated patients, 42 had early TCS: 23 ECMO and 19 Impella. Cardiac management, including PCI, was similar between the two groups, but ECMO patients were sicker than Impella patients (higher blood lactate level at ICU admission, higher vasoactive-inotroic and ENCOURAGE scores before TCS implantation, p ≤ 0.02). Three patients (7%) have had TCS implantation before admission, but TCS was implanted mostly in cathlab (43%, 1 during PCI, 13 just after PCI) or soon after ICU admission (50%, n = 21). Modification of the initial TCS choice was required in 10 cases (24%) for assistance upgrading in case of Impella (n = 4) or for left ventricle unloading in case of ECMO (n = 6). Extracorporeal membrane oxygenation is the technique of choice in case of profound CS, whereas Impella devices seem more appropriate for less severe hemodynamic compromise. Interestingly, the combination of both techniques may help to overcome the limits inherent to each device.

LncRNA RMRP accelerates hypoxia-induced injury by targeting miR-214-5p in H9c2 cells

OBJECTIVE

To elucidate the function of lncRNA RMRP in hypoxia-induced acute myocardial infarction (AMI) in vitro and explore its underlying mechanism.

METHODS

Hypoxic injury was confirmed by measurement of cell viability, LDH release, migration, invasion, and apoptosis in H9c2 cells. The interactions between RMRP and miR-214-5p as well as miR-214-5p and p53 were also investigated.

RESULTS

Hypoxia treatment significantly induced cell damage in H9c2 cells, accompanied with the up-regulation of RMRP expressions. Transfection of RMRP siRNA remarkably attenuated hypoxia-induced injury by enhancing cell viability, migration and invasion, and reducing cell apoptosis and LDH release; whereas, enforced expression of RMRP aggravated hypoxia-induced injury. Furthermore, RMRP served as an endogenous sponge for miR-214-5p, and its expression was negatively regulated by RMRP. The effects of RMRP knockdown on hypoxia-induced injury were further enhanced with miR-214-5p overexpression, but significantly abrogated with miR-214-5p silence. Moreover, p53 was verified as a direct target of miR-214-5p, and functional investigation revealed that RMRP regulated hypoxia-induced injury via modulating p53 signaling pathway, which was partially mediated by miR-214-5p.

CONCLUSION

Our findings demonstrated the novel molecular mechanism of RMRP/miR-214-5p/p53 axis on the regulation of hypoxia-induced myocardial injury in H9c2 cells, which might provide potential therapeutic targets for AMI treatment.

The usefulness of Veno-Arterial Extracorporeal Membranous Oxygenation in Patients with Cardiogenic Shock

BACKGROUND:

Venoarterial extracorporeal membranous oxygenation is a form of temporary mechanical circulatory support that gets as a salvage technique in patients with cardiogenic shock, we intended to evaluate the effect of (VA ECMO) support on hemodynamics and lactate levels in patients with cardiogenic shock.

AIM:

The aim of our study is to detect the ability to introduce veno-arterial extracorporeal membranous oxygenation (VA ECMO) as a temporary extracorporeal life support system (ECLS) in our unit, demonstrate the role of ECMO in cardiogenic shock patients regarding improving hemodynamics and microcirculation, and demonstrate the complications and drawbacks in our first center experience regarding VA ECMO.

MATERIAL AND METHODS:

This was a single-centre observational study that included 10 patients admitted with cardiogenic shock for which VA ECMO was used as mechanical circulatory support.

RESULTS:

The MAP increased after initiation of the support. It was 41.8 ± 9.3 mmHg and 59.5 ± 6.8 mmHg (P = 0.005). The use of VA ECMO support was associated with a statistically significant decrease in the base deficit (-10.6 ± 4.2 and -6.3 ± 7.4, P = 0.038). The serum lactate declined from 5.9 ± 3.5 mmoL/L to 0.6 ± 4.4 mmoL/L by the use of VA ECMO; a statistically significant change (P = 0.005).

CONCLUSIONS:

We concluded that VA ECMO as mechanical support for patients with cardiogenic shock might improve mean arterial blood pressure, base deficit and lactate clearance.

Cardiogenic Shock Following Acute Myocardial Infarction: What's New?

Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion primarily due to cardiac dysfunction. This condition is the most common cause of death in patients affected by acute myocardial infarction (AMI). Despite early revascularization, prompt optimal medical therapy, and up-to-date mechanical circulatory supports, mortality of patients with CS remains high.The objective of this review is to summarize epidemiology, pathophysiology, and treatment options of CS in light of the new European Society of Cardiology (ESC) recommendations. The latest European guidelines on myocardial revascularization have reviewed the previous guidelines with respect to early multivessel revascularization and routine use of intra-aortic balloon pump (IABP) in patients with AMI-related CS.Most of the current evidences come partly from randomized trials, but mostly from observational registries because of the difficulty to test different treatments in this life-threatening clinical setting.Some of the latest studies highlight the potential crucial benefit of newly introduced mechanical circulatory support devices, although evidences are not sufficient to definitely assess the benefit/risk ratio of the different systems.Many questions remain unanswered in this field, and further trials are advocated to better elucidate the best medical, reperfusion, and circulatory support approaches aimed to improve the poor prognosis of patients with CS after AMI.

Percutaneous temporary circulatory support devices and their use as a bridge to decision during acute decompensation of advanced heart failure

Temporary mechanical cardiac support (TMCS) devices intend to restore systemic perfusion and prevent further end-organ damage in patients with refractory cardiogenic shock until the insult is addressed. TMCS has been associated with reductions in hospital costs and in-hospital mortality. We review the four primary TMCS modalities available: intra-aortic balloon pump, TandemHeart, veno-arterial extracorporeal membrane oxygenation, and Impella pump. All have their own implantation technique and hemodynamic profile, and their use may therefore be tailored to the specific patient's needs. The appropriate TMCS may thus help stabilize the patient, enabling the care team to make decisions about durable support or transplantation.

Ultrasound-guided central venous catheter placement in the emergency department: experience in a hospital in Bogotá, Colombia

Introduction

The use of central venous catheters (CVCs) in the emergency room (ER) is a valuable tool for the comprehensive management of critically ill patients; however, the positioning of these devices is not free of complications. Currently, the use of ultrasound is considered a useful and safe tool to carry out these procedures, but in Colombia, the number of emergency departments providing this tool is scarce and there is no literature describing the experience in our country.

Objective

The objective of this study was to describe the experience regarding placement of ultrasound-guided CVCs by emergency physicians in an institution in Bogotá, as well as the associated complications.

Materials and methods

This is a descriptive cross-sectional retrospective study. Medical records of 471 patients requiring insertion of CVCs in the resuscitation area from January 2014 to December 2014 were reviewed. Insertion site and complications are described.

Results

For 471 total cases, the average age of patients was 68.6 years, the most frequent diagnosis was sepsis (30.7%), the preferred route of insertion was the right internal jugular vein, and insertion was successful at the first attempt in 85.9% of patients. Pneumothorax was the most common complication (1.2%), followed by extensive hematoma and infection.

Conclusion

Insertion of ultrasound-guided CVCs by emergency physicians is a safe procedure that involves complications similar to those reported in the literature; it is necessary to expand the use of ultrasound-guided CVCs in ERs.

Spontaneous coronary artery dissection causing acute myocardial infarction and cardiac arrest in a 25-year-old male

A 25-year-old previously healthy male presented to our emergency room with acute chest pain and ventricular arrhythmia-related cardiac arrest. ST elevation myocardial infarction was diagnosed and coronary angiography revealed diffuse critical narrowing from the proximal to the distal left anterior descending artery. Diffuse intramural hematoma was demonstrated on intravascular ultrasound. Two stents were placed to cover the whole dissection length and flow was successfully restored. Spontaneous coronary artery dissection can be a fatal event and could be mistaken for atherosclerotic plaque or coronary spasm rather than luminal compression on coronary angiography and intravascular imaging is helpful in this condition.

Long-term clinical outcomes in patients with ST-segment elevation acute myocardial infarction complicated by cardiogenic shock due to acute pump failure

BACKGROUND:

Cardiogenic shock remained the leading cause of death in ST-segment elevation acute myocardial infarction (STEMI) patients even in the primary percutaneous coronary intervention era.

METHODS:

Among 3942 STEMI patients with primary percutaneous coronary intervention within 24 h after symptom-onset in the Coronary Revascularization Demonstrating Outcome Study in Kyoto acute myocardial infarction registry, the study population of the current analysis consisted of 466 STEMI patients who were complicated by cardiogenic shock due to acute pump failure.

RESULTS:

The cumulative incidence of all-cause death of cardiogenic shock due to acute pump failure was 25.4% at 30 days, 38.7% at one year, and 51.4% at five years. Cumulative five-year incidence of all-cause death in patients with left main coronary artery culprit lesion was extremely high (left main coronary artery: 70.4%, left anterior descending artery: 52.5%, left circumflex artery: 50.6%, and right coronary artery; 44.3%, respectively, log-rank p<0.001). The cumulative five-year incidence of all-cause death in patients with onset-to-balloon time ⩽3 h as well as those with door-to-balloon time ⩽90 min were significantly lower than those without (43.3% versus 55.5%, log-rank p=0.008, and 44.9% versus 55.8%, log-rank p=0.003, respectively). After adjusting for confounders, onset-to-balloon time ⩽3 h and door-to-balloon time ⩽90 min were independently associated with lower long-term risk for all-cause death (hazard ratio: 0.69, 95% confidence interval: 0.49-0.96, p=0.03, and hazard ratio: 0.73, 95% confidence interval: 0.53-0.98, p=0.04, respectively).

CONCLUSIONS:

The long-term mortality of STEMI patients complicated by cardiogenic shock due to acute pump failure remains high even in the current clinical practice. In this high-risk category of patients, shorter onset-to-balloon and door-to-balloon time were associated with significantly lower long-term risk for mortality.

Primary Angioplasty For Patients in Cardiogenic Shock: Optimal Management

Cardiogenic shock complicates approximately 5-10 % of all MI events and remains the most common cause of death among MI cases. Over the past few decades, the mortality rate associated with cardiogenic shock has decreased with the introduction of early revascularisation, although there are limited data for patients with triple-vessel disease and left main stem disease. In more recent years, there have been a number of advances in the mechanical circulatory support devices that can help improve the haemodynamics of patients in cardiogenic shock. Despite these advances, together with progress in the use of inotropes and vasopressors, cardiogenic shock remains associated with high morbidity and mortality rates. This review will outline the management of cardiogenic shock complicating acute MI with a smajor focus on revascularisation techniques and the use of mechanical circulatory support devices.