Systematic Assessment of Shock Severity in Postoperative Cardiac Surgery Patients

BACKGROUND

The Society for Cardiovascular Angiography and Interventions (SCAI) shock classification has been shown to provide robust mortality risk stratification in a variety of cardiovascular patients.

OBJECTIVES

This study sought to evaluate the SCAI shock classification in postoperative cardiac surgery intensive care unit (CSICU) patients.

METHODS

This study retrospectively analyzed 26,792 postoperative CSICU admissions at a heart center between 2012 and 2022. Patients were classified into SCAI shock stages A to E using electronic health record data. Moreover, the impact of late deterioration (LD) as an additional risk modifier was investigated.

RESULTS

The proportions of patients in SCAI shock stages A to E were 24.4%, 18.8%, 8.4%, 35.5%, and 12.9%, and crude hospital mortality rates were 0.4%, 0.6%, 3.3%, 4.9%, and 30.2%, respectively. Similarly, the prevalence of postoperative complications and organ dysfunction increased across SCAI shock stages. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted OR: 1.26-16.59) compared with SCAI shock stage A, as was LD (adjusted OR: 8.2). The SCAI shock classification demonstrated a strong diagnostic performance for hospital mortality (area under the receiver operating characteristic: 0.84), which noticeably increased when LD was incorporated into the model (area under the receiver operating characteristic: 0.90).

CONCLUSIONS

The SCAI shock classification effectively risk-stratifies postoperative CSICU patients for mortality, postoperative complications, and organ dysfunction. Its application could, therefore, be extended to the field of cardiac surgery as a triage tool in postoperative care and as a selection criterion in research.

Rapid Pacing Decreases L-type Ca2+ Current and Alters Cacna1c Isogene Expression in Primary Cultured Rat Left Ventricular Myocytes

The L-type calcium current (I_CaL) is the first step in cardiac excitation-contraction-coupling and plays an important role in regulating contractility, but also in electrical and mechanical remodeling. Primary culture of cardiomyocytes, a widely used tool in cardiac ion channel research, is associated with substantial morphological, functional and electrical changes some of which may be prevented by electrical pacing. We therefore investigated I_CaL directly after cell isolation and after 24 h of primary culture with and without regular pacing at 1 and 3 Hz in rat left ventricular myocytes. Moreover, we analyzed total mRNA expression of the pore forming subunit of the L-type Ca²⁺ channel (cacna1c) as well as the expression of splice variants of its exon 1 that contribute to specificity of I_CaL in different tissue such as cardiac myocytes or smooth muscle. 24 h incubation without pacing decreased I_CaL density by ~ 10% only. Consistent with this decrease we observed a decrease in the expression of total cacna1c and of exon 1a, the dominant variant of cardiomyocytes, while expression of exon 1b and 1c increased. Pacing for 24 h at 1 and 3 Hz led to a substantial decrease in I_CaL density by 30%, mildly slowed I_CaL inactivation and shifted steady-state inactivation to more negative potentials. Total cacna1c mRNA expression was substantially decreased by pacing, as was the expression of exon 1b and 1c. Taken together, electrical silence introduces fewer alterations in I_CaL density and cacna1c mRNA expression than pacing for 24 h and should therefore be the preferred approach for primary culture of cardiomyocytes.

Standardized Forearm Angiography Increases Procedural Success Rates of Coronary Angiography and PCI: A Retrospective Analysis of an all-Comers Patient Cohort in a Real-Life Scenario

Background

There is a consensus, that Transradial-Access (TRA) for coronary procedures should be preferred over Transfemoral-Access (TFA). Previously, Forearm-Artery-Angiography (FA) was mainly performed when difficulties during the advancement of the guidewire/-catheter were encountered. We explored the implication of a Standardized Forearm-Angiography (SFA) on procedural success rates of TRA under real-world conditions.

Methods

In a single-center study, an all-comers-cohort of 1191 consecutive cases during 1/2020-12/2020 were assessed retrospectively. Primary TFA rates, crossover to TFA, reasons for Forearm-Artery-Access (FAA) failure, the prevalence of kinking at the level of the forearm and the occurrence of vascular complications were analyzed. Major forearm side branches including the common interosseus artery were assessed via SFA.

Results

In 1191 consecutive procedures, primary FAA access was attempted in 97.9% of cases. Crossover to TFA after a primary or secondary FAA attempt was necessary in 2.8%. Severe kinking was the most frequent cause of FAA failure and occurred in 3.0% of attempts. A second or third FAA attempt to avoid TFA was successful in 81%. Severe kinking at the level of the forearm was reported in 1.8% of procedures.

Conclusion

This is the first study to provide detailed success rates of a primary FAA strategy combined with a Standardized-Forearm-Angiography (SFA) in an all-comers-cohort. While severe kinking proved to be a rare but relevant challenge for FAA success, the prevalence of arterial spasm was marginal. Multiple attempts of FAA to avoid TFA might be safe possibly due to collateral blood supply by the common interosseus artery.