Impact of Access Site on Periprocedural Bleeding and Cerebral and Coronary Events in High-Bleeding-Risk Percutaneous Coronary Intervention: Findings from the RIVA-PCI Trial

INTRODUCTION

The preference for using transradial access (TRA) over transfemoral access (TFA) in patients requiring percutaneous coronary intervention (PCI) is based on evidence suggesting that TRA is associated with less bleeding and fewer vascular complications, shorter hospital stays, improved quality of life, and a potential beneficial effect on mortality. We have limited study data comparing the two access routes in a patient population with atrial fibrillation (AF) undergoing PCI, who have a particular increased risk of bleeding, while AF itself is associated with an increased risk of thromboembolism.

METHODS

Using data from the RIVA-PCI registry, which includes patients with AF undergoing PCI, we analyzed a high-bleeding-risk (HBR) cohort. These patients were predominantly on oral anticoagulants (OAC) for AF, and the PCI was performed via radial or femoral access. Endpoints examined were in-hospital bleeding (BARC 2-5), cerebral events (TIA, hemorrhagic or ischemic stroke) and coronary events (stent thrombosis and myocardial infarction).

RESULTS

Out of 1636 patients, 854 (52.2%) underwent TFA, while 782 (47.8%) underwent the procedure via TRA, including nine patients with brachial artery puncture. The mean age was 75.5 years. Groups were similar in terms of age, sex distribution, AF type, cardiovascular history, risk factors, and comorbidities, except for a higher incidence of previous bypass surgeries, heart failure, hyperlipidemia, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 60 ml/min in the TFA group. No clinically relevant differences in antithrombotic therapy and combinations were present at the time of PCI. However, upon discharge, transradial PCI patients had a higher rate of triple therapy, while dual therapy was preferred after transfemoral procedures. Radial access was more frequently chosen for non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP) cases (NSTEMI 26.6% vs. 17.0%, p < 0.0001; UAP 21.5% vs. 14.5%, p < 0.001), while femoral access was more common for elective PCI (60.3% vs. 44.1%, p < 0.0001). No differences were observed for ST-segment elevation myocardial infarction (STEMI). Both groups had similar rates of cerebral events (TFA 0.2% vs. TRA 0.3%, p = 0.93), but the TFA group had a higher incidence of bleeding (BARC 2-5) (4.2% vs. 1.5%, p < 0.01), mainly driven by BARC 3 bleeding (1.5% vs. 0.4%, p < 0.05). No significant differences were found for stent thrombosis and myocardial infarction (TFA 0.2% vs. TRA 0.3%, p = 0.93; TFA 0.4% vs. TRA 0.1%, p = 0.36).

CONCLUSIONS

In HBR patients with AF undergoing PCI for acute or chronic coronary syndrome, the use of TRA might be associated with a decrease in in-hospital bleeding, while not increasing the risk of embolic or ischemic events compared to femoral access. Further studies are required to confirm these preliminary findings.

Extracorporeal Life Support in Infarct-Related Cardiogenic Shock

BACKGROUND

Extracorporeal life support (ECLS) is increasingly used in the treatment of infarct-related cardiogenic shock despite a lack of evidence regarding its effect on mortality.

METHODS

In this multicenter trial, patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early ECLS plus usual medical treatment (ECLS group) or usual medical treatment alone (control group). The primary outcome was death from any cause at 30 days. Safety outcomes included bleeding, stroke, and peripheral vascular complications warranting interventional or surgical therapy.

RESULTS

A total of 420 patients underwent randomization, and 417 patients were included in final analyses. At 30 days, death from any cause had occurred in 100 of 209 patients (47.8%) in the ECLS group and in 102 of 208 patients (49.0%) in the control group (relative risk, 0.98; 95% confidence interval [CI], 0.80 to 1.19; P = 0.81). The median duration of mechanical ventilation was 7 days (interquartile range, 4 to 12) in the ECLS group and 5 days (interquartile range, 3 to 9) in the control group (median difference, 1 day; 95% CI, 0 to 2). The safety outcome consisting of moderate or severe bleeding occurred in 23.4% of the patients in the ECLS group and in 9.6% of those in the control group (relative risk, 2.44; 95% CI, 1.50 to 3.95); peripheral vascular complications warranting intervention occurred in 11.0% and 3.8%, respectively (relative risk, 2.86; 95% CI, 1.31 to 6.25).

CONCLUSIONS

In patients with acute myocardial infarction complicated by cardiogenic shock with planned early revascularization, the risk of death from any cause at the 30-day follow-up was not lower among the patients who received ECLS therapy than among those who received medical therapy alone. (Funded by the Else Kröner Fresenius Foundation and others; ECLS-SHOCK ClinicalTrials.gov number, NCT03637205.).

[ECMO support during the first two waves of the corona pandemic-a survey of high case volume centers in Germany]

BACKGROUND

At the onset of the coronavirus pandemic, concerns were raised about sufficiency of available intensive care resources. In many places, routine interventions were postponed and criteria for the allocation of scarce resources were formulated. In Germany, some hospitals were at times seriously burdened during the course of the pandemic. Intensive care units in particular experienced a shortage of resources, which may have led to a restriction of services and a stricter indication setting for resource-intensive measures such as extracorporeal membrane oxygenation (ECMO). The aim of this work is to provide an overview of how these pressures were managed at large ECMO centers in Germany.

METHODS

One representative of each major ECMO referral center in Germany was invited to participate in an online survey in spring 2021.

RESULTS

Of 34 invitations that were sent out, the survey was answered by 23 participants. In all centers, routine procedures were postponed during the pandemic. Half of the centers increased the number of beds on which ECMO procedures could be offered. Nevertheless, in one-third of the centers, the start of at least one ECMO support was delayed because of a feared resource shortage. In 17% of centers, at least one patient was denied ECMO that he or she would have most likely received under prepandemic conditions.

CONCLUSION

The results of this online survey indicate that the experienced pressures and resource constraints led some centers to be cautious about ECMO indications.

Current status of antithrombotic therapy and in-hospital outcomes in patients with atrial fibrillation undergoing percutaneous coronary intervention in Germany

BACKGROUND

Little is known about current patterns of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in clinical practice in Germany.

METHODS

The RIVA-PCI is a prospective, non-interventional, multicenter study with follow-up until hospital discharge including consecutive patients with AF undergoing PCI.

RESULTS

Between January 2018 and March 2020, 1636 patients (elective in 52.6%, non-ST elevation acute coronary syndrome [NSTE-ACS] in 39.3%, ST-elevation myocardial infarction in 8.2%) from 51 German hospitals were enrolled in the study. After PCI a dual antithrombotic therapy (DAT) consisting of OAC and a P2Y12 inhibitor was given to 66.0%, triple antithrombotic therapy (TAT) to 26.0%, dual antiplatelet therapy to 5.5%, and a mono-therapy to 2.5% of the patients. Non-vitamin K antagonist oral anticoagulants (NOACs) were given to 82.4% and vitamin K antagonists to 11.5% of the patients. In-hospital events included death in 12 cases (0.7%), myocardial infarction, stent thrombosis, and ischemic stroke in four (0.2%) patients each, while 2.8% of patients had bleeding complications. The recommended durations for DAT or TAT at discharge were 1 month (1.5%), 3 months (2.1%), 6 months (43.1%), and 12 months (45.6%), with a 6-month course of DAT (47.7%) most often recommended after elective PCI and a 12-month course of DAT (40.1%) after ACS.

CONCLUSION

The preferred therapy after PCI in patients with AF is DAT with a NOAC and clopidogrel. In-hospital ischemic and bleeding events were rare. The recommended durations for combination therapy vary considerably.

Rivaroxaban in Patients With Atrial Fibrillation Who Underwent Percutaneous Coronary Intervention in Clinical Practice

Little is known about the efficacy and safety of rivaroxaban in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) in clinical practice. We therefore conducted a prospective observational study to determine the rate of ischemic, embolic, and bleeding events in patients with AF and PCI treated with rivaroxaban in a real-world experience. The RIVA-PCI ("rivaroxaban in patients with AF who underwent PCI") (clinicaltrials.gov NCT03315650) is a prospective, noninterventional, multicenter study with a follow-up until 14 months, including patients with AF who underwent PCI discharged with rivaroxaban. Between January 2018 and March 2020, 700 patients with PCI treated with rivaroxaban (elective in 50.1%, non-ST-elevation acute coronary syndrome 43.0%, ST-elevation myocardial infarction in 6.9%) were enrolled at 51 German hospitals. After PCI, a dual antithrombotic therapy consisting of rivaroxaban and a P2Y12 inhibitor was administered in 70.7% and triple antithrombotic therapy in 27.9%, respectively. Follow-up information could be obtained in 695 patients (99.3%). Rivaroxaban has been stopped prematurely in 21.6% of patients. Clinical events under rivaroxaban during the 14-month follow-up compared with those observed in the PIONEER-AF PCI trial included cardiovascular death (2.0% % vs 2.0%), myocardial infarction (0.9% vs 3.0%), stent thrombosis (0.2% vs 0.8%), stroke (1.3% vs 1.3%), International Society on Thrombosis and Haemostasis major (4.2% vs 3.9%), and International Society on Thrombosis and Haemostasis nonmajor clinically relevant bleeding (15.3% vs 12.9%). Therefore, in this real-world experience, rivaroxaban in patients with AF who underwent PCI is associated with ischemic and bleeding event rates comparable with those observed in the randomized PIONEER-AF PCI trial.

Empfehlungen der S3-Leitlinie (AWMF) „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS-/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS-/ECMO-Therapie. Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde. Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

Empfehlungen der S3-Leitlinie (AWMF) Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS/ECMO-Therapie.

Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde.

Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure -A clinical practice Guideline Level 3

Aims Worldwide applications of extracorporeal circulation for mechanical support in cardiac and circulatory failure, which are referred to as extracorporeal life support (ECLS) or veno‐arterial extracorporeal membrane oxygenation (va‐ECMO), have dramatically increased over the past decade. In spite of the expanding use and the immense medical as well as socio‐economic impact of this therapeutic approach, there has been a lack of interdisciplinary recommendations considering the best available evidence for ECLS treatment.

Methods and Results In a multiprofessional, interdisciplinary scientific effort of all scientific societies involved in the treatment of patients with acute cardiac and circulatory failure, the first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy was developed in a structured approach under regulations of the AWMF (Association of the Scientific Medical Societies in Germany) and under use of GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. This article presents all recommendations created by the expert panel, addressing a multitude of aspects for ECLS initiation, continuation, weaning and aftercare as well as structural and personnel requirements.

Conclusions This first evidence‐ and expert consensus‐based guideline (level S3) on ECLS/ECMO therapy should be used to apply the best available care nationwide. Beyond clinical practice advice, remaining important research aspects for future scientific efforts are formulated.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.

[Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure : Short version of the S3 guideline]

In Germany, a remarkable increase regarding the usage of extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) systems has been observed in recent years with approximately 3000 ECLS/ECMO implantations annually since 2015. Despite the widespread use of ECLS/ECMO, evidence-based recommendations or guidelines are still lacking regarding indications, contraindications, limitations and management of ECMO/ECLS patients. Therefore in 2015, the German Society of Thoracic and Cardiovascular Surgery (GSTCVS) registered the multidisciplinary S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" to develop evidence-based recommendations for ECMO/ECLS systems according to the requirements of the Association of the Scientific Medical Societies in Germany (AWMF). Although the clinical application of ECMO/ECLS represents the main focus, the presented guideline also addresses structural and economic issues. Experts from 17 German, Austrian and Swiss scientific societies and a patients' organization, guided by the GSTCVS, completed the project in February 2021. In this report, we present a summary of the methodological concept and tables displaying the recommendations for each chapter of the guideline.

Arterial Lactate in Cardiogenic Shock: Prognostic Value of Clearance Versus Single Values

OBJECTIVES

This study sought to compare single lactate values at admission (L1) and after 8 h (L2) with lactate clearance (LC) for mortality prediction in cardiogenic shock (CS).

BACKGROUND

Early estimation of prognosis in CS complicating acute myocardial infarction is crucial for tailored treatment selection. Arterial lactate is the most widely used point-of-care parameter in CS. In septic shock, lactate reduction over time-LC-has been extensively investigated. However, in CS, only limited data exist, and the prognostic value of LC is unknown.

METHODS

This study is a subanalysis of the IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial and the corresponding registry. Lactate levels were prospectively collected. All-cause mortality at 30 days was assessed as primary endpoint.

RESULTS

For 671 of 783 (85.7%) patients, L1 and L2 values were available. The area under the receiver-operating characteristic curve (L1: 0.69; L2: 0.76; LC: 0.59) showed no difference between L1 and LC (p = 0.20). In contrast, L2 was a significantly better predictive parameter than L1 or LC (p < 0.001 for both). In multivariable stepwise Cox regression analysis, L2 ≥3.1 mmol/l (best cutoff value by Youden index) and LC <-3.45%/h remained independently predictive for time to death (p < 0.001 for both), with L2 showing the highest chi-square test score (42.1) and hazard ratio (2.89; 95% confidence interval: 2.10 to 3.97).

CONCLUSIONS

Arterial lactate after 8 h is superior in mortality prediction in comparison with baseline lactate and LC. A cutoff value of 3.1 mmol/l for lactate after 8 h showed the best discrimination for assessing early prognosis in CS and may serve as new treatment goal. (Intraaortic Balloon Pump in Cardiogenic Shock II [IABP-SHOCK II]; NCT00491036).

Extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock - Design and rationale of the ECLS-SHOCK trial

BACKGROUND

In acute myocardial infarction complicated by cardiogenic shock the use of mechanical circulatory support devices remains controversial and data from randomized clinical trials are very limited. Extracorporeal life support (ECLS) - venoarterial extracorporeal membrane oxygenation - provides the strongest hemodynamic support in addition to oxygenation. However, despite increasing use it has not yet been properly investigated in randomized trials. Therefore, a prospective randomized adequately powered clinical trial is warranted.

STUDY DESIGN

The ECLS-SHOCK trial is a 420-patient controlled, international, multicenter, randomized, open-label trial. It is designed to compare whether treatment with ECLS in addition to early revascularization with percutaneous coronary intervention or alternatively coronary artery bypass grafting and optimal medical treatment is beneficial in comparison to no-ECLS in patients with severe infarct-related cardiogenic shock. Patients will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoint of ECLS-SHOCK is 30-day mortality. Secondary outcome measures such as hemodynamic, laboratory, and clinical parameters will serve as surrogate endpoints for prognosis. Furthermore, a longer follow-up at 6 and 12 months will be performed including quality of life assessment. Safety endpoints include peripheral ischemic vascular complications, bleeding and stroke.

CONCLUSIONS

The ECLS-SHOCK trial will address essential questions of efficacy and safety of ECLS in addition to early revascularization in acute myocardial infarction complicated by cardiogenic shock.

Hypoperfusionssyndrom und kardiogener Schock

Der kardiogene Schock stellt nach wie vor ein Krankheitsbild mit hoher Mortalität dar. In dieser Situation entwickelt sich nahezu regelhaft eine Laktatazidose durch Gewebsischämie. Diese wiederum unterstützt den klinischen Gesamteindruck eines Schockzustandes. Das erhöhte Laktat bzw. mehr noch die verzögerte oder fehlende Laktatclearance sind harte Prädiktoren der schlechten Prognose. In dieser Situation ist die hämodynamische Stabilisierung neben der Ursachentherapie oberstes Gebot. Eine balancierte Volumen-/Katecholamintherapie stellt die Basis dar. Früh muss aber eine Entscheidung für oder gegen den Einsatz eines mechanischen Unterstützungssystems fallen. Entscheidungshilfen sind klinische, aber auch laborchemische und interventionelle Faktoren. Das fallende Laktat (die Laktatclearance) ist auch unter extrakorporalem System der wichtigste Ausdruck einer funktionierenden Therapie. Randomisierte Studien, die eine Prognoseverbesserung dieser schwer kranken Patienten beweisen, existieren derzeit nicht. Umso wichtiger ist der rationale, aber frühe Einsatz dieser Systeme nach in Positionspapieren definierten Kriterien.

Kardiovaskuläre Intensivmedizin im Krankenhaus

Kardiovaskuläre Intensivmedizin stellt einen wesentlichen Bestandteil der gesamten internistischen Intensivmedizin dar und andererseits der Tätigkeit des interventionell tätigen Kardiologen. In größeren Krankenhäusern werden Intensivstationen separat durch Anästhesisten bzw. Internisten geleitet. Dabei sind die internistischen Leitungen in den meisten Fällen auch Kardiologen. Dennoch bestehen Sorgen über ausreichenden Nachwuchs an qualifizierten Intensivmedizinern. Also sind Veränderungen nötig, welche die Ausbildung, die Rotationsmodelle und die Besetzungen der Intensivstationen betreffen, um die Motivation zu erhöhen, sich für die Intensivmedizin zu begeistern und zu engagieren. Es gibt die Zusatzweiterbildung „Intensivmedizin“ und zukünftig ein Curriculum Intensivmedizin der Deutschen Gesellschaft für Kardiologie. Am Ende muss es das Ziel sein, die Qualität der intensivmedizinischen Versorgung in der Behandlung meist schwer und oft interdisziplinär kranker Patienten weiter zu verbessern.

Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction: Long-Term 6-Year Outcome of the Randomized IABP-SHOCK II Trial

BACKGROUND

The role of intraaortic balloon counterpulsation (IABP) in cardiogenic shock is still a subject of intense debate despite the neutral results of the IABP-SHOCK II trial (Intraaortic Balloon Pump in Cardiogenic Shock II) with subsequent downgrading in international guidelines. So far, randomized data on the impact of IABP on long-term clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction are lacking. Furthermore, only limited evidence is available on general long-term outcomes of patients with cardiogenic shock treated by contemporary practice.

METHODS

The IABP-SHOCK II trial is a multicenter, randomized, openlabel trial. Between 2009 and 2012, 600 patients with cardiogenic shock complicating acute myocardial infarction undergoing early revascularization were randomized to IABP versus control.

RESULTS

Long-term follow-up was performed 6.2 years (interquartile range 5.6-6.7) after initial randomization. Follow-up was completed for 591 of 600 patients (98.5%). Mortality was not different between the IABP and the control group (66.3% versus 67.0%; relative risk, 0.99; 95% CI, 0.88-1.11; P=0.98). There were also no differences in recurrent myocardial infarction, stroke, repeat revascularization, or rehospitalization for cardiac reasons (all P>0.05). Survivors' quality of life as assessed by the EuroQol 5D questionnaire and the New York Heart Association class did not differ between groups.

CONCLUSIONS

IABP has no effect on all-cause mortality at 6-year longterm follow-up. Mortality is still very high, with two thirds of patients with cardiogenic shock dying despite contemporary treatment with revascularization therapy.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov/. Unique identifier: NCT00491036.

First-in-man analysis of the i-cor assist device in patients with cardiogenic shock

OBJECTIVE

In patients with refractory cardiogenic shock (CS) mechanical assistance by venous-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy may be considered to reach haemodynamic stabilization. In this first-in-man study, we analysed the applicability of the new i-cor VA-ECMO assist device equipped with a diagonal pump system.

METHODS AND RESULTS

In total, 15 patients with refractory CS were treated with the i-cor assist device in three tertiary care centres. In 71%, CS was due to acute myocardial infarction (AMI). At baseline, patients were hypotensive (systolic/diastolic blood pressure 97 ± 4/62 ± 4 mm Hg) despite high doses of catecholamines. Under ECMO therapy, a significant reduction in vasopressor therapy and serum lactate levels was observed (norepinephrine: 0.69 ± 0.1 µg/kg/min at baseline vs 0.21 ± 0.08 µg/kg/min on the last day of treatment, p<0.0001; serum lactate: 6.7 ± 1.4 mmol/l at baseline versus 1.3 ± 0.1 mmol/l on the last day, p<0.001). Inspiratory oxygen concentration was significantly reduced during the course of VA-ECMO support (80.4 ± 7.0% at baseline vs 42.7 ± 2.4% on final day; p<0.001). At baseline, three patients (20%) were on continuous haemodialysis treatment. Of the 12 patients without haemodialysis at baseline, only one patient required haemodialysis during the course of ECMO treatment. Glomerular filtration rate (GFR) significantly increased with treatment (41.2 ± 7.4 at baseline vs 69.0 ± 10.8 on last day; p=0.006). Bleeding at the insertion site was recorded in two patients (13.3%). Overall, 11 patients (73.3%) needed blood transfusion. Three patients (20%) developed signs of limb ischaemia that were fully reversible. Haemolysis was recorded in five patients (33%). None of the complications required the interruption of ECMO therapy. Overall mortality was 33.3% (five patients); two patients died during, and three patients after, ECMO therapy.

CONCLUSION

This first-in-man analysis suggests that the i-cor ECMO device is successfully applicable in humans. The data set the stage for further evaluation of this novel system and provide the necessary basis to design randomised evaluations.

Gender differences in patients with cardiogenic shock complicating myocardial infarction: a substudy of the IABP-SHOCK II-trial

BACKGROUND

Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is associated with high mortality. Previous studies regarding gender-specific differences in CS are conflicting and there are insufficient data for the presence of gender-associated differences in the contemporary percutaneous coronary intervention era. Aim of this study was therefore to investigate gender-specific differences in a large cohort of AMI patients with CS undergoing contemporary treatment.

METHODS

In the randomized Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial, 600 patients with CS complicating AMI undergoing early revascularization were assigned to therapy with or without intra-aortic balloon pump. We compared sex-specific differences in these patients with regard to baseline and procedural characteristics as well as short- and long-term clinical outcome.

RESULTS

Of 600 patients 187 (31%) were female. Women were significantly older than men and had a significantly lower systolic and diastolic blood pressure at presentation (p < 0.05 for all). Diabetes mellitus and hypertension were more frequent in women, whereas smoking was more frequent in men (p < 0.05 for all). Women showed a higher mortality within the first day after randomization (p = 0.004). However, after multivariable adjustment this numerical difference was no longer statistically significant. No gender-related differences in clinical outcome were observed after 1, 6 and 12 months of follow-up.

CONCLUSION

In this large-scale multicenter study in patients with CS complicating AMI, women had a worse-risk profile in comparison to men. No significant gender-related differences in treatment as well as short- and long-term outcome were observed.

Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial

BACKGROUND

In current international guidelines the recommendation for intra-aortic balloon pump (IABP) use has been downgraded in cardiogenic shock complicating acute myocardial infarction on the basis of registry data. In the largest randomised trial (IABP-SHOCK II), IABP support did not reduce 30 day mortality compared with control. However, previous trials in cardiogenic shock showed a mortality benefit only at extended follow-up. The present analysis therefore reports 6 and 12 month results.

METHODS

The IABP-SHOCK II trial was a randomised, open-label, multicentre trial. Patients with cardiogenic shock complicating acute myocardial infarction who were undergoing early revascularisation and optimum medical therapy were randomly assigned (1:1) to IABP versus control via a central web-based system. The primary efficacy endpoint was 30 day all-cause mortality, but 6 and 12 month follow-up was done in addition to quality-of-life assessment for all survivors with the Euroqol-5D questionnaire. A masked central committee adjudicated clinical outcomes. Patients and investigators were not masked to treatment allocation. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00491036.

FINDINGS

Between June 16, 2009, and March 3, 2012, 600 patients were assigned to IABP (n=301) or control (n=299). Of 595 patients completing 12 month follow-up, 155 (52%) of 299 patients in the IABP group and 152 (51%) of 296 patients in the control group had died (relative risk [RR] 1·01, 95% CI 0·86-1·18, p=0·91). There were no significant differences in reinfarction (RR 2·60, 95% CI 0·95-7·10, p=0·05), recurrent revascularisation (0·91, 0·58-1·41, p=0·77), or stroke (1·50, 0·25-8·84, p=1·00). For survivors, quality-of-life measures including mobility, self-care, usual activities, pain or discomfort, and anxiety or depression did not differ significantly between study groups.

INTERPRETATION

In patients undergoing early revascularisation for myocardial infarction complicated by cardiogenic shock, IABP did not reduce 12 month all-cause mortality.

FUNDING

German Research Foundation; German Heart Research Foundation; German Cardiac Society; Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte; University of Leipzig--Heart Centre; Maquet Cardiopulmonary; Teleflex Medical.

Intraaortic balloon support for myocardial infarction with cardiogenic shock

BACKGROUND

In current international guidelines, intraaortic balloon counterpulsation is considered to be a class I treatment for cardiogenic shock complicating acute myocardial infarction. However, evidence is based mainly on registry data, and there is a paucity of randomized clinical trials.

METHODS

In this randomized, prospective, open-label, multicenter trial, we randomly assigned 600 patients with cardiogenic shock complicating acute myocardial infarction to intraaortic balloon counterpulsation (IABP group, 301 patients) or no intraaortic balloon counterpulsation (control group, 299 patients). All patients were expected to undergo early revascularization (by means of percutaneous coronary intervention or bypass surgery) and to receive the best available medical therapy. The primary efficacy end point was 30-day all-cause mortality. Safety assessments included major bleeding, peripheral ischemic complications, sepsis, and stroke.

RESULTS

A total of 300 patients in the IABP group and 298 in the control group were included in the analysis of the primary end point. At 30 days, 119 patients in the IABP group (39.7%) and 123 patients in the control group (41.3%) had died (relative risk with IABP, 0.96; 95% confidence interval, 0.79 to 1.17; P=0.69). There were no significant differences in secondary end points or in process-of-care measures, including the time to hemodynamic stabilization, the length of stay in the intensive care unit, serum lactate levels, the dose and duration of catecholamine therapy, and renal function. The IABP group and the control group did not differ significantly with respect to the rates of major bleeding (3.3% and 4.4%, respectively; P=0.51), peripheral ischemic complications (4.3% and 3.4%, P=0.53), sepsis (15.7% and 20.5%, P=0.15), and stroke (0.7% and 1.7%, P=0.28).

CONCLUSIONS

The use of intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned. (Funded by the German Research Foundation and others; IABP-SHOCK II ClinicalTrials.gov number, NCT00491036.).

[Ethic rounds in intensive care. Possible instrument for a clinical-ethical assessment in intensive care units]

Ethical problems, such as medical end-of-life decisions or withdrawing life-sustaining treatment are viewed as an essential task in intensive care units. This article presents the ethics rounds as an instrument for evaluation of ethical problems in intensive care medicine units. The benchmarks of ethical reflection during the ethics rounds are considerations of ethical theory of principle-oriented medical ethics. Besides organizational aspects and the institutional framework, the role of the ethicist is described. The essential evaluation steps, as a basis of the ethics rounds are presented. In contrast to the clinical ethics consultation, the ethicist in the ethics rounds model is integrated as a member of the ward round team. Therefore ethical problems may be identified and analyzed very early before the conflict escalates. This preventive strategy makes the ethics rounds a helpful instrument in intensive care units.

Intraaortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock: design and rationale of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial

BACKGROUND

In current guidelines, intraaortic balloon pumping (IABP) is considered a class 1 indication in cardiogenic shock complicating acute myocardial infarction. However, evidence is mainly based on retrospective or prospective registries with a lack of randomized clinical trials. Therefore, IABP is currently only used in 20% to 40% of cardiogenic shock cases. The hypothesis of this trial is that IABP in addition to early revascularization by either percutaneous coronary intervention or coronary artery bypass grafting will improve clinical outcome of patients in cardiogenic shock.

STUDY DESIGN

The IABP-SHOCK II study is a 600-patient, prospective, multicenter, randomized, open-label, controlled trial. The study is designed to compare the efficacy and safety of IABP versus optimal medical therapy on the background of early revascularization by either percutaneous coronary intervention or coronary artery bypass grafting. Patients will be randomized in a 1:1 fashion to 1 of the 2 treatments. The primary efficacy end point of IABP-SHOCK II is 30-day all-cause mortality. Secondary outcome measures, such as hemodynamic, laboratory, and clinical parameters, will serve as surrogate end points for prognosis. Furthermore, an intermediate and long-term follow-up at 6 and 12 months will be performed. Safety will be assessed, by the GUSTO bleeding definition, peripheral ischemic complications, sepsis, and stroke.

CONCLUSIONS

The IABP-SHOCK II trial addresses important questions regarding the efficacy and safety of IABP in addition to early revascularization in patients with cardiogenic shock complicating myocardial infarction.

Peripheral chemosensor function is blunted in moderate to severe chronic kidney disease

BACKGROUND

Cardiovascular mortality is markedly increased in chronic kidney disease (CKD) and may be explained in part by sympathetic hyperactivity. Impaired hyperoxic chemoreflex sensitivity (CHRS) has been attributed to an increased sympathetic tone. The aim of the present study was to examine whether chemosensor function is altered in patients with CKD.

METHODS AND RESULTS

We assessed CHRS in 20 patients with stage 3 CKD [glomerular filtration rate (GFR) 30-59 ml/min/1.73 m(2)], in 15 patients with stage 4 CKD [GFR 15-29 ml/min/1.73 m(2)], as well as in 35 age and gender matched patients without any evidence of CKD. The difference in the R-R intervals divided by the difference in the oxygen pressures before and after deactivation of the chemoreceptors by inhalation of pure oxygen was calculated as the CHRS. A CHRS below 3.0 ms/mmHg was defined as pathological. CHRS was significantly depressed in patients with stage 3 CKD (2.9 ± 0.9 ms/mmHg, P=0.005) and in patients with stage 4 CKD (2.1 ± 0.6 ms/mmHg, P<0.001), as compared with patients without CKD (6.7 ± 0.9 ms/mmHg). There was a negative correlation between serum creatinine and CHRS (r=-0.51; P<0.001). In patients with CKD, chemosensor deactivation decreased mean arterial pressure from 91 ± 4 mmHg to 87 ± 3 mmHg (P=0.03). Multivariate analysis showed that GFR (P=0.001) was the only independent predictor of a pathological CHRS.

CONCLUSION

Using a relatively non-invasive bedside test we provide evidence for a blunted peripheral chemosensor function in chronic kidney disease. We thereby lay the basis for interventional studies assessing chemosensor function in chronic kidney disease.

Myocardial delayed contrast enhancement in patients with arterial hypertension: initial results of cardiac MRI

PURPOSE

In arterial hypertension left ventricular hypertrophy comprises myocyte hypertrophy, interstitial fibrosis and structural alterations of the coronary microcirculation. MRI enables the detection of myocardial fibrosis, infarction and scar tissue by delayed enhancement (DE) after contrast media application. Aim of this study was to investigate patients with arterial hypertension but without known coronary disease or previous myocardial infarction to detect areas of DE.

METHODS AND MATERIAL

Twenty patients with arterial hypertension with clinical symptoms of myocardial ischemia, but without history of myocardial infarction and normal coronary arteries during coronary angiography were investigated on a 1.0 T superconducting magnet (Gyroscan T10-NT, Intera Release 8.0, Philips). Fast gradient-echo cine sequences and T2-weighted STIR-sequences were acquired. Fifteen minutes after injection of Gadobenate dimeglumine inversion recovery gradient-echo sequences were performed for detection of myocardial DE. Presence or absence of DE on MRI was correlated with clinical data and the results of echocardiography and electrocardiography, respectively.

RESULTS

Nine of 20 patients showed DE in the interventricular septum and the anteroseptal left ventricular wall. In 6 patients, DE was localized intramurally and in 3 patients subendocardially. There was a significant correlation between myocardial DE and ST-segment depressions during exercise and between DE and left-ventricular enddiastolic pressure. Patients with intermittent atrial fibrillation showed a myocardial DE more often than patients without atrial fibrillation.

CONCLUSION

In our series, 45% of patients with arterial hypertension showed DE on cardiac MRI. In this clinical setting, delayed enhancement may be due to coronary microangiopathy. The more intramurally localization of DE, however, rather indicates myocardial interstitial fibrosis.

Brugada syndrome as a potential cardiac risk factor during electroconvulsive therapy (ECT)

A case of asystole (> 5 s) during electroconvulsive therapy (ECT) is reported in a patient who was subsequently diagnosed to have Brugada syndrome (BS). This hereditary sodium-channelopathy is characterized by typical, though intermittent, ECG abnormalities and carries a high risk of ventricular arrythmia and sudden cardiac death. The general occurence of BS is rare; however, it is more prevalent in men and in southeast Asian populations. As in the reported case, BS carriers may lack a telltale medical history and can present with normal ECG recordings. In these cases, BS can only be unmasked by repeated ECG recordings over time or by specialist cardiological examinations. To our knowledge, BS, which was first characterized in 1992, has not yet been in the focus of cardiac complications during ECT. However, as the presented case illustrates, this syndrome should be considered as a rare but potentially severe cardiac risk factor in the context of ECT.

Myocardial delayed contrast enhancement in patients with arterial hypertension: initial results of cardiac MRI

PURPOSE

In arterial hypertension left ventricular hypertrophy comprises myocyte hypertrophy, interstitial fibrosis and structural alterations of the coronary microcirculation. MRI enables the detection of myocardial fibrosis, infarction and scar tissue by delayed enhancement (DE) after contrast media application. Aim of this study was to investigate patients with arterial hypertension but without known coronary disease or previous myocardial infarction to detect areas of DE.

METHODS AND MATERIAL

Twenty patients with arterial hypertension with clinical symptoms of myocardial ischemia, but without history of myocardial infarction and normal coronary arteries during coronary angiography were investigated on a 1.0 T superconducting magnet (Gyroscan T10-NT, Intera Release 8.0, Philips). Fast gradient-echo cine sequences and T2-weighted STIR-sequences were acquired. Fifteen minutes after injection of Gadobenate dimeglumine inversion recovery gradient-echo sequences were performed for detection of myocardial DE. Presence or absence of DE on MRI was correlated with clinical data and the results of echocardiography and electrocardiography, respectively.

RESULTS

Nine of 20 patients showed DE in the interventricular septum and the anteroseptal left ventricular wall. In 6 patients, DE was localized intramurally and in 3 patients subendocardially. There was a significant correlation between myocardial DE and ST-segment depressions during exercise and between DE and left-ventricular enddiastolic pressure. Patients with intermittent atrial fibrillation showed a myocardial DE more often than patients without atrial fibrillation.

CONCLUSION

In our series, 45% of patients with arterial hypertension showed DE on cardiac MRI. In this clinical setting, delayed enhancement may be due to coronary microangiopathy. The more intramurally localization of DE, however, rather indicates myocardial interstitial fibrosis.

Continuous venovenous haemofiltration using a citrate buffered substitution fluid

Different methods of regional anticoagulation using citrate in continuous renal replacement therapy have been described in the past. However, these procedures were usually very complex or did not reach modem requirements for effective continuous renal replacement therapy. Furthermore, little is known about long-term acid-base stability and citrate levels during the treatment. We describe a system in which citrate is used both as anticoagulant and as the sole buffer substance in continuous venovenous haemofiltration. Our citrate-containing, calcium-free substitution fluid was used in predilution mode with a constant ratio between blood flow (120 to 150 ml/min) and substitution flow (2400 to 3000 ml/hour). Anticoagulation was limited to the extracorporeal circuit. Twenty patients with acute renal failure on mechanical ventilation were treated, four for eight hours, four for 24 hours and 12 as long they needed continuous renal replacement therapy (9.6 +/- 5.0 days, range 4.0 to 39.3 days). We achieved stable acid-base and electrolyte balance in all patients. We observed no bleeding complications (patient activated clotting time 112.4 +/- 17.1 s, post-filter circuit activated clotting time 270.5 +/- 80.3 s) and achieved appropriate filter life times (48.6 +/- 13.2 h). Predilution, citrate-based substitution fluid provides both anticoagulation within the extracorporeal circuit and control of acid-base balance in critically ill patients at risk of bleeding in acute renal failure. It is easy to apply and safe. Clearance can be varied as long as a constant ratio between blood and substitution flow is maintained.

The sepsis-related Organ Failure Assessment (SOFA) score is predictive for survival of patients admitted to the intensive care unit following allogeneic blood stem cell transplantation

Intensive care unit (ICU) support following allogeneic peripheral blood stem cell transplantation (PBSCT) is controversial due to the limited prognosis of these patients in case of secondary critical illness. In this retrospective single centre study, we looked for factors predicting survival in patients who needed ICU support after myeloablative (MAC) or non-myeloablative conditioning (non-MAC) therapy and allogeneic PBSCT. Between 1999 and 2006, 64 out of 319 patients following allogeneic PBSCT were admitted to the ICU (24 female and 40 male patients, median age 47 years, range 17-65 years; MAC 49 patients, non-MAC 15 patients). All 64 patients required mechanical ventilation. We looked for variables defining the Sepsis-related Organ Failure Assessment (SOFA) score as well as for baseline characteristics and transplant-associated parameters on the day of ICU admission possibly predictive for poor or good survival prognosis. Nineteen of 49 patients who had received MAC therapy survived the ICU stay for a median time of 9 months (range 2-29 months) and three of 15 patients who had received non-MAC therapy could be discharged from the ICU with a survival time of 4, 5 and 12 months. After univariate and multivariate analysis the SOFA score discriminated survivors and non-survivors of the ICU stay. We conclude that the SOFA score is predictive for survival when applied on the day of ICU admission.

[Particulate matter and cardiovascular health in the European Union: time for prevention?]

With reference to the EU-Council Directive (1999/30/EC) a discussion in the European Union between basic science, epidemiologic knowledge, and regulatory policies has become of growing public interest. The consequences following particulate matter (PM) exposure on the cardiovascular system, are actually not fully understood. This work reviews latest developments as regards the realization of the mentioned Council Directive and emphasizes the cardiovascular health impairment in this context. PM is assumed to increase the risk for arrhythmia, ischemic cardiovascular events, and worsens heart failure. The importance of the risk factor PM is due to the number of people who are affected, if consequent actions for air pollution prevention are not adequately transposed. Health-care providers can protect especially patients at high risk by informing them about behavior modification to prevent PM exposure and its possible consequences. To promote public health on the health-policy level, several action plans have been established. Forthcoming challenge for PM-associated cardiovascular health promotion remains an interdisciplinary approach to create synergistic effects of several sanctions, which primarily concerns scientific and political decision makers and public consciousness. In conclusion, further investigations are necessary to deepen the understanding of PM exposure and its consequences for the cardiovascular system and evaluate the success of preventive strategies.

Signal-averaged P-wave ECG as a marker of atrial electrical instability in patients with right ventricular dysfunction

Severe pulmonary hypertension (PAH) leads to right ventricular dysfunction and is associated with different atrial arrhythmias. In PAH patients, the echocardiographic Tei-index is used for monitoring right heart function. The P-wave signal-averaged ECG (SA-ECG) has been shown to have a potential role in identifying patients at risk of developing paroxysmal atrial fibrillation and those likely to change from paroxysmal to chronic atrial fibrillation. The aim of the present study was to define the correlation of the Tei-Index with parameters of P-wave triggered and bidirectional P-wave SA-ECG. A total of 18 patients (14 men, 4 women) with normal sinus rhythm and a mean age of 67+/-10 years (BMI 27.6+/-5.1 kg/m2) were included into the study. Right ventricular (RV) Tei-index was calculated from the sum of isovolumetric contraction time and relaxation time divided by ejection time. Furthermore, P-wave triggered P-wave signal averaged ECG was performed from an X, Y, and Z lead system. The results show that there was a statistically significant correlation between Tei-index and filtered P-wave duration (r=0.53; P=0.023). Teiindex did not correlate with the root mean square voltage of the last 20 ms of the P wave (r=-0.16; P=0.52). In conclusion, a correlation of RV Tei index with P-wave duration indicates that this echocardiographic measurement is not only a marker of right heart function, but also an indicator of electrical instability that could be useful to detect patients at risk for atrial arrhythmias.

Effects of continuous positive airway pressure on exercise capacity in chronic heart failure patients without sleep apnea

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea. It is known, that there are beneficial effects on cardiac function, which might be explained by suppression of apnea and specific hemodynamic effects of CPAP. Therefore, CPAP might act as an adjunct therapy in heart failure, even in the absence of sleep apnea. In the present study, 11 patients with congestive heart failure (EF=23.1+/-6.9%) without sleep apnea (AHI 3.0+/-1.2/h) were treated with nocturnal CPAP. Cardiopulmonary exercise testing was performed at baseline and after 8.6 +/-1.3 months. All patients underwent heart catheterization and myocardial biopsy to exclude myocarditis at baseline. Five (46%) of the 11 patients did not complete the study because of poor compliance and irregular use of the CPAP device. Six (54%) of the patients used CPAP regularly (>6 h/night) and completed the study. Cardiopulmonary exercise testing showed an improvement of work load (96+/-36 Watt vs. 112+/-34 Watt; P=0.025) and VO2 peak (1227+/-443 ml vs. 1525+/-470 ml; P=0.01). Oxygen-pulse was increased, although that did not reach significance (11.2+/-4.8 ml/beat vs. 12.6+/-3.9 ml/beat). In conclusion, CPAP might have beneficial effects on exercise capacity in patients with congestive heart failure even in the absence of sleep apnea. Nevertheless, poor compliance seems to be a limiting factor.