Caring for the Critically Ill Adult Congenital Heart Disease Patient

PURPOSE OF REVIEW

This review aims to discuss the unique challenges that adult congenital heart disease (ACHD) patients present in the intensive care unit.

RECENT FINDINGS

Recent studies suggest that ACHD patients make up an increasing number of ICU admissions, and that their care greatly improves in centers with specialized ACHD care. Common reasons for admission include arrhythmia, hemorrhage, heart failure, and pulmonary disease. It is critical that the modern intensivist understand not only the congenital anatomy and subsequent repairs an ACHD patient has undergone, but also how that anatomy can predispose the patient to critical illness. Additionally, intensivists should rely on a multidisciplinary team, which includes an ACHD specialist, in the care of these patients.

The management of heart failure cardiogenic shock: an international RAND appropriateness panel

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.

Implementing an Interdisciplinary Procedure Curriculum

INTRODUCTION

This curriculum was designed to improve access to procedures for our internal medicine residents.

METHODS

We created an interdisciplinary procedure course (IDPC) composed of two simulation sessions and a one-week procedural rotation supervised by multiple specialties including nephrology, cardiology, cardiothoracic anesthesiology, general anesthesiology, and interventional radiology. After the course, residents completed two surveys documenting the number of procedures and their level of confidence on a Likert scale (1 = very unconfident to 5 = very confident) prior to and after completing the curriculum.

RESULTS

Sixteen residents participated in the course from September 2021 to June 2022. The collective number of procedures performed by these 16 residents increased from 176 to 343 after a one-week rotation. For arterial lines, the proportion of residents that reported an improvement in confidence scores was 0.44 (95% confidence interval 0.23 to 1, p-value of 0.60). The proportion of residents that had an increase in their confidence performing central lines was 0.63 (95% confidence interval 0.39 to 1, p-value of 0.23). For intubations, the proportion of residents that reported an improvement in confidence was 0.94 (95% confidence interval 0.72 to 1, p-value of 0.0006).

CONCLUSION

By collaborating with multiple specialties, residents almost doubled the number of procedures performed during training and reported an increased level of confidence in procedural performance for airway intubation. We learned residents want to improve their access to procedures and described a curriculum that was easily implemented.

Glycemic Patterns and Impact of Early Hyperglycemia in Patients with Cardiogenic Shock on Mechanical Circulatory Support

BACKGROUND

Hyperglycemia has been an established predictor of poor outcomes in critically ill patients. The aim of the current study is to assess the pattern of early glycemic control in patients with cardiogenic shock (CS) on temporary mechanical circulatory support (MCS) and its impact on short term outcomes.

METHODS

All adult patients admitted to the Cleveland Clinic Cardiac Intensive Care Unit (CICU) between 2015 - 2019 with CS necessitating MCS with Intra-Aortic Balloon Pump (IABP), Impella or Venous Arterial- Extra Corporeal Membrane Oxygenation (VA- ECMO) exclusively for CS were retrospectively analyzed. Blood glucose values were collected for the first 72 hrs from the time of MCS insertion. Patients were categorized into three groups (group 1 = mean blood glucose (MBG) < 140, group 2 = MBG between 140-180, and group 3 = MBG >180). The primary outcome was 30-day all-cause mortality.

RESULTS

A total of 393 patients with CS on temporary MCS (Median age [Q1, Q3], 63 [54,70], 42% females), were admitted to our CICU during the study period. Of these, 144 patients (37%) were on IABP, 121 patients (31%) were on Impella, and 128 (32%) were on VA-ECMO. Upon stratifying the patients into groups depending on MBG during the initial time period after MCS placement, 174 patients (44%) had MBG less than 140 mg/dl, 126 patients (32%) had MBG between 140-180 mg/dl whereas 93 (24%) patients had MBG > 180 mg/dl. Overall, patients on IABP had the best glycemic control during the early period whereas those on ECMO had the highest MBG during the initial timeframe. Comparison of 30-day mortality revealed that patients with MBG >180 mg/dl had worse outcomes compared to the other two groups (p = 0.005). Multivariable logistic regression revealed that hyperglycemia was an independent predictor of poor outcomes in CS patients on MCS when undifferentiated by device type (aOR 2.27, 95% CI 1.19-4.42, p = 0.01). However, upon adjusting for the type of MCS device, this effect was no longer present.

CONCLUSIONS

A significant proportion of patients with CS on MCS manifest early hyperglycemia regardless of diabetic status. The presence of early hyperglycemia in these patients acted predominantly as a surrogate of the underlying shock severity and was associated with worse short-term outcomes. Future studies should assess whether strategies to optimize the glycemic control in this high-risk cohort can independently improve clinical outcomes.

Interaction Between Race and Income on Cardiac Outcomes After Percutaneous Coronary Intervention

Background

Compared with White Americans, Black Americans have a greater prevalence of cardiac events following percutaneous coronary intervention. We evaluated the association between race and neighborhood income on post–percutaneous coronary intervention cardiac events and assessed whether income modifies the effect of race on this relationship.

Methods and Results

Consecutive patients (n=23 822) treated with percutaneous coronary intervention from January 1, 2000, to December 31, 2016, were included. All‐cause mortality and major adverse cardiac event were assessed at 3 years. Extended 10‐year follow‐up was performed for those residing locally (n=1285). Neighborhood income was derived using median adjusted annual gross household income reported within the patient's zip code. We compared differences in treatment and outcomes, adjusting for race, income, and their interaction. In total, 3173 (13.3%) patients self‐identified as Black Americans, and 20 649 (86.7%) self‐identified as White Americans. Black Americans had a worse baseline cardiac risk profile and lower neighborhood income compared with White Americans. Although risk profile improved with increasing income in White Americans, no difference was observed across incomes among Black Americans. Despite similar long‐term outpatient cardiology follow‐up and medication prescription, risk profiles among Black Americans remained worse. At 3 years, unadjusted all‐cause mortality (18.0% versus 15.2%; P <0.001) and major adverse cardiac event (37.3% versus 34.6%; P <0.001) were greater among Black Americans and with lower income (both P <0.001); race, income, and their interaction were not significant predictors in multivariable models. At 10‐year follow‐up, increasing income was associated with improved outcomes only in White Americans but not Black Americans. In multivariable models for major adverse cardiac event, income (hazard ratio [HR], 0.97 [95% CI, 0.96–0.98]; P =0.005), Black race (HR, 1.77 [95% CI, 1.58–1.96]; P =0.006), and their interaction (HR, 0.98 [95% CI, 0.97–0.99]; P =0.003) were significant predictors. Similar findings were observed for cardiac death.

Conclusions

Early 3‐year post–percutaneous coronary intervention outcomes were driven by worse risk factor profiles in both Black Americans and those with lower neighborhood income. However, late 10‐year outcomes showed an independent effect of race and income, with improving outcomes with greater income limited to White Americans. These findings illustrate the importance of developing novel care strategies that address both risk factor modification and social determinants of health to mitigate disparities in cardiac outcomes.

Racial Differences and In-Hospital Outcomes Among Hospitalized Patients with COVID-19

OBJECTIVE

There is a paucity of data on how race affects the clinical presentation and short-term outcome among hospitalized patients with SARS-CoV-2, the 2019 coronavirus (COVID-19).

METHODS

Hospitalized patients ≥ 18 years, testing positive for COVID-19 from March 13, 2020 to May 13, 2020 in a United States (U.S.) integrated healthcare system with multiple facilities in two states were evaluated. We documented racial differences in clinical presentation, disposition, and in-hospital outcomes for hospitalized patients with COIVD-19. Multivariable regression analysis was utilized to evaluate independent predictors of outcomes by race.

RESULTS

During the study period, 3678 patients tested positive for COVID-19, among which 866 were hospitalized (55.4% self-identified as Caucasian, 29.5% as Black, 3.3% as Hispanics, and 4.7% as other racial groups). Hospitalization rates were highest for Black patients (36.6%), followed by other (28.3%), Caucasian patients (24.4%), then Hispanic patients (10.7%) (p < 0.001). Caucasian patients were older, and with more comorbidities. Absolute lymphocyte count was lowest among Caucasian patients. Multivariable regression analysis revealed that compared to Caucasians, there was no significant difference in in-hospital mortality among Black patients (adjusted odds ratio [OR] 0.53; 95% confidence interval [CI] 0.26-1.09; p = 0.08) or other races (adjusted OR 1.62; 95% CI 0.80-3.27; p = 0.18). Black and Hispanic patients were admitted less frequently to the intensive care unit (ICU), and Black patients were less likely to require pressor support or hemodialysis (HD) compared with Caucasians.

CONCLUSIONS

This observational analysis of a large integrated healthcare system early in the pandemic revealed that patients with COVID-19 did exhibit some racial variations in clinical presentation, laboratory data, and requirements for advanced monitoring and cardiopulmonary support, but these nuances did not dramatically alter in-hospital outcomes.

Sex Differences in the Utilization and Outcomes of Cardiac Valve Replacement Surgery for Infective Endocarditis: Insights From the National Inpatient Sample

Background

The data on the differential impact of sex on the utilization and outcomes of valve replacement surgery for infective endocarditis are limited to single‐center and small sample size patient population.

Methods and Results

We utilized the National Inpatient Sample database to identify patients with a discharge diagnosis of infective endocarditis from 2004 to 2015 to assess differences in the characteristics and clinical outcomes of patients hospitalized with infective endocarditis stratified by sex. We also evaluated trends in utilization of cardiac valve replacement and individual valve replacement surgeries in women versus men over a 12‐year period, and compared in‐hospital mortality after surgical treatment in women versus men. A total of 81 942 patients were hospitalized with a primary diagnosis of infective endocarditis from January 2004 to September 2015, of whom 44.31% were women. Women were less likely to undergo overall cardiac valve replacement (6.92% versus 12.12%), aortic valve replacement (3.32% versus 8.46%), mitral valve replacement (4.60% versus 5.57%), and combined aortic and mitral valve replacement (0.85% versus 1.81%) but had similar in‐hospital mortality rates. From 2004 to 2015, the overall rates of cardiac valve replacement increased from 11.76% to 13.96% in men and 6.34% to 9.26% in women and in‐hospital mortality declined in both men and women. Among the patients undergoing valve replacement surgery, in‐hospital mortality was higher in women (9.94% versus 6.99%, P<0.001).

Conclusions

Despite increased utilization of valve surgery for infective endocarditis in both men and women and improving trends in mortality, we showed that there exists a treatment bias with underutilization of valve surgeries for infective endocarditis in women and demonstrated that in‐hospital mortality was higher in women undergoing valve surgery in comparison to men.

Coronavirus disease and the cardiovascular system: a narrative review of the mechanisms of injury and management implications

Coronavirus disease (COVID-19), first identified in Wuhan, China, in December 2019, is now a pandemic, having already spread to 188 countries, with more than 28,280,000 infections worldwide. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the responsible infectious agent, and similar to other human coronaviruses, uses membrane-bound angiotensin-converting enzyme 2 (membrane-bound ACE2) for entry into the host cells. COVID-19 has important cardiovascular implications, especially for patients with pre-existing cardiovascular co-morbidities, potentially mediated through several mechanisms, including direct myocardial injury, worsening of those pre-existing cardiovascular co-morbidities, and adverse cardiovascular effects of potential therapies for COVID-19. The disease is causing a significant burden on health systems worldwide. Elective surgeries and procedures were postponed for a considerable period of time, and many patients with known cardiovascular disease (CVD) risk factors presented late to hospitals, for fear of contracting COVID-19, with serious adverse consequences. Significant negative impact on a population level is highlighted by prolonged isolation, decreased exercise and physical activity, and higher levels of depression and anxiety, all predisposing to elevated cardiovascular risk. This article provides a timely overview of COVID-19 and its impact on the cardiovascular system, focusing on the pathogenesis, potential adverse cardiovascular events, the potential treatment options, protection for health care providers and patients, and what the cardiovascular community could do to mitigate the impact of COVID-19.

Post-Myocardial Infarction Ventricular Septal Rupture Bridged to Heartmate 3 with an Impella 5.5

Optimal timing of surgical repair for patients diagnosed with a post-myocardial infarction ventricular septal rupture is controversial. Urgent surgical intervention to prevent hemodynamic decompensation must be balanced against delayed repair to allow for tissue stabilization and increased likelihood of a successful outcome. We report the use of an axillary Impella 5.5 (Abiomed Inc, Danvers, MA) temporary left ventricular assist device to aid in hemodynamic stabilization, shunt fraction reduction, and tissue maturation with eventual definitive surgical repair in a patient who presented with a post-myocardial infarction ventricular septal rupture and cardiogenic shock.

The Basics of ARDS Mechanical Ventilatory Care for Cardiovascular Specialists

The ongoing COVID-19 pandemic has placed pressure on health care systems and intensive care unit capacity worldwide. Respiratory insufficiency is the most common reason for hospital admission in patients with COVID-19. The most severe form of respiratory failure is acute respiratory distress syndrome (ARDS), which is associated with significant morbidity and mortality. Patients with ARDS are often treated with invasive mechanical ventilation according to established evidence-based and guideline recommended management strategies. With growing strain on critical care capacity, clinicians from diverse backgrounds, including cardiovascular specialists, might be required to help care for the growing number of patients with severe respiratory failure and ARDS. The aim of this article is to outline the fundamentals of ARDS diagnosis and management, including mechanical ventilation, for the nonintensivist. In the absence of mechanical ventilation trials specifically in patients with COVID-19-associated ARDS, the information presented is on the basis of general ARDS trials.

Distribution of omega-3 fatty acids in tissues of rabbits fed a flaxseed-supplemented diet

Diets rich in omega-3 polyunsaturated fatty acids are associated with decreased incidences of cardiovascular disease. The extent of incorporation and distribution of these beneficial fats into body tissues is uncertain. Rabbits were fed regular rabbit chow or a diet containing 10% ground flaxseed that is highly enriched with the omega-3 polyunsaturated fatty acid alpha-linolenic acid (ALA). The high-flaxseed diet resulted in an incorporation of ALA in all tissues, but mostly in the heart and liver with little in the brain. Docosahexaenoic and eicosapentaenoic acid levels were also selectively increased in some tissues, and the effects were not as large as ALA. Arachidonic acid and the ratio of omega-6/omega-3 fatty acids were decreased in all tissues obtained from the flax-supplemented group. Consumption of dietary flaxseed appears to be an effective means to increase ALA content in body tissues, but the degree will depend upon the tissues examined.

RyR1/SERCA1 cross-talk regulation of calcium transport in heavy sarcoplasmic reticulum vesicles

We investigated the functional interdependence of sarco-endoplasmic reticulum Ca2+ ATPase isoform 1 and ryanodine receptor isoform 1 in heavy sarcoplasmic reticulum membranes by synchronous fluorescence determination of extravesicular Ca2+ transients and catalytic activity. Under conditions of dynamic Ca2+ exchange ATPase catalytic activity was well coordinated to ryanodine receptor activation/inactivation states. Ryanodine-induced activation of Ca2+ release channel leaks also produced marked ATPase activation in the absence of measurable increases in bulk free extravesicular Ca2+. This suggested that Ca2+ pumps are highly sensitive to Ca2+ release channel leak status and potently buffer Ca2+ ions exiting cytoplasmic openings of ryanodine receptors. Conversely, ryanodine receptor activation was dependent on Ca2+-ATPase pump activity. Ryanodine receptor activation by cytosolic Ca2+ was (i) inversely proportional to luminal Ca2+ load and (ii) dependent upon the rate of presentation of cytosolic Ca2+. Progressive Ca2+ filling coincided with progressive loss of Ca2+ sequestration rates and at a threshold loading, ryanodine-induced Ca2+ release produced small transient reversals of catalytic activity. These data indicate that attainment of threshold luminal Ca2+ loads coordinates sensitization of Ca2+ release channels with autogenic inhibition of Ca2+ pumping. This suggests that Ca2+-dependent control of Ca2+ release in intact heavy sarcoplasmic reticulum membranes involves a Ca2+-mediated "cross-talk" between sarco-endoplasmic reticulum Ca2+ ATPase isoform 1 and ryanodine receptor isoform 1.