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Beneyto M, Martins R, Galand V, Kindo M, Schneider C, Sebestyen A, Boignard A, Sebbag L, Pozzi M, Genet T, Bourguignon T, Martin AC, Achouh P, Vanhuyse F, Blangy H, Henri C, Michel M, Anselme F, Litzler PY, Jungling M, Vincentelli A, Eschalier R, D'ostrevy N, Nataf P, Para M, Garnier F, Rajinthan P, Porterie J, Faure M, Picard F, Gaudard P, Rouvière P, Babatasi G, Blanchart K, Gariboldi V, Porto A, Flecher E, Delmas C. Right ventriculoarterial coupling surrogates and long-term survival in LVAD recipients: Results of the ASSIST-ICD multicentric registry. J Card Fail 2024:S1071-9164(24)00195-7. [PMID: 38851449 DOI: 10.1016/j.cardfail.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/09/2024] [Accepted: 05/10/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Prediction of outcomes remains an unmet need in LVAD candidates. Development of right heart failure portends an excess in mortality but imaging parameters of right ventricular systolic function have failed to demonstrate a prognostic role. By integrating pulmonary pressure, right ventriculoarterial coupling could fill this gap. METHODS The ASSIST-ICD registry was used to test right ventriculoarterial coupling surrogate parameters at implantation for the prediction of all-cause mortality. RESULTS The ratio of the tricuspid annular plane systolic excursion over the estimated systolic pulmonary pressure (TAPSE/sPAP) was not associated with long-term survival in univariate analysis (p = 0.89), neither was the pulmonary artery pulsatility index (PAPi) (p = 0.13). Conversely, the ratio of the right atrial pressure over the pulmonary capillary wedge pressure (RAP/PCWP) was associated with all-cause mortality (p <0.01). After taking tricuspid regurgitation severity, LVAD indication, LVAD model, age, blood urea nitrogen, and pulmonary vascular resistance into account, RAP/PCWP remained associated with survival (HR 1.35 [1.10 - 1.65], p <0.01). CONCLUSION Among pre-implant RVAC surrogates, only RAP/PCWP was associated with long-term all-cause mortality in LVAD recipients. This association was independent of established risk factors.
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Affiliation(s)
- Maxime Beneyto
- Cardiology Department, Toulouse University Hospital, Toulouse, France.
| | - Raphaël Martins
- Cardiology Department, Rennes University Hospital, Rennes, France
| | - Vincent Galand
- Cardiology Department, Rennes University Hospital, Rennes, France
| | - Michel Kindo
- Strasbourg University Hospital, Strasbourg, France
| | | | | | | | | | | | | | | | | | | | | | - Hugues Blangy
- Nancy University Hospital, Villeneuve les Nancy, France
| | - Charles Henri
- Institut du Thorax, Nantes University Hospital, nantes, France
| | - Magali Michel
- Institut du Thorax, Nantes University Hospital, nantes, France
| | | | | | | | | | | | | | | | - Marylou Para
- Bichat University Hospital, AP-HP, Paris, France
| | - Fabien Garnier
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | | | - Jean Porterie
- Cardiovascular Surgery department, Toulouse University Hospital, Toulouse, France
| | - Maxime Faure
- Cardiology department, Bordeaux University Hospital, Pessac, France
| | - François Picard
- Cardiology department, Bordeaux University Hospital, Pessac, France
| | - Philippe Gaudard
- Department of anesthesiology and critical care medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERN, CNRS, Montpellier, France
| | - Philippe Rouvière
- Department of cardiac surgery, CHU Montpellier, University of Montpellier, Montpellier, France
| | | | | | - Vlad Gariboldi
- Cardiac Surgery Department, La Timone University Hospital, AP-HM, Marseille, France
| | - Alizée Porto
- Cardiac Surgery Department, La Timone University Hospital, AP-HM, Marseille, France
| | - Erwan Flecher
- Cardiac Surgery Department, Rennes University Hospital, Rennes, France
| | - Clement Delmas
- Cardiology Department, Toulouse University Hospital, Toulouse, France; REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 Guideline Focused Update on Indication and Operation of PCPS/ECMO/IMPELLA. Circ J 2024; 88:1010-1046. [PMID: 38583962 DOI: 10.1253/circj.cj-23-0698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Yasutaka Hirata
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | | | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | | | - Takeshi Kitai
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center
| | - Takayuki Ohno
- Division of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Kazuhiro Satomi
- Department of Cardiovascular Medicine, Tokyo Medical University Hospital
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Koichi Toda
- Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center
| | - Yasumasa Tsukamoto
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Faculty of Medical Sciences, Kyushu University
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | | | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hirotsugu Kurobe
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
| | - Tetsuya Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Shogo Shimada
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Shinya Unai
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Shunei Kyo
- Tokyo Metropolitan Institute for Geriatrics and Gerontology
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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3
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Goldstein JA, Lerakis S, Moreno PR. Right Ventricular Myocardial Infarction-A Tale of Two Ventricles: JACC Focus Seminar 1/5. J Am Coll Cardiol 2024; 83:1779-1798. [PMID: 38692829 DOI: 10.1016/j.jacc.2023.09.839] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 05/03/2024]
Abstract
Right ventricular infarction (RVI) complicates 50% of cases of acute inferior ST-segment elevation myocardial infarction, and is associated with high in-hospital morbidity and mortality. Ischemic right ventricular (RV) systolic dysfunction decreases left ventricular preload delivery, resulting in low-output hypotension with clear lungs, and disproportionate right heart failure. RV systolic performance is generated by left ventricular contractile contributions mediated by the septum. Augmented right atrial contraction optimizes RV performance, whereas very proximal occlusions induce right atrial ischemia exacerbating hemodynamic compromise. RVI is associated with vagal mediated bradyarrhythmias, both during acute occlusion and abruptly with reperfusion. The ischemic dilated RV is also prone to malignant ventricular arrhythmias. Nevertheless, RV is remarkably resistant to infarction. Reperfusion facilitates RV recovery, even after prolonged occlusion and in patients with severe shock. However, in some cases hemodynamic compromise persists, necessitating pharmacological and mechanical circulatory support with dedicated RV assist devices as a "bridge to recovery."
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Affiliation(s)
- James A Goldstein
- Department of Cardiovascular Medicine, Beaumont University Hospital, Corewell Health, Royal Oak, Michigan, USA.
| | - Stamatios Lerakis
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pedro R Moreno
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Kato S, Kurosaka E, Nakata K. Point-of-Care Ultrasound (POCUS)-Guided Management of Cardiogenic Shock in COVID-19 Fulminant Myocarditis With Combined Veno-Arterial Extracorporeal Membrane Oxygenation and Impella (ECPELLA): A Case Report. Cureus 2024; 16:e60665. [PMID: 38774461 PMCID: PMC11107391 DOI: 10.7759/cureus.60665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 05/24/2024] Open
Abstract
The COVID-19 pandemic, which has been raging globally, has been reported to cause not only pneumonia but also various cardiovascular diseases. In particular, myocarditis poses a serious risk if it becomes severe. As a characteristic of myocardial damage in this disease, right ventricular dysfunction is frequently reported, and biventricular failure is not uncommon. In cases where cardiogenic shock occurs, ECPELLA, which combines veno-arterial extracorporeal membrane oxygenation and Impella, is used for management. Currently, in Japan, ECPELLA is the central treatment for severe biventricular failure in the acute phase. However, its management method has not been established. Weaning from ECPELLA requires the following three conditions: (1) improvement of left ventricular function; (2) improvement of right ventricular function; and (3) optimization of circulating plasma volume. However, since these conditions change moment by moment, frequent and detailed assessments are necessary. Nevertheless, considering the need for isolation due to COVID-19, there are limitations on the tests that can be performed. In this regard, point-of-care ultrasound (POCUS) allows repeated bedside evaluations while maintaining infection protection. We report that in the case of severe COVID-19-related myocarditis, the use of POCUS enabled the preservation of cardiac function and appropriate timing for weaning from ECPELLA.
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Affiliation(s)
- Shunichi Kato
- Department of Cardiology, Saitama Red Cross Hospital, Saitama, JPN
- Advanced Emergency and Critical Care Center, Saitama Red Cross Hospital, Saitama, JPN
| | - Eiji Kurosaka
- Department of Cardiology, Saitama Red Cross Hospital, Saitama, JPN
| | - Kentaro Nakata
- Department of Cardiology, Saitama Red Cross Hospital, Saitama, JPN
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5
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Ma JI, Owunna N, Jiang NM, Huo X, Zern E, McNeill JN, Lau ES, Pomerantsev E, Picard MH, Wang D, Ho JE. Sex Differences in Pulmonary Hypertension and Associated Right Ventricular Dysfunction. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.25.24306398. [PMID: 38712108 PMCID: PMC11071572 DOI: 10.1101/2024.04.25.24306398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Prior studies have established the impact of sex differences on pulmonary arterial hypertension (PAH). However, it remains unclear whether these sex differences extend to other hemodynamic subtypes of pulmonary hypertension (PH). Methods We examined sex differences in PH and hemodynamic PH subtypes in a hospital-based cohort of individuals who underwent right heart catheterization between 2005-2016. We utilized multivariable linear regression to assess the association of sex with hemodynamic indices of RV function [PA pulsatility index (PAPi), RV stroke work index (RVSWI), and right atrial: pulmonary capillary wedge pressure ratio (RA:PCWP)]. We then used Cox regression models to examine the association between sex and clinical outcomes among those with PH. Results Among 5208 individuals with PH (mean age 64 years, 39% women), there was no significant sex difference in prevalence of PH overall. However, when stratified by PH subtype, 31% of women vs 22% of men had pre-capillary (P<0.001), 39% vs 51% had post-capillary (P=0.03), and 30% vs 27% had mixed PH (P=0.08). Female sex was associated with better RV function by hemodynamic indices, including higher PAPi and RVSWI, and lower RA:PCWP ratio (P<0.001 for all). Over 7.3 years of follow-up, female sex was associated with a lower risk of heart failure hospitalization (HR 0.83, CI 95% CI 0.74- 0.91, p value <0.001). Conclusions Across a broad hospital-based sample, more women had pre-capillary and more men had post-capillary PH. Compared with men, women with PH had better hemodynamic indices of RV function and a lower risk of HF hospitalization. CLINICAL PERSPECTIVE What Is New? Although sex differences have been explored in pulmonary arterial hypertension, sex differences across pulmonary hypertension (PH) in broader samples inclusive of all hemodynamic subtypes remain less well definedWe delineate sex differences in hemodynamic subtypes of PH and associated right ventricular function in a large, heterogenous, hospital-based sample of individuals who underwent right heart catheterizationSex has a significant impact on prevalence of PH across hemodynamic subtypes as well as associated RV function What Are the Clinical Implications? Understanding sex differences across different PH hemodynamic subtypes is paramount to refining risk stratification between men and womenFurther elucidating sex differences in associated RV function and clinical outcomes may aid in developing sex-specific therapies or management strategies to improve clinical outcomes.
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6
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Akamkam A, Galand V, Jungling M, Delmas C, Dambrin C, Pernot M, Kindo M, Gaudard P, Rouviere P, Senage T, Chavanon O, Para M, Gariboldi V, Pozzi M, Litzler PY, Babatasi G, Bouchot O, Radu C, Bourguignon T, D'Ostrevy N, Abi Akar R, Vanhuyse F, Gaillard M, Chatelier G, Fels A, Flecher E, Guihaire J. Association between pulmonary artery pulsatility and mortality after implantation of left ventricular assist device. ESC Heart Fail 2024. [PMID: 38581135 DOI: 10.1002/ehf2.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024] Open
Abstract
AIMS Right ventricular failure after left ventricular assist device (LVAD) implantation is a major concern that remains challenging to predict. We sought to investigate the relationship between preoperative pulmonary artery pulsatility index (PAPi) and mortality after LVAD implantation. METHODS AND RESULTS A retrospective analysis of the ASSIST-ICD multicentre registry allowed the assessment of PAPi before LVAD according to the formula [(systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/central venous pressure]. The primary endpoint was survival at 3 months, according to the threshold value of PAPi determined by the receiver operating characteristic (ROC) curve. A multivariate analysis including demographic, echographic, haemodynamic, and biological variables was performed to identify predictive factors for 2 year mortality. One hundred seventeen patients were included from 2007 to 2021. The mean age was 58.45 years (±13.16), with 15.4% of women (sex ratio 5.5). A total of 53.4% were implanted as bridge to transplant and 43.1% as destination therapy. Post-operative right ventricular failure was observed in 57 patients (48.7%), with no significant difference between survivors and non-survivors at 1 month (odds ratio 1.59, P = 0.30). The median PAPi for the whole study population was 2.83 [interquartile range 1.63-4.69]. The threshold value of PAPi determined by the ROC curve was 2.84. Patients with PAPi ≥ 2.84 had a higher survival rate at 3 months [PAPi < 2.84: 58.1% [46.3-72.8%] vs. PAPi ≥ 2.84: 89.1% [81.1-97.7%], hazard ratio (HR) 0.08 [0.02-0.28], P < 0.01], with no significant difference after 3 months (HR 0.67 [0.17-2.67], P = 0.57). Other predictors of 2 year mortality were systemic hypertension (HR 4.22 [1.49-11.97], P < 0.01) and diabetes mellitus (HR 4.90 [1.83-13.14], P < 0.01). LVAD implantation as bridge to transplant (HR 0.18 [0.04-0.74], P = 0.02) and heart transplantation (HR 0.02 [0.00-0.18], P < 0.01) were associated with a higher survival rate at 2 years. CONCLUSIONS Preoperative PAPi < 2.84 was associated with a higher risk of early mortality after LVAD implantation without impacting 2 year outcomes among survivors.
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Affiliation(s)
- Ali Akamkam
- Department of Cardiovascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
| | - Vincent Galand
- Department of Cardiology, University of Rennes, CHU Rennes, Rennes, France
| | - Marie Jungling
- Department of Cardiac Surgery, Lille University Hospital, Heart-Lung Institute, Lille, France
| | - Clément Delmas
- Department of Cardiology, University Hospital of Toulouse, Toulouse, France
| | - Camille Dambrin
- Department of Cardiovascular Surgery, University Hospital of Toulouse, Toulouse, France
| | - Mathieu Pernot
- Haut-Lévêque Cardiological Hospital, Bordeaux II University, Bordeaux, France
| | - Michel Kindo
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, PhyMedExp, University of Montpellier, INSERM, CNRS, CHU Montpellier, Montpellier, France
| | - Philippe Rouviere
- Department of Cardiac Surgery, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Thomas Senage
- Department of Cardiology and Heart Transplantation Unit, CHU Nantes, Nantes, France
| | - Olivier Chavanon
- Department of Cardiology and Cardiovascular Surgery, CHU Michallon, Grenoble, France
| | - Marylou Para
- Department of Cardiology and Cardiac Surgery, Bichat-Claude Bernard Hospital, Paris, France
| | - Vlad Gariboldi
- Department of Cardiac Surgery, La Timone Hospital, Marseille, France
| | - Matteo Pozzi
- Department of Cardiac Surgery, 'Louis Pradel' Cardiologic Hospital, Lyon, France
| | - Pierre-Yves Litzler
- Department of Cardiology and Cardiovascular Surgery, Hospital Charles Nicolle, Rouen, France
| | - Gerard Babatasi
- Department of Cardiology and Cardiac Surgery, University of Caen and University Hospital of Caen, Caen, France
| | - Olivier Bouchot
- Department of Cardiology and Cardiac Surgery, University Hospital François Mitterrand, Dijon, France
| | - Costin Radu
- Department of Cardiology and Cardiac Surgery, AP-HP CHU Henri Mondor, Créteil, France
| | | | - Nicolas D'Ostrevy
- Department of Cardiac Surgery and Cardiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ramzi Abi Akar
- Department of Cardiovascular Surgery, European Georges Pompidou Hospital, Paris, France
| | - Fabrice Vanhuyse
- Department of Cardiology and Cardiac Surgery, CHU de Nancy, Hôpitaux de Brabois, Nancy, France
| | - Maïra Gaillard
- Department of Cardiovascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
| | - Gilles Chatelier
- Department of Clinical Research, Hôpital Paris Saint-Joseph, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Audrey Fels
- Department of Clinical Research, Hôpital Paris Saint-Joseph, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, University of Rennes, CHU Rennes, Rennes, France
| | - Julien Guihaire
- Department of Cardiovascular Surgery, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
- School of Medicine, University of Paris Saclay, Le Kremlin-Bicêtre, France
- Inserm U999, Marie Lannelongue Hospital, Le Plessis-Robinson, France
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7
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Natarajan RK, Rodgers N, Narasimhan S, Ambrose M, Rothman A, Shyne M, Evans M, Aggarwal V. Invasive haemodynamics predict outcomes in paediatric pulmonary artery hypertension. Cardiol Young 2024:1-8. [PMID: 38572557 DOI: 10.1017/s1047951124000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
BACKGROUND Invasive haemodynamics are often performed for initiating and guiding pulmonary artery hypertension therapy. Little is known about the predictive value of invasive haemodynamic indices for long-term outcomes in children with pulmonary artery hypertension. We aimed to evaluate invasive haemodynamic data to help predict outcomes in paediatric pulmonary artery hypertension. METHODS Patients with pulmonary artery hypertension who underwent cardiac catheterisation (2006-2019) at a single centre were included. Invasive haemodynamic data from the first cardiac catheterisation and clinical outcomes were reviewed. The combined adverse outcome was defined as pericardial effusion (due to right ventricle failure), creation of a shunt for pulmonary artery hypertension (atrial septal defect or reverse Pott's shunt), lung transplant, or death. RESULTS Among 46 patients with a median [interquartile range (IQR)] age of 13.2 [4.1-44.7] months, 76% had CHD. Median mean pulmonary artery pressure was 37 [28-52] mmHg and indexed pulmonary vascular resistance was 6.2 [3.6-10] Woods units × m2. Median pulmonary artery pulsatility index was 4.0 [3.0-4.7] and right ventricular stroke work index was 915 [715-1734] mmHg mL/m2. After a median follow-up of 2.4 years, nine patients had a combined adverse outcome (two had a pericardial effusion, one underwent atrial level shunt, one underwent reverse Pott's shunt, and six died). Patients with an adverse outcome had higher systolic and mean pulmonary artery pressures, higher diastolic and transpulmonary pressure gradients, higher indexed pulmonary vascular resistance, higher pulmonary artery elastance, and higher right ventricular stroke work index (p < 0.05 each). CONCLUSION Invasive haemodynamics (especially mean pulmonary artery pressure and diastolic pressure gradient) obtained at first cardiac catheterisation in children with pulmonary artery hypertension predicts outcomes.
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Affiliation(s)
| | - Nathan Rodgers
- Division of Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Shanti Narasimhan
- Division of Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Matthew Ambrose
- Division of Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Abraham Rothman
- Children's Heart Center of Nevada, UNLV School of Medicine, Las Vegas, NV, USA
| | - Michael Shyne
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Michael Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Varun Aggarwal
- Division of Pediatric Cardiology, University of Minnesota, Minneapolis, MN, USA
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8
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Senman B, Jentzer JC, Barnett CF, Bartos JA, Berg DD, Chih S, Drakos SG, Dudzinski DM, Elliott A, Gage A, Horowitz JM, Miller PE, Sinha SS, Tehrani BN, Yuriditsky E, Vallabhajosyula S, Katz JN. Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices. J Am Heart Assoc 2024; 13:e031979. [PMID: 38456417 PMCID: PMC11009990 DOI: 10.1161/jaha.123.031979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.
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Affiliation(s)
| | | | - Christopher F. Barnett
- Division of Cardiology, Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jason A. Bartos
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - David D. Berg
- Division of Cardiovascular MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Stavros G. Drakos
- Department of Medicine, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | | | - Andrea Elliott
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - Ann Gage
- Department of Cardiovascular MedicineCentennial Medical CenterNashvilleTNUSA
| | - James M. Horowitz
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of MedicineNew HavenCTUSA
| | - Shashank S. Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Behnam N. Tehrani
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Eugene Yuriditsky
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of MedicineWarren Alpert Medical School of Brown University and Lifespan Cardiovascular InstituteProvidenceRIUSA
| | - Jason N. Katz
- Division of CardiologyNYU Grossman School of Medicine & Bellevue Hospital CenterNew YorkNYUSA
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Javorski MJ, Bauza K, Xiang F, Soltesz E, Chen L, Bakaeen FG, Svensson L, Thuita L, Blackstone EH, Tong MZ. Identifying and mitigating risk of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00191-0. [PMID: 38452888 DOI: 10.1016/j.jtcvs.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
OBJECTIVES To identify preoperative predictors of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy and evaluate trajectory of postoperative ventricular function. METHODS From January 2017 to January 2020, 238 patients with ejection fraction <30% (206/238) or 30% to 34% with at least moderately severe mitral regurgitation (32/238) underwent conventional cardiac surgery at Cleveland Clinic, 125 with ischemic and 113 with nonischemic cardiomyopathy. Preoperative ejection fraction was 25 ± 4.5%. The primary outcome was postcardiotomy cardiogenic shock, defined as need for microaxial temporary left ventricular assist device, extracorporeal membrane oxygenation, or vasoactive-inotropic score >25. RandomForestSRC was used to identify its predictors. RESULTS Postcardiotomy cardiogenic shock occurred in 27% (65/238). Pulmonary artery pulsatility index <3.5 and pulmonary capillary wedge pressure >19 mm Hg were the most important factors predictive of postcardiotomy cardiogenic shock in ischemic cardiomyopathy. Cardiac index <2.2 L·min-1 m-2 and pulmonary capillary wedge pressure >21 mm Hg were the most important predictive factors in nonischemic cardiomyopathy. Operative mortality was 1.7%. Ejection fraction at 12 months after surgery increased to 39% (confidence interval, 35-40%) in the ischemic group and 37% (confidence interval, 35-38%) in the nonischemic cardiomyopathy group. CONCLUSIONS Predictors of postcardiotomy cardiogenic shock were different in ischemic and nonischemic cardiomyopathy. Right heart dysfunction, indicated by low pulmonary artery pulsatility index, was the most important predictor in ischemic cardiomyopathy, whereas greater degree of cardiac decompensation was the most important in nonischemic cardiomyopathy. Therefore, preoperative right heart catheterization will help identify patients with low ejection fraction who are at greater risk of postcardiotomy cardiogenic shock.
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Affiliation(s)
- Michael J Javorski
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Karolis Bauza
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xiang
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Soltesz
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lin Chen
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars Svensson
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio.
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10
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Lamberti KK, Keller SP, Edelman ER. Dynamic load modulation predicts right heart tolerance of left ventricular cardiovascular assist in a porcine model of cardiogenic shock. Sci Transl Med 2024; 16:eadk4266. [PMID: 38354226 DOI: 10.1126/scitranslmed.adk4266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024]
Abstract
Ventricular assist devices (VADs) offer mechanical support for patients with cardiogenic shock by unloading the impaired ventricle and increasing cardiac outflow and subsequent tissue perfusion. Their ability to adjust ventricular assistance allows for rapid and safe dynamic changes in cardiac load, which can be used with direct measures of chamber pressures to quantify cardiac pathophysiologic state, predict response to interventions, and unmask vulnerabilities such as limitations of left-sided support efficacy due to intolerance of the right heart. We defined hemodynamic metrics in five pigs with dynamic peripheral transvalvular VAD (pVAD) support to the left ventricle. Metrics were obtained across a spectrum of disease states, including left ventricular ischemia induced by titrated microembolization of a coronary artery and right ventricular strain induced by titrated microembolization of the pulmonary arteries. A sweep of different pVAD speeds confirmed mechanisms of right heart decompensation after left-sided support and revealed intolerance. In contrast to the systemic circulation, pulmonary vascular compliance dominated in the right heart and defined the ability of the right heart to adapt to left-sided pVAD unloading. We developed a clinically accessible metric to measure pulmonary vascular compliance at different pVAD speeds that could predict right heart efficiency and tolerance to left-sided pVAD support. Findings in swine were validated with retrospective hemodynamic data from eight patients on pVAD support. This methodology and metric could be used to track right heart tolerance, predict decompensation before right heart failure, and guide titration of device speed and the need for biventricular support.
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Affiliation(s)
- Kimberly K Lamberti
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Steven P Keller
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MA 21205, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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11
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Wei J, Kee A, Dukes R, Franke J, Leonardo V, Flynn BC. The Association of the Pulmonary Artery Pulsatility Index and Right Ventricular Function after Cardiac Surgery. Crit Care Res Pract 2024; 2024:5408008. [PMID: 38379715 PMCID: PMC10878756 DOI: 10.1155/2024/5408008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/19/2023] [Accepted: 01/27/2024] [Indexed: 02/22/2024] Open
Abstract
Background The pulmonary artery pulsatility index (PAPi) has been shown to correlate with right ventricular (RV) failure in patients with cardiac disease. However, the association of PAPi with right ventricular function following cardiac surgery is not yet established. Methods PAPi and other hemodynamic variables were obtained postoperatively for 959 adult patients undergoing cardiac surgery. The association of post-bypass right ventricular function and other clinical factors to PAPi was evaluated using linear regression. A propensity-score matched cohort for PAPi ≥ 2.00 was used to assess the association of PAPi with postoperative outcomes. Results 156 patients (16.3%) had post-bypass right ventricular dysfunction defined by visualization on transesophageal echocardiography. There was no difference in postoperative PAPi based on right ventricular function (2.12 vs. 2.00, p=0.21). In our matched cohort (n = 636), PAPi < 2.00 was associated with increased incidence of acute kidney injury (23.0% vs 13.2%, p < 0.01) and ventilator time (6.0 hours vs 5.6 hours, p=0.04) but not with 30-day mortality or intensive care unit length of stay. Conclusion In a general cohort of patients undergoing cardiac surgery, postoperative PAPi was not associated with postcardiopulmonary bypass right ventricular dysfunction. A postoperative PAPi < 2 may be associated with acute kidney injury.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brigid C. Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA
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12
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Yuriditsky E, Chonde M, Friedman O, Horowitz JM. Medical and Mechanical Circulatory Support of the Failing Right Ventricle. Curr Cardiol Rep 2024; 26:23-34. [PMID: 38108956 DOI: 10.1007/s11886-023-02012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW To describe medical therapies and mechanical circulatory support devices used in the treatment of acute right ventricular failure. RECENT FINDINGS Experts have proposed several algorithms providing a stepwise approach to medical optimization of acute right ventricular failure including tailored volume administration, ideal vasopressor selection to support coronary perfusion, inotropes to restore contractility, and pulmonary vasodilators to improve afterload. Studies have investigated various percutaneous and surgically implanted right ventricular assist devices in several clinical settings. The initial management of acute right ventricular failure is often guided by invasive hemodynamic data tracking parameters of circulatory function with the use of pharmacologic therapies. Percutaneous microaxial and centrifugal extracorporeal pumps bypass the failing RV and support circulatory function in severe cases of right ventricular failure.
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Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Langone Health, 530 First Ave. Skirball 9R, New York, NY, 10016, USA.
| | - Meshe Chonde
- Department of Cardiology, Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | - Oren Friedman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James M Horowitz
- Division of Cardiology, Department of Medicine, NYU Langone Health, 530 First Ave. Skirball 9R, New York, NY, 10016, USA
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13
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Manzi L, Sperandeo L, Forzano I, Castiello DS, Florimonte D, Paolillo R, Santoro C, Mancusi C, Di Serafino L, Esposito G, Gargiulo G. Contemporary Evidence and Practice on Right Heart Catheterization in Patients with Acute or Chronic Heart Failure. Diagnostics (Basel) 2024; 14:136. [PMID: 38248013 PMCID: PMC10814482 DOI: 10.3390/diagnostics14020136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Heart failure (HF) has a global prevalence of 1-2%, and the incidence around the world is growing. The prevalence increases with age, from around 1% for those aged <55 years to >10% for those aged 70 years or over. Based on studies in hospitalized patients, about 50% of patients have heart failure with reduced ejection fraction (HFrEF), and 50% have heart failure with preserved ejection fraction (HFpEF). HF is associated with high morbidity and mortality, and HF-related hospitalizations are common, costly, and impact both quality of life and prognosis. More than 5-10% of patients deteriorate into advanced HF (AdHF) with worse outcomes, up to cardiogenic shock (CS) condition. Right heart catheterization (RHC) is essential to assess hemodynamics in the diagnosis and care of patients with HF. The aim of this article is to review the evidence on RHC in various clinical scenarios of patients with HF.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy; (L.M.); (L.S.); (I.F.); (D.S.C.); (D.F.); (R.P.); (C.S.); (C.M.); (L.D.S.); (G.E.)
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14
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Sundaram AK, Gobeil K, Pundlik S, Capatina A, Scarnici A, Natarajan PP, Kashef MA, Haider A, Daoulah A, St Marie P, Lotfi A. Right to Left Cardiac Power Output- New Prognosticator in STEMI Patients With Cardiogenic Shock (R-Shock). Curr Probl Cardiol 2024; 49:102089. [PMID: 37774898 DOI: 10.1016/j.cpcardiol.2023.102089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
ST elevation myocardial infarction (STEMI) is a leading cause of cardiogenic shock (CS) and carries substantial mortality. Cardiac power output (CPO) is the strongest predictor of clinical outcome in CS, and worse outcomes result from concomitant right and left ventricular failure. Right ventricular performance is calculated using right sided CPO. Our aim was to measure the right sided CPO and compute their ratio to predict in-hospital mortality in STEMI patients with cardiogenic shock. This was a retrospective observational study of consecutive STEMI patients with CS that developed within the first 24hours of admission requiring left and right cardiac catheterization at a large tertiary care center from January 2014-December 2018. One hundred sixty-four patients identified with STEMI; 46% (75) excluded due to incomplete data. 88 remaining patients, 52.8% (47) developed CS. 98.9% within 24 hours. Mean left & right CPO 0.62 (SD 0.3) and 0.22 (SD 0.13), PAPi score 1.81. Logistic regression analysis indicated odds ratio of in-hospital mortality lower for low left CPO, high right CPO and low ratio of left to right CPO (95% CI; 0.69, 0.34, 1.20; 1.38, 0.87, 2.20; 0.52, 0.28, 1.00 respectively). This is the first study to assess right sided CPO and ratio of right and left side CPO and mortality. Our study indicates that there is trend towards higher in-hospital mortality in patients with high right sided CPO and lower ratio of left to right CPO. The exploratory results of this study need to be confirmed in a larger population.
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Affiliation(s)
| | - Kyle Gobeil
- Yale University School of Medicine, New Haven, CT
| | | | | | | | | | | | - Ali Haider
- New York-Presbyterian Medical Group of Queens, NY
| | - Amin Daoulah
- Department of Cardiovascular Medicine, King Faisal Specialist Hospital & Research Center, Jeddah, Saudi Arabia
| | | | - Amir Lotfi
- Baystate Medical Center, UMASS-Chan Medical School.
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15
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Wei J, Franke J, Kee A, Dukes R, Leonardo V, Flynn BC. Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2024; 38:214-220. [PMID: 37973507 DOI: 10.1053/j.jvca.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. DESIGN Single-center retrospective observational cohort study. SETTING The University of Kansas Medical Center, a tertiary-care academic medical center. PARTICIPANTS Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. INTERVENTIONS All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. MEASUREMENTS AND MAIN RESULTS Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. CONCLUSIONS The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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16
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Nakata J, Yamamoto T, Saku K, Ikeda Y, Unoki T, Asai K. Mechanical circulatory support in cardiogenic shock. J Intensive Care 2023; 11:64. [PMID: 38115065 PMCID: PMC10731894 DOI: 10.1186/s40560-023-00710-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023] Open
Abstract
Cardiogenic shock is a complex and diverse pathological condition characterized by reduced myocardial contractility. The goal of treatment of cardiogenic shock is to improve abnormal hemodynamics and maintain adequate tissue perfusion in organs. If hypotension and insufficient tissue perfusion persist despite initial therapy, temporary mechanical circulatory support (t-MCS) should be initiated. This decade sees the beginning of a new era of cardiogenic shock management using t-MCS through the accumulated experience with use of intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO), as well as new revolutionary devices or systems such as transvalvular axial flow pump (Impella) and a combination of VA-ECMO and Impella (ECPELLA) based on the knowledge of circulatory physiology. In this transitional period, we outline the approach to the management of cardiogenic shock by t-MCS. The management strategy involves carefully selecting one or a combination of the t-MCS devices, taking into account the characteristics of each device and the specific pathological condition. This selection is guided by monitoring of hemodynamics, classification of shock stage, risk stratification, and coordinated management by the multidisciplinary shock team.
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Affiliation(s)
- Jun Nakata
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan.
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research, Suita, Osaka, Japan
| | - Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University, School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takashi Unoki
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kuniya Asai
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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17
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Basir MB, Lemor A, Gorgis S, Patel KC, Kolski BC, Bharadwaj AS, Todd JW, Tehrani BN, Truesdell AG, Lasorda DM, Lalonde TA, Kaki A, Schrieber TL, Patel NC, Senter SR, Gelormini JL, Marso SP, Rahman AM, Federici RE, Wilkins CE, Thomas McRae A, Nsair A, Caputo CP, Khuddus MA, Chahin JJ, Dupont AG, Goldsweig AM, Lim MJ, Kapur NK, Wohns DHW, Zhou Y, Hacala MJ, O'Neill WW. Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative. J Am Heart Assoc 2023; 12:e031401. [PMID: 38014676 PMCID: PMC10727311 DOI: 10.1161/jaha.123.031401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Amir Kaki
- Ascension St. John HospitalDetroitMI
| | | | | | | | | | | | | | | | | | | | - Ali Nsair
- Ronald Reagan UCLA Medical CenterLos AngelesCA
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18
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Grinstein J, Houston BA, Nguyen AB, Smith BA, Chinco A, Pinney SP, Tedford RJ, Belkin MN. Standardization of the Right Heart Catheterization and the Emerging Role of Advanced Hemodynamics in Heart Failure. J Card Fail 2023; 29:1543-1555. [PMID: 37633442 DOI: 10.1016/j.cardfail.2023.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
The accurate assessment of hemodynamics is paramount to providing timely and efficacious care for patients presenting in cardiogenic shock. Recently, the regular use of the pulmonary artery catheter in cardiogenic shock has had a resurgence with emerging data indicating improved survival in the modern era. Optimal multidisciplinary management of advanced heart failure and cardiogenic shock relies on our ability to effectively communicate and understand the complete hemodynamic assessment. Standardization of data acquisition and a renewed focus on the physiological processes, and thresholds driving disease progression, including the coupling ratio and myocardial reserve, are needed to fully understand and interpret the hemodynamic assessment. This State-of-the-Art review discusses best practices in the cardiac catheterization laboratory as well as emerging data on the prognostic role of emerging advanced hemodynamic parameters.
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Affiliation(s)
- Jonathan Grinstein
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois.
| | - Brian A Houston
- Medical University of South Carolina, Department of Medicine, Section of Heart Failure, Charleston, South Carolina
| | - Ann B Nguyen
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
| | - Bryan A Smith
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
| | - Annalyse Chinco
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Sean P Pinney
- Mount Sinai Hospital, Department of Medicine, Section of Cardiology, New York, New York
| | - Ryan J Tedford
- Medical University of South Carolina, Department of Medicine, Section of Heart Failure, Charleston, South Carolina
| | - Mark N Belkin
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
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19
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Fnu A. Comment On: The Association of Multidimensional Sleep Health With Adiposity in Heart Failure With Preserved Ejection Fraction. Curr Probl Cardiol 2023; 48:101898. [PMID: 37392976 DOI: 10.1016/j.cpcardiol.2023.101898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Aparna Fnu
- Department of Medicine, Ghulam Muhammad Mahar Medical College, Sukkur, Sindh, Pakistan.
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20
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Aparna F. Comment on: Excess of Heart Failure-Related Deaths During the 2020 COVID-19 Pandemic in the United States. Curr Probl Cardiol 2023; 48:101906. [PMID: 37399860 DOI: 10.1016/j.cpcardiol.2023.101906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Affiliation(s)
- Fnu Aparna
- Department of Meidicine, Ghulam Muhammad Mahar Medical College, Sukkur, Pakistan.
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21
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Punshi VK, Punshi AK. Comment on: Time from Admission to Right Heart Catheterization in Cardiogenic Shock Patients. Curr Probl Cardiol 2023; 48:101899. [PMID: 37394205 DOI: 10.1016/j.cpcardiol.2023.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 07/04/2023]
Abstract
The study article "Time from Admission to Right Heart Catheterization in Cardiogenic Shock Patients" was recently published in your prestigious Journal. We are writing to offer a constructive review of the article. Even while we value the authors' attempts to shed light on this vital topic, a few issues deserve more attention.
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22
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Owyang CG, Rippon B, Teran F, Brodie D, Araos J, Burkhoff D, Kim J, Tonna JE. Pulmonary Artery Pressures and Mortality during VA ECMO: An ELSO Registry Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.08.23293859. [PMID: 37645725 PMCID: PMC10462237 DOI: 10.1101/2023.08.08.23293859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (VA ECMO). While these factors are intertwined with right ventricular (RV) function, the independent relationship between RV function and survival during VA ECMO is unknown. Objectives To identify the relationship between RV function with mortality and duration of ECMO support. Methods Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization (ELSO) Registry between 2010 and 2022 were queried. RV function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for Society for Cardiovascular Angiography and Interventions (SCAI) stage, age, gender, and concurrent clinical data (i.e., pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality. Results A total of 4,442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; non-survivors were more likely to be older, have a worse SCAI stage, and have longer pre-ECMO endotracheal intubation times (P < 0.05 for all) than survivors. Improving PAPP from pre-ECMO to on-ECMO time (Δ PAPP) was associated with reduced mortality per 10 mm Hg increase (OR: 0.91 [95% CI: 0.86-0.96]; P=0.002). Increasing on-ECMO PAPP was associated with longer time on ECMO per 10 mm Hg (Beta: 15 [95% CI: 7.7-21]; P<0.001). Conclusions Early improvements in RV function from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of Δ PAPP into risk prediction models should be considered.
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Affiliation(s)
- Clark G. Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Brady Rippon
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Felipe Teran
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | | | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY, 10021, USA
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA
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Abdel Jawad M, Abu Kar A, Saad A, Elkharbotly A, Fanari Z. Impella RP Use in Refractory Cardiogenic Shock in a Patient Presenting With Acute Right Coronary Artery Occlusion: A Case Report. Cureus 2023; 15:e43072. [PMID: 37680397 PMCID: PMC10481990 DOI: 10.7759/cureus.43072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/09/2023] Open
Abstract
It is common for patients with inferior myocardial infarction to experience right ventricular infarction, occurring in half of the patients with inferior myocardial infarction. Right ventricular failure due to acute right myocardial infarction is often associated with a worse prognosis. In this case, we report a patient with acute chest pain due to acute right coronary artery occlusion status post placement of multiple stents in the right coronary artery. Unfortunately, he developed refractory cardiogenic shock requiring biventricular assist device placement.
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Affiliation(s)
| | - Abdullah Abu Kar
- Hospital Medicine, University of California San Francisco, San Francisco, USA
| | - Andre Saad
- Cardiology, Ascension Via Christi St. Francis, Wichita, USA
| | | | - Zaher Fanari
- Cardiology, University of California San Francisco, Fresno, USA
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Ostad S, Sugarman J, Alkhodair A, Liang J, Mielniczuk LM, Hambly N, Helmersen D, Hirani N, Thakrar M, Varughese R, Norena M, Kularatne M, Swiston JR, Kapasi A, Weatherald J, Brunner NW. Association Between the Pulmonary Artery Pulsatility Index and Prognosis in Pulmonary Arterial Hypertension: A Multicentre Study. CJC Open 2023; 5:545-553. [PMID: 37496788 PMCID: PMC10366663 DOI: 10.1016/j.cjco.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/19/2023] [Indexed: 07/28/2023] Open
Abstract
Background Risk stratification is fundamental in the management of pulmonary arterial hypertension (PAH). Pulmonary artery pulsatility index (PAPi), defined as pulmonary arterial pulse pressure divided by right atrial pressure (RAP), is a hemodynamic index shown to predict acute right ventricular (RV) dysfunction in several settings. Our objective was to test the prognostic utility of PAPi in a diverse multicentre cohort of patients with PAH. Methods A multicentre retrospective cohort study of consecutive adult patients with a new diagnosis of PAH on right heart catheterization between January 2016 and December 2020 was undertaken across 4 major centres in Canada. Hemodynamic data, clinical data, and outcomes were collected. The association of PAPi and other hemodynamic variables with mortality was assessed by receiver-operating characteristic curves and Cox proportional hazards modeling. Results We identified 590 patients with a mean age of 61.4 ± 15.5 years, with 66.3% being female. A low PAPi (defined as < 5.3) was associated with higher mortality at 1 year: 10.2% vs 5.2% (P = 0.02). In a multivariable model including age, sex, body mass index, and functional class, a low PAPi was associated with mortality at 1 year (area under the curveof 0.64 (95% confidence interval 0.55-0.74). However, high RAP (> 8 mm Hg) was similarly predictive of mortality, with an area under the curve of 0.65. Conclusion PAPi was associated with mortality in a large incident PAH cohort. However, the discriminative value of PAPi was not higher than that of RAP alone.
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Affiliation(s)
- Sam Ostad
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Sugarman
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Respirology, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Alkhodair
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jiaming Liang
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa M. Mielniczuk
- Department of Medicine, Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Nathan Hambly
- Department of Medicine, Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - Doug Helmersen
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Naushad Hirani
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mitesh Thakrar
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Monica Norena
- Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Mithum Kularatne
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John R. Swiston
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ali Kapasi
- Department of Medicine, Division of Respirology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Weatherald
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nathan W. Brunner
- Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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Eftychiou S, Kalakoutas A, Proudfoot A. The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review. JOURNAL OF INTENSIVE MEDICINE 2023; 3:89-103. [PMID: 37188124 PMCID: PMC10175707 DOI: 10.1016/j.jointm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 05/17/2023]
Abstract
Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.
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Affiliation(s)
| | - Antonis Kalakoutas
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford RM7 0AG, UK
- Barts and the London School of Medicine and Dentistry, London E1 2AD, UK
| | - Alastair Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
- Queen Mary University of London, London EC1M 6BQ, UK
- Department of Anaesthesiology and Intensive Care, German Heart Centre Berlin, Berlin 13353, Germany
- Corresponding author: Alastair Proudfoot, Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London EC1A 7BE, UK
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26
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Bart N, Hungerford S, Emmanuel S, Kotlyar E, Keogh A, MacDonald P, Muller D, Hayward C. Pre‐operative pulmonary artery pulsatility index does not predict mortality post‐cardiac transplantation. ESC Heart Fail 2023; 10:1980-1986. [PMID: 37002648 DOI: 10.1002/ehf2.14226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/11/2022] [Accepted: 10/28/2022] [Indexed: 04/04/2023] Open
Abstract
AIMS The pulmonary artery pulsatility index (PAPi) is a novel haemodynamic marker that has previously been shown to predict right ventricular dysfunction and mortality in patients with pulmonary hypertension and advanced heart failure. Utility of the PAPi in predicting outcomes post-cardiac transplantation is unknown. The aim of this study was to compare the prognostic significance of PAPi against pulmonary vascular resistance (PVR) for the predication of morbidity and all-cause mortality post-transplantation. METHODS AND RESULTS All patients who underwent cardiac transplantation over a 6 year period were studied. Pre-operative right heart catheter data was obtained. The PAPi was calculated as follows: (systolic pulmonary artery pressure [sPAP] - diastolic pulmonary artery pressure [dPAP])/right atrial (RA) pressure. One hundred fifty-eight patients with a mean age of 49 ± 14 years were studied (43 with a pre-transplant left ventricular assist device [LVAD]). Three patients were excluded due to missing data. In the non-LVAD group, there was no significant difference in PAPi or PVR, nor was there any association with post-operative outcome (including stratification by natural history sub-type; all P > 0.05). In the LVAD group, there was no association with PAPi and post-operative outcome; however, PVR was predictive of post-operative mortality (mortality: 2.8 ± 1.3 WU vs. alive: 1.7 ± 0.7 WU; P = 0.005). CONCLUSIONS The PAPi was not able to discriminate mortality outcomes for patients post-cardiac transplantation. Pulmonary vascular resistance remains a marker of mortality in an LVAD cohort bridged to transplant (central illustration).
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Affiliation(s)
- Nicole Bart
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute Sydney New South Wales Australia
| | - Sara Hungerford
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Department of Cardiology Royal North Shore Hospital Sydney New South Wales Australia
| | - Sam Emmanuel
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute Sydney New South Wales Australia
| | - Eugene Kotlyar
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute Sydney New South Wales Australia
| | - Anne Keogh
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute Sydney New South Wales Australia
| | - Peter MacDonald
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute Sydney New South Wales Australia
| | - David Muller
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute Sydney New South Wales Australia
| | - Christopher Hayward
- Department of Cardiology St Vincent's Hospital Sydney New South Wales Australia
- St Vincent's Clinical School, Faculty of Medicine University of New South Wales Sydney New South Wales Australia
- Victor Chang Cardiac Research Institute Sydney New South Wales Australia
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Magder S, Slobod D, Assanangkornchai N. Right Ventricular Limitation: A Tale of Two Elastances. Am J Respir Crit Care Med 2023; 207:678-692. [PMID: 36257049 DOI: 10.1164/rccm.202106-1564so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular (RV) dysfunction is a commonly considered cause of low cardiac output in critically ill patients. Its management can be difficult and requires an understanding of how the RV limits cardiac output. We explain that RV stroke output is caught between the passive elastance of the RV walls during diastolic filling and the active elastance produced by the RV in systole. These two elastances limit RV filling and stroke volume and consequently limit left ventricular stroke volume. We emphasize the use of the term "RV limitation" and argue that limitation of RV filling is the primary pathophysiological process by which the RV causes hemodynamic instability. Importantly, RV limitation can be present even when RV function is normal. We use the term "RV dysfunction" to indicate that RV end-systolic elastance is depressed or diastolic elastance is increased. When RV dysfunction is present, RV limitation occurs at lowerpulmonary valve opening pressures and lower stroke volume, but stroke volume and cardiac output still can be maintained until RV filling is limited. We use the term "RV failure" to indicate the condition in which RV output is insufficient for tissue needs. We discuss the physiological underpinnings of these terms and implications for clinical management.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Douglas Slobod
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
| | - Nawaporn Assanangkornchai
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada; and
- Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand
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Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices. Curr Cardiol Rep 2023; 25:213-227. [PMID: 36847990 DOI: 10.1007/s11886-023-01843-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a complex clinical entity that continues to carry a high risk of mortality. The landscape of CS management has changed with the advent of several temporary mechanical circulatory support (MCS) devices designed to provide hemodynamic support. It remains challenging to understand the role of different temporary MCS devices in patients with CS, as many of these patients are critically ill, requiring complex care with multiple MCS device options. Each temporary MCS device can provide different types and levels of hemodynamic support. It is important to understand the risk/benefit profile of each one of them for appropriate device selection in patients with CS. RECENT FINDINGS MCS may be beneficial in CS patients through augmentation of cardiac output with subsequent improvement of systemic perfusion. Selecting the optimal MCS device depends on several variables including the underlying etiology of CS, clinical strategy of MCS use (bridge to recovery, bridge to transplant or durable MCS, or abridge to decision), amount of hemodynamic support needed, associated respiratory failure, and institutional preference. Furthermore, it is even more challenging to determine the appropriate time to escalate from one MCS device to another or combine different MCS devices. In this review, we discuss the current available data published in the literature on the management of CS and propose a standardized approach for escalation of MCS devices in patients with CS. Shock teams can play an important role to help in hemodynamic-guided management and algorithm-based step-by-step approach in early initiation and escalation of temporary MCS devices at different stages of CS. It is important to define the etiology of CS, and stage of shock and recognize univentricular vs biventricular shock for appropriate device selection and escalation of therapy.
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Schmack L, Schmack B, Papathanasiou M, Al-Rashid F, Weymann A, Pizanis N, Kamler M, Ruhparwar A, Rassaf T, Luedike P. Central extracorporeal circulatory life support (cECLS) in selected patients with critical cardiogenic shock. Front Cardiovasc Med 2023; 10:1142953. [PMID: 37139128 PMCID: PMC10150085 DOI: 10.3389/fcvm.2023.1142953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/28/2023] [Indexed: 05/05/2023] Open
Abstract
Background Percutaneous extracorporeal life support (pECLS) is increasingly applied in cardiogenic shock (CS) despite a lack of evidence from randomized trials. The in-hospital mortality rate of pECLS still reaches up to 60%, while vascular access site complications remain a shortcoming. Surgical approaches with central cannulation for ECLS (cELCS) have emerged as a bail-out option. To date, no systematic approach exists that allows a definition of inclusion or exclusion criteria for cECLS. Methods and results This single-center, retrospective, case-control study includes all patients fulfilling criteria for CS at the West German Heart and Vascular Center Essen/Germany between 2015 and 2020 who underwent cECLS (n = 58), excluding post-cardiotomy patients. Seventeen patients received cECLS (29.3%) as a first-line treatment strategy and 41 patients as a second-line strategy (70.7%). The main complications leading to the use of cECLS as a second-line strategy were limb ischemia (32.8%) and ongoing insufficient hemodynamic support (27.6%). The first-line cECLS cohort showed a 30-day mortality rate of 53.3% that was constant during follow-up. The 30-day mortality rate of secondary cECLS candidates was 69.8% and the rate at 3 and 6 months was 79.1%. Younger patients (<55 years) were more likely to exhibit survival benefit with cECLS (p = 0.043). Conclusion Surgical cECLS in CS is a feasible therapy for highly selected patients with hemodynamic instability, vascular complications, or peripheral access site limitations as complementary strategy in experienced centers.
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Affiliation(s)
- Leonie Schmack
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Maria Papathanasiou
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nikolaus Pizanis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
- Correspondence: Peter Luedike
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Isseh IN, Gorgis S, Dagher C, Sharma S, Basir MB, Parikh S. Effects of Escalating Temporary Mechanical Circulatory Support in Patients With Worsening Cardiogenic Shock. Tex Heart Inst J 2022; 49:489428. [PMID: 36538600 PMCID: PMC9809073 DOI: 10.14503/thij-21-7615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cardiogenic shock-related mortality is substantial, and temporary mechanical circulatory support (MCS) devices are frequently used. The authors aimed to describe patient characteristics and outcomes in patients with worsening cardiogenic shock requiring escalation of temporary MCS devices. METHODS Worsening cardiogenic shock was defined as persistent hypotension, increasing doses of vasopressors/inotropes, worsening hypoperfusion, or worsening invasive hemo-dynamics. Escalation of temporary MCS devices was defined as adding or exchanging an existing MCS device. Variables were evaluated by logistic regression models and receiver operating characteristic curves. RESULTS From July 1, 2016, to July 1, 2018, a total of 81 consecutive patients experienced worsening cardiogenic shock requiring temporary MCS escalation. The etiology of cardiogenic shock was heterogeneous (33.3% acute myocardial infarction and 61.7% decompen-sated heart failure). Younger age (<62 years), lower body mass index (<28.7 kg/m2), lower preescalation lactate levels (<3.1 mmol/L), higher postescalation blood pressure (>85 mm Hg), and lower postescalation lactate levels (<2.9 mmol/L) were associated with greater odds of survival. The presence of a pulmonary artery catheter at the time of escalation was associated with greater odds of survival (P = .05). Escalation of temporary MCS in Society for Cardiovascular Angiography and Interventions stage E shock was associated with 100% mortality (P = .05). The rate of overall survival to discharge was 32%. CONCLUSION Patients requiring temporary MCS escalation represent a high-risk cohort. Further work is needed to improve outcomes in this patient population.
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Affiliation(s)
- Iyad N. Isseh
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Sarah Gorgis
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Carina Dagher
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Shivani Sharma
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Mir B. Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Sachin Parikh
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
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Wei J, Houchin A, Nazir N, Leonardo V, Flynn BC. Comparing the associations of central venous pressure and pulmonary artery pulsatility index with postoperative renal injury. Front Cardiovasc Med 2022; 9:967596. [PMID: 36312290 PMCID: PMC9596935 DOI: 10.3389/fcvm.2022.967596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Cardiac surgery-associated acute kidney injury (CS-AKI) is associated with significant morbidity and mortality. We investigated the association of postoperative central venous pressure (CVP) and pulmonary artery pulsatility index (PAPi) with the development of CS-AKI. Methods This was a single-center, retrospective cohort study of patients undergoing cardiac surgery. CVP and PAPi were acquired hourly postoperatively and averaged for up to 48 h. PAPi was calculated as [(Pulmonary Artery Systolic Pressure–Pulmonary Artery Diastolic Pressure) / CVP]. The primary aim was CS-AKI. Secondary aims were need for renal replacement therapy (RRT), hospital and 30-day mortality, total ventilator and intensive care unit hours, and hospital length of stay. Logistic regression was used to calculate odds of development of renal injury and need for RRT. Results One thousand two hundred eighty-eight patients were included. The average postoperative CVP was 10.3 mmHg and average postoperative PAPi was 2.01. Patients who developed CS-AKI (n = 384) had lower PAPi (1.79 vs. 2.11, p < 0.01) and higher CVP (11.5 vs. 9.7 mmHg, p < 0.01) than those who did not. Lower PAPi and higher CVP were also associated with each secondary aim. A standardized unit decrease in PAPi was associated with increased odds of CS-AKI (OR 1.39, p < 0.01) while each unit increase in CVP was associated with both increased odds of CS-AKI (OR 1.56, p < 0.01) and postoperative RRT (OR 1.49, p = 0.02). Conclusions Both lower PAPi and higher CVP values postoperatively were associated with the development of CS-AKI but only higher CVP was associated with postoperative RRT use. When differences in values are standardized, CVP may be more associated with development of CS-AKI when compared to PAPi.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, United States,*Correspondence: Johnny Wei
| | - Abigail Houchin
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Niaman Nazir
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, United States
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Brigid C. Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS, United States
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Geller BJ, Sinha SS, Kapur NK, Bakitas M, Balsam LB, Chikwe J, Klein DG, Kochar A, Masri SC, Sims DB, Wong GC, Katz JN, van Diepen S. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e50-e68. [PMID: 35862152 DOI: 10.1161/cir.0000000000001076] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.
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Zhu S, Zhang Y, Qiao W, Wang Y, Xie Y, Zhang X, Wu C, Wang G, Li Y, Dong N, Xie M, Zhang L. Incremental value of preoperative right ventricular function in predicting moderate to severe acute kidney injury after heart transplantation. Front Cardiovasc Med 2022; 9:931517. [PMID: 36017097 PMCID: PMC9398196 DOI: 10.3389/fcvm.2022.931517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background Acute kidney injury (AKI) commonly occurs after heart transplantation (HTx), but its association with preoperative right ventricular (RV) function remains unknown. Consequently, we aimed to determine the predictive value of preoperative RV function for moderate to severe AKI after HTx. Materials and methods From 1 January 2016 to 31 December 2019, all the consecutive HTx recipients in our center were enrolled and analyzed for the occurrence of postoperative AKI staged by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Conventional RV function parameters, including RV fractional area change (RVFAC) and tricuspid annular plane systolic excursion (TAPSE), were obtained. The primary endpoint was moderate to severe AKI (the KDIGO stage 2 or 3). The secondary endpoints included the impact of AKI on intensive care unit (ICU) mortality, in-hospital mortality, and 1-year mortality. Results A total of 273 HTx recipients were included in the study. Postoperative AKI occurred in 209 (77%) patients, including 122 (45%) patients in stage 1 AKI, 49 (18%) patients in stage 2 AKI, and 38 (14%) patients in stage 3 AKI. Patients with higher AKI stage had lower baseline estimated glomerular filtration rate (eGFR), more frequent diabetes, higher right atrial pressure (RAP), longer cardiopulmonary bypass (CPB) duration, more perioperative red blood cell (RBC) transfusions, and worse preoperative RV function. A multivariate logistic regression model incorporating previous diabetes mellitus [odds ratio (OR): 2.21; 95% CI: 1.06–4.61; P = 0.035], baseline eGFR (OR: 0.99; 95% CI: 0.97–0.10; P = 0.037), RAP (OR: 1.05; 95% CI: 1.00–1.10; P = 0.041), perioperative RBC (OR: 1.18; 95% CI: 1.08–1.28; P < 0.001), and TAPSE (OR: 0.84; 95% CI: 0.79–0.91; P < 0.001) was established to diagnose moderate to severe AKI more accurately [the area under the curve (AUC) = 79.8%; Akaike information criterion: 274]. Conclusion Preoperative RV function parameters provide additional predicting value over clinical and hemodynamic parameters, which are imperative for risk stratification in patients with HTx at higher risk of AKI.
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Affiliation(s)
- Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yanting Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Weihua Qiao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yixuan Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuji Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xin Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Guohua Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Nianguo Dong,
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Mingxing Xie,
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Li Zhang,
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Orozco-Hernandez EJ, Kurt DeLay T, Hoopes CW, Gongora E, Pamboukian S, Xie R, Davies JE, Vardas PN. Preoperative hemodynamics as predictors of right heart failure post-left ventricular assist device. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00083-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Mechanical circulatory support has garnered significant popularity as both a bridge to transplant as well as a destination therapy for patients with end-stage heart failure. Right heart failure (RHF) is a devastating complication after LVAD placement and is very unpredictable. Assisted circulation of the left ventricle (LV) with an LVAD device could unmask an underlying RHF. However, otherwise healthy right ventricles (RVs) can develop RHF after LVAD placement as well due to poor adaptation to new filling pressures and altered hemodynamics. It has been proposed that preoperative volumetric measurements in the pulmonary and systemic vasculature may serve as indicators for a risk of RHF after LVAD implantation. The aim of this study is to examine a potential relationship of preoperative hemodynamic values such as pulmonary artery pulsatility index (PAPi) and the ratio of central venous pressure to pulmonary wedge pressure (CVP/PWP) as preoperative predictors for RHF post LVAD placement.
Methods
We retrospectively reviewed patients undergoing initially planned isolated LVAD implantation with or without concomitant procedures in our institution from January 1, 2017 to June 12, 2020. Data were gathered from hemodynamic records, echocardiographic interpretations, and clinical notes. Patients who had RHF after LVAD implantation but without hemodynamic data available within 14 days from the operation were excluded. Univariable analysis was performed.
Results
Of the 114 patients who received planned isolated LVAD surgery, 70 (61.4%) experienced RHF within the first 7 days postoperatively. PAPi did not correlate significantly with RHF vs non-RHF among LVAD recipients (3.1 ± 2.1 vs. 3.8 ± 3.4 P = 0.21). Pre-op CVP/PWP did not differ significantly between RHF and non-RHF patients (0.4 ± 0.2 vs. 0.5 ± 0.8 P = 0.28). There was a nonsignificant correlation between elevated pre-op PWP and those with RHF vs those without, OR = 1.05 (95% CI: 1.00, 1.10). Pre-op systolic pulmonary artery pressure (SysPAP) was elevated in patients with post-LVAD RHF compared to those without (51.3 ± 12.3 vs. 47.2 ± 13.0, P = 0.09).
Conclusion
Preoperative hemodynamic variables such as PAPi or CVP/PWP did not show a significant correlation predicting RHF post LVAD implantation. Acute RHF post LVAD implantation remains a complex medical entity. Several studies have devised multivariable risk scores; however, their performance has been limited. Despite the widespread use of preoperative hemodynamics measurements as risk scores, our study suggests these scores are not as accurate as their use would suggest, particularly among especially morbid patient populations. More prospective studies are needed to accurately demonstrate how preoperative hemodynamics could predict and help prevent this catastrophic complication.
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Is Pulmonary Artery Pulsatility Index (PAPi) a Predictor of Outcome after Pulmonary Endarterectomy? J Clin Med 2022; 11:jcm11154353. [PMID: 35955972 PMCID: PMC9368812 DOI: 10.3390/jcm11154353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Pulmonary endarterectomy (PEA) is the gold standard therapy for chronic thromboembolic pulmonary hypertension (CTEPH). Traditionally, pulmonary vascular resistance (PVR) represents the main prognostic factor after surgery. The pulmonary artery pulsatility index (PAPi) has been proposed for the assessment of RV in advanced heart failure, but it has never been applied in CTEPH patients. The aim of the present study is to describe PAPi in patients who underwent PEA, before and after surgery, and to define its predictive impact on postoperative outcomes. Methods: We retrospectively reviewed 188 consecutive adult patients who underwent PEA, between December 2003 and December 2021. PAPi was calculated for 186 patients and reported. Patients were partitioned in two groups using median preoperative PAPi as cutoff value: Group 1 with PAPi ≤ 8.6 (n = 94) and Group 2 with PAPi > 8.6 (n = 92). The propensity-score-matched analysis identified 67 pairs: Early outcomes were compared between two groups. Results: Mean preoperative PAPi was 10.3 ± 7.2. Considering matched populations, no differences emerged in terms of postoperative hemodynamics; Group 1 demonstrated higher 90-day mortality significance (10.4% vs. 3.0%, p = 0.082); the need for mechanical circulatory support (MCS) was similar, but successful weaning was unlikely (25% vs. 85.7%, p = 0.032). Conclusions: Mean PAPi in the CTEPH population is higher than in other diseases. Low PAPi (≤8.6) seems to be associated with lower postoperative survival and successful weaning from MCS.
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Kanwar MK, Everett KD, Gulati G, Brener MI, Kapur NK. Epidemiology and management of right ventricular-predominant heart failure and shock in the cardiac intensive care unit. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:584-594. [PMID: 35767583 DOI: 10.1093/ehjacc/zuac063] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 06/15/2023]
Abstract
Cardiogenic shock from left ventricular failure is a common presentation in the intensive care unit. In contrast, right ventricular (RV)-predominant heart failure (HF) causing shock is less well recognized. We review the epidemiology and mechanisms of RV-predominant HF and discuss pharmacologic and device-based approaches for the management of this challenging clinical problem.
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Affiliation(s)
- Manreet K Kanwar
- Department of Medicine, Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, USA
| | - Kay D Everett
- Department of Medicine, The CardioVascular Center, Tufts Medical Center, 800 Washington Street, Box # 80, Boston, MA 02111, USA
| | - Gaurav Gulati
- Department of Medicine, The CardioVascular Center, Tufts Medical Center, 800 Washington Street, Box # 80, Boston, MA 02111, USA
| | - Michael I Brener
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Navin K Kapur
- Department of Medicine, The CardioVascular Center, Tufts Medical Center, 800 Washington Street, Box # 80, Boston, MA 02111, USA
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Aktuelle Klassifikation und hämodynamisches Profil bei kardiogenem Schock. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2022. [DOI: 10.1007/s00398-022-00507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prognostic Value of Pulmonary Artery Pulsatility Index in Right Ventricle Failure-Related Mortality in Inoperable Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 11:jcm11102735. [PMID: 35628862 PMCID: PMC9147458 DOI: 10.3390/jcm11102735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/15/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an ominous disease leading to progressive right ventricular failure (RVF) and death. There is no reliable risk stratification strategy for patients with CTEPH. The pulmonary artery pulsatility index (PAPI) is a novel hemodynamic index that predicts the occurrence RVF. We aimed to investigate prognostic value of PAPI in inoperable CTEPH. Consecutive patients with inoperable CTEPH were enrolled. PAPI was calculated from baseline right heart catheterization data. A prognostic cut-off value was determined, and characteristics of low- and high-PAPI groups were compared. The association between risk assessment and survival was also evaluated. We included 50 patients (mean age 64 ± 12.2 years, 60% female). The number of deaths was 12 (24%), and the mean follow-up time was 52 ± 19.3 months. The established prognostic cut-off value for PAPI was 3.9. The low-PAPI group had significantly higher mean values of mean atrial pressure (14.9 vs. 7.8, p = 0.0001), end-diastolic right ventricular pressure (16.5 vs. 11.2, p = 0.004), and diastolic pulmonary artery pressure (35.8 vs. 27.7, p = 0.0012). The low-PAPI group had lower survival as compared to high-PAPI (log-rank p < 0.0001). PAPI was independently associated with survival and may be applicable for risk stratification in inoperable CTEPH.
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Kretzschmar D, Schulze PC. Right Heart Catheterization and Pulmonary Hemodynamics. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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40
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Bayram Z, Dogan C, Efe SC, Guvendi B, Karagoz A, Acar RD, Uysal S, Akbas RB, Yilmaz F, Akbal OY, Tokgoz HC, Kirali MK, Kaymaz C, Ozdemir N. Ischaemic versus non-ischaemic: how does heart failure aetiology affect pulmonary arterial capacitance and pulmonary artery pulsatility index in end-stage heart failure? Acta Cardiol 2022; 77:204-210. [PMID: 34923932 DOI: 10.1080/00015385.2021.1951999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aetiology of heart failure may have different effects on right ventricular (RV) function, pulmonary pressures and RV afterload. Pulmonary arterial capacitance (PAC) and pulmonary artery pulsatility index (PAPi) are novel haemodynamic indices used in determining RV afterload and RV function, respectively. We aimed to investigate whether there was a difference in PAC and PAPi between ischaemic cardiomyopathy (ICMP) and non-ischaemic cardiomyopathy (NICMP) in patients with end-stage heart failure. METHODS AND RESULTS A total of 215 subjects undergoing evaluation for heart transplantation or left ventricular (LV) assist device were classified into two groups: ICMP (n = 101) and NICMP (n = 114). The patients with LV ejection fraction ≤ 25% were included in the study. ICMP group had lower PAC and higher PAPi values compared to NICMP group [1.25 (0.82-1.86) vs. 1.58 (1.02-2.21), p = 0.002 and 3.4 (2.2-5.0) vs. 2.5 (1.7-4.0); p = 0.007]. Pulmonary vascular resistance, pulmonary artery systolic and mean pressure were higher in ICMP group compared to NICMP group [3.5 ± 1.8 vs. 2.9 ± 2.3, p = 0.004; 59.0 (42.0-73.0) vs. 46.0 (37.0-59.0), p < 0.001, 35.0 (27.0-46.0) vs. 31.0 (23.0-39.0), p = 0.002]. The patients with ICMP had higher tricuspid annular plane systolic excursion and less RV dilatation. ICMP was an independent risk factor for pulmonary hypertension (OR: 4.02, 95% CI: 1.13-14.24, p = 0.031). CONCLUSION ICMP was associated with lower PAC and higher PAPi. These results indicated that an ischaemic aetiology is associated with higher RV afterload and better RV function in the end-stage heart failure.
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Affiliation(s)
- Zubeyde Bayram
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Cem Dogan
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Suleyman C. Efe
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Busra Guvendi
- Department of Cardiology, Istanbul Maltepe State Hospital, Istanbul, Turkey
| | - Ali Karagoz
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Rezzan Deniz Acar
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Samet Uysal
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Ravza Betul Akbas
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Fatih Yilmaz
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Ozgur Y. Akbal
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Hacer Ceren Tokgoz
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Kaan Kirali
- Cardiovascular Surgery Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Cihangir Kaymaz
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Nihal Ozdemir
- Cardiology Department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
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Abstract
ABSTRACT Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.
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Bertaina M, Galluzzo A, Morici N, Sacco A, Oliva F, Valente S, D’Ascenzo F, Frea S, Sbarra P, Petitti E, Brach Prever S, Boccuzzi G, Zanini P, Attisani M, Rametta F, De Ferrari GM, Noussan P, Iannaccone M. Pulmonary Artery Catheter Monitoring in Patients with Cardiogenic Shock: Time for a Reappraisal? Card Fail Rev 2022; 8:e15. [PMID: 35541286 PMCID: PMC9069264 DOI: 10.15420/cfr.2021.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/19/2022] [Indexed: 12/20/2022] Open
Abstract
Cardiogenic shock represents one of the most dramatic scenarios to deal with in intensive cardiology care and is burdened by substantial short-term mortality. An integrated approach, including timely diagnosis and phenotyping, along with a well-established shock team and management protocol, may improve survival. The use of the Swan-Ganz catheter could play a pivotal role in various phases of cardiogenic shock management, encompassing diagnosis and haemodynamic characterisation to treatment selection, titration and weaning. Moreover, it is essential in the evaluation of patients who might be candidates for long-term heart-replacement strategies. This review provides a historical background on the use of the Swan-Ganz catheter in the intensive care unit and an analysis of the available evidence in terms of potential prognostic implications in this setting.
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Affiliation(s)
- Maurizio Bertaina
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | | | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; IRCCS S Maria Nascente – Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Alice Sacco
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Serafina Valente
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Simone Frea
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pierluigi Sbarra
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Elisabetta Petitti
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Silvia Brach Prever
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Giacomo Boccuzzi
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Paola Zanini
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Matteo Attisani
- Department of Cardiac Surgery, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | | | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Patrizia Noussan
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
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Bashline MJ, Rhinehart Z, Kola O, Fowler J, Kaczorowski D, Hickey G. Impella 5.0 is associated with a reduction in vasoactive support and improves hemodynamics in cardiogenic shock: A single-center experience. Int J Artif Organs 2022; 45:462-469. [PMID: 35365048 DOI: 10.1177/03913988221083993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment of cardiogenic shock (CS) often requires the use of vasopressors and inotropic agents, which are associated with an increase in mortality. Data on change in vasopressor and inotrope requirements post Impella 5.0 placement is scarce. Thus, we aimed to study the ability of Impella 5.0 to reduce these requirements. METHODS Retrospective analysis of consecutive patients with CS receiving Impella 5.0 was performed. Vasopressor-Inotrope Score (VIS) and a Modified Catecholamine Equivalent score (MCES) was calculated prior to and up to 72 h post-Impella implantation. Primary outcome was change in MCES from baseline to 48-h post implantation and secondary outcomes included change in VIS, changes in MCES according to SCAI Stage and to underlying etiology, and freedom from mortality at 30-days. RESULTS Twenty-eight patients with median age of 61 (48, 67) years were included. Impella 5.0 was associated with significant reduction in MCES from baseline [9.7 (5.3, 17)] to 48 h [5.7 (3.8, 7.5), p = 0.001]. VIS was also significantly reduced from baseline [8.3 (3.8, 19.9)] to 48 h [5.0 (2.5, 8), p = 0.003]. MCES at 48 h was significantly reduced in patients with SCAI Stage E versus Stage C (p = 0.026) and with acute myocardial infarction versus acute decompensated heart (p = 0.003). Thirty-day survival was 0% in patients that had a baseline MCES ⩾ 10 without a reduction in MCES of at least 5 at 24 h. CONCLUSION Impella 5.0 is associated with a significant reduction in MCES and VIS scores in patients presenting with CS with 30-day survival being dependent on MCES.
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Affiliation(s)
- Michael J Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Zachary Rhinehart
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Olivia Kola
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gavin Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Essandoh M, Kumar N, Hussain N, Dalia AA, Wang D, Al-Qudsi O, Wilsak D, Stahl D, Bhatt A, Sawyer TR, Iyer MH. Pulmonary Artery Pulsatility Index as a Predictor of Right Ventricular Failure in Left Ventricular Assist Device Recipients: A Systematic Review. J Heart Lung Transplant 2022; 41:1114-1123. [DOI: 10.1016/j.healun.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/16/2022] [Accepted: 04/19/2022] [Indexed: 12/25/2022] Open
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Knio ZO, Thiele RH, Wright WZ, Mazimba S, Naik BI, Hulse MC. A Novel Hemodynamic Index of Post-operative Right Heart Dysfunction Predicts Mortality in Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2022; 26:200-208. [PMID: 35332827 DOI: 10.1177/10892532221080382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION This study aimed to investigate whether mortality following cardiac surgery was associated with the pulmonary artery pulsatility index (PAPi): pulmonary artery pulse pressure divided by central venous pressure (CVP), and a novel index: mean pulmonary artery pressure (mPAP) minus CVP. METHODS This retrospective analysis investigated all cardiac surgery patients in the Society of Thoracic Surgeons registry at a single academic medical center from January 2017 through March 2020 (n = 1510). The primary and secondary outcomes were mortality at 1 year and serum creatinine increase during index surgical admission, respectively. CVP, mPAP, PAPi, mPAP-CVP gradient, mean arterial pressure (MAP), and cardiac index (CI) were sampled continually from invasive hemodynamic monitors post-operatively. Associations with mortality were tested with univariate and multivariate analyses. The relationship with serum creatinine was investigated with Pearson's correlation at alpha = .05. RESULTS One-year mortality was observed in 44/1200 patients (3.7%). On univariate analysis, mortality was associated with minimums for mPAP, MAP, and CI and maximums for CVP, mPAP, PAPi, mPAP-CVP gradient, and CI (all P < .10). Model selection revealed that the only independently predictive parameters were minimum MAP (AOR = .880 [.819-.944]), maximum mPAP-CVP gradient (AOR = 1.082 [1.031-1.133]), and maximum CI (AOR = 1.421 [.928-2.068]), with model c-statistic = .770. A maximum mPAP-CVP gradient >20.5 predicted mortality with 54.5% sensitivity and 79.30% specificity, maintaining significance on survival analysis (P < .001). Peak increase in serum creatinine from baseline demonstrated a weak association with all parameters (max |r| = .33). CONCLUSIONS Mortality was not predicted by the post-operative PAPi; rather, it was independently predicted by the mPAP-CVP gradient, MAP, and CI.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Robert H Thiele
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - W Zachary Wright
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Sula Mazimba
- Department of Medicine, Division of Cardiovascular Medicine, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA.,Department of Neurosurgery, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Matthew C Hulse
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
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Bertaina M, Galluzzo A, Rossello X, Sbarra P, Petitti E, Prever SB, Boccuzzi G, D'Ascenzo F, Frea S, Pidello S, Morici N, Sacco A, Oliva F, Valente S, De Ferrari GM, Ugo F, Rametta F, Attisani M, Zanini P, Noussan P, Iannaccone M. Prognostic implications of pulmonary artery catheter monitoring in patients with cardiogenic shock: A systematic review and meta-analysis of observational studies. J Crit Care 2022; 69:154024. [PMID: 35344825 DOI: 10.1016/j.jcrc.2022.154024] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE To investigate the impact of pulmonary artery catheter (PAC) monitoring on survival of cardiogenic shock(CS), in the light of the controversies in available evidence. MATERIALS AND METHODS MEDLINE, EMBASE, Cochrane library and Web of Science were systematically screened to identify most relevant studies on patients with CS comparing PAC use to non-use during hospital stay. Short-term mortality was the primary endpoint and the use of Mechanical Circulatory Support (MCS) devices was the secondary one. RESULTS Six observational studies including 1,166,762 patients were selected. The most frequent etiology of CS was post-myocardial infarction (75% [95% CI 55-89%] in PAC-group and 81%[95% CI 47-95%] in non-PAC group). Overall, PAC was used in 33%(95% CI 24-44%) of cases. Pooling data adjusted for confounders, a significant association between the PAC-group and a reduction in short-term mortality emerged when compared to the non-PAC group (36%[95% CI 27-45%] vs 47%[95% CI 35-59%];AdjustedOR 0.71, 95% CI 0.59-0.87, p < 0.01). MCS use was significantly higher in PAC vs non-PAC group (59% [95% CI 54-65%]) vs 48% [95% CI 43-53%]);OR 1.60 [95% CI 1.27-2.02, p < 0.01]). CONCLUSIONS PAC was associated with lower incidence of short-term mortality in CS pooling adjusted observational studies. Prospective studies are needed to confirm our hypothesis and better clarify the mechanisms of this potential prognostic benefit.
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Affiliation(s)
- Maurizio Bertaina
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy.
| | | | - Xavier Rossello
- Cardiology Department, Institut d'Investigació Sanitària Illes Balears, Hospital Universitari Son Espases, Palma, Spain
| | - Pierluigi Sbarra
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
| | | | | | - Giacomo Boccuzzi
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Italy
| | - Simone Frea
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Italy
| | - Stefano Pidello
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Italy
| | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; IRCCS S. Maria Nascente, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy.
| | - Alice Sacco
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Serafina Valente
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Italy
| | - Fabrizio Ugo
- Department of Cardiology, Sant'Andrea Hospital, Vercelli, Italy
| | | | - Matteo Attisani
- Department of Cardiovascular and Thoracic Surgery, Città della Salute e della Scienza, Molinette Hospital, University of Turin, Italy; Department of cardiovascular surgery, San Giovanni Bosco Hospital, Turin, Italy
| | - Paola Zanini
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
| | - Patrizia Noussan
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
| | - Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
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Point-of-Care Ultrasound in the Evaluation of Patients with Left Ventricular Assist Devices at the Emergency Department. J Emerg Med 2022; 62:348-355. [PMID: 34991913 DOI: 10.1016/j.jemermed.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/05/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) can be used as a bridging therapy for myocardial recovery or cardiac transplant, as well as a destination therapy for long-term support in patients with advanced heart failure. Patients with LVADs can present to the emergency department (ED) for acute deterioration and emergency physicians (EPs) must be equipped with the necessary knowledge and skill to treat this unique population. OBJECTIVE This review describes the role of point-of-care ultrasound (POCUS) in the evaluation of patients with LVADs and illustrates how EPs can incorporate POCUS into the evaluation of these patients in the ED. DISCUSSION The clinical applications for which POCUS may be useful in patients with LVADs include hypotension or shock, dyspnea, cardiac failure, dysrhythmia, syncope, and cardiac arrest. The normal features of POCUS in patients with LVADs and the features of POCUS associated with diseased states are presented. CONCLUSIONS Patients with LVADs have altered anatomy and physiology. Therefore, an understanding of key modifications to standard POCUS views is necessary so that EPs can use POCUS effectively in their evaluation of these patients.
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Montisci A, Sala S, Maj G, Cattaneo S, Pappalardo F. Comprehensive evaluation of Impella RP ® in right ventricular failure. Future Cardiol 2022; 18:285-298. [PMID: 35187952 DOI: 10.2217/fca-2021-0075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Right ventricular failure has a high morbidity and mortality in patients suffering from advanced heart failure, pulmonary hypertension, acute myocardial infarction after cardiac surgery and in left ventricular assist device patients. The Impella RP® catheter is a mechanical circulatory device, positioned from a venous femoral percutaneous access and passing through the tricuspid and pulmonary valves, reaches the pulmonary artery. Impella RP (Abiomed Inc., MA, USA) acts as a direct right ventricle bypass and it provides a flow up to 4.4 liters per minute, unloading the right ventricle. The main contraindications are: thrombi in the vena cava, right atrium and ventricle and pulmonary artery; mechanical tricuspid or pulmonary prostheses. In this review, the principles of operations, clinical applications and results of Impella RP are summarized and evaluated.
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Affiliation(s)
- Andrea Montisci
- Cardiothoracic Department, Division of Cardiothoracic Intensive Care, ASST Spedali Civili, Brescia 25123, Italy
| | - Silvia Sala
- Postgraduate in Anesthesia & Intensive Care, University of Brescia, Brescia, Italy
| | - Giulia Maj
- Department of Anesthesia & Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria 15121, Italy
| | - Sergio Cattaneo
- Cardiothoracic Department, Division of Cardiothoracic Intensive Care, ASST Spedali Civili, Brescia 25123, Italy
| | - Federico Pappalardo
- Department of Anesthesia & Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria 15121, Italy
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Perioperative Management of Patients Receiving Short-term Mechanical Circulatory Support with the Transvalvular Heart Pump. Anesthesiology 2022; 136:829-842. [PMID: 35120198 DOI: 10.1097/aln.0000000000004124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Use of the transvalvular heart pump to provide short-term circulatory support in the perioperative setting is growing. The considerations for the perioperative management of patients receiving transvalvular heart pump support are reviewed for the anesthesiologist.
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50
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Zern EK, Wang D, Rambarat P, Bernard S, Paniagua SM, Liu EE, McNeill J, Wang JK, Andrews CT, Pomerantsev EV, Picard MH, Ho JE. Association of Pulmonary Artery Pulsatility Index With Adverse Cardiovascular Events Across a Hospital-Based Sample. Circ Heart Fail 2022; 15:e009085. [PMID: 35135302 PMCID: PMC8855684 DOI: 10.1161/circheartfailure.121.009085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pulmonary artery pulsatility index (PAPi), calculated from the ratio of the pulmonary artery pulse pressure to right atrial pressure, is a predictor of right ventricular failure after inferior myocardial infarction and left ventricular assist device implantation. Whether PAPi is associated with adverse outcomes across a heterogeneous population is unknown. METHODS We examined consecutive patients undergoing right heart catheterization between 2005 and 2016 in a hospital-based cohort. Multivariable Cox models were utilized to examine the association between PAPi and all-cause mortality, major adverse cardiac events, and heart failure hospitalizations. RESULTS We studied 8285 individuals (mean age 63 years, 39% women) with median PAPi across quartiles 1.7, 2.8, 4.2, and 8.7, who were followed over a mean follow-up of 6.7±3.3 years. Patients in the lowest PAPi quartile had a 60% greater risk of death compared with the highest quartile (multivariable-adjusted hazard ratio, 1.60 [95% CI, 1.36-1.88], P<0.001) and a higher risk of major adverse cardiac events and heart failure hospitalizations (hazard ratio, 1.80 [95% CI, 1.56-2.07], P<0.001 and hazard ratio, 2.08 [95% CI, 1.76-2.47], P<0.001, respectively). Of note, patients in quartiles 2 and 3 also had increased risk of cardiovascular events compared with quartile 4 (multivariable P<0.05 for all). CONCLUSIONS Compared with the highest PAPi quartile, patients in PAPi quartiles 1 to 3 had a greater risk of all-cause mortality, major adverse cardiac events, and heart failure hospitalizations, with greatest risk observed in the lowest quartile. A low PAPi, even at values higher than previously reported, may serve an important role in identifying high-risk individuals across a broad spectrum of cardiovascular disease.
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Affiliation(s)
- Emily K. Zern
- Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, MA
| | - Dongyu Wang
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Paula Rambarat
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Samuel Bernard
- Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine
| | - Samantha M. Paniagua
- Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, MA
| | - Elizabeth E. Liu
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jenna McNeill
- Pulmonary and Critical Care Division, Massachusetts General Hospital, Boston, MA
| | - Jessica K. Wang
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Carl T. Andrews
- Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, MA
| | - Eugene V. Pomerantsev
- Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, MA
| | - Michael H. Picard
- Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, MA
| | - Jennifer E. Ho
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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