Echocardiographic Characteristics of Cardiogenic Shock Patients with and Without Cardiac Arrest

Artificial Intelligence ECG Diastolic Dysfunction and Survival in Cardiac Intensive Care Unit Patients

BACKGROUND

Left ventricular diastolic dysfunction (LVDD) predicts mortality in patients in cardiac intensive care units. An artificial intelligence enhanced ECG (AIECG) algorithm can predict LVDD and mortality in general populations but has not been examined in cardiac intensive care units.

METHODS

This historical cohort study included consecutive adults admitted to Mayo Clinic cardiac intensive care unit from 2007 to 2018 with an admission AIECG. The AIECG assigned the LVDD grade (0-3). Medial mitral E/e' ratio >15 on transthoracic echocardiogram (TTE) defined elevated filling pressures. In-hospital and 1-year mortality was evaluated, before and after multivariable adjustment.

RESULTS

We included 11 868 patients (median age 69.5 years, 37.7% female); 48% had heart failure and 44% had acute coronary syndromes. AIECG LVDD grade was 0 (normal), 33%; 1, 7%; 2, 39%; and 3, 21%. In-hospital and 1-year mortality increased in each higher AIECG LVDD grade. After adjustment, each higher AIECG LVDD grade was associated with higher in-hospital (adjusted odds ratio [OR], 1.22 [95% CI, 1.13-1.32]) and 1-year mortality (adjusted hazard ratio [HR], 1.23 [95% CI, 1.19-1.29]); this persisted after adjustment for TTE measurements. Patients with grade 2 or 3 LVDD by AIECG and medial mitral E/e' ratio >15 by TTE had the highest in-hospital (adjusted OR, 2.54 [95% CI, 1.69-3.88]) and 1-year (adjusted HR, 2.03 [95% CI, 1.65-2.48]) mortality, whereas patients meeting either of these criteria had similar, elevated mortality.

CONCLUSIONS

The AIECG LVDD grade was strongly associated with in-hospital and 1-year mortality in patients in cardiac intensive care units, even after adjusting for clinical variables and TTE measurements. Patients with concordant AIECG and TTE for elevated filling pressures were at highest risk.

Pulmonary Artery Pressures and Mortality During Venoarterial ECMO: An ELSO Registry Analysis

BACKGROUND

Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (ECMO). How the right heart (the right ventricle and pulmonary artery) affect survival during venoarterial ECMO is unknown. We aimed to identify the relationship between right heart function with mortality and the duration of ECMO support.

METHODS

Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization Registry between 2010 and 2022 were queried. Right heart function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for modified Society for Cardiovascular Angiography and Interventions stage, age, sex, and concurrent clinical data (ie, pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality.

RESULTS

A total of 4442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; nonsurvivors were more likely to be older, have a worse Society for Cardiovascular Angiography and Interventions stage, and have longer pre-ECMO endotracheal intubation times (P<0.05 for all) than survivors. Increasing PAPP from pre-ECMO to on-ECMO time (ΔPAPP) was associated with reduced mortality per 2 mm Hg increase (odds ratio, 0.98 [95% CI, 0.97-0.99]; P=0.002). Higher on-ECMO PAPP was associated with mortality reduction across quartiles with the greatest reduction in the third PAPP quartile (odds ratio, 0.75 [95% CI, 0.63-0.90]; P=0.002) and longer time on ECMO per 10 mm Hg (beta, 15 [95% CI, 7.7-21]; P<0.001).

CONCLUSIONS

Early on-ECMO right heart function and interval improvement from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of right heart metrics into risk prediction models should be considered.

Cardiogenic Shock: Pathogenesis, Classification, and Management

Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.