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Friebel J, Wegner M, Blöbaum L, Schencke PA, Jakobs K, Puccini M, Ghanbari E, Lammel S, Thevathasan T, Moos V, Witkowski M, Landmesser U, Rauch-Kröhnert U. Characterization of Biomarkers of Thrombo-Inflammation in Patients with First-Diagnosed Atrial Fibrillation. Int J Mol Sci 2024; 25:4109. [PMID: 38612918 PMCID: PMC11012942 DOI: 10.3390/ijms25074109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024] Open
Abstract
Patients with first-diagnosed atrial fibrillation (FDAF) exhibit major adverse cardiovascular events (MACEs) during follow-up. Preclinical models have demonstrated that thrombo-inflammation mediates adverse cardiac remodeling and atherothrombotic events. We have hypothesized that thrombin activity (FIIa) links coagulation with inflammation and cardiac fibrosis/dysfunction. Surrogate markers of the thrombo-inflammatory response in plasma have not been characterized in FDAF. In this prospective longitudinal study, patients presenting with FDAF (n = 80), and 20 matched controls, were included. FIIa generation and activity in plasma were increased in the patients with early AF compared to the patients with chronic cardiovascular disease without AF (controls; p < 0.0001). This increase was accompanied by elevated biomarkers (ELISA) of platelet and endothelial activation in plasma. Pro-inflammatory peripheral immune cells (TNF-α+ or IL-6+) that expressed FIIa-activated protease-activated receptor 1 (PAR1) (flow cytometry) circulated more frequently in patients with FDAF compared to the controls (p < 0.0001). FIIa activity correlated with cardiac fibrosis (collagen turnover) and cardiac dysfunction (NT-pro ANP/NT-pro BNP) surrogate markers. FIIa activity in plasma was higher in patients with FDAF who experienced MACE. Signaling via FIIa might be a presumed link between the coagulation system (tissue factor-FXa/FIIa-PAR1 axis), inflammation, and pro-fibrotic pathways (thrombo-inflammation) in FDAF.
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Affiliation(s)
- Julian Friebel
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Max Wegner
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
| | - Leon Blöbaum
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
| | - Philipp-Alexander Schencke
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
| | - Kai Jakobs
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
| | - Marianna Puccini
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
| | - Emily Ghanbari
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
| | - Stella Lammel
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
| | - Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Marco Witkowski
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
- Friede Springer Cardiovascular Prevention Center at Charité, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center at Charité, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Ursula Rauch-Kröhnert
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany; (J.F.); (P.-A.S.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center at Charité, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
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Wilken S, Thevathasan T, Kamali C, Guillot A, Ihlow J, Fehrenbach U, Danyel M, Pratschke J, Tacke F, Krenzien F. Patient with a novel syndrome with multiple benign hepatic lesions and extrahepatic neoplasms. Clin J Gastroenterol 2024; 17:300-306. [PMID: 38133737 PMCID: PMC10960739 DOI: 10.1007/s12328-023-01899-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023]
Abstract
Simultaneous occurrence of benign hepatic lesions of different types is a sporadic phenomenon. To the best of our knowledge, we report the first clinical case of a syndrome with simultaneous manifestations of three different entities of benign liver tumors (hepatocellular adenoma, focal nodular hyperplasia and hemangioma) with a novel mutation detected in the liver adenoma and in the presence of a number of further extrahepatic organ neoplasms. Furthermore, we describe for the first time the presence of liver epithelial cells of hepatocytic phenotype expressing cytokeratin 7 (CK7) at the border of the adenoma. These findings may be important for explaining pathogenesis of benign as well as malignant tumors based on genetic and histopathological features.
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Affiliation(s)
- Silvana Wilken
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Tharusan Thevathasan
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117, Berlin, Germany
| | - Can Kamali
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Adrien Guillot
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Jana Ihlow
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Uli Fehrenbach
- Clinic for Radiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Magdalena Danyel
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117, Berlin, Germany
- Institute of Medical Genetics and Human Genetics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité- Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Thevathasan T, Füreder L, Fechtner M, Mørk SR, Schrage B, Westermann D, Linde L, Gregers E, Andreasen JB, Gaisendrees C, Unoki T, Axtell AL, Takeda K, Vinogradsky AV, Gonçalves-Teixeira P, Lemaire A, Alonso-Fernandez-Gatta M, Sern Lim H, Garan AR, Bindra A, Schwartz G, Landmesser U, Skurk C. Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:464-474. [PMID: 38180032 PMCID: PMC10876179 DOI: 10.1097/ccm.0000000000006157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR. DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). STUDY SELECTION Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. DATA EXTRACTION Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model. DATA SYNTHESIS Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses. CONCLUSIONS ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Marie Fechtner
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | | | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Emilie Gregers
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jo Bønding Andreasen
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | | | - Takashi Unoki
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Koji Takeda
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | - Alice V Vinogradsky
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | | | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Hoong Sern Lim
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Arthur Reshad Garan
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Amarinder Bindra
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Gary Schwartz
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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Thevathasan T, Gregers E, Rasalingam Mørk S, Degbeon S, Linde L, Bønding Andreasen J, Smerup M, Eifer Møller J, Hassager C, Laugesen H, Dreger H, Brand A, Balzer F, Landmesser U, Juhl Terkelsen C, Flensted Lassen J, Skurk C, Søholm H. Lactate and Lactate Clearance as Predictors of One-Year Survival in Extracorporeal Cardiopulmonary Resuscitation - An International, Multicentre Cohort Study. Resuscitation 2024:110149. [PMID: 38403182 DOI: 10.1016/j.resuscitation.2024.110149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 02/27/2024]
Abstract
AIM Extracorporeal cardiopulmonary resuscitation (ECPR) can be considered in selected patients with refractory cardiac arrest. Given the risk of patient futility and high resource utilisation, identifying ECPR candidates, who would benefit from this therapy, is crucial. Previous ECPR studies investigating lactate as a potential prognostic marker have been small and inconclusive. It was hypothesised that the lactate level (immediately prior to initiation of ECPR) and lactate clearance (within 24 hours after ECPR initiation) are predictors of one-year survival in a large, multicentre study cohort of ECPR patients. METHODS Adult patients with refractory cardiac arrest at three German and four Danish tertiary cardiac care centres between 2011 and 2021 were included. Pre-ECPR lactate and 24-hour lactate clearance were divided into three equally sized tertiles. Multivariable logistic regression analyses and Kaplan-Meier analyses were used to analyse survival outcomes. RESULTS 297 adult patients with refractory cardiac arrest were included in this study, of which 65 (22%) survived within one year. The pre-ECPR lactate level and 24-hour lactate clearance were level-dependently associated with one-year survival: OR 5.40 [95% CI 2.30-13.60] for lowest versus highest pre-ECPR lactate level and OR 0.25 [95% CI 0.09-0.68] for lowest versus highest 24-hour lactate clearance. Results were confirmed in Kaplan-Meier analyses (each p log rank <0.001) and subgroup analyses. CONCLUSION Pre-ECPR lactate levels and 24 hour-lactate clearance after ECPR initiation in patients with refractory cardiac arrest were level-dependently associated with one-year survival. Lactate is an easily accessible and quickly available point-of-care measurement which might be considered as an early prognostic marker when considering initiation or continuation of ECPR treatment.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany; Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Emilie Gregers
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Sivagowry Rasalingam Mørk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus, Denmark
| | - Sêhnou Degbeon
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 17, 5000 Odense, Denmark
| | - Jo Bønding Andreasen
- Department of Anesthesiology and Intensive Medicine, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Morten Smerup
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 17, 5000 Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Helle Laugesen
- Department of Anesthesiology and Intensive Medicine, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Henryk Dreger
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Anna Brand
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; The Danish Heart Foundation, Vognmagergade 7, 3rd floor, 1120 Copenhagen, Denmark
| | - Jens Flensted Lassen
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 17, 5000 Odense, Denmark
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), partner site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany.
| | - Helle Søholm
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Cardiology, Zealand University Hospital Roskilde, Sygehusvej 10, 4000 Roskilde, Denmark
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5
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Voß F, Thevathasan T, Scholz KH, Böttiger BW, Scheiber D, Kabiri P, Bernhard M, Kienbaum P, Jung C, Westenfeld R, Skurk C, Adler C, Kelm M. Accredited cardiac arrest centers facilitate eCPR and improve neurological outcome. Resuscitation 2024; 194:110069. [PMID: 38061578 DOI: 10.1016/j.resuscitation.2023.110069] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) remains a frequent medical emergency with low survival rates even after a return of spontaneous circulation (ROSC). Growing evidence supports formation of dedicated teams in scenarios like cardiogenic shock to improve prognosis. Thus, the European Resuscitation Council (ERC) recommended introduction of Cardiac Arrest Centers (CAC) in their 2015 guidelines. Here, we aimed to elucidate the effects of newly introduced CACs in Germany regarding survival rate and neurological outcome. METHODS A multicenter retrospective observational cohort study was performed at three university hospitals and outcomes after OHCA were compared before and after CAC accreditation. Primary outcomes were survival until discharge and favorable neurological status (CPC 1 or 2) at discharge. RESULTS In total 784 patients (368 before and 416 after CAC accreditation) were analyzed. Rates of immediate percutaneous coronary intervention (40 vs. 52%, p = 0.01) and implementation of extracorporeal CPR (8 vs. 13%, p < 0.05) increased after CAC accreditation. Likelihood of favorable neurological status at discharge was higher after CAC accreditation (71 vs. 87%, p < 0.01), whereas overall survival remained similar (35 vs. 35%, p > 0.99). CONCLUSION CAC accreditation is linked to higher rates of favorable neurological outcome and unchanged overall survival.
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Affiliation(s)
- Fabian Voß
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin (Campus Benjamin Franklin), Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
| | - Karl Heinrich Scholz
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Robert-Koch-Straße 40, 34075 Göttingen, Germany
| | - Bernd W Böttiger
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Anaesthesiology and Intensive Care Medicine, Kerpener Str. 62, 50937 Cologne, Germany
| | - Daniel Scheiber
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Payam Kabiri
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin (Campus Benjamin Franklin), Hindenburgdamm 30, 12203 Berlin, Germany
| | - Michael Bernhard
- Emergency Department, University Hospital, Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany
| | - Peter Kienbaum
- Department of Anaesthesiology, Heinrich-Heine University, Medical Faculty, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225 Düsseldorf, Germany; Abiomed Europe GmbH Europe, Neunhofer Weg 3, 52074 Aachen, Germany.
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin (Campus Benjamin Franklin), Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christoph Adler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Cardiology, Kerpener Str. 62, 50937 Cologne, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Medical Faculty, Moorenstr. 5, 40225 Düsseldorf, Germany; CARID (Cardiovascular Research Institute Düsseldorf), Germany
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Thevathasan T, Paul J, Gaul AL, Degbeon S, Füreder L, Dischl D, Knie W, Girke G, Wurster T, Landmesser U, Skurk C. Mortality and healthcare resource utilisation after cardiac arrest in the United States - A 10-year nationwide analysis prior to the COVID-19 pandemic. Resuscitation 2023; 193:109946. [PMID: 37634860 DOI: 10.1016/j.resuscitation.2023.109946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Abstract
AIM Understanding the public health burden of cardiac arrest (CA) is important to inform healthcare policies, particularly during healthcare crises such as the COVID-19 pandemic. This study aimed to analyse outcomes of in-hospital mortality and healthcare resource utilisation in adult patients with CA in the United States over the last decade prior to the COVID-19 pandemic. METHODS The United States (US) National Inpatient Sample was utilised to identify hospitalised adult patients with CA between 2010 and 2019. Logistic and Poisson regression models were used to analyse outcomes by adjusting for 47 confounders. RESULTS 248,754 adult patients with CA (without "Do Not Resuscitate"-orders) were included in this study, out of which 57.5% were male. In-hospital mortality was high with 51.2% but improved significantly from 58.3% in 2010 to 46.4% in 2019 (P < 0.001). Particularly, elderly patients, non-white patients and patients requiring complex therapy had a higher mortality rate. Although the average hospital LOS decreased by 11%, hospital expenses have increased by 13% between 2010 and 2019 (each P < 0.001), presumably due to more frequent use of mechanical circulatory support (MCS, e.g. ECMO from 2.6% to 8.7% or Impella® micro-axial flow pump from 1.8% to 14.2%). Strong disparities existed among patient age groups and ethnicities across the US. Of note, the number of young adults with CA and opioid-induced CA has almost doubled within the study period. CONCLUSION Over the last ten years prior to the COVID-19 pandemic, CA-related survival has incrementally improved with shorter hospitalisations and increased medical expenses, while strong disparities existed among different age groups and ethnicities. National standards for CA surveillance should be considered to identify trends and differences in CA treatment to allow for standardised medical care.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany; Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany.
| | - Julia Paul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Anna L Gaul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Sêhnou Degbeon
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Dominic Dischl
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Wulf Knie
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Georg Girke
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Thomas Wurster
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany.
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Thevathasan T, Landmesser U, Skurk C. Reply to Letter: Potential problems with concomitant therapy with Impella® and veno-arterial extracorporeal membrane oxygenation in patients with cardiac arrest. Resuscitation 2023; 190:109915. [PMID: 37506816 DOI: 10.1016/j.resuscitation.2023.109915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany.
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany.
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Barbieri F, Mattig I, Beyhoff N, Thevathasan T, Romero Dorta E, Skurk C, Stangl K, Landmesser U, Kasner M, Dreger H, Reinthaler M. Procedural success of transcatheter annuloplasty in ventricular and atrial functional tricuspid regurgitation. Front Cardiovasc Med 2023; 10:1189920. [PMID: 37608815 PMCID: PMC10440603 DOI: 10.3389/fcvm.2023.1189920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/10/2023] [Indexed: 08/24/2023] Open
Abstract
Background Transcatheter annuloplasty is meant to target annular dilatation and is therefore mainly applied in functional tricuspid regurgitation (TR). Due to recent recognition of varying disease pathophysiology and differentiation of ventricular and atrial functional TR (VFTR and AFTR), comparative data regarding procedural success for both disease entities are required. Methods In this consecutively enrolled observational cohort study, 65 patients undergoing transcatheter annuloplasty with a Cardioband® device were divided into VFTR (n = 35, 53.8%) and AFTR (n = 30, 46.2%). Procedural success was assessed by comparing changes in annulus dilatation, vena contracta (VC) width, effective regurgitation orifice area (EROA), as well as reduction in TR severity. Results Overall, improvement of TR by at least two grades was achieved in 59 patients (90.8%), and improvement of TR by at least three grades was realised in 32 patients (49.2%). Residual TR of ≤2 was observed in 52 patients (80.0%). No significant differences in annulus diameter reduction [VFTR: 11 mm (9-13) vs. AFTR: 12 mm (9-16), p = 0.210], VC reduction [12 mm (8-14) vs. 12 mm (7-14), p = 0.868], and EROA reduction [0.62 cm2 (0.45-1.10) vs. 0.54 cm2 (0.40-0.70), p = 0.204] were reported. Improvement by at least two grades [27 (90.0%) vs. 32 (91.4%), p = 1.0] and three grades [14 (46.7%) vs. 18 (51.4%), p = 0.805] was similar in VFTR and AFTR, respectively. No significant difference in the accomplishment of TR grade of ≤2 [21 (70.0%) vs. 31 (88.6%), p = 0.118] was noted. Conclusion According to our results from a real-world scenario, transcatheter annuloplasty with the Cardioband® device may be applied in both VFTR and AFTR with evidence of significant procedural TR reduction.
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Affiliation(s)
- Fabian Barbieri
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
| | - Isabel Mattig
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Niklas Beyhoff
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Tharusan Thevathasan
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- Institute of Medical Informatics, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Elena Romero Dorta
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
| | - Carsten Skurk
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Karl Stangl
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Ulf Landmesser
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Mario Kasner
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
| | - Henryk Dreger
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Markus Reinthaler
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Institute of Active Polymers and Berlin-Brandenburg Center for Regenerative Therapies, Helmholtz-Zentrum Hereon, Teltow, Germany
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9
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Thevathasan T, Degbeon S, Paul J, Wendelburg DK, Füreder L, Gaul AL, Scheitz JF, Stadler G, Rroku A, Lech S, Buspavanich P, Huemer M, Attanasio P, Nagel P, Reinthaler M, Landmesser U, Skurk C. Safety and Healthcare Resource Utilization in Patients Undergoing Left Atrial Appendage Closure-A Nationwide Analysis. J Clin Med 2023; 12:4573. [PMID: 37510689 PMCID: PMC10380523 DOI: 10.3390/jcm12144573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. The aim of this study was to analyze outcomes of peri-procedural safety and healthcare resource utilization in 11,240 adult patients undergoing LAAC in the United States between 2016 and 2019. Primary outcomes (safety) were in-hospital ischemic stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolization and mortality. Secondary outcomes (resource utilization) were adverse discharge disposition, hospital length of stay (LOS) and costs. Logistic and Poisson regression models were used to analyze outcomes by adjusting for 10 confounders. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (p = 0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality (0.14%) remained stable. Hospital LOS decreased by 17% (0.78-0.87, p < 0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, p = 0.005) between 2016 and 2019, while hospital costs did not significantly change (p = 0.2). Female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]) while multi-morbid patients had higher risks of major bleeding (p < 0.001) and mortality (p = 0.031), longer hospital LOS (p < 0.001) and increased treatment costs (p = 0.073). Significant differences in all outcomes were observed between male and female patients across US regions. In conclusion, LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Sêhnou Degbeon
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Julia Paul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Darius-Konstantin Wendelburg
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Anna Leonie Gaul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Jan F Scheitz
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Gertraud Stadler
- Research Unit Gender in Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Andi Rroku
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Sonia Lech
- Institute for Medical Sociology and Rehabilitation Science, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
- Department of Psychiatry and Neurosciences, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Pichit Buspavanich
- Research Unit Gender in Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
- Institute for Sexology and Sexual Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Martin Huemer
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Philipp Attanasio
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Patrick Nagel
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Markus Reinthaler
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
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10
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Thevathasan T, Kenny MA, Krause FJ, Paul J, Wurster T, Boie SD, Friebel J, Knie W, Girke G, Haghikia A, Reinthaler M, Rauch-Kröhnert U, Leistner DM, Sinning D, Fröhlich G, Heidecker B, Spillmann F, Praeger D, Pieske B, Stangl K, Landmesser U, Balzer F, Skurk C. Left-ventricular unloading in extracorporeal cardiopulmonary resuscitation due to acute myocardial infarction - A multicenter study. Resuscitation 2023; 186:109775. [PMID: 36958632 DOI: 10.1016/j.resuscitation.2023.109775] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Guidelines advocate the use of extracorporeal cardio-pulmonary resuscitation with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with cardiac arrest. Effects of concomitant left-ventricular (LV) unloading with Impella® (ECMELLA) remain unclear. This is the first study to investigate whether treatment with ECMELLA was associated with improved outcomes in patients with refractory cardiac arrest caused by acute myocardial infarction (AMI). METHODS This study was approved by the local ethical committee. Patients treated with ECMELLA at three centers between 2016 and 2021 were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram rhythm, cardiac arrest location and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Sensitivity analyses on patient demographics and cardiac arrest parameters were performed. RESULTS 95 adult patients were included in this study, out of whom 34 pairs of patients were PS-matched. ECMELLA treatment was associated with decreased 30-day mortality risk (Hazard Ratio [HR] 0.53 [95% Confidence Interval (CI) 0.31-0.91], P = 0.021), prolonged hospital (Incidence Rate Ratio (IRR) 1.71 [95% CI 1.50-1.95], P < 0.001) and ICU LOS (IRR 1.81 [95% CI 1.57-2.08], P < 0.001). LV ejection fraction significantly improved until ICU discharge in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from additional LV unloading. CONCLUSIONS LV unloading with Impella® concomitant to VA-ECMO therapy in patients with therapy-refractory cardiac arrest due to AMI was associated with improved patient outcomes.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Megan A Kenny
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Finn J Krause
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Julia Paul
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Thomas Wurster
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Sebastian D Boie
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Julian Friebel
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Wulf Knie
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Georg Girke
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Arash Haghikia
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Markus Reinthaler
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Ursula Rauch-Kröhnert
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - David M Leistner
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - David Sinning
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Georg Fröhlich
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Bettina Heidecker
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Frank Spillmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 12203 Berlin, Germany
| | - Damaris Praeger
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Burkert Pieske
- Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany; Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 12203 Berlin, Germany
| | - Karl Stangl
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany; Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany; Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany.
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11
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Brala D, Thevathasan T, Grahl S, Barrow S, Violano M, Bergs H, Golpour A, Suwalski P, Poller W, Skurk C, Landmesser U, Heidecker B. Application of Magnetocardiography to Screen for Inflammatory Cardiomyopathy and Monitor Treatment Response. J Am Heart Assoc 2023; 12:e027619. [PMID: 36744683 PMCID: PMC10111485 DOI: 10.1161/jaha.122.027619] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Inflammatory cardiomyopathy is one of the most common causes of sudden cardiac death in young adults. Diagnosis of inflammatory cardiomyopathy remains challenging, and better monitoring tools are needed. We present magnetocardiography as a method to diagnose myocardial inflammation and monitor treatment response. Methods and Results A total of 233 patients were enrolled, with a mean age of 45 (±18) years, and 105 (45%) were women. The primary analysis included 209 adult subjects, of whom 66 (32%) were diagnosed with inflammatory cardiomyopathy, 17 (8%) were diagnosed with cardiac amyloidosis, and 35 (17%) were diagnosed with other types of nonischemic cardiomyopathy; 91 (44%) did not have cardiomyopathy. The second analysis included 13 patients with inflammatory cardiomyopathy who underwent immunosuppressive therapy after baseline magnetocardiography measurement. Finally, diagnostic accuracy of magnetocardiography was tested in 3 independent cohorts (total n=23) and 1 patient, who developed vaccine-related myocarditis. First, we identified a magnetocardiography vector to differentiate between patients with cardiomyopathy versus patients without cardiomyopathy (vector of ≥0.051; sensitivity, 0.59; specificity, 0.95; positive predictive value, 93%; and negative predictive value, 64%). All patients with inflammatory cardiomyopathy, including a patient with mRNA vaccine-related myocarditis, had a magnetocardiography vector ≥0.051. Second, we evaluated the ability of the magnetocardiography vector to reflect treatment response. We observed a decrease of the pathologic magnetocardiography vector toward normal in all 13 patients who were clinically improving under immunosuppressive therapy. Magnetocardiography detected treatment response as early as day 7, whereas echocardiographic detection of treatment response occurred after 1 month. The magnetocardiography vector decreased from 0.10 at baseline to 0.07 within 7 days (P=0.010) and to 0.03 within 30 days (P<0.001). After 30 days, left ventricular ejection fraction improved from 42.2% at baseline to 53.8% (P<0.001). Conclusions Magnetocardiography has the potential to be used for diagnostic screening and to monitor early treatment response. The method is valuable in inflammatory cardiomyopathy, where there is a major unmet need for early diagnosis and monitoring response to immunosuppressive therapy.
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Affiliation(s)
- Debora Brala
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Tharusan Thevathasan
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Simon Grahl
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Steve Barrow
- Division of Instrumentation at Space Telescope Science Institute Baltimore MD
| | - Michele Violano
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Hendrikje Bergs
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Ainoosh Golpour
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Phillip Suwalski
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Wolfgang Poller
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Carsten Skurk
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
| | - Ulf Landmesser
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany.,Berlin Institute of Health at Charité Berlin Germany
| | - Bettina Heidecker
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin Germany
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12
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Makrutzki-Zlotek K, Escher F, Karadeniz Z, Aleshcheva G, Pietsch H, Küchler K, Schultheiss HP, Heidecker B, Poller W, Landmesser U, Scheibenbogen C, Thevathasan T, Skurk C. FOXO3A acts as immune response modulator in human virus-negative inflammatory cardiomyopathy. Heart 2023; 109:846-856. [PMID: 36702542 DOI: 10.1136/heartjnl-2022-321732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 01/02/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Inflammatory cardiomyopathy is characterised by inflammatory infiltrates leading to cardiac injury, left ventricular (LV) dilatation and reduced LV ejection fraction (LVEF). Several viral pathogens and autoimmune phenomena may cause cardiac inflammation.The effects of the gain of function FOXO3A single-nucleotide polymorphism (SNP) rs12212067 on inflammation and outcome were studied in a cohort of patients with inflammatory dilated cardiomyopathy (DCMi) in relation to cardiac viral presence. METHODS Distribution of the SNP was determined in virus-positive and virus-negative DCMi patients and in control subjects without myocardial pathology. Baseline and outcome data were compared in 221 virus-negative patients with detection of cardiac inflammation and reduced LVEF according to their carrier status of the SNP. RESULTS Distribution of SNP rs12212067 did not differ between virus-positive (n=22, 19.3%), virus-negative (n=45, 20.4 %) and control patients (n=18, 23.4 %), indicating the absence of susceptibility for viral infection or inflammation per se (p=0.199). Patients in the virus-negative DCMi group were characterised by reduced LVEF 35.5% (95% CI) 33.5 to 37.4) and increased LVEDD (LV end-diastolic diameter) 59.8 mm (95% CI 58.5 to 61.2). Within the group, SNP and non-SNP carriers had similarly impaired LVEF 39.2% (95% CI 34.3% to 44.0%) vs 34.5% (95% CI 32.4 to 36.5), p=0.083, and increased LVEDD 58.9 mm (95% CI 56.3 to 61.5) vs 60.1 mm (95% CI 58.6 to 61.6), p=0.702, respectively. The number of inflammatory infiltrates was not different in both SNP groups at baseline. Outcome after 6 months showed a significant improvement in LVEF and clinical symptoms in SNP rs12212067 carriers 50.9% (95% CI 45.4 to 56.3) versus non-SNP carriers 41.7% (95% CI 39.2 to 44.2), p≤0.01. The improvement in clinical symptoms and LVEF was associated with a significant reduction in cardiac inflammation (ΔCD45RO+ p≤0.05; ΔMac-1+ p≤0.05; ΔLFA-1+ p≤0.01; ΔCD54+ p≤0.01) in the SNP cohort versus non-SNP cohort, respectively. Subgroup analyses identified ΔMac-1+, ΔLFA-1+, ΔCD3+ and Δperforin+ as predictors for improvement in cardiac function in SNP-positive patients. CONCLUSION FOXO3A might act as modulator of the cardiac immune response, diminishing cardiac inflammation and injury in pathogen-negative DCMi.
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Affiliation(s)
- Kamila Makrutzki-Zlotek
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany
| | - Felicitas Escher
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Virchow-Klinikum, Berlin, Germany.,DZHK, German Center for Cardiovascular Research, Berlin, Germany.,IKDT, Institute for Cardiac Diagnostics and Therapy, Berlin, Germany
| | - Zehra Karadeniz
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany
| | - Ganna Aleshcheva
- IKDT, Institute for Cardiac Diagnostics and Therapy, Berlin, Germany
| | - Heiko Pietsch
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Virchow-Klinikum, Berlin, Germany.,IKDT, Institute for Cardiac Diagnostics and Therapy, Berlin, Germany
| | - Konstanze Küchler
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany
| | | | - Bettina Heidecker
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany.,Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang Poller
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany.,Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany.,Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany.,BIH, Berlin Institute of Health at Charité, Berlin, Germany
| | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité Universitätsmedizin Berlin - Campus Virchow-Klinikum, Berlin, Germany
| | - Tharusan Thevathasan
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany.,DZHK, German Center for Cardiovascular Research, Berlin, Germany.,Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany.,BIH, Berlin Institute of Health at Charité, Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Berlin, Germany .,DZHK, German Center for Cardiovascular Research, Berlin, Germany
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13
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Jajcay N, Bezak B, Segev A, Matetzky S, Jankova J, Spartalis M, El Tahlawi M, Guerra F, Friebel J, Thevathasan T, Berta I, Pölzl L, Nägele F, Pogran E, Cader FA, Jarakovic M, Gollmann-Tepeköylü C, Kollarova M, Petrikova K, Tica O, Krychtiuk KA, Tavazzi G, Skurk C, Huber K, Böhm A. Data processing pipeline for cardiogenic shock prediction using machine learning. Front Cardiovasc Med 2023; 10:1132680. [PMID: 37034352 PMCID: PMC10077147 DOI: 10.3389/fcvm.2023.1132680] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Introduction Recent advances in machine learning provide new possibilities to process and analyse observational patient data to predict patient outcomes. In this paper, we introduce a data processing pipeline for cardiogenic shock (CS) prediction from the MIMIC III database of intensive cardiac care unit patients with acute coronary syndrome. The ability to identify high-risk patients could possibly allow taking pre-emptive measures and thus prevent the development of CS. Methods We mainly focus on techniques for the imputation of missing data by generating a pipeline for imputation and comparing the performance of various multivariate imputation algorithms, including k-nearest neighbours, two singular value decomposition (SVD)-based methods, and Multiple Imputation by Chained Equations. After imputation, we select the final subjects and variables from the imputed dataset and showcase the performance of the gradient-boosted framework that uses a tree-based classifier for cardiogenic shock prediction. Results We achieved good classification performance thanks to data cleaning and imputation (cross-validated mean area under the curve 0.805) without hyperparameter optimization. Conclusion We believe our pre-processing pipeline would prove helpful also for other classification and regression experiments.
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Affiliation(s)
- Nikola Jajcay
- Premedix Academy, Bratislava, Slovakia
- Department of Complex Systems, Institute of Computer Science, Czech Academy of Sciences, Prague, Czech Republic
| | - Branislav Bezak
- Premedix Academy, Bratislava, Slovakia
- Clinic of Cardiac Surgery, National Institute of Cardiovascular Diseases, Bratislava, Slovakia
- Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
- Correspondence: Branislav Bezak
| | - Amitai Segev
- The Leviev Cardiothoracic & Vascular Center, Chaim Sheba Medical Center, Ramat Gan, Israel
- Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- The Leviev Cardiothoracic & Vascular Center, Chaim Sheba Medical Center, Ramat Gan, Israel
- Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Michael Spartalis
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
- Global Clinical Scholars Research Training (GCSRT) Program, Harvard Medical School, Boston, MA, United States
| | - Mohammad El Tahlawi
- Department of Cardiology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I - Lancisi - Salesi”, Ancona, Italy
| | - Julian Friebel
- Department of Cardiology Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tharusan Thevathasan
- Department of Cardiology Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
- Institute of Medical Informatics, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | | | - Leo Pölzl
- Department for Cardiac Surgery, Cardiac Regeneration Research, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Nägele
- Department for Cardiac Surgery, Cardiac Regeneration Research, Medical University of Innsbruck, Innsbruck, Austria
| | - Edita Pogran
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | - F. Aaysha Cader
- Department of Cardiology, Ibrahim Cardiac Hospital & Research Institute, Dhaka, Bangladesh
| | - Milana Jarakovic
- Cardiac Intensive Care Unit, Institute for Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Can Gollmann-Tepeköylü
- Department for Cardiac Surgery, Cardiac Regeneration Research, Medical University of Innsbruck, Innsbruck, Austria
| | | | | | - Otilia Tica
- Cardiology Department, Emergency County Clinical Hospital of Oradea, Oradea, Romania
- Institute of Cardiovascular Sciences, University of Birmingham, Medical School, Birmingham, United Kingdom
| | - Konstantin A. Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
- Duke Clinical Research Institute Durham, NC, United States
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Carsten Skurk
- Department of Cardiology Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Allan Böhm
- Premedix Academy, Bratislava, Slovakia
- Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia
- Department of Acute Cardiology, National Institute of Cardiovascular Diseases, Bratislava, Slovakia
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14
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Thevathasan T, Füreder L, Donker DW, Nix C, Wurster TH, Knie W, Girke G, Al Harbi AS, Landmesser U, Skurk C. Case report: Refractory cardiac arrest supported with veno-arterial-venous extracorporeal membrane oxygenation and left-ventricular Impella CP ®-Physiological insights and pitfalls of ECMELLA. Front Cardiovasc Med 2022; 9:1045601. [PMID: 36407456 PMCID: PMC9674118 DOI: 10.3389/fcvm.2022.1045601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/19/2022] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION To the best of our knowledge, this is the first case report which provides insights into patient-specific hemodynamics during veno-arterio-venous-extracorporeal membrane oxygenation (VAV ECMO) combined with a left-ventricular (LV) Impella® micro-axial pump for therapy-refractory cardiac arrest due to acute myocardial infarction, complicated by acute lung injury (ALI). PATIENT PRESENTATION A 54-year-old male patient presented with ST-segment elevation acute coronary syndrome complicated by out-of-hospital cardiac arrest with ventricular fibrillation upon arrival of the emergency medical service. As cardiac arrest was refractory to advanced cardiac life support, the patient was transferred to the Cardiac Arrest Center for immediate initiation of extracorporeal cardiopulmonary resuscitation (ECPR) with peripheral VA ECMO and emergency percutaneous coronary intervention using drug eluting stents in the right coronary artery. Due to LV distension and persistent asystole after coronary revascularization, an Impella® pump was inserted for LV unloading and additional hemodynamic support (i.e., "ECMELLA"). Despite successful unloading by ECMELLA, post-cardiac arrest treatment was further complicated by sudden differential hypoxemia of the upper body. This so called "Harlequin phenomenon" was explained by a new onset of ALI, necessitating escalation of VA ECMO to VAV ECMO, while maintaining Impella® support. Comprehensive monitoring as derived from the Impella® console allowed to illustrate patient-specific hemodynamics of cardiac unloading. Ultimately, the patient recovered and was discharged from the hospital 28 days after admission. 12 months after the index event the patient was enrolled in the ECPR Outpatient Care Program which revealed good recovery of neurologic functions while physical exercise capacities were impaired. CONCLUSION A combined mechanical circulatory support strategy may successfully be deployed in complex cases of severe cardio-circulatory and respiratory failure as occasionally encountered in clinical practice. While appreciating potential clinical benefits, it seems of utmost importance to closely monitor the physiological effects and related complications of such a multimodal approach to reach the most favorable outcome as illustrated in this case.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
- Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Lisa Füreder
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk W. Donker
- Intensive Care Center, University Medical Centre Utrecht, Utrecht, Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, Netherlands
| | | | - Thomas H. Wurster
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Wulf Knie
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Girke
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Abdulla S. Al Harbi
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
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15
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Thevathasan T, Kenny MA, Krause FJ, Wurster TH, Friebel J, Knie W, Girke G, Balzer F, Landmesser U, Skurk C. Treatment with Impella and veno-arterial extracorporeal membrane oxygenation during cardiac arrest on survival in a multicenter cohort. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
International organisations advocate the use of extracorporeal cardio-pulmonary resuscitation (ECPR) with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients with therapy-refractory cardiac arrest [1–3]. Although VA-ECMO allows for full circulatory support, it is inherent to increased left ventricular (LV) pressure due to retrograde aortic perfusion, which may hamper myocardial recovery and aggravate pulmonary oedema. In order to mitigate these negative sequelae, adjunct LV unloading with an Impella microaxial flow pump may be considered. The effects of concomitant treatment with VA-ECMO and Impella (ECMELLA) in patients with therapy-refractory cardiac arrest due to acute myocardial infarction (AMI) remains unclear.
Objectives
To the best of our knowledge this is the first study to investigate whether treatment with ECMELLA is associated with improved 30-day mortality rate in patients with therapy-refractory cardiac arrest caused by AMI, compared to treatment with VA-ECMO alone.
Methods
Patients treated with ECMELLA were propensity score (PS)-matched to patients receiving VA-ECMO based on age, electrocardiogram (ECG) rhythm, cardiac arrest location (out-of-hospital or in-hospital) and Survival After Veno-Arterial ECMO (SAVE) score. Cox proportional-hazard and Poisson regression models were used to analyse 30-day mortality rate (primary outcome), hospital and intensive care unit (ICU) length of stay (LOS) (secondary outcomes). Multiple sensitivity analyses on patient demographics and cardiac arrest parameters were performed.
Results
95 adult patients from three tertiary care centers were included, out of whom 34 pairs were PS-matched. ECMELLA treatment was associated with 47% decreased 30-day mortality risk [95% Confidence Interval (CI) 0.31–0.91, P=0.021], 71% prolonged hospital [95% CI 1.50–1.95, P<0.001] and 81% prolonged ICU LOS [95% CI 1.57–2.08, P<0.001]. Kaplan-Meier analyses (Figure 1) and multiple sub-group analyses (age, sex, initial ECG rhythm, Charlson comorbidity index, body mass index, SAVE score, cardiac arrest location, lactate and pH levels) confirmed survival benefits in the ECMELLA group. Especially patients with prolonged low-flow time and high initial lactate benefited from ECMELLA therapy. Moreover, LV ejection fraction strongly improved in the ECMELLA group between ICU admission and ICU discharge from 15% to 40%, compared 15% and 20% in the VA-ECMO group.
Conclusion
In this multicenter propensity score-matched cohort of patients with ECPR during therapy-refractory cardiac arrest caused by AMI, treatment with ECMELLA was associated with improved survival compared to treatment with VA-ECMO alone. These findings support current guideline recommendations on early evaluation of ECPR in well selected patients with therapy-refractory cardiac arrest. A clinical trial is urgently needed to further evaluate the role of LV unloading in patients with therapy-refractory cardiac arrest.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- T Thevathasan
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - M A Kenny
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - F J Krause
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - T H Wurster
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - J Friebel
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - W Knie
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - G Girke
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - F Balzer
- Charite University Hospital, Institute of Medical Informatics , Berlin , Germany
| | - U Landmesser
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - C Skurk
- Charite University Hospital, Department of Cardiology , Berlin , Germany
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16
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Thevathasan T, Krause FJ, Paul J, Boie SD, Friebel J, Knie W, Girke G, Landmesser U, Balzer F, Skurk C. Impact of early readmission to the cardiac ICUon in-hospital mortality and hospital length of stay in 30,942 cardiac patients. Eur Heart J 2022. [PMCID: PMC9619528 DOI: 10.1093/eurheartj/ehac544.1494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The need for cardiac intensive care unit (ICU) beds remains high in order to monitor and treat emergency patients with severe cardiovascular diseases, particularly during the COVID-19 pandemic. Therefore, timely discharge strategies from the cardiac ICU to peripheral wards are crucial to meet the increasing demand for cardiac ICU beds. Early patient transfer from ICU to the peripheral ward may result in worsening of the patient's clinical condition and outcome with readmission to the ICU, while late transfer may require prolonged expert care and generate unwanted costs. Purpose To investigate whether unplanned readmission of cardiac patients to the cardiac ICU within 72 hours after the index ICU stay is associated with increased mortality risk (primary outcome) and prolonged total hospital length of stay (LOS) (secondary outcome), as well as to identify predictors of ICU readmission in cardiac patients. Methods Adult patients who were admitted to the cardiac ICU due to a primary cardiac admission diagnosis at a tertiary care center between 2003 and 2021 were included. Outcomes were analysed with multivariable regression models adjusted for 26 a priori defined variables on patient demographics, underlying comorbidity levels, ICU procedures and administered ICU drugs. Results 30,942 cardiac patients were included, out of whom 1,499 patients (4.84%) were readmitted to the cardiac ICU within 72 hours. 1,023 (68.2%) of readmitted patients were male. Compared to non-readmitted patients, readmitted patients were older, had more underlying comorbidities (Charlson Index), had more severe disease courses (SOFA score, TISS, APACHE II score and SAPS), as well as required more frequently vasopressor therapy, renal replacement therapy and coronary angiographies (Table 1). Readmission to the cardiac ICU was associated with higher in-hospital mortality risk (Odds Ratio 7.52, 95% Confidence Interval (CI) 4.15–12.27, P<0.001) and prolonged hospital LOS (Incidence Rate Ratio 1.56, 95% CI 1.15–1.58, P<0.001). Patients who were readmitted to the ICU had been discharged 18% earlier during the index ICU stay compared to non-readmitted patients (P<0.001). Of note, readmitted and non-readmitted patients had similar vital parameters at time of ICU discharge after their index ICU stay. During the index ICU stay, non-readmitted patients were prescribed more beta blockers (65.3% vs. 45.8%), ACE inhibitors (37.0% vs. 27.2%) and blood transfusions (10.7% vs. 7.7%). Conclusion Early readmission to the cardiac ICU was associated with increased in-hospital mortality and prolonged hospitalisation. Readmitted patients had been discharged earlier from their index ICU stay and required more comprehensive critical care. ICU discharge strategies should optimally be based on objective patient assessments to facilitate patient safety and shorten hospital length of stay. Artificial intelligence-based algorithms may support clinicians with safe ICU discharge. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- T Thevathasan
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - F J Krause
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - J Paul
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - S D Boie
- Charite University Hospital, Institute of Medical Informatics , Berlin , Germany
| | - J Friebel
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - W Knie
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - G Girke
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - U Landmesser
- Charite University Hospital, Department of Cardiology , Berlin , Germany
| | - F Balzer
- Charite University Hospital, Institute of Medical Informatics , Berlin , Germany
| | - C Skurk
- Charite University Hospital, Department of Cardiology , Berlin , Germany
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Thevathasan T, Colbatzky T, Schmelzle M, Pratschke J, Krenzien F. Risk factors for malignant transformation of hepatocellular adenoma to hepatocellular carcinoma: protocol for systematic review and meta-analysis. BMJ Open 2021; 11:e045733. [PMID: 34376442 PMCID: PMC8354264 DOI: 10.1136/bmjopen-2020-045733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Hepatocellular adenomas (HCAs) are solid liver tumours that are usually found incidentally during routine medical check-ups. Multiple modifiable and non-modifiable factors constitute a risk for the malignant transformation of HCAs to hepatocellular carcinoma (HCC), which has emerged to be one of the fastest growing causes of cancer-related mortality globally. This study protocol for a planned systematic review and meta-analysis documents the methodological approach to identify risk factors and their risk estimates for the transformation from HCA to HCC. METHODS AND ANALYSIS Two independent reviewers will systematically search and extract data from studies in patients of all ages published between January 1970 and June 2021 on PubMed, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus Web of Science, Ovid, The Cochrane Hepatobiliary Group Controlled Trials Register and The Cochrane Central Register of Controlled Trials by using an a priori defined search strategy. Study quality will be rated with the National Institute of Health quality assessment tools. Disagreements will be resolved by consensus with a third independent reviewer. The primary outcome will be the odds ratio (OR) of developing HCC in patients with prediagnosed HCA depending on the exposure to risk factors. HCC diagnosis must be inferred based on imaging techniques or pathology. We will use R V.4.0.2 to conduct meta-analyses and generate pooled ORs based on random effects models. Results will be presented as forest plots. Cochran's Q and I2 test will be performed to assess heterogeneity between included studies. Funnel plots and Egger's weighted regression will be used to evaluate publication bias. ETHICS AND DISSEMINATION No ethical approval is required as we will use and analyse data from previously published studies in which informed consent was obtained. The results will be disseminated in a peer-reviewed journal on completion. PROSPERO REGISTRATION NUMBER CRD42020206578.
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Affiliation(s)
| | - Teresa Colbatzky
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Thevathasan T, Copeland CC, Long DR, Patrocínio MD, Friedrich S, Grabitz SD, Kasotakis G, Benjamin J, Ladha K, Sarge T, Eikermann M. The Impact of Postoperative Intensive Care Unit Admission on Postoperative Hospital Length of Stay and Costs: A Prespecified Propensity-Matched Cohort Study. Anesth Analg 2019; 129:753-761. [PMID: 31425217 DOI: 10.1213/ane.0000000000003946] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In this prespecified cohort study, we investigated the influence of postoperative admission to the intensive care unit versus surgical ward on health care utilization among patients undergoing intermediate-risk surgery. METHODS Of adult surgical patients who underwent general anesthesia without an absolute indication for postoperative intensive care unit admission, 3530 patients admitted postoperatively to an intensive care unit were matched to 3530 patients admitted postoperatively to a surgical ward using a propensity score based on 23 important preoperative and intraoperative predictor variables. Postoperative hospital length of stay and hospital costs were defined as primary and secondary end points, respectively. RESULTS Among patients with low propensity for postoperative intensive care unit admission, initial triage to an intensive care unit was associated with increased postoperative length of stay (incidence rate ratio, 1.69 [95% CI, 1.59-1.79]; P < .001) and hospital costs (incidence rate ratio, 1.92 [95% CI, 1.81-2.03]; P < .001). By contrast, postoperative intensive care unit admission of patients with high propensity was associated with decreased postoperative length of stay (incidence rate ratio, 0.90 [95% CI, 0.85-0.95]; P < .001) and costs (incidence rate ratio, 0.92 [95% CI, 0.88-0.97]; P = .001). Decisions regarding postoperative intensive care unit resource utilization were influenced by individual preferences of anesthesiologists and surgeons. CONCLUSIONS In patients with an unclear indication for postoperative critical care, intensive care unit admission may negatively impact postoperative hospital length of stay and costs. Postoperative discharge disposition varies substantially based on anesthesia and surgical provider preferences but should optimally be driven by an objective assessment of a patient's status at the end of surgery.
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Affiliation(s)
- Tharusan Thevathasan
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Curtis C Copeland
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dustin R Long
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Maria D Patrocínio
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sabine Friedrich
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Stephanie D Grabitz
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - George Kasotakis
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston University School of Medicine, Boston, Massachusetts
| | - John Benjamin
- Department of Anesthesia, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Karim Ladha
- Department of Anesthesia and Pain Medicine, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Todd Sarge
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthias Eikermann
- Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
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Grabitz SD, Rajaratnam N, Chhagani K, Thevathasan T, Teja BJ, Deng H, Eikermann M, Kelly BJ. The Effects of Postoperative Residual Neuromuscular Blockade on Hospital Costs and Intensive Care Unit Admission: A Population-Based Cohort Study. Anesth Analg 2019; 128:1129-1136. [PMID: 31094777 DOI: 10.1213/ane.0000000000004028] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative residual neuromuscular blockade continues to be a frequent occurrence with a reported incidence rate of up to 64%. However, the effect of postoperative residual neuromuscular blockade on health care utilization remains unclear. We conducted a retrospective cohort study to investigate the effects of postoperative residual neuromuscular blockade on hospital costs (primary outcome), intensive care unit admission rate, and hospital length of stay (secondary outcomes). METHODS We performed a prespecified secondary analysis of data obtained in 2233 adult patients undergoing surgery under general anesthesia. Postoperative residual neuromuscular blockade was defined as a train-of-four ratio <0.9 in the postanesthesia care unit (PACU). Our confounder model adjusted for a variety of patient, surgical, and anesthesia-related factors. We fitted truncated negative binomial regression models for hospital cost and hospital length of stay analyses and a logistic regression model for our intensive care unit admission analysis. RESULTS Overall, 457 (20.5%) patients in our cohort had residual neuromuscular blockade on admission to the PACU. Postoperative residual neuromuscular blockade was not independently associated with increased hospital costs (adjusted incidence rate ratio, 1.04, CI, 0.98-1.11; P = .22). There were significantly higher odds of intensive care unit admission in those with postoperative residual neuromuscular blockade compared to those without (adjusted odds ratio, 3.03, CI, 1.33-6.87; P < .01). Further, we found a trend toward increased hospital length of stay in patients with postoperative residual neuromuscular blockade (adjusted incidence rate ratio, 1.09; P = .06). Sensitivity analysis using the same model in the day of surgery admissions and ambulatory surgery confirmed our findings. CONCLUSIONS Postoperative residual neuromuscular blockade at PACU admission was not significantly associated with increased hospital costs, but was associated with higher rates of intensive care unit admission. These findings support the view that clinicians should continue to work to reduce the rate of postoperative residual neuromuscular blockade.
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Affiliation(s)
- Stephanie D Grabitz
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nishan Rajaratnam
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Khushi Chhagani
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tharusan Thevathasan
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Bijan J Teja
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Hao Deng
- From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Barry J Kelly
- Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Friedrich S, Raub D, Teja BJ, Neves SE, Thevathasan T, Houle TT, Eikermann M. Effects of low-dose intraoperative fentanyl on postoperative respiratory complication rate: a pre-specified, retrospective analysis. Br J Anaesth 2019; 122:e180-e188. [PMID: 30982564 DOI: 10.1016/j.bja.2019.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/24/2019] [Accepted: 03/15/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Fentanyl is one of the most frequently administered intraoperative drugs and may increase the risk of postoperative respiratory complications (PRCs). METHODS We performed a pre-specified analysis of 145 735 adult non-cardiac surgical cases under general anaesthesia. Using multivariable logistic regression, we evaluated the association of intraoperative fentanyl dose and PRCs within 3 days after surgery (defined as reintubation, respiratory failure, pneumonia, pulmonary oedema, or atelectasis). We examined effect modification by patient characteristics, surgical site, and anaesthetics used. RESULTS PRCs within 3 days after surgery occurred in 18 839 (12.9%) patients. In comparison with high intraoperative fentanyl doses [median: 3.85; inter-quartile range (IQR): 3.42-4.50 μg kg-1, quartile 4 (Q4)], low intraoperative fentanyl dose [median: 0.80, IQR: 0.00-1.14 μg kg-1, quartile 1 (Q1)] was significantly associated with lower odds of PRCs [Q1 vs Q4: 10.9% vs 16.2%; adjusted odds ratio (aOR) 0.79; 95% confidence intervals (CI) 0.75-0.84; P<0.001; adjusted absolute risk difference (aARD) -1.7%]. This effect was augmented by thoracic surgery (P for interaction <0.001; aARD -6.2%), high doses of inhalation anaesthetics (P for interaction=0.016; aARD -2.2%) and neuromuscular blocking agents (NMBAs) (P for interaction=0.001; aARD -3.4%). Exploratory analysis demonstrated that compared with no fentanyl, low-dose fentanyl was associated with lower rates of PRCs (decile 2 vs decile 1: aOR 0.82, CI 0.75-0.89, P<0.001). CONCLUSIONS Intraoperative low-dose fentanyl (about 60-120 μg for a 70 kg patient) was associated with lower risk of postoperative respiratory complications compared with both no fentanyl and high-dose fentanyl. Beneficial effects of low-dose fentanyl were magnified in specific patient subgroups. CLINICAL TRIAL REGISTRATION NCT03198208.
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Affiliation(s)
- S Friedrich
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - D Raub
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B J Teja
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S E Neves
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - T Thevathasan
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - T T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Universitätsklinikum Essen, Essen, Germany.
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Fuchs G, Thevathasan T, Chretien YR, Mario J, Piriyapatsom A, Schmidt U, Eikermann M, Fintelmann FJ. Lumbar skeletal muscle index derived from routine computed tomography exams predict adverse post-extubation outcomes in critically ill patients. J Crit Care 2018; 44:117-123. [DOI: 10.1016/j.jcrc.2017.10.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/15/2017] [Accepted: 10/22/2017] [Indexed: 12/25/2022]
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Thevathasan T, Ruscic KJ, Eikermann M. Evolution of observational research and implementation science in neuromuscular pharmacology to improve the value of care. Br J Anaesth 2018; 120:605-606. [PMID: 29452822 DOI: 10.1016/j.bja.2017.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- T Thevathasan
- Department of Anaesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
| | - K J Ruscic
- Department of Anaesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anaesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA.
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Thevathasan T, Shih S, Safavi K, Berger D, Burns S, Grabitz S, Glidden R, Zafonte R, Eikermann M, Schneider J. Association between intraoperative non-depolarising neuromuscular blocking agent dose and 30-day readmission after abdominal surgery. Br J Anaesth 2017; 119:595-605. [DOI: 10.1093/bja/aex240] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2017] [Indexed: 01/16/2023] Open
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Anstey MH, Wibrow B, Thevathasan T, Roberts B, Chhangani K, Ng PY, Levine A, DiBiasio A, Sarge T, Eikermann M. Midodrine as adjunctive support for treatment of refractory hypotension in the intensive care unit: a multicenter, randomized, placebo controlled trial (the MIDAS trial). BMC Anesthesiol 2017; 17:47. [PMID: 28327122 PMCID: PMC5361788 DOI: 10.1186/s12871-017-0339-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients admitted to intensive care units (ICU) are often treated with intravenous (IV) vasopressors. Persistent hypotension and dependence on IV vasopressors in otherwise resuscitated patients lead to delay in discharge from ICU. Midodrine is an oral alpha-1 adrenergic agonist approved for treatment of symptomatic orthostatic hypotension. This trial aims to evaluate whether oral administration of midodrine is an effective adjunct to standard therapy to reduce the duration of IV vasopressor treatment, and allow earlier discharge from ICU and hospital. METHODS The MIDAS trial is an international, multicenter, randomized, double-blind, placebo-controlled clinical trial being conducted in the USA and Australia. We are targeting 120 patients. Adult patients admitted to the ICU who are resuscitated and otherwise stable on low dose IV vasopressors for at least 24 h will be considered for recruitment. Participants will be randomized to receive midodrine (20 mg) or placebo three times a day, in addition to standard care. The primary outcome is time (hours) from initiation of midodrine or placebo to discontinuation of IV vasopressors. Secondary outcomes include time (hours) from ICU admission to discharge readiness, ICU length of stay (LOS) (days), hospital LOS (days), rates of ICU readmission, and rates of adverse events related to midodrine administration. DISCUSSION Midodrine is approved by the Food and Drug Administration (FDA) for the treatment of symptomatic orthostatic hypotension. In August 2010, FDA proposed to withdraw approval of midodrine because of lack of studies that verify the clinical benefit of the drug. We obtained Investigational New Drug (IND 113,330) approval to study its effects in critically ill patients who require IV vasopressors but are otherwise ready for discharge from the ICU. A pilot observational study in a cohort of surgical ICU patients showed that the rate of decline in vasopressor requirements increased after initiation of midodrine treatment. We hypothesize that midodrine administration is effective to wean IV vasopressors and shorten ICU and hospital LOS. This trial may have significant implications on lowering costs of hospital care and obtaining FDA approval for new indications for midodrine. TRIAL REGISTRATION This study has been registered at clinicaltrials.gov on 02/09/2012 (NCT01531959).
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Affiliation(s)
- Matthew H Anstey
- Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Bradley Wibrow
- Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Tharusan Thevathasan
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | | | - Khushi Chhangani
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Pauline Yeung Ng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Alexander Levine
- Department of Pharmacy Practice and Administration, University of Saint Joseph, Hartford, CT, USA
| | - Alan DiBiasio
- Department of Pharmacy, Massachusetts General Hospital, Boston, USA
| | - Todd Sarge
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA. .,Universitaet Duisburg Essen, Klinik fuer Anaesthesiologie und Intensivmedizin, Essen, Germany.
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