The development of cardioplegia has facilitated complex cardiac surgery and allowed high-risk patients to safely tolerate life-saving procedures. By following the principles of electromechanical arrest, inducing hypothermia, and using adjunctive agents to help mitigate the effects of hypothermia and ischemia reperfusion injury, cardioplegia can be safely induced with various commercially available compositions, which can be delivered by several different surgical techniques. Although many studies have compared these methods, there is little consensus on whether any one method is superior to another. Just as a surgeon may need to modify technique according to individual patient factors, so too must a surgeon be flexible and be prepared to use different cardioplegia strategies according to the clinical circumstances. Increasing evidence shows the advantage of coronary artery bypass grafting (CABG) over percutaneous interventions in patients with low ejection fractions. Thus, optimal myocardial protection will continue to be necessary in this higher-risk cohort. Moreover, while patients in cardiogenic shock rarely present for CABG, the high mortality in this cohort demonstrates the need for ongoing efforts to improve myocardial protection. Lastly, there may be circumstances in which alternative approaches involving fibrillatory arrest or keeping the heart beating are more effective than conventional cardioplegia. These techniques should all be part of the surgeon’s armamentarium, enabling the surgeon to tailor the operation to the individual patient.

Existing literature evaluating the off-label use of midodrine has focused primarily on postoperative hypotensive patients requiring a single vasopressor. This study aimed to evaluate the impact of midodrine on vasopressor duration and length of stay in patients receiving vasopressors for sepsis-related hypotension. This is an institutional review board-approved, single-center, retrospective analysis of critically ill patients with hypotension secondary to sepsis who received midodrine and intravenous vasopressors compared to those who received intravenous vasopressors alone. Patients were matched by Acute Physiology and Chronic Health Evaluation II score, suspected source of infection, and presence of bacteremia. One hundred patients were included in this analysis. The median duration of vasopressors in the midodrine group (n = 50) was 36 hours (interquartile range [IQR] 18.94-61.94) compared to 26 hours (IQR 13.75-59.88) in the vasopressor-only group (P = .127). Patients in the midodrine group were in the intensive care unit (ICU) for a median of 3.9 days compared to 2.6 days in the vasopressor-only group (P = .017). Midodrine patients had a median hospital length of stay 3.7 days longer than the vasopressor-only group (P = .008). Eight patients (16%) were discharged on midodrine without an indication for therapy. This report assesses the use of midodrine in patients with sepsis requiring one or more vasopressors. Initiation of midodrine did not decrease the time to vasopressor discontinuation. The evaluation of midodrine indication and potential for its discontinuation is an intervention pharmacists can target at the transition of care from the ICU.

Acute valvular emergencies are common causes of cardiogenic shock. Patients with critical aortic pathologies causing shock frequently undergo percutaneous interventions for valve replacement. However, in cases of persistent cardiogenic shock after valve replacement, there are limited options for further mechanical support. In this case study, we report a patient with a prior history of aortic valve replacement who presented in cardiogenic shock. After a transcatheter aortic valve-in-valve replacement, he remained in persistent shock with worsening clinical parameters requiring escalating inotropic and vasopressor support. With input from a multidisciplinary care team, an Impella 5.5 (Abiomed, Inc.) was placed through the valve for mechanical circulatory support, ultimately serving as a bridge to a durable left ventricular assist device as destination therapy. This technically challenging approach was successful, and the patient was discharged to acute rehabilitation with improved symptoms.

Hyperthermia has been utilized for cancer therapy, including metastatic cancer, for decades with isolated success. Previous research has indicated that the elevated temperature of 42°C induces cell death, apoptosis, or senescence of responsive cancers, providing a mechanism for tumor destruction and management. Veno-venous perfusion-induced systemic hyperthermia (V-V PISH) may be the key to improving advanced tumor responsiveness to previously failed chemotherapy and/or radiation as combination therapy. The most recent iteration of V-V PISH, Hyperthermic Extracorporeal Applied Tumor Therapy (HEATT®), provides homogeneous heating of all tissues with electrolyte and pH control and continues to prove safe and effective. The utilization of HEATT® in advanced, unresponsive cancers should be further explored as a part of integrative oncology care.

Hemodynamics play an important role in cardiogenic shock assessment for prognosis estimation and for phenotyping cardiogenic shock. This is best done by pulmonary artery catheters. In general, at the beginning of cardiogenic shock, patients have vasoconstriction, which over time may lead to vasodilation. This is often triggered by percutaneous mechanical circulatory support. This review will elucidate the hemodynamics and the factors that possibly lead to vasodilation in patients with mechanical circulatory support.

The right ventricle is highly sensitive to afterload, and pulmonary compromise can increase pulmonary vascular resistance and lead to right ventricular dysfunction. Pulmonary hypertension can also be exacerbated by mechanical ventilation. Patients with COVID-19 pneumonia and respiratory failure, especially those ventilated with positive end-expiratory pressure, are prone to pulmonary hypertension. Understanding their right ventricular hemodynamics can have therapeutic and prognostic implications.

Patients with coronavirus disease of 2019 (COVID-19) may present with a wide range of symptoms ranging from asymptomatic to critically ill. Approximately 10-14% of patients require hospitalization. Those individuals requiring hospitalization can deteriorate rapidly with worsening hypoxemia or new-onset pneumonia, resulting in 20-30% of patients developing acute respiratory distress syndrome (ARDS). When refractory to medical management, severe ARDS secondary to other illnesses has been successfully treated with extracorporeal membrane oxygenation (ECMO). We completed a comprehensive literature review of ECMO utilization for patients with severe COVID-19 who were unresponsive to critical care management. Of the 1419 patients with a reported diagnosis of COVID-19-related ARDS requiring ECMO therapy, 53.6% were discharged alive, 8.4% remained on ECMO in the intensive care unit, and 43.0% are deceased. These results are similar to the discharge rate of 60% for patients with non-COVID-related ARDS treated with ECMO. Data reported by the Extracorporeal Life Support Organization notes that 49% of patients with COVID-19 ARDS were discharged alive, 38% of whom were discharged home or to a long-term facility, and 11% were discharged to another hospital. In summary, using ECMO to treat patients with severe ARDS unresponsive to critical care management yields similar results in both non-COVID and COVID-related ARDS.

The Surviving Sepsis Guidelines can serve as a structure to help educate and create a set of recommendations on how to care for patients through this complicated pathway of shock. Designing a cardiogenic shock bundle could reduce the variability of care and possibly improve survival. Also, a more standard protocol would allow a review of the outcomes and a system to change practice nationally when new data or technology becomes available. This could create a continuous quality improvement cycle. Creating a “Surviving Cardiogenic Shock” system could help provide awareness for recognition of cardiogenic shock and advanced management alternatives needed at level one and two hospitals. The creation of cardiogenic shock systems of care would support smaller hospitals with a Hub and Spoke structure. Cardiogenic shock is not septic shock, but those in cardiology and cardiac critical care can and should take lessons from the Surviving Sepsis Campaign.