Acute Hemodynamic Decompensation Research Articles

First experiences with protected VT ablation using surgical Impella 5.5

Abstract Introduction Ablation of ventricular arrhythmias (VA) is still challenging due to the complex substrate of the underlying heart disease. Depending on specific risk factors acute hemodynamic decompensation during or after VT ablation procedures may occur and hemodynamic support may be required. Protected VA ablation with different devices has been evaluated but associated complications like bleeding, vascular closure or weaning from the device have been restrictive. We present data on a dedicated approach to patients with anticipated hemodynamic deterioration using preventive surgical Impella support. Method 5 patients (2 female) underwent protected VT ablation under our standardized protocol. Indication for Impella support was severely impaired left ventricular function and multiple medical therapy refractory ventricular arrhythmias. 4 patients had conventional VT ablation before. Mean age was 66,8 years, mean CHADSVASC 4,4, 1 patient with non-ischemic cardiomyopathy (CMP), 1 with hypertrophic non-obstructive CMP, 3 patients with ischemic CMP. Mean EF was 20%, mean mixed venous saturation was 36 %, mean PAINESD score 27. In all patients a 5.5. Impella was implanted surgically 1 day before planned VT ablation via the right subclavian artery. VT ablation procedure started with substrate mapping, VT induction and activation mapping of the inducible VT to identify the critical VT isthmus. Ablation was directed to dissection of the critical isthmus of inducible VAs and elimination of all late potentials within low voltage areas. The Impella device was explanted after weaning off the hemodynamic support. Results Implantation of Impella 5.5 was successfully performed in all patients in general anesthesia without any complication via surgical approach. Specifically, no access site vascular complications were noted. In 4 patients the VT ablation procedure was performed in analgosedation, 1 patient in GA as this patient was intubated due to recurrent VA requiring defibrillation. Mean procedure time was 125 min, radiation time 1,3 min, inducible VTs 1,3 , median 2 morphologies. In all patients all inducible VTs could be eliminated, in 1 patient polymorphic VA was still inducible at the end of the procedure. Impella was explanted after mean 5,2 days (3-11 days). No complications occurred. All patients were discharged alive on heart failure medication and in 2 patients with amiodaron. At a mean follow up of 3.5 months, all patients are alive without VA recurrence and heart failure decompensation. Conclusion Surgical Impella implantation for protected VT ablation in severe heart failure patients is feasible and allows for effective VT mapping and ablation. Access site safety and protection for heart failure decompensation in addition to the possibility of individually mobilisation and weaning after the procedure make this protocol an attractive option. Prospective evaluation of standardized indication is needed.

Mechanical Circulatory Support Systems in the Management of Ventricular Arrhythmias: A Contemporary Overview.

Ventricular tachycardias (VTs) and electrical storms (ES) are life-threatening conditions mostly seen in the setting of structural heart disease (SHD). Traditional management strategies, predominantly centered around pharmacological interventions with antiarrhythmic drugs, have demonstrated limited efficacy in these cases, whereas catheter ablation is related with more favorable outcomes. However, patients with hemodynamically unstable, recurrent VT or ES may present cardiogenic shock (CS) that precludes the procedure, and catheter ablation in patients with SHD portends a multifactorial intrinsic risk of acute hemodynamic decompensation (AHD), that is associated with increased mortality. In this setting, the use of mechanical circulatory support (MCS) systems allow the maintenance of end-organ perfusion and cardiac output, improving coronary flow and myocardial mechanics, and minimizing the effect of cardiac stunning after multiple VT inductions or cardioversion. Although ablation success and VT recurrence are not influenced by hemodynamic support devices, MCS promotes diuresis and reduces the incidence of post-procedural kidney injury. In addition, MCS has a role in post-procedural mortality reduction at long-term follow-up. The current review aims to provide a deep overview of the rationale and modality of MCS in patients with refractory arrhythmias and/or undergoing VT catheter ablation, underlining the importance of patient selection and timing for MCS and summarizing reported clinical experiences in this field.

Substrate Imaging Before Catheter Ablation of Ventricular Tachycardia: Risk Prediction for Acute Hemodynamic Decompensation

BackgroundThe PAINESD (Pulmonary disease, Age, Ischemic cardiomyopathy, NYHA functional class, Ejection fraction, Storm, Diabetes mellitus) risk score has been validated as a predictor of periprocedural acute hemodynamic decompensation (AHD) in patients undergoing ventricular tachycardia (VT) ablation. Whether the addition of total scar volume (TSV) determined by preprocedure computed tomography imaging provides additional risk stratification has not been previously investigated. ObjectivesThe purpose of this study was to evaluate the impact of TSV on the risk of AHD and its adjunctive benefit to the PAINESD score newly modified as Pulmonary disease, Age, Ischemic cardiomyopathy, NYHA class, Ejection fraction, Storm, Scar volume, Diabetes mellitus (PAINES2D) based on the addition of scar volumes. MethodsThis was a retrospective analysis of all index VT ablations at a quaternary care center from 2017 to 2022. Associations between TSV and AHD were evaluated among patients with structural heart disease. ResultsAmong 61 patients with TSV data, 13 (21%) had periprocedural AHD. TSV and PAINESD were independently associated with AHD risk. Both TSV and PAINESD were associated with AHD (P = 0.016 vs P = 0.053, respectively). The highest TSV tertile (≥37.30 mL) showed significant association with AHD (P = 0.018; OR: 4.80) compared to the other tertiles. The PAINESD and PAINES2D scores had significant impact on AHD (P = 0.046 and P = 0.010, respectively). The PAINES2D score had a greater impact on AHD compared to PAINESD (area under the curve: 0.73; P = 0.011; 95% CI: 0.56-0.91 and area under the curve: 0.67; P = 0.058; 95% CI: 0.49-0.85, respectively). ConclusionsAddition of TSV to a modified PAINESD score, PAINES2D, enhances risk prediction of AHD. Further prospective study is needed to assess benefit in various cardiomyopathy populations undergoing VT ablation.

Periprocedural acute hemodynamic decompensation associated with substrate-based ablation of ventricular tachycardia in patients with structural heart disease - rare and nonpredictable event

Abstract Funding Acknowledgements Type of funding sources: None. Background Radiofrequency (RF) catheter ablation is an established treatment method in patients with structural heart disease (SHD) and recurrent ventricular tachycardia (VT). Due to underlying SHD, concomitant heart failure and a high burden of comorbidities, these patients are at considerable risk of periprocedural complications including acute hemodynamic decompensation (AHD) with a reported rate of up to 11%. The PAINESD score [sum of 5, 3, 6, 6, 3, 5, and 3 points for chronic obstructive pulmonary disease (COPD), age >60 years, ischemic cardiomyopathy (ICM), NYHA Class >2, LV ejection fraction (LVEF) <25%, electrical storm (ES), and diabetes mellitus (DM), respectively] was proposed to predict the risk of AHD, and identify the patients who may benefit from pre-emptive use of percutaneous left ventricular assist device (pVAD). Purpose The single-centre, retrospective study investigated the incidence of AHD in large-volume, tertiary referral EP centre and the predictive power of the PAINESD score. Methods We included patients who had their first ablation for SHD-related VT between August 2006 and December 2020. The procedure was performed under conscious sedation except for patients who were on mechanical ventilation because of hemodynamical or electrical instability before the ablation. Substrate mapping/ablation was performed primarily during spontaneous rhythm or right-ventricular pacing. Induced VTs were terminated by overdrive pacing or cardioverted. Activation and entrainment mapping were used rarely – only in well-tolerated VTs. The goal of ablation was to abolish all inducible VTs. A purposely established institutional registry for complications of invasive procedures was used to collect all periprocedural complications that were subsequently adjudicated using the source medical records. AHD triggered by ablation procedure was defined as intraprocedural or early post-procedural (<12 h) development of acute pulmonary oedema or refractory hypotension, requiring urgent intervention including (but not limited to) inotropic agents and/or artificial ventilation and/or pVAD implant. Results The study cohort consisted of 1143 patients (age: 63±13 years, males: 87%, ICM: 67%, ES: 25%, NYHA Class: 2.1±1.0, LVEF: 34±13%, DM: 32%, COPD: 12%). Their PAINESD score was 11.4±6.6 (median: 12, interquartile range: 6–17). The ablation procedure (total duration 187±78 min, RF time: 23±15 min) was complicated by AHD in 13/1143 = 1.1% patients and these adverse events were not predicted by PAINESD score (Figure). Conclusions We observed a substantially lower rate (1.1%) of AHD than previously reported (up to 11%). These events did not accumulate in patients with upper-tertile PAINESD score in whom the highest AHD risk was reported (up to 24%). This observation may be explained by careful substrate-based ablation under conscious sedation that prevents prolonged low-output state related to repeated VT induction and mapping in general anaesthesia.

PO-05-039 PERIPROCEDURAL ACUTE HEMODYNAMIC DECOMPENSATION ASSOCIATED WITH SUBSTRATE-BASED ABLATION OF VENTRICULAR TACHYCARDIA IN PATIENTS WITH STRUCTURAL HEART DISEASE – RARE AND NONPREDICTABLE EVENT

Patients with structural heart disease (SHD) and recurrent ventricular tachycardia (VT) are at considerable risk of periprocedural complications of radiofrequency (RF) catheter ablation including acute hemodynamic decompensation (AHD). The PAINESD score [sum of 5, 3, 6, 6, 3, 5, and 3 points for chronic obstructive pulmonary disease (COPD), age >60 years, ischemic cardiomyopathy (ICM), NYHA Class >2, LV ejection fraction (LVEF) <25%, electrical storm (ES), and diabetes mellitus (DM), respectively] was proposed to predict the risk of AHD, and identify the patients who may benefit from pre-emptive use of percutaneous left ventricular assist device (pVAD). The single-center, retrospective study investigated the incidence of AHD in large-volume, tertiary referral EP center and the predictive power of the PAINESD score. We included patients who had their first ablation for SHD-related VT between August 2006 and December 2020. The procedure was performed under conscious sedation except for patients who were on mechanical ventilation because of hemodynamical or electrical instability before the ablation. Substrate mapping/ablation was performed primarily during spontaneous rhythm or right-ventricular pacing. Activation and entrainment mapping were used rarely, only in well-tolerated VTs. The goal of ablation was to abolish all inducible VTs. AHD triggered by ablation procedure was defined as intra- or early post-procedural (<12 h) development of acute pulmonary oedema or refractory hypotension, requiring urgent intervention like inotropic agents and/or artificial ventilation and/or pVAD implant. The study cohort consisted of 1143 patients (age: 63±13 years, males: 87%, ICM: 67%, ES: 25%, NYHA Class: 2.1±1.0, LVEF: 34±13%, DM: 32%, COPD: 12%). Their PAINESD score was 11.4 ± 6.6 (median: 12, interquartile range: 6–17). The ablation procedure (total duration 187±78 min, RF time: 23±15 min) was complicated by AHD in 13/1143 = 1.1% patients and these adverse events were not predicted by PAINESD score (Figure). We observed a substantially lower rate (1.1%) of AHD than previously reported (up to 11%). These events did not accumulate in patients with upper-tercile PAINESD score in whom the highest AHD risk was reported (up to 24%). This observation may be explained by careful substrate-based ablation under conscious sedation that prevents prolonged low-output state related to repeated VT induction and mapping in general anesthesia.

Novel Pharmacomechanical Thrombolysis for Treating Intermediate-Risk Acute Pulmonary Embolism: The Bashir Endovascular Catheter.

Novel Pharmacomechanical Thrombolysis for Treating Intermediate-Risk Acute Pulmonary Embolism: The Bashir Endovascular Catheter.

Prophylactic mechanical circulatory support for protected ventricular tachycardia ablation: A meta-analysis of the literature.

Acute hemodynamic decompensation (AHD) during ventricular tachycardia (VT) ablation occurs in about 11% of cases. Prophylactic use of temporary mechanical circulatory support (pro-tMCS) has been applied to prevent AHD during VT ablation, but evidence supporting this practice is still lacking. This systematic review and meta-analysis assessed the procedural characteristics and outcomes of pro-tMCS for VT ablation. PubMed/Medline was screened until February 2020. Articles including adults receiving pro-tMCS for VT ablation were included, and a meta-analysis to compare proMCS and no-tMCS was performed. Primary outcome was in-hospital/30-day mortality. Five observational studies presenting 400 procedures (pro-tMCS: n=187; no-tMCS: n=213) were included. Baseline characteristics were comparable between groups. Impella and TandemHeart were used in 86.6% and 13.4% of cases, respectively. In the pro-tMCS group, more VTs were induced (mean difference: 0.52, confidence interval [CI]: 0.26-0.77, P<.0001), and patients remained in VT on average for 24.04minutes longer (CI: 18.28-29.80, P<.00001). Procedural success was comparable between groups, as was VT recurrence. Pro-tMCS patients had an odds ratio of 0.55 (CI: 0.28-1.05, P=.07) for in-hospital/30-day mortality and 0.55 (CI: 0.32-0.94, P=.03) for mortality at follow-up. Sixty-four percent of no-tMCS patients received rescue tMCS. The most common tMCS-related complications were bleeding events. Pro-tMCS allowed for a prolonged time on VTs and the induction of more VTs. Although these advantages were not associated with differences in procedural success, VT recurrence, or in-hospital/30-day mortality in the overall population, pro-tMCS might improve long-term survival. Further prospective studies are urgently needed to confirm these results.

Periprocedural Acute Kidney Injury in Patients With Structural Heart Disease Undergoing Catheter Ablation of VT.

This study sought to examine the impact of periprocedural acute kidney injury (AKI) in scar-related ventricular tachycardia (VT) patients undergoing radiofrequency catheter ablation (RFCA) on short- and long-term outcomes. The clinical significance of periprocedural AKI in patients with scar-related VT undergoing RFCA has not been previously investigated. This study included 317 consecutive patients with scar-related VT undergoing RFCA (age: 64 ± 13 years, mean left ventricular ejection fraction: 33 ± 13%, 55% ischemic cardiomyopathy). Periprocedural AKI was defined as an absolute increase in creatinine of≥0.3mg/dl over 48h or an increase of >1.5× the baseline values within 1week post-procedure. Periprocedural AKI occurred in 31 patients (10%). Independent predictors of AKI included chronic kidney disease (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 1.48 to 7.96; p=0.004), atrial fibrillation (OR: 2.42; 95%CI: 1.01 to 5.78; p=0.047), and peri-procedural acute hemodynamic decompensation (OR: 3.98; 95%CI: 1.17 to 13.52; p=0.003). After a median follow-up of 39months (interquartile range: 6 to 65months), 95 patients (30%) died. Periprocedural AKI was associated with increased risk of early mortality (within 30days; hazard ratio [HR]: 9.91; 95%CI: 2.87 to 34.22; p<0.001) and late mortality (within 1 year) (HR: 4.57; 95%CI: 2.08 to 10.05; p<0.001). After multivariable adjustment, AKI remained independently associated with increased risk of early and late mortality (HR: 4.49; 95%CI: 1.1 to 18.36; p=0.04, and HR: 3.28; 95%CI: 1.43 to 7.49; p=0.005, respectively). Periprocedural AKI occurs in 10% of patients undergoing RFCA of scar-related VT and is strongly associated with increased risk of early and late post-procedural mortality.

EkoSonic® endovascular system and other catheter-directed treatment reperfusion strategies for acute pulmonary embolism: overview of efficacy and safety outcomes

ABSTRACT Introduction Studies performed in the past decade suggested that evolving reperfusion strategies may improve early outcomes of patients with acute pulmonary embolism (PE) and hemodynamic decompensation. In this regard, catheter-directed treatment (CDT) options are receiving increasing attention. Areas covered A broad spectrum of CDT options exists for the treatment of patients with acute PE. Procedures include catheter-directed local thrombolysis with or without ultrasound assistance, catheter-directed mechanical or suction embolectomy, and combined pharmaco-mechanical approaches. We present here an overview of the available CDT techniques, focusing on the EkoSonic® endovascular system. Expert commentary CDT, particularly local ultrasound accelerated thrombolysis, continues to evolve. Its increasing popularity is the result of accumulating promising results, which suggest a relief of right ventricular (RV) pressure overload and improvement of RV function. These favorable effects on surrogate endpoints were accompanied by a low rate of procedure-related adverse events, notably intracranial hemorrhage. Although the overall risk of serious bleeding appears to be low in CDT, the lack of direct comparisons with other reperfusion options does not allow definitive conclusions. Prospective controlled trials with robust clinical outcomes are urgently needed to establish the postulated benefits of CDT in selected patients with acute PE.

Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features.

Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.

Effectiveness of a percutaneous left ventricular assist device in preventing acute hemodynamic decompensation during catheter ablation of ventricular tachycardia in advanced heart failure patients: A retrospective single-center analysis.

Acute hemodynamic decompensation during catheter ablation of ventricular tachycardia is associated with increased mortality. We assessed the effectiveness of mechanical circulatory support using a micro-axial percutaneous assist device in preventing acute hemodynamic decompensation. Twenty-six consecutive patients with structural heart disease undergoing 28 ventricular tachycardia ablations between May 2013 and October 2017 were included. All patients presenting with left ventricular ejection fraction <25%, symptomatic heart failure and arrhythmia associated hemodynamic decompensation underwent catheter ablation with mechanical circulatory support (Impella 2.5; Impella CP, Abiomed, Danvers, MA). Electro-anatomic mapping was performed using Ensite NavX (Abbott, Chicago, IL) or Rhythmia (Boston Scientific, Marlborough, MA) mapping systems. Mapping/ablation strategy included a substrate and activation mapping/ablation. Of the 26 patients, 80% had ischemic cardiomyopathy, the mean age was 68 ± 9 years; mean left ventricular ejection fraction 19.6% ± 3%, mean PAAINESD score was 21 ± 3. Mean tachycardia cycle length was 348 ± 76 ms (range 280-500 ms). The assist device was used pre-emptively in 25 patients and as rescue therapy in one patient. All ventricular tachycardias occurring during substrate ablation were activation mapped and ablated. The ablation procedure was accomplished in 25 of 26 patients, acute decompensation occurred only in one patient receiving circulatory support as bail-out therapy. In patients with advanced heart failure and a high probability of acute hemodynamic decompensation during catheter ablation, mechanical circulatory support prevented acute decompensation in 25 of 26 patients. Thus, mechanical circulatory support facilitates catheter ablation of unstable ventricular tachycardia in a critically ill patient population.

Intraprocedural slow continuous ultrafiltration: A novel strategy to prevent acute hemodynamic decompensation from volume overload during VT ablation.

Intraprocedural slow continuous ultrafiltration: A novel strategy to prevent acute hemodynamic decompensation from volume overload during VT ablation.

Metabolic Response of the Immature Right Ventricle to Acute Pressure Overloading.

BackgroundSurgical palliation or repair of complex congenital heart disease in early infancy can produce right ventricular (RV) pressure overload, often leading to acute hemodynamic decompensation. The mechanisms causing this acute RV dysfunction remain unclear. We tested the hypothesis that the immature right ventricle lacks the ability to modify substrate metabolism in order to meet increased energy demands induced by acute pressure overloading.Methods and ResultsTwenty‐two infant male mixed breed Yorkshire piglets were randomized to a sham operation (Control) or pulmonary artery banding yielding >2‐fold elevation over baseline RV systolic pressure. We used carbon 13 (13C)‐labeled substrates and proton nuclear magnetic resonance to assess RV energy metabolism. [Phosphocreatine]/[ATP] was significantly lower after pulmonary artery banding. [Phosphocreatine]/[ATP] inversely correlated with energy demand indexed by maximal sustained RV systolic pressure/left ventricular systolic pressure. Fractional contributions of fatty acids to citric acid cycle were significantly lower in the pulmonary artery banding group than in the Control group (medium‐chain fatty acids; 14.5±1.6 versus 8.2±1.0%, long‐chain fatty acids; 9.3±1.5 versus 5.1±1.1%). 13C‐flux analysis showed that flux via pyruvate decarboxylation did not increase during RV pressure overloading.ConclusionsAcute RV pressure overload yielded a decrease in [phosphocreatine]/[ATP] ratio, implying that ATP production did not balance the increasing ATP requirement. Relative fatty acids oxidation decreased without a reciprocal increase in pyruvate decarboxylation. The data imply that RV inability to adjust substrate oxidation contributes to energy imbalance, and potentially to contractile failure. The data suggest that interventions directed at increasing RV pyruvate decarboxylation flux could ameliorate contractile dysfunction associated with acute pressure overloading.

Outcomes with prophylactic use of percutaneous left ventricular assist devices in high-risk patients undergoing catheter ablation of scar-related ventricular tachycardia: A propensity-score matched analysis

The PAINESD score predicts the risk of periprocedural acute hemodynamic decompensation (AHD) and postprocedural mortality in patients undergoing catheter ablation (CA) of scar-related ventricular tachycardia (VT). The role of prophylactic placement of percutaneous left ventricular assist devices (pLVADs) in high-risk patients is unknown. The purpose of this study was to evaluate the outcomes of prophylactic use of pLVAD in high-risk patients undergoing CA of scar-related VT. We included 75 patients undergoing CA of scar-related VT in whom a prophylactic pLVAD was implanted because of perceived high risk. The control population was a propensity-matched group of 75 patients who did not undergo prophylactic pLVAD placement. The PAINESD score was used for propensity matching. The median PAINESD score was 13 (41% with score ≥15) in the prophylactic pLVAD group and 12 (40% with score ≥15) in the control group. Periprocedural AHD occurred in 5 patients (7%) in the prophylactic pLVAD group and in 17 patients (23%) in the control group (P < .01). The 12-month cumulative incidence of VT was 40% in the prophylactic pLVAD group vs 41% in the control group (P = .97), while the 12-month incidence of death/transplant was 33% vs 66%, respectively (P < .01). In multivariable analysis, left ventricular ejection fraction (HR 0.97, 95% CI 0.95-0.99, P = .03), chronic kidney disease (HR 2.24, 95% CI 1.35-3.72, P < .01), VT recurrence (HR 2.33, 95% CI 1.31-4.14, P < .01), and prophylactic pLVAD (HR 0.28, 95% CI 0.16-0.49, P< .01) were all independently associated with death/transplant. Prophylactic pLVAD placement in high-risk patients undergoing CA of scar-related VT is associated with a reduced risk of AHD and death/transplant during follow-up without affecting VT-free survival.

Outcomes of rescue cardiopulmonary support for periprocedural acute hemodynamic decompensation in patients undergoing catheter ablation of electrical storm

In patients with ventricular tachycardia or ventricular fibrillation (VT/VF) electrical storm (ES) undergoing catheter ablation (CA), hypotension due to refractory VT/VF, use of anesthesia, and cardiac stunning due to repeated implantable cardioverter-defibrillator shocks might precipitate acute hemodynamic decompensation (AHD). We evaluated the outcomes of emergent cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) to rescue AHD in patients undergoing CA of ES. Between January 1, 2010 and December 31, 2016, 21 patients with ES (VT in 11 and premature ventricular complex-triggered VF in 10) were referred for CA and had periprocedural AHD requiring emergent ECMO support. In 14 patients, AHD occurred a mean of 1.5 ± 1.7 days before the procedure. In the remaining 7 patients, AHD occurred during or shortly after the procedure. ECMO was started successfully in all patients. Ablation was performed in 18 patients (9 with VF and 9 with VT). In patients with VF, premature ventricular complex suppression was achieved in 8 of 9 (89%). In those with VT, noninducibility was achieved in 7 of 9 (78%). After a median follow-up of 10 days, 16 patients died (13 during the index admission). Death was due to refractory VT/VF in 4 patients, heart failure in 11, and noncardiac cause in 1 patient. Seven patients survived beyond 6 months postablation; 5 remained free of VT/VF and 3 ultimately received a destination therapy (heart transplantation in 2 and left ventricular [LV] assist device in 1). In patients with ES undergoing CA, the outcomes of ECMO support as rescue intervention for AHD are poor. The majority of these patients die of refractory heart failure in the short-term. Strategies to prevent AHD including preemptive use of hemodynamic support may improve survival.

Hypoplastic Left Heart Syndrome and Other Shunt-Dependent Single Ventricles.

In this review, we discuss the pathophysiology, treatment, and outcomes of patients with the hypoplastic left heart syndrome and other single ventricle variants prior to and following surgery. MEDLINE and PubMed. Patients with shunted single ventricle physiology are at increased risk for acute hemodynamic decompensation owing to the increased myocardial workload, the dynamic balance between systemic and pulmonary circulations, and the potential for shunt obstruction. Understanding of the physiology and anticipatory management are critical to prevent hemodynamic compromise and cardiac arrest.

Mediastinal Mass Excision-Simple and Safe in Non-specialised Centres

Introduction: The mediastinum is a site for a wide range of various neoplasms, with often rare histologies[1,2], imposing both diagnostic and therapeutic challenges. Particularly large mediastinal masses, or intrathoracic masses with mediastinal compression, offer surgical challenges, due to the complex anatomy of the mediastinum, with obstruction, compression, or invasion of vital surrounding structures. In addition, anesthesiological management during surgery can be complicated by the so-called “Mediastinal Mass Syndrome” (MMS)[3], characterized by acute respiratory and hemodynamic decompensation, due to mechanical compression of mediastinal structures. Therefore, meticulous preoperative assessment, preparation and collaboration between the surgeon and anesthesiologist are essential. Case Presentation: A 26-year old man asymptomatic presented to our hospital with obliteration of the right cardiophrenic sinus by a mass on Chest X-ray (Figure 1). He has no history of fever, weight loss, previous disease, or any neoplasm in his family. A noninvasive investigation CECT of chest demonstrated a tumoral mass which was continuous to the pericardium and caused extrinsic compression to the SVC and right atrium (Figure 2). The diagnosis of this tumor is very difficult through non-invasive investigation. The patient underwent surgical resection en-block via right thoracotomy (Figure 3). Slow and meticulous dissection is must to remove the mass encapsulated without causing it to rupture (Figure 4). Suspicion was a thymoma but surgical and anatomopathologic findings led to the diagnosis of a mature cystic teratoma (Figure 5). Discussion: The typical radiographic appearance of mature teratoma is that of a rounded, sometimes lobulated anterior mediastinal mass with the borders of the mass sharply marginated against the adjacent lung. Calcification has been reported in approximately 20-43% of cases and may be central, curvilinear, or peripheral (Michel et al.) [4]. The radiographic visualization of teeth is pathognomonic of teratoma (Rosai and Levine) [5]. Computed Tomography (CT) is the modality of choice for the diagnostic evaluation of these tumors. Meditational mature teratomas typically manifest on CT as heterogeneous sharply marginated, spherical or lobulated anterior mediastinal masses containing soft tissue, fluid, fat, or calcium attenuation, or any combination of the four. Malignant transformation must be ruled out if contrast enhanced CT scanning reveals a non-homogeneous cystic mass with a fat or oil component and a thick wall with calcification with invasion of the pericardium and great vessels (Dobranowski et al.) [6]. The patient underwent surgical excision. The treatment of mature teratoma consists of complete surgical excision of the mass. The prognosis is very good and 5 year survival rates approach 100%, in contrast to the prognosis of immature teratomas, which may exhibit an aggressive behaviour in adults and may have a poor prognosis (Hueb et al.) [7]. Conclusion: In the perioperative management of surgical treatment of large mediastinal masses or intrathoracic tumors with mediastinal compression, attention to anatomical details of the tumor and it relations with vital mediastinal surrounding structures is essential. Preoperative preparation measures include appropriate preoperative multimodality imaging, with emphasis on the vascular anatomy of the tumor. Multidisciplinary team discussions should assess whether neoadjuvant therapy can be beneficial on a case-by-case basis. With adequate preoperative team planning, a safe anesthesiological and surgical strategy can be realized. The management of these tumors are simple and safe if properly planned and with good anatomical knowledge and technique surgical excision can be done in nonspecialized centers.

Predictors of Acute Hemodynamic Decompensation in Early Sepsis: An Observational Study.

BackgroundThe study of sepsis is hindered by its heterogeneous time course and evolution. A subgroup of patients with severe sepsis develops shock soon after the initiation of treatment while others present hypotensive. We sought to determine the incidence of hypotension after the initiation of treatment for sepsis, and characterize their clinical features and course.MethodsA retrospective review of electronic medical record of all septic patients (n = 542) that met the definition of septic shock within 24 hours of admission (2011 - 2012) at an urban Veteran Affairs Hospital was performed. Subjects either had 1) initial normotension (INT) with hypotension developing within 24 hours or 2) initial hypotension (IH). Logistic regression was used to model associated factors of INT/IH.ResultsINT occurred in 62 patients (11%) with average initial blood pressure of 120/71 mm Hg and developed hypotension to 79/48 mm Hg. IH was identified in 52 patients (10%) with average presenting blood pressure of 81/46 mm Hg. INT showed evidence of increased sympathetic tone with significantly higher heart rate, blood pressure and temperature. INT patients were younger, more frequently on alpha-blockers, and more likely septic from pneumonia compared to IH patients. INT and IH patients had similar timing of antibiotic initiation, amount of 24-hour fluid resuscitation, vasopressor use, organ dysfunction and mortality at 28 days. Using alpha-blockers, being Caucasian, and having higher temperatures were independent predictors of INT.ConclusionINT is a distinctive presentation of septic shock characterized by rapid deterioration during early treatment. By further studying this subgroup, mediators of septic shock may be identified that clarify pathophysiology and provide timely targeted treatment.

EaRly-start ExerciSe training afTer acute hemodynAmic decompensation in patients with chRonic hearT failure (RE-START). A multicenter, randomized, controlled trial on short-term feasibility and impact on functional capacity, symptoms and neurohumoral activation .

RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an early-start AET program on functional capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient-reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP > 1000 pg/mI at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine > 2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6-min WT at day 1, 6, 12 and 30 and echocardiogram, patient-reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.

Near-Fatal Pneumopericardium During Tracheal Stent Exchange

PATIENTS WITH BRONCHIAL FISTULAS, including bronchopleural, bronchomediastinal, bronchopericardial, or bronchoesophageal, may present with significant difficulties in airway and ventilatory management. Fistulas are an infrequent, but well-described complication, of metal airway stents, and in the setting of advanced malignancy, communication with the mediastinal or pericardial space may occur. 1 Lund M.E. Force S. Airway stenting for patients with benign airway disease and the Food and Drug Administration advisory: A call for restraint. Chest. 2007; 132: 1107-1108 Crossref PubMed Scopus (61) Google Scholar , 2 Alazemi S. Lunn W. Majid A. et al. Outcomes, health-care resources use, and costs of endoscopic removal of metallic airway stents. Chest. 2010; 138: 350-356 Crossref PubMed Scopus (45) Google Scholar When these fistulas are present, positive-pressure ventilation has a high likelihood of developing cardiac tamponade, which may be catastrophic if diagnosis and management are delayed. 3 Xu Y. Xu Z. Wang Y. Cardiac tamponade due to pneumopericardium. Pak J Med Sci. 2014; 30: 924-926 Google Scholar The authors present a rare case of stent migration and fistula formation into the pericardial space that presented with acute intraoperative hemodynamic and respiratory decompensation, which never has been described in the literature.