Cardiac Power Index Research Articles

Peri-Procedural, Non-Invasive Hemodynamic Monitoring In TAVI-Patients: Potential Impact on Patient Selection and Outcome Prediction

Objectives and Background: To investigate short-term hemodynamic improvement following transcatheter aortic valve implantation (TAVI) in patients with severe aortic valve stenosis (AS) using the non-invasive NICaS® whole body electrical bio-impedance monitoring system. Methods: 52 unselected patients subjected to TAVI were analysed between January and September 2018. Endovascular TAVI was applied in local anaesthesia and analgosedation in all patients using the Medtronic Evolut R® (n=32), Edwards Sapien 3® (n=14) or Boston Scientific SYMETIS ACURATE neo ™ TF® (n=4) system. NICaS® measurements were performed at baseline, six to eight hours after TAVI procedure and before discharge. Results and Discussion: When comparing discharge to baseline, there was a successful increase in cardiac output (CO) from 5.01 ± 1.62 to 5.73 ± 1.41 L/min (P=0.009) corresponding to a cardiac index (CI) increase from 2.64 ± 0.80 to 3.13 ± 0.83 L/min/m2 (P=0.002) and of increase in cardiac power index (CPI) from 0.53 ± 0.18 to 0.61 ± 0.16 w/m2 (P=0.008). Additionally, total peripheral resistance (TPR) significantly decrease from 1597.58 ± 624.92 to 1291.29 ± 450.12 dynes*s/cm5 (P=0.0045) corresponding to a total peripheral resistance index (TPRI) decrease from 2968.88 ± 1078.78 to 2436.72 ± 902.37 dynes*s/cm5/m2 (P=0.006). Conclusion: Non-invasive hemodynamic measurements with NICaS® represent an accurate bedside-tool for monitoring short-term adaptive hemodynamic changes in unselected patients subjected to TAVI. Thus, results can be easily used for tailored peri-procedural management early patients´ mobilization and discharge planning.

The value of non-invasive measurement of cardiac output and total peripheral resistance to categorize significant changes of intradialytic blood pressure: a prospective study

BackgroundBlood pressure (BP) is currently the main hemodynamic parameter used to assess the influence of fluid removal during hemodialysis session. Since BP is dependent on cardiac output (CO) and total peripheral resistance (TPRI), investigating these parameters may help to better understand the influence of fluid removal on patient’s hemodynamics. We used a novel non-invasive whole-body bio-impedance cardiography device, recently validated in hemodialysis patients, to examine mechanisms of intradialytic hemodynamics in a Chinese dialysis population.MethodsChronic hemodialysis patients in Sichuan Provincial People’s Hospital were enrolled. Demographic data and dialysis prescriptions were collected. Hemodynamic measurements were made pre-treatment, every 20 min during treatment and immediately after treatment in each random dialysis session. These included blood pressure, cardiac index (CI), total peripheral resistance (TPRI) and cardiac power index (CPI). Patients were divided into 5 hemodynamic groups as per their major hemodynamic response to fluid removal: low CPI, low TPRI, high TPRI, High CPI and those with normal hemodynamics.ResultsTwenty-seven patients were enrolled, with 12 (44.4%) males. The average age was 65 ± 12 y. The average body mass index (BMI) was 23.7 ± 3.9 kg/m2. 12 (44.4%) patients were diabetic. Three hundred twenty-four hemodynamic measurements were made. Weight, BMI, total fluid removal, pretreatment systolic BP, CI, TPRI and CI differed significantly among the 5 hemodynamic groups.11.1% of patients had low CPI, 25.9% had low TPRI, 18.5% had high CPI, 3.7% had high TPRI and 40.7% had normal hemodynamics. Hemodynamic differences among the 5 subgroups were significant.ConclusionThis technology provides multi-dimensional insight into intradialytic hemodynamic parameters, which may be more informative than blood pressure only. Using hemodynamic parameters to describe patients’ status is more specific and accurate, and could help to work out specific and effective therapeutic actions according to underlying abnormalities.

Levosimendan in patients with cardiogenic shock complicating myocardial infarction: A meta-analysis

PurposeCardiac shock is the leading cause of death in patients with acute myocardial infarction. The objective of this systematic review and meta-analysis was to evaluate whether levosimendan, compared to any type of control, is associated with improved clinical outcomes in patients with cardiogenic shock complicating myocardial infarction. Materials and methodsThe PubMed, EMBASE, Cochrane Central Register, and China National Knowledge Information databases were searched for pertinent studies published up until 1 May 2016. Randomized and non-randomized clinical trials comparing levosimendan to standard therapy or placebo, in adult patients with cardiogenic shock complicating myocardial infarction, and reporting at least one outcome of interest were included. The primary outcome was mortality, whereas secondary outcomes were length of ICU stay, SOFA score, cardiac index (CI), cardiac power index (CPI), ejection fraction (EF), end-systolic volume (ESV), mean blood pressure (MBP), pulmonary arterial pressure (PAP), mixed venous oxygen saturation (SvO2), pulmonary artery occlusion pressure (PAOP) and glomerular filtration rate (GFR). We pooled risk ratio (RR) and 95% confidence interval (CI) using fixed and random effects models. ResultsThirteen studies comprising a total of 648 patients were included in the analysis. There was a nonsignificant reduction in mortality with levosimendan compared to the controls (RR=0.82 [0.65–1.01], P for effect=0.07, I2=0%). In the levosimendan group PAP and ESV were significantly reduced, while CI, CPI, EF, MBP and SvO2 were significantly increased. No differences in SOFA score, ICU days, PAOP or GFR were noted. ConclusionsLevosimendan can improve hemodynamic parameters and cardiac function when compared with a control group, with no evidence of benefit in terms of survival.

EARLY HEMODYNAMIC PREDICTORS OF LETHAL OUTCOMES OF ABDOMINAL SEPSIS

The objective of the study: to find early hemodynamic predictors of a lethal outcome of abdominal sepsis. Methods. 44 patients with abdominal sepsis with no signs of septic shock were enrolled into a retrospective study. The age of patients made 48.7 Ѓ} 2.26 years old; the severity of state according to APACHE II was 12.50 Ѓ} 0.55 scores, and as per SOFA ‒ 8 [6; 10]) scores. Hemodynamics was assessed through transpulmonary thermodilution. Results. During the first 24 hours, the following rates were the most sensitive and specific in respect of a lethal outcome: cardiac function index (odds ratio – 0.582; 95%CI 0.388-0.872; p = 0.008), and cardiac power index (odds ratio – 0.027; 95%CI 0.001-0.6; p = 0.022). The same results were observed in 4-5 days of treatment. At different stages of the study, the following rates demonstrated stable predictive significance: cardiac index (CI), systolic output index, global ejection fraction; and the area under ROC-curves (AUROC) for these rates was compatible with AUROC as per SOFA. Conclusion: The investigation of the after-load dependent relative cardiac efficiency proved that the normal values of CI could be predictive of an unfavorable sepsis outcome if after-load dependent relative cardiac efficiency was < 80%. It is sensible to define individual target values of cardiac hemodynamics, which significance is clinically proved in case of sepsis.

Hemodynamic response to fluid removal during hemodialysis: categorization of causes of intradialytic hypotension.

Intradialytic hypotension is a clinically significant problem, however, the hemodynamics that underlie ultrafiltration and consequent hypotensive episodes has not been studied comprehensively. Intradialytic cardiac output, cardiac power and peripheral resistance changes from pretreatment measurements were evaluated using a novel regional impedance cardiographic device (NICaS, NI Medical, Peta Tikva, Israel) in 263 hemodialysis sessions in 54 patients in dialysis units in the USA and Brazil with the goal of determining the various hemodynamic trends as blood pressure decreases. Hypotensive episodes occurred in 99 (13.5%) of 736 intra- and postdialytic evaluations. The hemodynamic profiles of the episodes were categorized: (i) The cardiac power index significantly decreased in 35% of episodes by 36%, from 0.66 [95% confidence interval (CI) 0.60-0.72] to 0.43 (95% CI 0.37-0.48) [w/m2] with a small reduction in the total peripheral resistance index. (ii) The total peripheral resistance index significantly decreased in 37.4% of episodes by 33%, from 3342 (95% CI 2824-3859) to 2251 (95% CI 1900-2602) [dyn × s/cm5 × m2] with a small reduction in the cardiac power index. (iii) Both the cardiac power index and total peripheral resistance index significantly decreased in 27.3% of episodes, the cardiac power index by 25% from 0.63 (95% CI 0.57-0.70) to 0.48 (95% CI 0.42-0.53) [w/m2] and the total peripheral resistance index by 23% from 2964 (95% CI 2428-3501) to 2266 (95% CI 1891-2642). The hemodynamic profiles clearly define specific hemodynamic mechanisms of cardiac power reduction and/or vasodilatation as underlying intradialytic hypotensive episodes. A reduction in cardiac power (reduction of both blood pressure and cardiac output) could be the result of preload reduction due to a high ultrafiltration rate with not enough refilling or low target weight. A reduction in peripheral resistance (reduction in blood pressure and increase in cardiac output) could be the result of relative vasodilatation as arteries do not contract to compensate for volume reduction due to autonomous dysfunction. As both phenomena are independent, they may appear at the same time. Based on these results, a reduction of ultrafiltration rate and an increase in target weight to improve preload or immediate therapeutic actions to increase peripheral resistance are rational measures that could be taken to maintain blood pressure and prevent hypotensive ischemic complications in dialysis patients.

PROGNOSTIC VALUE OF THE COMBINATION OF CARDIAC POWER INDEX AND MODEL OF END-STAGE LIVER DISEASE EXCLUDING INR (MELD-XI) SCORE IN PATIENTS ADMITTED FOR ACUTE DECOMPENSATED HEART FAILURE

Cardiac power is the rate of hydraulic work done by the heart. It has recently been shown that cardiac power index (CPI) provided prognostic independent and incremental prediction in adverse outcomes beyond traditional hemodynamic parameters in ambulatory patients with advanced heart failure. On the

Predictors of intra-aortic balloon pump hemodynamic failure in non-acute myocardial infarction cardiogenic shock

To characterize patient profile and hemodynamic profile of those undergoing intra-aortic balloon pump (IABP) for cardiogenic shock and define predictors of hemodynamic failure of IABP support. Clinical characteristics of IABP support in cardiogenic shock not related to acute myocardial infarction (AMI) remain poorly characterized. We retrospectively studied a cohort of 74 patients from 2010 to 2015 who underwent IABP insertion for cardiogenic shock complicating acute decompensated heart failure not due to AMI. In the overall cohort, which consisted primarily of patients with chronic systolic heart failure (89%), IABP significantly augmented cardiac index and lowered systemic vascular resistance (P<.05). Despite this improvement, 28% of these patients died (24%) or require urgent escalation in mechanical circulatory support (MCS) (4%). Multivariable regression revealed that baseline left ventricular cardiac power index (LVCPI), a measure of LV power output derived from cardiac index and mean arterial pressure (P=.01), and history of ischemic cardiomyopathy (P=.003) were significantly associated with the composite adverse-event endpoint of death or urgent MCS escalation. An IABP Failure risk score using baseline LVCPI <0.28 W/m2 and ischemic history predicted 28-day adverse events with excellent discrimination. Despite hemodynamic improvements with IABP support, patients with non-AMI cardiogenic shock still suffer poor outcomes. Patients with ischemic cardiomyopathy and low LVPCI fared significantly worse. These patients may warrant closer observation or earlier consideration of more advanced hemodynamic support.

Levosimendan in patients with cardiogenic shock complicating myocardial infarction: A meta-analysis

PurposeCardiac shock is the leading cause of death in patients with acute myocardial infarction. The objective of this systematic review and meta-analysis was to evaluate whether levosimendan, compared to any type of control, is associated with improved clinical outcomes in patients with cardiogenic shock complicating myocardial infarction. Materials and methodsThe PubMed, EMBASE, Cochrane Central Register, and China National Knowledge Information databases were searched for pertinent studies published up until 1 May 2016. Randomized and non-randomized clinical trials comparing levosimendan to standard therapy or placebo, in adult patients with cardiogenic shock complicating myocardial infarction, and reporting at least one outcome of interest were included. The primary outcome was mortality, whereas secondary outcomes were length of ICU stay, SOFA score, cardiac index (CI), cardiac power index (CPI), ejection fraction (EF), end-systolic volume (ESV), mean blood pressure (MBP), pulmonary arterial pressure (PAP), mixed venous oxygen saturation (SvO2), pulmonary artery occlusion pressure (PAOP) and glomerular filtration rate (GFR). We pooled risk ratio (RR) and 95% confidence interval (CI) using fixed and random effects models. ResultsThirteen studies comprising a total of 648 patients were included in the analysis. There was a nonsignificant reduction in mortality with levosimendan compared to the controls (RR=0.82 [0.65–1.01], P for effect=0.07, I2=0%). In the levosimendan group PAP and ESV were significantly reduced, while CI, CPI, EF, MBP and SvO2 were significantly increased. No differences in SOFA score, ICU days, PAOP or GFR were noted. ConclusionsLevosimendan can improve hemodynamic parameters and cardiac function when compared with a control group, with no evidence of benefit in terms of survival.

Differential responses to larger volume intra-aortic balloon counterpulsation: Hemodynamic and clinical outcomes.

ObjectivesExamine hemodynamic and clinical correlates of use of an intra‐aortic balloon pump catheter in a single center.BackgroundThe intra‐aortic balloon pump catheter (IABC) has been used for 50 years but the clinical benefit is still debated. We reviewed 76 patients with right heart catheter measurements prior to IABC to assess response and outcomes.MethodsAll patients who received IABC with a 50cc balloon for at least 1 hour were included in this retrospective chart review study. Demographics, comorbidities, lab values, and hemodynamic parameters were recorded at baseline and 15 h postinsertion.ResultsSeventy‐six patients had paired measurements of cardiac output. 60 patients had a higher cardiac output with IABC treatment (responder group) and 16 did not (nonresponders). In the 60 patients in the responder group, cardiac output and index significantly increased from baseline 3.6 ± 1.3 L/min to 5.2 ± 1.8 L/min, and 1.8 ± 0.5 L/min/m2 to 2.6 ± 0.8 L/min/m2 respectively following IABC placement (P < 0.0001 for both comparisons). Various hemodynamic variables were examined and the best predictor of response to IABC was a cardiac power index of 0.3 or less. Regardless of response, in hospital survival was similar between groups.ConclusionsThe majority of patients improve their cardiac output with IABC but survival was unchanged. Further work into the pathophysiology of cardiogenic shock is needed.

P3386Long-term prognostic value of cardiac power index in patients admitted for acute decompensated heart failure with reduced or preserved left ventricular ejection fraction

P3386Long-term prognostic value of cardiac power index in patients admitted for acute decompensated heart failure with reduced or preserved left ventricular ejection fraction

MILD HYPOTHERMIA IN CARDIOGENIC SHOCK COMPLICATING MYOCARDIAL INFARCTION: THE RANDOMIZED SHOCK-COOL PILOT TRIAL

Background —Experimental trials suggest improved outcome by mild therapeutic hypothermia for cardiogenic shock following acute myocardial infarction. The objective of this study was to inves-tigate hemodynamic effects of mild therapeutic hypothermia in patients with cardiogenic shock complicating acute myocardial infarction. Methods —Patients (n=40) with cardiogenic shock undergoing primary percutaneous coronary in-tervention without classical indication for mild therapeutic hypothermia underwent randomization in a 1:1 fashion to mild therapeutic hypothermia for 24 h or control. The primary endpoint was cardiac power index at 24 h; secondary endpoints included other hemodynamic parameters as well as serial measurements of arterial lactate. Results —No relevant differences were observed for the primary endpoint cardiac power index at 24 h (mild therapeutic hypothermia vs. control: 0.41 [interquartile range 0.31-0.52] vs. 0.36 [inter-quartile range 0.31-0.48] W/m 2 ; p=0.50, median difference -0.025 [95% confidence interval -0.12 to 0.06 W/m 2 ]). Similarly, all other hemodynamic measurements were not statistically different. Arterial lactate levels at 6, 8 and 10 hours were significantly higher in patients in the MTH group with a slower decline (p for interaction 0.03). There were no differences in 30-day mortality: (60 vs. 50%, hazard ratio 1.27 [95% confidence interval 0.55-2.94]; p=0.55). Conclusions —In this randomized trial mild therapeutic hypothermia failed to show a substantial beneficial effect in patients with cardiogenic shock after acute myocardial infarction on cardiac power index at 24 h. Clinical Trial Registration —URL: www.clinicaltrials.gov Unique Identifier: NCT01890317

Early Characteristics of Circulation in Patients with Poor Outcome of Abdominal Sepsis (Preliminary Report)

Aim: to study characteristics of the central hemodynamics (CHD) in patients with severe abdominal sepsis with different outcomes of the disease. Materials and Methods. 18 patients with abdominal sepsis, aged 50.2±3, with the APACHE II and SOFA severity scoring of 13.7±0.8 and 8.4±0.5, respectively, were enrolled in the retrospective study. The CHD was studied using the transpulmonary thermodilution. The following groups were identified: Group 1 (deceased, n=9) and Group 2 (survivors, n=9). The groups did not differ (P>0.05) in age, sex, and the severity of the condition at admission to the ICU. The significance of differences was assessed using the t-test and the chi-squared test. The prognostic value of the parameters was studied using the ROC analysis. Results. On Day 1, the intergroup differences included the average blood pressure (BPav) (85.3±3.3 and 101.6±4.6 mmHg, respectively (P 7 (sensitivity: 88.9%, specificity: 88.9%) was the most important predictor of the lethal outcome (areas under ROC curves: 0.957—0.994; P<0.05). Conclusion: during the first five days of the intensive treatment of severe sepsis in patients with unfavorable prognosis, a moderate decrease in the cardiac power index and overall cardiac systolic function was registered. The prognostic significance of such parameters as CPI and GEF may become obvious within the first 3 days of the intensive treatment.

Beneficial Effects of Norepinephrine Alone on Cardiovascular Function and Tissue Oxygenation in a Pig Model of Cardiogenic Shock.

The present study was developed to investigate the effects of norepinephrine alone on hemodynamics and intrinsic cardiac function in a pig model of cardiogenic shock mimicking the clinical setting. Cardiogenic shock was induced by 1-h ligation of the left anterior descending (LAD) artery followed by reperfusion. Pigs were monitored with a Swan-Ganz catheter, a transpulmonary thermodilution catheter, and a conductance catheter placed in the left ventricle for pressure-loop measurements. Measurements were performed before LAD occlusion, 1 h after LAD occlusion, and 4 h after myocardial reperfusion. Myocardial infarction and reperfusion was followed by cardiogenic shock characterized by a significant increase in heart rate and significant decreases in mean arterial pressure (MAP), mixed venous oxygen saturation (SVO2), left ventricular end-diastolic pressure (LVEDP), prerecruitable stroke work (PRSW), and cardiac power index (CPI). Lactate levels were significantly increased. The systemic vascular resistance index (SVRI) and global end-diastolic volume index (GEDVI) remained unchanged. When compared with the control group (n = 6), norepinephrine infusion (n = 6) was associated with no changes in heart rate, a significant increase in MAP, SVO2, left ventricular ejection fraction, pressure development during isovolumic contraction, SVRI, and CPI and a decrease in lactate level. Cardiac index tended to increase (P = 0.059), whereas PRSW did not change in the norepinephrine group. LVEDP and GEDVI remained unchanged. Norepinephrine alone is able to improve hemodynamics, cardiac function, and tissue oxygenation in a pig model of ischemic cardiogenic shock.

Impact of Therapeutic Plasma Exchange on Hemodynamic Parameters in Medical Intensive Care Unit Patients: An Observational Study.

Therapeutic plasma exchange (TPE) is an extracorporeal treatment with reported beneficial as well as detrimental effects on circulation. However, there is a lack of data using advanced hemodynamic monitoring during TPE. Therefore, we investigated the effects of TPE on hemodynamic parameters derived from transpulmonary thermodilution (TPTD) as well as the risk for transfusion-related acute lung injury (TRALI). We compared hemodynamic parameters obtained before and after a total of 30 sessions of TPE treatment in 10 intensive care unit patients. Among standard hemodynamic parameters, heart rate (P < 0.012) and systolic blood pressure (P < 0.008) significantly increase, whereas neither mean arterial pressure nor diastolic blood pressure was altered after TPE. The TPTD-derived cardiac function parameters, cardiac index (CI; P = 0.035), cardiac power index (CPI; P = 0.008), global ejection fraction (GEF; P = 0.002), and stroke volume index (SVI; P = 0.014), were significantly higher after TPE. Furthermore, systemic vascular index significantly increased (P < 0.042). Among the cardiac preload parameters, central venous pressure was significantly lower after TPE (P < 0.001), while the global end-diastolic volume index (GEDVI) did not change. Contractility marker dPmax did not change. Finally, TPE application did not significantly alter the pulmonary hydration and permeability parameters, extravascular lung water index (EVLWI) and pulmonary vascular permeability index. Vasopressor dose was not statistically significantly altered. Considering increases in SVI, CI, GEF, and CPI and stable values for GEDVI, EVLWI, and dPmax, our data do not give any hint for hemodynamic impairment or TRALI.

Transpulmonary thermodilution (TPTD) before, during and after Sustained Low Efficiency Dialysis (SLED). A Prospective Study on Feasibility of TPTD and Prediction of Successful Fluid Removal.

BackgroundAcute kidney injury (AKI) is common in critically ill patients. AKI requires renal replacement therapy (RRT) in up to 10% of patients. Particularly during connection and fluid removal, RRT frequently impairs haemodyamics which impedes recovery from AKI. Therefore, “acute” connection with prefilled tubing and prolonged periods of RRT including sustained low efficiency dialysis (SLED) has been suggested. Furthermore, advanced haemodynamic monitoring using trans-pulmonary thermodilution (TPTD) and pulse contour analysis (PCA) might help to define appropriate fluid removal goals.Objectives, MethodsSince data on TPTD to guide RRT are scarce, we investigated the capabilities of TPTD- and PCA-derived parameters to predict feasibility of fluid removal in 51 SLED-sessions (Genius; Fresenius, Germany; blood-flow 150mL/min) in 32 patients with PiCCO-monitoring (Pulsion Medical Systems, Germany). Furthermore, we sought to validate the reliability of TPTD during RRT and investigated the impact of “acute” connection and of disconnection with re-transfusion on haemodynamics. TPTDs were performed immediately before and after connection as well as disconnection.ResultsComparison of cardiac index derived from TPTD (CItd) and PCA (CIpc) before, during and after RRT did not give hints for confounding of TPTD by ongoing RRT. Connection to RRT did not result in relevant changes in haemodynamic parameters including CItd. However, disconnection with re-transfusion of the tubing volume resulted in significant increases in CItd, CIpc, CVP, global end-diastolic volume index GEDVI and cardiac power index CPI. Feasibility of the pre-defined ultrafiltration goal without increasing catecholamines by >10% (primary endpoint) was significantly predicted by baseline CPI (ROC-AUC 0.712; p = 0.010) and CItd (ROC-AUC 0.662; p = 0.049).ConclusionsTPTD is feasible during SLED. “Acute” connection does not substantially impair haemodynamics. Disconnection with re-transfusion increases preload, CI and CPI. The extent of these changes might be used as a “post-RRT volume change” to guide fluid removal during subsequent RRTs. CPI is the most useful marker to guide fluid removal by SLED.

Emergency transcatheter aortic valve replacement in patients with cardiogenic shock due to acutely decompensated aortic stenosis.

To assess outcomes of TAVR as a rescue therapy in patients with cardiogenic shock due to acutely decompensated aortic stenosis. Of 771 high-risk patients who underwent TAVR, 27 (3.5%; 78±9 years; 12 men) were treated emergently due to acutely decompensated aortic stenosis with cardiogenic shock. SAPIEN and CoreValve prostheses were implanted in 11 and 16 patients, respectively: the transfemoral access route was used in 25. Three patients died within 72 hours of successful valve deployment, and a further six died within a month, giving a 30-day mortality of 33.3%, which was significantly higher than in electively treated patients (7.7%, p<0.0001). Univariate predictors of 30-day mortality in cardiogenic-shock patients were baseline cardiac output <3.0 l/min, reduced cardiac power index, impaired renal function, and mechanical ventilation, as well as severe acute kidney injury after TAVR. Estimated one-year survival was 59.3% in emergently and 82.7% in electively treated patients (p=0.0009). However, 30-day landmark analysis showed no difference in cumulative survival between TAVR modalities. In cardiogenic-shock patients without concomitant reduced cardiac output and impaired renal function at baseline (n=22), estimated one-year survival was 72.7%. TAVR should be considered a reasonable rescue therapy in patients with cardiogenic shock secondary to decompensated aortic stenosis.

Toward catecholamine responsiveness in cardiogenic shock: insights from the CRASH score.

To model a prognostic score in patients with cardiogenic shock that incorporates catecholamine responsiveness and hemodynamics. Assessment of the best accuracy of the score (CRASH score: Catecholamine Refractoriness and Assistance guide based on cardiogenic Shock Hemodynamics) to predict in-hospital mortality and/or extracorporeal life support, based on a retrospective study performed in a medical-surgical intensive care unit. We included 66 patients with cardiogenic shock from various etiologies. We modeled the CRASH score to be a simple score with the best accuracy to predict in-hospital mortality and/or extracorporeal life support. The CRASH score was defined as the cardiac power index (CPI) divided by the square root of 1 + inotropic score (IS, sum of different catecholamines pondered with their variable efficiency): CRASH score = CPI/square root (IS + 1). A CRASH score &lt;0.0375 predicted death and/or extracorporeal life support with a sensitivity of 68% and a specificity of 92%. The area under the ROC curve was 0.851, achieving an overall accuracy of 0.833. The CRASH score had improved accuracy when compared with Simplified Acute Physiology, Sleeper, and CardSHOCK scores (p&lt;0.05 for all). With a threshold of 0.300 we found even higher specificity (95%) at the price of decreased sensibility (52%) and accuracy. In patients with cardiogenic shock, the CRASH score (= CPI/square root (IS + 1)) &lt;0.0375 allowed patients at high risk of adverse outcome to be identified.

Abstract 12070: Long-term Prognostic Value of Cardiac Power Index in Patients Admitted With Acute Decompensated Heart Failure

Backgrounds: Cardiac power is the rate of hydraulic work done by the heart. It has recently been shown that cardiac power index (CPI) provided prognostic independent and incremental prediction in adverse outcomes beyond traditional hemodynamic parameters in ambulatory patients with advanced heart failure. However, there is little information available on the long-term prognostic value of CPI in patients with acute decompensated heart failure (ADHF). Methods and Results: We studied 209 patients admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. CPI was calculated by: CPI W/m 2 = ([mean arterial pressure(mmHg) - [right arterial pressure(mm Hg)] x cardiac output [L/min] x K)/ (BSA m 2 ) where K = 0.0022. During a mean follow-up period of 4.4±3.3 yrs, 50 patients had cardiovascular death (CVD). CPI was significantly lower in patients with than without CVD (0.407±0.138 vs 0.550±0.258 W/m 2 , p=0.0002). Multivariate Cox regression analysis revealed that CPI (hazard ratio 0.092 [95%CI 0.017-0.497], p=0.005) was significantly associated with CVD, independently of body mass index, BUN and serum sodium levels, after adjustment for age, systolic blood pressure, pulmonary vascular resistance, and serum creatinine, albumin, and hemoglobin levels. Patients with low CPI (lowest tertile&lt;0.395 W/m 2 ) had a significantly higher CVD risk than those with middle CPI(0.395-0.565 W/m 2 ) and high CPI (highest tertile: &gt;0.565 W/m 2 ) (41%(28/69) vs 22%(15/70) vs 10%(10/70), p&lt;0.0001, respectively). The adjusted hazard ratio in patients with low CPI was 3.40 (95%CI 1.46-7.92). Conclusions: CPI could provide the long-term prognostic information in patients admitted with ADHF.

Clinical profile of patients with advanced age and inflammatoric dilated cardiomyopathy on endomyocardial biopsy.

BackgroundEndomyocardial biopsy (EMB) is an important tool when patients with inflammatoric cardiomyopathy (DCMi) are evaluated. We aimed to assess the clinical profile of elderly patients with DCMi on EMB.MethodsRetrospective study of all consecutive patients hospitalized from January 2007 to December 2011 with clinical suspicion of DCMi undergoing EMB. Patients with evidence of DCMi on EMB (Group 1 ≥ 70 years, n = 85; Group 3 < 70 years; n = 418) were compared to patients of the same age group without evidence of DCMi on EMB (Group 2 ≥ 70 years, n = 45; Group 4 < 70 years; n = 147).ResultsAmong 24,275 patients treated at our institution during the study period, 695 had clinical suspicion of DCMi and underwent EMB; 503 (2.1%) patients had DCMi on EMB. There were more male patients in Group 1, mean age was 74 ± 2.8 years, mean ejection fraction was 38% ± 14%. On presentation, signs of hemodynamic compromise (NYHA functional class III/IV, low cardiac output/index, and low cardiac power index) were more frequent in Group 1. EMB revealed viral genome in 78% of the patients, parvovirus B19 (PVB) was frequently encountered in both age groups (Group 1: 69.4% vs. Group 2: 59.6%); detection of more than one viral genome was more frequent in Group 1 (21.2% vs. 11.2%; P = 0.02) whereas the extent of immune response was significantly lower in individuals with advanced age.ConclusionsIn patients ≥ 70 years with DCMi on EMB signs of hemodynamic compromise, detection of multiple viral genomes together with an overall lower extent of immune response were more frequently observed.

Target temperature management of 33°C exerts benefi cial haemodynamic eff ects after out-of-hospital cardiac arrest

Background Accumulating evidence indicates that target temperature management (TTM) is benefi cial in patients resuscitated after cardiac arrest since it appears to improve neurological outcome. However, the optimal cooling method (surface vs intravascular) has not yet been specifi ed. Substantial heart disease is present in most of these patients and therefore haemodynamic eff ects of cooling need to be considered very carefully. We analysed the haemodynamic response to TTM in patients treated with surface versus intravascular cooling following out-of-hospital cardiac arrest.Methods and results In this observational study 63 consecutive subjects presenting to the hospital after successful resuscitation following of out-of-hospital cardiac arrest received an intravascular (40 patients) or external cooling device (23 patients) to induce TTM. While with intravascular cooling the target temperature of 33°C was reached after 159 minutes, the minimum temperature achieved with surface cooling was about 35°C after 437 minutes. Haemodynamic parameters were recorded in a 4-hour rhythm for the fi rst 12 hours after induction of hypothermia. Generally, TTM of 33°C resulted in a higher systemic vascular resistance index (749 vs 467 dyn*sec/cm5/m²; P= 0.04) but also in a marked reduction of heart rate (67.70 vs 100.00 bpm; P < 0.001), a higher mixed venous oxygen saturation (76 vs 68%; P= 0.016), and a higher stroke volume index (45 vs 33 ml/m²; P= 0.036). TTM additionally resulted in a higher cardiac power index (0.55 vs 0.46 Watt/m²; P= 0.024).Conclusion TTM of 33°C compared to 35°C exerts benefi cial haemodynamic eff ects and might be viewed as an adjunct inotropic therapy avoiding the undesired side eff ects of vasoactive substances.