Circulatory Decompensation Research Articles

The effect of optimization of diuretic therapy on kidney function during circulatory decompensation

The effect of optimization of diuretic therapy on kidney function during circulatory decompensation

Long-term results of revascularization of the lower extremities in patients with critical ischemia and diabetes mellitus with localization of the occlusive-stenotic process in the femoral artery

Aim: to determine the most preferable tactics of surgical treatment of patients with critical ischemia of the lower extremities of atherosclerotic genesis and diabetes mellitus based on a comparison of the results of revascularizing interventions. Methods: The study involved 82 patients who were treated in the department of vascular surgery due to critical ischemia of the lower extremities as a result of atherosclerotic occlusive-stenotic lesion of the femoral arterial segment against the background of diabetes mellitus. After the diagnostic stage and preoperative preparation, the patients were divided into two groups depending on the nature of the intervention performed: endovasal revascularization or femoropopliteal autovenous bypass grafting above the knee joint gap. In the postoperative period, dynamic observation of patients was continued with a predominant assessment of the clinical status. Results: Clinically, circulatory decompensation requiring repeated intervention or amputation was observed in 9 (30 %) patients from the first group and in 13 (25 %) patients from the second. High amputation was performed in 2 (6.6 %) study participants from the endovasal revascularization group and 3 (5.7 %) from the open surgery group. Over the entire observation period, 2 (6.7 %) and 4 (7.8 %) patients died in the groups under consideration, respectively. No statistically significant differences were obtained for any of the studied parameters, however, repeated interventions were significantly more frequently performed in patients undergoing endovascular revascularization. Conclusion: When analyzing the advantages and disadvantages of endovascular and open surgery in patients with diabetes mellitus and critical ischemia, the first should be preferred due to the possibility of repeated repetition throughout the patients life. Particular attention should be paid to conservative therapy and assessment of clinical status in the late postoperative period.

Complete Reconstruction of the Left Heart with Atriomegaly and Ventriculomegaly: Clinical Case

Implementation of the principles of medical preparation, comprehensive reconstruction of the left heart in patients with atriomegaly and ventriculomegaly and combined mitral-tricuspid valve diseases leads to improvement of myocardial function and morphometric parameters of the left atrium (LA) and left ventricle (LV).
 Case description. Patient R., male, 67 years old, underwent examination and treatment from April 22 to May 25, 2021 at the department of surgical treatment of acquired heart diseases of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine with the diagnosis of stage IV mitral regurgitation, stage IV tricuspid insufficiency, high grade pulmonary hypertension, permanent atrial fibrillation (lasting 10 years since 2011), IIB heart failure with reduced left ventricular ejection fraction (LVEF), secondary hypothyroidism (state of drug subcompensation). Upon admission, the patient was in a state of circulatory decompensation, which required long-term medical preparation for the operation. After his condition was improved, the patient underwent surgery: mitral valve replacement with complete preservation of the valve apparatus, triangular plasty of LA, tricuspid valve plasty with the imposition of a support ring and resection of the right atrium. There were no complications during the intraoperative period. The postoperative period was characterized by symptoms of hyperbilirubinemia, increased exudation from drainages on the first day after surgery. After appropriate treatment, the patient’s condition was stabilized. The patient was discharged on the 13th day after surgery with improvement.
 Conclusion. Given the initial severe condition of the patient with advanced heart disease with reduced LVEF, left atriomegaly 9.5x12.3 cm, high grade pulmonary hypertension (peak systolic pressure = 70 mm Hg) and comorbidities, comprehensive reconstruction of the left heart with atriomegaly and ventriculomegaly leads to improvement of functional state of the myocardium and morphometric parameters of LA and LV.

Clinical Assessment of Fetal Well-Being and Fetal Safety Indicators.

Delivering safe clinical trials of novel therapeutics is central to enable pregnant women and their babies to access medicines for better outcomes. This review describes clinical monitoring of fetal well‐being and safety. Current pregnancy surveillance includes regular antenatal checks of blood pressure and urine for signs of gestational hypertension. Fetal and placental development is assessed routinely using the first‐trimester “dating” and mid‐trimester “anomaly” ultrasound scans, but the detection of fetal anomalies can continue throughout pregnancy using targeted sonography or magnetic resonance imaging (MRI). Serial sonography can be used to assess fetal size, well‐being, and placental function. Carefully defined reproducible imaging parameters, such as the head circumference (HC), abdominal circumference (AC), and femur length (FL), are combined to calculate an estimate of the fetal weight. Doppler analysis of maternal uterine blood flow predicts placental insufficiency, which is associated with poor fetal growth. Fetal doppler analysis can indicate circulatory decompensation and fetal hypoxia, requiring delivery to be expedited. Novel ways to assess fetal well‐being and placental function using MRI, computerized cardiotocography (CTG), serum circulating fetoplacental proteins, and mRNA may improve the assessment of the safety and efficacy of maternal and fetal interventions. Progress has been made in how to define and grade clinical trial safety in pregnant women, the fetus, and neonate. A new system for improved safety monitoring for clinical trials in pregnancy, Maternal and Fetal Adverse Event Terminology (MFAET), describes 12 maternal and 18 fetal adverse event (AE) definitions and severity grading criteria developed through an international modified Delphi consensus process. This fills a vital gap in maternal and fetal translational medicine research.

Chest Compressions in Pediatric Patients With Continuous-Flow Ventricular Assist Devices: Case Series and Proposed Algorithm.

Patients with continuous flow ventricular assist devices (CF-VAD's) in the systemic ventricle (left ventricle or single ventricle) often have no palpable pulses, unreliable pulse oximetry waveforms and non-pulsatile arterial waveforms despite hemodynamic stability. When circulatory decompensation occurs, standard indicators to begin cardiopulmonary resuscitation (CPR) which are used in other pediatric patients (i.e., significant bradycardia or loss of pulse) cannot be applied in the same fashion. In this population, there may already be pulselessness and development of bradycardia in and of itself would not trigger chest compressions. There are no universal guidelines to dictate when to consider chest compressions in this population. As such, there may be a delay in decision-making or in recognizing the need for chest compressions, even in patients hospitalized in intensive care units (ICU) and cared for by experienced staff who perform CPR regularly. We present four examples of pediatric cardiac ICU patients from a single center who underwent CPR between 2018 and 2019. Based on this case series, we propose a decision-making algorithm for chest compressions in pediatric patients with CF-VADs in the systemic ventricle.

Acute kidney injury in patients with chronic heart failure

The problem of chronic heart failure (CHF) and especially CHF with reduced ejection fraction is one of the most significant for modern healthcare systems. This is due to the high mortality rate, reduced quality of life, frequent hospitalizations and marked comorbidity of patients with this pathology. Involvement of the kidneys in the pathological process is one of the most common comorbid conditions in cardiovascular disease. There are a large number of pathogenetic mechanisms of mutually negative impact of heart failure and renal dysfunction, reflected in the concept of «Cardiorenal syndrome». Moreover, drug therapy of CHF can be one of the causes of kidney damage. Episodes of acute circulatory decompensation as well as a new coronavirus infection (COVID-19) are particularly threatening conditions. The aim of this review is to consolidate the international literature on the problem of acute kidney injury in patients with CHF.

Anemia as a Risk Factor for Organ Dysfunctions in Patients Operated on Heart Valves.

Aim To study the effects of pre- and postoperative anemia on the risk and the structure of internal organ dysfunction in patients undergoing surgery for acquired heart diseases (AHD).Material and methods This was a retrospective cohort study including 610 primarily operated patients with AHD. A comparative analysis of the incidence and the structure of internal organ dysfunction was performed, and the likelihood of intraoperative hemotransfusion was determined for patients with preoperative anemia (Hb <130 g/l) and without it. The incidence and the nature of internal organ damage were compared in patients with postoperative Hb < 90 g/l and 90-130 g/l.Results The presence of postoperative anemia detected in 45 % of patients at two days after the surgery 6-fold increased the risk of acute heart failure (odds ratio [OR], 5.75; 95 % confidence interval [CI], 1.23-26.84; р=0.016), 4-fold increased the risk of multiorgan failure (MOF) (OR, 4.2; 95 % CI, 1.16-15.64; р=0.03), and 5-fold increased the likelihood of hemotransfusion (OR, 4.74; 95 % CI, 3.12-7.19; р<0.0001). Severe and moderate anemia (Hb <90 g/l) was observed in 11.2 % of patients, which presence 6-fold increased the risk of brain dysfunction (OR, 5.72; 95 % CI, 2.17-15.06; р=0.001) and MOF (OR, 5.97; 95 % CI, 1.94-18.35; р=0.004) compared to patients with Hb 90-130 g/l.Conclusion In patients with AHD, postoperative anemia increases the risk of circulatory decompensation at two days after the surgery and of MOF and also increases the likelihood of intraoperative hemotransfusion; postoperative anemia with Hb <90 g/l increases the risk of brain damage and MOF.

Evaluation of the Efficacy of Surgical Treatment of Patients With Chronic Critical Ischemia of Lower Extremities at the Stage of Trophic Complications

Relevance. Chronic critical ischemia of the lower extremities (CCILE) in the stage of trophic complications is the final stage of diseases of the arteries of the lower extremities, leading to disability of patients and having a poor prognosis in terms of preservation of the lower extremities and mortality.Aim of study. Objective assessment of the efficacy of lower limb revascularization in trophic disorders.Material and methods. The analysis of treatment of 52 patients with stage IV CCILE (according to the classification of R. Fontaine and A.V. Pokrovsky) was carried out. Of these, 42 patients underwent three-phase scintigraphy combined with X-ray computed angiography on a hybrid apparatus. After the operation, this study was conducted in 37 patients.Results. Out of 52 patients, surgery for revascularization of the lower extremities was performed in 37 patients, 15 were not operated on. Out of 37 operated patients, improvement of blood circulation occurred in 32 (86.5%). Circulatory decompensation was observed in 5 patients (9.7%). Among non-operated patients, improvement of blood circulation occurred in 9 patients (17.3%), no effect or decompensation — in 5 (9.7%). Subjective improvement in the condition and decrease in the degree of ischemia corresponded to the improvement of microcirculation according to the data of three-phase scintigraphy.Conclusion.1. Revascularization of the lower extremities in patients with trophic disorders is an effective method of treating this pathology. Therefore, all patients with chronic ischemia threatening limb loss should be considered as candidates for revascularization.2. If the leg arteries or short occlusive or stenotic lesions of the main arteries are affected, such patients should be discussed together with specialists in endovascular surgery for endovascular treatment or joint intervention.3. Hybrid radiation method (three-phase scintigraphy and single-photon emission computed tomography, combined with X-ray computed angiography) is an objective method that reflects the state of peripheral circulation and microcirculation, and allows you to objectively assess the effectiveness of the treatment.

Hemodynamics during the 10-minute NASA Lean Test: evidence of circulatory decompensation in a subset of ME/CFS patients

BackgroundLightheadedness, fatigue, weakness, heart palpitations, cognitive dysfunction, muscle pain, and exercise intolerance are some of the symptoms of orthostatic intolerance (OI). There is substantial comorbidity of OI in ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome). The 10-minute NASA Lean Test (NLT) is a simple, point-of-care method that can aid ME/CFS diagnosis and guide management and treatment of OI. The objective of this study was to understand the hemodynamic changes that occur in ME/CFS patients during the 10-minute NLT.MethodsA total of 150 ME/CFS patients and 75 age, gender and race matched healthy controls (HCs) were enrolled. We recruited 75 ME/CFS patients who had been sick for less than 4 years (< 4 ME/CFS) and 75 ME/CFS patients sick for more than 10 years (> 10 ME/CFS). The 10-minute NLT involves measurement of blood pressure and heart rate while resting supine and every minute for 10 min while standing with shoulder-blades on the wall for a relaxed stance. Spontaneously reported symptoms are recorded during the test. ANOVA and regression analysis were used to test for differences and relationships in hemodynamics, symptoms and upright activity between groups.ResultsAt least 5 min of the 10-minute NLT were required to detect hemodynamic changes. The < 4 ME/CFS group had significantly higher heart rate and abnormally narrowed pulse pressure compared to > 10 ME/CFS and HCs. The < 4 ME/CFS group experienced significantly more OI symptoms compared to > 10 ME/CFS and HCs. The circulatory decompensation observed in the < 4 ME/CFS group was not related to age or medication use.ConclusionsCirculatory decompensation characterized by increased heart rate and abnormally narrow pulse pressure was identified in a subgroup of ME/CFS patients who have been sick for < 4 years. This suggests inadequate ventricular filling from low venous pressure. The 10-minute NLT can be used to diagnose and treat the circulatory decompensation in this newly recognized subgroup of ME/CFS patients. The > 10 ME/CFS group had less pronounced hemodynamic changes during the NLT possibly from adaptation and compensation that occurs over time. The 10-minute NLT is a simple and clinically useful point-of-care method that can be used for early diagnosis of ME/CFS and help guide OI treatment.

Analysis of the effect of pneumonia on mortality (ORACLE-RF)

Objective — To analyze the effect of pneumonia on mortality among patients with circulatory decompensation. Material and methods — The study was based on the ORACLE-RF registry containing information obtained from 20 cities in Russia. Patients were monitored for one year. The research included men and women with symptoms of chronic heart failure during circulatory decompensation period. The patients' average age was 67±13 years. Final analysis included 2404 patients. Results — Hospital mortality was at 9%. By the 30th day of observation, overall mortality rate stood at 13%. Within the year, the overall mortality rate was 43%. Pneumonia and chronic kidney disease (CKD) had the most pronounced effect on death risk – 49.5% and 47.2%. The study showed that patients who do not have pneumonia and CKD among other associated diseases were 2.5 times more likely to survive after 360 days of observation than patients who have them among other associated diseases. The chances of favorable prognosis in patients without pneumonia are 1.7 times higher than in patients with pneumonia among other diseases. Conclusion — Pneumonia probably triggered the decompensation mechanism and significantly increased mortality in these patients.

Preeclampsia: a gestational cardiorenal syndrome.

It is generally accepted today that there are two different types of preeclampsia: an early-onset or placental type and a late-onset or maternal type. In the latent phase, the first one presents with a low output/high resistance circulation eventually leading in the late second or early third trimester to an intense and acutely aggravating systemic disorder with an important impact on maternal and neonatal mortality and morbidity; the other type presents initially as a high volume/low resistance circulation, gradually evolving to a state of circulatory decompensation usually in the later stages of pregnancy, with a less severe impact on maternal and neonatal outcome. For both processes, numerous dysfunctions of the heart, kidneys, arteries, veins and interconnecting systems are reported, most of them presenting earlier and more severely in early- than in late-onset preeclampsia; however, some very specific dysfunctions exist for either type. Experimental, clinical and epidemiological observations before, during and after pregnancy are consistent with gestation-induced worsening of subclinical pre-existing chronic cardiovascular dysfunction in early-onset preeclampsia, and thus sharing the pathophysiology of cardiorenal syndrome type II, and with acute volume overload decompensation of the maternal circulation in late-onset preeclampsia, thus sharing the pathophysiology of cardiorenal syndrome type 1. Cardiorenal syndrome type V is consistent with the process of preeclampsia superimposed upon clinical cardiovascular and/or renal disease, alone or as part of a systemic disorder. This review focuses on the specific differences in haemodynamic dysfunctions between the two types of preeclampsia, with special emphasis on the interorgan interactions between heart and kidneys, introducing the theoretical concept that the pathophysiological processes of preeclampsia can be regarded as the gestational manifestations of cardiorenal syndromes.

Clinical characterіstics and survival of hospitalized patients with chronic heart failure and reduced left ventricular ejection fraction depending on dynamics of nitrogen-releasing kidney function during period of overcoming clinical decompensation

The aim — to investigate the main clinical hemodynamic and laboratory characteristics in hospitalized patients with chronic heart failure (CHF), depending on the dynamics of the nitrogen‑releasing renal function during the period of overcoming decompensation and to determine the prognostic value of impaired renal function (IRF) in this category of patients.Materials and methods. The study involved 134 patients with CHF caused by ischemic heart disease or dilated cardiomyopathy, and a reduced (&lt; 40 %) left ventricular ejection fraction, heart failure of II B according to Strazhesko — Vasilenko criteria, III — IV functional class according to the criteria of the New York Heart Association (NYHA). They were hospitalized for circulatory decompensation. The median age was 59.5 (54; 68) years. All patients underwent general clinical examination, determined the level of creatinine, urea nitrogen, uric acid, interleukin‑6, plasma citrulline, N‑terminal fragment of the brain natriuretic peptide (NTproBNP) at admission and before discharge, glomerular filtration rate (GFR) using the equation CKD‑EPI. Patients received standard treatment. The patients were divided into two groups according to the level of increase in creatinine before discharge: the first one with RFW with an increase in creatinine level ≥ 17.7 mmol/l, the second one with no RFW.Results and discussion. 110 (82 %) patients showed no RFW after overcoming clinical decompensation; in 24 (18 %) patients, the creatinine level increased by 17.7 mmol/l or more, which corresponded to a decrease in GFR і 5 ml/(min 1.73 m2). At the stage of hospitalization, patients did not differ in age, frequency of comorbid pathology, main hemodynamic parameters, potassium plasma levels, glomerular filtration rate (GFR), urea nitrogen, uric acid, NTproBNP. After attaining the stable condition, lower blood pressure levels, higher levels of blood urea nitrogen, uric acid, interleukin‑6 and citrulline were observed in patients with impaired renal function. To overcome decompensation, these individuals took longer time, almost two times higher course and daily doses of loop and potassium‑preserving diuretics. Patients with impaired renal function had a statistically significantly worse prognosis regarding long‑term survival.Conclusions. Among patients with CHF and a reduced left ventricular ejection fraction (LVEF) hospitalized for circulatory decompensation, impaired renal function during treatment occurred in 18 % of cases. At the time of discharge, patients with impaired renal function compared with patients without one showed a significantly lower level of systolic blood pressure, a longer duration of decompensation overcoming, higher average daily doses of loop and potassium‑preserving diuretics, a higher content of uric acid, urea nitrogen, interleukin ‑6 and citrulline in plasma. Patients with decompensated CHF and impaired renal function had lower survival rate compared with patients without impaired renal function.

Maternal anaemia and risk of mortality: a call for action

Maternal anaemia and risk of mortality: a call for action

Respiratory pump maintains cardiac stroke volume during hypovolemia in young, healthy volunteers.

Spontaneous breathing has beneficial effects on the circulation, since negative intrathoracic pressure enhances venous return and increases cardiac stroke volume. We quantified the contribution of the respiratory pump to preserve stroke volume during hypovolemia in awake, young, healthy subjects. Noninvasive stroke volume, cardiac output, heart rate, and mean arterial pressure (Finometer) were recorded in 31 volunteers (19 women), 19-30 yr old, during normovolemia and hypovolemia (approximating 450- to 500-ml reduction in central blood volume) induced by lower-body negative pressure. Control-mode noninvasive positive-pressure ventilation was employed to reduce the effect of the respiratory pump. The ventilator settings were matched to each subject's spontaneous respiratory pattern. Stroke volume estimates during positive-pressure ventilation and spontaneous breathing were compared with Wilcoxon matched-pairs signed-rank test. Values are overall medians. During normovolemia, positive-pressure ventilation did not affect stroke volume or cardiac output. Hypovolemia resulted in an 18% decrease in stroke volume and a 9% decrease in cardiac output ( P < 0.001). Employing positive-pressure ventilation during hypovolemia decreased stroke volume further by 8% ( P < 0.001). Overall, hypovolemia and positive-pressure ventilation resulted in a reduction of 26% in stroke volume ( P < 0.001) and 13% in cardiac output ( P < 0.001) compared with baseline. Compared with the situation with control-mode positive-pressure ventilation, spontaneous breathing attenuated the reduction in stroke volume induced by moderate hypovolemia by 30% (i.e., -26 vs. -18%). In the patient who is critically ill with hypovolemia or uncontrolled hemorrhage, spontaneous breathing may contribute to hemodynamic stability, whereas controlled positive-pressure ventilation may result in circulatory decompensation. NEW & NOTEWORTHY Maintaining spontaneous respiration has beneficial effects on hemodynamic compensation, which is clinically relevant for patients in intensive care. We have quantified the contribution of the respiratory pump to cardiac stroke volume and cardiac output in healthy volunteers during normovolemia and central hypovolemia. The positive hemodynamic effect of the respiratory pump was abolished by noninvasive, low-level positive-pressure ventilation. Compared with control-mode positive-pressure ventilation, spontaneous negative-pressure ventilation attenuated the fall in stroke volume by 30%.

Features of intracardiac hemodynamics disoders in patients with chronic obstructive pulmonary disease complicated by the chronic pulmonary heart disease development and methods for their medical correction

Chronic pulmonary heart disease is a common pathology and has become one of the leading causes of disability and death in recent years [15]. According to the literature, two-thirds of patients with chronic obstructive pulmonary disease die during the period from 15 months to 5 years after the circulatory decompensation onset, which occupies the third place after hypertension and coronary heart disease among causes of death in the age group older than 50 years [14]. Pulmonary hypertension is considered to be the main pathogenetic mechanism of chronic pulmonary heart disease [11]. The mortality rate in patients with chronic pulmonary heart disease is directly related to the level of pulmonary artery systolic blood pressure. Thus, according to literature data, at the pulmonary artery systolic pressure from 30 to 50 mm Hg 4-5-year survival rate is 30%, and at the level of more than 50 mm Hg 5-year survival rate is zero [1]. Thus, pulmonary hypertension is a poor prognostic factor. Furthermore, it is known that the changes identified in the right ventricle amid the pulmonary hypertension are survival predictors in patients with chronic obstructive pulmonary disease [18]. Literature review showed that the hemodynamics feature in patients with chronic pulmonary heart disease is increased pressure in the pulmonary artery, which leads to both ventricles remodeling and in particular to the right heart enlargement, rise of both right and left ventricles diastolic dysfunction, reduced stroke volume and cardiac output. Furthermore, the review describes that such drug classes as angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers and selective β-blockers are successfully used for the revealed disorders correction in patients with chronic pulmonary heart disease.

Согласованная позиция экспертов по лечению пневмонии у пациентов с декомпенсацией кровообращения

Согласованная позиция экспертов по лечению пневмонии у пациентов с декомпенсацией кровообращения

Septic Shock in Pediatrics

Sepsis is defined as a clinical syndrome that complicates severe infection and is associated with the systemic inflammatory response syndrome as well as immune dysregulation. Circulatory decompensation and end-organ dysfunction will be the ultimate end if sepsis is not properly managed. In this syndrome, tissues remote from the original insult display the cardinal signs of inflammation, including vasodilation, increased microvascular permeability and leukocyte accumulation. Recently pediatric mortality from severe sepsis and septic shock has markedly decreased because of early recognition, aggressive fluid therapy and early administration of vasoactive agents in addition to antibiotics.

Прогностически значимые клинические фенотипы больных с декомпенсацией кровообращения в РФ

Прогностически значимые клинические фенотипы больных с декомпенсацией кровообращения в РФ

Pathogenesis and Clinical Presentation of Acute Heart Failure

Acute heart failure constitutes a heterogeneous clinical syndrome, whose pathophysiology is complex and not completely understood. Given the diversity of clinical presentations, several different pathophysiological mechanisms along with factors triggering circulatory decompensation are involved. This article discusses the available evidence on the pathophysiological phenomena attributed or/and associated with episodes of acute heart failure and describes different clinical profiles, which, from a clinical perspective, constitute a key element for therapeutic decision-making.

Patogenia y presentación clínica de la insuficiencia cardiaca aguda

Acute heart failure constitutes a heterogeneous clinical syndrome, whose pathophysiology is complex and not completely understood. Given the diversity of clinical presentations, several different pathophysiological mechanisms along with factors triggering circulatory decompensation are involved. This article discusses the available evidence on the pathophysiological phenomena attributed or/and associated with episodes of acute heart failure and describes different clinical profiles, which, from a clinical perspective, constitute a key element for therapeutic decision-making.Full English text available from:www.revespcardiol.org/en