Inotropic Support Research Articles

Clinical relevance and prognostic value of renal Doppler in acute decompensated precapillary pulmonary hypertension.

We aim to evaluate the clinical relevance and the prognostic value of arterial and venous renal Doppler in acute decompensated precapillary pulmonary hypertension (PH). The renal resistance index (RRI) and the Doppler-derived renal venous stasis index (RVSI) were monitored at admission and on Day 3 in a prospective cohort of precapillary PH patients managed in intensive care unit for acute right heart failure (RHF). The primary composite endpoint included death, circulatory assistance, urgent transplantation, or rehospitalization for acute RHF within 90 days following inclusion. Ninety-one patients were enrolled (58% female, age 58 ± 16 years). The primary endpoint event occurred in 32 patients (33%). In univariate logistic regression analysis, variables associated with RRI higher than the median value were non-variable parameters (age and history of hypertension), congestion (right atrial pressure and renal pulse pressure), cardiac function [tricuspid annular plane systolic excursion (TAPSE) and left ventricular outflow tract- velocity time integral], systemic pressures and NT-proBNP. Variables associated with RVSI higher than the median value were congestion (high central venous pressure, right atrial pressure, and renal pulse pressure), right cardiac function (TAPSE), severe tricuspid regurgitation, and systemic pressures. Inotropic support was more frequently required in patients with high RRI (P = 0.01) or high RVSI (P = 0.003) at the time of admission. At Day 3, a RRI value <0.9 was associated with a better prognosis after adjusting to the estimated glomerular filtration rate. Renal Doppler provides additional information to assess the severity of patients admitted to the intensive care unit for acute decompensated precapillary PH.

Inotropic support after Acute Coronary Syndrome. Levosimendan or dobutamine? Experience in our center

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Inotropic support after Acute Coronary Syndrome (ACS) is commonly used in Cardiac Critical Care Units (CCU). In this context, dobutamine is widely used, given the large experience with this drug, however recently levosimendan has emerged as a safe and effective alternative. Objective Our objective is to analyze the clinical and prognostic differences between patients treated with dobutamine or levosimendan. We wanted to detect the pattern of use of these drugs and determine the best therapeutic option in our patients. Methods Retrospective observational study of patients admitted for ACS at our CCU between August 2011 and September 2022. Patients treated with dobutamine or levosimendan were included, excluding those who required both drugs. We compared baseline characteristics and clinical events in both therapy groups. Results Our sample included 184 patients admitted for ACS who needed inotropic support during the admission period, with either dobutamine or levosimendan. In our cohort, the mean age was 67.95 +/- 12.04 years. 126 (68.48%) patients received dobutamine and 58 (31.52%) levosimendan. Regarding baseline characteristics of our population, we only found statistically significant differences in Diabetes Mellitus as a Risk Factor (p=0.0172) and Congestive Heart Failure (p=0.0128). We tended to use dobutamine over levosimendan as an inotropic agent in shocked patients (p=0.036). No significant differences were found in other data collected in the clinical history, including noradrenaline or intra aortic balloon pump use, arrhythmic events or in-hospital mortality. Multivariate analysis adjusted for clinical and epidemiological factors detected cardiogenic shock as the only independient predictor of in-hospital mortality. Conclusions In our experience, comparing with levosimendan, dobutamine was the preferred inotropic support in shocked patients. We detected no differences in terms of complications and prognosis between both drugs use.

Impella for the management of ventricular septal defect complicating acute myocardial infarction: insights from an European multicenter retrospective analysis. The VSD-IMPELLA study

Abstract Funding Acknowledgements Type of funding sources: None. Backgroud Ventricular septal defect (VSD), is a rare but fatal complication of myocardial infarction (MI) associated with high early mortality. Temporary mechanical circulatory support (t-MCS) of any type can be used to stabilize the patient as a bridge to surgical or percutaneous closure, or to heart transplantation or long-term ventricular assist device, but with a low level of evidence. The Impella® device is a trans-valvular aortic axial pump inserted surgically or percutaneously which pumps blood directly from the left ventricle into above the aortic valve. Its hemodynamic effects seem interesting, explaining its use by certain expert centers in this context, but the data in this indication are rare in the literature. Method It was an European retrospective multicentre registry of patients hospitalized for ischemic VSD managed with an Impella® (2.5, CP or 5.0) over the past 10 years (2010 to 2021). The primary endpoint was in-hospital mortality. The secondary endpoints were the monitoring of clinical, hemodynamic and biological data at 24 hours, the medications and organ supports used during hospitalization, intra-hospital complications and mortality at 6 months and 1 year. Results On 20 centers contacted, 17 responded (85%). A total of 28 patients managed with an Impella® device for an ischemic VSD in 7 European center were included (41% of respondents). All patients included were in cardiogenic shock (100%, n=28) with multiple organ failure (SAPSII 41 [IQR 53-27], Euroscore 57 [IQR 75-23] and arterial lactate 6 +/-5 mmol). The majority of patients required inotropic and vasopressor support (dobutamine 55% and norepinephrine 96%). In-hospital and 1-year mortalities were 75%. Surgical closure of the VSD was performed in 36% of patients, percutaneous closure in 21% and medical treatment alone for 43, with in-hospital mortality of 30, 92 and 100% respectively. Hospital mortality also seemed to be associated with the type of t-MCS used (71% for Impella alone, 67% for Impella® with IABP combination and 78% for Impella® with ECLS combination). Survivors were more likely to have benefited from CABG revascularization (p &amp;lt; 0.011). Conclusion Despite the potential hemodynamic advantages, the use of Impella® in patients with ischemic VSD is associated with high mortality which may be partly related to its exclusive use in the most severe cardiogenic shock patients, to associated therapies in particular the type of closure of the VSD, or the complications of the device itself.

After an acute coronary syndrome: levosimendan or dobutamine? this is our impression

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Inotropic support is frequently needed after acute coronary syndromes(ACS) at coronary care units(CCU). Despite it has being long time since approval of levosimendan(LV) as inotropic support to cardiogenic shock, dobutamine(DB) still being the basis of this treatment. We think levosimendan is a secure and effective alternative. Purpose To analyse the use of levosimendan and dobutamine done in our ACS patients to determine if we have followed some clear criteria of selection, and try to draw a defined pattern for future use. Method Retrospective, analytic, observational study of all ACS admitted to our CCU between 08/2011- 02/2022. We confront patients treated with dobutamine versus levosimendan. X2, U-Mann Whitney and T-Student were used when necessary. Statistical significance: p-value&amp;lt;0.05. Result 2881patients were admitted with ACS, 6.49%of them(n: 187) needed ionotropic support. Out of these, 60.96%(n: 114) were supported with dobutamine, 28.88%(n: 54) with levosimedan and 10.16%(n: 19)received in some time both drugs, so were excluded from the analysis. Mean age: 68.43±11.48years old. 66.66%(n: 112) men. 54.76%(n: 92)with persistent ST-segment elevation. No difference was found between groups, neither in past medical history, including cardiovascular risk factors, history of arrhythmias(11.3% of patients), previous use of betablockers(30.4%), antiarrhythmic drugs(0.6%) or having pacemaker(1.2%). 114 patients(67.86%)needed norepinephrine(70.17%with DB and 62.96% LV, p:0.35); 29(17.26%) were supported with intra-aortic balloon pump(20.18% in DB group and 11.11% in LV group, p:0.134), without differences by drug. 62 patients(36.9%) presented atrial fibrillation(33.33% in DB and 44.44% in LV, p:0.166), 58(34.52%)ventricular arrhythmias[sustained ventricular tachycardia/ventricular fibrillation](33.33% in DB and 37.04% in LV, p:0.638). In-hospital mortality of these patients was 29.17%(n:49), 29.82% in DB and 27.77% in LV, p:0.785. In multivariate analysis adjusted by clinic and epidemiologic factors, only cardiogenic shock resulted an independent predictor of in-hospital death. Pattern of use we use DB in those patients with worst Killip-kimball(KK) state(73.54%in DB group with KK-IV vs53.70%in LV´s) and LV in those in intermediate states of instability(38.88%LV in KK-II/III vs 8.84%DB in KK-II/III),p&amp;lt;0.001. We chose DB in those who became unstable in CCU and LV in those who became unstable in hospitalization room, p:0.049. Finally, we noted a significant change in trend of use during the period of study, falling use of DB in favour of LV(p&amp;lt;0.001). Conclusion In our experience, dobutamine has been the most frequent ionotropic drug used in last 11 years after an acute coronary syndrome. Nevertheless, a substitution by levosimendan trend is evolving. We did not detect differences in complications or prognosis dependent on the inotropic drug used, but the use of dobutamine were predominant in those patients with more severe situation.

Medium-Term Outcomes in Pediatric Patients Undergoing Cardiac Catheterization Early After Congenital Cardiac Surgery.

Safety and acute outcomes for patients who need catheterization shortly after congenital cardiac surgery has been established; literature on mid-term outcomes is lacking. We sought to evaluate the mid-term outcomes of patients who undergo early postoperative cardiac catheterization. This is a retrospective cohort study of patients who underwent cardiac catheterization within 6weeks of congenital cardiac surgery with longitudinal follow-up and assessment of mid-term outcomes. Multivariable analysis was utilized to relate variables of interest to outcomes. 99 patients underwent cardiac catheterizations within 6weeks of cardiac surgery between January 2008 and September 2016. Forty-six (45.5%) interventional procedures were performed at a median age of 41days (IQR 21-192) and a median weight of 3.9kg (3.3-6.6). During a median follow-up duration of 4.24years (1.6-5.6) in study survivors, 61% of patients remained free from the primary endpoint (death and/or transplant). Sixty-nine patients (69.7%) underwent an unplanned surgical or catheter procedure. Renal failure at catheterization (OR 280.5, p 0.0199), inotropic medication at catheterization (OR 14.8, p 0.002), and younger age were all significantly associated with meeting the primary endpoint. Patients requiring surgical intervention as an initial additional intervention underwent more unplanned re-interventions, while patients who survived to hospital discharge demonstrated favorable mortality, though with frequent need for re-intervention. In patients requiring early postoperative cardiac catheterization, renal failure, younger age, and need for inotropic support at catheterization are significantly associated with meeting the primary endpoint.

PO-02-012 A SYSTEMATIC REVIEW AND META-ANALYSIS OF CARDIAC RESYNCHRONIZATION THERAPY IN INOTROPE-DEPENDENT HEART FAILURE

Several studies have shown cardiac resynchronization therapy (CRT) to be beneficial in the management of heart failure (HF) with systolic dysfunction, widened QRS complex length, and New York Heart Association (NYHA) class III or IV. However, whether CRT is viable in HF patients who require inotropic support is still a matter of debate. To assess outcomes of CRT in end-stage inotrope-dependent HF. Following PRISMA guidelines, we searched Medline, EMBASE, Scopus, and Cochrane Library until December 31st 2021, with the following terms: “end-stage heart failure,” “catecholamine-dependent overt heart failure,” “inotrope-dependent heart failure,” “advanced heart failure,” “New York Heart Association class IV,” “NYHA class IV.” These terms were combined with “cardiac resynchronization therapy” OR “CRT” OR “biventricular device”. Studies were included if: 1) HF patients required on inotropic support at CRT implantation; 2) patients were at least 18 years old; and 3) provided a clear definition of “inotrope dependence” or “inability to wean.” A meta-analysis with random effects was performed in R (Version 3.5.1) with data presented as mean ± standard deviation. 9 studies comprised of 168 inotrope-dependent HF patients (mean age 64.4 ± 5.8 years, 79.6% male, 41.7% non-ischemic cardiomyopathy, mean QRS duration 173.9 ± 13.2 ms, 82.1% NYHA Class IV) were included for meta-analysis. Hospitalization rate for recurrence of HF 12-18 months post-CRT was 21% (95%CI: 15-28%, I2=0%, P=0.41, Fig 1C) and survival at 12 months post-CRT was 71% (95%CI: 58-83%, I2=68%, P<0.01, Fig 1D). A significant majority were weaned off inotropes at 93% (95%CI: 83-99%, I2=69%, P<0.01, Fig 1E) and 39% (95%CI: 19-61%, I2=69%, P<0.01, Fig 1H) improved to NYHA class II. A considerable proportion at 40% (95%CI: 15-68%, I2=88%, P<0.01, Fig 1G) improved to NYHA class III, but 12% (95%CI: 5-12%, I2=45%, P=0.09, Fig 1F) did not improve from NYHA class IV. Responders tended be male (85.7% vs. 40%, P=0.015, Table 1), have a history of left bundle branch block (71.4% vs. 30%, P=0.036, Table 1) or an increased left ventricular end-diastolic volume (274.3 mL vs. 225.9 mL, P=0.038, Table 1). Our findings suggest that CRT is a viable option for end-stage inotrope-dependent HF. Responders appear to be male with evidence of preserved diastolic function or a history of a left bundle branch block. Further work is necessary to optimize patient selection.Tabled 1Table 1 - Characteristics of Responders and Non-Responders to CRT. Data are presented as Mean ± Standard Deviation with percentages shown in brackets.FactorResponders to CRT (n=21)Non-Responders to CRT (n=10)p-valueMean Age (Years)65.5 ± 3.957.8 ± 5.80.412Males (%)18 (85.7)4 (40)0.015Hypertension (%)8 (38.1)2 (20)0.281Diabetes Mellitus (%)8 (38.1)2 (20)0.281Non-Ischemic Cardiomyopathy (%)18 (85.7)8 (80)0.528Atrial Fibrillation (%)8 (38.1)2 (20)0.281Left Bundle Branch Block (%)15 (71.4)3 (30)0.036Left Ventricular Ejection Fraction (%)19.5 ± 0.1524.1 ± 0.90.036Left Ventricular End-Systolic Volume (mL)218.2 ± 1.9175.5 ± 5.50.016Left Ventricular End-Diastolic Volume (mL)274.3 ± 7.2225.9 ± 6.10.038Pre-CRT QRS Length (ms)168.7 ± 8.4152.9 ± 6.10.298Post-CRT QRS Length (ms)156.7 ± 4.6149.7 ± 4.40.346 Open table in a new tab

Management of Cardiogenic Shock: Present and Future.

Management of Cardiogenic Shock: Present and Future.

PO-04-232 PERCUTANEOUS STELLATE GANGLION BLOCKADE FOR ELECTRICAL STORM: LARGE SINGLE CENTRE EXPERIENCE

Electrical storm (ES) is defined as three or more episodes of ventricular arrhythmia requiring defibrilltaion or anti tachycardia pacing within a day.Some times electrical storm may not respond to anti-arrhythmic drugs alone.Increased sympathetic activity plays significant role in electrical storm.Stellate ganglion blockade reduces sympathetic activity and helpful in reduction of ventricular arrhythmias. We aimed to study the effectiveness and outcomes of percutaneous stellate ganglion blockade (SGB) in the patients with drug-refractory electrical storm. The study included patients with a drug-refractory electrical storm. Before giving SGB, at least two anti-arrhythmic drugs(AAD) were given before SGB. Bupivacaine was injected in the vicinity of the stellate ganglion under Ultrasound quidance. A total of 83 procedures were performed on 56 patients (71% males, 60+6 years).Fourty three patients (76%) had ischemic heart disease. Nearly 66%(37/56) of patients were free from ventricular arrhythmias(VA) at 24 hours after left SGB and 51%(29/56) were arrhythmia free at 72 hours. Bilateral SGB was done in 16 patients who had failed left-sided SGB with a success rate of 36%. Heart failure and shock were documented in 65% and 55% respectively. Twenty Five (44%) patients were on both Intra-aortic balloon counterpulsation and inotrope support. All-cause mortality was 32% (18/56). Cardiovascular mortality was 28% (16/56). Septic shock in one patient and Ischemic brain stroke was the cause of death in the other patient. VA recurrence, poor left ventricular ejection fraction, and failed stellate ganglion blockade were associated with increased mortality. Procedure-related complications like transient bradycardia(16%), hematoma(14%), hoarseness of voice (10%), persistent ptosis(5%), and monoparesis(3.5%) were noted, all of which were resolved within two weeks of post-procedure. SGB helps to stabilize the hemodynamic status of the patients with electrical storm. It also provides time for

Severe cardiogenic shock and cardiac arrest due to fulminant cardiac sarcoidosis: a case report

BackgroundCardiac sarcoidosis is found to occur in approximately 5% of patients with sarcoidosis. Its presentation can typically range from complete heart block to ventricular arrhythmias. This condition can rarely present with severe heart failure and cardiogenic shock requiring aggressive and timely management strategies. Advanced imaging techniques are usually required to assist with its diagnosis.Case presentationA 70-year-old woman with a history of pulmonary sarcoidosis presented with non-ST elevation myocardial infarction, congestive hepatopathy, and acute renal failure. Left heart catheterization showed evidence of non-obstructive coronary artery disease, and right heart catheterization revealed severely elevated filling pressures and depressed cardiac index. She underwent aggressive diuresis and placement of an intra-aortic balloon pump in addition to initiation of inotropic and vasopressor support. While in the cardiac intensive care unit, she experienced frequent episodes of ventricular tachycardia and went into cardiac arrest requiring cardiopulmonary resuscitation. High clinical suspicion for cardiac sarcoidosis was confirmed by cardiac magnetic resonance imaging findings. After starting immunosuppressive therapy for cardiac sarcoidosis, she demonstrated clinical improvement.ConclusionPatients with cardiac sarcoidosis may remain asymptomatic or present with conduction abnormalities and arrhythmias. They rarely present with severe biventricular heart failure and cardiogenic shock, and in such cases, they require timely initiation of pharmacologic and device therapies, along with implementation of mechanical circulatory support.

Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes.

Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

Treatment Intensity for the Management of Cardiogenic Shock: Comparison Between STEMI and Non-STEMI

BackgroundCardiogenic shock is a leading cause of mortality in patients with acute myocardial infarction. ObjectivesThe authors sought to compare clinical characteristics, hospital trajectory, and drug and device use between patients with ST-segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) and those without (non-ST-segment elevation myocardial infarction complicated by cardiogenic shock [NSTEMI-CS]). MethodsWe analyzed data from 1,110 adult admissions with cardiogenic shock complicating acute myocardial infarction (AMI-CS) across 17 centers within Cardiogenic Shock Working Group. The primary end point was in-hospital mortality. ResultsOur study included 1,110 patients with AMI-CS, of which 731 (65.8%) had STEMI-CS and 379 (34.2%) had NSTEMI-CS. Most patients were male (STEMI-CS: 71.6%, NSTEMI-CS: 66.5%) and White (STEMI-CS: 53.8%, NSTEMI-CS: 64.1%). In-hospital mortality was 41% and was similar among patients with STEMI-CS and NSTEMI-CS (43% vs 39%, P = 0.23). Patients with out-of-hospital cardiac arrest had higher in-hospital mortality in patients with NSTEMI-CS (63% vs 36%, P = 0.006) as compared to patients with STEMI-CS (52% vs 41%, P = 0.16). Similar results were observed for in-hospital cardiac arrest in patients with STEMI-CS (63% vs 33%, P < 0.001) and NSTEMI-CS (60% vs 32%, P < 0.001). Only 27% of patients with STEMI-CS and 12% of NSTEMI-CS received both a drug and temporary mechanical circulatory support device during the first 24 hours, which increased to 78% and 61%, respectively, throughout the course of the hospitalization (P < 0.001 for both). ConclusionsDespite increasing use of inotropic and vasoactive support and mechanical circulatory support throughout the hospitalization, both patients with STEMI-CS and NSTEMI-CS remain at increased risk for in-hospital mortality. Randomized controls trials are needed to elucidate whether timing and sequence of escalation of support improves outcomes in patients with AMI-CS.

PO-05-007 CORONARY VENOUS ETHANOL ABLATION OF SUBEPICARDIAL SUBSTRATE IN PATIENTS WITH VENTRICULAR TACHYCARDIA AND LEFT VENTRICULAR ASSIST DEVICE.

Patients with a left ventricular assist device (LVAD) and ventricular tachycardia (VT) often have subepicardial substrate, which may not be amenable to epicardial ablation due to sternotomy-related adhesions and the LVAD itself. As an alternative approach, coronary venous ethanol ablation (VEA) can be used to ablate VT substrates without needing pericardial access. To assess the feasibility and acute safety of VEA in patients with LVAD and VT. We retrospectively studied patients with LVAD who underwent VT ablation using VEA between 8/2015 – 11/2022 at a tertiary referral medical center. Baseline patient and procedural characteristics were obtained. Of the 10 patients included, 7 presented with VT storm, 5 had prior VT ablation, 3 had multiple prior sternotomies, all were on amiodarone, 8 were on 2 or more antiarrhythmic drugs in the prior year, all had prior defibrillator implants, and 9 had shocks in the prior year. Across the cohort, 4 different vein territories were targeted for VEA, including the middle cardiac vein, posterolateral branch vein, anterolateral branch vein, and septal branch of the anterior interventricular vein. In 4 cases, 2 separate vein territories were targeted. An average of 17 ± 10 cc of ethanol was used per case. Concomitant radiofrequency ablation was used in all 10 patients. Procedure and fluoroscopy times were 290 ± 56 minutes, and 32 ± 15 minutes, respectively. Acute procedural success, defined as no inducible VT, was achieved in 9 cases. There was 1 complication, which was transiently increased threshold on the LV pacing lead and RV failure necessitating prolonged inotropic support. All the patients survived to hospital discharge. In an inherently high-risk LVAD population with VT, VEA can be used as an alternative approach to target subepicardial substrate that would otherwise be inaccessible via standard percutaneous access of the pericardial space. Acute procedural success was high in this limited cohort. Further study with larger numbers of cases and longer follow up is warranted.

PO-05-018 GIANT INTRASEPTAL HEMATOMA COMPLICATING LEFT BUNDLE BRANCH PACING: AN UNUSUAL CLINICAL CHALLENGE

Left bundle branch pacing (LBBP) is an excellent alternative to His bundle pacing (HBP). Due to its non-traditional intraseptal lead placement, rare but unusual complications have been described. We present the case of a unique complication of a very large septal hematoma following LBBP. n/a An 88-year-old female with Coronary disease, renal insufficiency, and uncontrolled atrial fibrillation was referred for AV node ablation and conduction system pacing. Due to high HBP thresholds, a LBBP lead was implanted in proximal location (Stim-V6 peak=70ms, QRSd=135ms) with a backup second LBBP lead at a slightly distal location (Stim-V6 peak=61ms, QRSd=121ms) with low capture thresholds. She was discharged home the same day. She was readmitted a-day later with nausea, weakness, and significant dyspnea. Echocardiogram revealed a very large septal hematoma (61mm x 40mm) with complete obliteration of right ventricle cavity and no pericardial effusion (Figure 1A). IV fluid bolus was given, and Apixaban/Clopidogrel/ASA were held. Angiography and possible embolization of bleeding septal perforator was considered but not performed due to her CKD and hemodynamic stability. Serial echo revealed improved RV filling, stable hematoma and absent effusion. She was discharged on day 7 in stable condition. Anticoagulation was resumed after 2 weeks. Repeat echo at 6 weeks showed complete resolution of interventricular septal hematoma and lead parameters were stable (Figure 1B). This is a unique and rare case of a giant interventricular septal hematoma post LBBP, successfully managed with conservative management. Given rarity of complication, maintaining a broad differential for early recognition and treatment remains paramount. Avoiding a very proximal and anterior left bundle area, if possible, can be considered to avoid a major septal perforator. Repeat imaging and close hemodynamic monitoring is recommended in such patients. Angiography to localize the bleeding septal perforator and possible embolization may be considered for hemodynamic instability. This was deferred in our patient due to severe renal insufficiency, as well as lack of pericardial effusion and improving hemodynamics not requiring inotropic support. However, we recommend a multidisciplinary heart team and critical care approach, as was used in this case, to help personalize management.

Effect of Shorter Cross Clamp Time vs. longer Cross Clamp time on cardiac enzyme levels in pts of CAD undergoing CABG

Aim: To compare mean cardiac enzyme levels in of shorter cross clamp time V/S longer cross Clamp time in patients undergoing CABG in local population. Study Design: Randomized Controlled Trial Place and duration: This study was performed from 2nd April 2020 to 2nd October 2020 in the Department of Cardiac Surgery Punjab Institute of Cardiology, Lahore. Methodology: After informed consent, all patients undergoing CABG were enrolled and divided into two groups. A predesigned performa was used to enter preop, intra op and post op variables and cardiac enzyme levels were compared between shorter (&lt;60 minutes) and longer (&gt;60 minutes) aortic cross clamp time groups. Results: Study had enrolled 300 patients and 150(50%) patients were designated group A (shorter cross clamp time and 150 (50%) patients were designated in group B (longer cross clamp time). Out of these 300, 246 patients (82%) were males and 54 (18%) were females. Extremes of age were 70 years and 37 years and mean age was 56.77±8.03 years. Group A (shorter cross clamp time) patients had mean age of 56.64 ±7.53 and group B (longer cross clamp time) patients had 56.89±8.52 .Mean EF (%) was 52.17±8.98 with 23% being minimum and 70% being maximum. In group A patients, 93 patients (62%) were hypertensive , 82(55%) were smokers and 67 (45%) patients were diabetic, while group B had 110 (73%) hypertensive, 84(56%) smokers and 73(49%) diabetic patients. Mean CPB time in group A was recorded to be 93.72±29.97 and mean CPB time in group B was 121.04±31.83. The P-value was 0.001, significant enough to represent difference in CPG time in both groups Practical Implication: Additionally, no notable difference was found in need of inotropic supports between two groups. Longer cross clamp time is also associated with longer CPB time which in turn correlates with higher morbidity and mortality. Conclusion: It is concluded that prolonged cross clamp time is an independent predictor of morbidity despite cardio protection by modern strategies Keywords: CKMB, IABP, CABG, CPB time, aortic cross clamp time, Shorter Cross

Characterising approaches to steroid therapy in paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2.

We describe approaches to steroid therapy use in paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS) and examine the association between steroid therapy and key clinical markers of severity. We conducted a retrospective review of children (<18 years) admitted to a tertiary paediatric hospital in the UK with PIMS-TS. We collected data on if and why steroid therapy was used; the duration, type and dosing of steroids prescribed; and approaches to hypothalamo-pituitary-adrenal (HPA) axis monitoring, if performed. We examined associations between steroid exposure/total steroid dose (mg/m2 /day) and paediatric intensive care unit admission, mechanical ventilation and inotropic support. Steroid therapy was commenced in most children (84.9%, n = 104) with a median total daily steroid dose (hydrocortisone equivalent) of 271.0 mg/m2 /day (interquartile range 232.5-355.5) and treatment length of 26.0 days (interquartile range 19.0-32.0). Dosing regimens predominantly involved a short course of high-dose methylprednisolone followed by tapering oral prednisolone. Basal and/or dynamic testing of the HPA axis was conducted in a minority (11.8%, n = 15) and was normal. Duration of steroid therapy correlated positively with durations of paediatric intensive care unit admission (r = 0.407, P < 0.001) and mechanical ventilation (r = 0.797, P < 0.001). A greater proportion of children receiving steroid therapy also received inotropic support compared to those that did not receive steroid therapy (71.4% vs. 45.5%, P = 0.025). Prolonged, high-dose steroid therapy is often used in the management of severe PIMS-TS with the potential for HPA axis suppression and should be withdrawn carefully.

Blood Purification with oXiris© in Critically Ill Children with Vasoplegic Shock

Introduction: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. As such, circulating cytokines and danger- and pathogen-associated molecular patterns (such as endotoxins) are recognized as central in the pathogenesis of sepsis and organ dysfunction. Removing these compounds by extracorporeal blood filtration, commonly considered blood purification, may improve the septic patients’ condition. This study aimed to assess the vaso-inotropic support evolution over time in pediatric patients with vasoplegic shock treated with oXiris©. Methods: All patients aged below 18 years admitted at the Paris Saclay University Quaternary Pediatric Intensive Care Unit with vasoplegic shock and acute kidney injury and treated with oXiris© between October 2017 and January 2020 were included. The vaso-inotropic score and the 28-day mortality were assessed. Improvement under treatment was defined as a 50% decrease in the vaso-inotropic score following 24 h of oXiris© therapy. Results: Eleven pediatric patients aged 2–15 years and weighing 11–60 kg were admitted with vasoplegic shock and acute kidney injury. They received thirteen sessions of oXiris© therapy for septic shock (N = 7) and liver failure (N = 6). Eight patients did not improve their condition during the session, and five ultimately died (37.5% survival). Five patients improved, decreasing their inotropic support by >50% in 24 h. Among them, four survived (80%). Conclusion: Hemofiltration and extracorporeal blood purification with oXiris© can be used in pediatric patients with vasoplegic shock with rapid improvement in hemodynamics in selected patients.

Clinical Study of a New Modified Early Warning Scoring System for Rapidly Evaluating Shock in Adults.

Shock is one of the most common severe syndromes requiring emergency treatment. Acute myocardial infarction guidelines, the surviving sepsis campaign, and low blood volume resuscitation guidelines indicate the prioritization ofearly identification of shock. APACHE II(Acute Physiology and Chronic Health Evaluation II), SOFA (Sequential Organ Failure Assessment), and MEWS (Modified Early Warning System) scores are used to predict mortality in ICU (intensive care unit) patients. However, similar to APACHE II, SOFA cannot be used forrapid assessment. Hence the need for a new scoring system that is simple, faster, and efficacious in predicting and preventing mortality among shock patients. The present study was conducted to evaluate a new MEWS scoring system for early identification and estimate mortality risk in patients with shock. A total of 170 patients with shock meeting the inclusion criteria who presented to the ICU of Ramaiah Hospitals from November 2019 to August 2021 were included in the study. Baseline variables, laboratory parameters, APACHE II score, SOFA score, MEWS score, and new MEWS score were compared between the two groups. Patients were followed up till mortality or discharge from ICU. Among the 170 patients included in the studyseptic shock (69.4%) was the most common type of shock followed by cardiogenic(7.64%) and hypovolemic shock (7.64%). The requirement of inotropic support and mechanical ventilation was associated with significantly higher mortality (55.6% and 52.6% respectively). The AUROC (area under the curve) for SOFA in predicting mortality was 0.738 (p<0.001). The AUROCfor APACHE II score in predicting mortality was 0.758 (p<0.001). The AUROC for MEWS score in predicting mortality was 0.655 (p=0.0002). The AUROC for the new MEWS score in predicting mortality was 0.684 which is more than that of the conventional MEWS score (p <0.001). New MEWS score is better than the MEWS score in predicting mortality. The new MEWS score is a simple, entirely clinical, inexpensive scoring system that can be done within a short time as a patient contact in an emergency. Hence, the new MEWS score can help in the quick identification of patients who are at high risk for developing shock and can be used as a better predictor of mortality.

Guideline on the investigation and management of acute transfusion reactions.

Guideline on the investigation and management of acute transfusion reactions.

Expanding Heart Donor Pool With a Broken Heart: Cardiac Transplant From Donor Following Circulatory Death With Takotsubo Syndrome.

Owing to the growth of patients with advanced heart failure and limited potential for donation after brain death, expanding donor source with hearts from controlled donation after circulatory death (cDCD) and meeting extended criteria are essential strategies. We present the first case of a patient who successfully underwent cardiac transplant (CT) from cDCD with Takotsubo syndrome (TTS). The donor was a 49-y-old man without risk factors for coronary artery disease (CAD) and terminal amyotrophic lateral sclerosis with respiratory failure and mechanical ventilation support. A decision was made with patient’s family to withdraw life-sustaining therapies (WLSTs). Organ donation option was presented and consented, and cDCD Maastricht Classification III1 was considered suitable. He presented normal blood tests, electrocardiogram, and echocardiogram. The cDCD process was performed using an extracorporeal membrane oxygenation circuit to perform thoracoabdominal normothermic regional perfusion.2 During intraoperative evaluation, transesophageal echocardiography revealed normal left ventricular ejection fraction (LVEF). However, after WLST, moderate dysfunction (LVEF 37%) and apical ballooning suggestive of TTS were observed (Figure 1A), continuing present after thoracoabdominal normothermic regional perfusion withdrawal and organ extraction. Epicardial coronary arteries palpation did not reveal pathology.FIGURE 1.: A, Intraoperative transesophageal echocardiography evaluation that shows the left ventricle in diastole and systole with apical akinesia and preserved contractility of basal segments. B, The 12-lead electrocardiogram reveals T wave inversion and prolonged QT interval. C, A graph of heart recovery timeline based on the high-sensitivity troponin T levels, left ventricular ejection fraction, and inotrope support, correlated with the d after cardiac transplant. D, Normal right and left coronary arteries in the post cardiac transplant protocol–based coronary angiography. LVEF, left ventricular ejection fraction.The heart recipient was a 52-y-old man with severe, irreversible ischemic cardiomyopathy and 10 d with a ventricular assist device, listed for CT after excluding severe comorbidities and a multidisciplinary team discussion. An orthotopic transplant was performed using the bicaval technique, with spontaneous heartbeat and cold ischemia time of 86 min. He required minimal vasoactive support, withdrawn 48 h after CT. The electrocardiogram showed diffuse negative T waves and prolonged QTc interval (Figure 1B), and peak level of high-sensitivity troponin T was 2115 ng/L. Six days after CT, LVEF normalized. The timeline of heart recovery is represented in Figure 1C. The coronary angiography ruled out donor CAD (Figure 1D). The patient was discharged 30 d after CT and is doing well 43 wk after. Serial echocardiograms reveal normal wall motion and function. DISCUSSION Although TTS and CT have been indirectly associated, few cases have been published on donor hearts with TTS, these with no compromised survival3; none in cDCD. Similar pathophysiological aspects, present in TTS and cDCD, could be responsible for the phenomenon that occurred during CT. In the cDCD, the heart experiences a warm ischemia period during the WLST, cardiac arrest, and CT. This implies ischemia–reperfusion injury: activation of inflammatory and coagulation cascades and release of catecholamines.4 The mechanisms behind TTS, clinical condition characterized by acute transient left ventricular dysfunction, remain unknown. The most widely accepted theory is catecholamine-induced cardiotoxicity, and growing evidence is arising for myocardial inflammation, endothelial and microcirculation dysfunction, and neurohormonal alterations.5 Because of donor’s age, low-risk profile of CAD, and echocardiographic abnormalities, TTS was suspected. The post-CT protocol–based coronary angiography ruled out obstructive CAD or atherosclerotic plaque rupture. There was a rapid normalization of LVEF, negative T waves in the electrocardiogram, and elevated cardiac enzymes. This fulfilled the most widely used TTS diagnostic criteria.5 A pre-CT coronary angiography in patients >40 y or at risk of CAD could avoid ruling out hearts with left ventricular dysfunction. CONCLUSION The pathophysiological knowledge of cDCD and TTS could increase CT rates. This first experience in cDCD should be cautiously interpreted and analyzed individually in future cases.

Megakaryoblasts in pleural fluid in neonate with transient leukaemia of Down's syndrome.

Twin baby boy born at 35+2 weeks gestation with a birth weight of 2070 grams via emergency cesarean section secondary to abnormal CTG and foetal distress. Full blood count obtained at birth showed haemoglobin 159 g/L, total white cell count 99.54 × 109/L platelet count 779 × 109/L. Manual differential showed an absolute neutrophil count of 2.01 × 109/L absolute lymphocyte count of 45.27 × 109/L and blast count of 50.3 × 109/L (50%). Initial peripheral blood smear morphology review revealed a thrombocytosis, platelet anisocytosis and micromegakaryocytes. It also demonstrated neutropenia, myeloid left shift, large blasts with a high N/C ratio and nucleoli. Additionally, numerous nucleated red blood cells were seen with marked red cell dysplasia including binucleate forms and abnormal haemoglobinisation. There was no prenatal diagnosis of Down's syndrome (DS). The above blood results along with the baby's clinical signs raised suspicion of DS and subsequently transient leukaemia of DS. This baby was then transferred to the regional neonatal intensive care unit on day 2 of life. On admission, he was noted to have bilateral pleural effusion, synthetic liver dysfunction with elevated creatinine and ammonia levels as well as ascites. He was intubated, and ventilated and required inotropic support. Due to adverse features of elevated white cell count, hepatosplenomegaly, pleural effusion as well as ascites [1] and following the multidisciplinary team (MDT) discussion and parental consent, the patient was commenced on low dose cytarabine for 7 days. He tolerated that well, however, did experience mild cytopenias and pyrexic episodes, followed by recovery during the following two weeks with a reduction in pleural effusions, hepatosplenomegaly and reduction in oxygen requirement which enabled successful extubation and commencement of continuous positive airway pressure. Unfortunately, on day 19 of life he was noted to have slowly increasing oxygen requirements with re-accumulation of pleural effusions and increasing hepatosplenomegaly as well as increasing blast count in peripheral blood. He proceeded to require intubation and ventilation again as well as placement of a chest drain to remove pleural fluid to improve respiratory compliance. A review of pleural fluid morphology had shown frequent ‘blast-like’ cells; these were medium-sized with a high N/C ratio with finely condensed chromatin nucleoli and budded basophilic cytoplasm thought to most likely represent megakaryoblasts [2]. As a result of the deterioration, a decision by MDT was made to give another cycle of low-dose cytarabine on days 1 through 5. Following the second cycle of cytarabine, the patient again experienced mild cytopenias and pyrexic episodes, was treated with antibiotics and supportive management and transfusions of packed red cells. He had complete count recovery and no blast population identified morphologically on peripheral blood film on day 26 of the second cycle of cytarabine. His GATA1 mutation was subsequently found to be positive. He continued to improve and was discharged home on day 67 of life Figures 1-3. Karolina Chmielowiec—wrote the manuscript, Gary Beattie—manuscript review, obtained image, obtained and analysed flow cytometry data, Kathryn Clarke—manuscript review, obtained and analysed flow cytometry, Ellen McCloy—manuscript review, morphology review, Bethany Mitchell—manuscript review, morphology review, Christine Macartney—manuscript review, supervising consultant. All authors discussed the results and commented on the manuscript. None. The authors declare no conflict of interest. No funding was required for this submission. Not applicable. Not Applicable. Not Applicable All authors have contributed to the acquisition, analysis and interpretation of data as well as either drafting the paper or revising it critically. All authors approved the submitted and final versions. For original data, please contact [email protected]