Need For Mechanical Circulatory Support Research Articles

Prediction of cardiac deterioration in acute heart failure patients: Evaluation of the efficacy of single laboratory indicator models versus comprehensive models.

This study aims to compare the efficacy of single-indicator models versus comprehensive models in predicting cardiac deterioration events in patients with acute heart failure (AHF), providing a more precise predictive tool for clinical practice. This retrospective cohort study included 484 patients with AHF treated at our hospital between June 2018 and January 2023. Patients were categorized into a deterioration group and a non-deterioration group based on the occurrence of cardiac deterioration events within 1 year, defined as cardiogenic shock, cardiac arrest, or the need for mechanical circulatory support. We collected clinical data, laboratory markers, and imaging indicators for analysis. Both single-indicator models and comprehensive models (clinical data + indicators) were constructed and evaluated using the area under the receiver operating characteristic (ROC) curve (AUC) to assess their predictive performance. Among the 484 AHF patients, 121 were in the deterioration group and 363 were in the non-deterioration group. Among the single indicators, WBC had the highest AUC of 0.683. The indicator model (WBC, NOMO, Cr, BUN, Troponin, NT-proBNP, D-Dimer, LVEF, and RVFAC) achieved an AUC of 0.886 in the training set and 0.876 in the validation set. The comprehensive model (age, time from onset to admission, heart failure type, WBC, NOMO, Cr, BUN, troponin, NT-proBNP, LA, D-dimer, fibrinogen, and RVFAC) had an AUC of 0.940 in the training set and 0.925 in the validation set. In the training set, the comprehensive model had a significantly higher AUC than the indicator model (P < .05), while no significant difference was observed between the 2 in the validation set (P > .05). Furthermore, decision curve analysis (DCA) and calibration curve analysis indicated that the comprehensive model provided greater clinical benefits and better predictive accuracy in clinical applications. The comprehensive model demonstrates superior predictive capability for cardiac deterioration events in AHF patients, significantly outperforming both single-indicator and indicator models. This suggests that a comprehensive assessment can more accurately identify high-risk patients, offering a more reliable basis for clinical decision-making.

A new prehospital cardiac risk assessment index derived from vital signs by first contact emergency medical service, including prehospital oxygen saturation, for accurate prehospital triage of acute m

Abstract Background: Rapid and accurate triage is essential to improve the prognosis of patients with severe acute myocardial infarction (AMI). However, prehospital triage using vital signs, including prehospital oxygen saturation (SpO2), by first medical contact has not been evaluated. Purpose: The purpose of this study was to develop a new risk stratification index for AMI using vital signs including SpO2 for rapid and accurate prehospital triage. Methods: From January 2013 to June 2022, 3006 AMI patients who were directly transported by ambulance were enrolled from the Mie ACS registry. Based on observed risk relationships in 3,006 AMI patients, we developed and evaluated a prehospital cardiac risk assessment index (P-CRAI) using age, heart rate, and systolic blood pressure (SBP) and SpO2 to predict 30-day mortality: (heart rate×[age/10]2)/SBP＋1.1(100-SpO2). We also analyzed whether P-CRAI predicted the need for mechanical circulatory support (MCS) or ventilator use. Results: In the receiver operating characteristic (ROC) curve analysis, P-CRAI 38.1 has a sensitivity of 84.4%, specificity of 72.7%, and accuracy of 84.3% for predicting 30-day mortality, and P-CRAI was a strong predictor of 30-day mortality compared with the other indices and variables (Figure 1A). When divided into two groups with P-CRAI 38, Kaplan-Meier survival curves showed significant differences in 30-day survival between the high and low groups (83.7% vs. 98.7%, P&amp;lt;0.001, Figure 1B). P-CRAI≥38 was the strongest independent predictor of 30-day mortality with a hazard ratio of 7.64 compared to the other factors by multivariate Cox regression analysis. The spline curve of 30-day mortality by P-CRAI shows a correlation with prognosis (Figure 2A). In this study, we then used the bootstrap method to generate a calibration curve and validate P-CRAI. The results showed an excellent fit and that P-CRAI accurately estimated patient prognosis (Figure 2B). In addition, P-CRAI was a robust predictor of the very early events of death at 24 hours and MCS or ventilator use by ROC curve analysis. (c-statistic 0.835 and 0.726, respectively, P&amp;lt;0.01). Conclusion: The P-CRAI was found to be a useful tool for prehospital triage of AMI patients, accurately predicting 30-day mortality and the need for MCS.Figure 1.Figure 2.

Prognostic Factors Associated with Mortality in Cardiogenic Shock — A Systematic Review and Meta-Analysis

BackgroundCardiogenic shock remains highly associated with early mortality, with mortality often exceeding 50%. We sought to determine the association between prognostic factors and in-hospital and 30-day mortality in cardiogenic shock.MethodsWe performed a systematic review and meta-analysis of prognostic factors in cardiogenic shock, searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for records up to June 5, 2023. English-language studies that investigated prognostic factors and in-hospital and/or 30-day mortality in cardiogenic shock were included. Studies were excluded if they evaluated the pediatric population, were postmortem studies, or included fewer than 100 patients. The primary aim was to identify modifiable and non-modifiable prognostic factors associated with in-hospital and 30-day mortality in cardiogenic shock.ResultsWe identified 160 studies, including 2,459,703 patients with a median in-hospital mortality of 41.4% (interquartile range, 33.6% to 49.2%). The majority were retrospective cohort studies. Patient factors potentially associated with an increase in early mortality included an age greater than or equal to 75 years of age, peripheral arterial disease, chronic kidney disease, and female sex. Procedural and presentation factors potentially associated with increased mortality included out-of-hospital cardiac arrest, left main culprit artery, left ventricular ejection fraction less than 30%, dialysis, and need for mechanical circulatory support. Revascularization in the form of coronary artery bypass graft and percutaneous coronary intervention were potentially associated with reduced in-hospital mortality.ConclusionsThis analysis quantifies the association between patient, presentation, and treatment-related factors and early mortality in cardiogenic shock. Increased certainty in the association of these prognostic factors with cardiogenic shock outcomes can aid in clinical risk assessment, development of risk tools, and analysis of clinical trials.

Prognostic Value of Speckle Tracking Echocardiography-Derived Strain in Unmasking Risk for Arrhythmias in Children with Myocarditis.

Background/Objectives: Risk assessment in pediatric myocarditis is challenging, particularly when left ventricular ejection fraction (LVEF) is preserved. This study aimed to evaluate LV myocardial deformation using speckle-tracking echocardiography (STE)-derived longitudinal +strain (LS) and assessed its diagnostic and prognostic value in children with myocarditis. Methods: Retrospective STE-derived layer-specific LV LS analysis was performed on echocardiograms from patients within the multicenter, prospective registry for pediatric myocarditis "MYKKE". Age- and sex-adjusted logistic regression and ROC analysis identified predictors of cardiac arrhythmias (ventricular tachycardia, ventricular fibrillation, atrioventricular blockage III°) and major adverse cardiac events (MACE: need for mechanical circulatory support (MCS), cardiac transplantation, and/or cardiac death). Results: Echocardiograms from 175 patients (median age 15 years, IQR 7.9-16.5 years; 70% male) across 13 centers were included. Cardiac arrhythmias occurred in 36 patients (21%), and MACE in 28 patients (16%). Impaired LV LS strongly correlated with reduced LVEF (r > 0.8). Impaired layer-specific LV LS, reduced LVEF, LV dilatation, and increased BSA-indexed LV mass, were associated with the occurrence of MACE and cardiac arrhythmias. In patients with preserved LVEF, LV LS alone predicted cardiac arrhythmias (p < 0.001), with optimal cutoff values of -18.0% for endocardial LV LS (sensitivity 0.69, specificity 0.94) and -17.0% for midmyocardial LV LS (sensitivity 0.81, specificity 0.75). Conclusions: In pediatric myocarditis, STE-derived LV LS is not only a valuable tool for assessing systolic myocardial dysfunction and predicting MACE but also identifies patients at risk for cardiac arrhythmias, even in the context of preserved LVEF.

Sex disparities in outcomes of transcatheter aortic valve implantation- a multi-year propensity-matched nationwide study

Transcatheter Aortic Valve Implantation (TAVI) has revolutionized the management of severe aortic stenosis (AS), but the impact of sex on TAVI outcomes remains unclear. In this study, we examined differences between men and women in the post-procedural outcomes of TAVI, including healthcare burden and readmission rates. The Nationwide Readmissions Database (2016–2020) was utilized to identify hospitalizations for TAVI. A propensity score matching (PSM) model was used to match males and females. Outcomes were examined using Pearson's chi-squared test. Among 320,324 hospitalizations for TAVI, 142,054 (44.3 %) procedures were performed in women. After propensity matching (N = 165,894 with 82,947 hospitalizations in each group), women had higher in-hospital mortality (2.48 % vs 2.11 %, p: 0.001), stroke (2.14 % vs 1.49 %, p < 0.001), post-procedural bleeding (2.34 % vs 1.72 %, p < 0.001), vascular complications (1.2 % vs 0.7 %, p < 0.001), pericardial complications (1.13 % vs 0.60 %, p < 0.001), acute respiratory failure (ARF) (5.10 % vs 4.63 %, p < 0.001), need for transfusion (7 % vs 5.56 %, p < 0.001), need for vasopressors (2.48 % vs 2.11 %, p < 0.001) and major adverse cardiac and cerebrovascular events (MACCE) (7.53 % vs 6.85 %, p < 0.001). Meanwhile, women had modestly lower incidence of acute kidney injury (AKI) (10.17 % vs 11.88 %, p < 0.001), sudden cardiac arrest (SCA) (0.96 % vs 1.06 %, p: 0.042), cardiogenic shock (1.69 % vs 2.05 %, p < 0.001) and mechanical circulatory support (MCS) requirement (0.69 % vs 0.84 %, p < 0.001). With regard to readmissions, men had higher readmission rates at 30 days (16.07 % vs 14.75 %, p < 0.001) and 90 days (23.8 % vs 21.9 %, p < 0.001). No significant difference was observed in 180-day readmission rates between men and women after TAVI. Notably, procedure-related mortality decreased for both sexes from 2016 to 2020, accompanied by faster recovery times and reduced hospitalization costs (p-trend <0.001). In conclusion, women had higher mortality and post-procedural complication rates, while men had higher readmission rates, cardiogenic shock, AKI and need for mechanical circulatory support. While procedure-related mortality and resource utilization for TAVI have improved over time from 2016 to 2020, irrespective of sex, our findings highlight that significant disparities exist in TAVI outcomes.

A Randomized Embedded Multifactorial Adaptive Platform for Extra Corporeal Membrane Oxygenation (REMAP ECMO) – Design and Rationale of the Left Ventricular Unloading trial domain

BackgroundThe use of Extracorporeal Membrane Oxygenation (ECMO) remains associated with high rates of complications, weaning failure and mortality which can be partly explained by a knowledge gap on how to properly manage patients on ECMO support. To address relevant patient management issues, we designed a “Randomized Embedded Multifactorial Adaptive Platform (REMAP)” in the setting of ECMO (REMAP ECMO) and a first embedded randomized controlled trial (RCT) investigating the effects of routine early left ventricular (LV) unloading through intra-aortic balloon pumping (IABP). MethodsREMAP ECMO describes a registry-based platform allowing for the embedding of multiple response adaptive RCTs (trial domains) which can perpetually address the effect of relevant patient management issues on ECMO weaning success. A first trial domain studies the effects of LV unloading by means of an IABP as an adjunct to veno-arterial (V-A) ECMO versus V-A ECMO alone on ECMO weaning success at 30 days in adult cardiogenic shock patients admitted to the Intensive Care Unit (ICU). The primary outcome of this trial is “successful weaning from ECMO” being defined as a composite of survival without the need for mechanical circulatory support, heart transplantation, or left ventricular assist device (LVAD) at 30 days after initiation of ECMO. Secondary outcomes include the need for interventional escalation of LV unloading strategy, mechanistic endpoints, survival characteristics until one year after ECMO initiation, and quality of life. Trial data will be analysed using a Bayesian statistical framework. The adaptive design allows for a high degree of flexibility, such as response adaptive randomization and early stopping of the trial for efficacy or futility. The REMAP ECMO LV unloading study is approved by the Medical Ethical Committee of the Erasmus Medical Center and is publicly registered. ConclusionThis REMAP ECMO trial platform enables the efficient roll-out of multiple RCTs on relevant patient management issues. A first embedded trial domain will compare routine LV unloading by means of an IABP as an adjunct to V-A ECMO versus V-A ECMO alone. Trial registrationClinicalTrials.gov, NCT05913622

Mechanical circulatory support early after pediatric heart transplantation—an analysis from the Pediatric Heart Transplant Society

BackgroundThe use of early Mechanical Circulatory Support (MCS) following pediatric heart transplantation is not well-published. This paper attempts to uncover the incidence, predisposing factors and outcomes of MCS in a large, international cohort. MethodsThe Pediatric Heart Transplant Society Database (an international, prospective, event-driven database) was retrospectively analyzed for all cases of primary heart transplant over an 11-year period (2010-2020), dividing the cohort based on need for MCS within 30 days of transplantation. ResultsOf 4321 primary transplants, 249 (5.8%) required MCS (230 ECMO, 19 VAD). In a Cox proportional hazard model, congenital heart disease (p = 0.0002), older donor age (p < 0.0001), and longer ischemic time (p = 0.018) were each related to an increased need for MCS; increasing recipient body surface area (p < 0.0001) and increasing donor left ventricular ejection fraction (p = 0.016) were both correlated with less MCS use. 1-year survival in those requiring MCS was 54.2%, compared with 94.8% in those who did not need MCS (p < 0.0001). Later survival in patients surviving to one year was similar between the groups. ConclusionsMCS is used infrequently following pediatric heart transplant, and is related to donor, recipient and transplant factors. Although mortality is high, those surviving the first year post-transplant have excellent outcomes. Judicious use in those patients who would otherwise perish is therefore justified.

A propensity-matched analysis of cardiac operation in patients with and without cardiac amyloidosis

ObjectiveThere are limited data on the outcome of routine cardiac operations in patients with cardiac amyloidosis. This study studied the impact of amyloidosis on early and late results of cardiac operations. MethodsThis was a retrospective, propensity-matched, case-control study of patients with cardiac amyloidosis undergoing cardiac surgery. Heart transplantation and ventricular assist implantation were excluded. Controls were patients without known cardiac amyloidosis matched on baseline patient characteristics, echocardiographic findings, and type of operation. Outcomes included operative complications and survival. ResultsIn total, 42 patients with cardiac amyloidosis (amyloid group [AG]) were matched with 168 controls (CON group). The median left ventricular ejection fraction was 63% in the AG group (vs 64% CON). Aortic valve replacement and septal myectomy were the most common operations. Cardiopulmonary bypass (P = .374) and crossclamp (P = .185) times were similar in the 2 groups. Complication rates were similar in the 2 groups, including the need for mechanical circulatory support (n = 1 AG group vs n = 1 CON; P = .361) and intra-aortic balloon pump use (n = 3 AG group vs n = 13 CON; P = 1.000). There were no operative deaths. Survival was similar in the 2 groups at 1 year (AG 93% vs 89% CON; P = .1) but was worse in the AG at 5 years (59% vs 68% CON; P = .1). ConclusionsEarly procedural outcomes and 1-year survival are similar in patients with and without cardiac amyloidosis with preserved cardiac function. Diagnosis of amyloidosis should not be a contraindication to cardiac surgery.

Changes in waiting time, need for mechanical circulatory support and outcomes in paediatric heart transplant recipients.

Heart transplantation is a well-established treatment for end-stage heart failure in paediatric patients, demonstrating excellent long-term outcomes. This retrospective study analyses 35years of data on 244 paediatric recipients (<18years) at a single institution from 1986 to 2022. The analysis explores changes in diagnoses, survival, waiting times and mechanical circulatory support (MCS) over three decades (1991-2000, 2001-2010 and 2011-2020). Survival outcomes significantly improved over the study period, with 1-year survival rates increasing from 79.3% (1991-2000) to 92.3% (2011-2020, P=0.041). The median overall survival was 18.0years, and median conditional survival to 1year post-transplant was 20.9years. Survival differences were noted among age groups, with infants under 1year of age experiencing higher early mortality, and adolescents (aged 11-17years) facing increased long-term risks, possibly linked to adult donor characteristics. Waiting times for heart transplantation increased, especially for younger age groups (0-5 and 6-10years), reflecting the growing demand for donor organs. The use of MCS, including ventricular assist devices (VAD), surged, with 67% of recipients in the most recent decade receiving pre-transplant VAD support. Importantly, despite prolonged waiting times and increased VAD use, overall survival continued to be favourable. Early and long-term results after paediatric heart transplantation have been continuously improving over the past decades. Despite an increased demand for donor organs and the growing reliance on VAD as bridge to transplantation, post-transplantation survival is not compromised.

Adverse Technical Events During Aortic Root Replacement

BackgroundAlthough adverse technical events during aortic root replacement (ARR) are not uncommon and are extremely challenging, there is scant literature to help surgeons prepare for such situations. We describe our experience of outstanding technical events during ARR. MethodsThis is a retrospective study of 830 consecutive ARRs at a single center from 2012 to 2022. Technical events were defined as intraoperative events that led to an unplanned cardiac procedure, need for mechanical circulatory support, or additional aortic cross-clamping. Logistic regression identified factors associated with operative mortality and technical events. ResultsTechnical events occurred in 90 patients (10.8%) and were attributed to bleeding (n = 26), nonischemic ventricular dysfunction (n = 23), residual valve disease (n = 20), myocardial ischemia (n = 19), and iatrogenic dissection (n = 2). Prior sternotomy (odds ratio [OR], 2.38; 95% CI, 1.36-4.19; P = .002) and complex aortic valve disease (OR, 3.09; 95% CI, 1.09-8.75; P = .03) were associated with technical events. Patients with technical events had higher rates of operative mortality (6.7% vs 2.3%, P = .03) and all major postoperative complications. Surgical indications of dissection (OR, 13.57; 95% CI, 4.95-37.23; P < .001) and complex aortic valve disease (OR, 14.09; 95% CI, 3.67-54.02; P < .001) but not adverse technical events (OR, 2.42; 95% CI, 0.81-7.26; P = .11) were associated with operative mortality. ConclusionsAdverse technical events occurred in 10.8% of ARRs and were associated with reoperative sternotomies. Technical events are associated with increased postoperative complications.

Impact of prolonged ischemic time on pediatric heart transplantation outcomes: Improved outcomes in the most recent era

BackgroundImpacts of ischemic time (IT) on pediatric heart transplant outcomes are multifactorial. We aimed to analyze the effect of prolonged IT on graft loss after pediatric heart transplantation. We hypothesized that graft survival with prolonged IT has improved across eras. MethodsPatients <18 years old in the Pediatric Heart Transplant Society database (1993-2019) were included (N=6765) and stratified by diagnosis and era (1993-2004, 2005-2009, and 2010-2019). Severe graft failure (SGF) was defined as death, re-transplant, or need for mechanical circulatory support in the first 7 days post-transplant. Descriptive statistical methods were used to compare differences between patient characteristics and IT. Kaplan-Meier survival analysis compared freedom from graft loss, rejection, and infection. Multivariable analysis was performed for graft loss and SGF (hazard and logistic regression modeling, respectively). ResultsDiagnoses were cardiomyopathy (N=3246) and congenital heart disease (CHD; N=3305). CHD were younger, more likely to have an IT >4.5 hours, and more likely to require extracorporeal membrane oxygenation or mechanical ventilation at transplant (all P<0.001). Median IT was 3.6 hours [IQR 2.98 to 4.31; range 0-10.5]. IT was associated with early graft loss (HR 1.012, 95% CI 1.005-1.019), but not when analyzed only in the most recent era. IT was associated with SGF (OR 1.016 95%CI 1.003 - 1.030). ConclusionsDonor IT was independently associated with increased risk of graft loss, albeit with a small effect relative to other risk factors. Graft survival with prolonged IT has improved in the most recent era but the risk of SGF persists.

Review of the Association Between Long-Term and Current Systemic Steroid Use With Electromechanical Complications and Inpatient Mortality After ST-Elevation Myocardial Infarction.

Background The impact of long-term systemic steroid use on electrical and mechanical complications following ST-segment elevation myocardial infarction (STEMI) has not been extensively studied. Methods In a retrospective cohort study of the National Inpatient Sample (NIS) from 2018 to 2020, adults admitted with STEMI were dichotomized based on the presence of long-term (current) systemic steroid (LTCSS) use. The primary outcome was all-cause mortality. Secondary outcomes included a composite of mechanical complications, electrical, hemodynamic, and thrombotic complications, as well as revascularization complexity, length of stay (LOS), and total charge. Multivariate linear and logistic regressions were used to adjust for confounders. Results Out of 608,210 admissions for STEMI, 5,310 (0.9%) had LTCSS use. There was no significant difference in the odds of all-cause mortality (aOR: 0.89, 95%CI: 0.74-1.08, p-value: 0.245) and the composite of mechanical complications (aOR: 0.74, 95%CI: 0.25-2.30, p-value: 0.599). LTCSS use was associated with lower odds of ventricular tachycardia, atrioventricular blocks, new permanent-pacemaker insertion, cardiogenic shock, the need for mechanical circulatory support, mechanical ventilation, cardioversion, a reduced LOS by 1 day, and a reduced total charge by 34,512 USD (all p-values: <0.05). There were no significant differences in the revascularization strategy (coronary artery bypass graft (CABG) vs. percutaneous coronary interventions (PCI)) or in the incidence of composite thrombotic events. Conclusion LTCSS use among patients admitted with STEMI was associated with lower odds of electrical dysfunction and hemodynamic instability but no difference in the odds of mechanical complications, CABG rate, all-cause mortality, cardiac arrest, or thrombotic complications. Further prospective studies are needed to evaluate these findings further.

Resolution of insulin resistance, lactic acidosis, and decrease in mechanical support requirements in patients post orthotopic heart transplant with the use of long-acting insulin glargine

ObjectiveThis study investigates the efficacy of using a long-acting insulin analog, along with the infusion of regular insulin, in achieving appropriate glycemic control and correcting lactic acidosis in patients post orthotopic heart transplant who demonstrate severe lactic acidosis and insulin resistance.MethodsThis was a retrospective study of two cohorts (IRB FLA 20-003) of patients post orthotopic heart transplant with severe lactic acidosis and insulin resistance who were admitted to a tertiary intensive care unit and treated with (group 1) or without long-acting insulin analog (group 2) within the first 24 h of admission to the intensive care unit. Insulin resistance is defined as the requirement for intravenous regular insulin infusion of more than 20 units/h without the ability to achieve appropriate serum glucose level (120–180 mg /dL). Severe lactic acidosis is defined as arterial lactic acid of more than 10 mmol/L. The following parameters were investigated: time to correct lactic acidosis, duration of postoperative mechanical ventilation, the need for periprocedural mechanical circulatory support, and 28-day mortality.ResultsThe 28-day mortality was zero in both groups. Two patients required periprocedural mechanical support in group one, and ten patients required mechanical support in group two (RR = 0.224, 95%, confidence interval 0.052–0.95, Z = 2.029, p = 0.042). Three patients required tracheostomy in group one, and four patients required tracheostomy in group two (RR 0.84, 95 confidence interval 0.20–3.48, Z = 0.23, P = 0.81). Wilcoxon rank-sum test was used to compare time to correct lactic acidosis, with lactic acid resolution being faster in group one (X¯\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\overline{X}$$\\end{document}1 = 19.7 h, SD ± 12.6 h X¯\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\overline{X}$$\\end{document}2 = 29.3 h, SD ± 19.6 h, Z-value − 2.02, p-value 0.043). The duration of mechanical ventilation was less in group one (X¯\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\overline{X}$$\\end{document}1 = 29 h, SD ± 12.7 h, X¯\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\overline{X}$$\\end{document}2 = 55.1 h, SD ± 44.5 h, Z-value: − 1.92, p-value 0.05).ConclusionAdministration of low-dose long-acting insulin glargine led to the resolution of the lactic acidosis, insulin resistance, and decreased requirements for pressor and inotropic support, which led to decreased need for mechanical circulatory support.

Severe Acute Kidney Injury Postheart Transplantation: Analysis of Risk Factors.

Acute kidney injury (AKI) is a common complication postheart transplantation and is associated with significant morbidity and increased mortality. We conducted a single-center, retrospective, observational cohort study of 109 consecutive patients undergoing heart transplantation between September 2019 and September 2021 to determine major risk factors for, and the incidence of, severe postoperative AKI as defined by Kidney Disease Improving Global Outcomes criteria in the first 48-h posttransplantation and the impact that this has on mortality and dialysis dependence. One hundred nine patients were included in our study, 83 of 109 (78%) patients developed AKI, 42 (39%) developed severe AKI, and 37 (35%) required renal replacement therapy in the first-week posttransplantation. We found preoperative estimated glomerular filtration rate (eGFR), postoperative noradrenaline dose, and the need for postoperative mechanical circulatory support to be independent risk factors for the development of severe AKI. Patients who developed severe AKI had a 19% 12-mo mortality compared with 1% for those without. Of those who survived to hospital discharge, 20% of patients in the severe AKI group required dialysis at time of hospital discharge compared with 3% in those without severe AKI. Severe AKI is common after heart transplantation. Preoperative kidney function, postoperative vasoplegia with high requirements for vasoactive drugs, and graft dysfunction with the need for mechanical circulatory supports were independently associated with the development of severe AKI in the first-week following heart transplantation. Severe AKI is associated with a significantly increased mortality and dialysis dependence at time of hospital discharge.

In-hospital outcomes of transcatheter aortic valve replacement in patients with chronic and end-stage renal disease: a nationwide database study

BackgroundChronic kidney disease (CKD) and end-stage renal disease (ESRD) have been associated with worse outcomes after transcatheter aortic valve replacement (TAVR). With TAVR indications extending to a wider range of patient populations, it is important to understand the current implications of chronic renal insufficiency on clinical outcomes. We aim to determine the impact of CKD and ESRD on in-hospital outcomes after TAVR.MethodsWe queried the National Inpatient Sample for TAVR performed between 2016 and 2020 using International Classification of Diseases-10th Revision codes. We compared in-hospital mortality and clinical outcomes between three groups: normal renal function, CKD and ESRD. The association between CKD/ESRD and outcomes was tested with multivariable logistic regression analyses, using normal renal function as baseline.ResultsIn the five-year study period, 279,195 patients underwent TAVR (mean age 78.9 ± 8.5 years, 44.4% female). Of all patients, 67.1% had normal renal function, 29.2% had CKD, and 3.7% had ESRD. There were significant differences in age, sex, and prevalence of comorbidities across groups. In-hospital mortality was 1.3%. Compared to patients with normal renal function, patients with renal insufficiency had higher in-hospital mortality, with the highest risk found in patients with ESRD (adjusted odds ratio: 1.4 [95% confidence interval: 1.2–1.7] for CKD; adjusted odds ratio: 2.4 [95% confidence interval: 1.8–3.3] for ESRD). Patients with CKD or ESRD had a higher risk of cardiogenic shock, need for mechanical circulatory support, and vascular access complications, compared to those with normal renal function. In addition, patients with ESRD had a higher risk of cardiac arrest and periprocedural acute myocardial infarction. The incidence of conversion to open heart surgery was 0.3% and did not differ between groups. Post-procedural infectious and respiratory complications were more common among patients with CKD or ESRD.ConclusionPatients with CKD and ESRD are at higher risk of in-hospital mortality, cardiovascular, and non-cardiovascular complications after TAVR. The risk of complications is highest in patients with ESRD and does not result in more frequent conversion to open heart surgery. These results emphasize the importance of individualized patient selection for TAVR and procedural planning among patients with chronic renal insufficiency.

Single center experience with ABO-incompatible and ABO-compatible pediatric heart transplantation.

The aim of this study was to analyze the results after pediatric heart transplantation (pHTx) at our single center differentiating between ABO-incompatible (ABOi) and -compatible (ABOc) procedures. We retrospectively analyzed outcomes of ABO-incompatible HTx procedures performed at our center and compared the data to ABO-compatible HTx of the same era. Eighteen children (<17 months) underwent pediatric HTx and seven of them underwent ABO-incompatible HTx between 2003 and 2015. Mechanical circulatory support as bridge to transplant was necessary in 3/7 patients before ABO-incompatible HTx and in 3/11 patients before ABO-compatible HTx. Mean waiting time on the list was 36 ± 30 days for ABO-incompatible HTx and 86 ± 65 days for ABO-compatible HTx. The 5-years re-transplant free survival was 86% following ABO-incompatible and 91% after ABO-compatible. In the cohort undergoing ABO-incompatible HTx, 2 patients showed an acute cellular rejection, while early graft failure was not observed. In the cohort undergoing ABOcompatible HTx, acute cellular rejection was observed in 9/11 patients, with early graft failure occurring in nine and CVP in two. A total of ten children were listed for ABO-incompatible HTx after 2015; however, all ten underwent an ABO-compatible transplantation. This study adds much needed information to the literature on ABOi-HTx by showing with a retrospective single center analysis that it is safe and leads to shorter waiting times. We conclude that strategies for ABOi-HTx should be elaborated further, potentially allowing more timely transplantation and thereby preventing waiting list complications such as the need for mechanical circulatory support and even death.

Modeling the Relationship Between Diastolic Phenotype and Outcomes in Pediatric Hypertrophic Cardiomyopathy

Pediatric hypertrophic cardiomyopathy (HCM) is associated with adverse events. The contribution of diastolic dysfunction to adverse events is poorly understood. The aim of this study was to explore the association between diastolic phenotype and outcomes in pediatric patients with HCM. Children <18years of age with diagnosed with HCM were included. Diastolic function parameters were measured from the first echocardiogram at the time of diagnosis, including Doppler flow velocities, tissue Doppler velocities, and left atrial volume and function. Using principal-component analysis, key features in echocardiographic parameters were identified. The principal components were regressed to freedom from major adverse cardiac events (MACE), defined as implantable cardioverter-defibrillator insertion, myectomy, aborted sudden cardiac death, transplantation, need for mechanical circulatory support, and death. Variables that estimate left ventricular filling pressures were highly collinear and associated with MACE (hazard ratio, 0.86; 95% CI, 0.75-1.00), though this was no longer significant after controlling for left ventricular thickness and genetic variation. Left atrial size parameters adjusted for body surface area were independently associated with outcomes in the covariate-adjusted model (hazard ratio, 0.69; 95% CI, 0.5-0.94). The covariate-adjusted model had an Akaike information criterion of 213, an adjusted R2 value of 0.78, and a concordance index of 0.82 for association with MACE. Echocardiographic parameters of diastolic dysfunction were associated with MACE in this population study, in combination with the severity of left ventricular hypertrophy and genetic variation. Left atrial size parameters adjusted for body surface area were independently associated with adverse events. Additional study of diastolic function parameters adjusted for patient size could facilitate the prediction of adverse events in pediatric patients with HCM.

Prognostic value of three iron deficiency definitions in patients with advanced heart failure

Abstract Background Iron deficiency (ID) is a common co-morbidity in patients with chronic heart failure (HF) and is an independent predictor of adverse prognosis including quality of life and exercise capacity (1-3). Intravenous iron replacement improves outcomes in HF patients including exercise capacity, quality of life, rate of HF hospitalisation and possibly mortality (1-4). Different definitions of ID are used in clinical practice. European HF guidelines define ID as a serum ferritin concentration of &amp;lt; 100 ng/ml, or a serum ferritin of concentration of 100-299 ng/ml with a transferrin saturation (TSAT) &amp;lt; 20% (5) because this definition was used in most trials of iron replacement in HF (1-3). However, other criteria to diagnose ID have been proposed based on comparison to the gold standard of bone marrow biopsy including serum iron ≤ 13 µmol/L and TSAT &amp;lt; 20% (6). Serum ferritin concentrations to diagnose ID has been criticised because inflammation can lead to increased serum ferritin concentrations even in patients who would fulfil ID criteria based on alternative definitions (7). Purpose The prognostic value of ID in patients with advanced HF, assessed for heart transplantation, is currently not well established. This patient population is characterised by relatively young age, single-organ pathology and prognosis is largely determined by the severity of heart disease rather than co-morbidities. In this study we investigated the prognostic value of various ID definitions in this patient cohort. Methods and Results Consecutive patients assessed for heart transplantation at a single UK centre between January 2010 and May 2022 were included. ID was defined as 1) serum ferritin concentration of &amp;lt; 100 ng/ml, or 100-299 ng/ml with transferrin saturation &amp;lt; 20% (guideline definition), 2) serum iron concentration ≤ 13 µmol/L, or 3) transferrin saturation &amp;lt; 20%. The primary outcome measure was a composite of all-cause mortality, urgent heart transplantation or need for mechanical circulatory support. 801 patients were included, and the prevalence of ID was 39-55% depending on definition used. ID, defined by either serum iron or transferrin saturation, was an independent predictor of the primary outcome measure [HR 1.532 (95% CI 1.264 - 1.944) and HR 1.595 (95% CI 1.323 - 2.033), respectively], but the same association was not seen with the guideline definition of ID [HR 1.085 (95% CI 0.8827 - 1.333)]. These findings were robust in multivariable cox regression analysis. ID, by all definitions, was associated with lower six-minute walk distance, lower peak oxygen consumption, higher intra-cardiac filling pressures and lower cardiac output. Conclusions ID, when defined by serum iron concentration or transferrin saturation was associated with increased frequency of adverse clinical outcomes in patients with advanced HF. The same association was not seen with guideline definition of ID.

Del Nido cardioplegia in adult cardiac surgery: Clinical outcomes in a single center all-comer study.

The use of Del Nido Cardioplegia (DNC) has been extended in the latest years from pediatrics to adult cardiac surgery with encouraging results. We sought to investigate clinical and biochemical outcomes in adult patients who underwent cardiac surgery with different degrees of complexity who received DNC for myocardial protection. Data on one-thousand patients were retrospectively collected from 2020 to 2022. The only exclusion criteria was off-pump adult cardiac surgery. Surgical procedures weight was categorized according EuroSCORE II in six groups: Single-CABG(G1), isolated non-CABG(mitral) (G2), isolated non-CABG(aortic) (G3), isolated non-CABG(any) (G4), 2-procedures(G5), 3/more-procedures(G6). Primary endpoint was to identify a binomial correlation between hs-TnT/CK-MB and the cross-clamp time (X-Clamp). A secondary endpoint was the comparison between the treatment groups of the vasoactive-inotropic score (VIS) and the need of mechanical circulatory support (MCS). A linear correlation was identified between hs-TnT and X-clamp in the overall population (rho:0.447, p< .001) and in the treatment groups (G1:rho=0.357, p< .001/G2:rho=0.455, p< .001/G3:rho=0.307, p= .001/G4:rho=0.165, p= .257/G5:rho=0.157, p= .031/G6:rho=0.226, p= .015). Similarly, a linear correlation between CK-MB and X-clamp in the overall population (rho=0.457, p< .001) and treatment group (G1:rho=0.282, p< .001/G2:rho=0.287, p= .025/G3:rho=0.211, p= .009/G4:rho=0.0878, p= .548/G5:rho=0.309, p< .001/G6: rho=0.212, p= .024) was identified. As regard for the secondary endpoint, no differences were reported between the treatment groups in terms of VIS and MCS (VIS G1:7; G2:4; G3:7; G4:7, G5:5.5, G6:6, p-value= .691) (MCS G1: 4.5%; G2:4.8%; G3:3.3%; G4:3.1%; G5:1.4%; G6:5.3%; p-value= .372). Del Nido Cardioplegia is a safe and useful tool in adult cardiac surgery allowing operators to achieve a stable and durable cardioplegic arrest. Despite accounting with different types of surgery, the six subgroups of our study population showed similar perioperative results.

A systematic review and meta-analysis of clinical outcomes of Takotsubo syndrome in patients with cancer

Abstract Background Recent studies suggested a relationship between Takotsubo syndrome (TS) and malignancy. However, the clinical outcomes of TS associated with cancer have not fully been assessed. Purpose The aim of this study was to investigate the outcomes of TS for patients with cancer. Methods We performed a systematic review and meta-analysis to evaluate the clinical outcome of TS in patients with and without malignancy. We searched for observational studies assessing the association of TS and malignancy until December 2022 in PubMed and Cochrane Library. The primary outcome was all-cause mortality. The secondary outcomes of this study were short-term mortality (in-hospital deaths or deaths within 30 days), shock, the need for mechanical respiratory support, and the need for mechanical circulatory support. A random-model meta-analysis was performed. Results Fourteen studies were finally included in this meta-analysis, totaling 189,210 patients with TS. The prevalence of current or previous malignancy among patients with TS was 8.7% (16,461 patients). Compared to patients without cancer, patients with malignancy demonstrated a higher risk of all-cause deaths in TS (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.95-2.98; p &amp;lt; 0.01; I2 = 74%; p for heterogeneity &amp;lt; 0.01). Cancer was significantly associated with an increased risk of short-term mortality (OR 1.97; 95% CI 1.75-2.22; p &amp;lt; 0.01; I2 = 0%; p for heterogeneity = 0.46). Also, malignancy was significantly associated with in-hospital shock and mechanical respiratory support (shock; OR 1.42; 95% CI 1.30-1.55; p &amp;lt; 0.001, mechanical respiratory support; OR 1.68; 95% CI 1.59-1.77; p &amp;lt; 0.01) but not mechanical circulatory support (OR 1.12; 95% CI 0.68-1.84; p = 0.66). Conclusion In this meta-analysis, either previous or active cancer was associated with an increased risk of all-cause mortality, short-term mortality, shock, and needs for mechanical respiratory support in patients with TS.