Meshe Chonde

BACKGROUND: Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. METHODS: The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units. Patients admitted with CS (2018–2023) had vasoactive dosing assessed at 4 and 24 hours from cardiac intensive care unit admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both time points, as well as change in VIS from 4 to 24 hours, were examined. Interaction testing was performed based on mechanical circulatory support status. RESULTS: Among 3665 patients, 82% had a change in VIS P _trend 4-fold difference in mortality comparing those with a ≥10-point increase to ≥10-point decrease in VIS ( P _trend P _interaction <0.0001). CONCLUSIONS: Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with the potential to be leveraged for clinical decision-making and research applications in CS.

BACKGROUND: Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. METHODS: The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. RESULTS: The median age of the study population was 66 (56–77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%–87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST–elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. CONCLUSIONS: In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.

Purpose of Review To describe medical therapies and mechanical circulatory support devices used in the treatment of acute right ventricular failure. Recent Findings Experts have proposed several algorithms providing a stepwise approach to medical optimization of acute right ventricular failure including tailored volume administration, ideal vasopressor selection to support coronary perfusion, inotropes to restore contractility, and pulmonary vasodilators to improve afterload. Studies have investigated various percutaneous and surgically implanted right ventricular assist devices in several clinical settings. Summary The initial management of acute right ventricular failure is often guided by invasive hemodynamic data tracking parameters of circulatory function with the use of pharmacologic therapies. Percutaneous microaxial and centrifugal extracorporeal pumps bypass the failing RV and support circulatory function in severe cases of right ventricular failure.

Objective. To determine whether the administration of intra-arrest cyclosporine (CCY) and methylprednisolone (MP) preserves left ventricular ejection fraction (LVEF) and cardiac output (CO) after return of spontaneous circulation (ROSC). Methods. Eleven, 25-30kg female swine were randomized to receive 10mg/kg CCY + 40mg MP or placebo, anesthetized and given a transthoracic shock to induce ventricular fibrillation. After 8 minutes, standard CPR was started. After two additional minutes, the experimental agent was administered. Animals with ROSC were supported for up to 12h with norepinephrine as needed. Echocardiography was performed at baseline, and 1, 2, 6 and 12h post-ROSC. Analysis was performed using generalized estimating equations (GEE) after downsampling continuously sampled data to 5 minute epochs. Results. Eight animals (64%) achieved ROSC after a median of 7 [IQR 5-13] min of CPR, 2 [ IQR 1-3] doses of epinephrine and 2 [IQR 1-5] defibrillation shocks. Animals receiving CCY+MP had higher post ROSC MAP (GEE coefficient -10.2, P = Conclusions. Intra-arrest cyclosporine and methylprednisolone decreased post-arrest cardiac output and increased mean arterial pressure without affecting left ventricular ejection fraction.

Objectives: Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the treatment of refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation [ECPR]) and postarrest cardiogenic shock (PACS). Our primary objective was to determine the 1-year survival of patients who were treated with ECMO for PACS or in ECPR. Methods: We conducted a retrospective analysis of hospitalized patients in a tertiary care facility who underwent treatment with ECMO for ECPR or PACS. Between January 2004 and December 2013, patients were prospectively entered into an institutional registry. One-year follow-up was assessed by electronic medical record or social security death index if clinical follow-up was unavailable. Results: Fifty-one patients were treated with ECMO during the study period. The mean age was 54.0 ± 10.9 years; the majority of patients were men (80.4%). The most common etiology of arrest was acute myocardial infarction (51.0%). Overall, 13 (25.4%) patients survived for at least 1 year. Preexisting coronary artery disease, hypertension, and hyperlipidemia were associated with reduced likelihood of survival. We observed a significant improvement in 1-year mortality in patients treated for PACS when compared to ECPR, 46.7% versus 16.7%, respectively. Conclusion: The use of ECMO for treatment of refractory cardiac arrest or cardiogenic shock may be a suitable treatment in a very select cohort of patients. Our results support a significantly higher 1-year survival in patients with PACS compared to refractory cardiac arrest.

Introduction: Reversible myocardial dysfunction after cardiac arrest (CA) appears common, but few studies have performed serial echocardiography in patients resuscitated from CA. Hypothesis: Evidence of reversible LV systolic dysfunction will be identified on serial echocardiography early after CA. Methods: We prospectively performed repeat transthoracic echocardiography (TTE) between 72 and 96 hours after CA in 17 patients who had undergone an initial TTE within 24 hours after CA. We compared mean values derived from 2D measurements, LVEF, spectral Doppler of mitral inflow and LV outflow, and peak systolic and early diastolic tissue Doppler of the mitral annulus between echocardiograms using paired t-tests. Mean changes in TTE parameters were compared between hospital survivors and non-survivors using paired t-tests. Results: In these 17 subjects, there were significant increases in LV fractional shortening (+0.12, p = 0.028), LV outflow tract velocity-time integral (+3.82cm, p = 0.002) and both septal (+2.6, p = 0.016) and lateral (+1.8, p = 0.014) mitral annular systolic tissue Doppler (s’) velocities on repeat TTE. There were nonsignificant increases in estimated LVEF (+11.25%, p = 0.063) and TAPSE (+0.32, p = 0.065) between initial and repeat TTE. Other TTE parameters did not differ significantly between initial and repeat TTE, although not all parameters were available in all patients. Hospital non-survivors had a significant decrease in their LV end-systolic diameter (-0.68cm, p = 0.0161) and a non-significant decrease in their LV end-diastolic diameter (-0.4cm, p = 0.0549) on repeat TTE, whereas survivors did not. Changes in both septal (6 vs. 1.5, p = 0.0044) and lateral (3.67 vs. 0.88, p = 0.0161) mitral annular s’ velocities were higher in non-survivors. Other changes in echocardiographic parameters did not significantly differ between survivors and non-survivors. Conclusions: LV fractional shortening, LV outflow tract velocity time integral and mitral annular s’ velocities increase between 24 hours and 72-96 hours after CA, consistent with reversible myocardial dysfunction. Hospital non-survivors had greater changes in LV dimensions and mitral annular s’ velocities between 24 hours and 72-96 hours than hospital survivors.