Claudius Mahr

Background: The arterial pulsatility index (API) is a promising hemodynamic surrogate of left ventricular function, but its prognostic value in acute myocardial infarction‐related cardiogenic shock (AMI‐CS) remains unclear. This study evaluated associations between API, a modified API (mAPI), clinical characteristics, and in‐hospital outcomes in AMI‐CS. Methods: Patients with AMI‐CS in the multicenter CSWG (Cardiogenic Shock Working Group) registry with available API or mAPI were analyzed. API was calculated as systemic arterial pulse pressure/pulmonary capillary wedge pressure; mAPI used pulmonary artery diastolic pressure instead of wedge pressure. Logistic/linear regression, spline modeling, and receiver operating characteristic curve analysis were used to assess associations with clinical characteristics and in‐hospital outcomes. Results: Among 487 patients with AMI‐CS, median API and mAPI were 2.1 (interquartile range [IQR], 1.3–3.2; n=139) and 1.7 (IQR, 1.0–2.8; n=487), respectively. API strongly correlated with mAPI (Pearson r =0.75, P P =0.051) or mAPI (41.2% versus 59.1%, P P =0.006; and 44.1% versus 32.2%; OR, 1.657 [95% CI, 1.147–2.402]; P =0.007). Every 0.5‐unit decrease in API or mAPI was associated with a 2.4% (β=0.024 [95% CI, 0.002–0.045]; P =0.030) and 1.4% (β=0.014 [95% CI, 0.002–0.026]; P =0.022) increase in in‐hospital mortality. Conclusions: In AMI‐CS, lower API and mAPI were associated with increased mortality. API and mAPI may facilitate early risk assessment and guide tailored treatment decisions in AMI‐CS.

We report a case of Medtronic HeartWare ventricular assist device (HVAD) pump failure-to-restart. Despite HVAD withdrawal from the market in June 2021, up to 4,000 patients remain on HVAD support worldwide, and many are at high risk for this serious complication. This report describes the first-in-man use of a new HVAD controller that restarted a defective HVAD pump and avoided a fatal outcome. This new controller has the potential of preventing unnecessary VAD exchanges and saving lives.

Background Cardiogenic shock (CS) is critical end-organ hypoperfusion due to reduced cardiac output. Early therapy, such as vasoactive agents or the initiation of mechanical circulatory support (MCS), requires early diagnosis and is associated with better outcomes. A novel ultrasound platform (GE Healthcare, Milwaukee, WI) has semi- automated imaging software (SAIS), which could simplify the point-of-care ultrasound (POCUS) diagnosis of CS. We assessed the feasibility of using POCUS with SAIS in patients in shock, determined the ability of SAIS to identify the subset of patients with CS, and described the process and outcome of care of patients with vs. without CS after presenting to Emergency Department (ED) with hypotension. Methods This prospective case-control study was conducted at an urban ED. Physicians with prior POCUS education received one hour of training with the study device. The qualitative ejection fraction was determined by visual assessment. SAIS measurements of hemodynamics were made with the study device and included left ventricle outflow tract velocity time integral (LVOT VTI), inferior vena cava collapsibility or distensibility indices, and pulmonary B- line assessment. ED patients with a systolic blood pressure = 90 mmHg or need for a vasopressor initiation in the ED were enrolled. The diagnosis of CS was determined by a medical record review. All data were summarized descriptively. Results Twenty-nine cases underwent POCUS, and 87 controls did not. Baseline characteristics, process, and outcome of care were similar between groups. Seventy-nine percent ( 79%) of cases had a complete POCUS with SAIS. Of these, 55% had reduced LVOT VTI, 38% had IVC collapsibility <50%, and 48% of cases had a B-line pattern consistent with pulmonary edema. The mean LVOT VTI for cases with CS was 9.4 +/- 5.4 cm; the mean LVOT VTI for cases without CS was 15.2 +/- 6.0 cm. Among patients who did not undergo POCUS, 31 (36%) had a formal echocardiogram, and eight (9%) had a final diagnosis of cardiogenic shock during hospitalization. Conclusion Physicians with one hour of platform-specific training were able to implement POCUS with SAIS among patients who present with shock. POCUS with SAIS may aid in the early recognition of CS.

The utilization of left ventricular assist devices (LVADs) in end-stage heart failure has doubled in the past ten years and is bound to continue to increase. Since the first of these devices was approved in 1994, the technology has changed tremendously, and so has the medical and surgical management of these patients. In this review, we discuss the history of LVADs, evaluating survival and complications over time. We also aim to discuss practical aspects of the medical and surgical management of LVAD patients and future directions for outcome improvement in this population.