Search

Aim: The aim of our study is to assess the predictors and the prognostic role of left ventricle ejection fraction (LVEF) recovery after Impella-supported percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (AMI). Methods: This retrospective, observational study included patients admitted for AMI who underwent Impella-supported PCI in two Italian high-volume cardiac catheterization laboratories. Only patients who underwent an echocardiographic assessment of left ventricle ejection fraction (LVEF) before the procedure (acute LVEF) and during follow-up (follow-up LVEF) were included in the present analysis. Patients with a baseline LVEF ≥40% were excluded from the present analysis. LVEF recovery was calculated as the difference between follow-up LVEF and acute LVEF. A delta ≥5% was considered significant and was used to define the responder group. Results: From April 2007 to December 2020, 64 consecutive patients were included in our study. A total of 55 patients (86%) received hemodynamic support with Impella 2.5, and 9 patients (14%) with Impella CP. Median LVEF at follow-up was significantly higher compared to baseline (36% (30–42) vs. 30% (24–33), p < 0.001). Based on LVEF recovery, 37 patients (57.8%) were deemed responders. According to multivariate analysis, complete functional revascularization was an independent predictor of a significant EF recovery (OR: 0.159; 95% CI: 0.038–0.668; p = 0.012). At three-year follow-up, lack of LVEF recovery was the only predictor of mortality (HR: 5.315; 95% CI: 1.100–25.676; p = 0.038). Conclusions: Functional complete revascularization is an independent predictor of the recovery of LVEF in patients presenting with AMI who underwent Impella-supported PCI. The recovery of LV function is associated with improved prognosis and could be used to stratify the risk of future events at long-term follow-up.

Acute hemodynamic decompensation (AHD) during ventricular tachycardia (VT) ablation occurs in about 11% of cases. Prophylactic use of temporary mechanical circulatory support (pro-tMCS) has been applied to prevent AHD during VT ablation, but evidence supporting this practice is still lacking. This systematic review and meta-analysis assessed the procedural characteristics and outcomes of pro-tMCS for VT ablation. PubMed/Medline was screened until February 2020. Articles including adults receiving pro-tMCS for VT ablation were included, and a meta-analysis to compare proMCS and no-tMCS was performed. Primary outcome was in-hospital/30-day mortality. Five observational studies presenting 400 procedures (pro-tMCS: n = 187; no-tMCS: n = 213) were included. Baseline characteristics were comparable between groups. Impella and TandemHeart were used in 86.6% and 13.4% of cases, respectively. In the pro-tMCS group, more VTs were induced (mean difference: 0.52, confidence interval [CI]: 0.26-0.77, P < .0001), and patients remained in VT on average for 24.04 minutes longer (CI: 18.28-29.80, P < .00001). Procedural success was comparable between groups, as was VT recurrence. Pro-tMCS patients had an odds ratio of 0.55 (CI: 0.28-1.05, P = .07) for in-hospital/30-day mortality and 0.55 (CI: 0.32-0.94, P = .03) for mortality at follow-up. Sixty-four percent of no-tMCS patients received rescue tMCS. The most common tMCS-related complications were bleeding events. Pro-tMCS allowed for a prolonged time on VTs and the induction of more VTs. Although these advantages were not associated with differences in procedural success, VT recurrence, or in-hospital/30-day mortality in the overall population, pro-tMCS might improve long-term survival. Further prospective studies are urgently needed to confirm these results.

Background The Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations. Methods A total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios. Results Among the seven different clinical scenarios, the types of fluids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as first-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specific drugs such as vasopressin or enoximone were used in

Percutaneous coronary intervention (PCI) is establishing as the last remaining revascularization option in an increasing number of patients affected by complex coronary artery disease not suitable for surgery. Over the past decade, percutaneous left ventricular assist device (pLVAD) has increasingly replaced intra-aortic balloon pump to provide hemodynamic support during such non-emergent complex high-risk indicated procedures (CHIP) averting the risk of circulatory collapse and of adverse events in long lasting and/or complicated procedures. This review article aims to report the key factors to define CHIP, to summarize the available pLVAD which have CEmark for temporarymechanical LV support and to discuss the rationale of their use in this subset of patients. Based on the expertise of the Italian Society of Interventional Cardiologyworking group, with the endorsement fromSpanish and Portuguese Society of Interventional Cardiologyworking groups, it will provide several practical suggestions in regards to the use of pLVAD in different clinical CHIP scenarios. (C) 2019 Elsevier B.V. All rights reserved.

Hintergrund: Der kardiogene Schock auf dem Boden eines akuten Koronarsyndroms (ACS) ist noch immer mit einer hohen Sterblichkeit assoziiert. Perkutane Unterstützungssysteme wie die Impella® Mikroaxialpumpe können die koronare Perfusion und die allgemeine hämodynamische Situation der Patienten unterstützen, indem sie Blut aus dem linken Ventrikel über die Aortenklappe in die Aorta ascendens pumpen. Allerdings ist die momentane Datenlage zur klinischen Effektivität des Systems noch unzureichend. Dementsprechend ist das Ziel dieser Arbeit, die Effekte der Impella® mit denen der noch vor kurzem vermehrt eingesetzten intraaortalen Ballonpumpe (IABP) zu vergleichen. Methoden: Es wurden 116 Patienten rekrutiert, die in den Jahren von 2011 bis 2017 in zwei tertiären Zentren für Kardiologie behandelt wurden. Diese entsprechend gewonnenen Daten wurden retrospektiv analysiert. Als primärer Endpunkt diente die 30-Tages Mortalität. Surrogatparameter des Schocks dienten als sekundäre Endpunkte. Resultate: 116 konsekutive Patienten, 62 Patienten mit Impella® CP oder Impella® 2.5. und 54 Patienten mit IABP, wurden in die Studie eingeschlossen. Die Krankheitsschwere charakterisiert durch den IABP-SHOCK II Score war in beiden Behandlungsgruppen nicht verschieden. In der frühen Therapiephase zeigte sich eine signifikante Reduktion der inotropen Scores (p, Background: Cardiogenic shock due to acute coronary syndrome (ACS) is associated with high mortality. Percutaneous assist devices such as the Impella® centrifugal pump may increase the coronary blood flow and provide hemodynamic support by pumping blood from the left ventricle into the aorta. However, only limited data are available to assess the effectiveness of the Impella®. Therefore, it was the aim of the present study to compare the effects of Impella® with the formerly used intraaortic balloon pump (IABP) on surrogate parameters of shock severity and early mortality in patients with cardiogenic shock due to ACS. Methods: 116 consecutive patients in cardiogenic shock due to ACS and treated with either Impella® or IABP, presenting between 2011 and 2017 to two tertiary cardiac care centers were retrospectively analyzed. The primary endpoint was overall mortality at 30 days. Surrogate parameters of shock severity were secondary endpoints. Results: 62 patients underwent circulatory support with Impella® CP or Impella® 2.5 and 54 with IABP. Severity of disease at baseline, assessed by the IABP-SHOCK II score, was similar among groups. In the early days post-implantation, a significant reduction of inotropic scores (p

International audience; BACKGROUND: Improving sepsis support is one of the three pillars of a 2017 resolution according to the World Health Organization (WHO). Septic shock is indeed a burden issue in the intensive care units. Hemodynamic stabilization is a cornerstone element in the bundle of supportive treatments recommended in the Surviving Sepsis Campaign (SSC) consecutive biannual reports.MAIN BODY: The "Pandera's box" of septic shock hemodynamics is an eternal debate, however, with permanent contentious issues. Fluid resuscitation is a prerequisite intervention for sepsis rescue, but selection, modalities, dosage as well as duration are subject to discussion while too much fluid is associated with worsen outcome, vasopressors often need to be early introduced in addition, and catecholamines have long been recommended first in the management of septic shock. However, not all patients respond positively and controversy surrounding the efficacy-to-safety profile of catecholamines has come out. Preservation of the macrocirculation through a "best" mean arterial pressure target is the actual priority but is still contentious. Microcirculation recruitment is a novel goal to be achieved but is claiming more knowledge and monitoring standardization. Protection of the cardio-renal axis, which is prevalently injured during septic shock, is also an unavoidable objective. Several promising alternative or additive drug supporting avenues are emerging, trending toward catecholamine's sparing or even "decatecholaminization." Topics to be specifically addressed in this review are: (1) mean arterial pressure targeting, (2) fluid resuscitation, and (3) hemodynamic drug support.CONCLUSION: Improving assessment and means for rescuing hemodynamics in early septic shock is still a work in progress. Indeed, the bigger the unresolved questions, the lower the quality of evidence.

Nobody could have been more surprised than the Fluid Expansion As Supportive Therapy (FEAST) trial clinicians when they heard the results of our 2011 phase III randomised controlled study in six East African clinical centres in Kenya, Tanzania and Uganda.1 Based on what they had witnessed at the bedside in children with severe febrile illness and impaired perfusion, they had all expected fluid bolus therapy (FBT) as compared with no bolus (but solely maintenance fluids at 4 mL/kg/hour) to have a better outcome. Even though FBT leads to substantially better early shock reversal, subsequently it results in excess 48-hour and 28-day mortality. The chief mode of excess mortality was cardiovascular collapse and not fluid overload (figure 1).2 Notable is that the vast majority of children only received a 20 mL/kg bolus of either 5% albumin or 0.9% saline, yet this intervention caused excess mortality in all subgroups (including a large subgroup with sepsis), across all ages, for all definitions of shock, and at each centre. This surprising finding is precisely why we need to do clinical trials! Figure 1 Cumulative incidence of mortality for bolus combined and no bolus arms by terminal clinical events for 297 children who died within 48 hours (from figure 7 from ref2). To date, the FEAST trial is the only completed phase III …

Sepsis remains one of the leading causes of mortality in children all over the world, especially in the developing nations. Early recognition of sepsis and septic shock facilitate the resuscitation, further reducing the morbidity and mortality related to septic shock in children.Current evidence and guidelines emphasize on goal-directed therapy and institution-specific bundles in the management of septic shock in children. There is an emerging evidence for the use of newer monitoring and therapeutic modalities in the various phases of septic shock in children - especially the de-resuscitation phase, which need validation by further trials.

OBJECTIVES:: A previous meta-analysis has shown a consistent survival benefit in children with severe malaria receiving human albumin solution compared to other resuscitation fluids. Human albumin solution is expensive and not readily available in Africa. We examined the safety and efficacy of the fluid resuscitation with two synthetic colloids, Dextran 70 and hydroxyethyl starch, to inform future trial design. DESIGN:: An open-label randomized, controlled, phase II safety and efficacy trial. SETTING:: High-dependency unit, Kilifi District Hospital, Kenya. PATIENTS:: Children aged >6 months with severe falciparum malaria and acidosis (base deficit >8 mmol). INTERVENTIONS:: Boluses (20-40 mL/kg) of 6% Dextran 70 and 6% hydroxyethyl starch (130/0.4). MEASUREMENTS AND MAIN RESULTS:: Primary end point: resolution of shock over 8 hrs. Secondary end points include resolution of acidosis, in-hospital mortality, and adverse events (allergic reactions, pulmonary edema, and neurologic sequelae). A total of 79 children were enrolled: 39 received Dextran 70 and 40 received hydroxyethyl starch. No significant difference was observed in Dextran 70 and hydroxyethyl starch groups for shock resolution at 8 hrs: 23/37 (62%) and 25/39 (64%), respectively (p = .99). Acidosis resolution and respiratory distress were marginally superior in the hydroxyethyl starch group: 3/39 (8%) remained acidotic at 8 hrs versus 10/37 (27%) in the Dextran 70 arm (p = .05). There were four deaths (5%): two per arm, including three deaths in the coma subgroup (3/39, 8%). No other new adverse event was reported. CONCLUSIONS:: Correction of shock by volume expansion with either Dextran 70 or hydroxyethyl starch in children with severe malaria acidosis is safe with low mortality, including the highest risk cases admitted in coma. Both solutions present an attractive and practical option for consideration in future volume resuscitation trials in severe malaria.