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The use of veno-arterial extracorporeal membrane oxygenation as extracorporeal cardiopulmonary resuscitation in patients suffering out-of-hospital cardiac arrest, largely increased in the last decade despite evidence supporting this practice being limited to non-randomized studies. However, between 2020 and 2023, four randomized studies were published comparing extracorporeal cardiopulmonary resuscitation to conventional cardiopulmonary resuscitation with controversial findings that triggered great debates. In this controversy, we discuss merits and pitfalls, and provide a critical interpretation of the available evidence from randomized trials on the use of extracorporeal cardiopulmonary resuscitation, with a particular focus on the recent multi-center INCEPTION trial.

Introduction: Simulation training offers an authentic team-based learning opportunity without risk to real patients. The Educational Corner at the annual congress of the European Branch of Extracorporeal Life Support Organisation (EuroELSO) provided an opportunity for multiple simulation training sessions facilitated by experts from all over the world. Aim: We aimed to review the educational impact of EuroELSO Educational Corner and whether it provides a quality ECLS training to a wide spectrum of multidisciplinary international attendees utilising high and low fidelity simulation, workshops and hands on sessions. Methods: During the congress, 43 sessions were conducted dedicated to ECLS education with identified educational objectives. The sessions focused on management of adults and children on V-V or V-A ECMO. Adult sessions covered emergencies on mechanical circulatory support with management of LVAD and Impella, managing refractory hypoxemia on V-V ECMO, emergencies on ECMO, renal replacement therapy on ECMO, V-V ECMO, ECPR cannulation and performing perfect simulation. Paediatric sessions covered ECPR neck and central cannulation, renal replacement on ECMO, troubleshooting, cannulation workshop, V-V recirculation, ECMO for single ventricle, PIMS-TS and CDH, ECMO transport and neurological injury. Results: The Educational Corner was attended by more than 400 participants over the two congress days. Majority of responders (88%) reported that training sessions met the set educational goals and objectives and that this would change their current practice. Almost all (94%) reported that they received useful information and 95% would recommend the session to their colleagues. Conclusion: The Educational Corner, as an integral component of the annual EuroELSO congress, achieved the set educational goals and provided quality education based on the recipient survey. Structured multidisciplinary ECLS education with standardised curriculum and feedback is an important key step in delivering quality training to an international audience. Standardisation of European ECLS education remains an important focus of the EuroELSO.

ImportanceDapagliflozin has been shown to improve overall health status based on aggregate summary scores of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in patients with heart failure (HF) with mildly reduced or preserved ejection fraction enrolled in the Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure (DELIVER) trial. A comprehensive understanding of the responsiveness of individual KCCQ items would allow clinicians to better inform patients on expected changes in daily living with treatment.ObjectiveTo examine the association of dapagliflozin treatment with changes in individual components of the KCCQ.Design, Setting, and ParticipantsThis is a post hoc exploratory analysis of DELIVER, a randomized double-blind placebo-controlled trial conducted at 353 centers in 20 countries from August 2018 to March 2022. KCCQ was administered at randomization and 1, 4, and 8 months. Scores of individual KCCQ components were scaled from 0 to 100. Eligibility criteria included symptomatic HF with left ventricular ejection fraction greater than 40%, elevated natriuretic peptide levels, and evidence of structural heart disease. Data were analyzed from November 2022 to February 2023.Main Outcomes and MeasuresChanges in the 23 individual KCCQ components at 8 months.InterventionsDapagliflozin, 10 mg, once daily or placebo.ResultsBaseline KCCQ data were available for 5795 of 6263 randomized patients (92.5%) (mean [SD] age, 71.5 [9.5] years; 3344 male [57.7%] and 2451 female [42.3%]). Dapagliflozin was associated with larger improvements in almost all KCCQ components at 8 months compared with placebo. The most significant improvements with dapagliflozin were observed in frequency of lower limb edema (difference, 3.2; 95% CI, 1.6-4.8; P P P Conclusions and RelevanceIn this study of patients with HF with mildly reduced or preserved ejection fraction, dapagliflozin was associated with improvement in a broad range of individual KCCQ components, with the greatest benefits in domains related to symptom frequency and physical limitations. Potential improvements in specific symptoms and activities of daily living might be more readily recognizable and easily communicated to patients.Trial RegistrationClinicalTrials.gov Identifier: NCT03619213

Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.

OBJECTIVES After cardiac arrest, a key factor determining survival outcomes is low-flow duration. Our aims were to determine the relation of survival and low-flow duration of extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) and if these 2 therapies have different short-term survival curves in relation to low-flow duration. METHODS We searched Embase, Medline, Web of Science and Google Scholar from inception up to April 2021. A linear mixed-effect model was used to describe the course of survival over time, based on study-specific and time-specific aggregated survival data. RESULTS We included 42 observational studies reporting on 1689 ECPR and 375 751 CCPR procedures. Of the included studies, 25 included adults, 13 included children and 4 included both. In adults, survival curves decline rapidly over time (ECPR 37.2%, 29.8%, 23.8% and 19.1% versus CCPR-shockable 36.8%, 7.2%, 1.4% and 0.3% for 15, 30, 45 and 60 min low-flow, respectively). ECPR was associated with a statistically significant slower decline in survival than CCPR with initial shockable rhythms (CCPR-shockable). In children, survival curves decline rapidly over time (ECPR 43.6%, 41.7%, 39.8% and 38.0% versus CCPR-shockable 48.6%, 20.5%, 8.6% and 3.6% for 15, 30, 45 and 60 min low-flow, respectively). ECPR was associated with a statistically significant slower decline in survival than CCPR-shockable. CONCLUSIONS The short-term survival of ECPR and CCPR-shockable patients both decline rapidly over time, in adults as well as in children. This decline of short-term survival in relation to low-flow duration in ECPR was slower than in conventional cardiopulmonary resuscitation. Trial registration Prospero: CRD42020212480, 2 October 2020.

OBJECTIVE The sodium–glucose cotransporter 2 inhibitor dapagliflozin reduced the risk of cardiovascular mortality and worsening heart failure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial. This report explores the effect of dapagliflozin on incident type 2 diabetes (T2D) in the cohort without diabetes enrolled in the trial. RESEARCH DESIGN AND METHODS The subgroup of 2,605 patients with heart failure and reduced ejection fraction (HFrEF), no prior history of diabetes, and an HbA1c of RESULTS At baseline, the mean HbA1c was 5.8%. At 8 months, there were minimal changes, with a placebo-adjusted change in the dapagliflozin group of −0.04%. Over a median follow-up of 18 months, diabetes developed in 93 of 1,307 patients (7.1%) in the placebo group and 64 of 1,298 (4.9%) in the dapagliflozin group. Dapagliflozin led to a 32% reduction in diabetes incidence (hazard ratio 0.68, 95% CI 0.50–0.94; P = 0.019). More than 95% of the participants who developed T2D had prediabetes at baseline (HbA1c 5.7–6.4%). Participants who developed diabetes in DAPA-HF had a higher subsequent mortality than those who did not. CONCLUSIONS In this exploratory analysis among patients with HFrEF, treatment with dapagliflozin reduced the incidence of new diabetes. This potential benefit needs confirmation in trials of longer duration and in people without heart failure.

Aims The improved clinical response in patients with left bundle branch block (LBBB) over LBBB‐free patients treated with cardiac resynchronization therapy with a defibrillator (CRT‐D) is commonly attributed to an LBBB abnormality. We aimed to find an alternative explanation. Methods and results We analysed an immediate effect of selecting the LBBB group of patients in a cohort of 63 non‐ischaemic cardiomyopathy (non‐ICM) and 83 ischaemic cardiomyopathy (ICM) patients treated with CRT‐D; 75% of non‐ICM and 51% of ICM patients had an LBBB abnormality on the electrocardiogram, with a significant difference (P = 0.0032 by χ 2). As a result of this difference, the proportion of non‐ICM patients increased from 43% in the primary cohort to 53% in LBBB selection and decreased to 28% in non‐LBBB group. By nonparametric survival analysis, the hazard ratio in non‐ICM patients in the LBBB selection decreased from 0.48 (P = 0.0488) to 0.36 (P = 0.0251) and increased in the non‐LBBB group to 0.75 (P = 0.6496). Any comparison of LBBB and non‐LBBB groups must compare sets with a significantly altered proportion of patients of different aetiologies. Most publications on LBBB patients are erroneous because they compare LBBB with non‐LBBB groups, not taking into account that the groups have been substantially changed by the selection process. Conclusions The declared outcome of the LBBB groups reflects inevitably the survival outcome of their non‐ICM patients and not the intended outcome of patients with LBBB. CRT‐D in patients with different aetiologies of cardiomyopathy calls for separate evaluation.

Despite advanced therapies, the mortality of patients with myocardial infarction (MI) complicated by cardiogenic shock (CS) remains around 50%. Mechanical complications of MI are rare nowadays but associated with high mortality in patients who present with CS. Different treatment strategies and mechanical circulatory support (MCS) devices have been increasingly used to improve the grim prognosis of refractory CS. This article discusses current evidence regarding the use of MCS in MI complicated by CS, ventricular septal rupture, free wall rupture and acute mitral regurgitation. Device selection should be tailored according to the cause and severity of CS. Early MCS initiation and multidisciplinary team cooperation is mandatory for good results. MCS associated bleeding remains a major complication and an obstacle to better outcomes. Ongoing prospective randomized trials will improve current knowledge regarding MCS indications, timing, and patient selection in the coming years.

Cardiogenic shock (CS) is a life-threatening complication of cardiac disorders defined by reduced cardiac output with critical end-organ hypoperfusion. Its management is challenging. Standard CS therapy involving catecholamines, inotropes, and early revascularization is often insufficient, and mortality remains 50% despite current advanced therapeutic options. Veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) has been increasingly used in cases of CS as it allows rapid hemodynamic stabilization. ECMO support serves as a bridge to decision, recovery, cardiac transplantation, or long-term mechanical support device destination therapy. Early ECMO initiation, careful patient selection, and comprehensive intensive care by an experienced team is key to a successful outcome in patients with CS. This chapter reviews the clinical management of ECMO in CS.

Extracorporeal life support (ECLS) is an established mechanical support in cases of severe cardiac and/or respiratory failure. When used during cardiopulmonary resuscitation (CPR) (e.g., implanted during ongoing cardiac arrest [CA]), it is usually called extracorporeal cardiopulmonary resuscitation (ECPR). In other words, ECPR is for the use of ECLS in patients who remain in CA despite conventional CPR or when intermittent return of spontaneous circulation (ROSC) occurs, but repetitive CA reoccurs again. It is essential that ECPR is being used in refractory CA, when reasonable time has been used to try to achieve ROSC or where chance of obtaining and sustaining ROSC is low. ECPR provides mechanical support/replacement for failed circulation or gas exchange, whatever the reason for CA was. The prognosis of refractory CA is generally very poor; therefore, ECPR also bears a grave prognosis. However, in institutions with well-functioning ECPR programs, reasonable survival may be achieved.

Chronicke srdecni selhani (CHSS) je v populaci caste a je spojeno se spatnou prognozou navzdory pokrokům v lecbě. V posledni dekadě probihaly studie s kardiovaskularnimi výslednými parametry u pacientů s diabetes mellitus 2. typu (DM2T) uživajicich inhibitory sodiko-glukozoveho kontransporteru 2 (SGLT2i). U tři těchto inhibitorů SGLT2 (empagliflozin, canagliflozin a dapagliflozin) byly prokazany přiznive ucinky na sniženi poctu hospitalizaci pro srdecni selhani. V posledni době navic bylo zjistěno, že dapagliflozin snižil riziko zhorseni srdecniho selhani nebo umrti z kardiovaskularnich přicin u pacientů s chronickým srdecnim selhanim se sniženou ejekcni frakci leve komory, nezavisle na přitomnosti diabetu 2. typu. Probiha a brzy bude prezentovana řada dalsich studii u pacientů se srdecnim selhanim se sniženou nebo zachovanou ejekcni frakci leve komory. Tento souborný dokument shrnuje nedavne důkazy z klinických studii a diskutuje roli inhibitorů SGLT2 při lecbě srdecniho selhani, než budou výsledky probihajicich studii u různých populaci pacientů s CHSS. © 2020 European Society of Cardiology. All rights reserved. Published by the Czech Society of Cardiology.

Background: Cardiogenic shock occurs in 10%-15% of patients with Takotsubo syndrome (TS). For several reasons catecholamines, and especially inotropes, should be avoided in TS. Temporary mechanical circulatory support (MCS) appears attractive as bridge-to-recovery, but prospective studies are lacking. Here we analyze the available literature on MCS use in patients with TS. Methods and results: PubMed/Medline was systematically screened until December 2019. 18 studies reporting pooled data of 5629 TS patients, of whom 227 had received MCS, were considered for a qualitative synthesis. 81 articles from 2003 through 2019 reporting individual data of 93 MCS cases were included in a meta-analysis. Median age was 57 (IQR: 43-68) years, 83.9% were women, and a physical trigger could be identified in 74.1% of cases. Median left ventricular ejection fraction (LVEF) before MCS was 20% (IQR: 15-25) and comparable between groups defined by MCS device. An apical TS type was present in 76.1% of cases. The overall number of publications on MCS for TS increased over time, as did those using veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and Impella, while those using intra-aortic balloon pump declined. MCS-related complications were not regularly reported. Median time on MCS was 3 (IQR: 2-7) days, with an overall survival of 94.6%. Conclusions: MCS for TS-related shock is increasingly reported, with a growing use of V-A ECMO and Impella. Currently available clinical data support this approach. Prospective studies are needed to evaluate safety and efficacy of different devices as well as timing of MCS in this special patient population. (C) 2020 Elsevier B.V. All rights reserved.

Giant cell myocarditis is a rare form of autoimmune myocarditis with high morbidity and mortality that affects mainly middle‐aged adults. We report a case study of a 70‐year‐old man on chronic immunosuppression who presented with sustained ventricular tachycardia and symptoms of acute systolic heart failure, both with poor response to standard measures. A decision to pursue endomyocardial biopsy established the diagnosis of GCM and lead to initiation of immunosuppressive therapy and a favourable outcome. Our case illustrates that a low threshold for endomyocardial biopsy in new onset heart failure can lead to actionable information even in patients of advanced age.

Kompletni atrioventrikularni (AV) blokada představuje vzacnou, avsak život ohrožujici komplikaci tyreotoxikozy. V literatuře bylo dosud popsano pouze několik připadů s nejistou kauzalni souvislosti s hypertyroidnim stavem. Vzhledem k nedostatku udajů nepanuje absolutni shoda ohledně reverzibility teto abnormality AV převodu, a tedy i nutnosti implantace trvaleho kardiostimulatoru. V nasi kazuistice popisujeme připad 35lete pacientky, u ktere se nově diagnostikovana Gravesova-Basedowova tyreotoxikoza poprve manifestovala synkopou při kompletni AV blokadě. V uvodu hospitalizace doslo ke spontanni obnově AV převodu v poměru 1 : 1, což vedlo k výrazne sinusove tachykardii s frekvenci 150/min, ktera byla symptomaticka bolestmi na hrudi, prekolapsovým stavem a vedla k rozvoji srdecniho selhani v důsledku hyperkineticke cirkulace. Dalsi komplikaci byla epizoda asystolie při recidivě uplne AV blokady bez nahradniho rytmu s nutnosti dvouminutove kardiopulmonalni resuscitace a emergentni docasne transvenozni kardiostimulace. Při lecbě tyreostatiky a kortikosteroidy se po 48 hodinach stabilizoval srdecni rytmus se sklonem k sinusove tachykardii. Dalsi průběh byl již nekomplikovaný, vcetně dobre tolerance lecby beta-blokatorem. Komplexni vysetřeni (vcetně magneticke rezonance srdce) neprokazalo žadnou jinou přicinu vysvětlujici kompletni AV blokadu. Zvažovanou implantaci trvaleho kardiostimulatoru pacientka odmitla. V nasledujicich třech měsicich sledovani již nebyla recidiva AV blokady zaznamenana. © 2019, CKS.

Pohybova aktivita představuje jednu z důležitých komponent zdraveho životniho stylu a komplexni přiznive působeni teměř na vsechny organy těla z ni cini teměř idealni lecebnou modalitu. Nicmeně oproti klidovemu stavu představuje pohybova aktivita hemodynamickou zatěž, ktera může u predisponovaných jedinců vest až k nahle srdecni zastavě/smrti. Jakakoli smrt sportovce i nesportovce je traumatizujici udalosti. Jsou použivany různe strategie, ktere maji incidenci nahle srdecni zastavy snižit nebo zmirnit jeji dopady, nicmeně vsem umrtim předejit nedokažeme. V předkladanem textu jsou shrnuty zakladni poznatky o nahle srdecni smrti a možnosti, jak ji předchazet. © 2020, CKS.

Uvadime připad opakovane systemove embolie u dosud zdrave 48lete ženy, kdy postupný klinický vývoj odhalil kombinaci vzacných anatomických a patologických nalezů. Prvnim projevem onemocněni u pacientky byla opakujici se systemova embolizace do leve paže vyžadujici opakovanou chirurgickou embolektomii ve velmi kratkem casovem sledu. Při souběžnem patrani po možnem zdroji byla postupně diagnostikovana klinicky něma plicni embolie, patentni foramen ovale a taktež významna cevni arteriovenozni (AV) malformace v leve plici. V dalsim průběhu doslo k necekanemu zvratu v podobě vzniku akutniho masivniho infarktu myokardu, opět embolizacniho původu, zdroj embolizace do leve koronarni tepny byl překvapivě objeven v ascendentni aortě. Nasledujici text podrobně popisuje průběh onemocněni teto pacientky. Připad poukazuje mimo jine na to, že i přes maximalni a vcasne diagnosticke a terapeuticke možnosti moderni kardiologie a interdisciplinarni spoluprace stale existuji vzacne a překvapive připady pacientů s hyperkoagulacnimi stavy, u kterých přicinu nemocnosti neumime zcela spolehlivě vysvětlit a i přes maximalni usili a terapii může být velmi obtižne odvratit připadne dalsi komplikace takoveho stavu. © 2019, CKS.

Purpose of review Cardiogenic shock (CS) therapy involving catecholamines, inotropes, fluids and revascularization is often insufficient, and short-term mortality remains 50%. Different treatment algorithms and mechanical circulatory support devices (MCS) have been increasingly used in the treatment of CS. Coronavirus disease 2019 (COVID-19) pandemic is a major challenge faced by intensive care medicine providers inevitably influencing also CS management. Recent findings There is a lack of prospective data as well as international consensus regarding CS classification, patient risk stratification, and MCS use. Veno-arterial extracorporeal membrane oxygenation is considered the first line MCS in refractory CS and Impella the MCS of choice for the left ventricle unloading. Several ongoing randomized trials will provide much-needed evidence for MCS use in the coming years. COVID-19 infection is associated with several cardiovascular disorders complicated by CS and more data regarding the prevalence and mortality of CS during COVID-19 infection are needed. Summary This review summarizes current trends in the use of MCS in CS and discusses differences in CS management during the COVID-19 pandemic. Careful patient selection, early MCS initiation, and comprehensive intensive care by experienced team is key to successful outcome in patients with refractory CS.

Guideline-directed medical therapy (GDMT) has the potential to reduce the risks of mortality and hospitalisation in patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data indicate that many patients with HFrEF do not receive optimised GDMT, which involves several different medications, many of which require up-titration to target doses. There are many challenges to implementing GDMT, the most important being patient-related factors (comorbidities, advanced age, frailty, cognitive impairment, poor adherence, low socioeconomic status), treatment-related factors (intolerance, side-effects) and healthcare-related factors that influence availability and accessibility of HF care. Accordingly, international disparities in resources for HF management and limited public reimbursement of GDMT, coupled with clinical inertia for treatment intensification combine to hinder efforts to provide GDMT. In this review paper, authors aim to provide solutions based on available evidence, practical experience, and expert consensus on how to utilise evolving strategies, novel medications, and patient profiling to allow the more comprehensive uptake of GDMT. Authors discuss professional education, motivation, and training, as well as patient empowerment for self-care as important tools to overcome clinical inertia and boost GDMT implementation. We provide evidence on how multidisciplinary care and institutional accreditation can be successfully used to increase prescription rates and adherence to GDMT. We consider the role of modern technologies in advancing professional and patient education and facilitating patient-provider communication. Finally, authors emphasise the role of novel drugs (especially sodium-glucose cotransporter-2 inhibitors), and a tailored approach to drug management as evolving strategies for the more successful implementation of GDMT. This article is protected by copyright. All rights reserved.

Conflicts and disagreements are normal part of human communication, in stressful situations. The area of healthcare, especially the intensive care unit (ICU), is susceptible to conflict emergence and escalation due to highly complex medical decisions in life-threatening conditions and often highly emotionally loaded patients’ life stories. Most of the conflicts occur either between families and ICU staff members or within the ICU team. Intra-family conflicts or conflicts with patients are less frequent. Poor communication (in quality and in quantity) and general and interpersonal behavior are the most frequent and critical problems creating conflicts. The problem of conflicts in the ICU is a complex issue involving specific social skills and requiring knowledge and practice of specific communication strategies. This suggests that while better insight through continuing high-quality research is necessary, it will be crucial to develop targeted medical education to improve conflict management.

Aims: In heart failure with reduced ejection fraction (HFrEF), there is an ‘obesity paradox’, where survival is better in patients with a higher body mass index (BMI) and weight loss is associated with worse outcomes. We examined the effect of a sodium–glucose co-transporter 2 inhibitor according to baseline BMI in the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF). Methods and results: Body mass index was examined using standard categories, i.e. underweight (2); normal weight (18.5–24.9 kg/m2); overweight (25.0–29.9 kg/m2); obesity class I (30.0–34.9 kg/m2); obesity class II (35.0–39.9 kg/m2); and obesity class III (≥40 kg/m2). The primary outcome in DAPA-HF was the composite of worsening heart failure or cardiovascular death. Overall, 1348 patients (28.4%) were under/normal-weight, 1722 (36.3%) overweight, 1013 (21.4%) obesity class I and 659 (13.9%) obesity class II/III. The unadjusted hazard ratio (95% confidence interval) for the primary outcome with obesity class 1, the lowest risk group, as reference was: under/normal-weight 1.41 (1.16–1.71), overweight 1.18 (0.97–1.42), obesity class II/III 1.37 (1.10–1.72). Patients with class I obesity were also at lowest risk of death. The effect of dapagliflozin on the primary outcome and other outcomes did not vary by baseline BMI, e.g. hazard ratio for primary outcome: under/normal-weight 0.74 (0.58–0.94), overweight 0.81 (0.65–1.02), obesity class I 0.68 (0.50–0.92), obesity class II/III 0.71 (0.51–1.00) (P-value for interaction = 0.79). The mean decrease in weight at 8 months with dapagliflozin was 0.9 (0.7–1.1) kg (P < 0.001). Conclusion: We confirmed an ‘obesity survival paradox’ in HFrEF. We showed that dapagliflozin was beneficial across the wide range of BMI studied. Clinical Trial Registration: ClinicalTrials.gov NCT03036124.

Objective The SGLT2 inhibitor dapagliflozin reduced the risk of cardiovascular mortality and worsening heart failure in the Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure trial (DAPA-HF). This report explores the effect of dapagliflozin on incident type 2 diabetes in the non-diabetic cohort enrolled in the trial. Research Design/Methods The subgroup of 2605 patients with heart failure and reduced ejection fraction (HFrEF), no prior history of diabetes, and a HbA1c of Results At baseline, the mean HbA1c was 5.8%. At 8 months, there were minimal changes, with a placebo-adjusted change in the dapagliflozin group of -0.04%. Over a median follow-up of 18 months, diabetes developed in 93/1307 patients (7.1%) in the placebo group and 64/1298 (4.9%) in the dapagliflozin group. Dapagliflozin led to a 32% reduction in diabetes incidence (HR 0.68, 95% CI, 0.50-0.94; p=0.019.) More than 95% of the participants who developed type 2 diabetes had prediabetes at baseline (HbA1c 5.7-6.4%.) Participants who developed diabetes in DAPA-HF had a higher subsequent mortality than those who did not. Conclusions In this exploratory analysis among patients with HFrEF, treatment with dapagliflozin reduced the incidence of new diabetes. This potential benefit needs confirmation in trials of longer duration and in people without heart failure.

Background: Multiple major health organisations recommend the use of extracorporeal membrane oxygenation (ECMO) support for COVID-19-related acute hypoxaemic respiratory failure. However, initial reports of ECMO use in patients with COVID-19 described very high mortality and there have been no large, international cohort studies of ECMO for COVID-19 reported to date. Methods: We used data from the Extracorporeal Life Support Organization (ELSO) Registry to characterise the epidemiology, hospital course, and outcomes of patients aged 16 years or older with confirmed COVID-19 who had ECMO support initiated between Jan 16 and May 1, 2020, at 213 hospitals in 36 countries. The primary outcome was in-hospital death in a time-to-event analysis assessed at 90 days after ECMO initiation. We applied a multivariable Cox model to examine whether patient and hospital factors were associated with in-hospital mortality. Findings: Data for 1035 patients with COVID-19 who received ECMO support were included in this study. Of these, 67 (6%) remained hospitalised, 311 (30%) were discharged home or to an acute rehabilitation centre, 101 (10%) were discharged to a long-term acute care centre or unspecified location, 176 (17%) were discharged to another hospital, and 380 (37%) died. The estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 37·4% (95% CI 34·4–40·4). Mortality was 39% (380 of 968) in patients with a final disposition of death or hospital discharge. The use of ECMO for circulatory support was independently associated with higher in-hospital mortality (hazard ratio 1·89, 95% CI 1·20–2·97). In the subset of patients with COVID-19 receiving respiratory (venovenous) ECMO and characterised as having acute respiratory distress syndrome, the estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 38·0% (95% CI 34·6–41·5). Interpretation: In patients with COVID-19 who received ECMO, both estimated mortality 90 days after ECMO and mortality in those with a final disposition of death or discharge were less than 40%. These data from 213 hospitals worldwide provide a generalisable estimate of ECMO mortality in the setting of COVID-19. Funding: None.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is a technique used in patients with severe heart failure. The aim of this study was to evaluate its effects on left ventricular afterload and fluid accumulation in lungs with electrical impedance tomography (EIT). In eight swine, incremental increases of extracorporeal blood flow (EBF) were applied before and after the induction of ischemic heart failure. Hemodynamic parameters were continuously recorded and computational analysis of EIT was used to determine lung fluid accumulation. With an increase in EBF from 1 to 4 l/min in acute heart failure the associated increase of arterial pressure (raised by 44 %) was accompanied with significant decrease of electrical impedance of lung regions. Increasing EBF in healthy circulation did not cause lung impedance changes. Our findings indicate that in severe heart failure EIT may reflect fluid accumulation in lungs due to increasing EBF.

An introduction to the issue is presented which include manuscripts related to Covid19 management, and the partnership between the "Perfusion" and the European Extracorporeal Life Support Organization (EuroELSO)

The substantial increase in the number of patients receiving extracorporeal membrane oxygenation over the last decade has led to an evolution of indications and an expansion into wider patient groups. One of the unanticipated benefits of the increase in extracorporeal membrane oxygenation has been a change in the understanding of the natural history of many respiratory diseases. Development in technology and materials, reduced extracorporeal membrane oxygenation–specific complications, and improvement of critical care, in general, have facilitated longer extracorporeal membrane oxygenation runs, and the definition of prolonged extracorporeal membrane oxygenation was recently expanded to continuous support for more than 28 days. This survey aimed to describe European ECMO centers’ perception and arbitrary definition of prolonged extracorporeal membrane oxygenation, patient management, and futility. Of 94 center responses, 37% regarded 14-21 days, 30% 21-28 days, and 28% >28 days as prolonged treatment. Bridge to recovery (64%) or to transplantation (20%) was the most common causes. Awake, and ambulation while on extracorporeal membrane oxygenation was reported from 34% of the centers. In case of perceived futility, decision to withdraw was taken in 65% of the centers in agreement between profession and family and in 30% by profession only. One-fourth of the centers did not discontinue support. Large differences prevail among European ECMO centers concerning local perception and patient management in prolonged extracorporeal membrane oxygenation.

Aims: The aim of this study was to examine whether left ventricular ejection fraction (LVEF) modified efficacy and safety of dapagliflozin 10 mg compared with placebo in the 4744 patients with LVEF ≤40% randomized in the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF). Methods and results: We examined whether LVEF, analysed categorically or continuously, modified the effect of dapagliflozin. The primary efficacy outcome was the composite of a worsening heart failure (HF) event (unplanned HF hospitalization/an urgent HF visit requiring intravenous therapy) or cardiovascular death. Mean LVEF was 31.1% and LVEF categories analysed were: 35% (n = 1396). Each 5% decrease in LVEF was associated with a higher risk of the primary outcome [hazard ratio (HR) 1.18; 95% confidence interval (CI) 1.13–1.24]. The benefit of dapagliflozin was consistent across the spectrum of LVEF: the dapagliflozin vs. placebo HR was 0.75 (95% CI 0.59–0.95) for LVEF 35% (P for interaction = 0.762). Similarly, the effect of dapagliflozin on the components of the primary endpoint was not modified by baseline LVEF (P for interaction for cardiovascular death = 0.974, and for worsening HF = 0.161). Safety of dapagliflozin was also consistent across the range of LVEF and neither efficacy nor safety were modified by diabetes status. Conclusion: Left ventricular ejection fraction was a significant predictor of hospitalization and mortality in patients with HF with reduced ejection fraction but did not modify the beneficial effect of dapagliflozin, overall or separately, in patients with and without diabetes. Clinical Trial Registration: ClinicalTrials.gov Identifier NCT03036124.

Extracorporeal life support (ECLS) is a mainstay of current practice in severe respiratory, circulatory or cardiac failure refractory to conventional management. The inherent complexity of different ECLS modes and their influence on the native pulmonary and cardiovascular system require patient-specific tailoring to optimize outcome. Echocardiography plays a key role throughout the ECLS care, including patient selection, adequate placement of cannulas, monitoring, weaning and follow-up after decannulation. For this purpose, echocardiographers require specific ECLS-related knowledge and skills, which are outlined here.

Cardiac arrest represents a leading cause of mortality and morbidity in developed countries. Extracorporeal cardiopulmonary resuscitation (ECPR) increases the chances for a beneficial outcome in victims of refractory cardiac arrest. However, ECPR and post-cardiac arrest care are affected by high mortality rates due to multi-organ failure syndrome, which is closely related to microcirculatory disorders. Therefore, microcirculation represents a key target for therapeutic interventions in post-cardiac arrest patients. However, the evaluation of tissue microcirculatory perfusion is still demanding to perform. Novel videomicroscopic technologies (Orthogonal polarization spectral, Sidestream dark field and Incident dark field imaging) might offer a promising way to perform bedside microcirculatory assessment and therapy monitoring. This review aims to summarise the recent body of knowledge on videomicroscopic imaging in a cardiac arrest setting and to discuss the impact of extracorporeal reperfusion and other therapeutic modalities on microcirculation.

Uvod: Srdecni zastava (SZ) s naslednou cerebralni hypoxii vede k multifaktorialnimu poskozeni mozku. Kognitivni deficit a vyssi mira depresivnich projevů jsou nejcastěji popisovanými psychickými důsledky SZ. Cilem předkladane studie je charakterizovat psychosocialni důsledky SZ.Metody: Průzkumneho setřeni se ucastnilo 113 osob. K 62 pacientům po SZ bylo dle demografických charakteristik a premorbidni inteligencni urovně přiřazeno 51 zdravých jedinců. Ucastnikům byly předloženy testy kognitivni výkonnosti (Montreal Cognitive Assessment, MoCA), depresivnich (Beck Depression Inventory-II, BDI-II) a uzkostných projevů (State-Trait Anxiety Inventory, STAI) a socialnich faktorů krize středniho věku (Skala faktorů krize středniho věku, SKSV).Výsledky: Analýza ukazala, že pacienti po SZ vykazuji nižsi kognitivni výkonnost (p = 0,016) a vyssi miru symptomů aktualni uzkosti (p = 0,023). V urovni depresivnich symptomů (p = 0,435) a v dlouhodobe uzkostnosti (p = 0,542) se pacienti po SZ nelisili od kontrolniho souboru. Ex-post facto analýza založena na logisticke regresi poukazuje na to, že nejsilnějsim psychologickým prediktorem SZ je pohlavi (OR = 4,45) a mira aktualně proživane uzkosti (OR = 0,50). Analýza diskriminacni funkce ukazuje, že predikce vzniku SZ je zavisla na věku, kognitivni výkonnosti a na miře aktualni uzkosti (λ = 0,81, p = 0,028).Zavěr: Výsledky studie ukazuji, že SZ ma významný vliv na rozvoj nežadoucich kognitivnich a neuropsychiatrických projevů. Zařazeni psychosocialni pece a neuropsychiatricke lecby do komplexni pece o pacienty po SZ je žadouci.