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Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61–80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1–8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years. [ABSTRACT FROM AUTHOR]

Adults with congenital heart disease represent a rapidly expanding patient population. Managing this patient population in the intensive care unit presents challenges that surpass the usual complexities. Congenitally corrected transposition of the great arteries is a rare congenital heart defect characterized by the transposition of the heart's great arteries and the inverse positioning of the ventricles. Management typically involves multiple heart surgeries that could lead to a myriad of complications, such as central veins occlusions. The patient is a 31-year-old male with a background of congenitally corrected transposition of the great arteries (ccTGA), ventricular spetal defect (VSD), and aortic coartation, who has undergone multiple cardiac interventions since the neonatal period. His clinical course over the years has been marked by progressive cardiac dysfunction, pacemaker dependence, and venous thromboses. The latest presentation included severe pulmonary edema with desaturation and epistaxis, leading to intensive care admission. The patient's condition deteriorated, necessitating intubation, inotropic support, diuretic therapy, and empirical antibiotic treatment. Despite initial interventions, his renal function declined severely. Due to the patient's extensive chronic venous thrombosis, demonstrated by multiple previous and actual CT angiogram, peritoneal dialysis was initially attempted as the first-line choice. However, it proved to be inadequate due to insufficient ultrafiltration and solute clearance. A Doppler ultrasound performed by a vascular specialist revealed patent femoral and superficial femoral veins with bilateral adequate blood flow. Following the vascular assessment, a 16 cm, 12.5 Fr(MAHURKAR™ Elite Acute Triple Lumen Catheter Kit) for Continuous Renal Replacement Therapy (CRRT) was placed under echoguidance. The catheter was carefully inserted within the left superficial femoral vein, with the puncture site 7 centimeters caudal to the inguinal ligament. This permitted the successful initiation and maintenance of a normal flow CRRT until the clinical parameters were normalized and there was a restoration of the patient's renal function. The patient was discharged from the ICU in overall good condition after 25 days, following successful CRRT and tracheostomy. The management of this 31-year-old patient with ccTGA posed significant challenges due to systemic right ventricular failure compounded by renal impairment and limited central vascular access. The decision to use the superficial femoral vein for CRRT was driven by the extensive venous thrombosis precluding conventional access points. Echoguidance and CT angiogram played a pivotal role in the precise placement of the catheter, showcasing the importance of imaging in facilitating complex vascular access. This intervention underscores the necessity of alternative approaches in the face of anatomical and pathological barriers and highlights the interdisciplinary collaboration required for managing complex vascular accesses. This case demonstrates that cannulation of the superficial femoral vein for the purpose of performing Continuous Renal Replacement Therapy (CRRT) can represent a valid alternative despite the presence of a downstream occlusion in the omolateral iliac vein. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The impact of minimally invasive extracorporeal circulation (MiECC) systems on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. This study compared in-hospital and 1 year outcomes of MI-AVR interventions using MiECC systems versus conventional extracorporeal circulation (c-ECC). METHODS Data from 288 consecutive patients undergoing primary isolated MI-AVR using MiECC (n  = 102) or c-ECC (n  = 186) were prospectively collected. Treatment selection bias was addressed by the use of propensity score matching (MiECC vs c-ECC). After propensity score matching, 2 groups of 93 patients each were created. RESULTS Compared with c-ECC, MiECC was associated with a higher rate of autologous priming (82.4% vs 0%; P  < 0.001) and a greater nadir haemoglobin (9.3 vs 8.7 g/dl; P  = 0.021) level and haematocrit (27.9% vs 26.4%; P  = 0.023). Patients who had MiECC were more likely to receive ultra-fast-track management (60.8% vs 26.9%; P  < 0.001) and less likely to receive blood transfusions (32.7% vs 44%; P  = 0.04). The in-hospital mortality rate was 1.1% in the MiECC group and 0% in the c-ECC group (P  = 0.5). Those in the MiECC group had reduced rates of bleeding requiring revision (0% vs 5.3%; P  = 0.031) and postoperative atrial fibrillation (AF) (30.1% vs 44.1%; P  = 0.034). The 1-year survival rate was 96.8% and 97.5% for MiECC and c-ECC patients, respectively (P  = 0.4). CONCLUSIONS MiECC systems were a safe and effective tool in patients who had MI-AVR. Compared with c-ECC, MiECC promotes ultra-fast-track management and provides better clinical outcomes as regards bleeding, blood transfusions and postoperative AF. Thus, by reducing surgical injury and promoting faster recovery, MiECC may further validate MI-AVR interventions. [ABSTRACT FROM AUTHOR]

CHRISTOPHER MUNCH TALKS WITH LODGE KERRIGAN Lodge Kerrigan's two feature films, Clean, Shaven (1993) and Claire Dolan (1998), are harrowing works because they deal with harrowing lives. The subjects of [...]