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Growth Differentiation Factor 15 (GDF15) is an emerging biomarker that significantly increases during acute stress responses, such as infections, and is moderately elevated in chronic and inflammation-driven conditions. While evidence suggests that high levels of GDF15 in cardiac surgery are associated with worse outcomes, its utility as an evaluator of early postoperative complications remains unclear. This study aims to characterize the postoperative profile of GDF15 in patients undergoing isolated surgical aortic valve replacement, evaluating its association with short-term outcomes. Serum samples from patients undergoing cardiac surgery were collected preoperatively and at defined postoperative time points (1 h, 6 h, 12 h, 24 h, and 48 h) to measure GDF15 levels. GDF15 levels significantly increased after surgery, peaking at 6 h. A positive correlation was observed between GDF15 levels and both cardiopulmonary bypass and aortic cross-clamp times. Notably, patients who developed postoperative acute kidney injury (AKI) or required prolonged hemodynamic support had significantly higher GDF15 levels, with increased mechanical ventilation time and extended intensive care unit length of stay. Furthermore, GDF15 levels correlated with postoperative SOFA scores at 24 h after surgery. GDF15 may be a valuable biomarker for risk stratification and guiding therapeutic decisions in cardiac surgery patients. Higher GDF15 levels were significantly associated with prolonged hemodynamic support, postoperative AKI, and measures of illness severity. [ABSTRACT FROM AUTHOR]

Introduction: Cardiogenic shock (CS) is a complex life-threatening condition that results from primary cardiac dysfunction, leading to persistent hypotension and systemic hypoperfusion. Among the therapeutic options for CS are various percutaneous mechanical circulatory support (MCS) devices that have emerged as an increasingly effective hemodynamic support option. Percutaneous therapies can act as short-term mechanical circulatory assistance and can be split into intra-aortic balloon pump (IABP) and non-IABP percutaneous mechanical devices. Areas covered: This review will evaluate the MCS value while considering the mortality rate improvements. We also aim to outline the function of pharmacotherapies and percutaneous hemodynamic MCS devices in managing CS patients to avoid the onset of end-organ dysfunction and improve both early and late outcomes. Expert opinion: Given the complexity, acuity and high mortality associated with CS, and despite the availability and efficacy of pharmacological management, MCS is required to achieve hemodynamic stability and improve survival. Various percutaneous MCS devices are available with varying indications and clinical outcomes. The rates of early mortality and complications were found to be comparable between the four devices, yet, IABP seemed to show the most optimal clinical profile whilst ECMO demonstrated its more long-term efficacy. [ABSTRACT FROM AUTHOR]

Objective. To determine the influence of the urgency of performing surgical decompression of the spinal cord (SC) on the course of acute and early periods of complicated injury of the lower cervical spine. Material and Methods. The results of treatment of 75 patients with acute complicated injury of the lower cervical spine with ASIA A and ASIA B severity of spinal cord injuries were retrospectively analyzed. Two groups were formed, depending on the timing of surgical decompression of the spinal cord after injury. Group I included 33 patients in whom the SC decompression was performed within the first eight hours after the injury, and Group II included 42 patients in whom the SC decompression was performed in more than eight hours after the injury. Results. The mean age of patients in Group I was 29 [25; 39] years, in Group II – 35 [30; 42] years (p = 0.129). There were 31 (94.0 %) male patients in Group I and 38 (90.5 %; p > 0.999) in Group II. The time from the moment of injury to decompression of the spinal cord was 6.1 [5.0; 7.5] hours in Group I and 16.9 [11.8; 39.6] hours in Group II (p < 0.001). Pneumonia developed in 55 % [38 %; 70 %] of patients in Group I and in 86 % [72 %; 93 %] of patients in Group II (p = 0.004). The duration of pneumonia in Group I was 18 [8; 20] days, and in Group II – 28 [20; 39] days (p < 0.001). It was shown that the risk ratio for developing pneumonia in patients with delayed decompression of the spinal cord was 2.08 [1.17; 3.67] times higher (p = 0.01). The duration of mechanical ventilation in Group I was 12 [7; 17] days versus 19 [11; 26] days in Group II (p = 0.001). Maintaining the target blood pressure levels ≥ 85 mm Hg was required in 73 (97.3 %) patients with a duration of hemodynamic support of 6 [3; 10] days in Group I versus 10 [5; 15] days in Group II (p = 0.019). It was shown that SC decompression within the first eight hours after injury reduced the proportion of patients with a SOFA score of 4 points or more by 20 % in the acute period and by 42 % by the fifth day of the early period of injury. Positive dynamic in neurological status was recorded in 30.0 % [17.0 %; 47.0 %] of patients in Group I and only in 2.0 % [0.0 %; 12.0 %] of patients in Group II (p < 0.001). The duration of treatment in the ICU was 20 [16; 25] days in Group I and 29 [23.5; 41.75] days in Group II (p = 0.001). The total length of hospital stay was 38 [27; 46] days in Group I versus 57 [45.75; 67.50] days in Group II (p < 0.001). Mortality was recorded only in Group II and amounted to 5.3 %. Conclusion. Decompression and stabilization surgery within the first eight hours after the injury, together with a complex of intensive care measures for acute complicated injury of the lower cervical spine have a significant positive effect on the course of the acute and early periods of traumatic SC disease.

Growth Differentiation Factor 15 (GDF15) is an emerging biomarker that significantly increases during acute stress responses, such as infections, and is moderately elevated in chronic and inflammation-driven conditions. While evidence suggests that high levels of GDF15 in cardiac surgery are associated with worse outcomes, its utility as an evaluator of early postoperative complications remains unclear. This study aims to characterize the postoperative profile of GDF15 in patients undergoing isolated surgical aortic valve replacement, evaluating its association with short-term outcomes. Serum samples from patients undergoing cardiac surgery were collected preoperatively and at defined postoperative time points (1 h, 6 h, 12 h, 24 h, and 48 h) to measure GDF15 levels. GDF15 levels significantly increased after surgery, peaking at 6 h. A positive correlation was observed between GDF15 levels and both cardiopulmonary bypass and aortic cross-clamp times. Notably, patients who developed postoperative acute kidney injury (AKI) or required prolonged hemodynamic support had significantly higher GDF15 levels, with increased mechanical ventilation time and extended intensive care unit length of stay. Furthermore, GDF15 levels correlated with postoperative SOFA scores at 24 h after surgery. GDF15 may be a valuable biomarker for risk stratification and guiding therapeutic decisions in cardiac surgery patients. Higher GDF15 levels were significantly associated with prolonged hemodynamic support, postoperative AKI, and measures of illness severity.

Advances in percutaneous coronary intervention (PCI) devices and techniques have expanded the pool of eligible patients for revascularization, including those with comorbidities, reduced left ventricular function, or anatomical complexity (defined as CHIP: complex and high-risk interventions in indicated patients). CHIP interventions are typically performed by selected operators who specialize in complex PCI. This review presents two cases performed in the USA, to discuss the similarities and differences in practice patterns between CHIP operators in Japan and the USA. The first case involves a 58-year-old male presenting with myocardial infarction and cardiogenic shock, and the second case involves a 51-year-old female with a history of coronary artery bypass grafting presenting with a chronic total occlusion and PCI complicated by vessel perforation. The discussion focuses on appropriate patient selection, the role of the heart team approach for decision-making, the use of hemodynamic support devices, and other relevant factors. By comparing practices in Japan and the USA, this review highlights opportunities for knowledge exchange and potential areas for improving patient outcomes. [Display omitted] • Prompt revascularization, early recognition and management is critical in acute myocardial infarction and shock. • Mechanical circulatory support selection is based on clinical status, patient-related factors, and local expertise. • Approach to chronic total occlusion (CTO) crossing is different between operators in Japan and the USA. • The algorithms for CTO interventions are evolving as more comparative data become available. [ABSTRACT FROM AUTHOR]

The utilization of extracorporeal membrane oxygenation (ECMO) in complex thoracic surgery has become more frequent in recent years due to advances in technology, increased availability, and improved outcomes. ECMO has emerged as a vital tool to facilitate thoracic surgery for patients who would have otherwise been deemed unsuitable candidates. It has redefined the boundaries of surgical possibility where conventional methods fall short. ECMO is typically employed in specific thoracic surgery where conventional ventilation is either inadequate or it interferes with the surgical field, and in procedures demanding both ventilatory and hemodynamic support. [ABSTRACT FROM AUTHOR]

This article discusses the hemodynamics and urinary excretion of kidney injury biomarkers in pediatric kidney transplantation. The study aimed to investigate the relationship between perioperative hemodynamic values and the excretion of acute kidney injury biomarkers in pediatric kidney transplantation with a large donor-acceptor size mismatch. The results suggest that an increased cardiac output (CO) is required to limit postreperfusion donor kidney injury, but excessive therapy to reach a supraphysiological CO, such as high central venous pressure (CVP) and vasopressor infusion rates, may be associated with early donor kidney injury. Further research is needed to determine the clinical consequences of hemodynamic therapy and the most sensitive biomarkers for detecting early donor kidney injury in pediatric kidney transplantation. [Extracted from the article]

Congenital diaphragmatic hernia (CDH) is a structural birth defect that with varying degrees of severity that results in significant neonatal morbidity and mortality. CDH occurs in 1:2,500 live births, and despite the advances in prenatal diagnosis and neonatal intensive care, the mortality and morbidity rate in infants with CDH is significant. In this article, we tried to summarize the main modalities of diagnosis, prognosis and medical treatment in CDH cases, found in specialty literature.

Objective: To study the correlation of objective parameters for diagnosing shock viz., perfusion index (PI), plethysmography variability index (PVI) and serum lactate (SL) with invasive blood pressure in late preterm and term infants with shock. Methods: Prospective observational study (diagnostic test) conducted at the neonatal intensive care unit of Kanchi Kamakoti CHILDS Trust Hospital, Chennai between June, 2018 and May, 2020. Term and late preterm neonates with shock were included in the study. PI, PVI, SL, SpO2 and heart rate were monitored. PI, PVI and SLL were recorded at 0,12, 24 and 72 hours of onset of shock. All the babies were followed up till discharge or death. Results: Total 78 neonates were enrolled in the study. At 0 hour, SL and PVI had negative correlation (P =0.002 and P=0.003) while PI had a weak-to-moderate positive correlation (P=0.002) with invasive blood pressure. SL ≥4.65 had a sensitivity of 75% and specificity of 75.8%, and PI <0.455 had a sensitivity of 65%, and specificity of 58.6% for predicting invasive hypotension. PVI ≥23.5 had a sensitivity of 90% and specificity of 63.8% in predicting invasive hypotension. Conclusion: PI has moderate positive correlation while SL and PVI have moderate negative correlation with invasive blood pressure. The cutoff values of SL ≥4.65, PI <0.45 and PVI ≥23.5 can predict invasive hypotension with good sensitivity and negative predictive value. [ABSTRACT FROM AUTHOR]

Purpose of Review: Cardiogenic shock (CS) is a complex clinical entity that continues to carry a high risk of mortality. The landscape of CS management has changed with the advent of several temporary mechanical circulatory support (MCS) devices designed to provide hemodynamic support. It remains challenging to understand the role of different temporary MCS devices in patients with CS, as many of these patients are critically ill, requiring complex care with multiple MCS device options. Each temporary MCS device can provide different types and levels of hemodynamic support. It is important to understand the risk/benefit profile of each one of them for appropriate device selection in patients with CS. Recent Findings: MCS may be beneficial in CS patients through augmentation of cardiac output with subsequent improvement of systemic perfusion. Selecting the optimal MCS device depends on several variables including the underlying etiology of CS, clinical strategy of MCS use (bridge to recovery, bridge to transplant or durable MCS, or abridge to decision), amount of hemodynamic support needed, associated respiratory failure, and institutional preference. Furthermore, it is even more challenging to determine the appropriate time to escalate from one MCS device to another or combine different MCS devices. Summary: In this review, we discuss the current available data published in the literature on the management of CS and propose a standardized approach for escalation of MCS devices in patients with CS. Shock teams can play an important role to help in hemodynamic-guided management and algorithm-based step-by-step approach in early initiation and escalation of temporary MCS devices at different stages of CS. It is important to define the etiology of CS, and stage of shock and recognize univentricular vs biventricular shock for appropriate device selection and escalation of therapy. [ABSTRACT FROM AUTHOR]

The unprimed right ventricle is exquisitely sensitive to acute elevations in afterload. High pulmonary vascular tone incurred with acute pulmonary embolism has the potential to induce obstructive shock and circulatory collapse. While emergent pulmonary reperfusion is essential in severe circumstances, an important subset of pulmonary embolism patients may exhibit a less extreme presentation posing a management dilemma. As intensive care therapies have the potential to both salvage and harm the failing right ventricle, a keen understanding of the pathophysiology is requisite in the care of the contemporary patient with hemodynamically significant pulmonary embolism. Here, we review right ventricular pathophysiology, an approach to risk stratification, and offer guidance on the medical and mechanical supportive and therapeutic strategies for the critically ill patient with acute pulmonary embolism., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Coronary artery bypass grafting is the standard of care for patients with obstructive left main (LM) coronary disease. In poor surgical candidates, high-risk percutaneous coronary artery intervention (PCI) is an alternative. Methods: We investigated a retrospective cohort of patients who underwent LM PCI from January 2010 to March 2014 (n = 89). Obstructive LM disease was defined as 50% angiographic obstruction of luminal flow, and the primary endpoint was inhospital mortality. Ventricular assist device (VAD) was defined as the use of either intra-aortic balloon pump (IABP) or Impella 2.5 devices before, during, or following PCI. Results: A total of 89 patients with LM PCI were divided into those with (n = 39) and without (n = 50) VAD support. The former group was further divided into those with support from either Impella 2.5 (n = 28) or IABP (n = 11). Age, race, and gender did not differ between patients who received unassisted LM-PCI from those with VAD support (P = 0.142, 1.0, and 0.776, respectively). The angiographic stenosis of atherosclerotic lesions in LM, proximal left anterior descending artery, and other native/surgical coronary vessels was similar between the groups. The duration of hospitalization was significantly longer for patients with VAD support compared to those without (7.19 ± 6.89 vs. 2.78 ± 3.39, P < 0.001). The incidence of cardiogenic shock and inhospital mortality was significantly higher in the VAD group (P = 0.009 and 0.001, respectively). Overall, inhospital mortality was 9% (8/89). The IABP and Impella 2.5 groups had mortality proportions of 46% (5/11) and 11% (3/28), respectively; P = 0.028. For all patients, inhospital mortality was higher for those with versus without cardiogenic shock (56% or 5/9 vs. 4% or 3/80; P < 0.001), and for those with versus without left ventricular systolic function

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. [ABSTRACT FROM AUTHOR]

Congenital diaphragmatic hernia (CDH) is a structural birth defect that with varying degrees of severity that results in significant neonatal morbidity and mortality. CDH occurs in 1:2,500 live births, and despite the advances in prenatal diagnosis and neonatal intensive care, the mortality and morbidity rate in infants with CDH is significant. In this article, we tried to summarize the main modalities of diagnosis, prognosis and medical treatment in CDH cases, found in specialty literature. [ABSTRACT FROM AUTHOR]

Percutaneous coronary or structural heart interventions may lead to complications, such as perforation and acute vessel closure that may in turn lead to cardiac arrest or cardiogenic shock. Moreover, acute coronary syndrome patients presenting with cardiogenic shock can be challenging to treat due to hemodynamic instability. In such cases, venoarterial extracorporeal membrane oxygenation (V-A ECMO) can provide hemodynamic stabilization and oxygenation allowing successful treatment of the complication or culprit lesion in acute coronary syndrome patients. We present 3 cases illustrating successful emergent use of V-A ECMO in the cardiac catheterization laboratory in the setting of acute left main dissection during a chronic total occlusion intervention, cardiogenic shock in the setting of non-ST segment elevation myocardial infarction and multivessel coronary artery disease, and aortic annular rupture during transcatheter aortic valve replacement. [ABSTRACT FROM AUTHOR]

Background: Coronary artery bypass grafting is the standard of care for patients with obstructive left main (LM) coronary disease. In poor surgical candidates, high-risk percutaneous coronary artery intervention (PCI) is an alternative. Methods: We investigated a retrospective cohort of patients who underwent LM PCI from January 2010 to March 2014 (n = 89). Obstructive LM disease was defined as 50% angiographic obstruction of luminal flow, and the primary endpoint was inhospital mortality. Ventricular assist device (VAD) was defined as the use of either intra-aortic balloon pump (IABP) or Impella 2.5 devices before, during, or following PCI. Results: A total of 89 patients with LM PCI were divided into those with (n = 39) and without (n = 50) VAD support. The former group was further divided into those with support from either Impella 2.5 (n = 28) or IABP (n = 11). Age, race, and gender did not differ between patients who received unassisted LM-PCI from those with VAD support (P = 0.142, 1.0, and 0.776, respectively). The angiographic stenosis of atherosclerotic lesions in LM, proximal left anterior descending artery, and other native/surgical coronary vessels was similar between the groups. The duration of hospitalization was significantly longer for patients with VAD support compared to those without (7.19 ± 6.89 vs. 2.78 ± 3.39, P < 0.001). The incidence of cardiogenic shock and inhospital mortality was significantly higher in the VAD group (P = 0.009 and 0.001, respectively). Overall, inhospital mortality was 9% (8/89). The IABP and Impella 2.5 groups had mortality proportions of 46% (5/11) and 11% (3/28), respectively; P = 0.028. For all patients, inhospital mortality was higher for those with versus without cardiogenic shock (56% or 5/9 vs. 4% or 3/80; P < 0.001), and for those with versus without left ventricular systolic function <40% (17% vs. 2%;P < 0.025). Conclusion: In a selected group of patients with LM disease, unsupported PCI appears to be a feasible and safe procedure. In high-risk patients, the use of Impella 2.5 appears to be superior to IABP in LM PCI resulting in favorable short-term outcomes. [ABSTRACT FROM AUTHOR]

The adverse outcomes of a ventricular heart failure (left, right or biventricular) caused by cardiogenic shock are aggravated by lung oedema and organ mal perfusion. Despite advances in medical sciences, revascularisation and mechanical hemodynamic support have proved ineffective in reducing the mortality rate in such patients. A thorough study of the data available about cardio-vascular diseases reveals that the application of conventional methods of treatment are least helpful to practically restore normal functions of heart when it experiences end-stage systolic ventricular failure. Thus, to overcome the challenges and find alternatives to address this issue, percutaneous ventricular support devices/machines were designed and successfully introduced. These devices have revolutionized the treatment of ventricular heart failures and are now in use all over the world. In this review paper a newer mechanical circulatory support (MCS) device, Impella, has been discussed and compared with a few other devices like (Intra-aortic Balloon Pump (IABP), Extracorporeal Circulation (ECLS) and Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO). This article studies the challenges being faced during the treatment of cardiogenic shock, and thoroughly discusses the use and effectiveness of Impella Cardiac Axial Pump in each emergency. It can be said that mechanical circulatory support (MCS) device use during percutaneous coronary intervention (PCI) should be individualized based on multiple factors with a recommended use in patients with the greatest potential benefit and a relatively low risk of device-related complications. The current literature suggests that the outcomes of use of Impella and other mechanical circulatory support devices like IABP and VA-ECMO are comparable. Though there seem to be a few advantages of Impella over the others, sufficiently powered, multi-centric, randomised control trials are needed to establish its superiority. [ABSTRACT FROM AUTHOR]

Introduction: Cardiogenic shock (CS) is a life-threatening condition and mechanical circulatory support (MCS) might exert a relevant impact on its clinical course. Among MCS devices, Impella is very promising. Yet, its usefulness is still debated. We performed a meta-analysis of all studies evaluating the clinical impact of Impella in CS. Methods: All studies including patients with CS and treated with Impella were included. The primary endpoint was short-term mortality. Secondary endpoints were vascular access complications and major bleeding. Data synthesis was obtained using random-effects metanalysis. Results: Thirty-three studies and 5204 patients were included. Short-term mortality was 47%. Meta-regression analysis showed that patients age (p = 0.01), higher support level (p = 0.004) and pre-PCI insertion (p

Cardiovascular disease is a leading cause of mortality worldwide; therefore, preventing death and improving patient outcomes are a priority. Increasing numbers of patients are surviving hospital admissions after an out-of-hospital cardiac arrest (OHCA). An OHCA has a poor prognosis, and myocardial infarctions (MIs) are the most common cause; hence, the use of emergency coronary angiography and percutaneous coronary intervention (PCI) is an important tool in trying to improve survival. This narrative review explores the role of PCI in OHCA management; understanding angiography findings in OHCA patients offers critical insights into underlying coronary artery disease burden, informing the necessity for PCI. Also, looking at specific subgroups, like females, is essential for equitable intervention access and outcome optimization. Understanding the role of support devices such as Impella and extracorporeal membrane oxygenation (ECMO), which show promise in enhancing outcomes by providing hemodynamic support during PCI and improved overall survival, is linked to better neurological outcomes, highlighting the significance of timely PCI and comprehensive post-PCI care., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Kashkosh et al.)

We describe a case of successful veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-supported percutaneous coronary intervention (PCI) for multivessel coronary artery disease in a patient considered as a candidate for transcatheter aortic valve replacement (TAVR). VA-ECMO-supported PCI for patients with severe aortic valve stenosis might be a feasible option before TAVR.

Purpose: Assess if timing of removal of a percutaneous left ventricular assist device (pLVAD) after ventricular tachycardia (VT) ablation alters patient outcomes. Methods: Sixty-nine patients underwent pLVAD support. Patients were divided into early (< 24 h, n = 43) and delayed (≥ 24 h, n = 26) removal groups after ablation. Factors for delayed pLVAD removal and predictors of 90-day mortality were analyzed. Results: The delayed removal group had lower LVEF (27.1 ± 9.3% vs. 20.6 ± 5.4%, p = 0.002), greater percentage LVEF < 25% (58.1% vs. 84.6%, p = 0.02), and more VT storm (41.9% vs. 96.2%, p < 0.001). Ventricular fibrillation (VF) was induced in 9/69 (13%), with incidence higher in delayed removal group (27% vs. 5%, p = 0.002). VT storm (OR = 34.72, 95% CI, 4.30–280.33; p = 0.001), LVEF < 25% (OR = 3.95, 95% CI, 1.16–13.48; p = 0.03), and VF induced during ablation (OR = 9.25, 95% CI, 1.71–50.0; p = 0.01) were associated with delayed pLVAD removal in univariate analysis. Delayed pLVAD removal had a significantly higher 90-day mortality rate (2.3% vs 30.2%; p < 0.001). Univariate Cox proportional hazard regression analysis revealed delayed pLVAD removal was a significant predictor of 90-day mortality. Conclusions: Prolonged pLVAD insertion (≥ 24 h) after VT ablation was associated with VT storm, LVEF < 25%, and VF induced during ablation. Delayed pLVAD removal was a significant predictor of 90-day mortality in patients undergoing VT ablation. [ABSTRACT FROM AUTHOR]

Abstract 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.

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.

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An 80-year-old man was referred for multi-vessel coronary artery disease with baseline SYNTAX score of 45 after evaluation for persistent stable angina. He underwent complete hybrid revascularization combining total endoscopic coronary artery bypass utilizing bilateral internal mammary arteries (IMA) with sequential LIMA to left anterior descending artery and diagonal arteries, and RIMA to obtuse marginal after Impella-assisted chronic total occlusion percutaneous coronary intervention of the right coronary artery. This represents a successful case of advanced hybrid coronary revascularization. [ABSTRACT FROM AUTHOR]

Background: There is a lack of compelling data regarding the benefit of percutaneous ventricular assist devices (PVAD) in patients undergoing ventricular tachycardia (VT) ablation. The study aims to conduct a meta-analysis comparing the safety and efficacy of PVAD versus no-PVAD (N-PVAD) during VT ablation.Methods: Studies meeting criteria were systematically reviewed. Baseline characteristics and clinical outcomes were extracted and analyzed. A meta-analysis was performed using random-effects model to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI).Results: The meta-analysis included five retrospective, observational studies consisting of 2026 patients (PVAD group-284 patients versus N-PVAD group-1742 patients). The PVAD group was sicker with significantly higher VT storm, lower LVEF and greater proportion of NYHA class ≥ III than N-PVAD (p < 0.050). The acute procedural success [RR 0.95, 95% CI, (0.89-1.00), p = 0.070], VT recurrence [RR 0.94, 95% CI, (0.66-1.34), p = 0.740] and mortality [RR 1.28, 95% CI, (0.43-3.83), p = 0.660] were similar on follow-up between PVAD versus N-PVAD. PVAD group also had significantly higher complications [RR 1.83, 95% CI (1.21-2.76), p = 0.004] and longer fluoroscopy [MD + 7.31 min, 95% CI (0.91-13.71), p = 0.030] and procedure time [MD + 71.41 min, 95% CI (31.67-111.14), p < 0.001] than N-PVAD.Conclusion: Patients receiving PVAD support during VT ablation were sicker with no significant difference in acute procedural success, VT recurrence, and mortality compared with N-PVAD. PVAD support was also associated with higher complications and longer fluoroscopy and procedure time. A prospective randomized controlled trial will identify if using PVAD support in unstable patients undergoing VT ablation will impact clinical outcomes. [ABSTRACT FROM AUTHOR]

Anti-toxin agents for severe B. anthracis infection will only be effective if they add to the benefit of the two mainstays of septic shock management, antibiotic therapy and titrated hemodynamic support. Both of these standard therapies could negate benefits related to anti-toxin treatment. At present, three anthrax anti-toxin antibody preparations have received US Food and Drug Administration (FDA) approval: Raxibacumab, Anthrax Immune Globulin Intravenous (AIGIV) and ETI-204. Each agent is directed at the protective antigen component of lethal and edema toxin. All three agents were compared to placebo in antibiotic-treated animal models of live B. anthracis infection, and Raxibacumab and AIGIV were compared to placebo when combined with standard hemodynamic support in a 96 h canine model of anthrax toxin-associated shock. However, only AIG has actually been administered to a group of infected patients, and this experience was not controlled and offers little insight into the efficacy of the agents. To provide a broader view of the potential effectiveness of these agents, this review examines the controlled preclinical experience either in antibiotic-treated B. anthracis models or in titrated hemodynamic-supported toxin-challenged canines. The strength and weaknesses of these preclinical experiences are discussed.

Objective Patients with infective endocarditis undergoing cardiac surgery are a high-risk population. Few data on incidence and predictors of need for high-dose inotropic support in this setting are currently available. Design Retrospective study. Setting Tertiary-care hospital. Participants Ninety consecutive patients undergoing cardiac surgery for infective endocarditis. Interventions None. Measurements and Main Results Baseline, intraoperative and outcome data were collected. Stepwise multiple logistic regression analysis was performed to identify preoperative predictors of postoperative hemodynamic support. High-dose postoperative inotropic support was defined as inotropic score >10 (calculated as dobutamine dose (in µg/kg/min) + dopamine dose (in µg/kg/min) + (epinephrine dose [in µg/kg/min] × 100) + (norepinephrine dose [in µg/kg/min] × 100) + (milrinone dose [in µg/kg/min] × 10) + (vasopressin dose [in U/kg/min] × 10 000) + (levosimendan dose [in µg/kg/min] × 50) or need for mechanical circulatory support at intensive care unit admission. Postoperative high-dose inotropic or mechanical circulatory support was required in 57 cases (61%). Stepwise multiple logistic regression identified 5 variables independently associated with need for postoperative circulatory support: male sex (odds ratio [OR] = 10.9), surgery duration (OR for every minute increase = 1.01), impairment of kidney function (eGFR <60 mL/min/m2 – OR = 19), preoperative new-onset heart failure (defined by clinical, imaging and laboratory parameters – OR = 5.30), and low preoperative platelet count (for every 1×103/μl increase – OR = 0.99). Conclusions Patients undergoing cardiac surgery for infective endocarditis are at high risk for postoperative hemodynamic instability. Preoperative organ failure is an important determinant for postoperative hemodynamic instability. [ABSTRACT FROM AUTHOR]

Objective Acute kidney injury (AKI) occurs frequently after cardiac surgery. Levosimendan might reduce the incidence of AKI in patients undergoing cardiac surgery. The authors investigated whether levosimendan administration could reduce AKI incidence in a high-risk cardiac surgical population. Design Post hoc analysis of a multicenter randomized trial. Setting Cardiac surgery operating rooms and intensive care units of 14 centers in 3 countries. Participants: The study comprised 90 patients who underwent mitral valve surgery with an estimated glomerular filtration rate <60 mL/min/1.73 m2 and perioperative myocardial dysfunction. Interventions Patients were assigned randomly to receive levosimendan (0.025-0.2 μg/kg/min) or placebo in addition to standard inotropic treatment. Measurements and Main Results Forty-six patients were assigned to receive levosimendan and 44 to receive placebo. Postoperative AKI occurred in 14 (30%) patients in the levosimendan group versus 23 (52%) in the placebo group (absolute difference –21.8; 95% confidence interval –41.7 to –1.97; p = 0.035). The incidence of major complications also was lower (18 [39%]) in the levosimendan group versus that in the placebo group (29 [66%]) (absolute difference –26.8 [–46.7 to –6.90]; p = 0.011). A trend toward lower serum creatinine at intensive care unit discharge was observed in the levosimendan group (1.18 [0.99-1.49] mg/dL) versus that in the placebo group (1.39 [1.05-1.76] mg/dL) (95% confidence interval –0.23 [–0.49 to 0.01]; p = 0.07). Conclusions Levosimendan may improve renal outcome in cardiac surgery patients with chronic kidney disease undergoing mitral valve surgery who develop perioperative myocardial dysfunction. Results of this exploratory analysis should be investigated in future properly designed randomized controlled trials. [ABSTRACT FROM AUTHOR]

The intra-aortic balloon pump (IABP) is frequently used to support severely compromised ventricles in critically ill patients. Its relatively affordability and ease of insertion has cemented its position as the first line of treatment for hemodynamic support in cardiogenic shock. Accordingly, the current ACC/AHA recommendations maintain a Class 2A for the use of IABP in shock. However, a review of the current literature suggests that the evidence supporting the American College of Cardiology and American Heart Association (ACC/AHA) guidelines are equivocal. Alternative uses for IABP such as perioperative support during high-risk cardiac surgery, treatment of left ventricular distention on extracorporeal membrane oxygenation, and as bridge to transplant have been proposed. The effectiveness of the IABP in these clinical situations remains largely unproven, due to the paucity of available data. [ABSTRACT FROM AUTHOR]

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Survivors of out-of-hospital cardiac arrest (OHCA) experience significant mortality rates and neurological impairment, potentially attributed to the hypoxic-ischemic injury sustained amid the cardiac arrest episode. Post-resuscitation care plays a crucial role in determining outcomes for survivors of OHCA. Supportive therapies have proven to be influential in shaping these outcomes. However, targeting higher blood pressure or oxygen levels during the post-resuscitative phase has not been shown to offer any mortality or neurological benefits. In terms of maintaining hemodynamic instability after resuscitation, it is recommended to use norepinephrine rather than epinephrine. While extracorporeal cardiopulmonary resuscitation has shown promising results, targeted temperature management has been found ineffective in improving outcomes despite its previous potential. This review also investigates various challenges and barriers associated with the practical implementation of these supportive therapies in clinical settings. The review also highlights areas ripe for future research and proposes potential directions to further enhance post-resuscitation supportive care for OHCA survivors., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Jagarlamudi et al.)

Antecedentes: los pacientes sometidos a cirugía cardiovascular representan un desafío de manejo en la unidad de cuidados intensivos debido principalmente al estrés hemodinámico que se deriva de la cirugía y a las comorbilidades que se presentan con frecuencia. Una alteración común en el cuidado pos-quirúrgico es la disfunción ventricular izquierda con el consiguiente requerimiento de soporte hemodinámico. Por tradición, se han establecido factores de riesgo para el requerimiento de agentes vasoactivos, pero no hay estudios de asociación entre hemoglobina baja en el pos-operatorio inmediato como marcador independiente para la necesidad de soporte hemodinámico. Objetivo: determinar si la anemia pos-operatoria inmediata en cirugía cardiovascular aumenta el uso tanto de vasopresores como de inotrópicos durante la estancia en la unidad de cuidados intensivos. Metodología: estudio observacional, descriptivo y retrospectivo, en el que se incluyeron 206 pacientes que fueron sometidos a cirugía cardiovascular, desde enero de 2008 hasta julio de 2009. Resultados: la mayoría de los pacientes (82%) no tuvo anemia pos-operatoria (Hb > 9 g/dL); entre éstos 37,9% requirió vasopresores y 20,6% uso de inotrópicos (incluyendo balón de contra-pulsación). Por otro lado, entre los pacientes con anemia pos-operatoria, 62% requirieron vasopresores y 41,6% inotrópicos durante su estancia en la unidad de cuidados intensivos. Conclusiones: la anemia en el pos-operatorio inmediato de cirugía cardiovascular es un adecuado predictor de la necesidad de vasopresores e inotrópicos durante la estancia en la unidad de cuidados intensivos.Background: patients undergoing cardiovascular surgery represent a management challenge in the intensive care unit, mainly due to the hemodynamic stress that results from surgery and to the co-morbidities frequently presented. A common disorder in the postoperative care is the left ventricular dysfunction with the consequent requirement of hemodynamic support. Traditionally, risk factors for the requirement of vasoactive agents have been established, but there are no studies for the association between low hemoglobin in the immediate postoperative period as independent marker, and the need of hemodynamic support. Objective: determine if the immediate postoperative anemia in cardiovascular surgery increases the use of both vasopressors and inotropes during the stay in the intensive care unit. Methodology: observational descriptive and retrospective study, in which 206 patients who underwent cardiovascular surgery from January 2008 to July 2009, were included. Results: most patients (82%) had no postoperative anemia (Hb > 9 g/dL); among these, 37,9% required vasopressors and 20,6 required inotropes (including balloon counter-pulsation). On the other hand, 62% of patients with postoperative anemia required vasopressors and 41% required inotropes during their stay in the intensive care unit. Conclusions: anemia during the immediate postoperative period of cardiovascular surgery is an adequate predictor of the need for vasopressors and inotropes during the stay in the intensive care unit.

JUSTIFICATIVA E OBJETIVOS: O choque ocorre quando o sistema circulatório não consegue manter a perfusão celular adequada. Caso ele não seja revertido a lesão celular irreversível instala-se. A terapia do choque tem como prioridade inicial à rápida recuperação da pressão arterial média e do debito cardíaco, e vigorosa para manter a vida e evitar ou diminuir as disfunções orgânicas. A reposição de fluídos, freqüentemente associada a fármacos vasoativas, é necessária para garantir adequada perfusão tecidual e a manutenção da função dos diferentes órgãos e sistemas, sempre guiados por monitorização cardiovascular. As recomendações listadas visam orientar o suporte hemodinâmico necessário para manter uma adequada perfusão celular. MÉTODO: O processo de desenvolvimento de recomendações utilizou o método Delphi modificado para criar e quantificar o consenso entre os participantes. A AMIB determinou um coordenador para o Consenso, o qual escolheu seis especialistas para comporem o Comitê Consultivo. Outros 18 peritos de diferentes regiões do país foram selecionados para completar o painel de 25 especialistas, médicos e enfermeiros. Um levantamento bibliográfico na MedLine de artigos na língua inglesa foi realizado no período de 1966 a 2004. RESULTADOS: Foram apresentadas recomendações referentes a 17 questões sobre suporte hemodinâmico, com ênfase em reposição volêmica, transfusão de concentrados de hemácias, fármacos vasoativos e terapia de otimização hemodinâmica. CONCLUSÕES: A monitorização hemodinâmica per se não é capaz de reduzir a mortalidade de pacientes graves. Os possíveis benefícios serão conseqüência da correta interpretação dos dados obtidos e do uso de protocolos de tratamento que permitam obtenção de metas hemodinâmicas adequadas.BACKGROUND AND OBJECTIVES: Shock occurs when the circulatory system cannot maintain adequate cellular perfusion. If this condition is not reverted irreversible cellular injury establishes. Shock treatment has as its initial priority the fast and vigorous correction of mean arterial pressure and cardiac output to maintain life and avoid or lessen organic dysfunctions. Fluid challenge and vasoactive drugs are necessary to warrant an adequate tissue perfusion and maintenance of function of different organs and systems, always guided by cardiovascular monitorization. The recommendations built in this consensus are aimed to guide hemodynamic support needed to maintain adequate tisular perfusion. METHODS: Modified Delphi methodology was used to create and quantify the consensus between the participants. AMIB indicated a coordinator who invited more six experts in the area of monitoring and hemodynamic support to constitute the Consensus Advisory Board. Twenty five physician and two nurses selected from different regions of the country completed the expert panel, which reviewed the pertinent bibliography listed at the MEDLINE in the period from 1996 to 2004. RESULTS: Recommendations were made answering 17 questions about hemodynamic support with focus on fluid challenge, red blood cell transfusions, vasoactive drugs and perioperative hemodynamic optimization. CONCLUSIONS: Hemodynamic monitoring by itself does not reduce the mortality of critically ill patients, however, we believe that the correct interpretation of the data obtained by the hemodynamic monitoring and the use of hemodynamic support protocols based on well defined tissue perfusion goals can improve the outcome of these patients.

Although the incidence of left main (LM) coronary artery disease is relatively low in patients undergoing routine angiography, it is a common presentation in patients with acute coronary syndromes. With the current interventional tools and techniques, percutaneous intervention for LM disease has become a viable alternative to the traditional coronary artery bypass grafting. Factors that contribute to the success and appropriateness of percutaneous intervention for LM disease include coronary anatomy and patient-specific factors such as left ventricular function. Multiple considerations should be taken into account prior to intervention, including hemodynamic support if necessary, intravascular imaging to guide therapy, and stent technique. This review provides an overview of the current body of literature to support the use of percutaneous intervention in LM disease and serves as guideline for the interventionalist approaching LM revascularization. [ABSTRACT FROM AUTHOR]

The objective of this review was to depict the physiological and clinical rationale for the use of vasopressin in hemodynamic support of organ donors. After summarizing the physiological, pharmacological concepts and preclinical findings, regarding vasopressin's pathophysiological impacts, we will present the available clinical data., Data Sources: Detailed search strategies in PubMed, OVID Medline, and EMBASE were undertaken using Medical Subject Headings and Key Words., Study Selection: Physiological articles regarding brain death, and preclinical animal and human studies about the use of vasopressin or analogs, as an intervention in organ support for donation, were considered., Data Extraction: Two authors independently screened titles, abstracts, and full text of articles to determine eligibility. Data encompassing models, population, methodology, outcomes, and relevant concepts were extracted., Data Synthesis: Following brain death, profound reduction in sympathetic outflow is associated with reduced cardiac output, vascular tone, and hemodynamic instability in donors. In addition to reducing catecholamine needs and reversing diabetes insipidus, vasopressin has been shown to limit pulmonary injury and decrease systemic inflammatory response in animals. Several observational studies show the benefit of vasopressin on hemodynamic parameters and catecholamine sparing in donors. Small trials suggest that vasopressin increase organ procurement and have some survival benefit for recipients. However, the risk of bias is overall concerning, and therefore the quality of the evidence is deemed low., Conclusions: Despite potential impact on graft outcome and a protective effect through catecholamine support sparing, the benefit of vasopressin use in organ donors is based on low evidence. Well-designed observational and randomized controlled trials are warranted., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)