bluuebunny/crossref_metadata_2025 huggingface dataset:
Levosimendan in patients undergoing cardiac surgery: does timing matter?
Authors: Carvalho P , Goncalves F , Pinto C , Moreira I
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Levosimendan (LEV) is an inotropic drug that improves myocardial contractility without increasing oxygen requirement and its use in cardiac surgery has been questioned. Early meta-analysis showed that it was associated with reduced mortality, however recent randomized trials failed to show a benefit of this drug in some specific subsets of patients.

Purpose

This study sought to evaluate if the timing of the initiation of LEV infusion could have impact in short-term prognosis.

Methods

This was an unicenter retrospective study of patients submitted to a cardiac surgery between December 2009 and December 2018 and who did LEV during hospitalization. Three groups were established upon the beginning of LEV administration: preoperative, intraoperative and postoperative. Statistical comparisons between groups are presented below in this order.

Results

Out of 141 patients, 40,4% belonged to the preoperative group, 31,2% to the intraoperative group and 28,4% to the postoperative group. Demographic data was balanced between the three groups with the exception of past history of peripheral artery disease (3,6% vs 15,9% vs 2,5%, p=0,024) and previous cardiac surgery (19,3% vs 4,5% vs 2,5%, p=0,009). The type of cardiac surgery, whether with or without cardiopulmonary bypass, was similar in all groups. Left ventricular ejection fraction was not significantly different (36,9±12,3% vs 41,2±12,5% vs 42,2±12,2%, p=0,080) and the same happened with the proportion of patients with right ventricle dysfunction (12,3% vs 9,1% vs 10%, p=0,865). Moreover, total dose of LEV and its infusion duration were not different (p=0,117 and p=0,242, respectively).

Compared to the postoperative group, preoperative and intraoperative initiation was not independently associated with a significantly lower risk of in-hospital cardiogenic shock requiring inotropic drugs (adjusted OR 0,84 (95% CI 0,23-3,06) and 1,04 (95% CI 0,30-3,60), respectively) or mechanical circulatory support (adjusted OR 1,29 (95% CI 0,18-9,34) and 0,57 (95% CI 0,06-5,64)), myocardial infarction (adjusted OR 1,25 (95% CI 0,16-9,87) and 1,46 (95% CI 0,20-10,51)) and death (adjusted OR 1,85 (95% CI 0,28-12,18) and 4,41 (95% CI 0,81-24,00)). However, preoperative LEV was associated with less acute kidney injury (adjusted OR 0,36 (95% CI 0,14-0,93)) compared to postoperative initiation. Still, the need for renal replacement therapy didn’t differ significantly between all groups. Overall, subgroup analysis showed identical results independently of biventricular systolic function, type of surgery and need of cardiopulmonary bypass.

Conclusions

In this heterogeneous population submitted to a cardiac surgery, timing of LEV initiation did not have a significant impact on short-term in-hospital major adverse outcomes, independently of biventricular systolic function and type of surgery.
Impella CP implantation during cardiopulmonary resuscitation for cardiac arrest: a multicenter experience
Authors: Panagides V , Vase H , Shah S , Basir MB , Mancini J , Kamran H , Batra S , Laine M , Eiskjaer H , Karami K , Paganelli F , Henriques JP , Bonello L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Abstract: Background

Impella CP is a left ventricular pump which may serve as a circulatory support during cardiopulmonary resuscitation (CPR) for cardiac arrest (CA). Nevertheless, the survival rate and factors associated with survival in patients undergoing Impella insertion during CPR for CA are unknown.

Methods

We performed a retrospective multicenter international registry of patients undergoing Impella insertion during on-going CPR for in- or out-of-hospital CA. We recorded immediate and 30-day survival with and without neurologic impairment using the cerebral performance category score and evaluated the factors associated with survival.

Results

Thirty-five patients had an Impella CP implanted during CPR for CA. Refractory ventricular arrhythmias were the most frequent initial rhythm (65.7%). In total, 65.7% of patients immediately survived. At 30 days, 45.7% of patients were still alive. The 30-day survival rate without neurological impairment was 37.1%. In univariate analysis, survival was associated with both an age < 75 years and a time from arrest to CPR ≤ 5 min (p = 0.035 and p = 0.008, respectively).

Conclusions

In our multicenter registry, Impella CP insertion during ongoing CPR for CA was associated with a 37.1% rate of 30-day survival without neurological impairment. The factors associated with survival were a young age and a time from arrest to CPR ≤ 5 min.
Chest pain post anti-Covid-19 vaccination with mRNA BNT162b2 vaccine : the experience of a secondary hospital
Authors: Stratinaki M , Vassilakis D , Stavrakis S , Bachlitzanaki E , Detoraki M , Korela D , Papaoikonomou E , Pitarokoilis M , Rogdakis E , Kafarakis P , Garidas G , Lamprogiannakis E , Foukarakis E
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Vaccination against Covid-19 has been proved an effective protective measure against the pandemic. It has been noticed that a number of patients visited the emergency department (ED) complaining of chest pain following their vaccination.

Purpose

To record the patients that visited the ED of our hospital referring chest pain following their vaccination with BNT162b2 vaccine, the clinical and laboratory parameters as well as their final diagnosis.

Methods

We recorded the patients that visited the ED of our hospital (secondary hospital) referring "chest pain after the vaccine", for a period of 6 months. We included patients that had received the first or the second dose of the vaccine 1-30 days prior their visit. We recorded basic demographic characteristics, ECG findings the laboratory test results as well as the possible diagnosis made in the ED.

Results

207 patients visited the ED complaining of "chest pain after having the Covid-19 vaccine", 96 male and 111 female, with mean age 47±8.2 years. 7 patients(3.38%) had elevated high sensitivity troponin and were diagnosed with myocarditis ( 2 female patients aged 5 and 62 years and 5 males aged 18-24 years. In 5/7 ST elevations were recorded in the 12-lead ECG, in 4/7 the transthoracic echocardiogram(TTE) revealed mildly impaired left ventricular function. Myocarditis was confirmed via cardiac MRI in all patients. Virology tests were negative for the common viruses.6/7 visited the ED 2-5 days after the second dose, whereas 1/7 10 days after the first dose). 2 patients(0.96%) were diagnosed with pericarditis (Both of them had received the second dose 5-7 days prior their visit, presented with pericardial rub and diffuse ST elevations in the ECG, as well as elevated CRP and moderate pericardial effusion). For the remaining 198 patients (95.65%) we did not record any abnormal findings in the ECG or the chest X ray and the chest pain was regarded non cardiac. Interestingly enough, 107 patients (51.69%) found to have a mild to moderate increase in the D-Dimer levels (mean 1.1±0.6 mg/l).Pulmonary embolism and aortic dissection was excluded to all of them based on our hospital’s protocol.

Conclusion

The vast majority (95.65%) of patients complaining of post Covid-19 vaccine chest pain had normal ECG and laboratory findings, suggesting a non cardiac origin.There were diagnosed some cases with myocarditis or pericarditis, a well described possible side effect of the BNT162b2 vaccine. Moreover, 51.69% of these patients were found to have elevated D-Dimer levels but we did not record any clinical significance.
Renal replacement therapy in acute coronary syndrome: what kind of patient requires it and what is its prognostic impact?
Authors: Martinez Nunez R , Altarejos Salido F , Paez Munoz R , Garcia Gonzalez N , Garcia Rubira JC
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

The clinical acuity and medical complexity in contemporary tertiary center Cardiology Critical Care Units (CCCU) have heralded an increase in the prevalence of acute and chronic kidney disease. Consequently, renal replacement therapy (RRT) has become a rising technique in these units.

Purpose

Our aim was to analyze the baseline characteristics, complications and prognosis of patients with acute coronary syndrome (ACS) who required RRT during their admission, and to compare them with the characteristics of those patients who did not.

Methods

Retrospective observational analysis of registered ACS patients admitted to the CCCU of a tertiary center between January 2011 and January 2021. A comparative analysis was performed between those patients who required RRT during their admission, either due to chronic kidney disease (CKD) or peri-infarct acute kidney injury, and the remaining patients.

Results

2596 patients were included in the analysis, showing the baseline characteristics listed in the table. A total of 53 (2%) required RRT during their admission. Patients requiring RRT more frequently presented ACS without ST elevation (69.8% vs 37.9%; p <0.001), multivessel disease (41.3% vs 17%; p <0.001) and a III or IV Killip-Kimbal (KK) score (38.5% vs 11%; p <0.001). During admission, they had a higher incidence of atrial fibrillation (AF) (34% vs 13.3%; p <0.001), bleeding (26.4% vs 10.5%; p <0.001), stroke (5.7% vs 1.2%; p 0.004), peri-infarct cardiorespiratory arrest (20.8% vs 10.2%; p 0.013) and in-hospital death (34% vs 5.9%; p <0.001). In the multivariate analysis performed, RRT was not an independent predictor of mortality when corrected for other risk factors (diabetes mellitus, GRACE and CRUSADE scores, STEACS, single vessel disease, or KK score on admission).

Conclusions

Patients admitted with ACS who required RRT had a higher risk profile, with a worse in-hospital prognosis and a higher incidence of complications. However, RRT was not found to be an independent predictor of mortality after adjusting for other variables.
Time course and prognostic impact of venoarterial extracorporeal membrane flow throughout cardiogenic shock
Authors: Montero S , Huang F , Rivas-Lasarte M , Chommeloux J , Brechot N , Hekimian G , Franchineau G , Luyt CE , Garcia-Garcia C , Bayes-Genis A , Lebreton G , Cinca J , Combes A , Alvarez-Garcia J , Schmidt M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

In VA-ECMO supported patients because of refractory cardiogenic shock (CS), there is a lack of evidence on what is the "optimal" ECMO flow.

Purpose

To describe the evolution of VA-ECMO flow in a CS population according to the degree of support and analyze the impact of early high-ECMO flows on short-term outcomes.

Methods We performed a retrospective, single-center study including patients in refractory CS supported with peripheral VA-ECMO admitted at an University Hospital. Based on the median flow over the first 48 hours of ECMO run, patients were classified as "high-flow" or "low-flow" when median ECMO flow was ⋝ or < than 3.6 L/min, respectively. All statistical tests were two-sided, with a p value ≤ 0.05 considered significant.

Results

Two hundred and nine patients were included. Median age was 51 (40-59) years, 78% were males, and the median SAPS II was 51 (32 - 66). The most frequent etiology leading to CS was end-stage-dilated cardiomyopathy (57%). "High-flow" and "low-flow" groups each represented 50% of the study population, respectively (Figure 1). Median flows between both groups were continuously lower in "low-flow" patients at any time-point, with the "low-flow" group maintaining VA-ECMO flows around 3.0-3.1 L/min. The "high-flow" group had a higher frequency of ischemic etiology and was significantly sicker at admission. Almost 70% of the study population was managed with LV unloading. More than 40% of patients were managed with an awake strategy, with much higher rates of awake ECMO in the "low-flow" group (52% vs 30%, p<0.001). Patients with "high-flow" had 50% more VAP than "low-flow" patients and median days on mechanical ventilation were significantly less in the "low-flow" group (4 [1.5 - 7.5] vs 6 [3 - 12] days, p=0.009, respectively). No differences were either found in total days in ICU or days of hospitalization. Finally, global in-hospital mortality was 46%, with less but not statistically significant differences in the "low-flow" group (41% vs 51%, p=0.144, respectively). Mortality at 60-days were alike for both groups.

Conclusions

In patients with refractory CS supported with VA-ECMO, sicker patients were managed with higher degree of support from early phases. Patients with high flows presented with higher rates of VAP, but presented similar in-hospital and short-term survival compared to patients with lower flows. Future research is now warranted to address the specific, direct, impact of higher flows in lung injury or length of MV.
Time trends in 30-day mortality in patients with pulmonary embolism
Authors: Vojtickova L , Kleissner M , Kettner J , Kautzner J , Sramko M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

There is a lack of evidence about recent mortality rates in patients with acute pulmonary embolism (PE).

Purpose

To compare 30-day mortality between the current and historical cohort of patients treated for acute PE.

Methods

We provide a retrospective analysis of clinical and imaging features of 400 consecutive patients who were admitted to our hospital with the diagnosis of acute pulmonary embolism between February 2010 and April 2021. Patients with out-of-hospital cardiac arrest without return of spontaneous circulation (14 patients) were excluded from the study cohort. The 30-day mortality was compared between patients admitted before January 2016 (n =178) and after January 2016 (n = 222). We stratified patients into low-, intermediate-, and high-risk group according to the ‘2019 ESC Guidelines on Acute Pulmonary Embolism’.

Results

The diagnosis of pulmonary embolism was based on results of computed tomography (86%), pulmonary ventilation/perfusion scan (7%), echocardiography (7%) and autopsy (1%).

Most patients were stratified as intermediate-risk (313 patients [78 %]), followed by low-risk (46 [12%]) and high-risk pulmonary embolism (41 [10%]).

The risk-stratification profile did not differ between the current and historical cohort (79% vs. 77% for intermediate-risk, 12% vs. 11% for low-risk, and 9% vs. 12% for high-risk patients, all p> 0.05).

Seventeen patients (4%) died within 30 days of admission to the hospital: ten patients in the high-risk (24%), seven in the intermediate-risk (2%), and none (0%) in the low-risk group (p <0.0001). There was no significant difference in 30-day mortality between the current and historical cohort (9 [4%] vs. 8 [4%], p = 0.83).

In a multivariate regression analysis, only the initial presence of cardiogenic shock was associated with higher 30-day mortality.

Conclusion

In-hospital mortality of patients with intermediate- and low-risk pulmonary embolism is lower than reported in the past and has not changed over the last decade. High-risk pulmonary embolism is associated with 24% 30-day mortality.
Intra-aortic balloon pump in patients with acute advanced heart failure. Results from a single-center study
Authors: Panagiotou C , Adamopoulos S , Sbarouni S , Miliopoulos D , Gkouziouta A , Bonios M , Leontiadis V , Voudris V , Rallidis L , Iliodromitis E
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with advanced heart failure are frequently referred to cardiac intensive care unit (CICU) for hemodynamic support. Despite optimum pharmacological therapy many of these patients persist in critical condition, demanding short term circulatory support until recovery or heart transplantation. Intra-aortic balloon pump is commonly used in patients with advanced heart failure in order to stabilize hemodynamically compromised patients as bridge to decision for further therapies.

Purpose

To investigate the outcomes of patients with acute advanced heart failure referred to cardiac intensive care unit and supported with short term mechanical support. To explore the hemodynamic effects of the Intra-aortic balloon pump therapy in these patients.

Material & Method

We retrospectively analyzed the data from 104 patients with acute advanced heart failure (either as worsening of existing symptoms of chronic HF or as first onset of HF). All patients had severe left ventricular dysfunction, which was frequently associated with right ventricular dysfunction and increased NT pro BNP levels. Demographic data were collected including co-morbidities. Laboratory data included NT-pro BNP, total bilirubin, serum creatinine, urea and baseline e GFR (MDRD Formula). All patients received IABP support and underwent right heart catheterization. Measurements were made before and after the insertion of the IABP. The study has been approved by the Scientific Committee and the Ethics Committee of the Hospital.

Results

The mean age of the sample was 44 ± 12 years. 76 patients (73, 08%) were male. 20 patients (19, 23%) were of ischemic etiology. The median time on IABP support for the entire cohort was 13 days (3 – 41, 25). There was statistically significant decrease in the NT-pro BNP levels (p<0, 0001). There was improvement in renal function (e GFR (p<0, 0001) and urea levels (p< 0,001)). There was statistically significant improvement in the right heart catheterization measurements (decrease of the right atrium pressure (p <0, 0001), of the PA pressure (p<0,001), and of the pulmonary capillary wedge pressure (p<0,001)). IABP provided clinical stabilization in 88 patients (87, 62%), that is completed pre-transplant evaluation and proceeded in surgery with permanent mechanical support or heart transplantation or transfer to regular ward, while 16 patients (15, 38%) ended up in CICU while being on IABP.

Conclusions

In this single center study the use of IABP improved the laboratory findings and the hemodynamic status of patients admitted in the cardiac intensive care unit with acute advanced heart failure. It was an effective method of managing patients as bridge to decision for further therapies.
12-lead post-ROSC electrocardiogram discriminates survival to hospital discharge. A sub-analysis of the PEACE study
Authors: Gentile FR , Baldi E , Schnaubelt S , Caputo ML , Clodi C , Bruno J , Compagnoni S , Benvenuti C , Domanovits H , Burkart R , Primi R , Ruzicka G , Holzer M , Auricchio A , Savastano S
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Once the return of spontaneous circulation (ROSC) after an out-of-hospital cardiac arrest (OHCA) is achieved the acquisition of a 12-lead electrocardiogram (ECG) is strongly recommended in order to determine candidates for urgent coronary angiography. However, little is known so far about the association of ECG features and survival to hospital discharge in OHCA patients.

Purpose

The aim of the present study is to assess whether ECG features could be associated with survival to hospital discharge.

Methods

We analysed all the post-ROSC ECGs collected from January 2015 to December 2018 in three European centres. For every ECG, the main features were analysed and filed in the database together with the pre-hospital data collected for every patient according to the Utstein style. Every ECG was evaluated by two independent cardiologists and in case of doubt a third one was asked to solve the dispute.

Results

We collected 370 ECGs: 287 males (77.6%); median age 62 years old (IQR 53-70 years); 121 from center 1 (32.7%), 38 from center 2 (10.3%) and 211 from center 3 (57.0%). In Cox univariable regression, age older than 62 years [HR 1.7 (95%CI 1.1-2.4), p=0.007], QRS wider than 120 msec [HR 1.87 (95%CI 1.3-2.7), p<0.001], the presence of ST elevation in more than one segment [HR 1.7 (95%IC 1.2-2.5), p=0.003], the presence of left bundle branch block (LBBB) [HR 1.7 (95%CI 1.1-2.9), p=0.03] and the presence of a right bundle branch block [HR 1.8 (95%CI 1.1-2.8), p=0.01] were associated with death before hospital discharge. In multivariable Cox regression, after correction for the ROSC-to-ECG time, age older than 62 years [HR 1.6 (95%CI 1.1-2.3), p=0.01], QRS wider than 120 msec [HR 1.7 (95%CI 1.2-2.5), p=0.004] and the presence of ST elevation in more than one segment [HR 1.7 (95%CI 1.2-2.5), p=0.004] were confirmed to be independently associated with death before hospital discharge. By assigning one point to each one of these three variables, we have created a score ranging from 0 to 3. The rate of survival to hospital discharge was found to be significantly different in the four categories [score=0: 80.8%; score=1: 71.2%; score=2: 61.9%; score=3: 34.4%; p<0.001, p for trend <0.001]. Lastly, with a Cox regression model, assuming score 0 as a reference, we confirmed how scores 2 or 3 were significantly associated with death before hospital discharge [HR 1.9 (95%CI 1-3.5), p=0.037 e HR 5.1 (95%CI 2.6-10.1), p<0.001 respectively].

Conclusions

Our study proves that after an out-of-hospital cardiac arrest, post-ROSC ECG features can be used for prognostic stratification in addition to the selection of patients who may benefit from urgent coronary angiography.
Age-dependency performance of diagnostic prediction rules for pulmonary embolism
Authors: Silva BV , Jorge C , Rodrigues T , Placido R , Rigueira J , Alves Da Silva P , G Almeida A , J Pinto F
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Age affects the performance of the diagnostic tests to rule out pulmonary embolism (PE), particularly with a decrease in specificity, leading to an overuse of computed tomography pulmonary angiography (CTPA). Current guidelines advice to consider using the age-adjusted cut-off in patients older than 50 years, but no specific recommendation is provided for very old patients.

We aimed to compare the age-dependency of the diagnostic accuracy of the standard approach (based on Wells and Geneva scores combined with a D-dimer cut-off of 500 ng/mL), with three alternative strategies (age-adjusted, YEARS and PEGeD algorithms) in patients admitted to the Emergency Department (ED) due to PE suspicion.

Methods

Consecutive outpatients admitted to the ED who underwent CTPA due to PE suspicion were retrospectively evaluated. The diagnostic accuracy was calculated and compared among the different diagnostic prediction rules and stratified by age.

Results

We included 1402 patients (mean age 69 years, 54% female). PE was confirmed in 25% (n=353), 86% occurred in patients over 50 years. Table 1 and 2 represents the sensitivity and specificity of diagnostic prediction rules stratified by age.

For all diagnostic strategies, specificity decreases with age. In patients over 80 years, the standard approach’s specificity could be as low as 8%. Compared to the standard approach, the age-adjusted strategy was associated with higher specificity over 50 years (p=0.008 for patients aged 51-60 years; p<0.001 for patients over 60 years), with similar sensitivities for patients under 70 years and a non-statistically significant decrease in sensitivity in patients over 70 years (p=0.03). YEARS and PEGeD algorithms had the highest specificities for all ages (p£0.001). Regarding sensitivity, except for patients aged between 61 and 70 years, YEARS and PEGeD showed lower sensitivity than the standard and age-adjusted approaches for all ages (p<0.001), particularly in patients under 60 years (sensitivity of 81% in patients aged between 51-60 years).

Conclusion

Compared to the standard approach, an age-adjusted strategy increased specificity with a non-significant decrease in sensitivity only in patients older than 70. YEARS and PEGeD algorithms had the highest specificity across all ages yet were associated with a significant decrease in sensitivity.
Heart failure in myocardial infarction with non-obstructive coronary arteries: predictors and prognosis
Authors: Santos M , Almeida I , Paula S , Santos H , Almeida S , Tavares J , Santos L , Almeida ML
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heart failure (HF) is a frequent complication of acute coronary syndromes (ACS). However, 5-15% of patients admitted with suspected acute myocardial infarction have no significant lesions on coronary angiography (>50%). Contrary to initial beliefs, MINOCA is not a benign disease, given that mortality and incidence of MACE is similar to ACS.

Objective

To evaluate predictors and prognosis of HF in the setting of MINOCA.

Methods

Based on a multicenter retrospective study, data collected from admissions between 2013 and 2020. Patients (pts) without data on cardiovascular history or uncompleted clinical data were excluded. Pts were divided in 2 groups (G): GA – pts without HF; GB - pts with HF during hospitalization.

Results

HF occurred in 63 (5.2%) out of 1218 pts with MINOCA. There were no differences between G regarding gender (p=0.779). GB pts were older (72±10 vs 65±13, p<0.001), had higher rates of arterial hypertension (88.9% vs 68.7%, p<0.001), diabetes (45% vs 27.5%, p=0.003), valvular disease (15.8% vs 2.1%, p<0.001), previous HF history (17.2% vs 6.2%, p=0.004), kidney dysfunction (15.1% vs 4.6%, p=0.006) and dementia (8.8% vs 0.7%, p<0.001). GA had higher rates of smoking habits (22.4% vs 3.3%, p<0.001). GB had higher heart rate at admission (92±25 vs 75±17, p<0.001), and higher rates of KK>1 (71.4% vs 6.3&, p<0.001), atrial fibrillation (25.5% vs 7.9%, p<0.001) and left branch bundle block (LBBB) (8.7% vs 1.4%, p=0.007). GB presented higher rates of kidney dysfunction (creatinine>2.0mg/dL) at admission (20.8% vs 4.8%, p<0.001)) and during hospital stay (31.6% vs 9.8%, p<0.001), lower haemoglobin levels at admission (13±1.8 vs 13.8±1.8, p=0.008) and during hospital stay (11.1±2.4 vs 12.7±1.8, p<0.001), higher BNP levels (BNP>400pg/ml) (100% vs 18.1%, p<0.001), and higher rates of left ventricle systolic dysfunction (LVEF<50%) (55.6% vs 17.6%, p<0.001).

Logistic regression confirmed that KK>1 (p<0.001, OR 37.4, CI 13.6-102.7), LBBB (p=0.005, OR 10.1, CI 2.0-51.0), LV dysfunction (p=0.002, OR 8.3, CI 2.1-32.1) and smoking (p=0.046, OR 0.096, CI 0.01-0.96) were predictors of HF in the setting of MINOCA. Survival analysis confirmed GA had better prognosis regarding 1 year mortality compared to GB (p<0.001).

Conclusion

As expected, HF in the setting of MINOCA is associated with poorer prognosis. Several features may help predict the HF occurrence during hospitalizations, allowing an earlier treatment.
Cardiogenic shock prognosis according to the type of infarction: STEMI vs non-STEMI. Acute-phase and 5-year mortality
Authors: Martinez Membrive MJ , Rueda Sobella F , Garcia Garcia C , Labata Salvador C , Oliveras Vila T , Montero Aradas S , Ferrer Massot M , El Ouaddi N , Serra Flores J , Lupon Roses J , Bayes Genis A
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Hospital Germans Trias i Pujol

Background

Cardiogenic shock (CS) is a severe complication of myocardial infarction (MI) and carries a high mortality. Clinical profile and prognosis of these patients could differ depending on the electrocardiographic pattern at admission. The objective of this study is to demonstrate these differences.

Methods

Prospective register of patients with MI complicated with CS admitted to the acute cardiac care unit of a tertiary hospital between 2010 and 2019. Clinical characteristics and mortality at 30-day and 5-year were compared according to the presence (STEMI) or absence (NSTEMI) of ST-segment elevation.

Results

This study included 239 patients, 79.5% had STEMI and 20.5% had NSTEMI. There were no differences in age (69 vs. 71 years, p=0.330), gender distribution (22.4% vs. 27.4% women, p=0.486) and ejection fraction (33% vs. 30%, p=0.231). However, patients with STEMI had more extensive MI (CK-MB peak 279 vs. 85 ng/ml, p<0.001) and mechanical complications (17.9% vs. 0% p<0.001). Nevertheless, patients with NSTEMI had greater prevalence of hypertension (81.6% vs. 62.6%, p=0.012), diabetes (53.1 vs. 36.3%, p=0.033), peripheral arteriopathy (34.7% vs. 13.7%, p=0.001), previous heart failure (14.3% vs. 3.7%, p=0.005), previous MI (44.9% vs. 10.0%, p<0.001), percutaneous coronary angioplasty (20.4% vs. 10.0%, p=0.047) and coronary artery bypass grafting (10.2% vs. 2.1%, p=0.020). This last group had more prevalence of three-vessel disease (80.4% vs. 34.9%, p<0.001) and main left artery (58.7% vs. 20.6%, p<0.001).

STEMI patients had higher 30-day mortality (59.5% vs 36.7%; p=0.004), but this difference progressively diminished. As a result, 5-year survival had no significant differences. After adjusting for main clinical predictors, STEMI was independently associated with 30-day mortality (HR 1.99), but this association disappeared when the follow-up was extended to 5 years.

Conclusions

Patients with CS and STEMI had more extensive infarcts and with more mechanical complications than NSTEMI. Patients with NSTEMI and CS had more cardiovascular risk factors, previous coronary artery disease, and multi-vessel involvement. 30-day mortality of STEMI with CS was higher than in NSTEMI, although 5-year mortality did not offer significant differences.
Acute cardiac injury (ACI) in COVID-19 pneumonia
Authors: Erba M , Ciarrocchi F , Dammassa V , Colombo C , Mojoli F , Tavazzi G
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Since the SARS-CoV2 break-out many reports focused on the role of cardiovascular system involvement in the patient’s outcome(1). However, few descriptions exist including only patients with severe ARDS admitted to general ICU.

Methods

We enrolled adult patients with severe ARDS related to COVID-19 infection consecutively admitted to ICU between February 2020 and March 2021. Acute cardiac injury was defined as a rise and fall of cTnI above the 99th percentile (i.e., ≥ 47 ng/L)(2). Hs-TnI was measured at admission and during ICU stay. Echocardiographic examinations were performed at ICU admission and at the time of worst cTnI.

Left ventricular (LV) and right ventricular (RV) systolic dysfunction were defined respectively as LV ejection fraction (LVEF) < 50% and as tricuspid annular plane systolic excursion (TAPSE) < 16 mm.

Results

A total of 148 patients were included in the analysis. Acute cardiac injury was present in 65 (44.9%) cases at admission. Forty-seven (21.8%) patients had isolated depressed LVEF, 13 (9.0%) had isolated RV systolic dysfunction and 24 (16,4%) presented with biventricular systolic dysfunction.

Eithy-two (56.1%) had a worsening of hs-TNI values during the admission of whom a consensual worsening of LVEF and TAPSE was observed in respectively 32 (21.8%) and 28 (19.2%) patients.

Cardiac injury at ICU admission yielded an increased risk of in-hospital mortality (OR 1.30 [95% CI 0.71 – 2.38]) (Figure 1 – left panel) as well as the presence of impaired echocardiography (OR 1.85 [95% CI 1.01 – 3.40]) (Figure 1 – right panel). Worst hs-TNI correlated with worst procalcitonin (PCT) values (p <0.001 r20.81) in case of on-going septic shock and 85 % of patients with RV dysfunction had either evidence of pulmonary thrombus at CT scan or high inspiratory peak pressure (> 30 cmH2O) at mechanical ventilation (respectively, p < 0.001 and p <0.01).

Bivariable analysis adjusted for the inverse probability of having an impaired echocardiographic exam confirmed the increased risk of in-hospital mortality in patients with cardiac injury (OR 2.01 [95% CI 1.28 – 3.15]) and in presence of altered echocardiography with RV dysfunction yielding a higher risk (OR 2.42 [95% CI 1.29 – 4.55]) compared with biventricular impairment (OR 1.86 [95% CI 0.87 – 4.00]) and isolated LV dysfunction (OR 1.30 [95% CI 0.77 – 2.19]) (Figure 2).

Conclusion

The use of echocardiography for the detection of cardiac dysfunction, has shown a greater correlation with mortality than the identification of acute cardiac damage using laboratory parameters. Of all the parameters obtained with the echocardiography, right ventricular dysfunction demonstrates the greatest correlation with mortality compared to left or biventricular dysfunction. However, the major cause of LV dysfunction in our population occurred during septic shock while RV dysfunction seemed to be due to pulmonary embolism and/or acute cor pulmonale ARDS-related.
Identification of triggers associated with health care-related adverse events in a cardiac care unit
Authors: Maruri Sanchez R , Martin Asenjo R , Puerto E , Dominguez Perez L , Vicent L , Durante Lopez A , Bruna V , Galan D , Moreno G , Arribas F , Bueno H
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

health care-related adverse events (HCRAE) are a safety concern with serious consequences for hospitalized patients. In medical literature there is a lack of evidence about the incidence, characteristics and prevention of HCRAE in a cardiac care unit (CCU). This study evaluates the utility of predefined triggers from the Global Trigger Tool method that are associated with the appearance of HCRAE, for their early detection and prevention in critical cardiac patients.

Purpose

validation of a set of predefined triggers from the Global Trigger Tool method that allow the detection of HCRAE in patients admitted to a CCU.

Methods

retrospective observational study. A review of medical history documents from a group of patients admitted to a CCU will be carried in search of HCRAE. The presence or absence of a set of predefined triggers from the Global Trigger Tool method will be analyzed in these patients. Statistical analysis will establish the relationship between the presence of these triggers and the incidence of HCRAE, as well as their sensitivity and specificity to detect these events.

Results

among 1086 patients admitted to a CCU during 2017, 120 were randomly evaluated. Fifty-nine patients (49%) experienced HCRAE. The total number of these events was 153 (at a median of 0 events per patient, Q1-Q3: 0-1). Forty-four predefined triggers from the Global Trigger Tool method were evaluated in all patients, regardless of whether or not they presented HCRAE. A median of 2 (Q1-Q3: 1-7) triggers per patient were detected. The mean review time for all triggers was 6.4 (± 3.07) minutes per patient. Among the 44 triggers evaluated, 7 were significantly associated with the incidence of HCRAE. These triggers are shown in Table 1. These triggers showed a sensitivity of 81% and a specificity of 90% for the detection of HCRAE. The ROC curve is shown in Figure 1.

Conclusions

HCRAE have serious consequences por patients; their prevention is a main goal for patient safety. In medical literature, there is a lack of evidence about this topic in the context of a CCU. In the present study, the incidence of HCRAE was evaluated in 120 critical cardiac patients. Forty-nine percent of patients experienced one or more HCRAE. Forty-four predefined triggers from the Global Trigger Tool method were evaluated; 7 of them were significantly associated with the incidence of HCRAE. These triggers showed a sensitivity of 81% and a specificity of 90% to detect HCRAE.
GRACE score - is it good for all NSTEMI patients
Authors: Santos M , Santos H , Paula S , Almeida I , Figueiredo M , Almeida S , Tavares J , Santos L , Almeida ML
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients (P) with a non-ST elevation myocardial infarction (NSTEMI) have a heterogenous prognosis and early risk stratification at admission is essential. GRACE score is validated to estimate in-hospital outcomes, as well as long term prognosis.

Objective

Evaluation of discriminatory capacity of GRACE score in P <65 years versus ≥65 presenting with NSTEMI.

Methods

Based on a single-center retrospective study, data collected from admissions between 1/01/2016 and 11/12/2019. Patients with cardiac arrest or hemodynamically unstable patients at admission were excluded. GRACE score was calculated using Killip-Kimball classification as a surrogate of heart failure. P were divided in 2 groups (G): G1 if <65 years old, G2 if ≥65 years. We evaluated the discriminatory capacity of GRACE score in predicting in-hospital MACE in both groups through ROC-curve analysis.

Results

We identified 405 patients with NSTEMI, 62.7% were males with an average age of 68.4±12.3 years old. Mean GRACE in global population was 118±28.3 points, lower in G1 P (G1 92.6±22.6, G2 130±21.2, p<0.001). At univariate analysis, GRACE score was predictor of MACE in G1 (p=0.05, OR 1.05) and G2 p=0.026, OR 1.03). Its discriminatory capacity was acceptable: for G1 the area under the curve (AUC) was 0.687 and in G2 AUC 0.785. Given the lower discriminatory capacity in G2, the authors determined other predictor factors (excluding GRACE) to accurate risk stratification in this G. At univariate analysis, predictor factors for MACE were diabetes (p=0.006, OR 5.4), left ventricle branch block (p=0.011, OR 2.2) and haemoglobin at admission (p=0.003, OR 0.63). At multivariate analysis, both diabetes (p=0.002) and haemoglobin (p=0.031) were independent predictor factors for MACE.

Conclusion

In our center, GRACE score was a better predictor for younger patients, while for other patients other factors, such as diabetes and haemoglobin at admission must be taken into account to assess risk stratification.
Embolic versus non- embolic acute coronary syndrome. Baseline characteristics and presentation
Authors: Carmona-Carmona J , Martinez-Primoy I , Martinez-Nunez R , Almendro-Delia M , Garcia-Rubira JC , Hidalgo-Urbano RJ
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronary embolism (CE) is a rare cause of acute coronary syndrome with current evidence from small case series. In our previous work (n=36), atrial fibrillation was the main risk factor and STEMI the most frequent presentation.

Objetives

In this analysis we compare baseline characteristics from an embolic versus a non-embolic cohort both with left anterior descending artery as culprit vessel.

Methods

Observational, retrospective descriptive study of patients admitted in our unit from July 2011 to march 2021 for acute coronary syndrome and diagnosed with CE (National Cerebral Cardiovascular Center Criteria). Comparative cohort data were analysed from ARIAM Andalucia Registry.

Results

646 patients were analysed (19 embolic vs 627 non-embolic). 73.7% were women in the embolic group, 27% in the non-embolic one (p<0.05). Mean age 75±12 in the embolic cases versus 62±13 in non-embolic ones (p<0.05). 9.3% of patients had history of ischemic events and there was more previous heart failure in the embolic cohort (21.1% vs 3.0%, p<0.05%). Smoking was more frequent in the non-embolic group (43.5% vs 5.3%, p<0.05), insulin-dependent diabetes mellitus was more prevalent in the embolic cohort (21.1% vs 6.1%, p<0.05). There were no differences in other cardiovascular risk factors. AF and anticoagulation therapy were more frequent in the embolic cohort (31.6% vs 6.2%, p<0.05; 31.6% vs 5%, p<0.05). Time to first medical attention was not significantly shorter in the embolic group (95±80min vs 503±3278min, p>0.05). De novo AF was more frequent in the embolic group (31.6% vs 0.8%, p=0.02). GRACE and CRUSADE scores values were higher in embolic patients (162±31 vs 145±40, p=0.042; 45±10 vs 23±23, p=0.001).

Conclusions

CE is an infrequent entity. Our data suggest that in STEMI, elder women patients, with atrial fibrillation, insulin-dependent diabetes mellitus and not smoking, and with short delay to first medical attention, should rise the suspiction of this fenomenon.
In-hospital mortality and 6-months prognosis on cardiogenic shock depending on the aetiology in a Mediterranean cohort. The Shock-CAT Study
Authors: Garcia-Garcia C , Andrea R , Sanz E , Ruiz M , Aboal J , Pastor P , Buera I , Sionis A , Lopez T , Perez-Rodriguez M , Ariza A , Tomas C , Baneras J , Cediel G , Rueda F
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Mortality in cardiogenic shock (CS) remains very high, although the CS aetiology could influence in the acute-phase and long term prognosis.

Purpose

The aim is to investigate in-hospital mortality and 6 months prognosis (all-cause mortality and cardiovascular readmission) in CS patients depending on the CS aetiology in a Mediterranean cohort.

Method

Shock CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Catalonia (Spain), including CS patients due to acute coronary syndrome (ACS) and other aetiologies. Data on clinical presentation, biomarkers, management, including mechanical assistance support were analyzed comparing ACS and non-ACS patients. In-hospital and 90-days mortality and 6-months prognosis (mortality and cardiovascular readmission) were available and have been compared between groups.

Results

A total of 382 CS patients were included, mean age was 65.3 (SD 13.9) years and 75.1% were men. Patient were classified in ACS (n=232, 60.7%) and non-ACS (n=150, 39.3%). In ACS group, 77.6% were STEMI, reperfusion in 84.7% of cases, all with primary angioplasty, 9% developed mechanical complications and 19.4% primary ventricular fibrillation. Main non-ACS aetiologies were severe heart failure (36.2%), malignant arrhythmias (22.1%), valve disease (8.0%) and myocarditis (7.4%). ACS group had less prevalence of women (17.7% vs 36%, p=0.001) and previous myocardial infarction (13.9% vs 24.8%, p=0.007). Mechanical assistance device was implanted more frequently in ACS patients (43.1% vs 16.7%, p<0.001, mainly intraaortic balloon pump (35.6% vs 9.8%, p<0.001) and ECMO (10.7% vs 3%, p=0.01). Both shock risk scores were higher in ACS patients, Cardshock (4.5 vs 4.0, p=0.006) and IABP (2.4 vs 1.9, p=0.005). All-patients in-hospital mortality was 33%. This acute-phase mortality was higher in ACS group (37.1% vs 26.7%, p=0.035) although this difference loss the significance at 90-days (40.9% vs 31.8%, p=0.074) and 6-months (45.2 vs 35.8%, p=0.176). Cardiovascular 6-months readmission was 8.7%, without differences between ACS and non-ACS group (9.7% vs 7.3%, p=0.155, respectively).

Conclusions

One-third of cardiogenic shock patients died during hospital admission. Patients with CS due to ACS had 28% higher in-hospital mortality than non-ACS, although this difference decreased at 90 days and 6 months. Cardiovascular 6-months readmission was 8.7%, without differences between groups.
Left ventricular outflow tract thrombus in a patient with COVID-19—a ticking time bomb: a case report
Authors: Muhammadzai Hamza Zahid Ullah , Rosal Nathaniel , Cheema Muhammad Arslan , Haas Donald
Published: May 2022

Background

Coronavirus disease 2019 (COVID-19) is a manifestation of severe acute respiratory syndrome coronavirus 2, which results in many different complications including left ventricular (LV) thrombi.

Case summary

We present a 30-year-old female presenting with chest pain and shortness of breath. Patient had an extensive history including heart failure with an ejection fraction 15–20% and COVID-19 2 months ago. Echocardiogram revealed a 3.3 cm ×  1.7 cm LV thrombus which was not present 4 months ago before her diagnosis of COVID-19. The LV thrombus embolized resulting in an embolus extending from the distal infrarenal abdominal aorta to the common iliac arteries bilaterally. Repeat COVID pre-procedure was positive. She underwent bilateral femoral artery cutdown, bilateral iliac artery embolectomy, superficial femoral artery embolectomy, and bilateral lower extremity fasciotomy. An extensive workup for the aetiology of the LV thrombus turned out to be negative and COVID-19 was deemed to be the aetiology of the thrombus. The patient was bridged from apixaban to warfarin and was successfully discharged within a few weeks.

Discussion

Hypercoagulability is a known complication of COVID-19 causing thrombi in various parts of the body including the LV. Early recognition with echocardiography, especially in patients with heart failure, and prompt treatment is key to avoid further complications such as embolization.
Primary thyroid leiomyosarcoma with transvenous extension to the right atrium: a case report
Authors: Dubrava Juraj , Martanovic Peter , Pavlovicova Marina , Babal Pavel
Published: May 2022

Background

Primary thyroid leiomyosarcoma (LMS) is a very rare tumour with less than 40 published cases yet. Direct metastatic extension into the great cervical veins and caval veins is extremely uncommon. Extension to the right heart has not yet been reported.

Case summary

A 62-year-old man was admitted for sudden onset of left neck pain and dyspnoea. Computed tomography and ultrasonography found an extensive mass of the left great cervical veins, superior vena cava, and a nodule in the left thyroid lobe. Transesophageal echocardiography visualized large protrusion of this mass into the right atrium. Cytology of a thyroid nodule diagnosed a benign hyperplastic nodule. The mass was considered to be likely an extensive thrombus. The patient was started on anticoagulant therapy. The next course was complicated by pulmonary embolism and later by enterorrhagia. Despite clinical stabilization, the patient died suddenly. Autopsy finding differed from the clinical conclusion. Microscopic investigation revealed that the mass seen in the cervical veins down to the right atrium was a spindle cell tumour with a primary site in the left thyroid lobe. Immunohistochemistry was consistent with the final diagnosis of primary thyroid LMS.

Discussion

Differential diagnosis of the masses of great cervical veins and right atrium can be challenging. Pure venous thrombus and tumour thrombus must be distinguished. Thyroid LMS should also be considered in patients with masses in the right atrium and thyroid nodules.
Continuous improvement of both hepatic and cardiac dysfunction by sequential plasma exchange in a patient with thyrotoxicosis and cardiogenic shock: a case report indicating the potential role of cardiohepatic interactions during thyroid storm
Authors: Suzuki Toshiaki , Asaumi Yasuhide , Kataoka Yu , Noguchi Teruo
Published: May 2022

Background

Thyroid storm (TS) complicated by cardiogenic shock is associated with high mortality due to the high incidence of multiple organ failure. It is recommended that TS patients with hepatic failure undergo plasma exchange (PE) and receive optimal anti-hyperthyroid medications. However, the effect of PE on cardiac dysfunction in TS patients has been unclear.

Case summary

A 46-year-old woman was admitted to our hospital for dyspnoea and tachycardia. She was diagnosed with TS pursuant to Graves’ disease complicated by acute decompensated heart failure (ADHF). Cardiac function was remarkably impaired [left ventricular ejection fraction (LVEF) = 15–20%], with rapid atrial fibrillation. Despite the management of both ADHF and hyperthyroidism, cardiogenic shock developed; therefore, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pumping (IABP) were initiated. Plasma exchange was performed after severe hepatic failure manifested on Day 2. After the first three PE treatments, cardiac and hepatic function improved immediately but deteriorated the next day. The improvement persisted after the fourth PE, and the patient was weaned from VA-ECMO and IABP on Days 10 and 11, respectively. She was discharged on Day 37, and her cardiac function was still normal 1.5 years later.

Discussion

In hyperthyroidism, severe hepatic dysfunction is more likely to occur in patients with acute ADHF than in those without it. Plasma exchange has the potential to improve not only hepatic but also cardiac dysfunction under optimal antithyroid treatment, especially in patients with TS complicated by severe hepatic dysfunction.