bluuebunny/crossref_metadata_2025 huggingface dataset:
Mechanical circulatory support in high-risk PE for more than a decade
Authors: Perez Barquin R , Lujan Valencia E , Margarida De Castro A , Zubiaur Zamacola J , Royuela Martinez N , Burgos Palacios V
Published: May 2024

Funding Acknowledgements

None.

Background/Introduction

Absence of solid evidence in clinical practice guidelines on the management of patients with a severe pulmonary thromboembolism (PTE) in a situation of cardiogenic shock requiring mechanical circulatory support (veno-arterial ECMO). A registry has been carried out in a tertiary hospital of patients admitted to the Cardiological Critical Care Unit (CCCU) with a diagnosis of high-risk PTE and V-A ECMO implantation.

Purpose

The objective is to describe the experience of our center due to the paucity of evidence from current guidelines in this area iin terms of morbimortality and expected outcomes.

Methods

Data were collected from all patients admitted with a diagnosis of high-risk PE in the CCCU from 05/01/2010 to 05/01/2023. Of these, only those in whom V-A ECMO was implemented during admission were analyzed and described below. Clinical, analytical and survival variables were explored.

Results

A total of 11 patients were included, 3 (27.27%) being women. The mean age was 53 years (SD 10.64).

Every V-A ECMO cannulation was performed in a femoro-femoral configuration by a surgical approach. The mean length of stay in the Critical Care Unit, total hospital stay length and circulatory support time were respectively: 8 days (SD 5.5); 20.7 days (DS 16.5) and 3 days (DS 1.9). The indication for the implantation of V-A ECMO was in a situation of SCAI-E in 7 patients (in 2 of them, V-A ECMO was implanted during cardiac arrest, and a 100% of mortality was described in the first 24 hours). On the other hand, in the remaining 4 patients, the indication for support was a deteriorating evolution despite amines. Of these, in 2 of them, there was a formal contraindication for the administration of systemic fibrinolytic treatment (recent major surgery, in one of them oncology). It should be noted that VA ECMO without adjuvant fibrinolysis was used in 6 of the patients (54.5%), and in 1 of them (16%) of them died (anoxic encephalopathy). However, the remaining 5 patients received combined VA ECMO therapy and systemic fibrinolysis (45.5%), with 2 deaths reported in this subgroup (40%). Those deceases happened both due to adequacy of the therapeutic effort in the context of multiple organ failure. No major bleeding was reported, even in the combination therapy group.

Conclusions

Support with V-A ECMO has allowed survival >70% in patients diagnosed with high-risk pulmonary embolism, including in those cases with absolute contraindication for systemic fibrinolysis. High safety profile in terms of bleeding even in those patients with a combined approach.
Respiratory support modalities in cardiogenic shock: insights from a prospective multicenter registry
Authors: Tavecchia G A , Frea S , De Ferrari G , Sorini Dini C , Briani M , Viola G , Bertaina M , Marini M , Bertolin S , Colombo C , Pappalardo F , Morici N , Potena L , Tavazzi G , Sacco A
Published: May 2024

Funding Acknowledgements

None.

Background

Respiratory support is a vital component of the comprehensive management of cardiogenic shock (CS). However, there is a lack of data comparing the application of different respiratory support modalities in CS patients.

Purpose

Aim of this study was to examine the use of low-flow oxygen (LFO), non-invasive ventilation (NIV), and invasive mechanical ventilation (IMV) in a cohort of CS patients and assess their effects on 60-day mortality.

Methods

We analyzed a cohort of CS patients enrolled in a multicenter prospective registry from twelve cardiac intensive care units from March 2020 to August 2022. Patients were categorized according to the maximum intensity of respiratory support during intensive care unit stay into three groups: LFO, NIV, and IMV. Clinical characteristics and mortality were compared between groups.

Results

A total of 375 patients were included in our analysis. The median age of the population was 65 years, with 77% being males. During their ICU stay, 139 patients (37%) received LFO, 61 (16%) were treated with NIV, and 175 (47%) underwent IMV. Patients treated with IMV presented more frequently with cardiac arrest (41% vs 8% in the LFO group and 5% in the NIV group, p = 0.00). Patients treated with LFO and NIV had a higher prevalence of CS related to acute decompensated heart failure (40% and 57% vs 21% in the IMV group, p = 0.00); moreover, they presented with less severe respiratory distress, milder tissue hypoperfusion, and better SCAI class upon admission. At sixty days follow-up 128 patients (34%) died: 41% in the IMV group, 28% in the LFO group and 26% in the NIV group (p = 0.02). Multivariate analysis revealed that NIV was independently associated with improved survival (OR 0.47, 95% CI 0.22-0.99, p = 0.05), while age, lactate levels, and glomerular filtration rate were predictors of mortality. A tendency towards improved survival with NIV was observed even after excluding patients with cardiac arrest.

Conclusions

Compared to previous registries, our study highlights a significant shift in the management of CS, marked by a growing preference for NIV. Notably, this approach, when employed in well-selected patients in the early stages of CS, correlates with lower mortality rates. These findings underscore the significance of personalized treatment strategies for CS patients, considering their clinical presentation, the degree of respiratory distress, and tissue perfusion.60-day survival curvesMultivariate regression analysis
Patients with acute decompensation of heart failure and and low natriuretic peptide levels
Authors: Stratinaki M , Georgopoulou T , Eleftheriadou E , Detoraki M , Aletras G , Stavrakis S , Pitarokoilis M , Honda E , Korela D , Foukarakis E
Published: May 2024

Funding Acknowledgements

None.

Background

Nt-proBNP is frequently used in the diagnosis of acute decompensated heart failure (ADHF). However, there are some patients that although they have the clinical features of ADHF present with paradoxically low Nt-proBNP levels.

Purpose

To record the clinical and epidemiological characteristics of patients presenting with ADHF and low Nt-proBNP levels and compare them with those patients with high Nt-proBNP levels.

Methods

We retrospectively analyzed the data from the patients admitted with ADHF in our department, for a period of 2 years and divided them in 2 groups : low Nt-proBNP group (BNP<300 pg/ml) and high Nt-proBNP group (>300pg/ml). We recorded the clinical and epidemiological characteristics, the laboratory findings as well as the treatment they received.

Results

We recorded 636 patients admitted due to ADHF. 512 (80.5%) were in the high Nt-proBNP group and 124(19.5%) in the low Nt-proBNP group. Patients in the low Nt-proBNP group had more frequently BMI>25 (low Nt-proBNP vs high Nt-proBNP group) (65% vs 32%, p<0.01), and were more often females (71% vs 39%, p<0.05). In terms of heart failure classification, the low Nt-proBNP group had more often preserved ejection fraction (66% vs 42%, p<0.01) whereas in HFrEF (22% vs 39%) and HFmrEF (19% vs 12%) we did not notice any significant difference. Regarding age, less patients in the low Nt-proBNP group were older than 65 years old (62% vs 87%, p<0.05). The low Nt-proBNP group patients stayed longer in the hospital (9.2±2.4 days vs 6.6±3.7 days, p<0.01) needed smaller doses of furosemide (60±12,8 mg/d vs 180±24.2 mg/d, p<0.01) and more rare vasopressor (37% vs 42%) or inotropic (27% vs 56% , p<0.05) support. On the contrary, they needed more often non invasive ventilation (NIV) (73% vs 42%, p<0.05). As far as the laboratory findings is concerned, the low Nt-proBNP group presented with lower high sensitivity troponin I (hsTnI) levels (56±17.9 pg/ml vs 127±36.2 pg/ml, p<0.01) and higher GFR (96±12.2 mL/min/1.73 m² vs 45±23.7 mL/min/1.73 m², p<0.05).

Conclusions

Patients admitted with ADHF and low Nt-proBNP levels seem to be younger, females, with higher BMI and more often with preserved ejection fraction. It seems that they need more frequently non invasive ventilation , smaller doses of diuretics and require more days in the hospital. More studies are needed to identify the characteristics of this subset of patients that could lead to more effective management.
Subclinical congestion in patients presenting with acute coronary syndrome
Authors: Stratinaki M , Georgopoulou T , Eleftheriadou E , Korela D , Detoraki M , Stavrakis S , Aletras G , Bachlitzanaki I , Pitarokoilis M , Foukarakis E
Published: May 2024

Funding Acknowledgements

None.

Introduction

Patients admitted due to acute coronary syndrome (ACS) are stratified using Killip class for the severity of the post myocardial infarction (MI) heart failure (HF). Killip class classification is mainly based on clinical examination and overt signs and symptoms are usually needed to be present.

Purpose

To evaluate subclinical congestion with lung ultrasound (LUS) in patients presenting with acute coronary syndrome.

Methods

For a period of 4 years, we recorded the patients presented to the emergency department of our hospital due to acute coronary syndrome (HF) and no symptoms or signs of heart failure (Killip class I). LUS was performed on admission and patients were classified as having either "wet lung" (>3 b-lines in at least 3 lung fields) or "dry lung". Baseline characteristcs, laboratory findings as well as the result of the coronary angiogram were alse recorded.

Results

286 patients were recorded, with mean age 71,2 years, 43,35% were female and 56,6% male. 36.01% of the patients presented with ST elevation MI (STEMI) and 63.98% with non ST elevation MI (NSTEMI). 34.2% of patients were classified as having "wet lung". Of them, 63.98% were STEMI patients and 36.1% NSTEMI. 27.2% were males and 72.8% females and 64.6% older than 60 years old. 10.7% had on admission left ventricular ejection fraction (LVEF) >50% whereas 89.3 % had LVEF <50%.Finally, 12,7% were found to have 1 vessel disease, 23.4% 2 vessel disease and 63.9% 3 vessel disease. Compared to patients classified as having "dry lung", patients with "wet lung" stayed in the hospital 74 days (vs 3.2, p<0.01), and their mean troponin levels were 10721 pg/ml (vs 3254 pg/ml, p<0.01). "Wet lung" patients were found to have mean GFR 56,2 mL/min/1.73 m² (vs 86.7 mL/min/1.73 m² , p<0.05).

Conclusion

34.2% of the patients admitted due to ACS Killip 1, were classified as having "wet lung" when examined with LUS, suggesting a status of subclinical congestion. These patients were most often STEMI patients, female and of older age and were found to have reduced LVEF. Compared to the "dry lung" patients had higher troponin levels and most oftenly impaired renal function. LUS could help identify these patients, that although they seem to be asymptomatic in terms of HF, they probably need closer monitoring.
Elevated Lp(a) and thrombophilic mutations : the experience of a general hospital
Authors: Stratinaki M , Georgopoulou T , Eleftheriadou E , Aletras G , Honda E , Detoraki M , Korela D , Pitarokoilis M , Foukarakis E
Published: May 2024

Funding Acknowledgements

None.

Background

Thrombophilia and elevated Lp(a) levels have been studied as risk factors predisposing to cardiovascular events. There is no evidence suggesting that the common mutations causing thrombophilia or elevated Lp(a) alone could be regarded as independent risk factors for acute coronary syndromes.

Purpose

To compare the frequency of the simultaneous presence of thrombophilic mutations along with elevated Lp(a) levels in young patients presenting with acute coronary syndrome (ACS) compared with those without ACS.

Methods

We retrospectively analyzed the data from all the young patients (males<40yo, females <45yo) who were referred for thrombophilia testing to our hospital for a period of 10 years and divided them in two groups : those who presented with ACS (ACS group) and those who were referred for thrombophilia testing for other reason (non ACS group). Lp(a) level >30mg/dl was considered as elevated. We compared the frequency of elevated Lp(a) levels in patients carrying the same mutation in the two groups. P<0.01 was considered statistically significant.

Results

Of the 127 patients recorded in the ACS group, 25 were factor V Leiden homozygotes, 11 factor V Leiden heterozygotes, 17 PAI 4G/5G homozygotes, 8 PAI 4G/5G heterozygotes, 36 G20210A homozygotes and 12 G20210A heterozygotes. In the non ACS group, we analyzed data from 312 patients.Of them, 12 were factor V Leiden homozygotes, 29 factor V Leiden heterozygotes, 31 PAI 4G/4G homozygotes, 17 PAI 4G/5G heterozygotes, 66 G20210A homozygotes and 57 G20210A heterozygotes. Elevated Lp(a) levels were found as follows : (ACS vs non-ACS group) factor V Leiden homozygotes 14/25(56%) vs 1/12(8.33%) (p<0.01), factor V Leiden heterozygotes 7/11(8.66%) vs 2/29(6.89%), p<0.01), PAI 4G/4G homozygotes 1/17(5.88%) vs 0/31, PAI 4G/5G heterozygotes 0/8 vs 0/31), G20210A homozygotes 0/36 vs 1/66(1.51%), G20210A heterozygotes 1/12(9.44%) vs 0/57).

Conclusions

Lp(a) was elevated more frequently in patients carrying factor V Leiden mutation (either homozygotes or heterozygotes) who presented with ACS when compared with patients without ACS. Although it is not established, further studies are needed in order to identify any possible correlation of the combination of this mutation along with elevated Lp(a) levels with the occurrence of ACS in young patients.
Sex disparities in mid-term outcomes of ST-segment elevation myocardial infarction across age
Authors: Pereira Santos M , Campinas A , Alexandre A , Sa Couto D , Ribeiro D , Santos R , Brochado B , Luz A , Silveira J , Torres S
Published: May 2024

Funding Acknowledgements

None.

Background

Women with ST-segment elevation myocardial infarction (STEMI) have been reported to have higher short-term mortality than men, especially in younger patients. However, data on long-term outcomes did not corroborate this association.

Purpose

We aimed to evaluate if sex was an independent predictor of major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up. A sub-analysis across different age subgroups was performed.

Methods

We retrospectively studied consecutive STEMI patients treated by primary percutaneous coronary intervention (PCI) from January 2008 to December 2017. Cox proportional hazard models were used to identify predictors of MACCE at 1-year follow-up (death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization). Patients were divided into four age groups, according to quartiles, for subgroup analysis (≤50, 51-60, 61-70, >71 years).

Results

Of the 1131 patients included in the study, 291 (25.7%) were women. Women were older [68.2 (±14.2) vs 60.6 (±12.2) years, p<0.001], more often non-smokers (21.5% vs 60.2%, p<0.001), and had a higher prevalence of diabetes (34,8% vs 20.9%, p<0.001) and hypertension (71.6% vs 50.2%, p<0.001). They also had lower haemoglobin [12.8 (±1.6) vs 14.5 (±1.7) g/dl, p<0.001] and lower creatinine clearance at admission [73.8 (±35.3) vs 92.6 (±35.2) ml/min, p<0.001], as well as longer door-to-balloon times [90 (60-166) vs 75(50-120) min, p=0.005]. However, total ischemic time was not significantly different between groups [250(175-480) vs 224(150-440) min, p=0.054].

Overall, women had a higher occurrence of MACCE (22.1% vs 15.4%; log-rank P = 0.008, Figure 1). On multivariate analysis, sex was not found to be an independent predictor of MACCE (HR 1.12; 95% CI, 0.77–1.65; P = 0.547). The risk of unfavourable outcomes was mainly driven by other comorbidities (namely, age, presence of peripheral arterial disease, lower haemoglobin concentration, lower systolic blood pressure on admission, a higher peak CK activity, and the utilization of a femoral approach). When MACCE was stratified by age, sex was not an independent predictor of MACCE in any age group (Figure 2).

Conclusion

Women with STEMI submitted to PCI had a higher rate of MACCE at 1-year follow-up compared with men, however, sex was not an independent predictor of these events on multivariate analysis, regardless of the age subgroups considered.
The structure of liver damage in patients with acute decompensated heart failure, the prognostic role of steatosis and liver density
Authors: Khutsishvili N , Misan I A , Arisheva O S , Garmash I V , Galochkin S A , Kobalava Z H D
Published: May 2024

Funding Acknowledgements

None.

Aim

To study the spectrum of liver damage in patients with acute decompensated heart failure (ADHF).

Materials and methods

Included were 566 patients hospitalized with ADHF, NYHA class II–IV, 66% men, mean age 72,4±11,4 years. All patients underwent laboratory and instrumental examination, the degree of steatosis and liver density were determined by transient elastometry methods, with an assessment of the controlled ultrasound attenuation parameter (CAP - Controlled Attenuation Parameter, S, dB/m) using a device according to standard methods. CAP values <294 dB/m with steatosis degree 0 - S0, 295-309 dB/m - S1, 310-330 dB/m - S2, ≥331 dB/m - S3. Liver density was used: ≤5,8 kPa – normal liver density, ≥5,9 – stage F1, ≥7,2 kPa – F2, ≥9,5 kPa – F3, ≥12,5 kPa – F4. Laboratory manifestations of liver damage were considered to be increased aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transpeptidase and alkaline phosphatase.

Results

The incidence of hepatic steatosis (≥S1) among patients with ADHF was 29%. Among patients with liver steatosis, minimal steatosis (S1) was detected in 19% of cases, moderate steatosis (S2) - 28,6%, severe steatosis S3 - 52,4%. In patients with steatosis, the frequency of laboratory indicators of liver damage was 53%, and in patients without steatosis - 49,2%. Liver density ≥ F1 was observed in 79,5% of patients. Stage F1 was diagnosed in 10,4% of cases, F2 - in 11%, F3 - 12,7%, F4 - 44,5%. However, no relationship was found between the severity of steatosis and liver density (p>0,05). Multivariate Cox regression analysis showed that extremely low CAP values (<234 dB/m) were associated with a worse prognosis and higher risk of HF mortality during the 3-year follow-up period (adjusted hazard ratio (aHR) 1,57 95% confidence interval (CI) 1,08–2,31, p=0,019) after adjustment for established risk factors and potential confounders. The presence of increased liver density >15,9 kPa was also associated with a worse prognosis of the risk of death from HF during the 3-year follow-up period by Cox multivariate analysis (aHR 1,24, 95% CI 1,01–1,52, p= 0,040).

Conclusion

Thus, extremely low CAP values (<234 dB/m) and the presence of a marked increase in liver density (>15,9 kPa) were associated with a worse prognosis in patients with ADHF during the 3-year follow-up period.
Acute-on-chronic heart failure leading to cardiogenic shock: any role for intra-aortic balloon pump? Results from a multicenter retrospective data collection
Authors: Colombo C N J , Sacco A , Villanova L , Calini A , Dammassa V , Frederiks P , Erba M , Fiocco E , Viola G , Tavecchia G , Mondino M , Morici N , Price S , Bottiroli M , Tavazzi G
Published: May 2024

Funding Acknowledgements

None.

Background

Intra-aortic balloon pump (IABP) implantation has been significantly reduced since IABP-SHOCK II trial did not show any clinical benefit in acute myocardial infarction (AMI)-related cardiogenic shock (CS)(1). For a long time, AMI has been recognized as the first cause of CS; however, in the last years, acute-on-chronic heart failure (HF)-CS has become predominant. We hypothesized that in HF-CS population the IABP may decrease mortality having a role in decreasing left ventricular afterload and improving peripheral perfusion(2).

Purpose

To investigate whether, in this phenotypical category of cardiogenic shock, IABP could improve 28-days mortality.

Methods

Multicenter retrospective observational study including adult HF-CS patients admitted in cardiac or general intensive care units in 3rd level centers. Hemodynamic variables before (T0) and after IABP implantation (T1), pharmacological support and outcome data were collected. Independent samples t-test was applied to assess any difference between IABP and non-IABP group; Kaplan-Meier and Cox’s regression (forward stepwise method) were performed as survival analysis on 28-days mortality.

Results

160 patients (35.6% female, 61 [47-74] years-old) were included from three centers; overall mortality was 42.5%. 50% received IABP support; amongst IABP patients, 24 received further MCS with VA-ECMO (p <0.001) and 4 with Impella (p 0.120). Patients’ baseline characteristics are shown in Figure 1-A. IABP patients had lower 28-days mortality. Patients who received IABP were younger, had lower systolic blood pressure (SBP), pulse pressure (PP) and lactate levels at T0. In reference to catecholaminergic drugs, patients supported with IABP had lower norepinephrine doses and vasoactive inotropic score (VIS) at baseline. After IABP implantation, no significant difference between the two groups in the time variation of these parameters was observed (Figure 1-B). Survival analysis graphs are shown in Figure 2. At Cox’s regression, a significant effect on 28-days mortality was found for IABP (HR 0.510 [0.293-0.887], p 0.017), SCAI classification-stage D (HR 2.582 [1.315-5.072], p 0.006), VIS-T0 above 15 (HR 2.348 [1.407-3.921], p 0.001) and SBP-T0 above 95 mmHg (HR 1.361 [1.016-1.823], p 0.039); no significant association was found for age above 61 years (overall median value) (p 0.091), mechanical ventilation (p 0.367), PP-T0 (0 0.081) and lactate-T0 (p 0.227).

Conclusions

Considering the specific pathophysiology of HF-CS, IABP may have a role in reducing mortality. These retrospective data need to be validated and compared with those deriving from ongoing randomized controlled trials(3).
STEMI in young patients: what are we dealing with?
Authors: Garcia Ugaldebere J A , Borderias Villarroel T E R E S A , Jimenez Melo O R , Legarra Oroquieta P A B L O , Martinez Basterra J A V I E R , Munarriz Arizcuren A , Ugarriza Ortueta J U L E N E , Lanaspa Gallego A R T U R O , Olaizola Balboa B E T E L , Villabona Rivas C , Odriozola Garmendia M A I T E , Virosta Gil M A R I N A , Loyola Arrieta A M A I A , Fernandez Gonzalez A N D O N I , Alvarez Asiain V
Published: May 2024

Funding Acknowledgements

None.

Background/Introduction

Acute Myocardial Infarction with ST-segment Elevation (STEMI) in young adults is infrequent, with an incidence ranging from 2-12%. Our objective is to analyse the clinical characteristics, management, and prognosis of patients aged 45 years or younger with STEMI activation.

Methods

We conducted a retrospective review of the "Code Infarct" registry at our hospital from January 2020 to March 2023. Out of the 867 codes, 51 patients aged 45 or younger were selected. We studied clinical, angiographic, and echocardiographic parameters.

Results

Table 1 presents the baseline and clinical characteristics of the patients. The median time from symptom onset to the first medical contact was 126 (30-160) minutes, and the median ischemic time was 226 (122-270) minutes.

Figure 1 displays the angiographic findings. Atherothrombotic disease was responsible in 78.4% of patients, with 75% of them having single-vessel coronary disease with similar involvement of the right and anterior descending coronary arteries. Five patients (9.8%) experienced spontaneous dissection, with the majority being women (80%). In 5 cases (9.8%), coronary arteries were found to be normal.

The second most commonly used antiplatelet agent was prasugrel (64.7%). Fibrinolysis was performed in 5 patients (9.8%). Only 3 patients (5.9%) required inotropic/vasopressor therapy, and 2 (3.9%) received intra-aortic balloon counterpulsation.

The most common complication during hospitalization was the occurrence of tachyarrhythmias (27.4%), followed by heart failure (7.8%). At discharge, 52.9% had a left ventricular ejection fraction (LVEF) >55%, 49.3% had LVEF between 40-55%, and only 7.8% had LVEF <40%. The median length of hospital stay was 5.7 (3-6) days, and there were no in-hospital deaths. One-year survival was 98%.

Conclusions

Atherothrombotic disease is the leading cause of STEMI in individuals aged 45 or younger in our population. Smoking and dyslipidaemia are the most prevalent risk factors. Ischemic time is longer than desired in this group, mainly due to a delay from symptom onset to initial medical contact. Promoting primary prevention and raising awareness about the clinical signs and importance of early diagnosis in STEMI could help reduce ischemic time in this population.Characteristics and Clinical PresentatioCoronary angiography findings.
Safety and efficacy of anticoagulation therapy post atrial fibrillation ablation
Authors: Saplaouras A , Mpatsouli A , Mililis P , Toulgaridis F , Letsas K , Xydonas S , Efremidis M
Published: May 2024

Funding Acknowledgements

None.

Background

Thromboembolic complications can be life-threatening during atrial fibrillation (AF) catheter ablation. The aim of our single center, retrospective study was to evaluate the safety and efficacy of continuous treatment using direct oral anticoagulants (DOACs) as an alternative to uninterrupted acenocoumarol for periprocedural anticoagulation.

Purpose

To record the safety and efficacy of the oral anticoagulants post atrial fibrillation ablation.

Methods

We studied 1999 patients undergoing AF catheter ablation between June 2013 and December 2021 in our center. All patients were assigned to take acenocoumarol (group 1, 194 patients) or DOACs (group 2, 1805 patients) for ≥2 months before the procedure. We compared thromboembolic and bleeding complications between the 2 groups.

Results

Our analysis showed no significant difference in major and minor complications between the 2 patient groups with the exception of the occurrence of groin hematoma with a clear superiority of DOACs (2.06%-0.5%, p<0.05). Specifically, 4 of 194 patients (2.06%) using uninterrupted acenocoumarol had a major complication (3 patients [1.55%] had transient ischemic attack resolved 8 hours later and 1 [0.52%] had pericardial tamponade, and 7 patients (3.61%) had minor complications (4 [2.06%] groin hematoma and 3 [1.55%] mild pericardial efussion). In group 2, 14 of 1805 patients (0.78%) had a major complication (11 patients had transient ischemic attack (0.61%) and 3 patients (0.17%) had pericardial tamponade). In the same group, 31 patients (1.72%) had a minor complication (3 patients [0.17%] presented with pseudoaneurysm or femoral arteriovenous fistula between the femoral artery and femoral vein, 19 [1.05%] with pericardial effusion <1 cm, and 9 [0.5%] groin hematoma).

Conclusions

DOACs and acenocoumarol have similar safety and effectiveness regarding thromboembolic complications prevention without increasing bleeding complications with the exception of the occurrence of groin hematoma with a clear superiority of DOACs.
Clinical characteristics, complications and in-hospital mortality in patients in the coronary care unit requiring invasive mechanical ventilation
Authors: Marin Andreu P , Arroyo-Monino D F , Rivadeneira-Ruiz M , Garcia-Gonzalez N , Garcia-Rubira J C
Published: May 2024

Funding Acknowledgements

None.

Introduction

Mechanical ventilation (MV) is one of the most widely used life support techniques in critically ill patients and, due to the increasing number of coronary care units (CCU), adequate management of this technique is essential.

Purpose

The aim of our study was to describe the profile of patients requiring invasive MV (IMV) in our CCU, as well as the mode of ventilation, complications and in-hospital mortality.

Methods

Single-center retrospective observational study of a cohort of patients admitted to a CCU between January 2018 and March 2023 who required IMV. Baseline characteristics, reason for admission and intubation, as well as evolution and complications during admission were analyzed.

Results

A total of 157 patients were included, 113 (72%) men. The mean age was 66.9 years (SD 12.2). Table 1 summarizes the history and baseline characteristics of the patients. Image 1 summarizes the reasons for admission. Regarding the causes of oro-tracheal intubation, the most frequent was cardiopulmonary arrest (CPA) (49.7%), followed by respiratory failure (32.5%) and cardiogenic shock (CS) (16.6%). Regarding left ventricular ejection fraction (LVEF) on admission, 69.4% had LVEF<52%, with 32.5% of all patients having LVEF below 30%.

The most used ventilation mode as initial mode was volume-controlled mode (VC/AC), used in 71.3% of patients. The mean stay in CCU was 11 (min 1-max 78, SD 12) and of orotracheal intubation was 5 days (min 1-max 64, SD 7). Mean days to weaning from VMI was 2 (min 0-max 8, SD 2). Failure on extubation occurred in 38 patients (19.1%), the most frequent reasons being need for reintubation (12.7%), need for noninvasive MV (8.9%) and self-extubation (2.5%). Only 7 patients (4.5%) required tracheostomy. Regarding complications, 49% developed sepsis, 61.1% had CS, and 7% required renal replacement therapy. In-hospital mortality was 38.2% (60 patients).

Conclusions

IMV is a technique that is increasingly used in our environment. Patients who require it are usually complex, with multiple comorbidities, with a high percentage of CPA and CS. These patients usually have prolonged stays in the CCU, with an average of more than 10 days, frequent complications and a high in-hospital mortality of almost 40%. It is essential to gather series as large as possible of these patients to improve our knowledge of their management and characteristics.
Admission plasma concentration of neutrophil gelatinase-associated lipocalin and -C-reactive protein have additive prognostic value in patients with STEMI
Authors: Frydland M , Hassager C , Holmvang L , Jensen L O , Helgestad O L , Meyer M , Moeller J E , Shacham Y
Published: May 2024

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): This work was supported by Righospitalets Forskningsfond (07IO) Lundbeck Foundation (R186-2015-2132).

Background

Inflammation plays an apparent critical role in patients with acute coronary syndrome (ACS) and is associated with mortality. However, the complex process is poorly understood. Neutrophil gelatinase-associated lipocalin (NGAL) is a novel biomarker originating from mature neutrophils and renal tubular cells. It has previously been shown to be associated with mortality and acute kidney injury in ACS patients. In this study we sought to assess the potential additive prognostic value of NGAL and its relation to other markers of inflammation.

Methods

In 1556 consecutive ST-elevation myocardial infarction (STEMI) patients, NGAL and C-reactive protein (CRP) plasma concentration were measured at hospital admission, before acute coronary angiography. Patients were stratified to plasma concentration of both biomarkers >/< the median concentration into 4 groups (low NGAL/ low CRP (group 1), low NGAL/high CRP (2), high NGAL/low CRP (3), high NGAL/high CRP(4)). Primary outcome was 30-day all-cause mortality.

Results

In total, 477 (31%), 324 (21%), 316 (20%), and 439 (28%) patients were stratified in group 1-4, respectively. With 0, 1, or 2 biomarker plasma concentration above the median (group 1 – 4), patients were older (61 – 67 years old, p<0.0001), had more comorbidity (hypertension (40 – 53%), p=0.002; previous stroke (4.0 – 9.9%), p=0.007; peripheral arterial disease (PAD) (2.6 – 10%), p<0.0001; chronic kidney dysfunction (CKD) (0.6 – 11%), p<0.0001) and more critical per-infarction circumstances (time from symptom debut to angiography (170 – 229 minutes), p<0.0001; cardiogenic shock (1.3 – 14%), p<0.0001, cardiac arrest (0.8 – 3.4%), p=0.0002) and lower left ventricular ejection fraction (LVEF) (48 – 43%, p<0.0001). Increased NGAL and CRP was associated with 30-day all-cause mortality (Figure A). Only high NGAL/high CRP was independently associated with 30-day mortality in a cox proportional hazard model when adjusting for age, hypertension, previous stroke, CKD, LVEF, and cardiogenic shock (HR (95% CI) 5.19 (1.20 – 22.52), p=0.03). Both CRP and NGAL had significant predictive value of 30-day mortality (AUC ROC 0.67, p<0.0001 and 0.78, p<0.0001, respectively). Combining NGAL and CRP did, however, not increase the predictive value of NGAL alone (AUC ROC 0.77, p=0.86) (Figure B).

Conclusion

Combined admission NGAL and CRP plasma concentration was independently associated with 30-day all-cause mortality in STEMI patients. Adding CRP to NGAL did, however, not increase the predictive value.Figure AFigure B
Variables associated with mortality in patients with atrial fibrillation and ischaemic heart disease in Spain
Authors: Minguez De La Guia E , Vallejo Calcerrada N , Corbi Pascual M J , Bonanad Lozano C , Cepas Guillen P , Cordero Fort A , Nunez Gil I , Thiscal Lopez M , Raposeiras Roubin S , Ferreiro Gutierrez J L , Moreno E , Diez Del Hoyo F , Ayesta A , Perez Rivera J A , Diez Villanueva P
Published: May 2024

Funding Acknowledgements

None.

Introduction

The prevalence of atrial fibrillation (AF) and ischaemic heart disease (IHD) increases with age, conditioning a complex and relatively frequent scenario in clinical practice. Our objective was to know the variables associated with prognosis in a cohort of patients with AF and IHD in our country after a year of follow-up.

Methods

An observational, prospective and multicentre study that included patients with AF and IHD in Spain. Baseline, clinical, laboratory and echocardiographic characteristics were assessed, as well as the clinical management and the choice of antithrombotic treatment. We studied long-term mortality.

Results

290 patients were included (mean age 77.7±9.7 years, 28% women). 84% of the patients were hypertensive, 42% diabetic, 69.7% dyslipidemic. The average comorbidity, characterized by the Charlson index, was 2.3±2. The average score on the CHADSVASC and HASBLED scales was 4.28±1.62 and 2.94±1, respectively. The clinical presentation of ischaemic heart disease was NSTEMI (45%), STEMI (22%) and stable angina (33%). 65.6% of patients underwent revascularisation, mostly percutaneously (92%). 42% of patients were discharged with triple therapy (double antiplatelet + anticoagulation), 30.1% with double therapy (antiplatelet + anticoagulation). After an average follow-up of 325±5.7 days, 35 patients (12%) died. The variables independently associated (multivariate analysis) with mortality during follow-up are shown in the Table (creatinine, leukocyte count, troponin elevation, number of diseased vessels, ventricular function, and comorbidity were mortality predictors in our study).

Conclusions

The presence of a series of simple variables identifies patients with AF and IHD as having a greater risk of mortality during follow-up.Variables independentily associated AF
Should the left internal mammary artery (LIMA) be imaged before radiotherapy in cases of unexpected early acute coronary syndrome?
Authors: Yilmaz I , Eksi N D , Oguz M O
Published: May 2024

Funding Acknowledgements

None.

Case

A 41-year-old male patient presented to the cardiology outpatient clinic with a complaint of exertional chest pain persisting for the past 4 months, along with occasional palpitation attacks. In his medical history, aside from being diagnosed with lymphoma 15 years ago, there were no known additional comorbidities. The electrocardiogram (EKG) revealed sinus rhythm (84 beats/minute), and the blood tests showed creatinine: 0.81 mg/dL, WBC: 11.26 mm^3, LYM: 3.69 mm^3.

Transthoracic echocardiography demonstrated an ejection fraction (EF) of 60%, with no additional pathologies except for grade 1 diastolic dysfunction. Considering the presence of typical chest pain, coronary imaging was performed to assess for stable angina. The coronary imaging revealed a lesion extending from the left main coronary artery (LMCA) to the proximal left circumflex artery (CX), with an 80% stenosis in the mid-segment of the LMCA, a 60% stenosis at the narrowest point of the CX proximal segment, and an 80% stenosis in the proximal right coronary artery (RCA). The left circumflex artery obtuse marginal branches (CX OM) appeared thin and extensively diseased (Figure-1)

The patient was promptly scheduled for early coronary artery bypass grafting (CABG), transferred to the cardiac surgery intensive care unit, and underwent a successful coronary bypass procedure with LAD-LIMA, Ao-saphenous-IM-saphenous-CxOM1 (sequential) grafting. Throughout the postoperative follow-up period, the patient continued to experience exertional chest pain despite medical treatment. A repeat coronary angiography was performed, revealing that the bypass grafts were opened, but a diffuse 80% stenosis was detected at the mid-segment of the LIMA graft, prior to the anastomosis.(Figure-2) Successful stent placement was performed at the narrowest point of the LIMA mid-segment (Figure-3).The patient had no anginal complaints during post-procedure follow-up and has been stable under observation.

Discussion

Routine clinical practice does not involve LIMA imaging in patients who have undergone diagnostic coronary angiography with multi-vessel involvement and a CABG decision. However, the use of coronary artery bypass graft surgery (CABG) may entail a risk of rendering the graft unusable due to extensive mediastinal fibrosis and radiation-induced damage to the left or right mammary artery. Therefore, in patients with a history of radiation exposure in the thoracic region and a CABG decision, the visualization of the intermammary artery during coronary angiography and the consideration of alternative grafts, such as the radiation-free radial artery, or the necessity for high-risk percutaneous stent implantation, should be discussed.figure-1figure-2
Urgent TAVI not associated with higher rates of conversion to urgent cardiac surgery: a systematic review and meta-analysis
Authors: Apostolos A , Ktenopoulos N , Chlorogiannis D D , Katsaros O , Koliastasis L , Kachrimanidis I , Simopoulou C , Sagris M , Konstantinou K , Tsalamandris S , Drakopoulou M , Karanasos A , Aggeli C , Tsioufis C , Toutouzas K
Published: May 2024

Funding Acknowledgements

None.

Introduction

Transcatheter Aortic Valve Implantation (TAVI) has been established as a therapeutic option in patients with severe Aortic valve Stenosis (AoS). Although TAVI has been associated with high procedural success, it is rarely required conversion to cardiac surgery, for the management of complications. It remains unknown whether the rate of conversion to urgent cardiac surgery is higher in patients undergoing urgent TAVI compared to elective TAVI.

Purpose

The aim of our systematic review and meta-analysis is to investigate whether patients treated with urgent TAVI are under higher risk for urgent conversion to cardiac surgery.

Methods

We systematically conducted a thorough search of three major databases (Medline, Cochrane Central Register of Controlled Trials, and Scopus) to identify studies comparing urgent and elective TAVI. Our primary endpoint in this systematic review and meta-analysis was the incidence of unanticipated, emergent conversions to open cardiac surgery during the TAVI procedure. Only studies that provided data on this endpoint were considered for inclusion in our analysis. Secondary endpoints included vascular complications, the presence of post-procedural moderate or severe aortic regurgitation, in-hospital mortality, and the device success. These secondary endpoints were evaluated during the inpatient stay of the patients. For the statistical analysis, we computed risk ratios (RR) with corresponding 95% confidence intervals (CIs). We employed a random-effects model (Mantel-Haenszel), to estimate the pooled RR.

Results

A total of six studies, encompassing 70,296 patients, were included in our analysis. Among them, 5,021 patients underwent an urgent TAVI procedure, while the remaining 65,275 underwent elective TAVI. During TAVI, conversion to urgent cardiac surgery did not vary significantly between the two groups (RR: 0.90, 95% CI:0.66-1.24]. Moreover, no significant differences were observed in vascular complications (RR:1.55, 95% CI: 0.92-2.61), post-procedural moderate or severe aortic regurgitation (RR:1.20, 95% CI: 0.85-1.69) and device success (RR:0.99, 95% CI: 0.98-1.00). Notably, in-hospital mortality was higher in urgent TAVR group (RR: 2.08, 95% CI: 1.69-2.56).

Conclusion

Our systematic review and meta-analysis have demonstrated that patients undergoing urgent TAVI are not at a higher risk for urgent cardiac surgery, device failure, vascular complications, or post-procedural moderate or severe aortic regurgitation. Notably, despite these findings, the higher in-hospital mortality observed in patients undergoing urgent TAVI suggests the presence of other factors that should be explored to account for this increased mortality.Urgent conversion to surgery
TAVI in younger patients: is it a reliable option?
Authors: Rocha De Almeida A , Carias De Sousa M , Congo K , Neves D , Patricio L
Published: May 2024

Funding Acknowledgements

None.

Background/Introduction

Severe aortic stenosis is the most common valve disease requiring intervention. It has very poor prognosis, and early intervention is recommended. Either surgical or percutaneous transcatheter intervention is possible. According to European guidelines, surgical aortic valve replacement (SAVR) is usually indicated for patients younger than 75 years old. However, some patients are refused surgery, and transcatheter aortic valve implantation (TAVI) might be an option of treatment for these patients, however medium-long term results are still uncertain.

Purpose

This study intends to evaluate the efficacy and safety of TAVI in younger patients with severe symptomatic aortic stenosis.

Methods

Retrospective cohort of 224 patients were submitted to TAVI in the last 3 years, of which 21 patients were younger than 75 years old. The primary endpoints are mortality, major adverse cardiovascular events (MACE) and rehospitalization (related to the procedure, valve, or heart failure). Efficacy and safety were evaluated during a follow-up of at least 6 months, compared with the traditional group.

Results

A total of 224 patients underwent TAVI during the last 3 years at our center. Of these, 21 patients (9%) were younger than 75 years. The mean age was 72,1±3 [62-75] years old and 33% were female (n=7). 95% (n=20) of the TAVI procedures were due to degenerative severe aortic stenosis and 5% (n=1) due to degenerative aortic surgical valve prothesis. The mean euroscore risk value was 6,2±1,3%, and 18 patients were refused for surgery (86%) and 3 patients refused surgery (14%). All procedures were performed by transfemoral access, with 2 peripheral access complications (9,5%), 1 hemorrhagic (4%), solved with covered stent, and 1 closure device occlusion solved with wire crossing and balloon inflation (4%). It was necessary to implant 3 temporary pacemakers, however, only 2 patients required a definitive pacemaker implantation (9,5%). There were no cases intraprocedural death, MACE or aortic severe complications. There was a statistically significant reduction of risk of peripheral complications and pacemaker implantation on younger patients comparing with older patients (p=0,04 and p=0,05 respectively).

Mean follow-up time was 14±8,3 months [6-39 months]. During follow-up there were no deaths, MACE or episodes of rehospitalization due to heart failure recorded. Regarding echocardiographic evaluation, there were no cases of significant valve degeneration, with mean aortic gradient of 13±4,1mmHg, no significant leakage or other echocardiographic findings.

In younger patients, TAVI appears to be also valid therapeutic option, with less risk of peripheral access complication or need of permanent pacemaker implantation. During the follow-up there was no cases of prothesis degeneration, proving to be a reliable option for the medium to long term.
Unloading the left ventricle in VA-ECMO: a comparative analysis of outcomes
Authors: Leite M , Nunes F , Ribeiro-Silva M , Brandao M , Silva M , Teixeira P , Ponte M , Dias A , Caeiro D
Published: May 2024

Funding Acknowledgements

None.

Introduction

Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) has radically changed the way we see and treat cardiogenic shock, despite the challenges it presents.

The retrograde delivery of oxygenated blood to the aorta via the arterial cannula imposes increased afterload on an already strained left ventricle (LV). Unloading techniques aim to reduce the preload and afterload caused by VA-ECMO on the LV.

Purpose

Our study aims to compare the clinical outcomes of patients on VA-ECMO where additional invasive techniques were employed to unload the LV, against those without unloading strategies.

Methods

Patients treated with VA-ECMO in our hospital since 2012 were categorized into two groups: the Venting Group (VG) that received LV unloading interventions and the Non-Venting Group (NVG) without such interventions. We collected comprehensive clinical data, including demographics, baseline characteristics, ECMO-related parameters, in-hospital complications, and patient outcomes. Statistical analyses involved chi-square tests for categorical variables and independent samples t-tests for continuous variables to assess the impact of unloading strategies on patient outcomes.

Results

Our hospital treated 100 patients with VA-ECMO (mean age 58.4 ± 11.9 years, 60% male). Approximately 39% of patients received LV unloading support. The choice of unloading device was guided by our center's expertise. Most commonly, Intra-Aortic Balloon Pump (IABP) was used (61.5%), followed by Impella CP (23.1%), percutaneous atrial septostomy (2.6%) and surgical LV venting (12.8%). Unloading techniques were implemented either concurrently with VA-ECMO cannulation (58.9%), before (17.9%), or after its insertion (23.2%). Most patients (68%) received inotropic drugs, predominantly dobutamine. The mean duration of venting device use was 4.2 ± 3.8 days.

Airway bleeding (3.3% NVG vs. 17.9% VG, p=0.032) and thromboembolic complications (19.7% NVG vs. 41.0% VG, p=0.036) were significantly more prevalent in the VG. There were no significant differences in the others reported ECMO-related complications.

No significant differences were observed in the mean duration of support with VA-ECMO (3 days NVG vs. 4 days VG, p=0.147) or in the mean duration of hospitalization (13 days NVG vs. 12 VG, p=0.619) between the two groups. The 30-day survival rates were 42% (95% CI, 0.30-0.59) in NVG and 29% (95% CI, 0.18-0.49) in VG, which did not display statistical significance, p=0.24 [Figure 1].

Conclusions

In our cohort, incorporating unloading devices alongside VA-ECMO did not yield major differences in survival rates, yet led to a considerable increase in airway bleeding and thromboembolic complications. The precocity of unloading device implantation occurred either as an initial strategy or to prevent increased afterload in hearts with limited contractile reserve.Characteristics and Clinical OutcomesSurviving Curves VG vs. NVG