Abstract
The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be ...advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a “weaning test” (ECMO flow < 2 L/min for at least 60 min). ECMO removal was left to the discretion of the medical team blinded to the results. Weaning failure was defined as a patient who died or required a new VA ECMO, heart transplant or LVAD 30 days after ECMO removal. Thirty-six patients (63.2%) were successfully weaned off VA ECMO, of whom 31 (54.4%) after the first weaning test. In case of first test failure, 3 out of 7 patients could be weaned after a 2nd test and 3 out of 4 patients after a 3rd test. Pre-existing ischemic heart disease (OR 9.6 1.1–83), pre-test left ventricular ejection fraction (LVEF) ≤ 25% and/or post-test LVEF ≤ 40% (OR 11 0.98–115), post-test systolic blood pressure ≤ 120 mmHg (OR 33 3–385), or length of ECMO support > 7 days (OR 24 2–269) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.
The optimal management of patients with ST-segment elevation myocardial infarction (STEMI) presenting late->12 hours following symptom onset-is still under debate.
The purpose of this study was to ...describe characteristics, temporal trends, and impact of revascularization in a large population of latecomer STEMI patients.
The authors analyzed the data of 3 nationwide observational studies from the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting between 12 and 48 hours after symptom onset were classified as latecomers.
A total of 6,273 STEMI patients were included in the 3 cohorts, 1,169 (18.6%) of whom were latecomers. After exclusion of patients treated with fibrinolysis and patients deceased within 2 days after admission, 1,077 patients were analyzed, of whom 729 (67.7%) were revascularized within 48 hours after hospital admission. At 30-day follow-up, all-cause death rate was significantly lower among revascularized latecomers (2.1% vs 7.2%; P < 0.001). After a median follow-up of 58 months, the rate of all-cause death was 30.4 (95% CI: 25.7-35.9) per 1,000 patient-years in the revascularized latecomers group vs 78.7 (95% CI: 67.2-92.3) per 1,000 patient-years in the nonrevascularized latecomers group (P < 0.001). In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant reduction of mortality occurrence during follow-up (HR: 0.65 95% CI: 0.50-0.84; P = 0.001).
Coronary revascularization of latecomer STEMI patients is associated with better short and long-term clinical outcomes.
Cardiogenic shock (CS) is a major challenge in contemporary cardiology. Despite a better understanding of the pathophysiology of CS, its management has only improved slightly. The prevalence of CS ...has remained stable over the past decade, but its outcome has seen few improvements, with the 1-month mortality rate still in the range of 40–60%. Inotropes and vasopressors are the first-line therapies for CS, but they are associated with significant hazards, and have well-known deleterious effects. Furthermore, a significant number of patients develop refractory CS with haemodynamic instability, causing critical organ hypoperfusion and/or pulmonary congestion, despite increasing doses of catecholamines. A major change has resulted from the recent advent and availability of potent mechanical circulatory support (MCS) devices. These devices, which ensure sustained blood flow, provide a great and long-awaited opportunity to improve the prognosis of CS. Several efficient MCS devices are now available, including left ventricle-to-aorta circulatory support devices and full pulmonary and circulatory support with venoarterial extracorporeal membrane oxygenation. However, evidence to support their indications, the timing of implantation and the selection of patients and devices is scarce. Because these devices are gaining momentum and are becoming readily available, the “Unité de Soins Intensifs de Cardiologie” group of the French Society of Cardiology aims to propose practical algorithms for the use of these devices, to help intensive care unit and cardiac care unit physicians in this complex area, where evidence is limited.
Le choc cardiogénique (CC) reste un enjeu majeur de la cardiologie contemporaine. Malgré une meilleure compréhension de sa physiopathologie, sa prise en charge n’a que peu évoluée. Au cours de la dernière décennie, sa prévalence est restée stable mais son pronostic ne s’est que peu amélioré avec une mortalité à un mois comprise entre 40 % et 60 %. Les inotropes et les vasopresseurs forment la première ligne de traitement dans le CC mais ils ont une efficacité variable et des effets délétères bien connus. De plus un nombre significatif de patients développent un CC réfractaire avec une hémodynamique instable et une hypoperfusion d’organe et/ou une congestion malgré des doses croissantes de catécholamines. La mise à disposition récente de systèmes efficaces de support hémodynamique mécanique représente un changement majeur. Ces dispositifs, qui assurent un support au flux sanguin, représentent une grande opportunité, attendue depuis longtemps, d’améliorer le pronostic du CC. Il y a aujourd’hui plusieurs systèmes de support hémodynamique mécaniques disponibles allant de dispositifs de support circulatoire du ventricule gauche vers l’aorte à un support cardio-pulmonaire complet avec les systèmes de circulation extracorporelle incluant une membrane d’oxygénation. Cependant les données concernant leurs indications, leur délai d’implantation, la sélection des patients ou du dispositif sont peu nombreuses. Du fait de la grande disponibilité de ces dispositifs et de l’équipement rapide des centres, le groupe « unité de soins intensifs cardiologiques » de la société française de cardiologie a voulu proposer un algorithme pratique d’utilisation pour aider les médecins de soins intensifs dans ce domaine où les données scientifiques sont rares.
Incidence and mortality rates for cardiovascular disease are declining, but it still remains a major cause of morbidity and mortality. Drug treatments to slow the progression of atherosclerosis focus ...on reducing cholesterol levels. The paradigm shift to consider atherosclerosis an inflammatory disease by itself has led to the development of new treatments. In this article, we discuss the pathophysiology of inflammation and focus attention on therapeutics targeting different inflammatory pathways of atherosclerosis and myocardial infarction. In atherosclerosis, colchicine is included in new recommendations, and eight randomized clinical trials are testing new drugs in different inflammatory pathways. After a myocardial infarction, no drug has shown a significant benefit, but we present four randomized clinical trials with new treatments targeting inflammation.
Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this ...study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients.
We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test).
Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05).
NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.
Factors underlying clinical tolerance and hemodynamic consequences of monomorphic sustained ventricular tachycardia (VT) need to be clarified.
Intra-arterial pressures (IAP) during VT were collected ...in patients admitted for VT ablation and correlated to clinical, ECG and baseline echocardiographical parameters.
114 VTs from 58 patients were included (median 67 years old, 81% ischemic heart disease, median left ventricular ejection fraction 30%). 61 VTs were untolerated needing immediate termination (54%). VT tolerance was tightly linked to the evolution of IAPs. Faster VT rates (p<0.0001), presence of resynchronization therapy (p = 0.008), previous anterior myocardial infarction (p = 0.009) and more marginally larger baseline QRS duration (p = 0.1) were independently associated with VT tolerance. Only an inferior myocardial infarction was more often present in patients with only tolerated VTs vs patients with only untolerated VTs in multivariate analysis (OR 3.7, 95% CI 1.4-1000, p = 0.03). In patients with both well-tolerated and untolerated VTs, a higher VT rate was the only variable independently associated with untolerated VT (p = 0.02). Two different patterns of hemodynamic profiles during VT could be observed: a regular 1:1 relationship between electrical (QRS) and mechanical (IAP) events or some dissociation between both. VT with the second pattern were more often untolerated compared to the first pattern (78% vs 29%, p<0.0001).
This study helps to explain the large variability in clinical tolerance during VT, which is clearly related to IAP. VT tolerance may be linked to resynchronization therapy, VT rate, baseline QRS duration and location of myocardial infarction.
Impact of COVID‐19 pandemic: isolation, impairment of well‐being, and insecurity With the current COVID‐19 pandemic, unprecedented restrictions have been decided by governmental authorities on social ...freedoms in order to allow strict social distancing to reduce transmission of SARS‐CoV‐2 and risk of COVID‐19 spread. 1 These measures aim to drastically reduce social interactions (school shutdown and home working), prohibiting visits from relatives and minimizing the use of public transports, and were gradually adopted worldwide. A greater duration of confinement, inadequate supplies, limited access to medical care and medications, and financial losses are aggravating factors. 2 Fear, uncertainty on the future, unclear or even contradictory messages from the authorities, and continuous and alarming media reports (daily number of deaths and insecurity) may play an additional impact on the emergence of emotional stress. 3 Takotsubo physiopathology and role of stressful event The pathophysiology of takotsubo syndrome (TTS) is complex and still not fully understood, but the role of stress and its interaction with the autonomic nervous system seems predominant. An increase in circulating and intracardiac catecholamines has been frequently described, as well as a modification of the activity of G proteins coupled to B2 receptors. 4 Animal TTS models (immobilization stress) have demonstrated a protective effect of beta‐blockers and alpha‐blockers, 5 which is also suspected in humans at the acute stage of TTS but does not persist in the long term. 6 Chronic stress (dependent, cancer and depression) seems to facilitate TTS occurrence. 7 An acute emotional or physical trigger is found in almost 50% of TTS cases. 8 Impact of COVID‐19 pandemic on TTS occurrence In this context of pandemic and containment, one could expect a rise in the rate of TTS episodes by an increase of triggering mechanisms such as stress and anxiety, but this remains to be proven.
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