Critical Illness-Related Corticosteroid Insufficiency in Cardiogenic Shock Patients: Prevalence and Prognostic Role.

BACKGROUND: Cardiogenic shock shares with septic shock common hemodynamic features, inflammatory patterns, and most likely similar complications such as critical illness-related corticosteroid insufficiency. The aim of this study was to evaluate the prevalence of critical illness-related corticosteroid insufficiency in cardiogenic shock patients and to secondarily assess its prognostic value on 90-day mortality. METHODS: A single-center prospective observational study conducted over a 3-year period and including all patients with cardiogenic shock. Main exclusion criteria were patients with prior cardiac arrest, sepsis, ongoing corticosteroid therapy, and etomidate administration. A short corticotropin test was performed in the first 24 h following admission. Serum cortisol levels were measured before (T0) and 60 min (T60) after administration of 250 µg of cosyntropin. Critical illness-related corticosteroid insufficiency was defined according to the 2017 consensus definition (basal total cortisol<10 µg·dL or a delta cortisol T60-T0<9 µg·dL) as well as the thresholds published in 2016 in cardiogenic shock patients associated with worst prognosis (basal total cortisol>29 µg·dL and delta cortisol T60-T0<17 µg·dL). RESULTS: Seventy-nine consecutive patients hospitalized in intensive care for cardiogenic shock met the inclusion criteria. Overall mortality was 43% at day 90. Forty-two percent had critical illness-related corticosteroid insufficiency using the 2017 consensus definition and 32% using the 2016 cardiogenic shock thresholds. Presence of critical illness-related corticosteroid insufficiency was not an independent factor associated with 90-day mortality irrespective of the thresholds used. CONCLUSION: Critical illness-related corticosteroid insufficiency is a frequent occurrence in medical cardiogenic shock. However, in this study, such insufficiency was not associated with prognosis.

Improving Patient Selection for Refractory Out of Hospital Cardiac Arrest Treated with Extracorporeal Life Support.

BACKGROUND: Despite recent management improvement, including Extracorporeal Life Support (ECLS), refractory out of hospital cardiac arrest (ROHCA) survival remains dramatically low. METHODS: We assessed an innovative strategy (Out of hoSpital Cardiac ARrest-ExtraCorporeal Life Support-"OSCAR-ECLS") to optimize access to ECLS of ROHCA patients and reduce the delay between recognition and ECLS implantation. METHODS: This study, conducted in a tertiary teaching hospital, compared the survival and delay times of ROHCA patients treated by ECLS before and after OSCAR-ECLS implementation. This procedure included an early recognition of ROHCA 10 min after initiation of advanced cardiopulmonary resuscitation; the optimization of patient selection and reduction in time from collapse to ECLS initiation. RESULTS: Fourteen patients before and 32 patients after OSCAR-ECLS implementation were identified between 2013 and 2016. Time to ECLS initiation was 99 (90-107) min before OSCAR-ECLS vs. 80 (65-94) min during the OSCAR-ECLS period (P = 0.0007), mostly due to a reduction in time spent on site: 48 (40.0-54.0) min vs. 24 (20.0-28.0) min (P = 0.0001). Survival at hospital discharge was 7% (1/14) before OSCAR-ECLS and 25% (8/32) during the OSCAR-ECLS period (P = 0.20). Only one patient survived with a Glasgow Pittsburgh Cerebral Performance Category (CPC) score = 1 before the OSCAR-ECLS procedure while during the OSCAR-ECLS procedure, eight patients (25%) survived, six with a CPC score = 1, one with a CPC score = 2, and one with a CPC score = 3. CONCLUSIONS: The use of a new paradigm of ROHCA dramatically shortened the time to ECLS initiation by reducing the time spent on site by more than 20 min. Survival improved from 7% to 25% after implementation of OSCAR-ECLS.

Prognostic value of pulmonary congestion assessed by lung ultrasound imaging during heart failure hospitalisation: A two-centre cohort study.

Pulmonary congestion assessed at discharge by lung ultrasonography predicts poor prognosis in heart failure (HF) patients. We investigated the association of B-lines with indices of hemodynamic congestion [BNP, E/e', pulmonary systolic arterial pressure (PAPs)] in HF patients, and their prognostic value overall and according to concomitant atrial fibrillation (AF), reduced (≤40%) ejection fraction (EF), and timing of quantification during hospitalisation for heart failure (HHF). In 110 HHF patients, B-lines were highly discriminative of BNP >400 pg/ml (AUC ≥ 0.80 for all), and moderately discriminative of PAPs >50 mmHg (AUC = 0.68, 0.56 to 0.80); conversely, B-lines poorly discriminated average E/e' ≥ 15, except at discharge. B-line count significantly predicted mid-term recurrent HHF or death (overall and in subgroups), regardless of AF status, EF, and timing of quantification during HHF (all p for interaction >0.10). regardless, B-lines ≥30 at discharge were most predictive of outcome (HR = 7.11, 2.06-24.48; p = 0.002) while B-lines ≥45 early during HHF were most predictive of outcome (HR = 9.20, 1.82-46.61; p = 0.007). Lung ultrasound was able to identify patients with high BNP levels, but not with increased E/e', also showing a prognostic role regardless of AF status, EF or timing of quantification; best B-line cut-off appears to vary according to the timing of quantification during hospitalization.

Temporal deformation pattern in acute and late phases of ST-elevation myocardial infarction: incremental value of longitudinal post-systolic strain to assess myocardial viability.

BACKGROUND: Identification of transmural extent and degree of non-viability after ST-segment elevation myocardial infarction (STEMI) is clinically important. The objective of the present study was to assess the regional mechanics and temporal deformation patterns using speckle tracking echocardiography (STE) in acute and later phases of STEMI to predict myocardial damage in these patients. METHODS AND RESULTS: Ninety-eight patients with first STEMI underwent both echocardiography and cardiac magnetic resonance imaging in acute phase and at 6 months follow-up with 2D STE-derived measurements of peak longitudinal strain (PLS), Pre-STretch index (PST) and post-systolic deformation index (PSI). For each segment, late gadolinium enhancement (LGE) was defined as transmural (LGE >66 %) or non-transmural (<66 %). Global deformation values were significantly correlated with LVEFCMR and infarct size at both visits. A significantly lower value of segmental PLS and higher PSI and PST in necrotic segments were observed comparatively to control, adjacent and remote segments. The best parameters to predict transmural extent in acute phase were PSI with a cutoff value of 8 % (AUC: 0.84) and PLS with a cutoff value of -13 % (AUC: 0.86). PST showed high specificity, but poor sensitivity in predicting transmural extent. More importantly, the addition of PSI and PST to PLS in acute phase was associated with improved prediction of viability at 6 months (integrated discrimination improvement 2.5 % p < 0.01; net reclassification improvement 27 %; p < 0.01). CONCLUSIONS: All systolic deformation values separated transmural from non-transmural scarring. PLS combined with additional information relative to post-systolic deformation appears to be the most informative parameters to predict the transmural extent of MI in the early and late phases of MI. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov/show/NCT01109225 ; NCT01109225.

Assessment of Left Ventricular Ejection Fraction Calculation on Long-axis Views From Cardiac Magnetic Resonance Imaging in Patients With Acute Myocardial Infarction.

To assess left ventricular ejection fraction (LVEF) accurately, cardiac magnetic resonance (CMR) can be indicated and lays on the evaluation of multiple slices of the left ventricle in short axis (CMRSAX). The objective of this study was to assess another method consisting of the evaluation of 2 long-axis slices (CMRLAX) for LVEF determination in acute myocardial infarction.One hundred patients underwent CMR 2 to 4 days after acute myocardial infarction. LVEF was computed by the area-length method on horizontal and vertical CMRLAX images. Those results were compared to reference values obtained on contiguous CMRSAX images in one hand, and to values obtained from transthoracic echocardiography (TTE) in the other hand. For CMRSAX and TTE, LVEF was computed with Simpson method. Reproducibility of LVEF measurements was additionally determined. The accuracy of volume measurements was assessed against reference aortic stroke volumes obtained by phase-contrast MR imaging.LVEF from CMRLAX had a mean value of 47 ±â€Š8% and were on average 5% higher than reference LVEF from CMRSAX (42 ±â€Š8%), closer to routine values from TTELAX (49 ±â€Š8%), much better correlated with the reference LVEF from CMRSAX (R = 0.88) than that from TTE (R = 0.58), obtained with a higher reproducibility than with the 2 other techniques (% of interobserver variability: CMRLAX 5%, CMRSAX 11%, and TTE 13%), and obtained with 4-fold lower recording and calculation times than for CMRSAX. Apart from this, CMRLAX stroke volume was well correlated with phase-contrast values (R = 0.81).In patients with predominantly regional contractility abnormalities, the determination of LVEF by CMRLAX is twice more reproducible than the reference CMRSAX method, even though the LVEF is consistently overestimated compared with CMRSAX. However, the CMRLAX LVEF determination provides values closer to TTE measurements, the most available and commonly used method in clinical practice, clinical trials, and guidelines in ischemic cardiomyopathy. Moreover, LVEF determination by CMRLAX allows a 63% gain of acquisition/reading time compared with CMRSAX. Thus, despite the fact that LVEF obtained from CMRSAX remains the gold standard, CMRLAX should be considered to shorten the overall imaging acquisition and reading time as a putative replacement.

Takotsubo Cardiomyopathy Triggered by Influenza A Virus.

We herein report the first case of Takotsubo cardiomyopathy triggered by influenza A virus. Myocardial involvement in influenza virus infection has been described in 10% of cases. The literature has principally reported cases of acute myocarditis ranging from asymptomatic to fulminant heart failure and cardiac tamponade. Takotsubo cardiomyopathy frequently occurs in the setting of significant emotional or physical stress or acute medical illness, with a predominance in postmenopausal women. We report the diagnosis, management and outcomes presented in this case, with the aim of describing a new cardiovascular complication of influenza virus infection.

Global and regional myocardial deformation mechanics of microvascular obstruction in acute myocardial infarction: a three dimensional speckle-tracking imaging study.

Microvascular obstruction (MVO) and transmural infarct size are prognostic factors after acute myocardial infarction (AMI). We assessed the value of myocardial deformation patterns using 3D speckle tracking imaging (3DSTI) in detecting myocardial and microvascular damage after AMI. One hundred patients with first ST-segment elevation MI from the REMI Study were prospectively included. Transthoracic echocardiography with 3DSTI and CMR were performed within 72 h after revascularization therapy. Global (3DG) and segmental (3DS) values of LV longitudinal (LS), circumferential and radial area strain were obtained. Late gadolinium enhancement (LGE) and MVO was quantified as transmural (>50%) or non-transmural (<50%). Predictive performance was assessed by area under the receiver operating curve characteristic (AUC). Mean LVEFCMR was 45.8 ± 9.2 % with 22.2 ± 12.7% transmural LGE. MVO was present in 55 patients (MVO transmural extent 11.4 ± 11.8%). In global analysis, all 3DG strain values were correlated with LVEFCMR and infarct size, with the best correlation obtained for 3DGAS (r = -0.678; p < 0.0001). All 3DG strain values, with the exception of LS, were significantly different between patients with and without MVO. In segmental analysis, all 3DS strain values were significantly lower in transmurally infarcted segments than in non-infarcted segments, and all 3DS values except 3DSRS were significantly lower in non-transmural infarcted segments than in non-infarcted segments. The best 3DS strain for detecting non-viable segments with MVO (MVO > 75%) was 3DSAS [AUC 0.867 (0.849-0.884), 78.0% sensitivity and 81.1% specificity for 3DSAS = -16.1%]. Importantly, 3DSRS and 3DSAS were associated with an increase in diagnostic accuracy of both transmural LGE and MVO over 3DSLS (all increase in AUC > 0.04, all p < 0.01). The newly developed 3DSTI, especially 3DSAS, is a sensitive and reproducible tool to predict and quantify the transmural extent of scar. This new early imaging strategy improve the prediction of MVO while enabling to assess the success of reperfusion and the risk of late systolic remodeling in STEMI.

Usefulness of Speckle-Tracking Imaging for Right Ventricular Assessment after Acute Myocardial Infarction: A Magnetic Resonance Imaging/Echocardiographic Comparison within the Relation between Aldosterone and Cardiac Remodeling after Myocardial Infarction Study.

BACKGROUND: Right ventricular (RV) dysfunction after acute myocardial infarction (AMI) is frequent and associated with poor prognosis. The complex anatomy of the right ventricle makes its echocardiographic assessment challenging. Quantification of RV deformation by speckle-tracking echocardiography is a widely available and reproducible technique that readily provides an integrated analysis of all segments of the right ventricle. The aim of this study was to investigate the accuracy of conventional echocardiographic parameters and speckle-tracking echocardiographic strain parameters in assessing RV function after AMI, in comparison with cardiac magnetic resonance imaging (CMR). METHODS: A total of 135 patients admitted for AMI (73 anterior, 62 inferior) were prospectively studied. Right ventricular function was assessed by echocardiography and CMR within 2 to 4 days of hospital admission. Right ventricular dysfunction was defined as CMR RV ejection fraction < 50%. Right ventricular global peak longitudinal systolic strain (GLPSS) was calculated by averaging the strain values of the septal, lateral, and inferior walls. RESULTS: Right ventricular dysfunction was documented in 20 patients. Right ventricular GLPSS was the best echographic correlate of CMR RV ejection fraction (r = -0.459, P < .0001) and possessed good diagnostic value for RV dysfunction (area under the receiver operating characteristic curve [AUROC], 0.724; 95% CI, 0.590-0.857), which was comparable with that of RV fractional area change (AUROC, 0.756; 95% CI, 0.647-0.866). In patients with inferior myocardial infarctions, the AUROCs for RV GLPSS (0.822) and inferolateral strain (0.877) were greater than that observed for RV fractional area change (0.760) Other conventional echocardiographic parameters performed poorly (all AUROCs < 0.700). CONCLUSIONS: After AMI, RV GLPSS is the best correlate of CMR RV ejection fraction. In patients with inferior AMIs, RV GLPSS displays even higher diagnostic value than conventional echocardiographic parameters.

Assessment of right ventricular functional recovery after acute myocardial infarction by 2D speckle-tracking echocardiography.

To assess the pattern of right ventricular (RV) functional recovery in a cohort of patients with successful reperfusion of a first episode of acute myocardial infarction (AMI) with 2D speckle-tracking echocardiography and cardiac magnetic resonance imaging (CMR). Ninety-five revascularized AMI patients were prospectively included (56.8 ± 11.1 years, 48 inferior, 47 anterior). RV function was assessed by echocardiography and CMR within the initial 72 h and 6 months later. A RV global strain was calculated while averaging strain values from septal, lateral and inferior walls. At the acute phase, RVEFCMR was lower in inferior than in anterior AMI patients (52.5 ± 6.8 vs. 56.0 ± 4.8, p = 0.006). Similarly, RV global, inferior and lateral strains were lower in inferior MI patients (p < 0.001 for all) whereas septal strain was not significantly different across groups. At 6 months, RVEFCMR and all strain parameters improved compared to baseline. Improvements were more substantial for patients with inferior than with anterior MI. RV parameters ultimately reached similar levels in the two groups at 6 months except for inferior strain which remained lower in patients with inferior MI (-24.5 ± 6.5 vs. -27.5 ± 5.4, p = 0.03). In low risk patients after AMI, RV function ultimately recovered over the 6 months of follow up. Higher levels of both initial impairment and subsequent recovery were observed for inferior MI. Although RV function was relatively preserved in these patients, RV strain analysis revealed a persistent impairment of RV inferior strain in patients with inferior MI, which may not be identified by RVEFCMR or conventional echocardiographic parameters.

Effects of ventricular resynchronization in previously paced patients developing refractory heart failure.

Biventricular resynchronization has been shown to be beneficial on morbidity and mortality in patients with symptomatic (NYHA class III or IV) systolic heart failure (left ventricular ejection fraction or LVEF is less or equal to 35%) under optimal medical treatment with electrical asynchrony (QRS > or = 120 ms) and in sinus rhythm. The purpose of this study was to evaluate the efficacy and safety of upgrading to biventricular resynchronization in paced patients presenting with symptomatic systolic heart failure. Over a period of eight years, 24 paced patients with symptomatic (class III or IV) systolic heart failure (LVEF < or =35%) with electrical asynchrony (QRS > or =160 ms) received an additional left ventricular pacing lead and a biventricular pulse generator. We compared the functional symptoms, QRS duration, LVEF, left ventricle telediastolic diameter and any aggravation or onset of ventricular arrhythmia before and after biventricular resynchronization. Biventricular resynchronization led to an improvement in dyspnea in 80% of cases (one or more class decrease on NHYA scale), a significant shortening in QRS duration (-40 ms, p < 0.05), a significant improvement in left ventricular dilation (-4 mm, p < 0.05) and a significant improvement in the ejection fraction (+4%, p < 0.05). This study showed that in paced patients presenting with cardiac failure and systolic dysfunction refractory to medical treatment, upgrading from a conventional pacing system to a biventricular pacemaker leads to a significant improvement in functional symptoms.