Left Ventricular Unloading With Impella Versus IABP in Patients With VA-ECMO: A Systematic Review and Meta-Analysis.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2 = 71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2 = 82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2 = 66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.

Myocardial work index during normal dobutamine stress echocardiography.

Dobutamine stress echocardiography is an alternative method to exercise stress echocardiography for the evaluation of ischemia. Recently, the novel speckle tracking imaging derived parameter, myocardial work index, was suggested for the evaluation of cardiac performance and was evaluated during exercise stress echocardiography. In this study, we analyzed the effect of dobutamine on myocardial work index variables during normal dobutamine stress echocardiography. Echocardiography examinations of patients with normal dobutamine stress echocardiography were collected and underwent off-line speckle tracking imaging analysis. Myocardial work index parameters were calculated at each dose of dobutamine and compared. 286 patients underwent dobutamine stress echocardiography during the study period. 102 patients were excluded due to pre-existed coronary artery disease or ischemia at dobutamine stress echocardiography. 65 patients were excluded due to suboptimal image quality unsuitable for speckle tracking imaging analysis. The remaining 119 patients with normal results were included. The global work index decreased from 2393.3 to 1864.7 mmHg%, p < 0.0004. Global constructive work decreased from 2681.7 to 2152.6 mmHg%, p = 0.001. Global wasted work increased from 78.8 to 128.3 mmHg%, p < 0.003. Global work efficacy decreased from 96.1 to 91.9%, p < 0.00001. Global strain increased from-19.6 to - 23.7%, p < 0.00001. Dobutamine stress echocardiography results in a decrease of all specific myocardial work index parameters even in normal subjects. Only global myocardial strain improved.

Biological basis of lymphocyte ratios for survival prediction in hemodialysis patients: a longitudinal study.

PURPOSE: The neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios have been proposed as emerging markers of inflammation and prognosis in maintenance hemodialysis (MHD) patients. However, to date, no longitudinal performance of these indices is known. The study's purpose was to examine the longitudinal relationship between NLR, PLR, inflammatory and nutritional parameters in MHD patients and how their changes over time associate with adverse clinical outcomes. METHODS: A historical longitudinal cohort study was conducted using a clinical database which included 554 patients (mean age, 67.6 ± 14.2 years; 34% women) from a single center receiving MHD from November 2007 to July 2018. NLR, PLR, C-reactive protein (CRP) and nutritional parameters were recorded at 0, 6, 12, 18, 24, 30 and 36 months, followed by 58 additional months of clinical observations. RESULTS: In a linear mixed-effects model adjusted for baseline demographics and clinical parameters, including white blood cell count, NLR and PLR were both associated with CRP levels at any given time point observation (linear estimates (95% CI): 1.53, (0.11-2.95) and 1.55 (0.15-2.93), respectively). For each 1.0-unit increase in NLR over time, the fully adjusted all-cause mortality hazard ratio using Cox models with the time-varying risk effect was 1.04 (95% CI 1.01-1.07, P = 0.006). However, when CRP was included in this model, the relationship was no longer significant. PLR's performance did not match the prognostic marker. CONCLUSION: Longitudinal changes in NLR mimic CRP changes and predict all-cause mortality risk in MHD patients.