Hemodynamic effects of larger volume intra-aortic balloon pump during high-risk percutaneous coronary interventions.

BACKGROUND: Percutaneous coronary intervention in high-risk patients (HRPCI) is associated with increased risk of complications. Mechanical circulatory support devices, including intra-aortic balloon pump (IABP) may bridge patient safely throughout the procedure. AIM: We aimed to describe hemodynamic effects of larger (MEGA) compared to standard (STRD) volume IABP or no balloon control group (CTRL) during HRPCI. METHODS: In this single-center, open-label randomized controlled trial HRPCI were randomly assigned to three groups according to planned hemodynamic support: MEGA, STDR and CTRL in a 1:1:1 scheme. Screening failure patients formed registry (REG). We analyzed data from pulmonary artery catheter especially cardiac output and cardiac power output (CPO) with Fick method and pulmonary artery wedge pressure (PCWP), as well as left ventricle systolic pressure (LVSP) with PIGTAIL catheter. We also calculated endocardial viability ratio (EVR) and analyzed pressure tracings from the IABP console. We compared baseline and on-support values. Final hemodynamic analysis was done on per-treatment basis, including REG patients. RESULTS: A total of 47 patients were analyzed (16 MEGA, 10 STRD and 21 CTRL). Compared to CTRL we found significant increase from baseline to on-support value for cardiac output and CPO in the MEGA, but not in the STRD group. The change in EVR (increase) and in LVSP (decrease) was significant equally in MEGA and STRD vs. CTRL group, but PCWP did not change significantly for both balloons vs. CTRL. Diastolic augmented pressure with IABP was higher in MEGA than STRD and was positively correlated with systolic unloading. CONCLUSIONS: We observed more favorable hemodynamic effects of larger compared to standard volume balloon.

Latest Developments in Robotic Percutaneous Coronary Interventions.

Since the first robotic-assisted percutaneous coronary intervention procedure (R-PCI) was performed in 2004, there has been a steady evolution in robotic technology, combined with a growth in the number of robotic installations worldwide and operator experience. This review summarises the latest developments in R-PCI with a focus on developments in robotic technology, procedural complexity, tele-stenting and training methods, which have all contributed to the global expansion in R-PCI.

Paroxysmal Sustained Ventricular Tachycardia with Cardiac Arrest and Myocardial Infarction in 29-Year-Old Man Addicted to Medical Marijuana-It Never Rains but It Pours.

This article presents the case of a 29-year-old male patient, addicted to prescribed medical marijuana administered for mixed anxiety and depressive disorder and without classic cardiovascular risk factors and history of myocarditis, suffering from episodes of paroxysmal hemodynamically unstable ventricular tachycardia. Cardiovascular magnetic resonance imaging of the heart revealed disseminated non-ischemic myocardial injury lesions of subepicardial and intramuscular location. Additionally, the individual experienced myocardial infarction without ST segment elevation following marijuana intake. Treatment required implantation of a cardioverter-defibrillator and ablation of the myocardial areas responsible for the origin of the arrhythmia, as well as appropriate pharmacotherapy and marijuana addiction treatment.

Complication during robotic-PCI: Iatrogenic guiding catheter dissection.

Robotic-assisted percutaneous interventions (R-PCI) is a revolutionary technology designed to improve operator safety and procedural precision. The second-generation CorPath GRX (Corindus) R-PCI platform allows operators to manipulate the guiding catheter using robotic joystick controls. We report a case where robotic guide catheter manipulation caused a dramatic left main stem dissection. We highlight important concepts learned following this complication.

Impact of COVID-19 Pandemic on Patients with ST-Segment-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest.

Patients with ST-segment-elevation myocardial infarction (STEMI) treated during the COVID-19 pandemic might experience prolonged time to reperfusion. The delayed reperfusion may potentially aggravate the risk of out-of-hospital cardiac arrest (OHCA) in those patients. Limited access to healthcare, more reluctant health-seeking behaviors, and bystander readiness to render life-saving interventions might additionally contribute to the suggested change in the risk of OHCA in STEMI. Thus, we sought to explore the effects of the COVID-19 outbreak on treatment delay and clinical outcomes of patients with STEMI with OHCA. Overall, 5,501 consecutive patients with STEMI complicated by OHCA and treated with primary percutaneous coronary intervention with stent implantation were enrolled. A propensity score matching was used to obviate the possible impact of non-randomized design. A total of 740 matched pairs of patients with STEMI and OHCA treated before and during the COVID-19 pandemic were compared. A similar mortality and prevalence of periprocedural complications were observed in both groups. However, patients treated during the COVID-19 outbreak experienced longer delays from first medical contact to angiography (88.8 (±61.5) vs. 101.4 (±109.8) [minutes]; p = 0.006). There was also a trend toward prolonged time from pain onset to angiography in patients admitted to the hospital in the pandemic era (207.3 (±192.8) vs. 227.9 (±231.4) [minutes]; p = 0.06). In conclusion, the periprocedural outcomes in STEMI complicated by OHCA were comparable before and during the COVID-19 era. However, treatment in the COVID-19 outbreak was associated with a longer time from first medical contact to reperfusion.

Circulatory support with larger volume intra-aortic balloon pump vs. standard volume or no-balloon pump during high-risk percutaneous coronary interventions. A randomised study.

INTRODUCTION: Percutaneous coronary intervention in high-risk patients (HRPCI) is associated with increased risk of periprocedural complications such as hypotension and shock. Mechanical circulatory support devices may the bridge patient safely throughout the procedure and are often used in this setting. AIM: We assessed the outcomes of patients subjected to HRPCI and supported with intra-aortic balloon pump (IABP) of larger volume (MEGA) compared to standard volume (STRD) or no balloon support at all (CTRL). MATERIAL AND METHODS: In this single-centre, open-label, randomised, controlled trial, HRPCI patients were randomly assigned to three groups: MEGA, STRD, and CTRL in a 1 : 1 : 1 scheme. Screening failure patients were assigned to the registry (REG). Composite haemodynamic endpoint (CHEP) was assessed during the procedure and major adverse cardiac even (MACE)/safety endpoints up to 1-year follow-up (FU). RESULTS: A total of 36 patients were randomised (13 MEGA, 14 STRD, and 9 CTRL). The incidence of in-hospital MACE was observed in 23.1% of MEGA, 7.1% of STRD and 33.3% of CTRL (p = 0.25) patients; MACE at FU in 50.0%, 35.7%, and 55.6% (p = 0.61); major bleeding in 46.2%, 28.6%, and 22.2%, (p = 0.45); and CHEP in 15.4%, 50.0%, and 44.4%, respectively (p = 0.13). On per-treatment (PT) analysis (16 MEGA, 10 STRD, and 21 CTRL), including 11 patients from REG, in-hospital MACE was observed in 18.8% of MEGA, 10.0% of STRD, and 23.8% of CTRL (p = 0.64) patients; MACE at FU in 53.3%, 20.0%, and 57.1% (p = 0.12); major bleeding in 37.5%, 20.0%, and 33.3% (p = 0.62); and CHEP in 15.5%, 50.0%, and 52.4%, respectively (p = 0.023). CONCLUSIONS: Larger volume intra-aortic balloon pump might be effective at reducing haemodynamic instability during HRPCI without a statistically significant effect on safety endpoints or MACE.

Adaptation of global hemostasis to therapeutic hypothermia in patients with out-of-hospital cardiac arrest: Thromboelastography study.

BACKGROUND: The use of mild therapeutic hypothermia (MTH) in patients after out-of-hospital cardiac arrest (OHCA) who are undergoing primary percutaneous coronary intervention (pPCI) can protect patients from thromboembolic complications. The aim of the study was to evaluate the adaptive mecha- nisms of the coagulation system in MTH-treated comatose OHCA survivors. METHODS: Twenty one comatose OHCA survivors with acute coronary syndrome undergoing imme- diate pPCI were treated with MTH. Quantitative and qualitative analyses of physical clot properties were performed using thromboelastography (TEG). Two analysis time points were proposed: 1) during MTH with in vitro rewarming conditions (37°C) and 2) after restoration of normothermia (NT) under normal (37°C) and in vitro cooling conditions (32°C). RESULTS: During MTH compared to NT, reaction time (R) was lengthened, clot kinetic parameter (a) was significantly reduced, but no effect on clot strength (MA) was observed. Finally, the coagulation index (CI) was significantly reduced with clot fibrinolysis attenuated during MTH. The clot lysis time (CLT) was shortened, and clot stability (LY60) was lower compared with those values during NT. In vitro cooling generally influenced clot kinetics and reduced clot stability after treatment. CONCLUSIONS: Thromboelastography is a useful method for evaluation of coagulation system dysfunc- tion in OHCA survivors undergoing MTH. Coagulation impairment in hypothermia was associated with a reduced rate of clot formation, increased weakness of clot strength, and disturbances of fibrinoly- sis. Blood sample analyses performed at 32°C during MTH, instead of the standard 37°C, seems to enhance the accuracy of the evaluation of coagulation impairment in hypothermia.

Clinical course and prognostic factors of patients in severe accidental hypothermia with circulatory instability rewarmed with veno-arterial ECMO - an observational case series study.

BACKGROUND: Recently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has become the rewarming treatment of choice in hypothermic cardiac arrest. The detailed indications for extracorporeal rewarming in non-arrested, severely hypothermic patients with circulatory instability have not been established yet. The primary purpose of the study was a preliminary analysis of all aspects of the treatment process, as well as initial identification of mortality risk factors within the group of severely hypothermic patients, treated with arteriovenous extracorporeal membrane oxygenation (VA-ECMO). The secondary aim of the study was to evaluate efficacy of VA-ECMO in initial 6-h period of treatment METHODS: From July 2013 to June 2016, thirty one hypothermic patients were accepted for extracorporeal rewarming at Severe Accidental Hypothermia Center, Cracow. Thirteen patients were identified with circulatory instability and were enrolled in the study. The evaluation took into account patients' condition on admission, the course of therapy, and changes in laboratory and hemodynamic parameters. RESULTS: Nine out of 13 analyzed patients survived (69%). Patients who died were older, had lower both systolic and diastolic pressure, and had increased creatinine an potassium levels on admission. In surviving patients, arterial blood gases parameters (pH, BE, HCO3) and lactates would normalize more quickly. Their potassium level was lower on admission as well. The values of the core temperature on admission were comparable. Although normothermia was achieved in 92% of patients, none of them had been weaned-off VA-ECMO in the first 6 h of treatment. DISCUSSION AND CONCLUSIONS: In our preliminary study more pronounced markers of cardiocirculatory instability and organ hypoperfusion were observed in non-survivors. Future studies on indications to extracorporeal rewarming in severely hypothermic, non-arrested patients should focus on the extent of hemodynamic disturbances. Short term (<6 h) treatment in severe hypothermic, non-arrested patients seems to be not clinically appropriate.

Ten-year experience of an invasive cardiology centre with out-of-hospital cardiac arrest patients admitted for urgent coronary angiography.

BACKGROUND AND AIM: The aim of the study was to evaluate survival and neurological function of out-of-hospital cardiac arrest (OHCA) patients admitted for urgent coronary angiography (UCA) with a view to percutaneous coronary intervention (PCI). METHODS: Hospital records of OHCA patients admitted to an invasive cardiology centre (providing 24 h a day/7 days a week service) in 2000-2010 were reviewed retrospectively, and similar data collected in 2011 were reviewed prospectively. Reports from the pre-hospital phase from emergency medical services (EMS) in Krakow were also analysed. Long-term follow-up data were collected by retrieving records from other hospitals (for patients transferred after UCA/PCI) and by phone calls to patients or their relatives. RESULTS: In 2000-2011, 405 OHCA patients were admitted for UCA/PCI. Most (78%) had ventricular fibrillation (VF) or ventricular tachycardia (VT) as the primary mechanism of cardiac arrest (asystole: 13%, pulseless electrical activity: 3%, unknown: 6%). The mean patient age was 61 (range 20-85) years, and 81% were males. On admission, about 70% of patients were unconscious and 11% were in cardiogenic shock. The mean resuscitation time (time to return of spontaneous circulation [ROSC]) was 26.7 (range 1-126) min. ST-T changes seen in an electrocardiogram recorded after ROSC included ST elevation and depression in 52% of cases, only ST depression in 21% of cases, only ST elevation in 17% of cases, unspecific changes (due to intraventricular conduction disturbances) in 7% of cases, negative T waves in 3% of cases, and no changes in 0.5% of cases. Coronary angiography revealed acute coronary occlusion in 48% of cases, critical coronary stenosis (> 90%) in 26% of cases, other significant coronary lesions (> 50% stenosis) in 15% of cases, and non-significant lesions in 11% of cases. An acute coronary syndrome (ACS) was diagnosed in 82% of patients (75% STEMI, 25% NSTEMI), and other cardiac cause (mostly ischaemic cardiomyopathy) was identified in 13% of patients. Among OHCA patients diagnosed with ACS, PCI was performed in 90% and additional 4% underwent coronary artery bypass grafting. Overall success rate of PCI, defined as TIMI 3 flow plus residual stenosis < 50% and resolution of ST elevation after PCI by > 30%, was 70%. Survival to hospital discharge in the entire group of OHCA patients was 63% and 30-day survival with good neurological outcomes (defined as Cerebral Performance Category 1 or 2) was 49%. Among patients who were initially unconscious, those figures were 52% and 33%, respectively. During long-term follow-up (up to 12 years), 49% of patients were alive and 42% had good neurological function (87% of those who survived). In multivariate analysis, independent predictors of survival with good neurological outcomes were preserved consciousness on admission, absence of shock, cardiac arrest witnessed by medical personnel, VF/VT as a primary mechanism of cardiac arrest, and preserved renal function. Successful PCI predicted survival until hospital discharge only when the neurological status of the patients was not taken into account. CONCLUSIONS: The most important cause of OHCA is coronary artery disease, in particular ACS. UCA and PCI seem to be important elements of appropriate post-resuscitation care because such treatment could improve survival but it is still unclear whether PCI might influence neurological outcomes as well.

[Quantitative culture sampling of tracheal aspirates for diagnosis of nosocomial pneumonia in the ITU]. / Szpitalne zapalenie pluc w OIT--obserwacje w oparciu o zastosowanie posiewu ilosciowego z tchawicy w diagnostyce zakazenia.

BACKGROUND: Nosocomial pneumonia is defined as a pneumonia developing within 48 hours of admission, in a patient with previously normal lung tissue. Ventilator-associated pneumonia (VAP) due to migration of microorganisms from the nose, throat and digestive tract is typical in ITU patients. Microbiological diagnosis is difficult, and there is no single method approved for VAP diagnosis. We have assessed the usefulness of Quantitative Endotracheal Aspirate (QETA) for this purpose, basing on its reported high sensitivity (mean 76% +/- 9%) and specificity (mean 75 +/- 28%). METHODS: Endotracheal aspirates were sampled from ITU patients fulfilling the following criteria: (1) New or progressive infiltrations in the lungs plus hyperthermia (>38.3 degrees C) or hypothermia (<36 degrees C); (2) leukocytosis (>12 G L(-1)) or leukopenia (<4 G L(-1)); or (3) purulent sputum. RESULTS: Nosocomial pneumonia was diagnosed in 40 out of 312 patients treated in the ITU during the study period. VAP was diagnosed in 33 patients. Multi-drug resistant bacteria: Pseudomonas aeruginosa (16), Acinetobacter baumannii (19), ESBL pathogens (8) and MRSA (1) were cultured from QETA in 32 patients. The sensitivity of QETA was 86%. CONCLUSION: The results allowed for early and accurate diagnosis of nosocomial pneumonia and institution of the best possible treatment.

[Microbiological characterization of pneumonia in patients of intensive care unit]. / Mikrobiologiczna charakterystyka zapalen pluc u pacjentów oddzialu intensywnej terapii.

The aim of study was bacteria characterization, isolated from 30 patients with microbiologically confirmed pneumonia, hospitalized in ICU of Rydygier's Hospital in Krakow. In the study, endotracheal aspirates (ETA) were being collected and quantitatively inoculated. Bacteria isolation at the concentration of > or =10(6) CFU/ml was recognized as bacteriological etiology of pneumonia. Studied 140 clinical materials and isolated 251 bacterial strains from 16 divers species. Isolation of bacteria at the concentration of > or = 10(6) CFU/ml, on the day of clinically recognized HAP, was observed in 26 patients and presence of 1 species of bacteria at the pathological concentration was detected in 17 patients. In the study of endotracheal aspirates, which were collected after 3 and 6 days of treatment, isolation of bacteria species at the significant concentration was observed appropriate in 15 and 10 patients. In the etiology of infections predominated: P. aeruginosa, A. baumannii, S. maltophilia (17 strains; 47.2%) and Enterobacteriaceae bacilli (12 strains; 33%), including bacilli ESBL-positive. The surveillance of bacterial susceptibility patterns detected high percentage of resistance P. aeruginosa strains to imipenem (38.7%).