Clinical effectiveness of therapy with continuous-flow left ventricular assist devices in nonischemic versus ischemic cardiomyopathy: a systematic review and meta-analysis.

Background: Clinicians may be less inclined to consider long-term left ventricular assist device (LVAD) therapy in end-stage heart failure (ESHF) as a result of nonischemic cardiomyopathy (NICM) versus ischemic cardiomyopathy (ICM) owing to potentially greater right ventricular involvement in the former; however, it is unknown whether the cause of heart failure has a clinically meaningful effect on outcomes following LVAD implantation. In this systematic review, we aimed to determine whether ischemic versus nonischemic etiology has any impact on patient-relevant outcomes. Methods: We searched MEDLINE, Embase, PubMed and the Cochrane Library for studies published in English between Jan. 1, 2000, and Nov. 22, 2018, that examined survival and transplantation rates following LVAD implantation in patients with NICM or ICM. Randomized clinical trials, cohort studies, case-control studies, cross-sectional studies and case series with a sample size of at least 8 patients were eligible for inclusion. To be included in the meta-analysis, outcomes had to include at least death reported at 30 days or 1 year after LVAD implantation. Quality of included studies was assessed by 2 independent reviewers using the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) quality-assessment tool was used to assess outcomes (30-d survival, 1-yr survival and cardiac transplantation following LVAD therapy) across studies. Results: From a total of 2843 citations identified, 7 studies met all inclusion criteria. Studies were generally of good quality, but reporting of patient demographic characteristics, outcomes and complications was heterogeneous. We found no significant difference in 30-day or 1-year survival or in cardiac transplantation rates after device implantation between the NICM and ICM groups. Patients in the 2 groups had similar outcomes up to 1 year with LVAD therapy. Conclusion: Early outcomes of LVAD therapy do not appear to be affected by heart failure etiology. Ongoing investigation is required to determine the long-term outcomes of LVAD therapy in ICM and NICM. Systematic review registration: PROSPERO register, record ID 76483.

Contexte: Les professionnels de la santé peuvent être moins enclins à envisager un traitement à long terme par dispositif d'assistance ventriculaire gauche (DAVG) en cas d'insuffisance cardiaque terminale résultant d'une myocardiopathie non ischémique plutôt que d'une myocardiopathie ischémique, en raison du risque potentiellement accru d'atteinte du ventricule droit dans le premier cas. Cependant, on ne sait pas si la cause de l'insuffisance cardiaque a un effet clinique significatif sur les issues après l'implantation d'un DAVG. Dans cette revue systématique, nous avons voulu déterminer si l'étiologie ischémique ou non ischémique a une incidence sur les issues pour les patients. Méthodes: Nous avons interrogé MEDLINE, Embase, PubMed et la Bibliothèque Cochrane pour trouver les études publiées en anglais entre le 1er janvier 2000 et le 22 novembre 2018 qui examinaient la survie et le taux de greffe après l'implantation d'un DAVG chez les patients atteints d'une insuffisance cardiaque ischémique ou non ischémique. Les essais cliniques randomisés, les études de cohorte, les études cas­témoins, les études transversales et les séries de cas ayant un échantillon d'au moins 8 patients étaient admissibles pour inclusion. Pour qu'une publication soit incluse dans la méta-analyse, les issues à l'étude devaient comprendre au minimum les décès dans les 30 jours ou dans l'année suivant l'implantation du DAVG. La qualité des études retenues a été évaluée par 2 évaluateurs indépendants au moyen de l'échelle Newcastle­Ottawa pour l'évaluation de la qualité des études de cohorte. L'outil GRADE (Grading of Recommendations Assessment, Development and Evaluation) a servi à évaluer la qualité des données sur les issues (survie après 30 jours, survie après 1 an et greffe cardiaque après le traitement par DAVG) dans l'ensemble des études. Résultats: Sur les 2843 citations recensées, 7 études respectaient tous les critères d'inclusion. Elles étaient généralement de bonne qualité, mais l'indication des caractéristiques démographiques des patients, des issues et des complications était hétérogène. Nous n'avons trouvé aucune différence significative dans la survie après 30 jours ou après 1 an, ni dans le taux de greffe cardiaque après l'implantation du dispositif entre les groupes ischémique et non ischémique. Les patients des 2 groupes avaient des issues similaires jusqu'à 1 an après le traitement par DAVG. Conclusion: Les issues à court terme du traitement par DAVG ne semblent pas influencées par l'étiologie de l'insuffisance cardiaque. Il faudra faire d'autres études pour caractériser les issues à long terme en présence d'insuffisance cardiaque ischémique et non ischémique. Enregistrement de la revue systématique: Registre PROSPERO, numéro 76483.

Indication for ECMO predicts time to first actionable bleeding complication.

Purpose: Bleeding is a major complication of patients requiring extracorporeal membrane oxygenation (ECMO). Several risk factors have been identified; however, there remains a paucity of evidence for optimal management of anticoagulation and bleeding in ECMO patients. Methods: A total of 255 patients required ECMO from January 1996 to December 2021 at a single institution. The Bleeding Academic Research Consortium (BARC) Score was used for defining actionable bleeding. Univariate and multivariate testing were used for outcome analysis. Kaplan-Meier survival curves were plotted for time-to-event analysis. Results: Of the 255 patients, 147 patients had no actionable bleeding complications, while 108 had at least one actionable bleeding complication. Duration of support (p<0.001) and total number of transfusions (p<0.001) differed between the two groups significantly, with no significant difference in survival to discharge (p=0.894). On multivariate regression, significant predictors for actionable bleeding complications included diabetes (OR 2.01, p=0.03), precannulation hematocrit (OR 0.97, p<0.001), length of support (OR 1.00, p<0.001), use of warfarin (OR 2.28, p=0.03), and post-cardiotomy indication for ECMO (OR 0.77, p=0.02). The median time to first actionable bleeding complication after cannulation was 141.2 h. When stratified by indication for ECMO or type of ECMO circuit, there was a significant difference in time to first actionable bleeding complication (p=0.001, p=0.018). Conclusions: Indication for ECMO and type of ECMO circuit both are predictive of timing to first actionable bleeding complication in our study. Further data are needed to reliably establish individualized anticoagulation strategies and bleeding management based on indication and circuit setup. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01601-9.

Radical mediastinal lipectomy for tamponade-like cardiac physiology.

BACKGROUND: Re-opening the chest is an unwanted and potentially morbid complication after open heart surgery, most commonly required for refractory bleeding or tamponade. In this report, we present a unique case of a postoperative coronary artery bypass patient, demonstrating clinical features of cardiac tamponade of the right atrium and ventricle with inconclusive findings on imaging. CASE PRESENTATION: A 62 year-old male presented to hospital with exertional angina and a coronary angiogram found severe three-vessel coronary artery disease with preserved left ventricular function. He underwent an uncomplicated triple coronary artery bypass surgery. Over the following hours in the cardiac intensive care unit, the patient had a climbing serum lactate level and increasing vasopressor requirements. On investigations, there was evidence of compression of the right heart. The patient was taken back to the operating room where very little clot or bleeding was identified, rather there was significant amounts of mediastinal fat surrounding the heart which was subsequently resected with wide margins. The patient had complete resolution of their symptoms and an uncomplicated postoperative course thereafter. CONCLUSIONS: To our knowledge, this case is the first reported occurrence of cardiac constriction from excessive mediastinal fat after open heart surgery. Identifying patients at high-risk for excessive pericardial fat, as well as considering alternative modalities of imaging appear to be the main stay in diagnosis at this point. Current treatment is a mediastinal lipectomy with wide margins, avoiding injury to surrounding structures such as the phrenic nerve and innominate vein. Future study might consider the value of prophylactic mediastinal lipectomy at time of surgery, and methods to improve detection with current and future imaging modalities.

Bridge to heart transplantation in patients with cardiogenic shock: a 20-year experience with two different surgical strategies.

AIMS: We aimed to describe how treatment of patients in cardiogenic shock bridged to heart transplantation with mechanical circulatory support, using either biventricular assist devices (BVADs) or extracorporeal life support (ECLS), has evolved in the last 20 years in our centre. METHODS: Since 1998, 72 patients with refractory heart failure and indication for heart transplantation have received mechanical circulatory support: 40 had an ECLS system and 32 a BVAD. RESULTS: Early mortality was similar (17.5 vs. 9.4%, P = 0.25) regardless of the type of support. After a median support time of 8 (1-27) vs. 34 (0-385) days (P < 0.01), 70 vs. 65.6% (P = 0.69) of patients underwent transplantation in the two groups. Prior to transplantation, BVAD patients were more stable with lower need for mechanical ventilation (9 vs. 57%, P < 0.01) and dialysis (0 vs. 38%, P < 0.01). Thirty-day mortality after transplantation was similar (18 vs. 14%, P = 0.53). Patients with extracorporeal support had higher rates of renal (P = 0.02) and respiratory failure (P = 0.03), infections (P = 0.02), atrial fibrillation (P = 0.03) and longer ICU stay (P = 0.01). Late survival was similar, while 5-year freedom from coronary vasculopathy was higher in those with BVAD (P = 0.03). CONCLUSION: Although ECLS provides faster and simpler assistance compared with BVADs, no differences in early and medium-term outcomes in the last 20 years were observed in patients with cardiogenic shock. However, BVADs provided longer duration of support, better multiorgan recovery allowing more adequate graft selection, resulting in a lower rate of posttransplant complications.

Critical Care Management of the Acute Postimplant LVAD Patient.

Left ventricular assist devices (LVADs) improve survival and quality of life in refractory end-stage heart failure. However, the therapy itself is associated with some degree of morbidity and mortality at highest risk during the first 30 days postimplantation. Management of the patient with a freshly implanted LVAD requires an in-depth understanding of the acute postimplant period and common critical care issues including coagulopathy, hemodynamic lability, and metabolic derangements. This requires meticulous hemostatic control and a firm understanding of hemodynamic principles that focus on optimizing end-organ perfusion, right-ventricular function, and measured LVAD titration. This contemporary practical guide to management of the acute postimplant LVAD patient includes a focused approach to troubleshooting common LVAD issues that may arise from the operating room to discharge from critical care.

Cost-Effectiveness Analysis of Frailty Assessment in Older Patients Undergoing Coronary Artery Bypass Grafting Surgery.

BACKGROUND: In perioperative settings, frailty assessment has been shown to reduce mortality. This study examined the cost effectiveness of frailty assessment among patients aged 65 with coronary artery disease under consideration for coronary artery bypass grafting surgery. METHODS: A combined decision tree and Markov model was developed to estimate costs and quality-adjusted life years (QALYs) over a 21-year time horizon. Clinical parameters were obtained from published literature. Utilities were derived from the literature and the Canadian Community Health Survey. Costs were obtained from the Ontario fee schedule and published literature. Sensitivity and scenario analyses were conducted to assess the robustness of the results. Expected value of perfect information (EVPI) analysis was conducted to estimate the value of further research. RESULTS: The frailty assessment initiative had a lower average cost than no frailty assessment ($19,567 compared with $20,062). QALYs with frailty assessment were 0.47 years more than with no frailty assessment. Thus, frailty assessment was dominant compared with no frailty assessment. Results were robust to changes in the input parameters. At a willingness to pay (WTP) threshold of $50,000/QALY, there was 100% probability of frailty assessment being cost-effective, and the EVPI per patient was $0. Scenario and sensitivity analysis showed frailty screening remained cost effective when changing the cohort average age, removing health benefits for nonfrail patients, and using subjective judgement to modify effectiveness parameters. CONCLUSIONS: Frailty assessment may be good value for money. However, limited availability of geriatric consultation services, may hinder implementation. Thus, the estimated benefits of frailty screening may not be achievable in practice.

Efferocytic Defects in Early Atherosclerosis Are Driven by GATA2 Overexpression in Macrophages.

The loss of efferocytosis-the phagocytic clearance of apoptotic cells-is an initiating event in atherosclerotic plaque formation. While the loss of macrophage efferocytosis is a prerequisite for advanced plaque formation, the transcriptional and cellular events in the pre-lesion site that drive these defects are poorly defined. Transcriptomic analysis of macrophages recovered from early-stage human atherosclerotic lesions identified a 50-fold increase in the expression of GATA2, a transcription factor whose expression is normally restricted to the hematopoietic compartment. GATA2 overexpression in vitro recapitulated many of the functional defects reported in patient macrophages, including deficits at multiple stages in the efferocytic process. These findings included defects in the uptake of apoptotic cells, efferosome maturation, and in phagolysosome function. These efferocytic defects were a product of GATA2-driven alterations in the expression of key regulatory proteins, including Src-family kinases, Rab7 and components of both the vacuolar ATPase and NADPH oxidase complexes. In summary, these data identify a mechanism by which efferocytic capacity is lost in the early stages of plaque formation, thus setting the stage for the accumulation of uncleared apoptotic cells that comprise the bulk of atherosclerotic plaques.

Starch or Saline After Cardiac Surgery: A Double-Blinded Randomized Controlled Trial.

BACKGROUND: Despite decades of investigation, the balance of clinical risks and benefits of fluid supplementation with starch remain unresolved. Patient-centered outcomes have not been well explored in a "real-world" trial in cardiac surgery. OBJECTIVE: We sought to compare a starch-based fluid strategy with a saline-based fluid strategy in the cardiac surgery patient. DESIGN: A pragmatic blinded randomized controlled trial comparing starch-based with saline-based fluid strategy. SETTING: A large tertiary academic center in London Ontario between September 2009 and February 2011. PARTICIPANTS: Patients undergoing planned, isolated coronary revascularization. MEASUREMENTS: Serum creatinine and patient weight were measured daily postoperatively. METHODS: Patients were randomized to receive 6% hydroxyethyl starch (Voluven) or saline for perioperative fluid requirements. Fluid administration was not protocolized. Co-primary outcomes were incidence of acute kidney injury (AKI) and maximum postoperative weight gain. Secondary outcomes included bleeding, transfusion, inotropic and ventilator support, and fluid utilization. RESULTS: The study was prematurely terminated due to resource limitations. A total of 69 patients (19% female, mean age = 65) were randomized. Using RIFLE criteria for AKI, "risk" occurred in 12 patients in each group (risk ratio [RR] = 1.0; 95% confidence interval [CI] = 0.5-1.9; P = 1.00), whereas "injury" occurred in 7 of 35 (20%) and 3 of 34 (9%) of patients in the starch and saline groups, respectively (RR = 2.3; 95% CI = 0.6-8.1; P = .31). Maximum weight gain, bleeding and blood product usage, and overall fluid requirement were similar between groups. LIMITATIONS: The study had to be prematurely terminated due to resource limitations which led to a small sample size which was not sufficiently powered to detect a difference in the primary outcomes. CONCLUSIONS: This pragmatic double-blinded randomized controlled trial revealed a number of interesting hypothesis-generating trends and confirmed the feasibility of undertaking a logistically complex trial in a pragmatic fashion.

CONTEXTE: L'équilibre entre les avantages et les risques cliniques d'une supplémentation en fluides à base d'amidon n'est toujours pas établi malgré des décennies d'études. Les résultats des patients subissant une chirurgie cardiaque n'ont pas été explorés suffisamment dans le cadre d'un essai concret. OBJECTIF: Comparer deux stratégies de supplémentation liquidienne, une solution à base d'amidon et une solution saline, chez des patients subissant une chirurgie cardiaque. TYPE D'ÉTUDE: Un essai pragmatique, contrôlé, à répartition aléatoire et mené en double insu comparant deux stratégies de supplémentation liquidienne une solution à base d'amidon et une solution saline. CADRE: Un grand centre universitaire de soins tertiaires de London (Ontario) entre septembre 2009 et février 2011. SUJETS: Des patients subissant une revascularisation coronarienne planifiée et isolée. MESURES: La créatinine sérique et le poids du patient ont été mesurés quotidiennement à la suite de l'intervention. MÉTHODOLOGIE: Les patients ont été répartis aléatoirement pour recevoir du Voluven (solution d'amidon hydroxyéthylé à 6 %) ou une solution saline pour les fluidiques périopératoires. L'administration ne s'est pas faite selon un protocole établi. L'incidence d'insuffisance rénale aiguë (IRA) et un gain pondéral maximal après l'intervention constituaient les deux principaux résultats mesurés. Les résultats secondaires incluaient une hémorragie, l'utilisation de transfusion sanguine, d'inotrope, d'assistance respiratoire et l'administration de fluides. RÉSULTATS: L'étude a été interrompue prématurément par manque de ressources. Les 69 patients (19 % de femmes) répartis aléatoirement avaient en moyenne 65 ans. La classification RIFLE avait permis de détecter un « risque ¼ d'IRA chez 12 patients dans chacun des groupes (RC: 1,0; IC 95 %: 0,5-1,9; p=1,00) et une « insuffisance ¼ chez 7 patients sur 35 (20 %) du groupe « amidon ¼ et 3 patients sur 34 (9 %) du groupe « saline ¼ (RC: 2,3; IC 95 %: 0,6-8,1; p=0,31). Le gain pondéral maximal, le nombre d'hémorragies, l'utilisation de produits sanguins et les besoins liquidiens étaient similaires dans les deux groupes. LIMITES: L'étude a été interrompue prématurément en raison d'un manque de ressources. Par conséquent, le faible échantillon de patients s'avère insuffisamment puissant pour détecter des différences significatives entre les deux groupes. CONCLUSIONS: Cette étude a mis en lumière quelques tendances permettant d'émettre des hypothèses intéressantes. L'étude a également confirmé la possibilité d'entreprendre un essai logistique complexe de manière pragmatique.

Levosimendan in patients with reduced left ventricular function undergoing isolated coronary or valve surgery.

OBJECTIVE: In the Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial, no differences in clinical outcomes were observed between levosimendan and placebo in a broad population of patients undergoing cardiac surgery. In previous studies, the benefits of levosimendan were most clearly evident in patients undergoing isolated coronary artery bypass grafting (CABG) surgery. In a prespecified analysis of LEVO-CTS, we compared treatment-related outcomes and costs across types of cardiac surgical procedures. METHODS: Overall, 563 (66.4%) patients underwent isolated CABG, 97 (11.4%) isolated valve, and 188 (22.2%) combined CABG/valve surgery. Outcomes included the co-primary 4-component composite (30-day mortality, 30-day renal replacement, 5-day myocardial infarction, or 5-day mechanical circulatory support), the 2-component composite (30-day mortality or 5-day mechanical circulatory support), 90-day mortality, low cardiac output syndrome (LCOS), and 30-day medical costs. RESULTS: The 4- and 2-component outcomes were not significantly different with levosimendan and placebo in patients undergoing CABG (15.2% vs 19.3% and 7.8% vs 10.4%), valve (49.0% vs 33.3% and 22.4% vs 2.1%), or combined procedures (39.6% vs 35.9% and 24.0% vs 19.6%). Ninety-day mortality was lower with levosimendan in isolated CABG (2.1% vs 7.9%; hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.11-0.64), but not significantly different in valve (8.3% vs 2.0%; HR, 4.10; 95% CI, 0.46-36.72) or combined procedures (10.4% vs 7.6%; HR, 1.39; 95% CI, 0.53-3.64; interaction P = .011). LCOS (12.0% vs 22.1%; odds ratio, 0.48; 95% CI, 0.30-0.76; interaction P = .118) was significantly lower in levosimendan-treated patients undergoing isolated CABG. Excluding study drug costs, median and mean 30-day costs were $53,707 and $65,852 for levosimendan and $54,636 and $67,122 for placebo, with a 30-day mean difference (levosimendan - placebo) of -$1270 (bootstrap 95% CI, -$8722 to $6165). CONCLUSIONS: Levosimendan was associated with lower 90-day mortality and LCOS in patients undergoing isolated CABG, but not in those undergoing isolated valve or combined CABG/valve procedures.

Prophylactic Right Ventricular Assist Device for High-Risk Patients Undergoing Valve Corrective Surgery.

BACKGROUND: Right ventricular failure (RVF) after cardiac surgery is associated with poor outcomes. Treatment commonly consists of afterload reduction, contractility optimization, and systemic vasopressors. The aim of this study was to propose a novel strategy of prophylactic right ventricular assist device (RVAD) insertion during valve corrective surgery for patients at high risk for RVF. METHODS: Between 2014 and 2017, 10 consecutive patients at high risk for RVF (severe baseline right ventricular dysfunction or systemic pulmonary artery pressures) underwent valve reconstructive surgery with prophylactic RVAD insertion. We reviewed patient characteristics and outcomes. RESULTS: All 10 patients had successful RVAD insertion, support and wean, and survival to hospital discharge. Generally, the right ventricle showed echocardiographic evidence of worsening function perioperatively but recovery of function at the time of follow-up. Patients required minimal inotropic support, and no patients required extracorporeal membrane oxygenation. Major complications included prolonged mechanical ventilation (n = 4), metabolic encephalopathy (n = 1), and sternal wound infection (n = 2). At a mean follow-up of 445.1 ± 230.9 days, 7 of 8 patients had clinically New York Heart Association functional class 1 (n = 7), and 1 patient had New York Heart Association functional class 2 (n = 1). There were 2 late mortalities. CONCLUSION: Prophylactic RVAD insertion may be useful in supporting patients at high risk for RVF perioperatively when undergoing high-risk valve corrective surgery. Further investigation is warranted.

INTRODUCTION: L'insuffisance ventriculaire droite (IVD) après l'intervention chirurgicale au cœur est associée à une évolution médiocre. Le traitement consiste généralement dans la réduction de la postcharge, l'optimisation de la contractilité et les vasopresseurs systémiques. L'objectif de la présente étude était de proposer une nouvelle stratégie d'implantation d'un dispositif d'assistance ventriculaire droite (DAVD) à visée prophylactique durant l'intervention de correction valvulaire chez les patients exposés à un risque élevé d'IVD. MÉTHODES: Entre 2014 et 2017, 10 patients consécutifs exposés à un risque élevé d'IVD (dysfonction initiale grave du ventricule droit ou pressions artérielles pulmonaires systémiques) ont subi une intervention de reconstruction valvulaire accompagnée de l'implantation d'un DAVD à visée prophylactique. Nous avons passé en revue les caractéristiques et l'évolution des patients. RÉSULTATS: Les 10 patients ont eu l'implantation d'un DAVD, l'assistance et le sevrage, et la survie jusqu'à la sortie de l'hôpital. Généralement, le ventricule droit montrait des signes échocardiographiques de détérioration de la fonction en phase périopératoire, mais un rétablissement de la fonction au moment du suivi. Les patients ont eu besoin d'un traitement inotrope minimal, mais aucun patient n'a eu besoin d'une oxygénation par membrane extracorporelle. Les principales complications étaient les suivantes : la ventilation mécanique prolongée (n = 4), l'encéphalopathie métabolique (n = 1) et l'infection de plaie sternale (n = 2). Au suivi moyen de 445,1 ± 230,9 jours, 7 des 8 patients étaient cliniquement dans la catégorie 1 selon la clase fonctionnelle de la New York Heart Association (n = 7), et 1 patient était dans la catégorie 2 selon la clase fonctionnelle de la New York Heart Association (n = 1). Le taux de mortalité tardive était de 2. CONCLUSION: L'implantation d'un DVAD à visée prophylactique peut être utile chez les patients exposés à un risque élevé d'IVD en phase périopératoire lorsqu'ils subissent une intervention de correction valvulaire à risque élevé. D'autres études sont justifiées.

Optimal Strategy and Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal Life Support for Adults in Cardiogenic Shock: A Systematic Review and Meta-Analysis.

BACKGROUND: Veno-arterial extracorporeal life support (VA-ECLS) is widely used to treat refractory cardiogenic shock. However, increased left ventricular (LV) afterload in VA-ECLS can worsen pulmonary congestion and compromise myocardial recovery. Our objectives were to explore the efficacy, safety, and optimal timing of adjunctive LV venting strategies. METHODS: A systematic search was performed on Medline, EMBASE, PubMed, CDSR, CCRCT, CINAHL, ClinicalTrials.Gov, and WHO ICTRP from inception until January 2019 for all relevant studies, including LV venting. Data were analyzed for mortality and weaning from VA-ECLS on the basis of timing of LV venting, along with adverse complications. RESULTS: A total of 7995 patients were included from 62 observational studies, wherein 3458 patients had LV venting during VA-ECLS. LV venting significantly improved weaning from VA-ECLS (odds ratio, 0.62 [95% CI, 0.47-0.83]; P=0.001) and reduced short-term (30 day; risk ratio [RR], 0.86 [95% CI, 0.77-0.96]; P=0.008) but not in-hospital (RR, 0.92 [95% CI, 0.83-1.01] P=0.09) or long-term (6 months; RR, 0.96 [95% CI, 0.90-1.03]; P=0.27) mortality. Early (<12 hours; RR, 0.86 [95% CI, 0.75-0.99]; P=0.03) but not late (≥12 hours; RR, 0.99 [95% CI, 0.71-1.38]; P=0.93) LV venting significantly reduced short-term mortality. Patients with LV venting spent more time on VA-ECLS (3.6 versus 2.8 days, P<0.001), and mechanical ventilation (7.1 versus 4.6 days, P=0.013). With the exception of hemolysis (RR, 2.18 [95% CI, 1.58-3.01]; P<0.00001), overall adverse events did not differ. CONCLUSIONS: LV venting, especially if done early (<12 hours), appears to be associated with an increased success of weaning and reduced short-term mortality. Future studies are required to delineate the importance of any or early LV venting adjuncts on mortality and morbidity outcomes.

Hemodynamic performance of stentless versus stented valves: a systematic review and meta-analysis.

BACKGROUND: Several trials have compared stentless with stented valves following aortic valve replacement (AVR). The goal of this review was to systematically locate, critically appraise, and quantitatively combine results to determine if stentless valves improve cardiac hemodynamics. METHODS: We performed an unrestricted search of Pubmed Medline, EMBASE, CINAHL, the Cochrane databases, and EBM reviews. Article reference lists and online abstracts from major North American conferences were also searched. We included randomized trials of adults undergoing AVR that compared stentless and stented valves. Blinded reviewers performed assessment of trials for inclusion and trial quality. Two individuals performed data extraction independently. Kappa statistics were used to assess reviewer agreement. A random effects model was employed for statistical analyses. Assessments were made for postoperative, early, and late outcomes. Heterogeneity was explored with sensitivity analyses. RESULTS: Eight studies were identified for inclusion in the primary analysis, with four others included in sensitivity analyses. Baseline comparisons between groups revealed no differences. Our primary analyses revealed no differences between groups for assessments of LV mass or mean transvalvular gradients. Secondary analyses showed stentless valves to have lower peak gradients. Sensitivity analyses were supportive of our primary results. Heterogeneity was observed in some comparisons and sensitivity analyses failed to completely explain this heterogeneity. CONCLUSIONS: Stentless valves did not display hemodynamic benefit in terms of LV mass regression or postoperative mean gradients, but do appear to display superior hemodynamics in terms of peak gradients. Further well-designed and adequately powered trials are required to fully address this question.

Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins.

Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)-in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post-cardiac arrest syndrome also require diligent observation and management, including post-cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.

Neurologic outcomes after extracorporeal membrane oxygenation assisted CPR for resuscitation of out-of-hospital cardiac arrest patients: A systematic review.

INTRODUCTION: Extracorporeal membrane oxygenation-assisted CPR (ECPR) is an evolving adjunct for resuscitation of OHCA patients. The primary objective of this systematic review was to assess survival-to-hospital discharge with good neurologic recovery after OHCA among patients treated with ECPR compared to conventional CPR (CCPR). METHODS: A systematic search of MEDLINE® and EMBASE® electronic databases was performed from inception until July 2016 to identify studies reporting ECPR use in adults with OHCA and survival outcomes. RESULTS: Of the 1512 citations identified, 75 studies met our inclusion criteria (63 case series and 12 cohort studies). Among case series, 0 to 71.4% of patients treated with ECPR survived to discharge with a good neurologic outcome. Subgroup analysis of the cohort studies demonstrated survival-to-hospital discharge with good neurologic recovery in the ECPR group ranging from 8.3 to 41.6% compared to 1.5 to 9.1% in the CCPR group. Five cohort studies adjusted for confounders, 3 of which demonstrated significantly increased adjusted odds ratios of survival among the ECPR-treated patients. Due to significant heterogeneity (I2 = 63%, p = 0.03), pooling of outcomes and a meta-analysis were not conducted. CONCLUSION: Although a trend towards improved survival with good neurologic outcome was reported in controlled, low-risk of bias cohort studies, a preponderance of low quality evidence may ascribe an optimistic effect size of ECPR on survival among OHCA patients. Our confidence in a clinically relevant difference in outcomes compared to current standards of care for OHCA remains weak. In this state of equipoise, high quality RCT data is urgently needed.

Barriers and opportunities related to extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Canada: A report from the first meeting of the Canadian ECPR Research Working Group.

For a French translation of the executive summary, please see the Supplementary Material at DOI: 10.1017/cem.2017.429.

Cardiac-Referenced Leukocyte Telomere Length and Outcomes After Cardiovascular Surgery.

Leukocyte telomere shortening reflects stress burdens and has been associated with cardiac events. However, the patient-specific clinical value of telomere assessment remains unknown. Moreover, telomere shortening cannot be inferred from a single telomere length assessment. The authors investigated and developed a novel strategy for gauging leukocyte telomere shortening using autologous cardiac atrial referencing. Using multitissue assessments from 163 patients who underwent cardiovascular surgery, we determined that the cardiac atrium-leukocyte telomere length difference predicted post-operative complexity. This constituted the first evidence that a single-time assessment of telomere dynamics might be salient to acute cardiac care.

Temporary Mechanical Circulatory Support in Cardiac Critical Care: A State of the Art Review and Algorithm for Device Selection.

With more than 60 years of continuous development and improvement, a variety of temporary mechanical circulatory support (MCS) devices and implantation strategies exist, each with unique advantages and disadvantages. A thorough understanding of each available device is essential for optimizing patient outcomes in a fiscally responsible manner. In this state of the art review we examine the entire range of commonly available peripheral and centrally cannulated temporary MCS devices, including intra-aortic balloon pumps, the Impella (Abiomed, Danvers, MA) family of microaxial pumps, the TandemHeart (CardiacAssist Inc, Pittsburg, PA) pump and percutaneous cannulas, centrally cannulated centrifugal pumps such as the CentriMag (Thoratec Corp, Pleasanton, CA/St Jude Medical, St Paul, MN/Abbott Laboratories, Abbott Park, IL) and Rotaflow (Maquet Holding BV & Co KG, Rastatt Germany), and extracorporeal membrane oxygenation. Several factors need detailed consideration when contemplating MCS in any given patient, mandating a balanced, algorithmic approach for these sick patients. In this review we describe our approach to MCS, and emphasize the need for multidisciplinary input to consider patient-related, logistical, and institutional factors. Evidence is summarized and referenced where available, but because of the lack of high-quality evidence, current best practice is described. Future directions for investigation are discussed, which will better define patient and device selection, and optimize MCS-specific patient care protocols.

Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era: A systematic review.

OBJECTIVE: To evaluate the hospital survival in patients with severe ARDS managed with ECMO and low tidal volume ventilation as compared to patients managed with low tidal volume ventilation alone. METHODS: Electronic databases were searched for studies of at least 10 adult patients with severe ARDS comparing the use of ECMO with low tidal volume ventilation to mechanical ventilation with a low tidal volume alone. Only studies reporting hospital or ICU survival were included. All identified studies were assessed independently by two reviewers. RESULTS: Of 1782 citations, 27 studies (n=1674) met inclusion criteria. Hospital survival for ECMO patients ranged from 33.3 to 86%, while survival with conventional therapy ranged from 36.3 to 71.2%. Five studies were identified with appropriate control groups allowing comparison, but due to the high degree of variability between studies (I2=63%), their results could not be pooled. Two of these studies demonstrated a significant difference, both favouring ECMO over conventional therapy. CONCLUSION: Given the lack of studies with appropriate control groups, our confidence in a difference in outcome between the two therapies remains weak. Future studies on the use of ECMO for severe ARDS are needed to clarify the role of ECMO in this disease.