Early temporary mechanical circulatory support for cardiogenic shock: Real-life data from a regional cardiac assistance network.

BACKGROUND: Temporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network. METHODS: Prospective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centers organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality. RESULTS: Two hundred and forty-six patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95% CI:0.65-1.26). Patients with mechanical assistance had a higher rate of complications than others with longer Intensive Care Unit and hospital stays. CONCLUSIONS: In the conditions of a cardiac assistance regional network, in-hospital mortality was not improved by early mechanical assistance implantation. A high incidence of complications of temporary mechanical circulatory support may have jeopardized its potential benefit.

Effects of Fluid Therapy on Mesenteric Microcirculation Using New Probe-Based Confocal Laser Endomicroscopy (Cellvizio®) in a Porcine Model of Endotoxic Shock.

BACKGROUND: Microcirculatory alterations have been observed at the early phase of sepsis, although macrocirculation seems preserved. The aim of this study was to analyze the effect of crystalloid fluid therapy on mesenteric microcirculation, assessed by using the confocal laser endomicroscope Cellvizio®, in an endotoxic porcine model. METHODS: It is a prospective endotoxic shock (lipopolysaccharide infusion) experimental trial. Piglets were divided into 3 groups: 6 in the sham group (no LPS injection, no fluid), 9 in the control group (LPS infusion, no fluid), and 6 in the crystalloids group (LPS infusion and fluid resuscitation with crystalloids). Fluid resuscitation consisted in a fluid bolus of 20 mL/kg 0.9% saline over 30 min followed by a 10 mL/kg/h fluid rate over 4 h. Mesenteric microcirculation was assessed using a confocal laser endomicroscope (Cellvizio®). Blood flow within capillaries was visually assessed according to the point of care microcirculation (POEM) score. RESULTS: At baseline, the 3 groups were similar regarding hemodynamic, biological, and microcirculatory parameters. At T360, the POEM score significantly decreased in the control and crystalloids groups, whereas it remained unchanged in the sham group (respectively, 1.62 ± 1.06, 1.2 ± 0.45, and 5.0 ± 0, p = 0.011). There was no significant difference in cardiac output at T360 between the sham and crystalloids groups (3.1 ± 0.8 vs. 2.3 ± 0.6, p = 0.132) or between the control and crystalloids groups (2.0 ± 0.6 vs. 2.3 ± 0.6, p = 0.90). CONCLUSION: There was no significant improvement of microcirculatory alterations after crystalloids resuscitation despite improvement in macrocirculatory parameters in early experimental sepsis.

Point-of-care chest ultrasound to diagnose acute heart failure in emergency department patients with acute dyspnea: diagnostic performance of an ultrasound-based algorithm. / Rendimiento de un algoritmo basado en ecografía cardiopulmonar a la cabecera del paciente (POCUS) para el diagnóstico de insuficiencia cardiaca aguda en pacientes que consultan en urgencias por disnea aguda.

OBJECTIVES: Cardiopulmonary ultrasound imaging can be useful for diagnosing acute heart failure (AHF). We aimed to evaluate the diagnostic performance of an algorithm based on point-of-care ultrasound (POCUS) in patients coming to the emergency department with acute dyspnea. MATERIAL AND METHODS: Prospective analysis of a convenience sample of patients with acute dyspnea in 2 hospital emergency departments. The POCUS algorithm included lung ultrasound findings and 3 echocardiographic measurements taken from an apical view of 4 chambers: mitral annular plane systolic excursion, Doppler mitral flow velocity, and tissue Doppler imaging of the lateral mitral annulus. The definitive diagnosis was made by 2 physicians blinded to the POCUS findings. RESULTS: A total of 103 adult patients with a mean (SD) age of 73 (12) years were included; about half (51 patients) were women. Forty-two patients (41%) were finally diagnosed with AHF. Interindividual agreement on the physicians' diagnoses was good (k = 0.82). The POCUS algorithm assigned an AHF diagnosis to 76 patients (74%); 56 of them (85%) were in sinus rhythm. The diagnostic performance indicators for the algorithm were as follows: area under the receiver operating characteristic curve, 0.94 (95% CI, 0.88-1.00); sensitivity 96% (95% CI, 78%-100%); specificity, 93% (95% CI, 8%-98%); positive predictive value, 85% (95% CI, 67%-100%); negative predictive value, 98% (95% CI, 88%-100%). CONCLUSION: The POCUS-based algorithm for diagnosing AHF performed well in patients coming to the emergency department with acute dyspnea.

OBJETIVO: La ecografía cardiopulmonar puede ser útil para diagnosticar insuficiencia cardiaca aguda (ICA). Se evaluó el rendimiento diagnóstico de un algoritmo basado en ecografía cardiopulmonar a la cabecera del paciente (POCUS) para el diagnóstico de ICA en pacientes que consultan en urgencias por disnea aguda. METODO: Se evaluó prospectivamente una muestra de conveniencia de pacientes con disnea aguda en dos servicios de urgencias hospitalarios (SUH). El algoritmo POCUS incluía la ecografía pulmonar y tres mediciones ecocardiográficas realizadas en un plano apical de cuatro cámaras. Se midió el MAPSE (desplazamiento sistólico del plano del anillo mitral), doppler de flujo mitral y doppler tisular en el anillo mitral lateral. El diagnóstico final fue asignado por dos médicos ciegos entre sí y a los hallazgos ecográficos. RESULTADOS: Se incluyeron 103 pacientes adultos, la edad media fue 73 (12) años, 51 (50%) mujeres. El diagnóstico final fue ICA en 42 (41%) pacientes. La concordancia entre asignadores fue buena para el diagnóstico de ICA (k = 0,82). El algoritmo asignó un diagnóstico en 76 (74%) pacientes, 57 (85%) estaban en ritmo sinusal. El rendimiento diagnóstico del algoritmo de los 76 pacientes categorizados mostró un área bajo la curva de 0,94 (IC 95%: 0,88-1,00), sensibilidad 96% (IC 95%: 78-100%), especificidad 93% (IC 95%: 8-98%), valor predictivo positivo 85% (IC 95%: 67-100%), valor predictivo negativo 98% (IC 95%: 88-100%). CONCLUSIONES: El rendimiento de un algoritmo basado en ecografía cardiopulmonar POCUS fue bueno para diagnosticar ICA en pacientes que consultan en urgencias por disnea aguda.

Prognostic value and time course evolution left ventricular global longitudinal strain in septic shock: an exploratory prospective study.

Our main objective was to describe the course of GLS during the first days of septic shock and to assess the agreement between GLS values and longitudinal strain measured in apical four chambers. A prospective observational single centre study was conducted at the Nimes University Hospital's ICU. All patients admitted for a diagnosis of septic shock without pre-existing heart disease were eligible. Echocardiography (LVEF and GLS) was performed on the first day, and repeated once between day 3 and day 5 then once between day 6 and day 8. We enrolled 40 consecutive patients. Four patients were excluded. In overall population, GLS at T1 was impaired (- 11.0%, IQR(interquartile range) [- 15; - 10]). On T2 exams, a significant improvement of the GLS (- 11% vs - 16% p = 0.02) was observed whereas LVEF remained stable over time. A good agreement between GLS and longitudinal strain measured on a four chambers view was found. Based on the Bland and Altman method, the mean of differences for T1 exams was 0.1 (95% CI [- 0.6; 0.8]) with limits of agreement ranging from - 4 to 4. Myocardial strain is depressed at the early phase of septic shock and improves over time. A single measurement of LS4C view appears sufficient at bedside.