Diagnosis and Management of Vasoplegia in Temporary Mechanical Circulatory Support: A Narrative Review.

Refractory vasodilatory shock, or vasoplegia, is a pathophysiologic state observed in the intensive care unit and operating room in patients with a variety of primary diagnoses. Definitions of vasoplegia vary by source but are qualitatively defined clinically as a normal or high cardiac index and low systemic vascular resistance causing hypotension despite high-dose vasopressors in the setting of euvolemia. This definition can be difficult to apply to patients undergoing mechanical circulatory support (MCS). A large body of mostly retrospective literature exists on vasoplegia in the non-MCS population, but the increased use of temporary MCS justifies an examination of vasoplegia in this population. MCS, particularly extracorporeal membrane oxygenation, adds complexity to the diagnosis and management of vasoplegia due to challenges in determining cardiac output (or total blood flow), lack of clarity on appropriate dosing of noncatecholamine interventions, increased thrombosis risk, the difficulty in determining the endpoints of adequate volume resuscitation, and the unclear effects of rescue agents (methylene blue, hydroxocobalamin, and angiotensin II) on MCS device monitoring and function. Care teams must combine data from invasive and noninvasive sources to diagnose vasoplegia in this population. In this narrative review, the available literature is surveyed to provide guidance on the diagnosis and management of vasoplegia in the temporary MCS population, with a focus on noncatecholamine treatments and special considerations for patients supported by extracorporeal membrane oxygenation, transvalvular heart pumps, and other ventricular assist devices.

Impact of Pressure Recovery Adjustment on Aortic Valve Area Classification of Disease Severity in Transcatheter Aortic Valve Replacement Patients.

OBJECTIVES: To determine the impact of pressure recovery (PR) adjustment on disease severity grading in patients with severe aortic stenosis. The authors hypothesized that accounting for PR would result in echocardiographic reclassification of aortic stenosis severity in a significant number of patients. DESIGN: A retrospective observational study between October 2013 and February 2021. SETTING: A single-center, quaternary-care academic center. PARTICIPANTS: Adults (≥18 years old) who underwent transcatheter aortic valve implantation (TAVI). INTERVENTIONS: TAVI. MEASUREMENTS AND MAIN RESULTS: A total of 342 patients were evaluated in this study. Left ventricle mass index was significantly greater in patients who continued to be severe after PR (100.47 ± 28.77 v 90.15 ± 24.03, p = < 0.000001). Using PR-adjusted aortic valve area (AVA) resulted in the reclassification of 81 patients (24%) from severe to moderate aortic stenosis (AVA >1.0 cm2). Of the 81 patients who were reclassified, 23 patients (28%) had sinotubular junction (STJ) diameters >3.0 cm. CONCLUSION: Adjusting calculated AVA for PR resulted in a reclassification of a significant number of adult patients from severe to moderate aortic stenosis. PR was significantly larger in patients who reclassified from severe to moderate aortic stenosis after adjusting for PR. PR appeared to remain relevant in patients with STJ ≥3.0 cm. Clinicians need to be aware of PR and how to account for its effect when measuring pressure gradients with Doppler.

Obesity and Extracorporeal Membrane Oxygenation (ECMO): Analysis of Outcomes.

Traditionally, patients with obesity have been deemed ineligible for extracorporeal life support (ELS) therapies such as extracorporeal membrane oxygenation (ECMO), given the association of obesity with chronic health conditions that contribute to increased morbidity and mortality. Nevertheless, a growing body of literature suggests the feasibility, efficacy, and safety of ECMO in the obese population. This review provides an in-depth analysis of the current literature assessing the effects of obesity on outcomes among patients supported with ECMO (venovenous [VV] ECMO in noncoronavirus disease 2019 and coronavirus disease 2019 acute respiratory distress syndrome, venoarterial [VA] ECMO, and combined VV and VA ECMO), offer a possible explanation of the current findings on the basis of the obesity paradox phenomenon, provides a framework for future studies addressing the use of ELS therapies in the obese patient population, and provides guidance from the literature for many of the challenges related to initiating, maintaining, and weaning ELS therapy in patients with obesity.

ABO Blood Group and Bleeding and Survival in VA-ECMO Patients.

ABO blood group has been shown to be a major determinant of plasma von Willebrand factor (vWF) levels. O blood group is associated with the lowest vWF levels and confers an increased risk of hemorrhagic events, while AB blood group has the highest levels and is associated with thromboembolic events. We hypothesized in extracorporeal membrane oxygenation (ECMO) patients that O blood type would have the highest and AB blood type would have the lowest transfusions, with an inverse relationship to survival. A retrospective analysis of 307 VA-ECMO patients at a major quaternary referral hospital was performed. The distribution of blood groups included 124 group O (40%), 122 group A (40%), 44 group B (14%), and 17 group AB (6%) patients. Regarding usage of packed red blood cells, fresh frozen plasma, and platelets, there was a non-statistically significant difference in transfusions, with group O having the least and group AB having the most requirements. However, there was a statistically significant difference in cryoprecipitate usage when comparing to group O: group A (1.77, 95% CI: 1.05-2.97, P < .05), group B (2.05, 95% CI: 1.16-3.63, P < .05), and group AB (3.43, 95% CI: 1.71-6.90, P < .001). Furthermore, a 20% increase in length of days on ECMO was associated with a 2-12% increase in blood product usage. The cumulative 30-day mortality rate for groups O and A was 60%, group B was 50%, and group AB was 40%; the 1-year mortality rate for groups O and A was 65%, group B was 57%, and group AB was 41%; however, the mortality differences were not statistically significant.

Should Obesity Be an Exclusion Criterion for Extracorporeal Membrane Oxygenation Support? A Scoping Review.

Obesity is often considered a contraindication to extracorporeal membrane oxygenation (ECMO) candidacy due to technical challenges with vascular access, higher cardiac output requirements, and known associations between obesity and overall increased morbidity and mortality due to chronic health conditions. However, a growing body of literature suggests that ECMO may be as safe and efficacious in both obese and nonobese patients. This scoping review provides a synthesis of the available literature on the outcomes of obese patients supported with (1) venovenous (VV)-ECMO in acute respiratory distress syndrome (ARDS) not due to coronavirus disease 2019 (COVID-19), (2) VV-ECMO in ARDS due to COVID-19, (3) venoarterial (VA)-ECMO for all indications, and (4) studies combining data of patients supported with VA- and VV-ECMO. A librarian-assisted search was performed using 4 primary electronic medical databases (PubMed, Web of Science, Excerpta Medica database [Embase], and Cochrane Library) from January 2003 to March 2023. Articles that reported outcomes of obese patients requiring ECMO support were included. Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. A total of 354 publications were imported for screening on titles and abstracts, and 30 studies were selected for full-text review. A total of 26 publications met the inclusion criteria: 7 on VV-ECMO support in non-COVID-19 ARDS patients, 6 on ECMO in COVID-19 ARDS patients, 8 in patients supported with VA-ECMO, and 5 combining both VA- and VV-ECMO data. Although the included studies are limited to retrospective analyses and display a heterogeneity in definitions of obesity and comparison groups, the currently available literature suggests that outcomes and complications of ECMO therapy are equivalent in obese patients as compared to nonobese patients. Hence, obesity as measured by body mass index alone should not be considered an exclusion criterion in the decision to initiate ECMO.

A rare case of echo enhancing agent anaphylaxis complicated by acute coronary syndrome.

Enhancing agents in echocardiography are used frequently to improve endocardial border visualization and assessment of structural heart disease. We present a unique case of anaphylactic shock with acute coronary syndrome following administration of sulfur hexafluoride echo enhancing agent. This case emphasizes the importance of recognizing anaphylaxis to enhancing agents, as well as recognizing the potential relationship between anaphylaxis and acute coronary syndrome with in-stent thrombosis.

Preoperative Pulmonary Artery-to-Aorta Diameter Ratio as a Predictor of Postoperative Severe Right Ventricular Failure and 1-Year Mortality After Left Ventricular Assist Device Implantation.

OBJECTIVES: To evaluate the association of pulmonary artery diameter and pulmonary artery- to-aorta diameter ratio (PA/Ao) with right ventricular failure and mortality within 1 year after left ventricular assist device implantation. DESIGN: This was a retrospective observational study between March 2013 and July 2019. SETTING: The study was conducted at a single, quaternary-care academic center. PARTICIPANTS: Adults (≥18 years old) receiving a durable left ventricular assist device (LVAD). Inclusion if (1) a chest computed tomography scan was performed within 30 days before the LVAD and (2) a right and left heart catheterization was completed within 30 days before the LVAD. INTERVENTIONS: A left ventricular assist device was used for intervention. MEASUREMENTS AND MAIN RESULTS: A total of 176 patients were included in this study. Median PA diameter and PA/Ao ratio were significantly greater in the severe right ventricular failure (RVF) group (p = 0.001, p < 0.001, respectively). Receiver operating characteristic analysis revealed PA/Ao and RVF as predictors for mortality (area under the curve = 0.725 and 0.933, respectively). Logistic regression analysis-predicted probability gave a PA/Ao ratio cutoff point of 1.04 (p < 0.001). Survival probability was significantly worse in patients with a PA/Ao ratio ≥1.04 (p = 0.005). CONCLUSIONS: The PA/Ao ratio is an easily measurable noninvasive indicator that can predict RVF and 1-year mortality after LVAD implantation.

Red blood cell distribution width predicts mortality of adult patients receiving veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: Red blood cell distribution width (RDW) is a numerical measure of the variation in the size of circulating red blood cells. Recently, there is increasing interest in the role of RDW as a biomarker for inflammatory states and as a prognostication tool for a wide range of clinical manifestations. The predictive power of RDW on mortality among patients receiving mechanical circulatory support remains largely unknown. METHODS: A retrospective analysis of 281 VA-ECMO patients at a tertiary referral academic hospital from 2009 to 2019 was performed. RDW was dichotomized with RDW-Low <14.5% and RDW-High ≥14.5%. The primary outcome was all-cause mortality at 30 days and 1 year. Cox proportional hazards models were used to examine the association between RDW and the clinical outcomes after adjusting for additional confounders. RESULTS: 281 patients were included in the analysis. There were 121 patients (43%) in the RDW-Low group and 160 patients (57%) in the RDW-High group. Survival to ECMO decannulation [RDW-H: 58% versus RDW-L: 67%, p = 0.07] were similar between the two groups. Patients in RDW-H group had higher 30-days mortality (RDW-H: 67.5% vs RDW-L: 39.7%, p < 0.001) and 1 year mortality (RDW-H: 79.4% vs RDW-L: 52.9%, p < 0.001) compared to patients in the RDW-L group. After adjusting for confounders, Cox proportional hazards model demonstrated that patients with high RDW had increased odds of mortality at 30 days (hazard ratio 1.9, 95% CI 1.2-3.0, p < 0.01) and 1 year (hazard ratio 1.9, 95% CI 1.3-2.8, p < 0.01) compared to patients with low RDW. CONCLUSIONS: Among patients receiving mechanical circulatory support with VA-ECMO, a higher RDW was independently associated with increased 30-days and 1-year mortality. RDW may serve as a simple biomarker that can be quickly obtained to help provide risk stratification and predict survival for patients receiving VA-ECMO.

Interaction between ischemic time and donor age under the new donor heart allocation system: Effect on post-transplant survival.

BACKGROUND: Ischemic time (IT) under the new heart transplant (HTx) allocation system has increased compared to the old system. We investigated the effect of IT and donor age on post-HTx survival. METHODS: The United Network for Organ Sharing (UNOS) database was analyzed to identify adult HTx between October 2015 and August 2020. Recipients were stratified by donor age, transplantation era, and IT. Kaplan-Meier and log-rank tests were used to compare 180-day post-HTx mortality. Cox proportional hazards modeling and propensity score matching were performed to adjust for confounders. RESULTS: Under the new system (N = 3654), IT≥4 h led to decreased survival compared to IT < 4 h (91.4% vs. 93.7%; P = .02), although this decrease was undetectable among those with donors ≥39 years old (90.4% vs. 91.1%; P = .73). IT≥4 h led to decreased survival with donors < 39 years old (91.7% vs. 94.6%; P < .01). Under the old system (N = 5987), IT≥4 h resulted in decreased survival (89.8% vs. 93.9%; P < .01), including with donors ≥39 years old (86.9% vs. 92.4%; P < .01). CONCLUSIONS: IT≥4 h remains a risk for post-HTx mortality under the new system. However, the magnitude of this effect is blunted when donor age is ≥39 years, likely secondary to increased allocation of these organs to lower status, more stable recipients.

Association Between Body Mass Index and Outcomes in Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: The association between obesity, or elevated body mass index (BMI), and outcomes in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) has not been well established. Recent studies in patients receiving venovenous ECMO did not detect an association between obesity and increased mortality. The purpose of this retrospective observational study is to evaluate the association between BMI and survival in patients receiving VA-ECMO for cardiogenic shock. METHODS: All patients >18 years of age supported on VA-ECMO for refractory cardiogenic shock in a single academic center between 2009 and 2019 were included. ECMO outcomes, including successful ECMO decannulation and 30-day survival, were analyzed after stratification according to BMI. Multivariable and univariate logistic regression were used to assess the association between BMI and VA-ECMO outcomes. RESULTS: Of the total patients (n = 355) cannulated for VA-ECMO, 61.7% of the patients survived to ECMO recovery/decannulation, 45.5% of the patients survived to 30 days after ECMO decannulation, and 38.9% of the patients survived to hospital discharge with no statistically significant differences among the BMI groups. Multivariable logistic regression did not reveal any associations between obesity as defined by BMI and survival to ECMO decannulation (odds ratio [OR] 1.07 per 5 unit increase in BMI, 95% confidence interval [CI], 0.86-1.33; P = .57), 30-day survival (OR = 0.91, 95% CI, 0.73-1.14; P = .41) or survival to hospital discharge (OR = 0.95, 95% CI, 0.75-1.20; P = .66). CONCLUSIONS: Despite potential challenges to cannulation and maintaining adequate flow during ECMO, this single centered, retrospective observational study did not detect association between BMI and survival to ECMO decannulation, 30-day survival, or survival to hospital discharge for patients requiring VA-ECMO for refractory cardiogenic shock. These data suggest that obesity alone should not exclude candidacy for VA-ECMO.The primary outcome in this retrospective study was survival of the ECMO therapy (survival to ECMO decannulation), defined as surviving >24 hours after decannulation without a withdrawal of care. Secondary outcomes included survival at 30 days and survival to hospital discharge.

Methylene blue for vasodilatory shock in the intensive care unit: a retrospective, observational study.

BACKGROUND: Refractory vasodilatory shock is a state of uncontrolled vasodilation associated with underlying inflammation and endothelial dysregulation. Rescue therapy for vasoplegia refractory to catecholamines includes methylene blue (MB) which restores vascular tone. We hypothesized that (1) at least 40% of critically ill patients would respond positively to MB administration and (2) that those who responded to MB would have a survival benefit. METHODS: This study was a retrospective review that included all adult patients admitted to an intensive care unit treated with MB for the indication of refractory vasodilatory shock. Responders to MB were identified as those with a ≥ 10% increase in mean arterial pressure (MAP) within the first 1-2 hours after administration. We examined the association of mortality to the groups of responders versus non-responders to MB. A subgroup analysis in patients undergoing continuous renal replacement therapy (CRRT) was also performed. Statistical calculations were performed in Microsoft Excel® (Redmond, WA, USA). Where appropriate, the comparison of averages and standard deviations of demographics, dosing, MAP, and reductions in vasopressor dosing were performed via Chi squared, Fisher's exact test, or two-tailed t-test with a p-value < 0.05 being considered as statistically significant. After using the F-test to assess for differences in variance, the proper two tailed t-test was used to compare SOFA scores among responders versus non-responders. RESULTS: A total of 223 patients were included in the responder analysis; 88 (39.5%) had a ≥ 10% increase in MAP post-MB administration that was not associated with a significant change in norepinephrine requirements between responders versus non-responders (p=0.41). There was a non-statistically significant trend (21.6% vs 14.8%, p=0.19) toward improved survival to hospital discharge in the MB responder group compared to the non-responder group. In 70 patients undergoing CRRT, there were 33 responders who were more likely to survive than those who were not (p = 0.0111). CONCLUSIONS: In patients with refractory shock receiving MB, there is a non-statistically significant trend toward improved outcomes in responders based on a MAP increase >10%. Patients supported with CRRT who were identified as responders had decreased ICU mortality compared to non-responders.

Mechanical Circulatory Support Options in Patients With Aortic Valve Pathology.

Mechanical circulatory support (MCS) is used in cardiogenic shock for periprocedural hemodynamic stability in high-risk patients and to support patients with symptomatic coronary artery disease. Depending on the MCS type, oxygenation and ventilation, in addition to increasing blood pressure by augmenting blood flow, can be achieved. MCS typically follows a failure of less invasive maneuvers or intolerance to them, such as significant ventricular arrhythmia burden from inotropic support. MCS options include intra-aortic balloon pump, transvalvular percutaneous left ventricular assist devices, venoarterial extracorporeal membrane oxygenation, and surgically implanted left ventricular assist devices. The number of MCS options has increased, and this has made the decision-making process complicated. MCS decision-making is complex, even in patients without valvular pathology. The presence of aortic valve (AV) abnormalities, such as aortic stenosis, aortic insufficiency, replaced AVs, or AV masses, adds even further to the challenge of selecting the appropriate support strategy. In this narrative review, a concise review of MCS options and the special considerations for various AV pathologies are presented.

One-Year Survival for Adult Venoarterial Extracorporeal Membrane Oxygenation Patients Requiring Renal-Replacement Therapy.

OBJECTIVES: Acute kidney injury (AKI) and chronic kidney disease (CKD) previously have been associated with in-hospital and long-term mortality of patients undergoing support with venoarterial extracorporeal membrane oxygenation (VA-ECMO). Patient selection criteria and survival prediction scores for VA-ECMO often include AKI or CKD, but exclude patients requiring renal replacement therapy (RRT). The need for RRT in ECMO patients is associated with increased intensive unit care and in-hospital mortality. The effect RRT has on mortality beyond hospital survival is not well-reported. The authors hypothesized that the timing of initiation (pre-ECMO v during ECMO) of RRT can have a significant impact on short- and long-term mortality. DESIGN: The authors categorized patients into 3 groups: those receiving RRT before initiation of ECMO, those initiated on RRT while on ECMO, and those who did not need RRT while on ECMO. The authors compared survival to decannulation, 30 days and 1 year between the 3 groups. A multivariate survival analysis also was conducted. SETTING: This was a single center retrospective review of all patients receiving VA-ECMO. PARTICIPANTS: A total of 347 adult VA-ECMO extracorporeal membrane oxygenation patients. INTERVENTIONS: None, retrospective. MEASUREMENTS AND MAIN RESULTS: The authors' cohort included 347 total patients, 39 required RRT before ECMO, 139 while on ECMO, and 169 did not require RRT while on ECMO. If RRT was initiated before ECMO, survival to decannulation was 48.72%, 46.6% if RRT was initiated on ECMO, and 73.96% for patients who did not need RRT while on ECMO. One-year survival was 25.64%, 23.74%, and 46.75%, respectively. There was no significant difference in survival between patients initiated on RRT before ECMO and those who required RRT while on ECMO. CONCLUSIONS: The authors demonstrated that the need for RRT before or while on ECMO has reduced short- and long-term survival when compared with those who did not need RRT while on ECMO. The authors believe that RRT is a marker for severe multiorgan failure and that, despite the benefits of RRT, high mortality will occur. This lack of mortality difference between patients previously on RRT and those newly requiring RRT may help clinicians in deciding to initiate ECMO for patients previously on RRT. Further investigation into complication rates between the groups is required.

Using aortic arch short axis views during transesophageal echocardiographic examination facilitates right ventricular assist device imaging.

Given the increased need for mechanical circulatory support and subsequent development of right ventricular assist devices (RVAD), appropriate imaging needs to be described to facilitate care in patients with cardiogenic shock and heart failure. We present three cases in which the upper esophageal aortic arch short axis (UE AA SAX) view on transesophageal echocardiography (TEE) was utilized to effectively image RVADs: to confirm normal positioning, to detect and guide repositioning, and to visualize malfunction. These cases support the importance of the UE AA SAX TEE view in RVAD outflow imaging and, when obtainable, should be included in routine RVAD assessment.

Methylene Blue for Vasoplegia During Extracorporeal Membrane Oxygenation Support.

OBJECTIVE: The treatment of refractory vasodilatory shock in patients undergoing extracorporeal membrane oxygenation (ECMO) is an area in which there is minimal literature. Based on previous literature, the authors hypothesized that at least 40% of ECMO patients with vasoplegia would respond positively to methylene blue (MB) administration and that those who responded to MB would have increased survival. DESIGN: Retrospective observational study. SETTING: Single institution, quaternary care hospital. PARTICIPANTS: The study comprised 45 patients who received MB for vasoplegia during ECMO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 45 patients who received MB, 25 patients (55.6%) experienced a ≥10% increase in mean arterial pressure (MAP) and a reduction in norepinephrine dosing in the one-to-two hour interval after MB administration. There was a trend for improvement in survival to discharge for those who responded to MB (32% v 10%; p = 0.15). In addition, patients who did not have at least a >5% increase in MAP (29 experienced a >5% increase and 16 experienced a ≤5% increase) after MB administration, experienced 100% mortality (p = 0.008). CONCLUSION: This study suggested that approximately 50% of ECMO patients with vasoplegia can be expected to respond to MB with a >10% MAP improvement. The lack of a blood pressure response >5% after MB administration may portend poor survival. Larger prospective studies are needed to verify these preliminary results.

Tissue Doppler Imaging (E/e') and Pulmonary Capillary Wedge Pressure in Patients With Severe Aortic Stenosis.

OBJECTIVE: Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e') in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e' and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis. DESIGN: Retrospective cohort study. PARTICIPANTS: The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PCWP and E/e'ave (average of the lateral and medial annulus tissue Doppler velocities) were measured with a pulmonary artery catheter and transthoracic echocardiography during preprocedural evaluation. Patients were grouped by left ventricular ejection fraction (LVEF) ≥50% and LVEF <50%. Spearman rank correlation, analysis of variance, and t and chi-square tests were used to analyze the data. Seventy-nine patients met the inclusion criteria. There was no significant correlation between E/e'ave and PCWP (n = 79, Spearman r = 0.096; p = 0.3994). This correlation did not improve when ventricular function was considered (LVEF <50%: n = 11, Spearman r = -0.097; p = 0.776 and LVEF ≥50%: n = 68, Spearman r = 0.116; p = 0.345). There was no statistically significant difference in mean PCWP between each range of E/e'ave. CONCLUSION: A clinically relevant relationship between E/e' and PCWP was not observed in patients with severe aortic stenosis.

Treatment With Angiotensin II Is Associated With Rapid Blood Pressure Response and Vasopressor Sparing in Patients With Vasoplegia After Cardiac Surgery: A Post-Hoc Analysis of Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) Study.

OBJECTIVE: The present study investigated outcomes in patients with vasoplegia after cardiac surgery treated with angiotensin II plus standard-of-care vasopressors. Vasoplegia is a common complication in cardiac surgery with cardiopulmonary bypass and is associated with significant morbidity and mortality. Approximately 250,000 cardiac surgeries with cardiopulmonary bypass are performed in the United States annually, with vasoplegia occurring in 20%to-27% of patients. DESIGN: Post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) study. SETTING: Multicenter, multinational study. PARTICIPANTS: Sixteen patients with vasoplegia after cardiac surgery with cardiopulmonary bypass were enrolled. INTERVENTIONS: Angiotensin II plus standard-of-care vasopressors (n = 9) compared with placebo plus standard-of-care vasopressors (n = 7). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was mean arterial pressure response (mean arterial pressure ≥75 mmHg or an increase from baseline of ≥10 mmHg at hour 3 without an increase in the dose of standard-of-care vasopressors). Vasopressor sparing and safety also were assessed. Mean arterial pressure response was achieved in 8 (88.9%) patients in the angiotensin II group compared with 0 (0%) patients in the placebo group (p = 0.0021). At hour 12, the median standard-of-care vasopressor dose had decreased from baseline by 76.5% in the angiotensin II group compared with an increase of 7.8% in the placebo group (p = 0.0013). No venous or arterial thrombotic events were reported. CONCLUSION: Patients with vasoplegia after cardiac surgery with cardiopulmonary bypass rapidly responded to angiotensin II, permitting significant vasopressor sparing.

Successful use of Impella 5.5 to manage cardiogenic shock complicated by COVID-19.

BACKGROUND: Acute decompensated heart failure in patients with coronavirus disease 2019 (COVID-19) is becoming increasingly common. AIMS: In this case report, we describe the successful use of an Impella 5.5 (Abiomed) to treat cardiogenic shock refractory to inotropic therapy. MATERIALS & METHODS: Transthoracic and transesophageal echocardiography confirmed severely diminished left ventricular ejection fraction and a reverse-transcription polymerase chain reaction test revealed that the patient was COVID-19 positive during his hospital admission. RESULTS: Following initiation of inotropic therapy, we placed an Impella 5.5 for further cardiac support. The patient's LVEF and cardiac index improved after 21 days on the Impella 5.5 and was maintained following explant. DISCUSSION & CONCLUSION: The findings reported here demonstrate successful use of an Impella 5.5 to improve native heart function in refractory cardiogenic shock and further indicate its use as an option for those in acute decompensated heart failure who have tested positive for COVID-19 infection.

A Rapid Development of a Right Ventricular Aneurysm Postmyocardial Infarction.

Myocardial infarctions may cause ventricular aneurysms. Ischemia-induced ventricular changes are more common in the left ventricle owing to the larger vascular supply, greater volume of myocardium, and increased intra-ventricular pressure. Ischemia-induced right ventricular free wall abnormalities are rare owing to the lower ventricular pressure. The authors describe the echocardiographic progression of a right ventricular ischemic aneurysm resulting from an ST-elevated myocardial infarction in a 71- year-old man. In this E-Challenge, the authors will review the echocardiographic findings and pathophysiology of ischemic aneurysms.