Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock.

Cardiogenic shock (CS) is a clinical condition characterized by inadequate tissue perfusion in the setting of low cardiac output. CS is the leading cause of death following acute myocardial infarction (AMI). Several temporary mechanical support devices are available for hemodynamic support in CS until clinical recovery ensues or until more definitive surgical procedures have been performed. Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) has evolved as a powerful treatment option for short-term circulatory support in refractory CS. In the absence of randomized clinical trials, the utilization of ECMO has been guided by clinical experience and based on data from registries and observational studies. Survival to hospital discharge with the use of VA-ECMO ranges from 28-67%. The initiation of ECMO requires venous and arterial cannulation, which can be performed either percutaneously or by surgical cutdown. Components of an ECMO circuit include an inflow cannula that draws blood from the venous system, a pump, an oxygenator, and an outflow cannula that returns blood to the arterial system. Management considerations post ECMO initiation include systemic anticoagulation to prevent thrombosis, left ventricle unloading strategies to augment myocardial recovery, prevention of limb ischemia with a distal perfusion catheter in cases of femoral arterial cannulation, and prevention of other complications such as hemolysis, air embolism, and Harlequin syndrome. ECMO is contraindicated in patients with uncontrolled bleeding, unrepaired aortic dissection, severe aortic insufficiency, and in futile cases such as severe neurological injury or metastatic malignancies. A multi-disciplinary shock team approach is recommended while considering patients for ECMO. Ongoing studies will evaluate whether the addition of routine ECMO improves survival in AMI patients with CS who undergo revascularization.

Outcomes of Prediabetes Compared with Normoglycaemia and Diabetes Mellitus in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis.

Background: Patients with prediabetes are at increased risk of coronary artery disease (CAD). However, the association between prediabetes and adverse clinical outcomes following percutaneous coronary intervention (PCI) is inconsistent, in contrast to outcomes in patients with diabetes mellitus (DM). Thus, this meta-analysis evaluated the impact of dysglycaemia on PCI outcomes. Methods: The PubMed, Embase, Cochrane, and ClinicalTrials.gov databases were systematically reviewed from inception of databases until June 2022. In 17 studies, outcomes of PCI in patients with prediabetes were compared with patients who were normoglycaemic, and patients with DM. The primary outcome was all-cause mortality at the longest follow-up. Results: Included were 12 prospective and five retrospective studies, with 11,868, 14,894 and 13,536 patients undergoing PCI in the prediabetes, normoglycaemic and DM groups, respectively. Normoglycaemic patients had a statistically lower risk of all-cause mortality, (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.52-0.84), myocardial infarction (MI; RR 0.76, 95% CI 0.61-0.95) and cardiac mortality (RR 0.58, 95% CI 0.39-0.87) compared with prediabetic patients undergoing PCI at the longest follow-up. Patients with prediabetes had a lower risk of all-cause mortality (RR=0.72 [95% CI 0.53-0.97]) and cardiac mortality (RR =0.47 [95% CI 0.23-0.93]) compared with patients with DM who underwent PCI. Conclusion: Among patients who underwent PCI for CAD, the risk of all-cause and cardiac mortality, major adverse cardiovascular events and MI in prediabetic patients was higher compared with normoglycaemic patients but lower compared with patients with DM.

A case report of non-dominant right coronary artery occlusion: not always benign!

Background: Non-dominant right coronary artery (RCA) occlusion is uncommon and usually affects a small area of the myocardium. Rarely, it can complicate fatal outcomes such as shock, cardiac arrest, bradyarrhythmia, or tachyarrhythmia. Case summary: A 50-year-old man with no significant medical history presented with ventricular fibrillation (VF) cardiac arrest. He required prolonged cardiopulmonary resuscitation and multiple defibrillation shocks to achieve return of spontaneous circulation. ST elevation was noted on inferior leads. Due to refractory VF, extracorporeal membrane oxygenation (ECMO) was initiated followed by coronary angiography which demonstrated 100% acute occlusion of proximal RCA (small non-dominant), 90% stenosis of ramus intermedius (RI), and 80% stenosis of obtuse marginal (OM) arteries. Left ventricular ejection fraction was 35%. Percutaneous coronary intervention (PCI) of the RCA was performed with drug eluting stent. He had excellent clinical recovery without any neurological deficits. The ECMO was weaned off and decannulated within three days. Guideline directed medical therapy was administered. He remained hemodynamically stable and underwent staged PCI of RI and OM to achieve complete revascularization. Discussion: Non-dominant RCA lesions are usually considered benign. However, when acute RCA occlusion results in cardiac arrest as seen in our patient, prompt revascularization is necessary. Treatment of cardiogenic shock with appropriate pharmacological and mechanical therapies is important, such as ECMO in our patient.

Intracoronary Imaging Versus Coronary Angiography Guidance for Implantation of Second and Third Generation Drug Eluting Stents in a Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Intracoronary imaging (ICI) facilitates stent implant by characterizing the lesion calcification, providing accurate vessel dimensions, and optimizing the stent results. We sought to investigate the outcomes of routine ICI versus coronary angiography (CA) to guide percutaneous coronary intervention (PCI) with second- and third-generation drug-eluting stents. A systematic search of PubMed, Medline, and Cochrane databases was conducted from their inception to July 16, 2022 for randomized controlled trials comparing routine ICI with CA. The primary outcome was major adverse cardiovascular events. The secondary outcomes of interest were target lesion revascularization, target vessel revascularization, myocardial infarction, stent thrombosis, and cardiac and all-cause mortality. A random-effects model was used to calculate the pooled incidence and relative risk (RR) with 95% confidence intervals (CIs). A total of 9 randomized controlled trials with 5,879 patients (2,870 ICI-guided and 3,009 CA-guided PCI) met the inclusion criteria. The ICI and CA groups were similar in demographic characteristics and co-morbidity profiles. Compared with CA, patients in the routine ICI-guided PCI group had lower rates of major adverse cardiovascular events (RR 0.61, 95% CI 0.48 to 0.78, p <0.0001), target lesion revascularization (RR 0.60, 95% CI 0.43 to 0.83, p = 0.002), target vessel revascularization (RR 0.72, 95% CI 0.51 to 1.00, p = 0.05), and myocardial infarction (RR 0.48, 95% CI 0.25 to 0.95, p = 0.03). There were no significant differences in stent thrombosis or cardiac/all-cause mortality between the 2 strategies. In conclusion, routine ICI-guided PCI strategy, compared with CA guidance alone, is associated with improved clinical outcomes, largely driven by lower repeat revascularization.

Cardiogenic shock and severe secondary mitral regurgitation successfully treated with transcatheter edge-to-edge repair: a case report.

Background: Cardiogenic shock (CS) associated with severe mitral regurgitation (MR) forebodes a high risk of morbidity and mortality. Transcatheter edge-to-edge repair (TEER) is a rapidly evolving technique for severe MR in haemodynamically stable patients. However, the safety and efficacy of TEER for severe MR in CS are not well established. Case summary: An 83-year-old male presented with dyspnoea and was hospitalized for heart failure. Chest X-ray revealed pulmonary oedema. Transthoracic echocardiography showed severely depressed ejection fraction (EF) with severe secondary MR. Right heart catheterization confirmed a low cardiac index. Diuretics and inotropes were administered. Due to persistent hypotension, we could not wean inotropes. The patient was deemed high risk for surgery by the heart team, and a decision was made to proceed with TEER with MitraClip. Under transoesophageal echocardiography and fluoroscopic guidance, two MitraClips were deployed sequentially. The MR grade was reduced to two mild jets subsequently. The patient was weaned off inotropes and eventually discharged. At the 30-day follow-up, he was participating in physical activities such as golf. Discussion: Cardiogenic shock complicated by severe MR carries high mortality. With severe MR, the forward stroke volume is lower than the stated EF leading to poor organ perfusion. Inotropes and/or mechanical circulatory support devices are paramount for initial stabilization; however, they do not treat underlying MR. Transcatheter edge-to-edge repair with MitraClip has been shown to improve survival in CS patients with severe MR in observational studies. However, prospective trials are lacking. Our case demonstrates the utility of MitraClip to treat severe secondary MR refractory to medical therapy in a CS patient. The heart team must evaluate risks and benefits of this therapy in CS patients.

Same-Day Discharge after Percutaneous Left Atrial Appendage Closure: Insights from the Nationwide Readmission Database 2015-2019.

Data on the feasibility of same-day discharge (SDD) following percutaneous left atrial appendage closure (LAAC) remain limited. We analyzed the US Nationwide Readmission Database from quarter four of 2015 to 2019 to study the safety and feasibility of SDD after LAAC. After excluding non-elective cases and in-hospital deaths, a total of 54,880 cases of LAAC were performed during the study period. Following LAAC, 2% (n=1077) of patients underwent SDD, 88% (n=48,428) underwent next-day discharge (NDD), 5.2% (n=2881) were discharged on the second day (ScD), and 4.5% of patients (n = 2494) were discharged 3 or more days after LAAC. There was no difference in 30-day readmission rates between SDD and NDD (7.3% [n=79] vs 7.4% [n=3585], P=0.94). The hospitalization costs were significantly lower for SDD compared with NDD ($22,963 vs $27,079, P≤0.01). SDD discharge following percutaneous LAAC appears to be safe and is associated with lower hospitalization costs. Further prospective studies are needed to determine the safety and feasibility of SDD with percutaneous LAAC.

Sex Differences in Clinical Profile and Outcome After Percutaneous Coronary Intervention for Chronic Total Occlusion.

BACKGROUND: There are limited data around sex differences in the risk profile, treatments and outcomes of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) lesions in contemporary interventional practice. We investigated the impact of sex on clinical and procedural characteristics, complications and clinical outcomes in a national cohort. METHODS & RESULTS: We created a longitudinal cohort (2006-2018, n = 30,605) of patients with stable angina who underwent CTO PCI in the British Cardiovascular Intervention Society (BCIS) database. Clinical, demographic, procedural and outcome data were analysed in two groups stratified by sex: male (n = 24,651), female (n = 5954). Female patients were older (68 vs 64 years, P < 0.001), had higher prevalence of diabetes mellitus (DM), hypertension (HTN) and prior stroke. Utilization of intravascular ultrasound (IVUS), drug eluting stents (DES), radial or dual access and enabling strategies during CTO PCI were higher in male compared to female patients. Following multivariable analysis, there was no significant difference in in-patient mortality (adjusted odds ratio (OR):1.40, 95 % CI: 0.75-2.61, P = 0.29) and major cardiovascular and cerebrovascular events (MACCE) (adjusted OR: 1.01, 95 % CI: 0.78-1.29, P = 0.96). The crude and adjusted rates of procedural complications (adjusted OR: 1.37, 95 % CI: 1.23-1.52, P < 0.001), coronary artery perforation (adjusted OR: 1.60, 95 % CI: 1.26-2.04, P < 0.001) and major bleeding (adjusted OR: 2.06, 95 % CI: 1.62-2.61, P < 0.001) were higher in women compared with men. CONCLUSION: Female patients treated by CTO PCI were older, underwent lesser complex procedures, but had higher adjusted risk of procedural complications with a similar adjusted risk of mortality and MACCE compared with male patients.

Management and outcomes of patients admitted with type 2 myocardial infarction with and without standard modifiable risk factors.

BACKGROUND: Whilst it is known patients without standard modifiable cardiovascular risk factors (SMuRF; hypertension, diabetes, hypercholesterolaemia, smoking) have worse outcomes in Type 1 acute myocardial infarction (AMI), the relationship between type 2 AMI (T2AMI) and outcomes in patients with and without SMuRF is unknown. This study aimed to determine the prevalence, characteristics and clinical outcomes of patients hospitalised with T2AMI based on the presence of SMuRF. METHODS: Using the National Inpatient Sample, all hospitalizations with a primary discharge diagnosis of T2AMI were stratified according to SMuRF status (SMuRF and SMURF-less). Primary outcome was all-cause mortality while secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and ischemic stroke. Multivariable logistic regression was used to determine adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). RESULTS: Among 17,595 included hospitalizations, 1345 (7.6%) were SMuRF-less and 16,250 (92.4%) were SMuRF. On adjusted analysis, SMuRF-less patients had increased odds of all-cause mortality (aOR 2.43, 95% CI 1.83 to 3.23), MACCE (aOR 2.32, 95% CI 1.79 to 2.90) and ischaemic stroke (aOR 2.57, 95% CI 1.56 to 4.24) compared to their SMuRF counterparts. Secondary diagnoses among both cohorts were similar, with respiratory disorders most prevalent followed by cardiovascular and renal disorders. CONCLUSIONS: T2AMI in the absence of SMuRF was associated with worse in-hospital outcomes compared to SMuRF-less patients. There was no SMuRF-based difference in the secondary diagnoses with the most common being respiratory, cardiovascular, and renal disorders. Further studies are warranted to improve overall care and outcomes of SMuRF-less patients.

A Comprehensive Review of Mechanical Circulatory Support Devices.

Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.

Differential Patterns and Outcomes of 20.6 Million Cardiovascular Emergency Department Encounters for Men and Women in the United States.

Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest. In logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage had higher risk of hospitalization and death. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest. Conclusions In this large nationally representative sample of cardiovascular emergency department presentations, we demonstrate significant sex differences in disease distribution, hospitalization, and death.

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device.

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with normal to low pulmonary artery (PA) and pulmonary capillary wedge pressures (PCWP), remains a significant cause of morbidity and mortality worldwide if left untreated. Therapies for the treatment of RV shock range from medical management to durable or percutaneous mechanical circulatory support (MCS). A unique MCS device, a percutaneous right ventricular assist device (pRVAD), approved for use by the Food and Drug Administration (FDA) in 2014, works by temporarily off-loading the RV through a single, dual lumen catheter with extracorporeal mechanical support and is capable of shunting blood from the right atrium (RA) to the main PA. Although initially approved as venous-venous extracorporeal membrane oxygenation (VV-ECMO) device, this work will focus on the use of RV support, as ambulatory VV-ECMO strategies have been described previously. The catheter is most commonly inserted through the right internal jugular (IJ) vein into the PA and connected to an external pump, allowing flow up to 5 L/min. This device may be an attractive choice for the treatment of RV shock due to its percutaneous, minimally invasive insertion and removal and its ability to allow patient ambulation while the device is in place. This protocol discusses in detail the equipment, hemodynamic effects, indications, contraindications, complications, currently available research in the literature, and step-by-step instructions on how to implant, manage, and extract the device, along with the guidance on use and troubleshooting complications from one of the largest, single-center experiences with the device.