3D Printing for Left Ventricular Assist Device Exchange: Insights From Real-World Experience.

Left ventricular assist devices (LVADs) are used in end-stage heart failure. Inadequate positioning of the inflow cannula may necessitate replacement of the LVAD. We present the successful use of a three-dimensional printed model used to optimize surgical planning and allow for simulation and training for the LVAD exchange procedure.

Dengue Myocarditis: A Case Report and Major Review.

Dengue is a viral disease transmitted by the bite of a female arthropod, prevalent primarily in tropical and subtropical regions. Its manifestations include asymptomatic infections, dengue fever, and a severe form called hemorrhagic dengue or dengue shock syndrome. Atypical manifestations can also occur, called expanded dengue syndrome. We describe the case of a 43-year-old man with an unusual presentation of dengue, demonstrating a workup suggestive of myocardial and pericardial damage. Symptoms and markers indicative of cardiac compromise improved after five days on anti-inflammatory treatment. Dengue myocarditis is considered an uncommon complication of dengue, although its reported incidence is likely an underestimation. In general, most cases of dengue myocarditis are self-limited, with only a minority at risk of progressing to heart failure. In order to improve recognition and prevent progression, healthcare providers should maintain a high degree of suspicion regarding potential cardiac complications in patients with dengue.

Emerging concepts in heart failure management and treatment: circulatory support with extracorporeal membrane oxygenation (ECMO).

Circulatory support with extracorporeal membrane oxygenation (ECMO) is being increasingly used in several critical situations but evidence of its impact on outcomes is inconsistent. Understanding of the specific indications and appropriate timing of implantation of this technology might lead to improved results. Indeed, the line between success and futility may be sometimes very thin when facing a patient in critical condition. New techniques with lighter, simpler and effective devices are being developed. Hence, ECMO has become an accessible technology that is being increasingly used outside of the operating room by heart failure specialists, critical care cardiologists and intensivists. Proper timing of utilization and choice of device may lead to better outcomes. We herein aim to improve this knowledge gap by conducting a literature review to provide simple information, evidence-based indications and a practical approach for cardiologists who may encounter acutely ill adult patients that may be ECMO candidates. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Emerging concepts in heart failure management and treatment: focus on vericiguat.

The nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway is dysregulated in patients with heart failure (HF) resulting in myocardial and vascular dysfunction that contributes to its progression. Vericiguat is a novel direct sGC stimulator that targets in at least two ways the NO-sGC-cGMP pathway with the subsequent restoration of cGMP activity. The VICTORIA trial assessed the effects of vericiguat (versus placebo) in 5050 patients with chronic HF (NYHA class II-IV), left ventricular ejection fraction (LVEF) <45%, elevated natriuretic peptide levels and a recent HF decompensation (hospitalized or outpatient intravenous diuretics). After a median follow-up of 10.8 months, a lower risk (10% reduction) of the primary combined outcome (cardiovascular death or HF hospitalization) was achieved (HR 0.90, 95% CI 0.83-0.98; p=0.02). The composite endpoint was driven by HF hospitalizations (HR 0.9, 95% CI 0.81-1.00; p=0.048) whilst CV death reduction was not statistically significant on its own. The target dose was achieved in 89% of patients treated with vericiguat, and no significant differences were observed in the rates of syncope or hypotension. The VICTORIA trial showed that vericiguat was safe, well tolerated and without need of laboratory testing. The aim of this review is to provide comprehensive information about vericiguat in terms of its differential mechanism of action and clinical data particularly focused on the VICTORIA trial. A comparison is also made with DAPA-HF and EMPEROR-Reduced considering that, in all these contemporary trials, a new study medication was added to the standard triple HF therapy. This is a relevant issue because the VICTORIA trial had a significant but less powerful effect than DAPA-HF and EMPEROR-Reduced on HF outcomes in a setting of more severe disease, higher event rate and shorter follow-up. In addition, relevant data on other previous studies are also provided in both HF with reduced LVEF (SOCRATES-Reduced) and HF with preserved LVEF (SOCRATES-Preserved and VITALITY-Preserved). This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Emerging concepts in heart failure management and treatment: focus on point-of-care ultrasound in cardiogenic shock.

Point-of-care ultrasound (POCUS) plays a strategic role in the diagnostic and therapeutic evaluation of critically ill patients and, especially, in those who are haemodynamically unstable. In this context, POCUS allows a more precise identification of the cause, its differential diagnosis, the eventual coexistence with another entity and, finally, guiding of the therapeutic approach. It implies a portable use of ultrasound in acute settings covering different specified protocols, such as echocardiography, vascular, lung or abdominal ultrasound. This article reviews POCUS application in the emergency department or the intensive care unit, focused on severely compromised patients with cardiogenic shock with an emergent bedside assessment. Considering the high mortality rate of this entity, POCUS provides the intensivist/clinician with an appropriate tool for accurate diagnoses and a timely management plan. The authors propose practical algorithms for the diagnosis of patients using POCUS in these settings. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Emerging concepts in heart failure management and treatment: focus on tachycardia-induced cardiomyopathy.

Tachycardia-induced cardiomyopathy is an entity characterized by reversible dysfunction of the left ventricle, which can be induced by different types of arrhythmia such as atrial fibrillation, atrial flutter, incessant supraventricular tachycardia and ventricular arrhythmia (more frequent causes). Correct identification of the causative arrhythmia and normalization of the heart rate (e.g through medical treatment, electrical cardioversion, ablation) can lead to recovery of left ventricular function. Tachycardia-induced cardiomyopathy should be suspected in patients with tachycardia and left ventricular dysfunction (heart failure setting), especially when there is no history of previous heart disease. Its usual phenotype is that of non-ischaemic/non-valvular dilated cardiomyopathy and it can occur in both children (main cause: permanent junctional reciprocating tachycardia) and adults (main cause: atrial fibrillation). With proper treatment, most cases recover within a few months, though there is a risk of relapse, especially when the causal arrhythmia reappears or its control is lost. This is a narrative review that comprehensively addresses the pathophysiology, clinical manifestations, and therapeutic management of tachycardia-induced cardiomyopathy. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Emerging concepts in heart failure management and treatment: focus on current guideline-directed medical therapy for heart failure with reduced ejection fraction.

One of the most relevant and differentiating aspects provided by the 2021 European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure is the retraction of the historical stepped and vertical pharmacological treatment scheme for heart failure with reduced ejection fraction (HFrEF). Subsequently, it was replaced by an updated algorithm that places four therapeutic families in the same initial horizontal step with an equally high degree of recommendation (class I). In this context, these four pillars, which have demonstrated a significant reduction in mortality and hospitalizations in patients with HFrEF, include (1) angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB)/angiotensin II receptor-neprilysin inhibitors (ARNi), (2) beta blockers, (3) mineralocorticoid receptor antagonists (MRA) and (4) sodium-glucose cotransporter 2 inhibitors (SGLT2is) as the main novelty. This manuscript reviews the current therapeutic algorithm with a special focus on the therapeutic value of adding an MRA (still underused in both clinical trials and real world), changing an ACEi/ARB for an ARNi and incorporating an SGLT2i in patients with HFrEF. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.

Continuation versus discontinuation of renin-angiotensin system inhibitors in patients admitted to hospital with COVID-19: a prospective, randomised, open-label trial.

BACKGROUND: Biological considerations suggest that renin-angiotensin system inhibitors might influence the severity of COVID-19. We aimed to evaluate whether continuing versus discontinuing renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) affects outcomes in patients admitted to hospital with COVID-19. METHODS: The REPLACE COVID trial was a prospective, randomised, open-label trial done at 20 large referral hospitals in seven countries worldwide. Eligible participants were aged 18 years and older who were admitted to hospital with COVID-19 and were receiving a renin-angiotensin system inhibitor before admission. Individuals with contraindications to continuation or discontinuation of renin-angiotensin system inhibitor therapy were excluded. Participants were randomly assigned (1:1) to continuation or discontinuation of their renin-angiotensin system inhibitor using permuted block randomisation, with allocation concealed using a secure web-based randomisation system. The primary outcome was a global rank score in which participants were ranked across four hierarchical tiers incorporating time to death, duration of mechanical ventilation, time on renal replacement or vasopressor therapy, and multiorgan dysfunction during the hospitalisation. Primary analyses were done in the intention-to-treat population. The REPLACE COVID trial is registered with ClinicalTrials.gov, NCT04338009. FINDINGS: Between March 31 and Aug 20, 2020, 152 participants were enrolled and randomly assigned to either continue or discontinue renin-angiotensin system inhibitor therapy (continuation group n=75; discontinuation group n=77). Mean age of participants was 62 years (SD 12), 68 (45%) were female, mean body-mass index was 33 kg/m2 (SD 8), and 79 (52%) had diabetes. Compared with discontinuation of renin-angiotensin system inhibitors, continuation had no effect on the global rank score (median rank 73 [IQR 40-110] for continuation vs 81 [38-117] for discontinuation; ß-coefficient 8 [95% CI -13 to 29]). There were 16 (21%) of 75 participants in the continuation arm versus 14 (18%) of 77 in the discontinuation arm who required intensive care unit admission or invasive mechanical ventilation, and 11 (15%) of 75 participants in the continuation group versus ten (13%) of 77 in the discontinuation group died. 29 (39%) participants in the continuation group and 28 (36%) participants in the discontinuation group had at least one adverse event (χ2 test of adverse events between treatment groups p=0·77). There was no difference in blood pressure, serum potassium, or creatinine during follow-up across the two groups. INTERPRETATION: Consistent with international society recommendations, renin-angiotensin system inhibitors can be safely continued in patients admitted to hospital with COVID-19. FUNDING: REPLACE COVID Investigators, REPLACE COVID Trial Social Fundraising Campaign, and FastGrants.

Randomized elimination and prolongation of ACE inhibitors and ARBs in coronavirus 2019 (REPLACE COVID) Trial Protocol.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), is associated with high incidence of multiorgan dysfunction and death. Angiotensin-converting enzyme 2 (ACE2), which facilitates SARS-CoV-2 host cell entry, may be impacted by angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), two commonly used antihypertensive classes. In a multicenter, international randomized controlled trial that began enrollment on March 31, 2020, participants are randomized to continuation vs withdrawal of their long-term outpatient ACEI or ARB upon hospitalization with COVID-19. The primary outcome is a hierarchical global rank score incorporating time to death, duration of mechanical ventilation, duration of renal replacement or vasopressor therapy, and multiorgan dysfunction severity. Approval for the study has been obtained from the Institutional Review Board of each participating institution, and all participants will provide informed consent. A data safety monitoring board has been assembled to provide independent oversight of the project.

Héroes, vectores o víctimas: Los profesionales de la Salud requieren todos los recursos indispensables para luchar contra la pandemia de CoViD-19

La afectación de la infección por SARS-CoV-2 en el personal de salud constituye un serio problema para el control de los efectos de la pandemia. El contagio del personal de salud constituye no sólo un riesgo para los profesionales que son contagiados; sino también, para su entorno laboral, familiar y social, constituyéndose en un “vector de confianza” durante el período de incubación de la enfermedad. El desconocimiento de un período de contagio viral exacto y la alta posibilidad de que pacientes totalmente asintomáticos u oligosintomáticos sean transmisores del virus constituyen un serio problema y es uno de los factores del rápido y creciente número de infecciones. El avance de la pandemia, su rápida aceleración y fácil propagación, el acceso del personal de salud al equipo de protección adecuado para el manejo de pacientes portadores o con riesgo de ser portadores del virus SARS-CoV-2 es una preocupación creciente. En muchos países, los trabajadores de la salud tienen prioridad en el acceso a los escasos equipos de protección personal (EPP), pero frecuentemente se ven en la obligación de asistir pacientes posiblemente en períodos de contagio sin manifestación clínica. Convertirse en vectores de esta patología es una causa de preocupación más para los trabajadores de la salud. El hecho de que estos trabajadores deban muchas veces trabajar en varias instituciones aumenta aun más el riesgo de transmisión, y ante el contagio se ven obligados al aislamiento total, dejando sin cobertura a sus lugares de trabajo, obligados al contrato de nuevo personal, muchas veces sin la formación adecuada o desconociendo la metodología de trabajo en dicho lugar con el consecuente incremento de errores en el manejo adecuado de los pacientes. Es vital que las autoridades no vean a los trabajadores de la salud como simples peones para ser desplegados en un campo de batalla sin el armamento adecuado para combatir la pandemia. Deben priorizar los recursos indispensables, además del económico, y brindar no sólo las medidas de protección personal para él y para sus pacientes; sino también, la provisión de descanso adecuado, apoyo a él y a su familia e incluso apoyo psicológico y legal que permitan sobrellevar esta batalla con la menor cantidad de víctimas. Por cierto, uno puede adquirir los elementos de protección en el mercado, quizá de un día para otro, pero no podrá formar personal de salud capacitado en tan poco tiempo. La siguiente presentación intenta brindar a las autoridades y a los profesionales de la salud una visión de las formas de protección que se hacen absolutamente necesarias, aún después del fallecimiento del paciente, para evitar convertirse en vectores de la enfermedad y continuar trabajando como los héroes de esta pandemia. Es absolutamente necesario comprender que protegiéndolos a ellos se protege a su entorno, a otros pacientes, a su familia y finalmente a la comunidad, evitando así el círculo vicioso que mantiene la pandemia.

The involvement of SARS-CoV-2 infection in health personnel constitutes a serious problem for controlling the effects of the pandemic. The contagion of health personnel constitutes not only a risk for the professionals who are infected, but also for their work, family and social environment, becoming a “vector of trust” during the incubation period of the disease. The ignorance of an exact viral contagion period and the high possibility that totally asymptomatic or oligosymptomatic patients are transmitters of the virus constitutes a serious problem and is one of the factors of the fast and increasing number of infections. The advance of the pandemic, its rapid acceleration and easy spread, the access of health personnel to the adequate protection equipment for the management of patients who are carriers or at risk of being carriers of the SARS-CoV-2 virus is a growing concern. In many countries, health workers have priority in accessing the scarce personal protective equipment (PPE), but frequently they are obliged to assist patients, possibly in periods of infection without clinical manifestations. Becoming vectors of pathology is another cause of concern for health workers. The fact that these workers often have to work in various institutions further increases the risk of transmission and, due to the contagion, they are forced to complete isolation, leaving their workplaces uncovered, forced to hire new personnel, often without adequate training or unaware of the work methodology in that place with the consequent increase in errors in the proper management of patients. It is vital that the authorities do not see health workers as mere pawns to be deployed on a battlefield without the adequate weapons to combat the pandemic, but must prioritize the indispensable resources in addition to the economic one and provide, in addition to the measures of personal protection for him and his patients, but also of the resources, provision of adequate rest, support for him and his family and even psychological and legal support that allow him to carry out this battle with the least amount of victims. By the way, one can acquire the protection elements on the market perhaps from one day to the next, but they will not be able to train trained health personnel in such a short time. The following presentation tries to provide authorities and health professionals with a vision of the forms of protection that are absolutely necessary, even after the patient’s death, to avoid becoming vectors of the disease and continue working as the heroes of this disease. pandemic. It is absolutely necessary to understand that protecting them protects their environment, other patients, their family and finally the community, thus avoiding the vicious circle that maintains the pandemic.

O envolvimento da infecção por SARS-CoV-2 na equipe de saúde constitui um problema sério para controlar os efeitos da pandemia. O contágio do pessoal de saúde constitui não apenas um risco para os profissionais infectados; mas também para seu trabalho, ambiente familiar e social, tornando-se um “vetor de confiança” durante o período de incubação da doença. O desconhecimento de um período exato de contágio viral e a alta possibilidade de pacientes totalmente assintomáticos ou oligossintomáticos serem transmissores do vírus constituem um problema sério e são um dos fatores do número crescente e rápido de infecções. O avanço da pandemia, sua rápida aceleração e fácil disseminação, o acesso do pessoal da saúde ao equipamento de proteção adequado para o gerenciamento de pacientes portadores ou em risco de serem portadores do vírus SARSCoV-2 é uma preocupação crescente. Em muitos países, os profissionais de saúde têm prioridade no acesso aos escassos equipamentos de proteção individual (EPI), mas frequentemente são obrigados a ajudar os pacientes, possivelmente em períodos de infecção sem manifestações clínicas. Tornar-se vetores de patologia é outra causa de preocupação para os profissionais de saúde. O fato de esses trabalhadores frequentemente trabalharem em várias instituições aumenta ainda mais o risco de transmissão e, devido ao contágio, são forçados a completar o isolamento, deixando seus locais de trabalho descobertos, forçados a contratar novos funcionários, muitas vezes sem treinamento adequado ou desconhecem a metodologia de trabalho naquele local, com o consequente aumento de erros no manejo adequado dos pacientes. É vital que as autoridades não vejam os trabalhadores da saúde como meros peões a serem implantados em um campo de batalha sem as armas adequadas para combater a pandemia, mas devem priorizar os recursos indispensáveis além do econômico e fornecer, além das medidas de proteção pessoal para ele e seus pacientes, mas também recursos, provisão de descanso adequado, apoio a ele e sua família e até apoio psicológico e jurídico que lhe permitam realizar essa batalha com o menor número de vítimas. A propósito, é possível adquirir os elementos de proteção no mercado, talvez de um dia para o outro, mas eles não poderão treinar pessoal de saúde treinado em tão pouco tempo. A apresentação a seguir tenta fornecer às autoridades e profissionais de saúde uma visão das formas de proteção que são absolutamente necessárias, mesmo após a morte do paciente, para evitar se tornarem vetores da doença e continuar trabalhando como heróis dessa doença. pandemia. É absolutamente necessário entender que protegê-los protege o meio ambiente, os demais pacientes, a família e, finalmente, a comunidade, evitando o círculo vicioso que mantém a pandemia.

Feasibility of combining serial smartphone single-lead electrocardiograms for the diagnosis of ST-elevation myocardial infarction.

BACKGROUND: The rate-limiting step in STEMI diagnosis often is the availability of a 12-lead electrocardiogram (ECG) and its interpretation. The potential may exist to speed the availability of 12-lead ECG information by using commonly available mobile technologies. We sought to test whether combining serial smartphone single-lead ECGs to create a virtual 12-lead ECG can accurately diagnose STEMI. METHODS: Consenting patients presenting with symptoms consistent with a possible STEMI had contemporaneous standard 12-lead and smartphone '12-lead equivalent' ECG (produced by electronically combining serial single-lead ECGs) recordings obtained. Matched ECGs were evaluated qualitatively and quantitatively by a panel of blinded readers and classified as STEMI/STEMI equivalent (LBBB), Not-STEMI, or uninterpretable. Interpretable ECG pairs were graded as showing good, fair, or poor correlation. RESULTS: Two hundred four subjects (age = 60 years, males = 57%, STEMI activation = 45%) were enrolled from 5 international sites. Smartphone ECG quality was graded as good in 151 (74.0%), fair in 32 (15.7%), poor in 8 (3.9%), and uninterpretable in 13 (6.4%). A STEMI/STEMI equivalent diagnosis was identified by standard 12-lead ECG in 57/204 (27.9%) recordings. For all interpretable pairs of smartphone ECGs compared with standard ECGs (n = 190), the sensitivity, specificity, and positive and negative predictive values for STEMI/STEMI equivalent by smartphone were 0.89, 0.84, 0.70 and 0.95, respectively. CONCLUSIONS: A '12-lead equivalent' ECG obtained from multiple serial single-lead ECGs from a smartphone can identify STEMI with good correlation to a standard 12-lead ECG. This technology holds promise to improve outcomes in STEMI by enhancing the reach and speed of diagnosis and thereby early treatment.

Smartphone ECG for evaluation of ST-segment elevation myocardial infarction (STEMI): Design of the ST LEUIS International Multicenter Study.

In patients experiencing an ST-elevation myocardial infarction (STEMI), rapid diagnosis and immediate access to reperfusion therapy leads to optimal clinical outcomes. The rate-limiting step in STEMI diagnosis is the availability and performance of a 12-lead ECG. Recent technology has provided access to a reliable means of obtaining an ECG reading through a smartphone application (app) that works with an attachment providing all 12-leads of a standard ECG system. The ST LEUIS study was designed to validate the smartphone ECG app and its ability to accurately assess the presence or absence of STEMI in patients presenting with chest pain compared with the gold standard 12-lead ECG. We aimed to support the diagnostic utility of smartphone technology to provide a timely diagnosis and treatment of STEMI. The study will take place over 12months at five institutions. Approximately 60 patients will be enrolled per institution, for a total recruitment of 300 patients.

Unmet goals in the treatment of Acute Myocardial Infarction: Review.

Reperfusion therapy decreases myocardium damage during an acute coronary event and consequently mortality. However, there are unmet needs in the treatment of acute myocardial infarction, consequently mortality and heart failure continue to occur in about 10% and 20% of cases, respectively. Different strategies could improve reperfusion. These strategies, like generation of warning sign recognition and being initially assisted and transferred by an emergency service, could reduce the time to reperfusion. If the first electrocardiogram is performed en route, it can be transmitted and interpreted in a timely manner by a specialist at the receiving center, bypassing community hospitals without percutaneous coronary intervention capabilities. To administer thrombolytic therapy during transport to the catheterization laboratory could reduce time to reperfusion in cases with expected prolonged transport time to a percutaneous coronary intervention center or to a center without primary percutaneous coronary intervention capabilities with additional expected delay, known as pharmaco-invasive strategy. Myocardial reperfusion is known to produce damage and cell death, which defines the reperfusion injury. Lack of resolution of ST segment is used as a marker of reperfusion failure. In patients without ST segment resolution, mortality triples. It is important to note that, until recently, reperfusion injury and no-reflow were interpreted as a single entity and we should differentiate them as different entities; whereas no-reflow is the failure to obtain tissue flow, reperfusion injury is actually the damage produced by achieving flow. Therefore, treatment of no-reflow is obtained by tissue flow, whereas in reperfusion injury the treatment objective is protection of susceptible myocardium from reperfusion injury. Numerous trials for the treatment of reperfusion injury have been unsuccessful. Newer hypotheses such as " controlled reperfusion", in which the interventional cardiologist assumes not only the treatment of the culprit vessel but also the way to reperfuse the myocardium at risk, could reduce reperfusion injury.

New Impella Cardiac Power Device Used in Patient with Cardiogenic Shock due to Nonischemic Cardiomyopathy.

The new percutaneous Impella CP (Cardiac Power; Abiomed, Inc., Danvers, MA) was designed to provide a higher level of support than Impella 2.5 (Abiomed, Inc.). We present the first documented case of a patient that was transitioned from the Impella 2.5 to Impella CP. A 48-year-old male patient with no medical history was transferred to our institution with a one day history of worsening shortness of breath. The patient was unstable and found to have monomorphic ventricular tachycardia at 220 beats/min that was cardioverted to normal sinus rhythm. An emergent right and left heart catheterization was performed showing nonobstructive coronary artery disease, biventricular failure with a left ventricular ejection fraction (LVEF) of 5 to 10%, high pulmonary capillary wedge pressure (PCWP) 22 mm Hg, right atrial (RA) pressure 22 mm Hg, and a very low cardiac index of 1.0 L/min/m2. Because of severe cardiogenic shock, Impella 2.5 was inserted providing flow up to 2.1 L/min; however, the patient remained unstable and critically ill with severe multiorgan failure. To provide better mechanical support, the device was upgraded to the new Impella CP that can provide up to 3.5 L/min of cardiac output. Over the course of the next 72 hours, the patient showed significant improvement in hemodynamics and cardiac function (LVEF 45%), with recovery of liver function. The Impella CP was removed with no complications. The new Impella CP was shown to be safe and effective for prolonged use in critically ill patients and may significantly improve their prognosis.

Smartphone ECG for evaluation of STEMI: results of the ST LEUIS Pilot Study.

BACKGROUND: 12-lead ECG is a critical component of initial evaluation of cardiac ischemia, but has traditionally been limited to large, dedicated equipment in medical care environments. Smartphones provide a potential alternative platform for the extension of ECG to new care settings and to improve timeliness of care. OBJECTIVE: To gain experience with smartphone electrocardiography prior to designing a larger multicenter study evaluating standard 12-lead ECG compared to smartphone ECG. METHODS: 6 patients for whom the hospital STEMI protocol was activated were evaluated with traditional 12-lead ECG followed immediately by a smartphone ECG using right (VnR) and left (VnL) limb leads for precordial grounding. The AliveCor™ Heart Monitor was utilized for this study. All tracings were taken prior to catheterization or immediately after revascularization while still in the catheterization laboratory. RESULTS: The smartphone ECG had excellent correlation with the gold standard 12-lead ECG in all patients. Four out of six tracings were judged to meet STEMI criteria on both modalities as determined by three experienced cardiologists, and in the remaining two, consensus indicated a non-STEMI ECG diagnosis. No significant difference was noted between VnR and VnL. CONCLUSIONS: Smartphone based electrocardiography is a promising, developing technology intended to increase availability and speed of electrocardiographic evaluation. This study confirmed the potential of a smartphone ECG for evaluation of acute ischemia and the feasibility of studying this technology further to define the diagnostic accuracy, limitations and appropriate use of this new technology.

Availability of a baseline Electrocardiogram changes the application of the Sclarovsky-Birnbaum Myocardial Ischemia Grade.

BACKGROUND AND AIMS: The electrocardiogram (ECG) based Sclarovsky-Birnbaum Ischemia Grade may be used to determine the prognosis of patients with ST-elevation myocardial infarction (STEMI). However, application of the method is based on assumption of the baseline QRS morphology. Thus, the aims of this study were to determine if the baseline QRS morphology was correctly assumed based on an ECG recorded during induced ischemia, and if reference to the baseline ECG altered the designated Ischemia Grade. METHODS: Sixty-three patients with chronic ischemic heart disease that underwent elective percutaneous transluminal coronary angioplasty were included. Baseline ECG and ECG during the procedure were recorded. In the latter, Ischemia Grade was classified according to assumed baseline QRS morphology. Then the baseline ECG was used as reference and Ischemia Grade was determined based on change from the baseline ECG. RESULTS: In 66.6% (42/63) of patients the criteria for STEMI were fulfilled; the incidence was similar between left anterior descending (LAD) and right coronary artery (RCA) occlusion. In LAD patients who fulfilled STEMI criteria, assumption of baseline QRS morphology in involved leads was accurate in only 35% (7/20) and this altered the Ischemia Grade in 10% (2/20) of patients. In RCA patients who fulfilled STEMI criteria, assumption of baseline QRS morphology in involved leads was accurate in 77.3% (17/22) and this altered the Ischemia Grade in 9.1% (2/22) of patients. CONCLUSION: Application of the Sclarovsky-Birnbaum Ischemia Grade with reference to a baseline ECG altered Ischemia Grade in approximately 10% of patients. All patients that were reclassified were assigned a higher Ischemia Grade. Future research is needed to determine the impact of availability of the baseline ECG on the clinical diagnostic and prognostic performances of the Sclarovsky-Birnbaum Ischemia Grade.