Cardiogenic shock etiology and exit strategy impact survival in patients with Impella 5.5.

BACKGROUND: Despite historical differences in cardiogenic shock (CS) outcomes by etiology, outcomes by CS etiology have yet to be described in patients supported by temporary mechanical circulatory support (MCS) with Impella 5.5. OBJECTIVES: This study aims to identify differences in survival and post-support destination for these patients in acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF) CS at a high-volume, tertiary, transplant center. METHODS: A retrospective review of patients who received Impella 5.5 at our center from November 2020 to June 2022 was conducted. RESULTS: Sixty-seven patients underwent Impella 5.5 implantation for CS; 23 (34%) for AMI and 44 (66%) for ADHF. AMI patients presented with higher SCAI stage, pre-implant lactate, and rate of prior MCS devices, and fewer days from admission to implantation. Survival was lower for AMI patients at 30 days, 90 days, and discharge. No difference in time to all-cause mortality was found when excluding patients receiving transplant. There was no significant difference in complication rates between groups. CONCLUSIONS: ADHF-CS patients with Impella 5.5 support have a significantly higher rate of survival than patients with AMI-CS. ADHF patients were successfully bridged to heart transplant more often than AMI patients, contributing to increased survival.

Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury.

BACKGROUND: Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS: We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS: We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS: Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.

Severe COVID-19 disease in a 2nd trimester pregnancy: Successful ECMO and mechanical ventilation management.

Extracorporeal membrane oxygenation (ECMO) is an invasive support strategy for cardiac, respiratory, or combined cardiorespiratory failure. ECMO has become increasing utilized in patients with severe respiratory failure due to COVID-19 infection. To our knowledge there is no report of successful ECMO utilization in second trimester of pregnancy leading to a successful outcome. We present a case of severe COVID-19 infection in a patient causing respiratory failure in the second trimester pregnancy. With diligent utilization of ECMO and mechanical ventilation we were able to support the patient's respiratory needs to allow her pregnancy to continue. Ultimately, the patient underwent successful caesarean section in the third trimester. This case highlights excellent lung injury protection and lung recovery can be achieved through optimal utilization of ECMO support together with a careful and closely monitored lung protective ventilation strategy, even while also supporting the patient through the increasing metabolic circumstances of a progressing pregnancy.

Vulvar metastasis of an early-stage well-differentiated endometrial cancer after minimally invasive surgery.

Endometrial cancer is the most common gynecologic malignancy, often manifesting as early-stage well-differentiated endometrioid adenocarcinoma associated with a high likelihood of long-term recurrence-free survival. Minimally invasive surgery for surgical staging of endometrial lesions is now routinely practiced, with laparoscopy the preferred surgical approach at many cancer centers. Recurrence or metastasis of early-stage well-differentiated endometrial endometrioid adenocarcinoma is uncommon, and may occur due to iatrogenic microscopic seeding of malignant cells during surgery, as suggested by previous reports of cancer metastasis to port sites after minimally invasive surgery, laparotomy incisions after open surgery, or intraperitoneal spread after hysteroscopy or uterine manipulation. Herein we report the only described case of isolated vulvar metastasis of an early-stage FIGO stage IB well-differentiated (histologic grade 1) endometrial endometrioid adenocarcinoma after minimally invasive surgery for surgical staging. The patient had recurrent endometrioid adenocarcinoma metastasis at the vulva 8 months after robotic-assisted total laparoscopic hysterectomy and surgical staging with specimen removal through the vagina. In selected cases, we suggest that use of a specimen bag during removal of the uterus through the vagina may limit seeding of malignant cells during minimally invasive surgery to treat cancer.