The real incidence of sudden death: Fair estimations or futile speculations?

BACKGROUND: The true incidence of sudden death remains undetermined, with controversial results from various publications over time and countries. AIM: To investigate if different estimations would reach the values usually reported for France. METHODS: Three different kinds of estimations were used. First, the number of resuscitated sudden deaths and necropsies for sudden death in the Haute-Garonne French administrative department (i.e. county) over the last 10years was expanded to the national level. Second, sudden death coding of death certificates was collected at the national level. Third, the total number of out-of-hospital cardiac arrests leading to any emergency call (with/without intervention) in Haute-Garonne over the last 10years was expanded to the national level. RESULTS: There was a mean of 26 resuscitated sudden deaths and 145 necropsies for sudden death each year in Haute-Garonne, i.e. 12 to 14 sudden deaths for 100,000 inhabitants, and 7700 to 9400 sudden deaths yearly when related to the whole French population, according to the year of inclusion. Based on death certificates, a mean of 6584 sudden deaths was registered each year in France. Finally, there were about 600 yearly calls/interventions for out-of-hospital cardiac arrests in Haute-Garonne, i.e. 40 to 50 sudden deaths for 100,000 inhabitants, and 16,000 to 27,000 sudden deaths yearly for the whole French territory, according to the year of inclusion. CONCLUSIONS: The incidence of sudden death ranges from 6500 to 27,000 in France according to the calculation methods. This huge difference raises the question of the true current incidence of sudden death, which may have been overestimated previously or may be underestimated in France. More straight prospective surveys are needed to solve this question, because of relevant implications for priorities that should be given to sudden death.

Optimal Heart Failure Medical Therapy and Mortality in Survivors of Cardiogenic Shock: Insights From the FRENSHOCK Registry.

BACKGROUND: The effects of pharmacological therapy on cardiogenic shock (CS) survivors have not been extensively studied. Thus, this study investigated the association between guideline-directed heart failure (HF) medical therapy (GDMT) and one-year survival rate in patients who are post-CS. METHODS AND RESULTS: FRENSHOCK (French Observatory on the Management of Cardiogenic Shock in 2016) registry was a prospective multicenter observational survey, conducted in metropolitan French intensive care units and intensive cardiac care units. Of 772 patients, 535 patients were enrolled in the present analysis following the exclusion of 217 in-hospital deaths and 20 patients with missing medical records. Patients with triple GDMT (beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists) at discharge (n=112) were likely to have lower left ventricular ejection fraction on admission and at discharge compared with those without triple GDMT (n=423) (22% versus 28%, P<0.001 and 29% versus 37%, P<0.001, respectively). In the overall cohort, the one-year mortality rate was 23%. Triple GDMT prescription was significantly associated with a lower one-year all-cause mortality compared with non-triple GDMT (adjusted hazard ratio 0.44 [95% CI, 0.19-0.80]; P=0.007). Similarly, 2:1 propensity score matching and inverse probability treatment weighting based on the propensity score demonstrated a lower incidence of one-year mortality in the triple GDMT group. As the number of HF drugs increased, a stepwise decrease in mortality was observed (log rank; P<0.001). CONCLUSIONS: In survivors of CS, the one-year mortality rate was significantly lower in those with triple GDMT. Therefore, this study suggests that intensive HF therapy should be considered in patients following CS.

Mottling as a prognosis marker in cardiogenic shock.

AIMS: Impact of skin mottling has been poorly studied in patients admitted for cardiogenic shock. This study aimed to address this issue and identify determinants of 30-day and 1-year mortality in a large cardiogenic shock cohort of all etiologies. METHODS AND RESULTS: FRENSHOCK is a prospective multicenter observational registry conducted in French critical care units between April and October, 2016. Among the 772 enrolled patients (mean age 65.7 ± 14.9 years; 71.5% male), 660 had skin mottling assessed at admission (85.5%) with almost 39% of patients in cardiogenic shock presenting mottling. The need for invasive respiratory support was significantly higher in patients with mottling (50.2% vs. 30.1%, p < 0.001) and likewise for the need for renal replacement therapy (19.9% vs. 12.4%, p = 0.09). However, the need for mechanical circulatory support was similar in both groups. Patients with mottling at admission presented a higher length of stay (19 vs. 16 days, p = 0.033), a higher 30-day mortality rate (31% vs. 23.3%, p = 0.031), and also showed significantly higher mortality at 1-year (54% vs. 42%, p = 0.003). The subgroup of patients in whom mottling appeared during the first 24 h after admission had the worst prognosis at 30 days. CONCLUSION: Skin mottling at admission in patients with cardiogenic shock was statistically associated with prolonged length of stay and poor outcomes. As a perfusion-targeted resuscitation parameter, mottling is a simple, clinical-based approach and may thus help to improve and guide immediate goal-directed therapy to improve cardiogenic shock patients' outcomes.

Characteristics, management, and outcomes of active cancer patients with cardiogenic shock.

AIMS: Characteristics, management, and outcomes of patients with active cancer admitted for cardiogenic shock remain largely unknown. This study aimed to address this issue and identify the determinants of 30-day and 1-year mortality in a large cardiogenic shock cohort of all aetiologies. METHODS AND RESULTS: FRENSHOCK is a prospective multicenter observational registry conducted in French critical care units between April and October 2016. 'Active cancer' was defined as a malignancy diagnosed within the previous weeks with planned or ongoing anticancer therapy. Among the 772 enrolled patients (mean age 65.7 ± 14.9 years; 71.5% male), 51 (6.6%) had active cancer. Among them, the main cancer types were solid cancers (60.8%), and hematological malignancies (27.5%). Solid cancers were mainly urogenital (21.6%), gastrointestinal (15.7%), and lung cancer (9.8%). Medical history, clinical presentation, and baseline echocardiography were almost the same between groups. In-hospital management significantly differed: patients with cancers received more catecholamines or inotropes (norepinephrine 72% vs. 52%, P = 0.005 and norepinephrine-dobutamine combination 64.7% vs. 44.5%, P = 0.005), but had less mechanical circulatory support (5.9% vs. 19.5%, P = 0.016). They presented a similar 30-day mortality rate (29% vs. 26%) but a significantly higher mortality at 1-year (70.6% vs. 45.2%, P < 0.001). In multivariable analysis, active cancer was not associated with 30-day mortality but was significantly associated with 1-year mortality in 30-day survivors [HR 3.61 (1.29-10.11), P = 0.015]. CONCLUSION: Active cancer patients accounted for almost 7% of all cases of cardiogenic shock. Early mortality was the same regardless of active cancer or not, whereas long-term mortality was significantly increased in patients with active cancer.

Hemodynamical consequences and tolerance of sustained ventricular tachycardia.

AIMS: Factors underlying clinical tolerance and hemodynamic consequences of monomorphic sustained ventricular tachycardia (VT) need to be clarified. METHODS: Intra-arterial pressures (IAP) during VT were collected in patients admitted for VT ablation and correlated to clinical, ECG and baseline echocardiographical parameters. RESULTS: 114 VTs from 58 patients were included (median 67 years old, 81% ischemic heart disease, median left ventricular ejection fraction 30%). 61 VTs were untolerated needing immediate termination (54%). VT tolerance was tightly linked to the evolution of IAPs. Faster VT rates (p<0.0001), presence of resynchronization therapy (p = 0.008), previous anterior myocardial infarction (p = 0.009) and more marginally larger baseline QRS duration (p = 0.1) were independently associated with VT tolerance. Only an inferior myocardial infarction was more often present in patients with only tolerated VTs vs patients with only untolerated VTs in multivariate analysis (OR 3.7, 95% CI 1.4-1000, p = 0.03). In patients with both well-tolerated and untolerated VTs, a higher VT rate was the only variable independently associated with untolerated VT (p = 0.02). Two different patterns of hemodynamic profiles during VT could be observed: a regular 1:1 relationship between electrical (QRS) and mechanical (IAP) events or some dissociation between both. VT with the second pattern were more often untolerated compared to the first pattern (78% vs 29%, p<0.0001). CONCLUSION: This study helps to explain the large variability in clinical tolerance during VT, which is clearly related to IAP. VT tolerance may be linked to resynchronization therapy, VT rate, baseline QRS duration and location of myocardial infarction.

Incidence, management, and prognosis of post-ischaemic ventricular septal defect: Insights from a 12-year tertiary centre experience.

Background: Among mechanical complications of acute myocardial infarction, ventricular septal defect (VSD) is uncommon but still serious. The evolution of emergency coronary revascularisation paradoxically decreased our knowledge of this disease, making it even rarer. Aim: To describe ischaemic VSD incidence, management, and associated in-hospital and 1-year outcomes over a 12-years period. Methods: A retrospective single-centre register of patients managed for ischaemic VSD between January 2009 and December 2020. Results: Ninety-seven patients were included representing 8 patients/ years and an incidence of 0.44% of ACS managed. The majority of the patients were 73-years-old males (n = 54, 56%) with STEMI presentation (n = 75, 79%) and already presented with Q necrosis on ECG (n = 70, 74%). Forty-nine (51%) patients underwent PCI, 60 (62%) inotrope/vasopressors infusion, and 70 (72%) acute mechanical circulatory support (IABP 62%, ECMO 13%, and Impella® 3%). VSD surgical repair was performed for 44 patients (45%) and 1 patient was transplanted. In-hospital mortality was 71%, and 86% at 1 year, without significant improvement over the decade. Surgery appears to be a protective factor [0.51 (0.28-0.94) p = 0.003], whereas age [1.06 (1.03-1.09), p < 0.001] and lactate [1.16 (1.09-1.23), p < 0.001] were linked to higher 1-year mortality. None of the patients that were managed medically survived 1 year. Conclusion: Post-ischaemic VSD is a rare but serious complication still associated with high mortality. Corrective surgery is associated with better survival, however, timing, patient selection, and a place for mechanical circulatory support need to be defined.

Externalized Reusable Permanent Pacemaker for Prolonged Temporary Cardiac Pacing in Critical Cardiac Care Units: An Observational Monocentric Retrospective Study.

INTRODUCTION: The use of temporary cardiac pacing is frequent in critical care units for severe bradycardia or electrical storm, but may be associated with frequent and potentially severe complications, especially when indwelling for several days. In some cases, transient indication or ongoing contraindication for a permanent pacemaker justifies prolonged temporary pacing. In that case, the implantation of an active-fixation lead connected to an externalized pacemaker represents a valuable option to increase safety and patient comfort. Yet, evidence remains scarce. We aimed to describe the population receiving prolonged temporary cardiac pacing (PTCP) and their outcomes. METHODS: We retrospectively included all consecutive patients, admitted to our hospital from 2016 to 2021, who underwent PTCP. We collected in-hospital and six-month outcomes. RESULTS: Forty-six patients (median age of 73, 63% male) were included, and twenty-nine (63%) had prior heart disease. Indications for PTCP were found: seventeen (37%) potentially reversible high-grade conduction disorders, fourteen (30%) indications for permanent pacemaker but ongoing infection, seven (15%) cardiac implantable electronic device infections requiring extraction in pacing-dependent patients, seven (15%) severe vagal hyperreactivity in prolonged critical care hospitalizations, and one (2%) recurrent sustained ventricular tachycardia requiring overdrive pacing. The median PTCP duration was nine (5-13) days. Ten (22%) patients exhibited at least one complication during hospitalization. Twenty-six (56.5%) patients required definite device implantation (twenty-five pacemakers and one cardioverter-defibrillator) and twenty (43.5%) did not (fifteen PTCP device removal for recovery and five deaths under PTCP). At six months, two (5%) deaths and two (5%) new infections of a definite implanted device occurred, all in patients with initial active infection. CONCLUSION: The use of prolonged temporary cardiac pacing, with an active -fixation lead connected to an externalized pacemaker, is possible and reasonable; this would allow for the possible recovery or resolution of contraindication for definite device implantation.

Use of Percutaneous Atrioseptotosmy for Left Heart Decompression During Veno-Arterial Extracorporeal Membrane Oxygenation Support: An Observational Study.

Background Left ventricular overload is frequent under veno-arterial extracorporeal membrane oxygenation, which is associated with a worsening of the prognosis of these patients. Several left heart decompression (LHD) techniques exist. However, there is no consensus on their timing and type. We aimed to describe characteristics and outcomes of patients undergoing LHD and to compare percutaneous atrioseptostomy (PA) to other LHD techniques. Methods and Results Retrospective analysis was conducted of consecutive and prospectively collected patients supported by veno-arterial extracorporeal membrane oxygenation for refractory cardiac arrest or cardiogenic shock between January 2015 and April 2018, with a 90-day follow-up in our tertiary center. Patients were divided according to the presence of LHD, and then according to its type (PA versus others). Thirty-nine percent (n=63) of our patients (n=163) required an LHD. Patients with LHD had lower left ventricular ejection fraction, more ischemic cardiomyopathy, and no drug intoxication-associated cardiogenic shock. PA was frequently used for LHD (41% of first-line and 57% of second-line LHD). PA appears safe and fast to realize (6.3 [interquartile range, 5.8-10] minutes) under fluoroscopic and echocardiographic guidance, with no acute complications. PA was associated with fewer neurological complications (12% versus 38%, P=0.02), no need to insert a second LHD (0% versus 19%, P=0.04), and higher 90-day survival compared with other techniques (42% versus 19%, log-rank test P=0.02), despite more sepsis (96% versus 73%, P=0.02) and blood transfusions (13.5% versus 7%, P=0.01). Multivariate analysis confirms the association between PA and 90-day survival (hazard ratio, 2.53 [1.18-5.45], P=0.019). Conclusions LHD was frequently used for patients supported with veno-arterial extracorporeal membrane oxygenation, especially in cases of ischemic cardiomyopathy and low left ventricular ejection fraction. PA seems to be a safe and efficient LHD technique associated with greater mid-term survival justifying the pursuit of research on this topic.

Predictors of weaning failure in case of VA ECMO implantation.

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a "weaning test" (ECMO flow < 2 L/min for at least 60 min). ECMO removal was left to the discretion of the medical team blinded to the results. Weaning failure was defined as a patient who died or required a new VA ECMO, heart transplant or LVAD 30 days after ECMO removal. Thirty-six patients (63.2%) were successfully weaned off VA ECMO, of whom 31 (54.4%) after the first weaning test. In case of first test failure, 3 out of 7 patients could be weaned after a 2nd test and 3 out of 4 patients after a 3rd test. Pre-existing ischemic heart disease (OR 9.6 [1.1-83]), pre-test left ventricular ejection fraction (LVEF) ≤ 25% and/or post-test LVEF ≤ 40% (OR 11 [0.98-115]), post-test systolic blood pressure ≤ 120 mmHg (OR 33 [3-385]), or length of ECMO support > 7 days (OR 24 [2-269]) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.

Prevalence, management, and outcomes of haemorrhagic events in left ventricular assist device recipients.

AIMS: Left ventricular assist devices (LVADs) have reduced the mortality of patients with advanced heart failure both as bridge-to-transplant and as destination therapy. However, LVADs are associated with various complications, including bleedings, which affect the prognosis. The aim of the study was to explore the prevalence, management, and outcomes of haemorrhagic adverse events in LVAD recipients. METHODS AND RESULTS: We conducted a retrospective, single-centre, cohort study including all patients who received an LVAD from January 2008 to December 2019 in our tertiary centre (Rangueil University Hospital, Toulouse, France). Bleeding events, death, and heart transplantation were collected from electronic medical files. Eighty-eight patients were included, and 43 (49%) presented at least one bleeding event. Gastrointestinal (GI) bleeding was the most frequent (n = 21, 24%), followed by epistaxis (n = 12, 14%) and intracranial haemorrhage (n = 9, 10%). Bleeding events were associated with increased mortality [hazard ratio (HR) 3.8, 95% confidence interval (CI) 1.5-9.3, P < 0.01], particularly in case of intracranial haemorrhage (HR 14.6, 95% CI 4.2-51.1, P < 0.0001). GI bleedings were associated with a trend towards increased mortality (HR 3.0, 95% CI 0.9-9.3, P = 0.05). Each bleeding episode multiplied the risk of death by 1.8 (95% CI 1.2-2.7, P < 0.01). Finally, only early bleedings (<9 months post-implantation) had an impact on mortality (HR 4.2, 95% CI 1.6-11.1, P < 0.01). Therapeutic management was mainly based on temporary interruption of anticoagulation and permanent interruption of antiplatelet therapy. Invasive management was rarely performed. CONCLUSIONS: Haemorrhagic events in LVAD recipients are frequent and associated with increased mortality. GI bleedings are the most frequent, and intracranial haemorrhages the most associated with mortality. Management remains empirical requiring more research.

Diuretic vs. placebo in intermediate-risk acute pulmonary embolism: a randomized clinical trial.

AIMS: The role of diuretics in patients with intermediate-risk pulmonary embolism (PE) is controversial. In this multicentre, double-blind trial, we randomly assigned normotensive patients with intermediate-risk PE to receive either a single 80 mg bolus of furosemide or a placebo. METHODS AND RESULTS: Eligible patients had at least a simplified PE Severity Index (sPESI) ≥1 with right ventricular dysfunction. The primary efficacy endpoint assessed 24 h after randomization included (i) absence of oligo-anuria and (ii) normalization of all sPESI items. Safety outcomes were worsening renal function and major adverse outcomes at 48 hours defined by death, cardiac arrest, mechanical ventilation, or need of catecholamine. A total of 276 patients underwent randomization; 135 were assigned to receive the diuretic, and 141 to receive the placebo. The primary outcome occurred in 68/132 patients (51.5%) in the diuretic and in 49/132 (37.1%) in the placebo group (relative risk = 1.30, 95% confidence interval 1.04-1.61; P = 0.021). Major adverse outcome at 48 h occurred in 1 (0.8%) patients in the diuretic group and 4 patients (2.9%) in the placebo group (P = 0.19). Increase in serum creatinine level was greater in diuretic than placebo group [+4 µM/L (-2; 14) vs. -1 µM/L (-11; 6), P < 0.001]. CONCLUSION: In normotensive patients with intermediate-risk PE, a single bolus of furosemide improved the primary efficacy outcome at 24 h and maintained stable renal function. In the furosemide group, urine output increased, without a demonstrable improvement in heart rate, systolic blood pressure, or arterial oxygenation.ClinicalTrials.gov identifier NCT02268903.

Successful Reversal of Severe Tachycardia-Induced Cardiomyopathy with Cardiogenic Shock by Urgent Rhythm or Rate Control: Only Rhythm and Rate Matter.

Background and objectives Severe forms of Tachycardia-induced cardiomyopathy (TIC) with cardiogenic shock are not well described so far, and efficiency of catheter ablation in this setting is unknown. Methods We retrospectively included consecutive patients admitted to the Intensive Cardiac Care Unit for acute heart failure with cardiogenic shock associated with atrial arrhythmia and managed by ablation. Result Fourteen patients were included, each with cardiogenic shock and two needing the use of extracorporeal membrane oxygenation. Successful ablation was performed in the acute setting or over the following weeks. Two patients experienced relapses of arrhythmias and were treated by new ablation procedures. At 7.5 ± 5 months follow-up, all patient were alive with stable sinus rhythm. The left ventricular Ejection Fraction dramatically improved (21 vs. 54%, p = 0.001) as well as the end-diastolic left ventricular diameter (61 vs. 51 mm, p = 0.01) and NYHA class (class IV in all vs. median 1, p = 0.002). Conclusion Restoration and maintenance of sinus rhythm in severe TIC with cardiogenic shock and atrial arrhythmias lead to a major increase or normalization of LVEF, reduction of ventricular dimensions, and improvement in functional status. Ablation is efficient in long-term maintenance of sinus rhythm and may be proposed early in refractory cases.

Prevalence and Prognosis Impact of Frailty Among Older Adults in Cardiac Intensive Care Units.

BACKGROUND: Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU. METHODS: This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7. RESULTS: A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group. CONCLUSIONS: Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.

CONTEXTE: On ignore si la fragilité, définie comme un syndrome biologique reflétant une diminution des réserves physiologique et une vulnérabilité au stress, impacte le pronostic des sujets âgés admis en unité de soins intensifs cardiologiques (USIC). Notre objectif était de déterminer la prévalence de la fragilité et son impact sur la mortalité chez les sujets âgés de 80 ans ou plus admis en USIC. MÉTHODOLOGIE: Il s'agit d'une étude prospective monocentrique observationnelle conduite sur les patients de 80 ans ou plus admis en USIC dans un centre tertiaire. La fragilité a été évaluée par l'échelle de fragilité d'Edmonton (EFS) qui donne un score allant de 0 (pas fragile) à 17 (très fragile). La population a été divisé en 3 classes : score EFS de 0 à 3, score EFS de 4 à 6, et score EFS de > 7. RÉSULTATS: Cent quatre-vingt-dix-neuf patients ont été inclus avec un suivi médian de 365 jours. L'âge moyen était de 84,8 ans. Cinquante patients (25,1 %) sont décédés au cours de la période de suivi. Quarante-cinq patients (22,6 %) avaient un score EFS de 0 à 3, 60 patients (30,2 %) avaient un score EFS de 4 à 6 et 94 patients (47,2 %) avaient un score EFS de ≥ 7. Les taux de mortalité toutes causes étaient de 4,4 % dans la classe de score EFS de 0 à 3, 27,1 % dans la classe de score EFS de 4 à 6 et 37,2 % dans la classe de score EFS de ≥ 7, (p < 0.001). En analyse multivariée, la fragilité demeurait associée avec la mortalité toutes causes : le rapport de risques instantanés (RRI) était à 2,60 (intervalle de confiance [IC] à 95 % [0,54 - 12,45]) dans la classe de score EFS de 4 à 6, et le RRI était à 5,46 (IC à 95 % [1,23 - 24,08]) dans la classe de score EFS de ≥ 7. CONCLUSION: La fragilité est fortement prévalente dans la population des sujets âgés admis en USIC et constitue un facteur pronostique fort de mortalité toutes causes à un an.

Early Evaluation of Patients on Axial Flow Pump Support for Refractory Cardiogenic Shock is Associated with Left Ventricular Recovery.

We investigated prognostic factors associated with refractory left ventricle (LV) failure leading to LV assist device (LVAD), heart transplant or death in patients on an axial flow pump support for cardiogenic shock (CS). Sixty-two CS patients with an Impella® CP or 5.0 implant were retrospectively enrolled, and clinical, biological, echocardiographic, coronarographic and management data were collected. They were compared according to the 30-day outcome. Patients were mainly male (n = 55, 89%), 58 ± 11 years old and most had no history of heart failure or coronary artery disease (70%). The main etiology of CS was acute coronary syndrome (n = 57, 92%). They presented with severe LV failure (LV ejection fraction (LVEF) 22 ± 9%), organ malperfusion (lactate 3.1 ± 2.1 mmol/L), and frequent use of inotropes, vasopressors, and mechanical ventilation (59, 66 and 30%, respectively). At 24 h, non-recovery was associated with higher total bilirubin (odds ratios (OR) 1.07 (1.00-1.14); p = 0.039), lower LVEF (OR 0.89 (0.81-0.96); p = 0.006) and the number of administrated amines (OR 4.31 (1.30-14.30); p = 0.016). Early evaluation in patients with CS with an axial flow pump implant may enable the identification of factors associated with an unlikely recovery and would call for early screening for LVAD or heart transplant.

Predictive factors for long-term mortality in miscellaneous cardiogenic shock: Protective role of beta-blockers at admission.

BACKGROUND: Despite advances in intensive care medicine, management of cardiogenic shock (CS) remains difficult and imperfect, with high mortality rates, regardless of aetiology. Predictive data regarding long-term mortality rates in patients presenting CS are sparse. AIM: To describe prognostic factors for long-term mortality in CS of different aetiologies. METHODS: Two hundred and seventy-five patients with CS admitted to our tertiary centre between January 2013 and December 2014 were reviewed retrospectively. Mortality was recorded in December 2016. A Cox proportional-hazards model was used to determine predictors of long-term mortality. RESULTS: Most patients were male (72.7%), with an average age of 64±16 years and a history of cardiomyopathy (63.5%), mainly ischaemic (42.3%). Leading causes of CS were myocardial infarction (35.3%), decompensated heart failure (34.2%) and cardiac arrest (20.7%). Long-term mortality was 62.5%. After multivariable analysis, previous use of beta-blockers (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.41-0.89; P=0.02) and coronary angiography exploration at admission (HR 0.57, 95% CI 0.38-0.86; P=0.02) were associated with a lower risk of long-term mortality. Conversely, age (HR 1.02 per year, 95% CI 1.01-1.04; P<0.001), catecholamine support (HR 1.45 for each additional agent, 95% CI 1.20-1.75; P<0.001) and renal replacement therapy (HR 1.66, 95% CI 1.09-2.55; P=0.02) were associated with an increased risk of long-term mortality. CONCLUSIONS: Long-term mortality rates in CS remain high, reaching 60% at 1-year follow-up. Previous use of beta-blockers and coronary angiography exploration at admission were associated with better long-term survival, while age, renal replacement therapy and the use of catecholamines appeared to worsen the prognosis, and should lead to intensification of CS management.

Prognosis Impact of Frailty Assessed by the Edmonton Frail Scale in the Setting of Acute Coronary Syndrome in the Elderly.

BACKGROUND: Elderly patients represent a large proportion of patients admitted for acute coronary syndrome (ACS). Whether frailty-defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors-may impact the clinical outcomes in this population remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted for ACS. METHODS: This prospective observational study was conducted in patients aged 80 years or older admitted to a tertiary hospital for ACS. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS score 0-3, EFS score 4-6; and EFS score >7. RESULTS: Two hundred thirty-six patients were included, with a mean follow-up duration of 470 days. The mean age was 85.9 years. Seventy-five patients died during the follow-up period. One hundred nineteen patients (50.4%) had an EFS score of 0-3, 68 patients (28.8%) had an EFS score of 4-6, and 49 patients (20.8%) had an EFS score ≥ 7. The all-cause mortality rate was 17.7% in the EFS 0-3 group, 35.3% in the EFS 4-6 group, and 61.2% in the EFS ≥ 7 group (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: the hazard ratio (HR) was 1.53 (95% confidence interval [CI], 0.74-3.16) in the EFS 4-6 group, and the HR was 3.60 (95% CI, 1.70-7.63) in the EFS ≥ 7 group. CONCLUSIONS: Frailty is a strong and independent prognostic factor for midterm all-cause mortality in elderly patients presenting with ACS.

Early Prediction of 3-month Survival of Patients in Refractory Cardiogenic Shock and Cardiac Arrest on Extracorporeal Life Support.

BACKGROUND: Extracorporeal life support (ECLS) holds the promise of significant improvement of the survival of patient in refractory cardiogenic shock (CS) or cardiac arrest (CA). Nevertheless, it remains to be shown to which extent these highly invasive supportive techniques could improve long-term patient's outcome. METHODS: The outcomes of 82 adult ECLS patients at our institution between January 2012 and December 2013 were retrospectively analyzed. RESULTS: Patients were essentially men (64.7%) and are 54 years old. Preexisting ischemic (53.7%) and dilated cardiomyopathy (14.6%) were frequent. ECLS indications were shared equally between CA and CS. ECLS-specific adverse effects as hemorrhage (30%) and infection (50%) were frequent. ECLS was effective for 43 patients (54%) with recovery for 35 (43%), 5 (6%) heart transplant, and 3 (4%) left ventricular assist device support. Mortality rate at 30 days was 59.8%, but long-term and 3-month survival rates were similar of 31.7%. Initial plasma lactate levels >5.3 mmol/L and glomerular filtration rate <43 ml/min/1.73 m2 were significantly associated with 3-month mortality (risk ratio [RR] 2.58 [1.21-5.48]; P = 0.014; RR 2.10 [1.1-4]; P = 0.024, respectively). Long-term follow-up had shown patients paucisymptomatic (64% New York Heart Association 1-2) and autonomic (activities of daily living [ADL] score 6 ± 1.5). CONCLUSION: In case of refractory CA or CS, lactates and renal function at ECLS initiation could serve as outcome predictor for risk stratification and ECLS indication.

Diuretic versus placebo in normotensive acute pulmonary embolism with right ventricular enlargement and injury: a double-blind randomised placebo controlled study. Protocol of the DiPER study.

INTRODUCTION: In acute pulmonary embolism (PE), poor outcome is usually related to right ventricular (RV) failure due to the increase in RV afterload. Treatment of PE with RV failure without shock is controversial and usually relies on fluid expansion to increase RV preload. However, several studies suggest that fluid expansion may worsen acute RV failure by increasing RV dilation and ischaemia, and increase left ventricular compression by RV dilation. By reducing RV enlargement, diuretic treatment may break this vicious circle and provide early improvement in normotensive patients referred for acute PE with RV failure. METHODS AND ANALYSIS: The Diuretic versus placebo in Pulmonary Embolism with Right ventricular enlargement trial (DiPER) is a prospective, multicentre, randomised (1:1), double-blind, placebo controlled study assessing the superiority of furosemide as compared with placebo in normotensive patients with confirmed acute PE and RV dilation (diagnosed on echocardiography or CT of the chest) and positive brain natriuretic peptide result. The primary end point will be a combined clinical criterion derived from simplified Pulmonary Embolism Severity Index (PESI) score and evaluated at 24 h. It will include: (1) urine output >0.5 mL/kg/min for the past 24 h; (2) heart rate <110 bpm; (3) systolic blood pressure >100 mm Hg and (4) arterial oxyhaemoglobin level >90%. Thirty-day major cardiac events defined as death, cardiac arrest, mechanical ventilation, need for catecholamine and thrombolysis, will be evaluated as a secondary end point. Assuming an increase of 30% in the primary end point with furosemide and a ß risk of 10%, 270 patients will be required. ETHICS AND DISSEMINATION: Ethical approval was received from the ethical committee of Ile de France (2014-001090-14). The findings of the trial will be disseminated through peer-reviewed journals, and national and international conference presentations. TRIAL REGISTRATION NUMBER: NCT02268903.

Usefulness of cardiothoracic chest ultrasound in the management of acute respiratory failure in critical care practice.

BACKGROUND: This study investigated the clinical relevance of early general chest ultrasonography (ie, heart and lung recordings) in patients in the ICU with acute respiratory failure (ARF). METHODS: We prospectively compared this diagnostic approach (ultrasound) to a routine evaluation established from clinical, radiologic, and biologic data (standard). Subjects were patients consecutively admitted to the ICU of a university teaching hospital during a 1-year period. Inclusion criteria were age ≥ 18 years and the presence of severe ARF criteria to justify ICU admission. We compared the diagnostic approaches and the final diagnosis determined by a panel of experts. RESULTS: Seventy-eight patients were included (age, 70 ± 18 years; sex ratio, 1). Three patients given two or more simultaneous diagnoses were subsequently excluded. The ultrasound approach was more accurate than the standard approach (83% vs 63%, respectively; P < .02). Receiver operating characteristic curve analysis showed greater diagnostic performance of ultrasound in cases of pneumonia (standard, 0.74 ± 0.12; ultrasound, 0.87 ± 0.14; P < .02), acute hemodynamic pulmonary edema (standard, 0.79 ± 0.11; ultrasound, 0.93 ± 0.08; P < .007), decompensated COPD (standard, 0.8 ± 0.09; ultrasound, 0.92 ± 0.15; P < .05), and pulmonary embolism (standard, 0.65 ± 0.12; ultrasound, 0.81 ± 0.17; P < .04). Furthermore, we found that the use of ultrasound data could have significantly improved the initial treatment. CONCLUSIONS: The use of cardiothoracic ultrasound appears to be an attractive complementary diagnostic tool and seems able to contribute to an early therapeutic decision based on reproducible physiopathologic data.