Coronary angiography after cardiac arrest without ST-elevation myocardial infarction: a network meta-analysis.

AIMS: This network meta-analysis aimed to assess the effect of early coronary angiography (CAG) compared with selective CAG (late and no CAG) for patients after out-of-hospital cardiac arrest without ST-elevation myocardial infarction (NSTE-OHCA). METHODS AND RESULTS: A systematic literature search was performed using the EMBASE, MEDLINE and Web of Science databases without restrictions on publication date. The last search was performed on 15 July 2022. Randomized controlled trials (RCTs) and non-randomized studies (NRS) comparing the effect of early CAG to selective CAG after NSTE-OHCA on survival and/or neurological outcomes were included. Meta-analyses were performed based on a DerSimonian-Laird random effects model. A total of 18 studies were identified by the literature search. After the exclusion of two studies due to high risk of bias, 16 studies (six RCTs, ten NRS) were included in the final analyses. Meta-analyses showed a statistically significant increase in survival after early CAG compared with selective CAG in the overall analysis [OR: 1.40, 95% confidence interval (CI): (1.12-1.76), P < 0.01, I2 = 68%]. This effect was lost in the subgroup analysis of RCTs [OR: 0.89, 95% CI: (0.73-1.10), P = 0.29, I2 = 0%]. Random effects model network meta-analysis of NRS based on a Bayesian method showed statistically significant increased survival after late compared with early CAG [OR: 4.20, 95% CI: (1.22, 20.91)]. CONCLUSION: The previously reported superiority of early CAG after NSTE-OHCA is based on NRS at high risk of selection and survivorship bias. The meta-analysis of RCTs does not support routinely performing early CAG after NSTE-OHCA.

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: first results and outcomes of a newly established ECPR program in a large population area.

OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) is associated with excessively high mortality rates. Recent studies suggest benefits from extracorporeal cardiopulmonary resuscitation (ECPR) performed in selected patients. We sought to present the first results from our interdisciplinary ECPR program with a particular focus on early outcomes and potential risk factors associated with in-hospital mortality. METHODS: Between January 2016 and December 2019, 44 patients who underwent ECPR selected according to our institutional ECPR protocol were retrospectively analyzed regarding pre-hospital, in-hospital, and early outcome parameters. Patients were divided into survivors (S) and non-survivors (NS). Statistical analysis of risk factors regarding in-hospital mortality of the patient cohort analyzed was performed. RESULTS: The mean age of the population was 53 ± 12 years, with most patients being male (n = 40). The leading cause of cardiac arrest (CA) was myocardial infarction (n = 24, 55%). The median hospital stay was 1 (1;13) day. Twenty-three percent of patients (n = 10) were discharged from hospital including eight patients (18%) with CPC 1-2. Survivors showed a trend toward shorter pre-hospital CPR duration (60 (59;60) min (S) vs 60 (55;90) min (NS), p = 0.07). CONCLUSION: Establishing ECPR programs in large population areas offers the option to improve survival rates for OHCA patients. Stringent compliance of institutional criteria (mainly age, witnessed arrest, and time of pre-hospital resuscitation) and providing ECPR to strictly selected patients seems to be a vital factor for such programs' success. Pre-clinical settings and therapeutic measures must be adjusted in this regard to improve outcomes for this highly demanding patient cohort.

[Extracorporeal cardiopulmonary resuscitation for treatment of out-of-hospital cardiac arrest]. / Die extrakorporale kardiopulmonale Reanimation für die Behandlung des außerklinischen Herz-Kreislauf-Stillstands.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) affects ca. 75,000 people each year in Germany and is associated with a limited prognosis and a high mortality. Extracorporeal cardiopulmonary resuscitation (eCPR) using arteriovenous extracorporeal membrane oxygenation (av-ECMO) systems is an additional option for treatment, which is increasingly more widespread and since 2020 anchored in the guideline algorithm. METHODS: A selective search of the literature was carried out in PubMed and Embase focusing on studies that investigated eCPR for OHCA. Furthermore, clinical studies on this topic that are currently recruiting and running are summarized. RESULTS: The available data on the benefits of eCPR for OHCA are mostly based on retrospective cohort studies. A survival advantage and an advantage in the neurological outcome could be derived from these data for selected patients treated with eCPR vs. conventionally resuscitated patients (CPR). This effect could be confirmed by two current randomized controlled studies. Studies which are currently running are investigating if out-of-hospital ECMO cannulation at the earliest time possible at the site of OHCA of patients could be associated with a better survival. CONCLUSION: Despite a current scarcity of data, a survival advantage for eCPR treatment in selected OHCA patients must be assumed. If this can be substantiated by other high-quality studies, it seems to be indicated to evaluate if and to what extent resource-intensive eCPR programs can be comprehensively established.

Gender-related differences in treatment and outcome of extracorporeal cardiopulmonary resuscitation-patients.

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to significant improvement in selected patients' survival rates. Gender-related differences might impact the outcome of therapeutic measures. Therefore, we sought to investigate patients with eCPR at our interdisciplinary extracorporeal membrane oxygenation center regarding sex-related differences with the view to potentially adjusting current selection criteria. From January 2016 to December 2019, 71 patients underwent eCPR at our institution. Data before eCPR and early outcome parameters were analyzed comparing male and female patients. The cohort analyzed consisted of 60 male (84%) and 11 female (15%) patients. Comparing both groups, male patients significantly more frequently suffered out-of-hospital cardiac arrest (68% male vs. 36% female, P = .04), whereas female patients were associated with more in-hospital cardiac arrest (32% male vs. 64% female, P = .04). Creatinine levels differed significantly (1.5 (1.1;2.1) mg/dL in male vs. 1.0 (0.7;1.5) mg/dL in female patients, P = .03). Also, several hepatic parameters showed a significant difference between the groups: aspartate aminotransferase 423 (249;804) U/L in male vs. 115 (61;408) U/L in female patients, P = .01; alanine aminotransferase 174 (102;446) U/L in male vs. 86 (36;118) U/L in female patients, P = .01). Renal failure requiring hemodialysis occurred more frequently in men than in women (P < .01). There is a significant effect of male sex regarding renal failure with subsequent continuous venovenous hemodialysis (CVVH) (R2  = 0.11, ANOVA P = .01, 95% CI = -0.79--0.079). However, in-hospital mortality was comparable between the groups (78% in male vs. 72% in female patients, P = .68). Our retrospective study showed several gender-related differences associated with different cardiac arrest scenarios. Male sex was associated with a significantly higher risk for renal failure requiring CVVH. Survival rates were comparable between the groups. Further investigations should include gender in the evaluation of risk stratification for eCPR-related complications to further improve selection criteria for this demanding therapy.

Nitro-Oleic Acid (NO2-OA) Improves Systolic Function in Dilated Cardiomyopathy by Attenuating Myocardial Fibrosis.

Nitro-oleic acid (NO2-OA), a nitric oxide (NO)- and nitrite (NO2-)-derived electrophilic fatty acid metabolite, displays anti-inflammatory and anti-fibrotic signaling actions and therapeutic benefit in murine models of ischemia-reperfusion, atrial fibrillation, and pulmonary hypertension. Muscle LIM protein-deficient mice (Mlp-/-) develop dilated cardiomyopathy (DCM), characterized by impaired left ventricular function and increased ventricular fibrosis at the age of 8 weeks. This study investigated the effects of NO2-OA on cardiac function in Mlp-/- mice both in vivo and in vitro. Mlp-/- mice were treated with NO2-OA or vehicle for 4 weeks via subcutaneous osmotic minipumps. Wildtype (WT) littermates treated with vehicle served as controls. Mlp-/- mice exhibited enhanced TGFß signalling, fibrosis and severely reduced left ventricular systolic function. NO2-OA treatment attenuated interstitial myocardial fibrosis and substantially improved left ventricular systolic function in Mlp-/- mice. In vitro studies of TGFß-stimulated primary cardiac fibroblasts further revealed that the anti-fibrotic effects of NO2-OA rely on its capability to attenuate fibroblast to myofibroblast transdifferentiation by inhibiting phosphorylation of TGFß downstream targets. In conclusion, we demonstrate a substantial therapeutic benefit of NO2-OA in a murine model of DCM, mediated by interfering with endogenously activated TGFß signaling.

Concomitant ECMO And IABP Support in Postcardiotomy Cardiogenic Shock Patients.

OBJECTIVES: Simultaneous mechanical circulatory support (MCS) with intra-aortic balloon pump (IABP) to extracorporeal membrane oxygenation (ECMO) is common in postcardiotomy cardiogenic shock (PCS). This study aimed to analyse the effect of concomitant ECMO and IABP therapy on the short-term outcomes of patients with PCS. METHODS: Between March 2006 and March 2017, 172 consecutive patients with central (c) or peripheral (p) veno-arterial ECMO therapy due to PCS were identified at the current institution and included in this retrospective analysis. Patients were divided into ECMO+IABP and ECMO alone groups. Further, the impact of ECMO flow direction was analysed for the groups. RESULTS: A total of 129 patients received ECMO+IABP support and 43 patients were treated with ECMO alone. Median ECMO duration did not differ between the groups (68 [34; 95] hours ECMO+IABP vs 44 [20; 103] hours ECMO; p=0.151). However, a trend toward a higher weaning rate was evident in ECMO+IABP patients (75 [58%] ECMO+IABP vs 18 [42%] ECMO; p=0.078). Concomitant IABP support with either cECMO (73% [n=24] cECMO+IABP vs 50% [n=11] ECMO; p=0.098) or pECMO (57% [n=55] ECMO+IABP vs 33% [n=7] ECMO; p=0.056) was also associated with a trend toward a higher weaning rate off ECMO. In-hospital mortality did not differ between the groups. CONCLUSION: This analysis found that, independent of ECMO type, additional IABP support might increase ECMO weaning; however, it did not influence survival in PCS patients. Larger studies are necessary to further analyse the impact of this concomitant MSC therapy on clinical outcomes.

Pulmonary hypertension associated with left-sided heart failure.

PURPOSE OF REVIEW: Pulmonary hypertension is a common phenomenon in heart failure patients that is highly relevant for morbidity and outcome. Although postcapillary in nature, the pathophysiology of pulmonary hypertension in patients with heart failure with reduced or preserved ejection fraction is complex, and decisions about management strategies remain challenging. RECENT FINDINGS: Recently, the hemodynamic definitions and subclassification of postcapillary pulmonary hypertension have been revisited. The distinction between isolated postcapillary pulmonary hypertension (IpcPH) and combined post and precapillary pulmonary hypertension (CpcPH) and their definition are essential. Novel data on the prognostic impact of hemodynamic variables and right ventricular function highlight the importance of cardiopulmonary interaction in patients with left-sided heart failure (LHF). Furthermore, the impact of management strategies including medical therapy, remote hemodynamic monitoring, and interventional approaches on hemodynamics and outcome has recently been investigated. Here, we critically review recent developments and future considerations in this field, and highlight distinct treatment strategies targeting the underlying left heart condition, the pulmonary circulation, and/or impaired right ventricular function. SUMMARY: Detailed hemodynamic characterization and proper phenotyping are essential for prognostication and the management of patients with pulmonary hypertension associated with LHF, both in clinical practice and when addressing research questions.

Single center experience with patients on veno arterial ECMO due to postcardiotomy right ventricular failure.

OBJECTIVES: Right ventricular (RV) failure is associated with poor outcome and increased mortality in cardiac surgery. Aim of our study was to analyze the outcome of veno arterial extracorporeal membrane oxygenation (va ECMO) therapy in patients with isolated RV failure in postcardiotomy cardiogenic shock (PCS) and to evaluate risk factors associated with 30-day-mortality. METHODS: Between August 2006 until August 2016, 64 consecutive patients with va ECMO therapy due to fulminant RV failure in PCS were identified and included in this retrospective observation. Further, outcome data and a comparison of va ECMO survivors and nonsurvivors was conducted. RESULTS: The mean age of the patient cohort was 63 ± 14 years. Patients were treated with va ECMO for 79 ± 61 hours. Twenty-eight patients (44%) were successfully weaned off ECMO support. Overall 30-day-mortality was 88% (56/64). Hemoglobin concentration before ECMO implantation, maximum rise of muscle-brain type creatine kinase during ECMO therapy, as well as lactic acid concentration 24 hours after initiation of va ECMO therapy were predictive for 30-day mortality. CONCLUSION: ECMO therapy in RV failure due to PCS is shown to be associated with an excessive mortality. Regarding our data, va ECMO might only be an appropriate short-term mechanical assist device separating patients form cardiopulmonary bypass with an acceptable weaning rate. Particularly, in case of failed hemodynamic recovery of the right heart on va ECMO, direct RV bypass systems might function as a bailout option. Additionally, cardiac enzymes and lactic acid might provide valuable information in meeting therapy-related decisions.

Central vs peripheral venoarterial ECMO in postcardiotomy cardiogenic shock.

OBJECTIVES: Central or peripheral venoarterial extracorporeal membrane oxygenation (va ECMO) is widely used in postcardiotomy cardiogenic shock (PCS). Available data suggest controversial results for both types. Our aim was to investigate PCS patients treated with either peripheral (pECMO) or central ECMO (cECMO) concerning their outcome. METHODS: Between April 2006 and October 2016, 156 consecutive patients with va ECMO therapy due to PCS were identified and included in this retrospective analysis. Patients were divided into cECMO and pECMO groups. Statistical analysis of risk factors concerning 30-day mortality of the mentioned patient cohort was performed using IBM SPSS Statistics. RESULTS: Fifty-six patients received cECMO and 100 patients were treated with pECMO due to PCS. In the group of cECMO peripheral vascular disease was significantly more present (cECMO 19 [34%] vs pECMO 14 [14%]; P < .01). On-site ECMO complications occurred significantly more frequent in patients treated with cECMO (cECMO 44 [79%] vs pECMO 54 [54%] g/dL; P < 0.01). More often cECMO patients required a second look operation due to mediastinal bleeding (cECMO 52 [93%] vs pECMO 61 [61%] g/dL; P < .01). Thirty-day mortality was comparable with nearly 70% in both cohorts (cECMO 39 [70%] vs pECMO 69 [69%]; P = .93). CONCLUSION: Patients supported by cECMO or pECMO due to refractory PCS did not show significant differences in 30-day mortality, despite a lower incidence of on-site ECMO complications and re-exploration in pECMO patients. PCS itself is associated with high mortality and peripheral cannulation might help to save resources compared with central cannulation.

TIMP-2/IGFBP7 predicts acute kidney injury in out-of-hospital cardiac arrest survivors.

BACKGROUND: Acute kidney injury (AKI) is a common complication after cardiopulmonary resuscitation (CPR) and predicts in-hospital mortality. To which extent post-resuscitation disease or the initial event of cardiac arrest and the duration of insufficient cardiac output triggers AKI is challenging to discriminate. Knowledge on molecular mediators of AKI is scarce. Early identification of patients at high risk of AKI is hampered by the low sensitivity of the established tests in clinical routine practice. The present study aimed to determine the diagnostic utility of the novel urine biomarkers tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) for the early recognition of AKI in patients with non-traumatic shock. METHODS: The performance of [TIMP-2]·[IGFBP7] was prospectively analysed in 48 patients with shock following out-of-hospital cardiac arrest (OHCA). All patients were treated with target temperature management (TTM) for 24 h. Urinary [TIMP-2]·[IGFBP7] samples were collected at 3 and 24 h after determination of OHCA. RESULTS: Patients (n = 31 (65%)) developed AKI after an average of 26 ± 12 h. Patients who developed AKI had significantly higher [TIMP-2]·[IGFBP7] compared to individuals that did not develop AKI (1.52 ± 0.13 vs. 0.13 ± 0.14; p < 0.05) as early as 3 h after determination of OHCA,. For urine [TIMP-2]*[IGFBP7], the area under the curve (AUC) for the development of AKI was 0.97 (CI 0.90-1.00) at 3 h after OHCA. The optimal [TIMP-2]·[IGFBP7] cut-off value for the prediction of AKI was 0.24. The sensitivity was 96.8% and specificity was 94.1%. CONCLUSIONS: Urinary [TIMP-2]•[IGFBP7] reliably predicts AKI in high-risk patients only 3 h after determination of OHCA with a cut-off at 0.24. This novel test may help to identify patients at high risk of AKI to enrol into clinical studies to further elucidate the pathophysiology of AKI and devise targeted interventions in the future.

Cardiac liposarcoma-a review of outcome after surgical resection.

OBJECTIVE: This review was performed to pool the current surgical strategies for cardiac liposarcoma. METHODS: A literature search was performed and all studies published in full-text or abstract forms were eligible for inclusion without applying any language restrictions. Case reports without surgical intervention, reporting noncardiac liposarcoma, animal cases, or review articles were excluded after initial abstract review. Analyzed postoperative outcomes included intraoperative and in-hospital mortality, longest reported survival, and recrudescence. RESULTS: After a critical evaluation 53 unique surgically treated case reports published between the years 1966 and December 2012 were included in this review. Most of the reported cardiac liposarcoma are myxoid (49.1%), pleomorphic liposarcoma occur with a prevalence of 20.8%, and well-differentiated tumors are observed in 13.2%. One-year survival rate increases the more differentiated the tumor is categorized: 54.5% for pleomorphic, 65.4% for myxoid, and 100% for well-differentiated liposarcoma (p = 0.096). CONCLUSION: Total surgical resection of cardiac liposarcoma is the only curative option, as it tends to local and distant recurrence. Therefore, a frequent follow-up examination should be considered.

Changes in neuron-specific enolase are more suitable than its absolute serum levels for the prediction of neurologic outcome in hypothermia-treated patients with out-of-hospital cardiac arrest.

BACKGROUND: To determine neurologic outcome in patients with out-of-hospital cardiac arrest (OHCA) and treatment with mild therapeutic hypothermia (MTH). METHODS: Seventy-three consecutive OHCA patients treated with MTH were retrospectively analyzed. Serum neuron-specific enolase (NSE) was measured 24, 48, and 72 h after admission. In patients with no motor response 48 h after termination of analgosedation (n = 40), clinical neurological examination and evoked potentials (EPs) were determined. Neurological outcome was assessed after 2 months based on the cerebral performance categories (CPC), and categorized as good (CPC 1-3) or poor (CPC 4 and 5). RESULTS: Forty-three patients had a CPC score of 1-3 and 30 patients had a CPC 4-5. The best predictive value for poor neurologic outcome was an increase of NSE by ≥4.3 ng/mL between day 1 and day 2 (sensitivity 80 %, specificity 100 %, positive predictive value (PPV) 100 %, negative predictive value 86 %). Absolute NSE values were less reliable in the prediction of poor outcome with the highest sensitivity (88 %) and specificity (95 %) if values reached ≥36.3 ng/mL on day 3. Somatosensory EPs (SSEPs) showed a specificity of 100 % and PPV of 100 %; however, sensitivity for evoked potentials was low (29 %). Intriguingly, two initially comatose patients with excessive NSE values (24 h NSE: 101 and 256 ng/mL, and 48 h NSE: 93 and 110 ng/mL, respectively) had physiological SSEPs and regained a CPC score of 1. CONCLUSION: In patients treated with MTH after OHCA changes in NSE are more suitable than its absolute serum levels for the prediction of poor neurologic outcome. Since unequivocal prediction of poor neurologic outcome is of utmost importance in these patients the decision to limit therapy must be based on several prediction tools with the highest PPV and specificity including SSEPs.

Oral anticoagulation in patients with left ventricular thrombus: a systematic review and network meta-analysis with reconstructed time-to-event data.

BACKGROUND: Left ventricular thrombus (LVT) is associated with high rates of systemic embolism. Vitamin K antagonists (VKAs) are the only approved treatment for LVT. Although evidence suggests direct oral anticoagulant (DOACs) to be at least equally effective in general, the efficacy of individual DOACs remains unclear. METHODS: A literature search was performed in EMBASE, MEDLINE and Web of Science looking for randomized controlled trials (RCTs) and non-randomized controlled studies of interventions (NRSI) comparing individual DOACs to VKAs for the treatment of LVT. Individual patient data was reconstructed and incorporated in a Bayesian network meta-analysis (NMA) and a Cox frailty regression model. RESULTS: A total of 2545 patients across 19 studies (4 RCTs, 15 NRSI) were included. 1738 received VKAs, 581 received Rivaroxaban, 226 received Apixaban, 82 received Dabigatran and 2 received Edoxaban. LVT resolution was less likely with VKAs compared to Rivaroxaban in the time-to-event analysis (HR 0.66, 95% CI [0.49; 0.91], p = 0.01). There was no difference for other DOACs compared to VKAs. Rivaroxaban reduced ischemic stroke compared to VKAs (OR 0.18, 95% CrI [0.05; 0.49]), other DOACs did not. CONCLUSION: In this NMA, Rivaroxaban showed faster LVT resolution and consecutively lower odds of ischemic stroke than VKAs while Apixaban and Dabigatran showed at least equal efficacy. Given the quality and size of the available studies, these differences between individual DOACs should be acknowledged as hypothesis generating only. Future adequately powered randomized controlled trials are needed to assess possible time-varying effects between individual DOACs.

Percutaneous Coronary Intervention versus Optimal Medical Therapy in Patients with Chronic Total Occlusion: A Meta-Analysis.

Background/Objectives: Chronic total occlusion (CTO) is a prevalent finding in patients with coronary artery disease and is associated with increased mortality. Prior reports on the efficacy of percutaneous coronary intervention (PCI) compared to optimal medical therapy (OMT) were controversial. Following the emergence of recently published new evidence, a meta-analysis is warranted. The current meta-analysis assessed the effects of PCI compared to OMT in the treatment of CTO. Methods: A structured literature search was performed. Randomized controlled trials (RCTs) and non-randomized controlled studies of interventions were eligible. The primary outcome was an accumulated composite of cardiac mortality, myocardial infarction and target vessel/lesion revascularization events. Results: Thirty-two studies reporting on 11260 patients were included. Of these, 5712 (50.7%) were assigned to the PCI and 5548 (49.3%) were allocated to the OMT group. The primary outcome occurred in 14.6% of the PCI and 20.1% of the OMT group (12 trials, OR 0.66, 95% CI 0.50 to 0.88, p = 0.005, I2 = 67%). Subgrouping demonstrated a consistent reduction in the primary outcome for the PCI group in RCTs (six trials, OR 0.58, 95% CI 0.33 to 0.99, p = 0.05). The primary outcome reduction was irrespective of the study design, and it was replicable in sensitivity and subgroup analyses. Advantages in other outcomes were rather related to statistical pooling effects and dominated by observational data. Conclusions: CTO-PCI was associated with improved patient-oriented primary outcome compared to OMT in a study-level meta-analysis. This composite outcome effect was mainly driven by target vessel treatment, but a significant reduction in mortality and myocardial infarction was observed, irrespectively. These findings have hypothesis-generating implications. Future RCTs with adequate statistical power are eagerly awaited.

Optic Nerve Sheath Diameter for Assessing Prognosis after Out-of-Hospital Cardiac Arrest.

PURPOSE: Evaluate optic nerve sheath and pial diameters (ONSD, ONPD) via sonography and computed tomography (CT) after out-of-hospital cardiac arrest (CA) and to compare their prognostic significance with other imaging and laboratory biomarkers. MATERIALS AND METHODS: A prospective observational study enrolling patients after successful resuscitation between December 2017 and August 2021. ONSD and ONPD were measured with sonography. Additionally, ONSD, and also grey-to-white ratio at basal ganglia (GWRBG) and cerebrum (GWRCBR), were assessed using CT. Lactate and neuron specific enolase (NSE) blood levels were measured. RESULTS: Sonographically measured ONSD and ONPD yielded no significant difference between survival and non-survival (p values ≥0.4). Meanwhile, CT assessed ONSD, GWRBG, GWRCBR, and NSE levels significantly differed regarding both, survival (p values ≤0.005) and neurological outcome groups (p values ≤0.04). For survival prognosis, GWRBG, GWRCBR, and NSE levels appeared as excellent predictors; in predicting a good neurological outcome, NSE had the highest accuracy. CONCLUSIONS: CT diagnostics, in particular GWRBG and GWRCBR, as well as NSE as laboratory biomarker, appear as excellent outcome predictors. Meanwhile, our data lead us to recommend caution in utilizing sonography assessed ONSD and ONPD for prognostic decision-making post-CA.

Accredited cardiac arrest centers facilitate eCPR and improve neurological outcome.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains a frequent medical emergency with low survival rates even after a return of spontaneous circulation (ROSC). Growing evidence supports formation of dedicated teams in scenarios like cardiogenic shock to improve prognosis. Thus, the European Resuscitation Council (ERC) recommended introduction of Cardiac Arrest Centers (CAC) in their 2015 guidelines. Here, we aimed to elucidate the effects of newly introduced CACs in Germany regarding survival rate and neurological outcome. METHODS: A multicenter retrospective observational cohort study was performed at three university hospitals and outcomes after OHCA were compared before and after CAC accreditation. Primary outcomes were survival until discharge and favorable neurological status (CPC 1 or 2) at discharge. RESULTS: In total 784 patients (368 before and 416 after CAC accreditation) were analyzed. Rates of immediate percutaneous coronary intervention (40 vs. 52%, p = 0.01) and implementation of extracorporeal CPR (8 vs. 13%, p < 0.05) increased after CAC accreditation. Likelihood of favorable neurological status at discharge was higher after CAC accreditation (71 vs. 87%, p < 0.01), whereas overall survival remained similar (35 vs. 35%, p > 0.99). CONCLUSION: CAC accreditation is linked to higher rates of favorable neurological outcome and unchanged overall survival.

Analysis of Cerebral CT Based on Supervised Machine Learning as a Predictor of Outcome After Out-of-Hospital Cardiac Arrest.

BACKGROUND AND OBJECTIVES: In light of limited intensive care capacities and a lack of accurate prognostic tools to advise caregivers and family members responsibly, this study aims to determine whether automated cerebral CT (CCT) analysis allows prognostication after out-of-hospital cardiac arrest. METHODS: In this monocentric, retrospective cohort study, a supervised machine learning classifier based on an elastic net regularized logistic regression model for gray matter alterations on nonenhanced CCT obtained after cardiac arrest was trained using 10-fold cross-validation and tested on a hold-out sample (random split 75%/25%) for outcome prediction. Following the literature, a favorable outcome was defined as a cerebral performance category of 1-2 and a poor outcome of 3-5. The diagnostic accuracy was compared with established and guideline-recommended prognostic measures within the sample, that is, gray matter-white matter ratio (GWR), neuron-specific enolase (NSE), and neurofilament light chain (NfL) in serum. RESULTS: Of 279 adult patients, 132 who underwent CCT within 14 days of cardiac arrest with good imaging quality were identified. Our approach discriminated between favorable and poor outcomes with an area under the curve (AUC) of 0.73 (95% CI 0.59-0.82). Thus, the prognostic power outperformed the GWR (AUC 0.66, 95% CI 0.56-0.76). The biomarkers NfL, measured at days 1 and 2, and NSE, measured at day 2, exceeded the reliability of the imaging markers derived from CT (AUC NfL day 1: 0.87, 95% CI 0.75-0.99; AUC NfL day 2: 0.90, 95% CI 0.79-1.00; AUC NSE day: 2 0.78, 95% CI 0.62-0.94). DISCUSSION: Our data show that machine learning-assisted gray matter analysis of CCT images offers prognostic information after out-of-hospital cardiac arrest. Thus, CCT gray matter analysis could become a reliable and time-independent addition to the standard workup with serum biomarkers sampled at predefined time points. Prospective studies are warranted to replicate these findings.

A contemporary training concept in critical care cardiology.

Critical care cardiology (CCC) in the modern era is shaped by a multitude of innovative treatment options and an increasingly complex, ageing patient population. Generating high-quality evidence for novel interventions and devices in an intensive care setting is exceptionally challenging. As a result, formulating the best possible therapeutic approach continues to rely predominantly on expert opinion and local standard operating procedures. Fostering the full potential of CCC and the maturation of the next generation of decision-makers in this field calls for an updated training concept, that encompasses the extensive knowledge and skills required to care for critically ill cardiac patients while remaining adaptable to the trainee's individual career planning and existing educational programs. In the present manuscript, we suggest a standardized training phase in preparation of the first ICU rotation, propose a modular CCC core curriculum, and outline how training components could be conceptualized within three sub-specialization tracks for aspiring cardiac intensivists.

Look before you leap: the importance of ECG in management of out-of-hospital cardiac arrest.

Graphical abstractReconstructed pre-hospital ECG, 25 mm/s 10 mm/mV.

["Long lie trauma" patients: retrospective analysis of a patient cohort presenting to a university hospital emergency department]. / Liegetrauma: retrospektive Analyse einer Patientenkohorte aus einer universitären Notaufnahme.

BACKGROUND: Patients discovered recumbent, helpless and incapacitated, awake or unresponsive are referred to as "long lie trauma" (LLT) in the German medical jargon. Yet, a characterization of this cohort is missing. METHODS: We retrospectively analyzed all LLT patients admitted to the emergency department of the University Hospital Cologne from July 2018 to December 2020. RESULTS: A total of 50 LLT patients (median age 76 years, median time on the ground 13.5 h) were identified. The FD was most often attributed to primary cerebral causes in 40% of the cases (20% ischemic stroke, 16% intracranial hemorrhage, 4% epilepsy), intoxication/overdose (12%), and trauma (10%). It was often associated with infection (52%), injury (22%), hypovolemia (66%), acute kidney injury (20%), and severe rhabdomyolysis (creatine kinase ≥ 5000 U/l, 21%) as well as severe hypothermia < 32 °C (20%). Overall, 69% of the patients were admitted to an intensive care unit and in-hospital mortality was 50%. CONCLUSION: The term "long lie trauma" describes a complex clinical situation, in which various conditions lead to an incapacitated state with acute onset, which then causes further adverse health effects. Trauma or tissue damage were no obligatory requirement in this syndrome. Considering the high morbidity and in-hospital mortality, patients should initially be treated in the emergency room by an interdisciplinary team.