Cardiogenic Shock Medical and Health News Headlines

A Simple Way to Decompress the Left Ventricle during Venoarterial Bypass.

Thorac Cardiovasc Surg. 2008 Sep;56(6):337-41

Authors: Segesser LK, Kwang K, Tozzi P, Horisberger J, Dembitsky W

OBJECTIVE: The aim of this investigation was to improve the hemodynamics during venoarterial bypass by remote decompression of the left ventricle (LV). METHODS: Venoarterial bypass was established in 5 bovine experiments (69 +/- 10 kg) by the transjugular insertion of a self-expanding cannula (smartcanula(R)) with return through a carotid artery. Cardiogenic shock was simulated with ventricular fibrillation induced by an external stimulator. Left ventricular decompression was achieved by switching to transfemoral drainage of the pulmonary artery (PA) with a long self-expanding cannula. RESULTS: Initial pump flow was 4.7 +/- 0.9 l/min and the aortic pressure accounted for 75 +/- 21 mmHg. After induction of ventricular fibrillation, the pump flow dropped after 11 +/- 8 min to 2.5 +/- 0.1 l/min. Transfemoral decompression increased the pump flow to 5.6 +/- 0.7 l/min, while the RV pressure decreased from 27 +/- 9 to 3 +/- 5 mmHg, the PA pressure decreased from 29 +/- 7 to 5 +/- 4 mmHg, the LV pressure decreased from 29 +/- 6 to 7 +/- 2 mmHg, and the aortic pressure increased from 31 +/- 3 to 47 +/- 11 mmHg. CONCLUSIONS: Remote drainage of the pulmonary artery during venoarterial bypass allows for effective decompression of the left ventricle and provides superior hemodynamics.

PMID: 18704855 [PubMed - in process]

CARDIOGENIC SHOCK SECONDARY TO TAKOTSUBO SYNDROME AFTER DEBRIDEMENT OF MALIGNANT ENDOBRONCHIAL OBSTRUCTION.

Chest. 2008 Aug 8;

Authors: Guerrero J, Majid A, Armin E

Transient left ventricular dysfunction syndrome, or Takotsubo syndrome, occurs following intense emotional or physical stress and simulates the clinical presentation of an acute myocardial infarction. We report a case of a 77-year-old man with esophageal adenocarcinoma with local invasion of the central airways who underwent rigid bronchoscopy for tumor debridement followed by placement of a stent. Postoperatively the patient developed cardiogenic shock and echocardiography revealed akinesis of the left ventricular apex with an ejection fraction of 15%. Emergent coronary angiography revealed no significant coronary artery disease. The patient required intraaortic balloon counterpulsation and pressors. Seventy-two hours later, a repeat echocardiogram showed an ejection fraction of 45% with improvement in apical function and the patient was discharged home in stable condition shortly there after. A 5-month follow up echocardiogram revealed an ejection fraction >55% and the patient enjoyed an excellent performance status.

PMID: 18689580 [PubMed - as supplied by publisher]

[The determination of the factors impacting on in-hospital mortality in patients with acute heart failure in a tertiary referral center.]

Anadolu Kardiyol Derg. 2008 Aug;8(4):255-259

Authors: Zoghi M, Duygu H, Güngör H, Nalbantgil S, Yılmaz GM, Tülüce K, Ozerkan F, Akıllı A, Akın M

OBJECTIVE: Despite impressive advances in therapeutics in the last years, acute heart failure (AHF) remains a major cause of cardiovascular morbidity and mortality. Patients hospitalized because of heart failure (HF), irrespective of left ventricular systolic function, represent a high-risk population with limited short-term prognosis. A substantial component of HF-related mortality occurs during a hospital stay. In this study, we aimed to determine the factors impacting on in-hospital mortality in patients with AHF. METHODS: During a 15-month period (December 2005-March 2007), 85 consecutive patients with (mean age: 64+/-8 years, male: 54%) an episode of AHF were included in this study. The effect of demographic, clinical, electrocardiographic, and echocardiographic characteristics, laboratory findings on in-hospital mortality were evaluated retrospectively. RESULTS: Of 85 patients 24.7% of patients had new-onset HF. Coronary artery disease (61%) was the most common underlying disease. The 44.7% of patients had hypertension, 37.6% had diabetes mellitus, 21% had chronic renal failure and 16.4% had chronic obstructive pulmonary disease. Left ventricular ejection fraction was 35+/-7%. In-hospital mortality rate was found as 11.7% (10 patients).The major cause of mortality was the progression of HF to cardiogenic shock in 60% of deaths. In comparison with surviving patients in terms of the clinical, demographic, electrocardiographic, and laboratory characteristics and left and right ventricular functions, patients died during hospitalization had higher blood urea nitrogen (45+/-20 mg/dl vs. 36+/-12 mg/dl, p=0.04), higher creatinine level (2.2+/-0.8 mg/dl vs. 1.1+/-0.5 mg/dl, p=0.001), and wider QRS duration (130+/-13 ms vs. 116+/-18 ms, p=0.04) whereas they had lower plasma sodium level (128+/-5 mmol/l vs. 135+/-9 mmol/l, p=0.02) and systolic blood pressure (p=0.01). Logistic regression analysis revealed that plasma creatinine level (OR 1.5, 95% CI 1.2 to 2.1, p=0.01), blood urea nitrogen (OR 2.1, 95% CI 1.8 to 3.1, p=0.001), plasma sodium level (OR 1.3, 95% CI 1.1 to 1.7, p=0.02), and systolic blood pressure (OR 2.2, 95% CI 1.9 to 2.8, p=0.01) were the independent predictors of in-hospital mortality. CONCLUSION: In-hospital mortality increases in patients who had lower systolic blood pressure, lower plasma sodium level, and renal dysfunction on admission.

PMID: 18676300 [PubMed - as supplied by publisher]

Excellent outcome after surgical treatment of massive pulmonary embolism in critically ill patients.

J Thorac Cardiovasc Surg. 2008 Aug;136(2):448-51

Authors: Kadner A, Schmidli J, Schönhoff F, Krähenbühl E, Immer F, Carrel T, Eckstein F

OBJECTIVE: Treatment of central and paracentral pulmonary embolism in patients with hemodynamic compromise remains a subject of debate, and no consensus exists regarding the best method: thrombolytic agents, catheter-based thrombus aspiration or fragmentation, or surgical embolectomy. We reviewed our experience with emergency surgical pulmonary embolectomy. METHODS: Between January of 2000 and March of 2007, 25 patients (17 male, mean age 60 years) underwent emergency open embolectomy for central and paracentral pulmonary embolism. Eighteen patients presented in cardiogenic shock, 8 of whom had cardiac arrest and required cardiopulmonary resuscitation. All patients underwent operation with mild hypothermic cardiopulmonary bypass. Concomitant procedures were performed in 8 patients (3 coronary artery bypass grafts, 2 patent foramen ovale closures, 4 ligations of the left atrial appendage, 3 removals of a right atrial thrombus). Follow-up is 96% complete with a median of 2 years (range, 2 months to 6 years). RESULTS: All patients survived the procedure, but 2 patients died in the hospital on postoperative days 1 (intracerebral bleeding) and 11 (multiorgan failure), accounting for a 30-day mortality of 8% (95% confidence interval: 0.98-0.26). Four patients died later because of their underlying disease. Pre- and postoperative echocardiographic pressure measurements demonstrated the reduction of the pulmonary hypertension to half of the systemic pressure values or less. CONCLUSION: Surgical pulmonary embolectomy is an excellent option for patients with major pulmonary embolism and can be performed with minimal mortality and morbidity. Even patients who present with cardiac arrest and require preoperative cardiopulmonary resuscitation show satisfying results. Immediate surgical desobstruction favorably influences the pulmonary pressure and the recovery of right ventricular function, and remains the treatment of choice for patients with massive central and paracentral embolism with hemodynamic and respiratory compromise.

PMID: 18692656 [PubMed - in process]

Myocardial revascularization in infants and children by means of coronary artery proximal patch arterioplasty or bypass grafting: a single-institution experience.

J Thorac Cardiovasc Surg. 2008 Aug;136(2):298-305

Authors: Bergoënd E, Raisky O, Degandt A, Tamisier D, Sidi D, Vouhé P

OBJECTIVE: We sought to evaluate midterm functional and anatomic results after coronary artery surgical arterioplasty or bypass grafting in infants and children. METHODS: Data concerning all consecutive patients operated on for myocardial revascularization in our institution between 1992 and 2004 were retrospectively analyzed. RESULTS: Twenty-five patients (mean age, 5.3 years) underwent surgical arterioplasty of a main coronary trunk, and this was for coronary obstruction after the arterial switch operation in 19 patients. Eight patients (mean age, 8.0 years) underwent a coronary bypass, and this was for postoperative coronary obstruction in all of them. One patient died 4 days after arterioplasty because of cardiogenic shock. One patient died suddenly 3.5 months after bypass from an unknown cause. All other patients were alive after a mean follow-up of 3.4 years after arterioplasty and 4.4 years after bypass. Among the 3 patients in whom the surgical enlargement of the left main trunk was extended to the left anterior descending coronary artery, 2 presented a restenosis of this artery and necessitated a coronary bypass 2.6 and 5.7 years, respectively, after arterioplasty. Among patients who had a postoperative angiogram, 17 (89%) of 19 after arterioplasty and 3 (50%) of 6 after bypass showed a good result. A internal thoracic artery graft was occluded, another one showed a complete string sign, and, finally, a patient presented with a tight stenosis of the bypass distal anastomosis. Eighteen (72%) patients after arterioplasty and 5 (63%) after bypass remained symptom free at last follow-up. CONCLUSIONS: Provided that the left main coronary artery bifurcation was not involved in the stenotic process, surgical arterioplasty of the main coronary trunks led to good functional and anatomic midterm results. On the other hand, variable indications and poorer preoperative cardiac conditions might have contributed to the disappointing results observed after coronary bypass.

PMID: 18692633 [PubMed - in process]

Critical care aspects in the management of patients with acute coronary syndromes.

Emerg Med Clin North Am. 2008 Aug;26(3):685-702

Authors: Naples RM, Harris JW, Ghaemmaghami CA

The spectrum of acute coronary syndromes (ACS) includes several clinical complexes that frequently cause critical instability in affected patients. This article focuses on several critical care aspects of these unstable ACS patients. The management of cardiogenic shock can be particularly challenging because the mechanical defects are varied in cause, severity, and specific treatment. Complications of fibrinolytic therapy are potentially deadly and arrhythmias are relatively common in the ACS patients. Discussions on the management of these problems should help the emergency physician more effectively to treat critically ill patients with ACS.

PMID: 18655940 [PubMed - in process]

Bivalirudin With Provisional Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing Primary Angioplasty in the Setting of Cardiogenic Shock.

Am J Cardiol. 2008 Aug 1;102(3):287-91

Authors: Bonello L, De Labriolle A, Roy P, Steinberg DH, Pinto Slottow TL, Xue Z, Smith K, Torguson R, Suddath WO, Satler LF, Kent KM, Pichard AD, Waksman R

In patients undergoing percutaneous coronary intervention (PCI), clinical trials have demonstrated that the use of bivalirudin with provisional glycoprotein IIb/IIIa inhibitors is not inferior to heparin with systematic glycoprotein IIb/IIIa inhibitors on major adverse cardiac events and is associated with lower rates of bleeding in various clinical settings. Patients with cardiogenic shock (CS), however, have been excluded from all pivotal trials. A retrospective analysis of 86 consecutive patients undergoing PCI for acute myocardial infarction complicated by CS in our center from April 2003 to September 2007 was performed. In-hospital death, major adverse cardiac events, and bleeding rates were compared in 37 patients who received bivalirudin with or without glycoprotein IIb/IIIa inhibitors and 49 patients who were treated with heparin and glycoprotein IIb/IIIa inhibitors as anticoagulation management. Baseline demographic, clinical, and biological characteristics were similar in the 2 groups. The in-hospital death rate was significantly lower in the bivalirudin group (5.4 vs 32.7%, p = 0.002). There were no differences in the rate of major hematoma between the bivalirudin group and the heparin group (3 vs 2.6%, p = 0.46). In conclusion, bivalirudin with provisional use of glycoprotein IIb/IIIa inhibitors appears to be a safe and effective anticoagualtion strategy in patients undergoing primary PCI for acute myocardial infarction complicated by CS.

PMID: 18638588 [PubMed - in process]

Observations and outcomes of definite and probable drug-eluting stent thrombosis seen at a single hospital in a four-year period.

Am J Cardiol. 2008 Aug 1;102(3):298-303

Authors: Pinto Slottow TL, Steinberg DH, Roy PK, Buch AN, Okabe T, Xue Z, Kaneshige K, Torguson R, Lindsay J, Pichard AD, Satler LF, Suddath WO, Kent KM, Waksman R

Stent thrombosis (ST) is a major safety concern after drug-eluting stent (DES) deployment, resulting in significant morbidity and mortality. The goal of this study was to examine the incidence, timing, clinical correlates, and outcomes after DES thrombosis in a real-world population. A retrospective analysis of 8,402 patients who underwent percutaneous coronary intervention and received a DES was performed. After DES implantation, 84 definite (DST) and 127 probable ST events occurred. The incidence of early DST was 0.8%, late DST was 0.4%, and very late DST was 0.4%. Multivariate analysis showed that a history of diabetes mellitus, myocardial infarction during admission, number of stents, and DES placement in a restenotic lesion were independently associated with DST. The incidence of early definite or probable ST (DPST) was 1.9%, late DPST was 1.4%, and very late DPST was 0.7%. Multivariate analysis showed that a history of diabetes, myocardial infarction during admission, cardiogenic shock, number of stents, and DES use in a restenotic lesion were independently associated with DPST. Both types of ST were associated with significantly higher rates of all-cause death, Q-wave myocardial infarction, and revascularization up to 24 months after DES implantation. In conclusion, ST after DES implantation in contemporary practice continues to occur from 30 days to 2 years at a rate >/=0.36%/year and is associated with high rates of morbidity and mortality. Diabetes mellitus, myocardial infarction, and DES use in a restenotic lesion were strongly associated with DST; therefore, careful consideration should apply when deploying a DES in these populations.

PMID: 18638590 [PubMed - in process]

Determinants of in-hospital death in left main coronary artery myocardial infarction complicated by cardiogenic shock.

J Cardiol. 2008 Aug;52(1):24-9

Authors: Sakakura K, Kubo N, Hashimoto S, Ikeda N, Funayama H, Hirahara T, Sugawara Y, Yasu T, Ako J, Kawakami M, Momomura S

BACKGROUND: Acute myocardial infarction (AMI) due to left main coronary artery disease is associated with significantly elevated morbidity and mortality. The aim of this study was to identify the predictors of in-hospital death from left main AMI complicated by cardiogenic shock. METHODS: Clinical record review identified a total of 25 cases of left main AMI with cardiogenic shock. Patients' background characteristics, laboratory data, and angiographic findings were analyzed according to the in-hospital mortality. RESULTS: In this patient subset, in-hospital mortality (60%) was associated with a history of hypertension (p=0.02) and a higher heart rate (p=0.02). Furthermore, in-hospital mortality was also associated with a complete right bundle branch block (CRBBB) pattern in the admission ECG (p=0.01) and low HCO(3)(-) (p=0.0004). In stepwise logistic regression analysis, a CRBBB pattern (OR 48.59, 95% CI 1.34-1768.10, p=0.03) and low HCO(3)(-) (OR 0.62, 95% CI 0.40-0.94, p=0.02) were found to be independent predictors of mortality. CONCLUSIONS: Left main AMI with cardiogenic shock was associated with high in-hospital mortality. A CRBBB pattern in the ECG on admission and a low HCO(3)(-) concentration were significant independent predictors of in-hospital death.

PMID: 18639774 [PubMed - in process]

CentriMag left ventricular assist system: cannulation through a right minithoracotomy.

Tex Heart Inst J. 2008;35(2):184-5

Authors: Gregoric ID, Cohn WE, Akay MH, La Francesca S, Myers T, Frazier OH

The CentriMag left ventricular assist system can be used for perioperative or postcardiotomy circulatory support of the failing heart. The device resides at the patient's bedside, and the cannulae are usually inserted through a midline sternotomy, with the inflow cannula in the left ventricle or right superior pulmonary vein and the outflow cannula in the aorta. In a patient whose chest has been closed and who has a delayed need for temporary mechanical support, a less invasive method of left ventricular assist device cannula insertion is preferred. In these cases, the CentriMag cannulae can be inserted through a right minithoracotomy with the inflow cannula in the right superior pulmonary vein and the outflow cannula in the aorta, with no heparinization. Herein, we describe this approach in a patient who experienced postcardiotomy cardiogenic shock after aortocoronary bypass surgery. This technique may facilitate ambulation and recovery in selected patients.

PMID: 18612493 [PubMed - in process]

The TandemHeart as a bridge to a long-term axial-flow left ventricular assist device (bridge to bridge).

Tex Heart Inst J. 2008;35(2):125-9

Authors: Gregoric ID, Jacob LP, La Francesca S, Bruckner BA, Cohn WE, Loyalka P, Kar B, Frazier OH

End-stage heart-failure patients in acute refractory cardiogenic shock with multi-organ dysfunction require aggressive medical therapy that includes inotropic support. Historically, the intra-aortic balloon pump was the last option for patients who were dying of acute cardiogenic shock. Short-term extracorporeal pulsatile or nonpulsatile cardiac assist devices or extracorporeal membrane oxygenation offered further treatment options; however, these therapies required invasive surgical procedures. Patients in this high-risk group had increased mortality rates from major procedures that required cardiopulmonary bypass. We used the TandemHeart, a percutaneously implanted device for short-term cardiac assistance, to lower the risk of death and improve hemodynamic performance and end-organ perfusion before implanting long-term assist devices in selected patients with signs of profound cardiogenic shock. Nine end-stage heart-failure patients (mean age, 37.7 yr) in acute refractory hemodynamic decompensation received a percutaneously implanted TandemHeart pump as a bridge to an implantable axial-flow pump. To determine the relative risk for these patients, prognostic scores were calculated before and after insertion of the TandemHeart. Percutaneous support times ranged from 1 to 22 days (mean, 5.9 d). The mean cardiac index before support, 1.02 L/(min.m2) (range, 0.0-1.8 L/[min.m2]) (0.0 L/[min.m2] implies active cardiopulmonary resuscitation), improved to 2.97 L/(min.m2) (range, 2.2-4.0 L/[min.m2]) during support. Three patients underwent successful cardiac transplantation; 5 are currently supported by axial-flow pumps; and 1 died of complications unrelated to the axial-flow pump, after 587 days. End-organ function and overall condition improved uniformly in our patients, thus decreasing the preoperative risk factors for implantation of the long-term device.

PMID: 18612448 [PubMed - in process]

Related Articles

Procalcitonin in acute myocardial infarction.

Acute Card Care. 2008;10(1):30-6

Authors: Kafkas N, Venetsanou K, Patsilinakos S, Voudris V, Antonatos D, Kelesidis K, Baltopoulos G, Maniatis P, Cokkinos DV

OBJECTIVE: Procalcitonin (PCT) is released in severe bacterial infections, sepsis and in infection independent cases such as major surgery, multiple trauma, cardiogenic shock, burns, resuscitation, and after cardiac surgery. The aim of this study was to determine the levels and the kinetics of PCT in AMI and to investigate their possible correlation with the release of IL-6 and CRP. DESIGN-PATIENTS: The study included 60 patients (47 men, 63.2+/-14.8 years) with the diagnosis of AMI at admission. In all patients, serum levels of PCT, IL-6, CK-MB, TnI and CRP were measured at admission, at 3, 6, 12, 24, 48 and 72 h and at the seventh day. RESULTS: PCT was elevated in all patients with AMI. It was initially detected in serum approximately 2-3 h after the onset of the symptoms. The median value at admission was 1.3 ng/ml (95% CI: 0.89 to 1.80). The value of PCT showed an increase and reached a plateau after 12-24 h. The median value at 24 h was 3.57 ng/ml (95% CI: 2.89 to 4.55). PCT values fell to baseline (<0.5 ng/ml) by the seventh day. PCT was detected in serum earlier than CK-MB or TnI in 56 of the 60 patients (93.3%). The kinetics of PCT was similar to those of CK-MB and TnI. The maximal values of PCT were positively correlated with the maximal values of IL-6 (r = 0.59, P = 0.00) and of CRP (r = 0.65, P = 0.001). The maximal values of IL-6 were positively correlated with max CRP (r = 0.35, P = 0.045). CONCLUSIONS: PCT could be considered as a novel sensitive myocardial index. Its release in AMI is probably due to the inflammatory process that occurs during AMI.

PMID: 17924232 [PubMed - in process]