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Aims Age is an important risk factor for mortality among patients with cardiogenic shock and heart failure (HF). We sought to assess the extent to which age modified the performance of the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage for in‐hospital and 1 year mortality in cardiac intensive care unit (CICU) patients with and without HF. Methods and results We retrospectively reviewed unique admissions to the Mayo Clinic CICU during 2007–2015 and stratified patients by age and SCAI shock stage. The association between age and in‐hospital mortality was analysed using multivariable logistic regression, and 1 year mortality was analysed using Cox proportional hazards analysis, both in the entire cohort and among patients with an admission diagnosis of HF or acute coronary syndrome (ACS). The final study population included 10 004 unique patients with a mean age of 67 ± 15 years, including 46.1% with HF and 43.1% with ACS. Older patients more frequently had HF and had more extensive co‐morbidities, higher illness severity, more organ failure, and differential use of critical care therapies. The percentage of patients with SCAI shock stages A, B, C, D, and E were 46%, 30%, 16%, 7%, and 1%, respectively. Patients with HF were older, had greater severity of illness and higher SCAI shock stage, and had higher rates of death at all time points. In‐hospital mortality occurred in 908 (9%) patients, including 549 (12%) patients with HF (61% of all hospital deaths). Age was independently associated with hospital mortality (adjusted odds ratio per 10 years 1.3, 95% confidence interval 1.2–1.4, P < 0.001) and 1 year mortality (adjusted hazard ratio per 10 years 1.2, 95% confidence interval 1.2–1.3, P < 0.001) in the overall cohort. The associations of age with both hospital mortality (adjusted odds ratio 1.6 vs. 1.3 per 10 years older) and 1 year mortality (adjusted hazard ratio 1.5 vs. 1.3 per 10 years older) were higher for patients with ACS compared with patients with HF. Older age was associated with higher adjusted hospital mortality and 1 year mortality in each SCAI shock stage (all P < 0.05). Additive increases in both hospital mortality and 1 year mortality were observed with increasing age and SCAI shock stage. Conclusions Age is an independent risk factor for mortality that modifies the relationship between the SCAI shock stage and mortality risk in CICU patients, providing robust risk stratification for in‐hospital and 1 year mortality. Although patients with HF had a higher risk of dying, age was more strongly associated with mortality among patients with ACS.

Large meta-analyses suggested a potential mortality reduction of 11% using intra-aortic balloon pump (IABP) in patients with myocardial infarction.4 These optimistic projections, however, were not confirmed by prospective randomized trials, either at short- or long-term time points.5,6 Similarly, despite reports suggesting that early use of Impella devices may reduce hospital mortality by 48%, both IABP and Impella had similar 30- and 90-day outcomes.7,8 Furthermore, even the immediate implementation of venoarterial extracorporeal membrane oxygenation (ECMO) in CS in a randomized comparison to conservative management without early use of venoarterial-ECMO did not result in improved 30-day mortality.9 These trials were predominantly conducted in the United States and Europe. Issues not captured in this study are the promise of gradual improvement in outcomes through optimization of shock protocols, configuration of devices with appropriate ECMO cannula sizing, placement of distal perfusion cannulas, and a multidisciplinary team approach, in addition to ventricular unloading strategies as seen by the French CRISTAL registry.12 Despite the improvement over the decade, however, even with rising use of increasingly powerful tMCS, mortality rates are sadly unchanged! In 2001, the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart trial revolutionized the trajectory for patients with end-stage heart failure with improved quality of life and survival benefit from the HeartMate XVE left ventricular assist device (Abbott, Abbott Park, Illinois).15 Nearly 2 decades and multiple iterations later, as a community, we learned best practices to improve outcomes.

Aims Transthyretin cardiac amyloidosis (ATTR‐CA) is most often associated with heart failure with preserved ejection fraction (HFpEF). However, patients may present with impaired systolic function at the time of diagnosis, which has not been widely investigated. We sought to explore the prevalence of various heart failure (HF) phenotypes and their associated clinical characteristics at the time of ATTR‐CA diagnosis. Methods We performed a single‐centre retrospective cohort study of consecutive patients with ATTR‐CA evaluated between February 2016 and December 2022. Data on patient demographics, comorbidities, imaging and laboratory findings were compared across HF phenotypes (age: 78.1 ± 8.6 years, with 91.1% male). A total of 21.6% (n = 46) presented with heart failure with reduced ejection fraction (HFrEF), 17.8% (n = 38) with heart failure with mildly reduced ejection fraction (HFmrEF) and 60.6% (n = 129) with HFpEF at the time of diagnosis with ATTR‐CA. Those presenting with HFrEF or HFmrEF were more likely to be African American and had significantly worse New York Heart Association (NYHA) functional class, higher N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) and higher serum creatinine levels as compared with those with HFpEF. Conclusions Although ATTR‐CA is traditionally thought to be seen primarily among patients with HFpEF, our data suggest that ATTR‐CA has a higher prevalence among patients with HFrEF, which underscores the importance of heightened clinical suspicion regardless of ejection fraction when considering ATTR‐CA. Furthermore, although comorbidities are similar, patients with HFmrEF and HFrEF had a worse symptom burden.

Cardiac amyloidosis (CA), an infiltrative restrictive cardiomyopathy, is a frequently underrecognized etiology of diastolic heart failure (HF). This study aimed to evaluate inpatient outcomes among patients hospitalized with decompensated diastolic HF with and without a secondary diagnosis of amyloidosis, utilizing data from the National Inpatient Sample (2018–2021). Among 2,444,699 patients hospitalized for decompensated diastolic HF, 9205 (0.3%) had a documented secondary diagnosis of amyloidosis. After 1:1 propensity-score matching, 1841 patients in each group were analyzed. Multivariate logistic regression revealed that the presence of amyloidosis was associated with significantly higher odds of in-hospital mortality (4.0% vs. 2.7%), cardiogenic shock (5.4% vs. 2.4%), acute kidney injury (28.3% vs. 22.0%), ventricular tachycardia (12.4% vs. 6.0%), and acute myocardial injury (9.5% vs. 6.0%) (all p < 0.05). Additionally, patients with amyloidosis had a longer mean length of stay (7.1 vs. 5.7 days) and higher mean hospitalization costs ( $85,594 vs. $ 48,484, p < 0.05). Although the overall incidence of acute myocardial injury was elevated, subgroup analysis of ST-elevation and non–ST-elevation myocardial infarction revealed no significant differences. These findings underscore the considerable clinical and economic burden of amyloidosis in patients hospitalized with decompensated diastolic heart failure.

When a patient with an intra‐aortic balloon pump needs different support, it is simple to use a stiff 0.018‐inch interventional wire (360 cm) to exchange the balloon for a new sheath. This allows the team to start with a balloon and then switch if the support is not sufficient. When a patient with an intra‐aortic balloon pump needs different support, it is simple to use a stiff 0.018‐inch interventional wire (360 cm) to exchange the balloon for a new sheath. This allows the team to start with a balloon and then switch if the support is not sufficient.

Background. The prevalence of peripheral vascular disease has led to the re-emergence of percutaneous axillary vascular access as a suitable alternative access site to femoral artery. We sought to investigate the efficacy and safety of manual hemostasis in the axillary artery. Methods. Data were collected from a prospective internal registry of patients who had a Maquet® (Rastatt, Germany) Mega 50 cc intra-aortic balloon pumps (IABP) placed in the axillary artery position. They were anticoagulated with weight-based intravenous heparin to maintain an activated partial thromboplastin time (aPTT) of 50–80 seconds. Anticoagulation was discontinued 2 hours prior to the device explantation. Manual compression was used to achieve the hemostasis of the axillary artery. Vascular and bleeding complications attributable to manual hemostasis were classified based on the Valve Academic Research Consortium-2 (VARC-2) and Bleeding Academic Research Consortium-2 (BARC-2) classifications, respectively. Results. 29 of 46 patients (63%) achieved axillary artery homeostasis via manual compression. The median duration of IABP implantation was 12 days (range 1–54 days). Median compression time was 20 minutes (range 5–60 minutes). There were no major vascular or bleeding complications as defined by the VARC-2 and BARC-2 criteria, respectively. Conclusion. Manual compression of the axillary artery appears to be an effective and safe method for achieving hemostasis. Large prospective randomized control trials may be needed to corroborate these findings.

Objectives There are four immunoglobulin (IgG) subtypes that have varying complement‐activating ability: strong (IgG3 and IgG1) and weak (IgG2 and IgG4). The standard flow cytometric crossmatch (FCM) assay does not distinguish between the various subtypes of the IgG molecule. This study outlines the development and use of a novel cell‐based IgG subtype‐specific FCM assay that is able to detect the presence of and quantitate the IgG subtypes bound to donor cells. Methods A six‐colour lyophilised reagent was designed that specifically detects the four IgG subtypes, as well as distinguishes between T cells and B cells in the lymphocyte population. To test the efficacy of this reagent, a retrospective evaluation of a group of highly sensitised patients awaiting heart and kidney transplant was carried out, who, because of positive standard FCM results, had been deemed incompatible with numerous prior potential donors. Results Observations in this study demonstrate that the positive standard FCM results were mainly because of the presence of noncomplement‐activating IgG2 or IgG4 antibodies. The results were supported by the absence of C3d‐binding donor‐specific antibodies (DSA) and a negative complement‐dependent cytotoxicity crossmatch (CDC). Conclusion Preliminary data presented in this study demonstrate the reliability of the novel IgG subtype assay to detect the presence of pretransplant, complement‐activating antibodies bound to donor cells. The knowledge gained from the IgG subtype assay and the C3d‐binding specificities of DSAs provides improved identification of donor suitability in pretransplant patients, potentially increasing the number of transplants. In this study, we demonstrate that our novel IgG subtype‐specific FCM assay is able to distinguish between complement‐activating and noncomplement‐activating antibodies bound to donor cells. We observed that in highly sensitised heart and kidney transplant patients, the positive standard FCM results were mainly because of the presence of noncomplement‐binding IgG2 and/or IgG4 antibodies, which was supported by negative CDC assay results and the absence of C3d binding DSAs. Thus, incorporating the IgG subtype assay in the transplant testing regimen for patients awaiting solid organ transplant may aid in increasing donor availability for highly sensitised pretransplant patients.

•A total of 7 studies evaluated outcomes of Impella versus IABP in patients with cardiogenic shock on venoarterial extracorporeal membrane oxygenation.•The use of Impella and IABP in patients on venoarterial extracorporeal membrane oxygenation has comparable effects on short-term mortality.•However, Impella use was associated with a significantly higher risk of major bleeding and hemolysis.•No significant differences were observed in left ventricular assist devices transition, continuous renal replacement therapy initiation, or stroke.•In patients with cardiogenic shock, IABP may be as effective as Impella in LV unloading. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2 = 71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2 = 82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2 = 66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.

The five-stage Society for Cardiovascular Angiography and Intervention (SCAI) cardiogenic shock classification scheme can stratify hospital mortality risk in patients admitted to the cardiac intensive care unit (CICU). We sought to evaluate the SCAI shock classification for prediction of post-discharge mortality in CICU survivors. We retrospectively analyzed hospital survivors admitted to a single CICU between 2007 and 2015. SCAI CS stages A through E were classified using CICU admission data using a previously published algorithm. All-cause post-discharge mortality was compared across SCAI stages using Kaplan-Meier analysis and Cox proportional hazards models. Among 9096 unique hospital survivors, 43.2% had acute coronary syndrome (ACS), 44.6% had heart failure (HF), and 8.7% had cardiac arrest (CA) on admission. The proportion of patients in each SCAI shock stage was: A, 49.1%; B, 30.6%; C, 15.2; D/E 5.2%. Kaplan-Meier survival at 5 years in each SCAI shock stage was: A, 88.2%; B, 81.6%; C, 76.7%; D/E, 71.7% (P < .001 by log-rank). Each higher SCAI shock stage was associated with increased adjusted post-discharge mortality compared to SCAI shock stage A (all P < .001); results were consistent among patients with ACS or HF. Late hemodynamic deterioration after 24 hours, but not an admission diagnosis of CA, was associated with higher post-discharge mortality. The SCAI shock classification assessed at the time of CICU admission was predictive of post-discharge mortality risk among hospital survivors, although an admission diagnosis of CA was not. The SCAI shock classification can be used for post-discharge mortality risk stratification.

Patients were assigned to monitoring for rejection after cardiac transplantation either according to the standard practice of endomyocardial biopsies or with gene-expression profiling. At 19 months, the rates of rejection with hemodynamic compromise, graft dysfunction, death, or retransplantation were similar in the two groups, although the power of the trial was limited. Patients were assigned to monitoring for rejection after cardiac transplantation either according to the standard practice of endomyocardial biopsies or with gene-expression profiling. At 19 months, the rates of rejection were similar in the two groups. Advances in immunosuppression after cardiac transplantation have increased the rates of 1-year survival among recipients to nearly 90%. However, acute cellular rejection is still observed during the first year after transplantation (at a rate of approximately 30 to 40%) and occurs at a lower rate thereafter. 1 – 4 Rejection episodes are associated with an increased risk of allograft vasculopathy and loss. 5 – 7 Endomyocardial biopsy has remained the primary method of monitoring for rejection, despite the discomfort and the rare but potentially serious complications of the procedure. 8 – 12 Quantitative assessment of mononuclear-cell gene expression in peripheral-blood specimens has been explored as a . . .