Search

Graphical Abstract

ObjectiveCurrent data on intensive care unit (ICU) admissions in patients with adult congenital heart disease (ACHD) are limited and focus on admissions after elective cardiac surgery. This study describes non-elective ICU admissions in patients with ACHD.MethodsA retrospective matched cohort study was performed from January 2000 until December 2015 in a tertiary care centre ICU (there was no cardiac care unit). Primary outcomes were short-term (during hospital stay or <30 days after discharge) and long-term (>30 days after discharge until end of follow-up) mortality. Outcomes were compared with non-ACHD non-elective ICU admissions, matched 1:1 on age, sex and admission diagnosis.ResultsA total of 138 admissions in 104 patients with ACHD (65.9% male, median age 30 years) were included, during 8.6 years of follow-up. The majority had a moderate-to-severe heart defect. Arrhythmia was the most common admission diagnosis (44.2%), followed by haemorrhage (10.9%), heart failure (8.7%) and pulmonary disease (8.7%). Short-term mortality and total mortality were lower in the ACHD admissions than in the non-ACHD admissions (4.8% vs 16.3%, p=0.005 and 17.3% vs 28.9%, p=0.030), whereas long-term (12.5% vs 12.6%, p=0.700) did not differ. Severe CHD (HR 3.1, 95% CI 1.1 to 8.6) at baseline, and mechanical circulatory support device use (8.3, 1.4 to 47.4) and emergency intervention (0.2, 0.1 to 0.7) during the ICU stay were independently associated with mortality in the ACHD group.ConclusionsNon-elective ICU admissions in patients with ACHD are most often for arrhythmia and in patients with moderate-to-severe CHD. Reassuringly, short-term and total mortality are lower compared with patients without ACHD, however, long-term mortality is higher than expected for patients with ACHD.

Supplemental digital content is available in the text.

To examine whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) improves survival of patients with acute pulmonary embolism (PE).

We study sex differences in 1-year mortality of out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients admitted to the intensive care unit (ICU).

Disordered thyroid hormone transport, due to mutations in the SLC16A2gene encoding monocarboxylate transporter 8 (MCT8), is characterised by intellectual and motor disability resulting from cerebral hypothyroidism and chronic peripheral thyrotoxicosis. We sought to systematically assess the phenotypic characteristics and natural history of patients with MCT8 deficiency.

Background: After early revascularisation, restoration of macrocirculatory perfusion parameters is the primary objective in the management of cardiogenic shock complicated acute myocardial infarction. Nevertheless, vital organ perfusion may be compromised at the systemic microcirculatory level, even in patients with preserved macrohaemodynamics. Microvascular perfusion was shown to have independent prognostic value for early mortality. The present study aims to compare the prognostic value of microcirculatory versus macrocirculatory perfusion parameters.Methods: This substudy of the culprit lesion-only percutaneous coronary intervention versus multivessel percutaneous coronary intervention in cardiogenic shock (CULPRIT-SHOCK) trial examined the sublingual capillary network using videomicroscopy post-percutaneous coronary intervention to determine the proportion of perfused capillaries (<20 µm) and perfused capillary density. Thirty-day follow-up was performed to obtain the occurrence of a combined clinical endpoint of all-cause death and renal replacement therapy.Results: Videomicroscopy measurements were performed in 66 patients. There was a significant adjusted association between microcirculatory perfusion parameters and the combined clinical endpoint (proportion of perfused capillaries: P=0.020; perfused capillary density: P=0.035), whereas there was no significant adjusted association between macrocirculatory perfusion parameters and the combined clinical endpoint (systolic blood pressure: P=0.205). Normotensive patients with compromised microcirculatory perfusion parameters had a higher risk of the combined clinical endpoint than normotensive patients with preserved microcirculatory perfusion parameters (proportion of perfused capillaries: Breslow P=0.014; perfused capillary density: Breslow P=0.076).Conclusions: There is a significant and independent association between microcirculatory perfusion parameters perfused capillary density and proportion of perfused capillaries and the combined clinical endpoint of all-cause death and renal replacement therapy at 30 days follow-up. In patients with loss of haemodynamic coherence between microcirculatory and macrocirculatory perfusion parameters, microcirculatory perfusion parameters confer dominant prognostic value.

Background: Short-term mechanical circulatory support devices are increasingly used in cardiogenic shock after acute myocardial infarction. As no randomised evidence is available, the choice between high-output Impella or extra-corporeal membrane oxygenation (ECMO) is still a matter of debate. Real-life data are necessary to assess adverse outcomes and to help guide the treatment decision between the different devices. The purpose of this study was to compare characteristics and clinical outcomes of Impella CP/5.0 with ECMO support in patients with cardiogenic shock from myocardial infarction.Methods: A retrospective, two-centre study was performed on all cardiogenic shock from myocardial infarction patients with Impella CP/5.0 or ECMO support, from 2006 until 2018. The primary outcome was 30-day mortality. Potential baseline imbalance between the groups was adjusted using inverse probability treatment weighting, and survival analysis was performed with an adjusted log-rank test. Secondarily, the occurrence of device-related complications (limb ischaemia, access site-related bleeding, access site-related infection) was evaluated.Results: A total of 128 patients were included (Impella, N=90; ECMO, N=38). The 30-day mortality was similar for both groups (53% vs. 49%, P=0.30), also after adjustment for potential baseline imbalance between the groups (weighted log-rank P=0.16). Patients with Impella support had significantly fewer device-related complications than patients treated with ECMO (respectively, 17% vs. 40%, P<0.01).Conclusions: Patients treated with Impella CP/5.0 or ECMO for cardiogenic shock after myocardial infarction did not differ in 30-day mortality. More device-related complications occurred with ECMO compared to Impella support.

Deficiency of the thyroid hormone transporter monocarboxylate transporter 8 (MCT8) causes severe intellectual and motor disability and high serum tri-iodothyronine (T3) concentrations (Allan–Herndon–Dudley syndrome). This chronic thyrotoxicosis leads to progressive deterioration in bodyweight, tachycardia, and muscle wasting, predisposing affected individuals to substantial morbidity and mortality. Treatment that safely alleviates peripheral thyrotoxicosis and reverses cerebral hypothyroidism is not yet available. We aimed to investigate the effects of treatment with the T3analogue Triac (3,3',5-tri-iodothyroacetic acid, or tiratricol), in patients with MCT8 deficiency.

Supplemental Digital Content is available in the text.There are no reports of acute pump thrombosis in the latest, continuous flow left ventricular assist devices type HeartMate 3, other than thrombus ingestion. We present a case of early thrombosis of the pump and outflow graft, necessitating acute pump and outflow graft replacement. A combination of low-flow episodes and subtherapeutic levels of anticoagulation was the most likely cause.

Critical illness associated with cardiac pump failure results in reduced tissue perfusion in all organs and occurs in various conditions such as sepsis, cardiogenic shock, and heart failure. Mechanical circulatory support (MCS) devices can be used to maintain organ perfusion in patients with cardiogenic shock and decompensated chronic heart failure. However, correction of global hemodynamic parameters by MCS does not always cause a parallel improvement in microcirculatory perfusion and oxygenation of the organ systems, a condition referred to as a loss of hemodynamic coherence between macro- and microcirculation (MC). In this paper, we review the literature describing hemodynamic coherence or loss occurring during MCS of the heart. By using Embase, Medline Cochrane, Web of Science, and Google Scholar, we analyzed the literature on the response of MC and macrocirculation to MCS of the heart in critical illness.

Aims: Early risk stratification is important in patients with cardiogenic shock from ST-elevation myocardial infarction (STEMI). We aimed to develop a simple risk chart that includes clinical parameters that are readily available at time of hospital admission to assess risk of 30-day mortality.Methods and results: A series of 544 STEMI patients admitted to undergo primary percutaneous coronary intervention and presenting with cardiogenic shock were included between 2000 and 2012. Overall 30-day mortality was 38.4% and did not change over the years (p-trend=0.64). Baseline variables that were available at time of hospital admission were entered into a logistic regression model in a forward stepwise manner. Only age (odds ratio (OR) per year 1.05, 95% confidence interval (CI) 1.04–1.07, p<0.001), initial serum lactate level (OR per mmol/l 1.17, 95% CI 1.11–1.24, p<0.001) and initial creatinine level above the upper limit of normal (OR 2.89, 95% CI 1.90–4.37, p<0.001) remained independent predictors, and were subsequently used to develop a risk chart that stratifies risk of 30-day mortality into categories ranging from 0–20% to 80–100%. The calibration plot showed a close relationship between expected and observed mortality. The risk chart had a higher discriminative accuracy than the GRACE score (c-index 0.75 vs. 0.66, p=0.009). Adding variables that were obtained from coronary angiography and during clinical course did not significantly improve discriminative accuracy of risk chart (c-index 0.77, p=0.48).Conclusion: Mortality of patients with cardiogenic shock from STEMI undergoing primary percutaneous coronary intervention can be well predicted already at time of hospital admission by a risk chart that uses only three variables, namely, age, initial serum lactate and creatinine level.

The aim of this study was to evaluate short- and long-term outcome in patients undergoing coronary artery bypass grafting (CABG), who received an intra-aortic balloon pump (IABP) prior to surgery. Between January 1990 and June 2004, all patients (n=154) who received an IABP prior to on-pump CABG in our center were included. Patients received the IABP for vital indications (i.e. either unstable angina refractory to medical therapy or cardiogenic shock; group 1: n=99) or for prophylactic reasons (group 2: n=55). A Cox proportional hazards model was used to identify predictors of long-term all-cause mortality. Compared with the EuroSCORE predictive model, observed 30-day mortality in group 1 (15.2%) was slightly higher than predicted (10.3%). A decrease in 30-day mortality occurred in group 2 (median predicted mortality was 7.2% and observed was 0%). Cumulative 1-, 5-, and 6-year survival was 82.8+/-3.8%, 70.1+/-4.9%, and 67.3+/-5.1% for group 1 vs. 98.2+/-1.8%, 84.0+/-5.6% and 84.0+/-5.6% for group 2 (Log-rank: P=0.02). Logistic EuroSCORE (HR 1.03 [1.01-1.05], P=0.007) was an independent predictor of long-term all-cause mortality.

Supplemental Digital Content is available in the text.Trials on intra-aortic balloon pump (IABP) use in cardiogenic shock related to acute myocardial infarction have shown disappointing results. The role of IABP in cardiogenic shock treatment remains unclear, and new (potentially more potent) mechanical circulatory supports with arguably larger device profile are emerging. A reappraisal of the physiological premises of intra-aortic counterpulsation may underpin the rationale to maintain IABP as a valuable therapeutic option for patients with acute decompensated heart failure and tissue hypoperfusion. Several pathophysiological features differ between myocardial infarction- and acute decompensated heart failure–related hypoperfusion, encompassing cardiogenic shock severity, filling status, systemic vascular resistances rise, and adaptation to chronic (if preexisting) left ventricular dysfunction. IABP combines a more substantial effect on left ventricular afterload with a modest increase in cardiac output and would therefore be most suitable in clinical scenarios characterized by a disproportionate increase in afterload without profound hemodynamic compromise. The acute decompensated heart failure syndrome is characterized by exquisite afterload-sensitivity of cardiac output and may be an ideal setting for counterpulsation. Several hemodynamic variables have been shown to predict response to IABP within this scenario, potentially guiding appropriate patient selection. Finally, acute decompensated heart failure with hypoperfusion may frequently represent an end stage in the heart failure history: IABP may provide sufficient hemodynamic support and prompt end-organ function recovery in view of more definitive heart replacement therapies while preserving ambulation when used with a transaxillary approach.