Kanwar, Ardaas

Axillary artery intra-aortic balloon pump (axIABP) placement has been implemented as a bridging solution before heart transplantation. This study evaluates complications associated with axIABP support and describes an approach to minimize adverse events. We previously described a percutaneous approach for axIABP placement. However, patients receiving axIABP between September 1, 2017, and September 26, 2019 (n = 32) demonstrated a high rate of balloon pump malfunction (8/32; 25%) and other complications (totaling 15/32; 47%). Sixty-four patients were sequentially treated under a revised protocol. Compared to the initial cohort, no significant differences in demographics were noted. A significant reduction in rate of balloon malfunction (8/32, 25% vs. 1/64, 2%; p < 0.001) and total complications (15/32, 47% vs. 10/64, 16%; p = 0.0025) during the period of support were noted after intervention. Subsequent analysis of total complications per device size (40 vs. ≤ 34 ml balloon) revealed significantly reduced complications in patients with smaller devices (40% vs. 13%, respectively; p = 0.0022). This study provides guidelines to limit complications in patients supported with axIABP, facilitating a protracted period of bridging support.

Introduction: Multi-disciplinary care with integration of the palliative care services (PCS) in acutely ill cardiac patients is known to improve resource utilization and overall patient care. However, there are limited data on the role of PCS in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). Methods: We used the National Inpatient Sample (2000-2017) to identify adult AMI admissions with concomitant CA. We evaluated temporal trends and predictors of PCS use, and in-hospital mortality, length of stay, and discharge disposition in AMI-CA admissions with and without PCS use. A propensity matching analysis using 1:1 nearest neighbor matching was performed between cohorts with and without PCS use to derive a propensity-matched sample with standardized differences <5% for all baseline characteristics. Results: During the study period, there were a total of 584,263 AMI-CA admissions, of which 26,919 (4.6%) received PCS. PCS use increased from <1% in 2000 to 11.5% by 2017. AMI-CA admissions that received PCS were on an average older (70.1 ± 13.0 vs 66.7 ± 13.5), had greater comorbidity with higher rates of cardiogenic shock (44.5% vs 26.6%) and non-cardiac organ failure (80.6% vs 41.6%)(all p<0.001). Admissions receiving PCS had lower rates of angiography (48.6% vs 63.3%) and percutaneous coronary intervention (37.4% vs 46.9%) use (p<0.001). Older age, greater comorbidity, and acute organ failure were independently associated with PCS use. In-hospital mortality was higher in the PCS cohort (84.6% vs 42.9%, adjusted odds ratio 3.62 [95% CI 3.48-3.76]; p<0.001). Similar findings were seen in the propensity-matched cohort with higher in-hospital mortality for AMI-CA admissions receiving PCS (84.7% vs 66.2%, p<0.001) The PCS cohort had higher do-not-resuscitate status use (47.6% vs. 3.7%), shorter hospital stays (4 vs 5 days), and more frequent skilled nursing facility discharges (73.6% vs. 20.4%); p<0.001. Conclusions: Despite an increase in PCS use in AMI-CA, it remains significantly underutilized, highlighting the need to further integrate PCS specialists into the care of high-risk conditions such as cardiac arrest to deliver holistic patient care.

Introduction: The role of seasons in the outcomes and management of acute myocardial infarction (AMI) patients with cardiac arrest (CA) remains understudied. Methods: We used the National Inpatient Sample (2000-2017) to identify adults AMI admissions with concomitant CA. Admission month was used to classify them into- Spring (March-May), Summer (June-August), Fall (September-November) and Winter (December-February) admissions. We evaluated seasonal variation in the prevalence of CA among AMI admissions and associated in-hospital mortality. Use of cardiac and non-cardiac procedures, hospital length of stay, hospitalization costs and discharge disposition were also analyzed. Results: Between 2000-2017, of the 10,880,856 AMI admissions with information on admission month available, CA was identified in 546,334 (5.0%). Incidence of CA was 4.9% in spring, 5.0% in summer, 5.1% in fall, and 5.1% in winter AMI admissions. Adjusted trends identified a steady increase in STEMI-CA admissions with a relatively stable or declining trend for NSTEMI-CA admissions across all seasons. AMI-CA admissions admitted in summer were less often female, had lower comorbidity, more often presented with STEMI and had higher rates of cardiogenic shock and shockable rhythms compared to AMI-CA admissions in spring, fall and winter. Compared to AMI-CA admissions in other seasons, those admitted in winter had slightly lower rates of coronary angiography (61.4% vs. 63.3%-64.3%) and PCI (45.6% vs. 47.2-48.4%) (p<0.001). Compared to those admitted in the spring, adjusted in-hospital mortality was higher for winter (OR 1.08 [95% CI 1.06-1.10]; p<0.001), lower for summer (OR 0.96 [95% CI 0.94-0.98]; p<0.001) and comparable for fall (OR 1.00 [95% CI 0.98-1.02]; p=0.91) AMI-CA admissions. Length of hospital stay, total hospitalization charges, and discharge dispositions for AMI-CA admissions were comparable across the seasons. Conclusions: Lower use of guideline directed therapies and higher in-hospital mortality was identified in winter AMI-CA hospitalizations. The role of pathobiology and/or impact of environmental conditions across seasons in AMI-CA remains to be evaluated.

For patients in cardiogenic shock, percutaneous mechanical circulatory support devices (MCSD) have emerged as critical tool to improve hemodynamics and optimize end-organ perfusion; successfully bridging patients to recovery, decision or transplantation. The most commonly utilized MCSD is the femoral intra-aortic balloon pump (IABP). However, femoral access hampers the patient's mobility, quality of life, and capacity to participate in rehabilitation. The advent of the axillary artery approach has served to circumvent limitations associated with the femoral artery approach. However, optimum anatomical placement of IABP within the axillary artery (axIABP) is a topic of debate considering its proximity to the brachial plexus. Here, we report our experince with percutaneous access of the third poriton of the axillary artery which showed promising results with minimal device related complications or adverse events. Methods/Results: Between 2017-2023, a total of 89 patients in cardiogenic shock underwent percutaneous axIABP placement at the Mayo Clinic, MN. All demographic, clinical, and periprocedural data were obtained from hospital chart review and recorded in a database under IRB approval. Indications for axIABP support was determined by multidisciplinary assessment. Complications encountered in the cohort included infection at site 6.7% (n=6), device malfunction [rupture, fracture, leak] 8.98%(n=8), and balloon migration 5.61% (n=5). One patient developed local erythema, 4 (4.49%) patients developed significant vascular complications, including access site bleeding in two patients 2.24%, arterial thrombosis in three patients 3.37%, and self-limited intracranial bleeding in one patient 1.12%. Of note, no nerve injury or damage was observed in the entire patient cohort. Conclusion: Our study highlights the feasibility of percutaneous axIABP in the third portion of the axillary artery, while assessing safety profile and ease of removal. Notably in our review, we did not encounter any brachial nerve damage. Ultrasound was pivotal in identifying and avoiding nerves and nerve bundles during initial access. In conclusion, this approach of axIABP insertion is feasible and can be leveraged for delivery of future innovation in MCSD

Abstract Aims It is widely held that heart failure (HF) does not cause exertional hypoxaemia, based upon studies in HF with reduced ejection fraction, but this may not apply to patients with HF and preserved ejection fraction (HFpEF). Here, we characterize the prevalence, pathophysiology, and clinical implications of exertional arterial hypoxaemia in HFpEF. Methods and results Patients with HFpEF (n = 539) and no coexisting lung disease underwent invasive cardiopulmonary exercise testing with simultaneous blood and expired gas analysis. Exertional hypoxaemia (oxyhaemoglobin saturation &lt;94%) was observed in 136 patients (25%). As compared to those without hypoxaemia (n = 403), patients with hypoxaemia were older and more obese. Patients with HFpEF and hypoxaemia had higher cardiac filling pressures, higher pulmonary vascular pressures, greater alveolar–arterial oxygen difference, increased dead space fraction, and greater physiologic shunt compared to those without hypoxaemia. These differences were replicated in a sensitivity analysis where patients with spirometric abnormalities were excluded. Regression analyses revealed that increases in pulmonary arterial and pulmonary capillary pressures were related to lower arterial oxygen tension (PaO2), especially during exercise. Body mass index (BMI) was not correlated with the arterial PaO2, and hypoxaemia was associated with increased risk for death over 2.8 (interquartile range 0.7–5.5) years of follow-up, even after adjusting for age, sex, and BMI (hazard ratio 2.00, 95% confidence interval 1.01–3.96; p = 0.046). Conclusion Between 10% and 25% of patients with HFpEF display arterial desaturation during exercise that is not ascribable to lung disease. Exertional hypoxaemia is associated with more severe haemodynamic abnormalities and increased mortality. Further study is required to better understand the mechanisms and treatment of gas exchange abnormalities in HFpEF.

ABSTRACT Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.

Acute myocardial infarction with cardiogenic shock (AMI-CS) is associated with high mortality and morbidity despite advancements in cardiovascular care. AMI-CS is associated with multiorgan failure of non-cardiac organ systems. Acute kidney injury (AKI) is frequently seen in patients with AMI-CS and is associated with worse mortality and outcomes compared to those without. The pathogenesis of AMI-CS associated with AKI may involve more factors than previously understood. Early use of renal replacement therapies, management of comorbid conditions and judicious fluid administration may help improve outcomes. In this review, we seek to address the etiology, pathophysiology, management, and outcomes of AKI complicating AMI-CS.

Background There are limited contemporary data on the use of emergent coronary artery bypass grafting (CABG) in acute myocardial infarction. Methods and Results Adult (aged >18 years) acute myocardial infarction admissions were identified using the National (Nationwide) Inpatient Sample (2000–2017) and classified by tertiles of admission year. Outcomes of interest included temporal trends of CABG use; age‐, sex‐, and race‐stratified trends in CABG use; in‐hospital mortality; hospitalization costs; and hospital length of stay. Of the 11 622 528 acute myocardial infarction admissions, emergent CABG was performed in 1 071 156 (9.2%). CABG utilization decreased overall (10.5% [2000] to 8.7% [2017]; adjusted odds ratio [OR], 0.98 [95% CI, 0.98–0.98]; P <0.001), in ST‐segment–elevation myocardial infarction (10.2% [2000] to 5.2% [2017]; adjusted OR, 0.95 [95% CI, 0.95–0.95]; P <0.001) and non–ST‐segment–elevation myocardial infarction (10.8% [2000] to 10.0% [2017]; adjusted OR, 0.99 [95% CI, 0.99–0.99]; P <0.001), with consistent age, sex, and race trends. In 2012 to 2017, compared with 2000 to 2005, admissions receiving emergent CABG were more likely to have non–ST‐segment–elevation myocardial infarction (80.5% versus 56.1%), higher rates of noncardiac multiorgan failure (26.1% versus 8.4%), cardiogenic shock (11.5% versus 6.4%), and use of mechanical circulatory support (19.8% versus 18.7%). In‐hospital mortality in CABG admissions decreased from 5.3% (2000) to 3.6% (2017) (adjusted OR, 0.89; 95% CI, 0.88–0.89 [ P <0.001]) in the overall cohort, with similar temporal trends in patients with ST‐segment–elevation myocardial infarction and non–ST‐segment–elevation myocardial infarction. An increase in lengths of hospital stay and hospitalization costs was seen over time. Conclusions Utilization of CABG has decreased substantially in acute myocardial infarction admissions, especially in patients with ST‐segment–elevation myocardial infarction. Despite an increase in acuity and multiorgan failure, in‐hospital mortality consistently decreased in this population.

Background: The clinical utility of routine electrocardiographic monitoring following percutaneous coronary interventions (PCI) is not well studied. Methods: We prospectively evaluated the incidence, cost, and the clinical implications of actionable arrhythmia alarms on telemetry monitoring following PCI. One thousand three hundred fifty-eight PCI procedures (989 [72.8%] for acute coronary syndrome and 369 [27.2%] for stable angina) on patients admitted to nonintensive care unit were identified and divided into 2 groups; group 1, patients with actionable alarms (AA) and group 2, patients with non-AA. AA included (1) ≥3 s electrical pause or asystole; (2) high-grade Mobitz type II atrioventricular block or complete heart block; (3) ventricular fibrillation; (4) ventricular tachycardia (>15 beats); (5) atrial fibrillation with rapid ventricular response; (6) supraventricular tachycardia (>15 beats). Primary outcomes were 30-day all-cause mortality. Cost-savings analysis was performed. Results: Incidence of AA was 2.2% (37/1672). Time from end of procedure to AA was 5.5 (0.5, 24.5) hours. Patients with AA were older, presented with acute congestive heart failure or non–ST-segment–elevation myocardial infarction, and had multivessel or left main disease. The 30-day all-cause mortality was significantly higher in patients with AA (6.5% versus 0.3% in non-AA [ P <0.001]). Applying the standardized costing approach and tailored monitoring per the American Heart Association guidelines lead to potential cost savings of $622 480.95 for the entire population. Conclusions: AA following PCI were infrequent but were associated with increase in 30-day mortality. Following American Heart Association guidelines for monitoring after PCI can lead to substantial cost saving.