Isha, Shahin

Introduction/Background: Patients admitted with sepsis are at risk of developing septic cardiomyopathy (SCM), which may elevate their risk of short-term mortality. However, the effect of SCM on long-term outcomes after sepsis is poorly understood. This study explores whether patients with sepsis and SCM have worse long-term outcomes compared to those without SCM. Research Questions/Hypothesis: What are the long-term major adverse cardiovascular events, including death, stroke, and myocardial infarction (MACE) 36 months after ICU discharge for septic patients with abnormal global left ventricular strain (LV GLS)? Methods: We conducted a retrospective study of 396 sepsis patients from August 2018 to September 2022, approved by the Mayo Clinic IRB. Patient demographics, comorbidities, echo parameters, and outcomes were collected. Due to the expected non-linear relation between LV GLS and Hazard Ratio (HR) of MACE we employed Cox regression analysis with Restricted Cubic Splines. Secondly, we divided the population into 2 groups, patients with and without normal LV GLS (between -23 and -16). The effect of non-normal LV GLS on MACE was evaluated using Cox regression weight by inverse probability weighting (IPWT) analysis after propensity score assessment, adjusting for diabetes, hypertension, BMI, history of stroke or myocardial infarction, chronic kidney disease, age, and sex. Results: Demographic variables did not differ significantly based on normal versus abnormal LV GLS. In the restricted cox regression with cubic spline models, we observed that patients with normal values had HR lower than one compared with patients without normal values (Figure 1). Secondly, we found that the HR of MACE in patients with normal LV GLS was significantly lower in the crude analysis (HR 0.66 [CI 95% 0.5, 0.86]; p<0.01) and in the analysis adjusted by IPWT (HR 0.7 [CI 95% 0.53, 0.92]; p=0.01). Conclusion: Sepsis patients with abnormal global left ventricular strain (LV GLS) have a higher risk of major adverse cardiovascular events (MACE) within 36 months post-ICU discharge compared to those with normal strain. LV GLS values outside the range of -23 to -16 are associated with increased risk. Monitoring LV GLS in sepsis patients is important for identifying those at elevated risk for long-term cardiovascular complications.

Introduction/Background: Patients with heart failure and those waiting for a heart transplant often experience a significant decrease in their ability to perform daily activities and exercise, leading to a lower quality of life. Although exercise-based cardiac rehabilitation (EBCR) is a possible treatment option, its effectiveness has not been well measured, resulting in limited adoption. Research Questions/Hypothesis: Could physical rehabilitation before receiving a heart transplant improve functional status and better outcomes? Goals/Aims: Our objective is to evaluate the effect of pre-transplant physical therapy on the standardized improvement of AM-PAC scores, measured from the earliest pre-transplant assessment to the most recent pre-transplant evaluation. Our second objective is to assess the impact of the latest Pre-Transplant AM-PAC Score on the number of hospital-free days following transplantation. Methods: We conducted a retrospective study on 91 heart transplant patients who received Impella support from January 2019 to April 2023, approved by the Mayo Clinic Institutional Review Board. We collected data on demographics, AMPAC scores, and outcomes at three time points. Continuous variables were compared using the T-test or Mann-Whitney test, and categorical variables using the Chi-square or Fisher's exact test. We used a linear regression model to investigate the relationship between rehabilitation duration and AMPAC scores. Quantile regression was preferred due to the non-normal distribution of the outcome, hospital-free days. Results: We conducted a linear regression analysis and found a statistically significant association between increased hours spent in PT and greater improvement. After one hour of physical therapy, there was an average increase of 1.07 (95% CI 0.1, 2; p=0.03) in AMPAC scoore. We also compared the change in the AMPAC score with hospital-free days, and it was statistically significant in quantile regression analysis, indicating an increase of 0.28 (95% CI 0.2, 0.55; P=0.03) points in the AMPAC Score, corresponding to an additional hospital-free day. Conclusion: Increased hours spent in physical therapy show a significant positive association with greater improvement in standardized AM-PAC Mobility scores and hospital-free days. These findings encourage increasing uptake and support of cardiac rehabilitation programs.

Background: The new Global definition of ARDS recently introduced a subgroup known as non-intubated ARDS. This study aimed to assess the risk of progression from noninvasive oxygen support to intubation and ARDS severity based on the S pO 2 /F IO 2 among non-intubated subjects with ARDS. Methods: This retrospective study included subjects with COVID-19 admitted to 7 hospitals (5 in the United States and 2 in Argentina) from January 2020–January 2023. Subjects meeting the new non-intubated ARDS definition (high-flow nasal cannula [HFNC] with an S pO 2 /F IO 2 ≤315 [with S pO 2 ≤97%] or a P aO 2 /F IO 2 ≤300 mm Hg while receiving ≥30 L/min O 2 via HFNC) were included. The study evaluated the proportion of subjects who progressed to intubation, severity levels using the S pO 2 /F IO 2 cutoff proposed in the new ARDS definition, and mortality. Results: Nine hundred sixty-five non-intubated subjects with ARDS were included, of whom 27% ( n = 262) progressed to meet the Berlin criteria within a median of 3 d (interquartile range 2–6). The overall mortality was 23% (95% CI 20–26) ( n = 225), and among subjects who progressed to the Berlin criteria, it was 37% (95% CI 31–43) ( n = 98). Additionally, the worst S pO 2 /F IO 2 within 1 d of ARDS diagnosis was correlated with mortality, with mortality rates of 26% (95% CI 23–30) ( n = 177) for subjects with S pO 2 /F IO 2 ≤148, 17% (95% CI 12–23) ( n = 38) for those with S pO 2 /F IO 2 between 149–234, and 16% (95% CI 8–28) ( n = 10) for subjects maintaining an S pO 2 /F IO 2 higher than 235 ( P < .001). Conclusions: The non-intubated ARDS criteria encompassed a broader spectrum of subjects with lower in-hospital mortality compared to the Berlin criteria. The S pO 2 /F IO 2 and ARDS severity cutoff proposed in the new Global ARDS definition were valuable predictors of in-hospital mortality in these subjects.

Extracorporeal membrane oxygenation (ECMO) is often used in acute respiratory distress syndrome (ARDS) with refractory hypoxemia. There is limited literature highlighting the development of right ventricular (RV) failure while on ECMO. We conducted a retrospective multicenter observational study including 70 patients who were placed on veno-venous (VV)-ECMO for respiratory failure at Mayo Clinic, Jacksonville, and Mayo Clinic, Rochester, between January 2018 and June 2022 and had at least two post-ECMO transthoracic echoes. The primary outcomes were the incidence and progression of RV dysfunction and dilatation. The secondary outcome was in-patient mortality. Among 70 patients in our cohort, 60.6% had a normal RV function at the time of ECMO placement, whereas only 42% had a normal RV function at the second post-ECMO echo. On multinomial regression, a moderate decrease in RV function was associated with ECMO flow (odds ratio [OR] = 2.32, p = 0.001) and ECMO duration (OR = 1.01, p = 0.01). A moderately dilated RV size was also associated with ECMO flow (OR = 2.62, p < 0.001) and ECMO duration (OR = 1.02, p = 0.02). An increasing degree of RV dysfunction was associated with worse outcomes. Our study showed that the increasing duration and flow of VV-ECMO correlated with progressive RV dilatation and dysfunction, which were associated with poor survival.