Hillerson, Dustin

Abstract Aims Cardiogenic shock (CS) is characterized by impaired left ventricular (LV) mechanical performance and adverse remodelling. We evaluated whether transthoracic echocardiography (TTE)-derived modified cardiac efficiency (mCE), integrating stroke work and residual LV volume, is associated with short- and long-term mortality in CS and whether its prognostic value differs by shock aetiology. Methods and results In this retrospective cohort study, consecutive adults admitted with CS to the cardiac intensive care unit at Mayo Clinic (2007–2018) were included if TTE was performed within 24 h. mCE was calculated as (stroke volume × estimated LV end-systolic pressure) divided by LV end-systolic volume and categorized into quartiles. Primary outcome was in-hospital mortality; secondary outcome was 1-year mortality. Multivariable logistic and Cox models adjusted for illness severity, comorbidity burden, shock aetiology, cardiac arrest, vasoactive therapy, and mechanical circulatory support. Among 667 patients, median mCE was 48 mmHg (IQR 32–74). In-hospital mortality was 28% and increased stepwise across decreasing mCE quartiles. The lowest quartile had a 2.5-fold higher adjusted odds of in-hospital death (OR 2.53; 95%CI: 1.49–4.37; P < 0.001). One-year mortality was 41%; the lowest quartile had a two-fold higher adjusted hazard of death (HR 2.05; 95%CI: 1.45–2.89; P < 0.001). Associations were stronger in acute coronary syndrome-related CS (interaction P = 0.035 for in-hospital; P = 0.015 for 1-year). Within the lowest quartile, reduced systolic pressure further amplified mortality risk. Conclusion Early TTE-derived mCE was independently associated with short- and long-term mortality in CS, particularly in acute coronary syndrome-related CS, and captured the interaction between ventricular remodelling and mechanical performance underlying high-risk phenotypes.

Background The prognostic significance of an adverse acid–base milieu despite venoarterial extracorporeal membrane oxygenation support in patients with cardiogenic shock remains poorly defined. We examined metabolic and respiratory disturbances in the ELSO (Extracorporeal Life Support Organization) Registry among patients who received venoarterial extracorporeal membrane oxygenation support for refractory cardiogenic shock. Methods Arterial blood gas acid–base values at 24 hours following venoarterial extracorporeal membrane oxygenation initiation were analyzed, with patients classified by pH, arterial partial pressure of carbon dioxide, and bicarbonate. Multivariable logistic regression and exploratory machine learning analyses were used to assess predictors of in‐hospital mortality. Results Among 15 144 adult patients, 74.6% (10 860) had neither respiratory nor metabolic acidosis, 13.1% (1909) had isolated respiratory acidosis, 11.6% (1684) had isolated metabolic acidosis, and 0.7% (100) had combined acidosis. In‐hospital mortality occurred in 7719 (51.0%) patients and increased incrementally across patients with lower pH (adjusted odds ratio [OR], 2.03 with each 0.1‐unit decrease in pH, using 7.4 as a reference point [95% CI, 1.82–2.26]), bicarbonate (adjusted OR, 1.93 per each 5‐mEq/L <24 mEq/L [95% CI, 1.76–2.12]) or base excess (adjusted OR, 1.90 per each 5‐mEq/L <0 mEq/L [95% CI, 1.75–2.07]) (all P <0.01). Mortality varied significantly, being highest for the low‐pH metabolic acidosis cluster (adjusted OR, 1.90 [95% CI, 1.70–2.12], P <0.01). Conclusions Survival decreased progressively with worse acidemia or metabolic acidosis despite 24 hours of hemodynamic support with venoarterial extracorporeal membrane oxygenation among patients with cardiogenic shock. Our findings emphasize the prognostic significance of metabolic parameters as potentially modifiable risk factors and underscore the need for early recognition and interventions to mitigate severe metabolic derangements.

Background There is limited evidence on the epidemiology and prognostic significance of acid-base disorders in the cardiovascular intensive care unit (CICU). This study examines the association of acid-base status at admission with in-hospital mortality among CICU patients. Methods We conducted a retrospective analysis of adults admitted to the Mayo Clinic CICU from 2007-2018 with available blood gas data, utilizing values obtained closest to CICU admission. Arterial pH, serum bicarbonate, base excess, and partial pressure of carbon dioxide (PaCO 2 ) were examined as predictors of in-hospital mortality. Multivariable logistic regression was used to assess associations, with adjustment for demographics, comorbidities, illness severity, and interventions. Results Among 3229 patients included for analysis, acidemia (pH < 7.35) emerged as the strongest predictor of in-hospital mortality (adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI] 1.29-1.98, P < .003). Metabolic acidosis (HCO3 < 20 mEq/L, aOR 1.55, 95% CI 1.24-1.95, P < .001) and respiratory acidosis (PaCO2 > 45 mm Hg, aOR 1.44, 95% CI 1.14-1.81, P = .002) were associated with higher in-hospital mortality, whereas metabolic and respiratory alkalosis were not. After adjustment, lower pH and more negative base excess were associated with higher in-hospital mortality (both P < .001), whereas HCO3 and PaCO2 were not ( P = .053 and P = .051, respectively). Patients with combined metabolic and respiratory acidosis had the highest in-hospital mortality (56.3%). Conclusions Short-term survival in CICU patients decreases progressively with worse acidemia, especially in the context of combined metabolic and respiratory acidosis. Incorporating metabolic acid-base disorders as key therapeutic targets in randomized cardiogenic shock trials may improve outcomes in this complex population by addressing hemometabolic shock.

Background Patients with cardiohepatic syndrome are at higher risk of adverse outcomes in the cardiac intensive care unit. We hypothesized that cardiohepatic syndrome phenotypes would exhibit differences in their clinical and transthoracic echocardiogram hemodynamic profiles, portending a higher risk of mortality. Methods We included unique CICU patients with an admission diagnosis of heart failure from 2007 to 2018 with available data for 1 or more admission liver function tests. Echocardiographic variables were extracted from patients who had a transthoracic echocardiogram within 1 day of admission. We assigned patients to 1 of 4 mutually exclusive cardiohepatic syndrome phenotype groups: normal, hepatocellular, cholestasis, and combined. Results We included 3992 CICU patients; 2483 had an available transthoracic echocardiogram. Patients with cholestasis had more right ventricular systolic dysfunction and congestion, whereas those with hepatocellular injury had more left ventricular systolic dysfunction and poor forward flow; hemodynamics and biventricular function were worst in the combined group. In‐hospital mortality occurred in 14.6% and was higher for patients with cholestasis or hepatocellular injury, especially those with greater extent/severity and worse biventricular function or poor hemodynamics. After adjustment, only the group with hepatocellular injury (adjusted odds ratio [OR], 1.35 [95% CI, 1.04–1.75], P =0.03) and the combined group (adjusted OR, 1.75 [95% CI, 1.30–2.34], P <0.001) remained at higher risk. One‐year mortality was highest in the combined group (adjusted hazard ratio [HR], 1.29 [95% CI, 1.10–1.51], P =0.002). Conclusions Cardiohepatic syndrome phenotypes are associated with distinct echocardiographic profiles. Patients with the combined cardiohepatic syndrome phenotype were at highest risk of mortality, particularly if this was combined with poor cardiac function.

Abstract Background Effusive-constrictive pericarditis (ECP) is a condition where acute pericarditis causes a pericardial effusion and stiffening of the pericardium, which can result in haemodynamic instability due to compression of right-sided cardiac chambers. Here, we present a patient with cardiac tamponade followed by ECP complicating treatment of acute myocardial infarction/cardiogenic shock supported with a percutaneous left ventricular assist device (PVAD). Case summary A 65-year-old male presented with an anterior ST-elevation myocardial infarction and cardiogenic shock. The left anterior descending artery was stented, and a PVAD was placed. The patient was haemodynamically unstable, and the PVAD had frequent suction alarms at higher flow rates. Pulsus paradoxus was noted on the arterial line tracing. Echocardiography showed a large pericardial effusion, which was drained with improvement in cardiac output. However, the patient soon worsened again with continued PVAD suction alarms, and this time echocardiography demonstrated constrictive physiology. The patient was treated with anti-inflammatory medications with improvement in haemodynamics. The PVAD was able to be weaned, and the patient was discharged in stable condition. Discussion Effusive-constrictive pericarditis is a syndrome exhibiting the physiology of both cardiac tamponade and constrictive pericarditis. Effusive-constrictive pericarditis should be considered in patients whose haemodynamics do not improve after pericardiocentesis. This patient had a PVAD placed, which relies on left ventricular preload to increase cardiac output. The numerous suction alarms encountered during this patient’s intensive care unit course were likely due to ECP decreasing preload.

Abstract Aims Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. Methods and results The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018–2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th–75th percentile, 1.6–2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66–86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. Conclusion In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.