Cardiogenic shock (CS) is the deadliest manifestation of acute heart failure, with persistently high mortality rates and a lack of recent therapeutic breakthroughs. Accurate risk prediction is crucial in clinical decision-making and the design of future clinical trials. We aimed to validate the CLIP score, a biomarker-based risk score comprising cystatin C, lactate, interleukin-6 and NT-proBNP, for predicting mortality in acute coronary syndrome (ACS) related CS, and to compare its predictive value with the previously published CardShock risk score.

The study is a post hoc analysis of the CardShock Study, a prospective, observational European multicentre study on CS. The CLIP score was calculated 12 h after hospital admission, and its ability to predict 90-day mortality was assessed using are under the curve (AUC) of the receiver-operating characteristics (ROC) curve analysis. The discriminative ability of the CLIP score was compared with the CardShock risk score by comparing the AUC's. The cohort was dichotomized into low and high risk groups by the optimal cut-off value derived from the ROC analysis of the CLIP score. Kaplan-Meier curves were constructed to evaluate risk stratification when combining the CLIP and CardShock risk scores. The cohort (n = 121) comprised 77% (n = 93) men and the median age was 67 years (IQR 61-76). A total of 21% (n = 25) of the patients had non-ACS related CS. The CLIP score demonstrated appropriate predictive accuracy for 90-day mortality (AUC 0.84, 95% CI 0.77-0.91), comparable with the CardShock risk score (AUC 0.77 [95% CI 0.69-0.85]; P = 0.064 for comparison). A CLIP score cut-off of 0.28 stratified patients into high risk (65% mortality) and low risk (16% mortality) groups. In addition, incorporating the CLIP score enhanced risk stratification in all CardShock risk score categories.

The CLIP score, calculated within 12 h of hospital admission, accurately predicted 90-day mortality in CS and complemented the CardShock risk score. The biomarker-based score has potential utility in dynamic mortality risk assessment and could inform clinical management and trial design.

The goal of this study was to assess the feasibility, safety and efficacy of consecutive treatment with isoprenaline/adenosine (ISO/ADE) in a pig model of myocardial infarction and cardiac surgery.

The final ISO/ADE dose was selected from a pilot study (n = 8). In the subsequent randomized trial, 16 pigs underwent cardiac magnetic resonance imaging 4 weeks after a myocardial infarction, then were randomized to either the ISO/ADE (n = 8) or the control (n = 8) group before undergoing cardiac surgery with 1 h recovery. Feasibility and safety end points included the method of ISO/ADE delivery, serial blood pressure, heart rate, pH, HCO3-, circulating lactate levels, troponin levels and arrhythmias. Biomarkers of efficacy included serial lactate levels and serial pO2 mean arterial-to-venous functional ratio along with histologic levels of glycogen, protein carbonyls, O2, CO2, HCO3- and fibrosis. Postoperative rates of low cardiac output and death were also recorded.

Cardiac magnetic resonance measures of myocardial infarction did not differ between the groups. The selected method of ISO/ADE delivery was feasible. At no time were all safety outcomes measured in the ISO/ADE group worse than those in the control group. ISO/ADE reduced circulating lactate levels, preserved the serial pO2 mean arterial-to-venous functional ratio and reduced tissue-based glycogen and protein carbonylation. No other differences were observed. Low cardiac output and death occurred in 3/8 (37.5%) and 2/8 (25%) control animals versus 0% in the ISO/ADE group.

The therapy was feasible and safe and improved biomarkers of efficacy. ISO/ADE was not associated with any postoperative low cardiac output and deaths versus 37.5% and 25%, respectively, in the control group. A pilot human study is warranted.

Cardiogenic shock (CS) is a severe condition characterised by low cardiac output and often hypotension, which results in organ hypoperfusion due to cardiac failure. As a form of acute heart failure, this condition seems to share similar underlying pathological mechanisms. It is well established that iron deficiency is correlated with chronic and acute heart failure, causing worsening of the symptoms, reduction of quality of life and survival and simultaneously increasing the rehospitalisation rates for all causes in these patients. It remains unclear whether there is an association between iron deficiency and CS. The objective of this scoping review will be to determine the actual state of the art regarding the significance of iron deficiency in patients affected by CS.

We will conduct a systematic review of the literature using MEDLINE and EMBASE via 'Ovid' (Elsevier) and Web of Science (2024 Clarivate). The goal is to analyse the incidence and clinical significance of iron deficiency in patients affected by cardiogenic shock. To gain a deeper insight into the underlying pathophysiological mechanisms, the review will include basic research conducted on both human subjects and on animal models as well as observational, randomised controlled studies and systematic reviews and meta-analysis. To maximise the identification of relevant reports and reduce loss of information, a systematic search of the literature will be performed from inception until January 2025 using the terms "iron deficiency" as well as "iron", "ferritin", "transferrin", "transferrin saturation", "hepcidin" and "soluble transferrin receptor" matching these terms with the keywords "cardiogenic shock", "acute heart failure", "advanced heart failure", "decompensated heart failure", "lvad", "left ventricular assist device", "mechanical circulatory support", "VA-ECMO" and "Extracorporeal Life Support". We will also use the corresponding MeSH and Emtree terms. In order to find grey literature, we will use the OADT.org internet-based database.

No additional ethics approval is required, as this review is based on existing research without new data collection. Only studies with ethics approval will be included. We plan to publish our findings in a peer-reviewed journal and present them at international conferences on cardiology, intensive and acute cardiovascular care, cardiac surgery and cardioanaesthesiology.

Cardiogenic shock (CS) remains a critical condition with high mortality rates despite advances in treatment. This study aims to comprehensively evaluate both macrocirculatory and tissue perfusion variables over the initial 24 h post-admission to determine their impact on patient prognosis and identify potential hemodynamic thresholds for optimal outcomes. Secondary aims were to explore the correlation between macrocirculatory and tissue perfusion variables.

This is a post hoc analysis of data from two prospective studies, OptimaCC (NCT01367743) and MicroShock (NCT03436641), involving only patients with CS. Both studies applied regular assessment of hemodynamic variables at specific time points (admission, 6, 12, and 24 h) to ensure consistency in data collection, enrolling 118 patients between September 2011 and July 2021, with similar inclusion criteria and care processes.

The median age of the cohort was 69 years, 59% being male. The primary outcome, 30-day mortality, occurred in 37% of patients. Average macrocirculation variables over the first 24 h of CS such as mean arterial pressure (MAP), cardiac output (CO), cardiac index (CI), and cardiac power index (CPI) were significantly lower in patients meeting the primary outcome. Accordingly, average tissue perfusion variables (ΔPCO2 and ΔPCO2/C(a-v)O2) over the first 24 h of CS were also consistently impaired in patients meeting the primary outcome. The optimal clinically relevant thresholds of the first 24 h time course for poor outcomes, closely approximating the optimal values identified in the analysis, were: mean SAP < 95 mmHg, MAP < 70 mmHg, CO < 3.5 L/min, CI ≤ 1.8 L/min/m2, CPI < 0.27 W/m2, ScvO2 < 70%, ΔPCO2 ≥ 9 mmHg, and ΔPCO2/C(a-v)O2 ≥ 1.5 mmHg/mL.

This study is the first to identify critical hemodynamic thresholds, encompassing both macrocirculatory and tissue perfusion variables, within the initial 24 h of CS that are associated with adverse outcomes. The identified thresholds suggest specific hemodynamic targets that may guide resuscitation strategies.

BackgroundThe left ventricular assist device (LVAD) has been proven to be an effective therapy for providing temporary circulatory support. However, the use of this device can cause myocardial injury due to multiple insertions of various catheters.ObjectiveTherefore, this study aimed to evaluate the hemodynamic performance of a newly developed double-lumen catheter (DLC) for LVAD.MethodsTwo different LVAD DLC prototypes (a semi-circular and a concentric catheter) were designed based on the structure of venous DLC. Computational fluid dynamics (CFD) simulations were performed using the finite element method. The CFD results were confirmed through the testing of the 31 Fr prototype. The aorta is a large vessel with shear rates up to >300 s-1 and we used a reasonable approximation to model blood as a Newtonian fluid.ResultsAt a flow rate of 5 L/min, the semi-circular prototype achieved an infusion pressure of 74.68 mmHg, while the concentric prototype achieved an infusion pressure of 46.11 mmHg. The CFD results matched the experimental results with a mean percentage error of less than 7%. The peak wall shear stress in the semi-circular prototype (717.5 Pa) was higher than the hemolysis threshold (400 Pa), which could cause blood damage, and it also had a higher hemolysis index compared to concentric prototype. Moreover, both prototypes exhibited areas of blood stagnation and recirculation, suggesting a possible risk of thrombosis.ConclusionBoth prototypes of the LVAD DLC demonstrated similar blood flow rates. The semi-circular prototype showed superior infusion pressure compared to the concentric prototype, but had poorer hemolysis performance. However, the potential risk of thrombosis for both still exists. Therefore, further in vivo experiments are necessary to verify the safety and effectiveness of the LVAD DLC.

Cardiogenic shock (CS) is a severe complication of acute coronary syndrome (ACS) with mortality rates approaching 50%. The ability to identify high-risk patients prior to the development of CS may allow for pre-emptive measures to prevent the development of CS. The objective was to derive and externally validate a simple, machine learning (ML)-based scoring system using variables readily available at first medical contact to predict the risk of developing CS during hospitalization in patients with ACS.

Observational multicentre study on ACS patients hospitalized at intensive care units. Derivation cohort included over 40 000 patients from Beth Israel Deaconess Medical Center, Boston, USA. Validation cohort included 5123 patients from the Sheba Medical Center, Ramat Gan, Israel. The final derivation cohort consisted of 3228 and the final validation cohort of 4904 ACS patients without CS at hospital admission. Development of CS was adjudicated manually based on the patients' reports. From nine ML models based on 13 variables (heart rate, respiratory rate, oxygen saturation, blood glucose level, systolic blood pressure, age, sex, shock index, heart rhythm, type of ACS, history of hypertension, congestive heart failure, and hypercholesterolaemia), logistic regression with elastic net regularization had the highest externally validated predictive performance (c-statistics: 0.844, 95% CI, 0.841-0.847).

STOP SHOCK score is a simple ML-based tool available at first medical contact showing high performance for prediction of developing CS during hospitalization in ACS patients. The web application is available at https://stopshock.org/#calculator.

The effect of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) on left atrial pressure (LAP) in the presence of interventricular interaction and the Frank-Starling mechanism is unknown. We developed and validated a mock circulatory loop (MCL) incorporating a novel, 3D-printed biventricular heart model and Frank-Starling algorithm, and used this model to assess the determinants of LAP during VA-ECMO support.

The MCL was designed to allow a separate ventricle or biventricular configuration, with or without an active Frank-Starling mechanism. The biventricular model with Frank-Starling mechanism was validated in terms of (1) the presence and degree of ventricular interactions; (2) its ability to simulate Frank-Starling physiology; and (3) its capacity to simulate normal and pathological cardiac states. In the separate ventricle and biventricular with Frank-Starling models, we assessed the effect on LAP of changes in mean aortic pressure (mAoP), ECMO pump speed, LV contractility and ECMO return flow direction.

In the biventricular configuration, clamping RA inflow decreased RAP, with a concurrent decrease in LAP, consistent with direct ventricular interaction. With a programmed Frank-Starling mechanism, decreasing RAP was associated with a significant reduction in both LV outflow and LV end-systolic pressure. In the biventricular model with a Frank-Starling algorithm, the MCL was able to reproduce pre-defined normal and pathological cardiac output, and arterial and ventricular pressures. Increasing aortic pressure caused a linear increase in LAP in the separate ventricle model, which was attenuated in the biventricular model with Frank-Starling mechanism. Increasing ECMO pump speed caused no change in LAP in the separate ventricle model (p = 0.75), but significantly decreased LAP in the biventricular model with Frank-Starling mechanism (p = 0.039), with stabilization of LAP at the highest pump speeds. Changing the direction of VA-ECMO return flow did not affect LAP in either the separate ventricle (p = 0.91) or biventricular model with Frank-Starling mechanism (p = 0.76).

Interventricular interactions and the Frank-Starling mechanism can be simulated in a physical, biventricular MCL. In their presence, the effects of VA-ECMO on LAP are mitigated, with LAP reduction and stabilization at maximal VA-ECMO speeds.

Acute myocardial infarction-related cardiogenic shock (AMICS) is a severe complication associated with exceedingly high mortality rates. While mechanical circulatory support (MCS) has emerged as a potential intervention, the evidence base for independent MCS use remains weak. In contrast, systematic reviews of observational studies have revealed significant mortality reduction when a combination of MCS was used: VA-ECMO in conjunction with a left ventricular (LV) unloading device (Impella or IABP). The ongoing dilemma concerning the selection between two LV unloading devices (VA-ECMO + Impella vs. VA-ECMO + IABP) warrants further investigation and clarification.

This is the first systematic review and meta-analysis assessing the short-term efficacy and safety of VA-ECMO + Impella versus VA-ECMO + IABP in treatment of AMICS.

A systematic search was performed on the EMBASE, MEDLINE, and Cochrane databases. Studies reporting the short-term (30-day/inpatient) mortality and complications of adult patients with AMICS treated with VA-ECMO + Impella and VA-ECMO + IABP were included. Subgroup analysis was performed including studies with ACS predominant CS (CS etiology 100% by AMI).

Four observational studies with 14,247 patients were included. There was no significant difference in mortality between VA-ECMO + Impella and VA-ECMO + IABP (56.5% vs. 66.5%; OR, 0.90; 95% CI, 0.79-1.02; p = 0.09). However, VA-ECMO + Impella was associated with significantly lower mortality in patients with ACS predominant CS (53.2% vs. 67.7%; OR, 0.72; 95% CI, 0.62-0.85; p < 0.0001). VA-ECMO + Impella was concomitantly associated with a significantly higher risk of complications.

When comparing LV unloading devices in patients with AMICS requiring a combination of MCS, VA-ECMO + Impella was superior in mortality reduction only in the cohort where 100% of CS was caused by AMI.

While corticosteroid administration in septic shock has been shown to result in faster shock reversal and lower short-term mortality, the role of corticosteroids in the management of cardiogenic shock (CS) remains unexplored.

Determine the impact of corticosteroid administration on 90-day mortality (primary outcome) in patients admitted to a critical care unit with CS.

In this retrospective cohort study, we used the critical care database of Medical Information Mart for Intensive Care-IV, and included all adult patients diagnosed with CS excluding repeated admissions, patients with adrenal insufficiency, those receiving baseline corticosteroids, and those requiring extracorporeal life support. We considered exposure based on receiving systemic corticosteroids from 6 hours before to 24 hours post-critical care admission.

We calculated Cox proportional hazards using multivariate analysis for 90-day mortality (primary outcome). We also explored the association of corticosteroid use with hospital length of stay, ventilator-free days (VFDs), vasopressor-free days, ventilator-associated pneumonia, central-line-associated bloodstream infections, and hyperglycemia.

We included 2000 eligible patients, with 143 (7.2%) receiving systemic corticosteroids. Corticosteroid-treated patients were younger (67.7 vs. 71.2 yr; p = 0.006), had higher Sequential Organ Failure Assessment scores at baseline (9.4 vs. 7.8; p < 0.001), and more often required vasopressors (78% vs. 63%; p < 0.001), and invasive mechanical ventilation (73% vs. 45%; p < 0.001). Corticosteroid use was associated with increased 90-day mortality in multivariate analysis (hazard ratio, 1.60; 95% CI, 1.25-2.05) and fewer VFDs (2.8 d fewer; 95% CI, 0.35-5.26) with no effect on other secondary outcomes.

Use of corticosteroids may be associated with increased mortality and a reduction in VFDs in patients admitted to critical care with CS. These findings suggesting potential harm of corticosteroids in CS might reflect unmeasured confounding and require corroboration through additional observational studies and ultimately randomized clinical trials.

Despite significant morbidity and mortality, recent advances in cardiogenic shock (CS) management have been associated with increased survival. However, little is known regarding the management of patients who survive CS with heart failure (HF) with reduced left ventricular ejection fraction (LVEF, HFrEF), and the utilization of guideline-directed medical therapy (GDMT) in these patients has not been well described. To fill this gap, we investigated the use of GDMT during an admission for CS and short-term outcomes using the Inova single-centre shock registry.

We investigated the implementation of GDMT for patients who survived an admission for CS with HFrEF using data from our single-centre shock registry from January 2017 to December 2019. Baseline characteristics, discharge clinical status, data on GDMT utilization and 30 day, 6 month and 12 month patient outcomes were collected by retrospective chart review.

Among 520 patients hospitalized for CS during the study period, 185 (35.6%) had HFrEF upon survival to discharge. The median age was 64 years [interquartile range (IQR) 56, 70], 72% (n = 133) were male, 22% (n = 40) were Black and 7% (n = 12) were Hispanic. Forty-one per cent of patients (n = 76) presented with shock related to acute myocardial infarction (AMI), while 59% (n = 109) had HF-related CS (HF-CS). The median length of hospital stay was 12 days (IQR 7, 18). At discharge, the proportions of patients on beta-blockers, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor/neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs) were 78% (n = 144), 58% (n = 107) and 55% (n = 101), respectively. Utilization of three-drug GDMT was 33.0% (n = 61). Ten per cent of CS survivors with HFrEF (n = 19) were not prescribed any component of GDMT at discharge. Multivariable logistic regression adjusted for baseline GDMT use revealed that patients with lower LVEF and those who transferred to our centre from an outside hospital were more likely to experience GDMT addition (P < 0.05). Patients prescribed at least one additional class of GDMT during admission had higher odds of 6 month and 1 year survival (P < 0.01): On average, 6 month survival odds were 7.1 times greater [confidence interval (CI) 1.9, 28.5] and 1 year survival odds were 6.0 times greater than those who did not have at least one GDMT added (CI 1.9, 20.5).

Most patients who survived CS admission with HFrEF in this single-centre CS registry were not prescribed all classes or goal doses of GDMT at hospital discharge. These findings highlight an urgent need to augment multidisciplinary efforts to enhance the post-discharge medical management and outcomes of patients who survive CS with HFrEF.

Severe early graft dysfunction (EGD) is defined by mechanical circulatory support (MCS) <24 hours of heart transplantation (HT). We classified severe EGD based on timing of post-HT MCS: ''Immediate'' intra-operative vs ''Delayed'' post-operative MCS (after admission into intensive care unit (ICU) from operating theater). We hypothesized that (1) risk factors and clinical course differ between ''Immediate'' and ''Delayed'' MCS; and (2) diastolic perfusion pressure (DPP=diastolic blood pressure-central venous pressure) and Norepinephrine equivalents (NE=sum of vasopressor doses), as measures of vasoplegia are related to ''Delayed'' MCS.

Two-center study of 216 consecutive patients who underwent HT. Recipient, donor, vasopressor doses and hemodynamic data at T0 and T6 (on admission and 6 hours after admission into ICU) were collected.

Of the 216 patients, 67 patients had severe EGD (''Immediate'' MCS: n = 43, ''Delayed'' MCS: n = 24). The likelihood of ''immediate'' MCS but not ''delayed'' MCS increased with increasing warm ischemic and cardiopulmonary bypass times on multinomial regression analysis with ''no MCS'' as the referent group. One-year mortality was highest in ''Immediate'' MCS vs ''no MCS'' and ''delayed'' MCS (34.9% vs 3.4% and 8% respectively, p < 0.001). Of the patients who had no immediate post-transplant MCS, DPP and NE at T6 were independently associated with subsequent ''delayed'' MCS. Sensitivity and specificity of NE≥ 0.2 mcg/kg/min for ''Delayed'' MCS were 71% and 81%. Sensitivity and specificity of DPP of ≥40 mmHg for No MCS were 83% and 74%. The discriminatory value of systemic vascular resistance for ''Delayed'' MCS was poor.

Risk factors and 1-year survival differed significantly between ''Immediate'' and ''Delayed'' post-HT MCS. The latter is related to lower DPP and higher NE, which is consistent with vasoplegia as the dominant pathophysiology.

Extracorporeal membrane oxygenation (ECMO) is a critical treatment for severe cardiopulmonary failure. However, traditional ECMO decannulation methods, such as manual compression and surgical repair, are associated with significant complications. This study evaluates suture-mediated closure devices, specifically Perclose ProGlide, as a potentially favorable decannulation strategy.

A retrospective review was conducted on 31 patients who underwent arterial decannulation with the post-closing technique using Perclose ProGlide devices between September 2023 and June 2024. Patients were selected using various inclusion criteria for the approach. Decannulation was performed at the bedside by well-trained vascular surgeons. Outcome parameters like the hemostatic result, wound complication, and limb ischemia were analyzed.

The study included 31 patients with a need for decannulation of ECMO arterial cannula, with a mean age of 51.1 years. Thirty patients (96.8%) achieved successful primary hemostasis. The patient who failed primary hemostasis developed acute ischemia due to septic shock caused by the use of inotropic agents. No significant complications were observed in the rest of the patients.

The post-closing technique using suture-mediated closure devices demonstrated high success and low complication rates, making it a safer and more effective alternative to traditional ECMO decannulation methods. This study showed outstanding results compared to previously published articles. This technique can provide various significant advantages under certain clinical situations.

Nursing care is important and necessary for Acute Coronary Syndrome patients who have undergone angiography and stenting, to minimize complications. The purpose of this study was to assess the effects of High-Quality Nursing Interventions on the quality of life and cardiac index of Acute Coronary Syndrome patients, treated with drug-eluting stents.

In this randomized trial, 70 patients of the cardiac intensive care units in one of Jahrom university of medical sciences hospitals (Iran) were selected from July 2023 to October 2023 by the available method, and randomly allocated (stochastic assignment) to two intervention (High-Quality Nursing Interventions) and control groups (routine nursing care). Quality of life and Cardiac Index were measured by cardiac index calculation formula and the McNew Cardiac Quality Questionnaire, respectively. Data were analysed using SPSS version 19 software, Mann‒Whitney, chi‒square and Wilcoxon tests, with a significance level at a p < .05.

A statistically significant difference demonstrated between the mean of the quality of life and cardiac index in the intervention group(p < .05).

High-Quality Nursing Interventions improved quality of life and cardiac index of Acute Coronary Syndrome patients, treated with drug-eluting stents. Therefore, it is recommended to use this nursing approach in special cardiac care units.

IRCT79432(2024.10.08), "Retrospectively registered".

Patients on extracorporeal membrane oxygenation (ECMO) often experience worse renal outcomes and higher mortality rates as the severity of kidney injury increases. Nevertheless, the in-hospital mortality risks of patients with end-stage renal disease (ESRD) are poorly understood. This study evaluated several prognostic factors associated with in-hospital mortality in patients with ESRD receiving ECMO therapy.

This study reviewed the medical records of 90 adult patients with ESRD on venoarterial ECMO in intensive care units in Linkou Chang Gung Memorial Hospital between March 2009 and February 2022. Fourteen patients who died within 24 h of receiving ECMO support were excluded; the remaining 76 patients were enrolled. Demographic, clinical, and laboratory variables were retrospectively collected as survival predictors. The primary outcome was in-hospital mortality.

The overall in-hospital mortality rate was 69.7%. The most common diagnosis requiring ECMO support was postcardiotomy cardiogenic shock, and the most frequent ECMO-associated complication was infection. Multiple logistic regression analysis revealed that the Acute Physiology and Chronic Health Evaluation II (APACHE II) score on day 1 of ECMO support was an independent risk factor for in-hospital mortality. The APACHE II score demonstrated satisfactory discriminative power (0.788 ± 0.057) in the area under the receiver operating characteristic curve. The cumulative survival rates at the 6-month follow-up differed significantly (p < 0.001) between patients with APACHE II score ≤ 29 versus those with APACHE II score >29.

For patients with ESRD on ECMO, the APACHE II score is an excellent predictor of in-hospital mortality.

As the field of percutaneous coronary intervention grows in volume, expertise, and available tools, interventional cardiologists are increasingly performing more complex and higher-risk coronary artery procedures. Mechanical circulatory support devices, previously used only in urgent situations, are now being utilized as supplementary tools to enhance outcomes in elective complex cases. This shift has sparked significant discussions about patient and device selection, as well as the potential risks involved. In this article, we explore the various devices and their distinct features. Additionally, we also introduce algorithms for device selection, placement and weaning to help guide physicians during their care for their high-risk PCI patients.

Continuous cardiac output monitoring is not standard practice during cardiac surgery, even though patients are at substantial risk for systemic hypoperfusion. Thus, the frequency of low cardiac output during cardiac surgery is unknown.

We conducted a prospective cohort study at a tertiary medical center from July 2021 to November 2023. Eligible patients were ≥18 undergoing isolated coronary bypass (CAB) surgery with the use of cardiopulmonary bypass (CPB). Cardiac output indexed to body surface area (CI) was continuously recorded at 5-second intervals throughout surgery using a US Food and Drug Administration (FDA)-approved noninvasive monitor from the arterial blood pressure waveform. Mean arterial blood pressure (MAP) and central venous pressure (CVP) were also analyzed. Low CI was defined as <2 L/min/m 2 and low MAP as <65 mm Hg. We calculated time with low CI for each patient for the entire surgery, pre-CPB and post-CPB periods, and the proportion of time with low CI and normal MAP. We used Pearson correlation to evaluate the relationship between CI and MAP and paired Wilcoxon rank sum tests to assess the difference in correlations of CI with MAP before and after CPB.

In total, 101 patients were analyzed (age [standard deviation, SD] 64.8 [9.8] years, 25% female). Total intraoperative time (mean [SD]) with low CI was 86.4 (62) minutes, with 61.2 (42) minutes of low CI pre-CPB and 25.2 (31) minutes post-CPB. Total intraoperative time with low CI and normal MAP was 66.5 (56) minutes, representing mean (SD) 69% (23%) of the total time with low CI; 45.8 (38) minutes occurred pre-CPB and 20.6 (27) minutes occurred post-CPB. Overall, the correlation (mean [SD]) between CI and MAP was 0.33 (0.31), and the correlation was significantly higher pre-CPB (0.53 [0.32]) than post-CPB (0.29 [0.28], 95% confidence interval [CI] for difference [0.18-0.34], P < .001); however, there was substantial heterogeneity among participants in correlations of CI with MAP before and after CPB. Secondary analyses that accounted for CVP did not alter the correlation between CI and MAP. Exploratory analyses suggested duration of low CI (C <2 L/min/m 2 ) was associated with increased risk of postoperative acute kidney injury (odds ratios [ORs] = 1.09; 95% CI; 1.01-1.13; P = .018).

In a prospective cohort of patients undergoing CAB surgery, low CI was common even when blood pressure was normal. CI and MAP were correlated modestly. Correlation was higher before than after CPB with substantial heterogeneity among individuals. Future studies are needed to examine the independent relation of low CI to postoperative kidney injury and other adverse outcomes related to hypoperfusion.

Cardiogenic shock is a significant economic burden on healthcare facilities and patients. The prevalence and outcome of cardiogenic shock in the South Bronx are unknown. The aim of the study was to examine the burden of non-AMI CS in Hispanic and Black population in South Bronx and characterize their in-hospital outcomes.

We reviewed patient charts between 1/1/2022 and 1/1/2023 to identify patients with a primary diagnosis of cardiogenic shock (ICD codes R57.0, R57, R57.8, R57.9) residing in the following zip codes: 10451-59 and 10463. Student's T-test was used to assess differences for continuous variables; chi-square statistic was used for categorical variables. A logistic regression analysis model was used to assess independent predictors of mortality. A P-value of < 0.05 was considered significant.

87 patients were admitted with cardiogenic shock (60% African American, 67% male, mean age =62±15 years) of which 54 patients (62%) died. Those who died were older, had > 1 pressor, out-of-hospital arrest, arrested within 24 hours of admission, and had higher SCAI class, lactate, and ALT levels than those who were discharged. The logistic regression analysis model showed that older age ((RR=3.4 [95% CI: 3.3-3.45]), > 1 pressor (RR=3.4 [95% CI: 2.6-4.2]) and higher SCAI class (2.1 [95% CI: 1.5-2.1], all P < 0.05)) were independent predictors of mortality in patients with cardiogenic shock. Additionally, most of the patients had either Medicare or Medicaid insurance in predominantly African American study population.

Cardiogenic shock carries a significant risk of death. Factors such as advanced age, the administration of more than one vasopressor, and a higher SCAI classification have been identified as independent predictors of mortality among inpatients with cardiogenic shock. Additionally, the progression and outcomes of the condition are influenced by variables like race (e.g., African American individuals in this study) and economic challenges, including the type of insurance coverage (e.g., Medicaid or Medicare). Further research is essential to explore strategies that could enhance survival rates in cardiogenic shock patients, with a particular focus on addressing economic and racial disparities.

The use of microaxial percutaneous left ventricular assist devices (pLVADs) in cardiogenic shock (CS) has increased in recent years, despite limited evidence, and data on sex disparities are particularly scarce. This study aimed to compare short-term outcomes between males and females.

Data were retrospectively collected from the Dresden Impella Registry, which is a large, prospective, single-centre registry that consecutively enrolled patients who received microaxial pLVAD. Inclusion criteria were CS due to left ventricular failure with serum lactate >4 mM. Patients with pLVAD other than Impella CP were excluded. The primary endpoint was the composite of all-cause mortality at 30 days or requirement of renal replacement therapy (RRT). Secondary endpoints were the components of the primary endpoint alone. Propensity score matched (PSM) analysis was used to adjust for baseline characteristics.

A total of 319 male (69 years; body mass index, 26.7 kg/m2) and 113 female patients (74 years; 27.9 kg/m2) were included in the study. The primary composite endpoint occurred less frequently in female patients in the unmatched analysis (♂ 75.9% [n=239] vs ♀ 64.4% [n=72]; p=0.040) but not in the PSM analysis (♂ 81.1% [n=73] vs ♀ 68.9% [n=42]; p=0.056). However, females less frequently required RRT in both analyses (♂ 48.2% [n=126] vs ♀ 25.9% [n=25]; p=0.001; PSM: ♂ 49.1% [n=36] vs ♀ 23.3% [n=12]; p=0.007). All-cause mortality did not differ between the cohorts.

This study showed no differences in all-cause mortality at 30 days between male and female patients receiving microaxial pLVAD in CS. Larger studies are required to confirm whether female sex is associated with reduced requirement of RRT in CS treated with microaxial pLVAD.

Early identification of cardiogenic shock (CS) patients at risk for renal replacement therapy (RRT) is crucial for improving clinical outcomes. This study aimed to develop and validate a prediction model using readily available clinical variables.

A retrospective cohort study was conducted using data from 4,133 CS patients from the MIMIC and eICU-CRD databases. Patients from MIMIC databases were randomly divided into 80 % training and 20 % validation cohorts, while those from eICU-CRD constituted the test cohort. Feature selection involved univariate logistic regression (LR), LASSO, and Boruta methods. Prediction models for RRT were developed using stepwise selection by LR and five machine learning (ML) algorithms (naive bayes, support vector machines, k-nearest neighbors, random forest, extreme gradient boosting) in the training cohort. Model performance was evaluated in both validation and test cohorts. A nomogram was constructed based on LR model. Kaplan-Meier survival analysis assessed 28-day mortality.

The incidence of RRT was approximately 13 % across all cohorts. Ten variables were selected: age, anion gap, chloride, bun, creatinine, potassium, ast, lactate, estimated glomerular filtration rate (eGFR), and mechanical ventilation. Compared with ML models, the LR model showed superior predictive performance with an AUC of 0.731 in the validation cohort and 0.714 in the test cohort. Four variables that best predicted the need for RRT (age, lactate, mechanical ventilation, and creatinine) were used to generate the CMLA nomogram risk score. The CMLA model showed better predictive accuracy for RRT in the test cohort compared to the previous CALL-K model (AUC: 0.731 vs. 0.699, DeLong test P < 0.05). Calibration curves and decision curve analysis (DCA) indicated that the CMLA model also had good calibration (Hosmer-Lemeshow P=0.323) and clinical utility in the test cohort. Kaplan-Meier analysis indicated significantly higher 28-day mortality in the high-risk CMLA group.

A clinically applicable nomogram with four key variables was developed to predict RRT risk in CS patients. It demonstrated good performance, promising enhanced clinical decision-making.

The Impella 5.5 device is a surgically inserted, trans-valvular, microaxial flow device capable of providing 5.5 L/min of continuous, antegrade flow from the left ventricle (LV) to the aorta. The ability of the Impella 5.5 to fully pressure and volume unload the dysfunctional LV while allowing for mobilization and rehabilitation has rapidly expanded its use. Clinical use scenarios include escalation of support for acute myocardial infarction cardiogenic shock (AMICS), transition from extracorporeal membrane oxygenation to mobile support, bridge to transplantation or durable MCS in acute decompensated heart failure, or perioperative use in post-cardiotomy cardiogenic shock (PCCS).

This review provides a profile of the Impella 5.5 device, summarizes the current literature surrounding clinical applications, reviews active and upcoming clinical trials, and projects future applications for the device through an expert review.

The development of the Impella 5.5 has allowed for monitoring of left-heart recovery, optimizing right ventricular function, and rehabilitating patients to meet bridging endpoints. The 2018 heart transplant allocation system modifications have expanded the use of temporary mechanical circulatory support (tMCS) on the transplant waitlist, increasing the number of patients transplanted on support. With increased safety and durability, an expanding frontier is used in perioperative support for PCCS in high-risk cardiac surgery.

Cardiogenic shock (CS) presents a medical challenge with limited treatment options. Positive end-expiratory pressure (PEEP) during mechanical ventilation has been linked with clinical benefits in patients with CS. This study investigated whether increasing PEEP levels could unload the left ventricle (LV) in CS in a large animal model of LV-CS.

Left ventricle cardiogenic shock was induced in 26 female pigs (60 kg) by microsphere injections into the left main coronary artery. In one study, protocol PEEP was increased (5, 10, and 15 cm H2O) and then reverted (15, 10, and 5 cm H2O) in 3-min intervals. In another protocol, PEEP increments with higher granularity were conducted through 3-min intervals (5, 8, 10, 13, and 15 cm H2O). Hemodynamic measurements were performed at all PEEP levels during a healthy state and in LV-CS with LV pressure-volume loops. The primary endpoint was pressure-volume area. Secondary endpoints included other mechanoenergetic parameters and estimates of LV preload and afterload.

Cardiac output (CO) decreased significantly in LV-CS from 4.5 ± 1.0 to 3.1 ± 0.9 l/min (P < 0.001). Increasing PEEP resulted in lower pressure-volume area, demonstrating a 36 ± 3% decrease in the healthy state (P < 0.001) and 18 ± 3% in LV-CS (P < 0.001) at PEEP 15 cm H2O. These effects were highly reversible when PEEP was returned to 5 cm H2O. Although mean arterial pressure declined with higher PEEP, CO remained preserved during LV-CS (P = 0.339). Increasing PEEP caused reductions in key measures of LV preload and afterload during LV-CS. The right ventricular stroke work index was decreased with increased PEEP. Despite a minor increase in heart rate at PEEP levels of 15 cm H2O (71 beats/min vs. 75 beats/min, P < 0.05), total mechanical power expenditure (pressure-volume area normalized to heart rate) decreased at higher PEEP.

Applying higher PEEP levels reduced pressure-volume area, preserving CO while decreasing mean arterial pressure. Positive end-expiratory pressure could be a viable LV unloading strategy if titrated optimally during LV-CS.

Cardiogenic shock (CS) remains the primary cause of in-hospital death after acute coronary syndromes (ACS), with its plateauing mortality rates approaching 50%. To test novel interventions, personalized risk prediction is essential. The ORBI (Observatoire Régional Breton sur l'Infarctus) score represents the first-of-its-kind risk score to predict in-hospital CS in ACS patients undergoing percutaneous coronary intervention (PCI). However, its sex-specific performance remains unknown, and refined risk prediction strategies are warranted.

This multinational study included a total of 53 537 ACS patients without CS on admission undergoing PCI. Following sex-specific evaluation of ORBI, regression and machine-learning models were used for variable selection and risk prediction. By combining best-performing models with highest-ranked predictors, SEX-SHOCK was developed, and internally and externally validated.

The ORBI score showed lower discriminative performance for the prediction of CS in females than males in Swiss (area under the receiver operating characteristic curve [95% confidence interval]: 0.78 [0.76-0.81] vs. 0.81 [0.79-0.83]; P =.048) and French ACS patients (0.77 [0.74-0.81] vs. 0.84 [0.81-0.86]; P = .002). The newly developed SEX-SHOCK score, now incorporating ST-segment elevation, creatinine, C-reactive protein, and left ventricular ejection fraction, outperformed ORBI in both sexes (females: 0.81 [0.78-0.83]; males: 0.83 [0.82-0.85]; P < .001), which prevailed following internal and external validation in RICO (females: 0.82 [0.79-0.85]; males: 0.88 [0.86-0.89]; P < .001) and SPUM-ACS (females: 0.83 [0.77-0.90], P = .004; males: 0.83 [0.80-0.87], P = .001).

The ORBI score showed modest sex-specific performance. The novel SEX-SHOCK score provides superior performance in females and males across the entire spectrum of ACS, thus providing a basis for future interventional trials and contemporary ACS management.

Cardiogenic shock (CS) is a critical condition with high mortality rate, as the current management of CS presents significant challenges. Exploration of more effective therapies is necessitated. This review article comprehensively examines the efficacy and safety of levosimendan in the management of CS. By synthesising evidence from numerous studies, a comparison of levosimendan over traditional inotropic agents, such as enoximone, dobutamine, dopamine and norepinephrine, is highlighted. The unique mechanism of action of levosimendan enhances myocardial contractility without increasing oxygen demand, offering a promising alternative for patients with CS. This review also delves into comparative studies that demonstrate the superiority of levosimendan in improving survival rates, haemodynamic parameters, and reducing the incidence of CS complications. Safety profiles and adverse effects are critically assessed to provide a balanced view of the therapeutic window provided by levosimendan. The review concludes that levosimendan is a valuable addition to the therapeutic strategy against CS, with the potential to improve patient outcomes.

Inflammation and neurohormonal activation play a significant role in the adverse outcome seen in acute myocardial infarction (AMI) and the development of cardiogenic shock (CS), which is associated with a mortality rate up to 50%. Treatment with anti-inflammatory drugs such as tocilizumab, an interleukin-6 receptor antagonist, has been shown to reduce troponin release and reduce the myocardial infarct size in AMI patients and it may therefore have cardioprotective properties.

This is a double-blind, placebo-controlled, single-center randomized clinical trial, including adult AMI patients without CS at hospital arrival, undergoing percutaneous coronary intervention (PCI) within 24 h from symptom onset, and at intermediate to high risk of developing CS (ORBI risk score ≥ 10). A total of 100 participants will be randomized to receive a single intravenous dose of tocilizumab (280 mg) or placebo (normal saline). The primary outcome is peak plasma pro-B-type natriuretic peptide (proBNP) within 48 h, assessed using serial measurements at intervals: before infusion, 12, 24, 36, and 48 h after infusion. Secondary endpoints include the following: (1) cardiac magnetic resonance imaging (CMR) during 24-48 h after admission and at follow-up after 3 months with assessment of left ventricular area at risk, final infarct size, and the derived salvage index and (2) biochemical markers of inflammation (C-reactive protein and leukocyte counts) and cardiac injury (troponin T and creatinine kinase MB).

Modulation of interleukin-6-mediated inflammation in patients with AMI, treated with acute PCI, and at intermediate to high risk of in-hospital CS may lead to increased hemodynamic stability and reduced left ventricular infarct size, which will be assessed using blood biomarkers with proBNP as the primary outcome and inflammatory markers, troponin T, and CMR with myocardial salvage index as the secondary endpoints.

Registered with the Regional Ethics Committee (H-21045751), EudraCT (2021-002028-19), ClinicalTrials.gov (NCT05350592). Study registration date: 2022-03-08, Universal Trial Number U1111-1277-8523.

Cardiogenic shock (CS) occurs in 5-10% of patients with acute myocardial infarction (AMI), and the condition is associated with a 30-day mortality rate of up to 50%. Most of the AMI patients are in SCAI SHOCK stage B upon hospital arrival, but some of these patients will progression through the stages to overt shock (SCAI C-E). Around one third of patients who develop CS are not in shock at the time of hospital admission. Pro-B-type natriuretic peptide (proband) is a biomarker closely related to CS development. The aim of this study is to investigate the potential for preventing progression of hemodynamic instability by early inotropic support with low-dose dobutamine infusion administrated after revascularization in AMI patients with intermediate to high risk of in-hospital CS development.

This investigator-initiated, double-blinded, placebo-controlled, randomized, single-center, clinical trial will include 100 AMI patients (≥ 18 years) without CS at hospital admission and at intermediate-high risk of in-hospital CS development (ORBI risk score ≥ 10). Patients will be randomized in a 1:1 ratio to a 24 h intravenous (IV) infusion of dobutamine (5 μg/kg/min) or placebo (NaCl) administrated after acute percutaneous coronary intervention (PCI) (< 24 h from symptom onset). Blood samples are drawn at time points from study inclusion (before infusion, 12, 24, 36, and 48 h). The primary outcome is peak plasma proBNP within 48 h after infusion as a surrogate-measure for the hemodynamic status. Hemodynamic function will be assessed pulse rate, blood pressure, and lactate within 48 h after infusion and by transthoracic echocardiography (TTE) performed after 24-48 h and at follow-up after 3 months. Markers of cardiac injury (troponin T and creatine kinase MB (CK-MB)) will be assessed.

Early inotropic support with low-dose dobutamine infusion in patients with AMI, treated with acute PCI, and at intermediate-high risk of in-hospital CS may serve as an intervention promoting hemodynamic stability and facilitating patient recovery. The effect will be assessed using proBNP as a surrogate marker of CS development, hemodynamic measurements, and TTE within the initial 48 h and repeated at a 3-month follow-up.

The Regional Ethics Committee : H-21045751. EudraCT: 2021-002028-19.

gov: NCT05350592, Registration date: 2022-03-08. WHO Universal Trial Number: U1111-1277-8523.

Heart failure is defined as increased intracardiac pressures, either alone or combined with reduced cardiac output. Clinically, it is presented with signs and symptoms of congestion and compensated perfusion. Cardiogenic shock, on the other hand, is the spectrum of hemodynamic disturbances that lead to hypoperfusion or need for circulatory support, due to cardiac disease. Both entities affect millions of people worldwide, have a dismal prognosis, and constitute a severe socioeconomic burden. Heart failure can be the aftermath of ischemic heart disease, hypertension, arrhythmias, or cardiomyopathies. It undergoes multiple classifications, facilitating its investigation and treatment. The pathogenetic mechanisms differ in various types of heart failure, regarding the affected ventricles, the duration of symptoms, and their primary/secondary onset. These mechanisms reflect the complex interactions between cardiopulmonary, vascular, and hepatorenal systems. Acute deterioration of cardiac function can lead to cardiogenic shock. Myocardial infarction accounts for 81% of such cases. Healthy lifestyle and timely management of coronary artery disease are paramount, as they can prevent this life-threatening situation and reduce mortality and the economic burden for healthcare systems. Irrespective of the etiology, cardiogenic shock is interpreted using the pressure-volume loop. This can be modified for each ventricle, the underlying pathophysiology, and the time since symptoms' onset. It therefore provides valuable information about the native circulation and the expected alterations under mechanical or pharmacological support, facilitating the decision-making progress. In 2019, given the phenotypical heterogeneity of cardiogenic shock, the Society for Cardiovascular Angiography and Interventions introduced a classification system. According to this, patients are stratified in five stages proportionally to the severity of their condition. Aside from this classification, various biochemical, imaging, and hemodynamic monitoring indices are used to assess coagulation pathway and cardiac, hepatorenal, and pulmonary function, enabling the heart team to tailor therapy. Additionally, the prognostication progress is facilitated by scores, such as the Observatoire Regional Breton sur l'Infarctus (ORBI) score, the intra-aortic balloon pump (IABP) SHOCK-II score, and the CardShock score, indicating suitable escalation or de-escalation strategies. Despite the current progress, there are several areas of advancement regarding the role of vasoactive drugs in cardiogenic shock, revascularization options, mechanical ventilation patterns, hypothermia treatment, and mechanical circulatory support protocols.

Cardiogenic shock (CS) is the most critical complication after acute myocardial infarction (AMI) with mortality above 50%. Both blood urea nitrogen and left ventricular ejection fraction were important prognostic indicators. We aimed to evaluate the prognostic value of admission blood urea nitrogen to left ventricular ejection fraction ratio (BUNLVEFr) in patients with AMI complicated by CS (AMI-CS).

268 consecutive patients with AMI-CS were divided into two groups according to the admission BUNLVEFr cut-off value determined by Youden index. The primary endpoint was 30-day all-cause mortality and the secondary endpoint was the composite events of major adverse cardiovascular events (MACEs). Cox proportional hazard models were performed to analyze the association of BUNLVEFr with the outcome.

The optimal cut-off value of BUNLVEFr is 16.63. The 30-day all-cause mortality and MACEs in patients with BUNLVEFr≥16.63 was significantly higher than in patients with BUNLVEFr<16.63 (30-day all-cause mortality: 66.2% vs. 17.1%, p < 0.001; 30-day MACEs: 80.0% vs. 48.0%, p < 0.001). After multivariable adjustment, BUNLVEFr≥16.63 remained an independent predictor for higher risk of 30-day all-cause mortality (HR = 3.553, 95% CI: 2.125-5.941, p < 0.001) and MACEs (HR = 2.026, 95% CI: 1.456-2.820, p < 0.001). Subgroup analyses found that the effect of BUNLVEFr was consistent in different subgroups (all p-interaction>0.05).

The admission BUNLVEFr provided important prognostic information for AMI-CS patients.

Stress-induced hyperglycemia (SIH) is associated with poor outcomes in cardiogenic shock (CS), and there have been inconsistent results among patients with or without diabetes mellitus (DM). The glycemic gap (GG) is derived by subtracting A1c-derived average glucose from blood glucose levels; it is a superior indicator of SIH. We aimed to explore the role of GG in the outcomes of patients with CS.

Data on patients diagnosed with CS were extracted from the MIMIC-IV v2.0 database to investigate the relationship between GG and 30-day mortality (Number of absolute GG subjects = 359; Number of relative GG subjects = 357). CS patients from the Second Affiliated Hospital of Wenzhou Medical University were enrolled to explore the correlation between GG and lactic acid (Number of absolute GG subjects = 252; Number of relative GG subjects = 251). Multivariate analysis, propensity score-matched (PSM) analysis, inverse probability treatment weighting (IPTW), and Pearson correlation analysis were applied.

Absolute GG was associated with 30-day all-cause mortality in CS patients (HRadjusted: 1.779 95% CI: 1.137-2.783; HRPSM: 1.954 95% CI: 1.186-3.220; HRIPTW: 1.634 95% CI: 1.213-2.202). The higher the absolute GG level, the higher the lactic acid level (βadjusted: 1.448 95% CI: 0.474-2.423). A similar trend existed in relative GG (HRadjusted: 1.562 95% CI: 1.003-2.432; HRPSM: 1.790 95% CI: 1.127-2.845; HRIPTW: 1.740 95% CI: 1.287-2.352; βadjusted:1.294 95% CI: 0.369-2.219). Subgroup analysis showed that the relationship existed irrespective of DM. The area under the curve of GG combined with the Glasgow Coma Scale (GCS) for 30-day all-cause mortality was higher than that of GCS (absolute GG: 0.689 vs. 0.637; relative GG: 0.688 vs. 0.633). GG was positively related to the triglyceride-glucose index. Kaplan-Meier curves revealed that groups of higher GG with DM had the worst outcomes. The outcomes differed among races and GG levels (all P < 0.05).

Among patients with CS, absolute and relative GGs were associated with increased 30-day all-cause mortality, regardless of DM. The relationship was stable after multivariate Cox regression analysis, PSM, and IPTW analysis. Furthermore, they reflect the severity of CS to some extent. Hyperlactatemia and insulin resistance may underlie the relationship between stress-induced hyperglycemia and poor outcomes in CS patients. They both improve the predictive efficacy of the GCS.

Cardiogenic shock (CS) mortality remains near 40%. In addition to inadequate cardiac output, patients with severe CS may exhibit vasodilation. We aimed to examine the prevalence and consequences of vasodilation in CS.

We analyzed all patients hospitalized at a CS referral center who were diagnosed with CS stages B to E and did not have concurrent sepsis or recent cardiac surgery. Vasodilation was defined by lower systemic vascular resistance (SVR), higher norepinephrine equivalent dose, or a blunted SVR response to pressors. Threshold SVR values were determined by their relation to 14-day mortality in spline models. The primary outcome was death within 14 days of CS onset in multivariable-adjusted Cox models.

This study included 713 patients with a mean age of 60 years and 27% females; 14-day mortality was 28%, and 38% were vasodilated. The median SVR was 1308 dynes•s•cm-5 (interquartile range, 870-1652), median norepinephrine equivalent was 0.11 µg/kg per minute (interquartile range, 0-0.2), and 28% had a blunted pressor response. Each 100-dynes•s•cm-5 decrease in SVR below 800 was associated with 20% higher mortality (adjusted hazard ratio, 1.23; P=0.004). Each 0.1-µg/kg per minute increase in norepinephrine equivalent dose was associated with 15% higher mortality (adjusted hazard ratio, 1.12; P<0.001). A blunted pressor response was associated with a nearly 2-fold mortality increase (adjusted hazard ratio, 1.74; P=0.003).

Pathophysiologic vasodilation is prevalent in CS and independently associated with an increased risk of death. CS vasodilation can be identified by SVR <800 dynes•s•cm-5, high doses of pressors, or a blunted SVR response to pressors. Additional studies exploring mechanisms and treatments for CS vasodilation are needed.

Acute coronary syndromes are a clinical entity frequently encountered in practice and are responsible for significant morbidity and mortality, despite therapeutic advances. The initiation of early reperfusion therapy reduces mortality and morbidity and improves patients' prognosis, but this depends on how quickly patients receive their treatment. Although it is often easy to diagnose in the presence of typical symptoms, certain patients, such as diabetics, sometimes have atypical symptoms, resulting in a delay in management. In nearly 50% of cases, inferior wall ischaemia is accompanied by right ventricular myocardial infarction; the clinical outcomes range from no hemodynamic compromise to severe hypotension and cardiogenic shock. In this article, we present the case of a 54-year-old male patient with active smoking and poorly controlled type 2 diabetes as cardiovascular risk factors who initially consulted at the first hour for epigastric pain, for which he received symptomatic treatment. As the symptoms persisted, he was admitted to our department at the eighth hour, where he was diagnosed with a biventricular infarction.

Objective.Instantaneous, non-invasive evaluation of left ventricular end-diastolic pressure (LVEDP) would have significant value in the diagnosis and treatment of heart failure. A new approach called cardiac triangle mapping (CTM) has been recently proposed, which can provide a non-invasive estimate of LVEDP. We hypothesized that a hybrid machine-learning (ML) method based on CTM can instantaneously identify an elevated LVEDP using simultaneously measured femoral pressure waveform and electrocardiogram (ECG).Approach.We studied 46 patients (Age: 39-90 (66.4 ± 9.9), BMI: 20.2-36.8 (27.6 ± 4.1), 12 females) scheduled for clinical left heart catheterizations or coronary angiograms at University of Southern California Keck Medical Center. Exclusion criteria included severe mitral/aortic valve disease; severe carotid stenosis; aortic abnormalities; ventricular paced rhythm; left bundle branch and anterior fascicular blocks; interventricular conduction delay; and atrial fibrillation. Invasive LVEDP and pressure waveforms at the iliac bifurcation were measured using transducer-tipped Millar catheters with simultaneous ECG. LVEDP range was 9.3-40.5 mmHg. LVEDP = 18 mmHg was used as cutoff. Random forest (RF) classifiers were trained using data from 36 patients and blindly tested on 10 patients.Main results.Our proposed ML classifier models accurately predict true LVEDP classes using appropriate physics-based features, where the most accurate demonstrates 100.0% (elevated) and 80.0% (normal) success in predicting true LVEDP classes on blind data.Significance.We demonstrated that physics-based ML models can instantaneously classify LVEDP using information from femoral waveforms and ECGs. Although an invasive validation, the required ML inputs can be potentially obtained non-invasively.

Intraoperative goal-directed hemodynamic therapy (GDHT) is a cornerstone of enhanced recovery protocols. We hypothesized that use of an advanced noninvasive intraoperative hemodynamic monitoring system to guide GDHT may decrease intraoperative hypotension (IOH) and improve perfusion during pancreatic resection.

The monitor uses machine learning to produce the Hypotension Prediction Index to predict hypotensive episodes. A clinical decision-making algorithm uses the Hypotension Prediction Index and hemodynamic data to guide intraoperative fluid versus pressor management. Pre-implementation (PRE), patients were placed on the monitor and managed per usual. Post-implementation (POST), anesthesia teams were educated on the algorithm and asked to use the GDHT guidelines. Hemodynamic data points were collected every 20 s (8942 PRE and 26,638 POST measurements). We compared IOH (mean arterial pressure <65 mmHg), cardiac index >2, and stroke volume variation <12 between the two groups.

10 patients were in the PRE and 24 in the POST groups. In the POST group, there were fewer minimally invasive resections (4.2% versus 30.0%, P = 0.07), more pancreaticoduodenectomies (75.0% versus 20.0%, P < 0.01), and longer operative times (329.0 + 108.2 min versus 225.1 + 92.8 min, P = 0.01). After implementation, hemodynamic parameters improved. There was a 33.3% reduction in IOH (5.2% ± 0.1% versus 7.8% ± 0.3%, P < 0.01, a 31.6% increase in cardiac index >2.0 (83.7% + 0.2% versus 63.6% + 0.5%, P < 0.01), and a 37.6% increase in stroke volume variation <12 (73.2% + 0.3% versus 53.2% + 0.5%, P < 0.01).

Advanced intraoperative hemodynamic monitoring to predict IOH combined with a clinical decision-making tree for GDHT may improve intraoperative hemodynamic parameters during pancreatectomy. This warrants further investigation in larger studies.