Veno-arterial ECMO ventricular assistance as a direct bridge to heart transplant: A single center experience in a low-middle income country.

INTRODUCTION: The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a direct bridge to heart transplantation (BTT) is not common in adults worldwide. BTT with ECMO is associated with increased early/mid-term mortality compared with other interventions. In low- and middle-income countries (LMIC), where no other type of short-term mechanical circulatory support is available, its use is widespread and increasingly used as rescue therapy in patients with cardiogenic shock (CS) as a direct bridge to heart transplantation (HT). OBJECTIVE: To assess the outcomes of adult patients using VA-ECMO as a direct BTT in an LMIC and compare them with international registries. METHODS: We conducted a single-center study analyzing consecutive adult patients requiring VA-ECMO as BTT due to refractory CS or cardiac arrest (CA) in a cardiovascular center in Argentina between January 2014 and December 2022. Survival and adverse clinical events after VA-ECMO implantation were evaluated. RESULTS: Of 86 VA-ECMO, 22 (25.5%) were implanted as initial BTT strategy, and 52.1% of them underwent HT. Mean age was 46 years (SD 12); 59% were male. ECMO was indicated in 81% for CS, and the most common underlying condition was coronary artery disease (31.8%). Overall, in-hospital mortality for VA-ECMO as BTT was 50%. Survival to discharge was 83% in those who underwent HT and 10% in those who did not, p < .001. In those who did not undergo HT, the main cause of death was hemorrhagic complications (44%), followed by thrombotic complications (33%). The median duration of VA-ECMO was 6 days (IQR 3-16). There were no differences in the number of days on ECMO between those who received a transplant and those who did not. In the Spanish registry, in-hospital survival after HT was 66.7%; the United Network of Organ Sharing registry estimated post-transplant survival at 73.1% ± 4.4%, and in the French national registry 1-year posttransplant survival was 70% in the VA-ECMO group. CONCLUSIONS: In adult patients with cardiogenic shock, VA-ECMO as a direct BTT allowed successful HT in half of the patients. HT provided a survival benefit in listed patients on VA-ECMO. We present a single center experience with results comparable to those of international registries.

[Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest]. / Impacto del equipo multidisciplinario "ECMO Team" en el pronóstico de pacientes sometidos a membrana de oxigenación extracorpórea venoarterial por choque cardiogénico o paro cardiorrespiratorio refractario.

Objectives: Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown. Objective: We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA. Materials and methods: . We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume. Results: Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups. Conclusions: After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.

New combined risk score to predict atrial fibrillation after cardiac surgery: COM-AF.

Background and Aims: Atrial fibrillation frequently occurs in the postoperative period of cardiac surgery, associated with an increase in morbidity and mortality. The scores POAF, CHA2DS2-VASc and HATCH demonstrated a validated ability to predict atrial fibrillation after cardiac surgery (AFCS). The objective is to develop and validate a risk score to predict AFCS from the combination of the variables with highest predictive value of POAF, CHA2DS2-VASc and HATCH models. Methods: We conducted a single-center cohort study, performing a retrospective analysis of prospectively collected data. The study included consecutive patients undergoing cardiac surgery in 2010-2016. The primary outcome was the development of new-onset AFCS. The variables of the POAF, CHA2DS2-VASc and HATCH scores were evaluated in a multivariate regression model to determine the predictive impact. Those variables that were independently associated with AFCS were included in the final model. Results: A total of 3113 patients underwent cardiac surgery, of which 21% presented AFCS. The variables included in the new score COM-AF were: age (≥75: 2 points, 65-74: 1 point), heart failure (2 points), female sex (1 point), hypertension (1 point), diabetes (1 point), previous stroke (2 points). For the prediction of AFCS, COM-AF presented an AUC of 0.78 (95% CI 0.76-0.80), the rest of the scores presented lower discrimination ability (P < 0.001): CHA2DS2-VASc AUC 0.76 (95% CI 0.74-0.78), POAF 0.71 (95% CI 0.69-0.73) and HATCH 0.70 (95% CI: 0, 67-0.72). Multivariable analysis demonstrated that COM-AF score was an independent predictor of AFCS: OR 1,91 (IC 95% 1,63-2,23). Conclusion: From the combination of variables with higher predictive value included in the POAF, CHA2DS2-VASc, and HATCH scores, a new risk model system called COM-AF was created to predict AFCS, presenting a greater predictive ability than the original ones. Being necessary future prospective validations.

Utilización de oxigenación por membrana extracorpórea venoarterial en el shock cardiogénico y paro cardiorrespiratorio refractarios: experiencia inicial de 7 años en un centro de cardiología de adultos / Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock and Cardiac Arrest: An Initial 7-Year Experience in an Adult Cardiology Center

RESUMEN Introducción: La oxigenación por membrana extracorpórea venoarterial (ECMO VA) es una intervención de rescate en pacientes con shock cardiogénico (SC), y paro cardiorrespiratorio (PCR) refractarios a las terapias convencionales. Objetivo: Describir las características, y resumir nuestra experiencia inicial de 7 años de pacientes que requirieron ECMO VA por SC o PCR. Material y métodos: Se realizó un estudio de cohorte unicéntrico. Se analizaron retrospectivamente los pacientes adultos consecutivos que fueron asistidos con ECMO VA por SC o PCR refractarios entre 2014 y 2020 en el ICBA Instituto Cardiovascular. Resultados: Se incluyeron 54 pacientes, (54 ± 12 años). El 36,5% presentó miocardiopatía isquémica, y el 23,1% enfermedad valvular significativa. Las indicaciones para ECMO VA fueron: poscardiotomía (43,4%), SC refractario (28,3%), y falla primaria del injerto (20,8%). La reanimación cardiopulmonar previa a la ECMO VA se realizó en el 18,5%. La canulación fue periférica en el 81,5%, el 83,3% se asistió en INTERMACS 1, y el 87% presentaba balón de contrapulsación intraaórtico. La duración de asistencia en ECMO VA fue de 5,5 días (RIC 2,8-10). La tasa de supervivencia en ECMO VA fue del 63% (37% puente a trasplante cardíaco, y 26% recuperación), y al alta del 42,6%. Las complicaciones más frecuentes fueron: sangrado (61,1%), infección (51,9%), y complicaciones tromboembólicas (46,3%). Conclusión: La ECMO VA como tratamiento del SC o PCR refractarios en nuestro centro presentó una sobrevida aceptable al alta hospitalaria. La ECMO VA es un tratamiento efectivo cuando las terapias convencionales fallan, siendo aparentemente útil y aplicable en un país donde existe acceso limitado a los dispositivos de asistencia ventricular compleja.

ABSTRACT Background: Venoarterial extra corporeal membrane oxygenation (VA-ECMO) is a rescue intervention used in patients with cardiogenic shock (CS) or cardiac arrest (CA) refractory to conventional medical therapies. Objective: The aim of the present study is to describe the characteristics and summarize our 7-year experience in patients with CS or CA supported with VA-ECMO. Methods: We conducted a single-center retrospective study analyzing consecutive adult patients requiring VA-ECMO due to refractory CS or CA at ICBA, Instituto Cardiovascular between January 2014 and December 2020. Results: A total age 54 patients were included (54 ± 12 years), 36.5% presented ischemic cardiomyopathy and 23.1% significant valvular heart disease. The indications for VA-ECMO implantation were post-cardiotomy (43.4%), refractory CS (28.3%) and primary graft dysfunction (20.8%). Cardiopulmonary resuscitation before VA-ECMO occurred in 18.5% of the cases. Peripheral cannulation was performed in 81.5% of the cases, 83.3% had INTERMACS profile 1 and 87% were on intraaortic balloon pump. Duration of ventricular assistance on VA- ECMO was 5.5 days (IQR 2.8-10). Survival rate on ECMO VA was 63% (37% as a bridge to cardiac transplantation and 26% as a bridge to recovery) and survival to discharge was 42.6%. The most common complications were hemorrhage (61.1%), infections (51.9%), and thromboembolic complications (46.3%). Conclusion: In our center, VA-ECMO as a treatment for refractory CS or CA showed acceptable survival during ventricular support and on hospital discharge. It is an effective life support treatment to rescue critically ill patients when conventional therapies fail, is apparently useful and can be implemented in a country with limited resources and access to complex ventricular assist devices.

Una aplicación digital aumenta la adherencia al tratamiento farmacológico en síndromes coronarios / Use of a smartphone application to increase adherence to medical treatment

Resumen La adherencia al tratamiento médico farmacológico en pacientes que cursaron una hospitalización por un síndrome coronario agudo (SCA) es deficiente. El objetivo primario fue demostrar que, mediante la utilización de una aplicación digital para smartphones, se incrementa por lo menos un 30% la adherencia al tratamiento, en relación al grupo control, en pacientes con SCA. Se realizó un estudio unicéntrico aleatorizado, controlado, con distribución 1:1, simple ciego, que comparó la utilización de una aplicación para smartphones (grupo intervención), frente a la indicación de tratamiento farmacológico por escrito (grupo control), en términos de adherencia médica farmacológica total, en 90 pacientes que cursaron internación por un SCA. La adherencia fue determinada mediante el Cuestionario de Adherencia a la Medicación de Morisky. El paciente se consideró como "totalmente adherente" de obtener un puntaje perfecto (8/8 puntos). El período de seguimiento fue de 90 días posterior al egreso hospitalario. La edad promedio fue 63 ± 9 años, con el 76% de sexo masculino. El objetivo primario ocurrió en 67.4% (31/46) del grupo intervención vs. 20.5% (9/44) del grupo control (p < 0.001). En pacientes que cursaron una hospitalización por SCA, la utilización de una aplicación digital para smartphones incrementó la adherencia al tratamiento médico farmacológico.

Abstract Adherence to cardiovascular medications following acute coronary syndrome hospitalization is generally poor. The primary outcome was to demonstrate that the use of a digital application for smartphones increases the adherence to pharmacological treatment by 30 % in relation to the group without intervention, in patients with an acute coronary syndrome with or without ST segment elevation. In this unicentric, single blinded, randomized controlled trial with 1:1 allocation we compared the use of a digital application for smartphones and written information as standard of care, for the adherence to pharmacological treatment in 90 patients admitted to the hospital with an acute coronary syndrome. Adherence to medical treatment was measured by Morisky Medication Adherence Scale. A patient is considered to have good adherence when score is perfect (8 points). The follow up period was 90 days after hospital discharge. The mean age of the population was 63 ± 9 and 76% were male. At 90 days, 67.4% (31/46) of patients using the smartphone application were adherent compared with 20.5% (9/44) of patients in the control group (p < 0.001). In patients with acute coronary syndrome, the use of a smartphone application increased the medication adherence compared with the standard of care.

[Use of a smartphone application to increase adherence to medical treatment]. / Una aplicación digital aumenta la adherencia al tratamiento farmacológico en síndromes coronarios.

Adherence to cardiovascular medications following acute coronary syndrome hospitalization is generally poor. The primary outcome was to demonstrate that the use of a digital application for smartphones increases the adherence to pharmacological treatment by 30 % in relation to the group without intervention, in patients with an acute coronary syndrome with or without ST segment elevation. In this unicentric, single blinded, randomized controlled trial with 1:1 allocation we compared the use of a digital application for smartphones and written information as standard of care, for the adherence to pharmacological treatment in 90 patients admitted to the hospital with an acute coronary syndrome. Adherence to medical treatment was measured by Morisky Medication Adherence Scale. A patient is considered to have good adherence when score is perfect (8 points). The follow up period was 90 days after hospital discharge. The mean age of the population was 63 ± 9 and 76% were male. At 90 days, 67.4% (31/46) of patients using the smartphone application were adherent compared with 20.5% (9/44) of patients in the control group (p < 0.001). In patients with acute coronary syndrome, the use of a smartphone application increased the medication adherence compared with the standard of care.

La adherencia al tratamiento médico farmacológico en pacientes que cursaron una hospitalización por un síndrome coronario agudo (SCA) es deficiente. El objetivo primario fue demostrar que, mediante la utilización de una aplicación digital para smartphones, se incrementa por lo menos un 30% la adherencia al tratamiento, en relación al grupo control, en pacientes con SCA. Se realizó un estudio unicéntrico aleatorizado, controlado, con distribución 1:1, simple ciego, que comparó la utilización de una aplicación para smartphones (grupo intervención), frente a la indicación de tratamiento farmacológico por escrito (grupo control), en términos de adherencia médica farmacológica total, en 90 pacientes que cursaron internación por un SCA. La adherencia fue determinada mediante el Cuestionario de Adherencia a la Medicación de Morisky. El paciente se consideró como "totalmente adherente" de obtener un puntaje perfecto (8/8 puntos). El período de seguimiento fue de 90 días posterior al egreso hospitalario. La edad promedio fue 63 ± 9 años, con el 76% de sexo masculino. El objetivo primario ocurrió en 67.4% (31/46) del grupo intervención vs. 20.5% (9/44) del grupo control (p < 0.001). En pacientes que cursaron una hospitalización por SCA, la utilización de una aplicación digital para smartphones incrementó la adherencia al tratamiento médico farmacológico.

Proyecto de mejora de calidad para reducir errores de prescripción en pacientes internados por patologías cardiovasculares / Quality Improvement Project to Reduce Prescription Errors in Patients Hospitalized due to Cardiovascular Diseases

Introducción: Los errores de prescripción son un problema frecuente que amenaza la seguridad de los pacientes internados, especialmente en áreas de cuidados críticos. Objetivo: Evaluar la efectividad de un proyecto de mejora de la calidad para reducir errores de prescripción en pacientes internados por patologías de origen cardiovascular. Material y métodos: Se implementó un proyecto de mejora de la calidad destinado a reducir errores de prescripción intrahos-pitalaria. Los tres componentes principales del proyecto fueron: supervisión obligatoria de las indicaciones, utilización de un software que ordena las indicaciones por sistemas biológicos e implementación de una norma de formato universal de prescripción de medicamentos, que incluyó un diccionario de abreviaturas y de diluciones normalizadas. Con anterioridad a la implementación de estos cambios se midió la cantidad de errores de prescripción semanales, estratificados por área de internación. Se analizó el impacto del proyecto dividiendo las muestras en cuatro períodos consecutivos de 9 semanas cada uno (un período preintervención y tres posintervención) y se comparó luego la cantidad de errores detectados en cada uno de ellos. En cada período se evaluaron de manera aleatoria las indicaciones de 180 pacientes. Resultados: Se analizaron en total 720 prescripciones. La implementación del proyecto de mejora logró reducir la cantidad de errores de manera rápida y sostenida en el tiempo (mediana preintervención de 85, RIC 70-95 y mediana final de 26, RIC 21-37; p = 0,0004). Conclusión: El proyecto de mejora de la calidad implementado permitió reducir significativamente la cantidad de errores de prescripción en pacientes internados por patologías cardiovasculares.