ABSTRACT
Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a standard of care for severe cardiogenic shock, refractory cardiac arrest and related impending multiorgan failure. The widespread clinical use of this complex temporary circulatory support modality is still contrasted by a lack of formal scientific evidence in the current literature. This might at least in part be attributable to VA ECMO related complications, which may significantly impact on clinical outcome. In order to limit adverse effects of VA ECMO as much as possible an indepth understanding of the complex physiology during extracorporeally supported cardiogenic shock states is critically important. This review covers all relevant physiological aspects of VA ECMO interacting with the human body in detail. This, to provide a solid basis for health care professionals involved in the daily management of patients supported with VA ECMO and suffering from cardiogenic shock or cardiac arrest and impending multiorgan failure for the best possible care.
Subject(s)
Extracorporeal Membrane Oxygenation , Shock, Cardiogenic , Extracorporeal Membrane Oxygenation/methods , Humans , Shock, Cardiogenic/therapy , Shock, Cardiogenic/physiopathology , Multiple Organ Failure , Heart Arrest/therapy , Heart Arrest/physiopathologyABSTRACT
INTRODUCTION: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) improves end-organ perfusion in cardiogenic shock but may increase afterload, which can limit cardiac recovery. Left ventricular (LV) unloading strategies may aid cardiac recovery and prevent complications of increased afterload. However, there is no consensus on when and which unloading strategy should be used. METHODS: An online survey was distributed worldwide via the EuroELSO newsletter mailing list to describe contemporary international practice and evaluate heterogeneity in strategies for LV unloading. RESULTS: Of 192 respondents from 43 countries, 53% routinely use mechanical LV unloading, to promote ventricular recovery and/or to prevent complications. Of those that do not routinely unload, 65% cited risk of complications as the reason. The most common indications for unplanned unloading were reduced arterial line pulsatility (68%), pulmonary edema (64%) and LV dilatation (50%). An intra-aortic balloon pump was the most frequently used device for unloading followed by percutaneous left ventricular assist devices. Echocardiography was the most frequently used method to monitor the response to unloading. CONCLUSIONS: Significant variation exists with respect to international practice of ventricular unloading. Further research is required that compares the efficacy of different unloading strategies and a randomized comparison of routine mechanical unloading versus unplanned unloading.
Subject(s)
Extracorporeal Membrane Oxygenation , Humans , Extracorporeal Membrane Oxygenation/methods , Surveys and Questionnaires , Female , Male , Shock, Cardiogenic/therapy , Shock, Cardiogenic/physiopathology , Heart-Assist DevicesSubject(s)
Myocardial Infarction , Shock, Cardiogenic , Humans , Shock, Cardiogenic/therapy , Shock, Cardiogenic/etiology , Shock, Cardiogenic/physiopathology , Myocardial Infarction/complications , Myocardial Infarction/physiopathology , Myocardial Infarction/therapy , Hemodynamic Monitoring/methods , HemodynamicsABSTRACT
Cardiogenic shock (CS) is a heterogeneous syndrome with high mortality and a growing incidence. It is characterized by an imbalance between the tissue oxygen demands and the capacity of the cardiovascular system to meet these demands, due to acute cardiac dysfunction. Historically, acute coronary syndromes have been the primary cause of CS. However, non-ischemic cases have seen a rise in incidence. The pathophysiology involves ischemic damage of the myocardium and a sympathetic, renin-angiotensin-aldosterone system and inflammatory response, perpetuating the situation of tissue hypoperfusion and ultimately leading to multiorgan dysfunction. The characterization of CS patients through a triaxial assessment and the widespread use of the Society for Cardiovascular Angiography and Interventions (SCAI) scale has allowed standardization of the severity stratification of CS; this, coupled with early detection and the "hub and spoke" approach, could contribute to improving the prognosis of these patients.
Subject(s)
Shock, Cardiogenic , Humans , Shock, Cardiogenic/physiopathology , Shock, Cardiogenic/etiology , Shock, Cardiogenic/classification , Prognosis , Severity of Illness IndexABSTRACT
PURPOSE: Mechanical circulatory support (MCS) using a venoarterial extracorporeal membrane oxygenation (VA-ECMO) device or a catheter-type heart pump (Impella) is critical for the rescue of patients with severe cardiogenic shock. However, these MCS devices require large-bore cannula access (14-Fr and larger) at the femoral artery or vein, which often requires surgical decannulation. METHODS: In this retrospective study, we evaluated post-closure method using a percutaneous suture-mediated vascular closure system, Perclose ProGlide/ProStyle (Abbott Vascular, Lake Bluff, IL, Perclose), as an alternative procedure for MCS decannulation. Closure of 83 Impella access sites and 68 VA-ECMO access sites performed using Perclose or surgical method between January 2018 and March 2023 were evaluated. RESULTS: MCS decannulation using Perclose was successfully completed in all access sites without surgical hemostasis. The procedure time of ProGlide was shorter than surgical decannulation for both Impella and VA-ECMO (13 min vs. 50 min; p < 0.001, 21 min vs. 65 min; p < 0.001, respectively). There were no significant differences in the 30-day survival rate and major adverse events by decannulation including arterial dissection requiring endovascular treatment, hemorrhage requiring a large amount of red blood cell transfusion, and access site infection. CONCLUSION: Our results suggest that the post-closure technique using the percutaneous suture-mediated closure system appears to be a safe and effective method for large-bore MCS decannulation.
Subject(s)
Catheterization, Peripheral , Extracorporeal Membrane Oxygenation , Heart-Assist Devices , Hemostatic Techniques , Punctures , Vascular Closure Devices , Humans , Retrospective Studies , Male , Female , Treatment Outcome , Middle Aged , Aged , Extracorporeal Membrane Oxygenation/adverse effects , Extracorporeal Membrane Oxygenation/instrumentation , Time Factors , Hemostatic Techniques/instrumentation , Hemostatic Techniques/adverse effects , Catheterization, Peripheral/adverse effects , Catheterization, Peripheral/instrumentation , Device Removal/adverse effects , Suture Techniques/instrumentation , Suture Techniques/adverse effects , Femoral Artery , Shock, Cardiogenic/therapy , Shock, Cardiogenic/mortality , Shock, Cardiogenic/physiopathology , Shock, Cardiogenic/diagnosis , Risk Factors , Hemorrhage/etiology , Hemorrhage/prevention & controlABSTRACT
ABSTRACT: Background: Both sepsis-induced cardiomyopathy and worsening of preexisting cardiac disease can contribute to circulatory shock in septic patients. The early use of pulmonary artery catheter (PAC) could play a pivotal role in the management of sepsis-associated cardiogenic shock. In this study, we aimed to evaluate the impact of early invasive hemodynamic monitoring with PAC in patients with sepsis-associated cardiogenic shock. Method: We performed a retrospective study using the National Inpatient Sample data from January 2017 to December 2019. The early use of PAC was defined as the use of PAC within 2 days from the admission. We performed the multivariable logistic regression analysis to investigate the association between the early use of PAC and in-hospital mortality in patients with sepsis-associated cardiogenic shock and sepsis without cardiogenic shock, respectively. Results: There was no difference in in-hospital mortality between PAC and no PAC groups in sepsis without cardiogenic shock (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] = 0.82-1.35, P = 691). On the other hand, the early use of PAC was independently associated with lower in-hospital mortality in patients with sepsis-associated cardiogenic shock (aOR = 0.58, 95% confidence interval [CI] = 0.46-0.72, P < 0.001). The use of PAC was also associated with increased use of mechanical circulatory support in those with sepsis-associated cardiogenic shock (aOR = 12.26, 95% CI = 9.37-16.03, P < 0.001). For patients with sepsis-associated cardiogenic shock, the use of PAC after 2 days of admission was associated with significantly higher in-hospital mortality and decreased use of mechanical circulatory support. Conclusion: The use of pulmonary artery catheters in sepsis-associated cardiogenic shock was associated with significantly lower in-hospital mortality and increased use of mechanical circulatory supports in patients with sepsis-associated cardiogenic shock.
Subject(s)
Catheterization, Swan-Ganz , Hemodynamic Monitoring , Hospital Mortality , Sepsis , Shock, Cardiogenic , Humans , Shock, Cardiogenic/mortality , Shock, Cardiogenic/etiology , Shock, Cardiogenic/physiopathology , Shock, Cardiogenic/therapy , Male , Female , Retrospective Studies , Middle Aged , Aged , Sepsis/complications , Sepsis/mortality , Sepsis/physiopathology , Hemodynamic Monitoring/methods , Pulmonary Artery/physiopathologyABSTRACT
Objective Abnormal endotoxin activity in critically ill patients has been described in the absence of Gram-negative bacterial (GNB) infection. As disease severity seems to be crucial in the detection of this phenomenon, we decided to assess and compare endotoxin exposure in those patients representing the critical situation: septic shock and cardiogenic shock. Design Prospective, observational non intervention study. Setting Critical Care Department of a University tertiary hospital. Patients Cardiogenic shock (CS) and septic shock (SS) patients. Interventions None. Measurements and main results Follow-up was performed for the first three days. Inflammatory biomarkers (C-reactive protein, procalcitonin and interleuquin-6) and IgM antiendotoxin-core antibodies titter (IgM EndoCAb) were daily analyzed. Sixty-two patients were included; twenty-five patients with SS and thirty-seven with CS. Microbial etiology was established in 23 SS patients (92%) and GNB were present in 13 cases (52%). Although infection was suspected and even treated in 30 CS patients (81%), any episode could be finally confirmed. EndoCAb consumption was more intense in SS patients, although twenty-two CS patients (59.5%) had IgM anti-endotoxin value below 10th percentile range for healthy people. No statistically significant difference in endotoxin exposure was detected between Gram-positive and Gram-negative infections in the SS group. Endotoxin exposure ability to distinguish between SS and CS was moderate (AUC 0.7892, 95% IC: 0.65640.9218).Conclusions In the severely ill patient some mechanisms take place allowing endotoxin incursion and therefore blurring the limits of diseases pathophysiology. Our work representatively shows how exposure to endotoxin was not fully capable of distinguishing between CS and SS. (AU)
Objetivo En el paciente crítico se ha descrito una actividad incrementada de la endotoxina no asociada a infección por bacterias gramnegativas (BGN). La gravedad de la enfermedad influye en este fenómeno, por ello realizamos este estudio en el paciente crítico por antonomasia: shock séptico y cardiogénico. Diseño Estudio prospectivo, observacional, sin intervención.Lugar de estudioUnidad de Cuidados Intensivos. Pacientes Pacientes en shock cardiogénico (SC) o séptico (SS).Intervención Ninguna. Determinaciones y principales resultados Seguimiento durante los 3 primeros días. Proteína C reactiva, procalcitonina e interleucina-6, y el título de anticuerpos IgM anti-edotoxina (IgM EndoCAb) se analizaron diariamente. Se incluyó a 62 pacientes; 25 con SS y 37 con SC. La etiología fue identificada en 23 pacientes con SS (92%), los BGN estuvieron presentes en 13 casos (52%). Se sospechó e incluso trató la infección en 30 pacientes con SC, pero en ningún caso se pudo confirmar. El consumo de EndoCAb fue más intenso en los pacientes con SS, pero 22 pacientes con SC (59,5%) tuvieron unos valores por debajo del percentil 10. Los niveles de EndoCAb no fueron significativamente diferentes entre las infecciones por BGN y cocos grampositivos. La capacidad de EndoCab para diferenciar entre SC y SS resultó ser moderada (AUC 0,7892; IC del 95%, 0,6564-0,9218).Conclusiones En el paciente crítico es frecuente que la endotoxina provoque una respuesta inflamatoria y la sumación de distintos mecanismos fisiopatológicos. En este sentido, nuestro trabajo pone de manifiesto que la determinación de exposición a endotoxina no es totalmente capaz de distinguir entre los pacientes con SC y SS. (AU)
Subject(s)
Humans , Male , Female , Middle Aged , Aged , Shock, Cardiogenic/blood , Shock, Septic/blood , Immunoglobulin M/blood , Endotoxins/blood , Shock, Cardiogenic/physiopathology , Shock, Septic/physiopathology , Prospective StudiesABSTRACT
BACKGROUND: Extracorporeal left ventricular assist device is often required for acute myocardial infarction patients in cardiogenic shock when temporary mechanical circulatory support fails to provide hemodynamic stabilization. This study aimed to evaluate the clinical outcomes of acute myocardial infarction patients in cardiogenic shock supported by an extracorporeal left ventricular assist device. METHODS: This retrospective study enrolled 13 acute myocardial infarction patients in cardiogenic shock treated with an extracorporeal left ventricular assist device from April 2011 to July 2020. RESULTS: Twelve (92.3%) and eleven (84.6%) patients were supported using venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pumping before implantation, respectively. The median duration from acute myocardial infarction to extracorporeal left ventricular assist device implantation was 7 (3.5-24.5) days. The overall in-hospital mortality rate was 30.8% (n = 4). Extracorporeal left ventricular assist device was explanted in one patient for cardiac recovery; eight (61.5%) patients were approved as heart transplant candidates in whom the extracorporeal left ventricular assist device was exchanged for a durable left ventricular assist device; two (15.4%) expired while waiting for a heart transplant, and two (15.4%) received a successful transplant. The 1- and 3-year overall survival rates after extracorporeal left ventricular assist device implantation were 68.3% and 49.9%, respectively. CONCLUSIONS: The operative mortality after extracorporeal left ventricular assist device implantation in acute myocardial infarction patients in cardiogenic shock was favorable. Our strategy of early hemodynamic stabilization with extracorporeal left ventricular assist device implantation in these patients as a bridge-to-bridge therapy was effective in achieving better survival.
Subject(s)
Extracorporeal Membrane Oxygenation/instrumentation , Heart Transplantation , Heart-Assist Devices , Hemodynamics , Myocardial Infarction/surgery , Shock, Cardiogenic/surgery , Ventricular Function, Left , Waiting Lists , Adolescent , Adult , Device Removal , Extracorporeal Membrane Oxygenation/adverse effects , Extracorporeal Membrane Oxygenation/mortality , Female , Hospital Mortality , Humans , Male , Middle Aged , Myocardial Infarction/diagnosis , Myocardial Infarction/mortality , Myocardial Infarction/physiopathology , Prosthesis Design , Recovery of Function , Retrospective Studies , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/mortality , Shock, Cardiogenic/physiopathology , Time Factors , Time-to-Treatment , Treatment Outcome , Waiting Lists/mortality , Young AdultABSTRACT
OBJECTIVE: Mechanical circulatory support (MCS) devices are widely used for cardiogenic shock (CS). This network meta-analysis aims to evaluate which MCS strategy offers advantages. METHODS: A systemic search of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was performed. Studies included double-blind, randomized controlled, and observational trials, with 30-day follow-ups. Paired independent researchers conducted the screening, data extraction, quality assessment, and consistency and heterogeneity assessment. RESULTS: We included 39 studies (1 report). No significant difference in 30-day mortality was noted between venoarterial extracorporeal membrane oxygenation (VA-ECMO) and VA-ECMO plus Impella, Impella, and medical therapy. According to the surface under the cumulative ranking curve, the optimal ranking of the interventions was surgical venting plus VA-ECMO, medical therapy, VA-ECMO plus Impella, intra-aortic balloon pump (IABP), Impella, Tandem Heart, VA-ECMO, and Impella plus IABP. Regarding in-hospital mortality and 30-day mortality, the forest plot showed low heterogeneity. The results of the node-splitting approach showed that direct and indirect comparisons had a relatively high consistency. CONCLUSIONS: IABP more effectively reduce the incidence of 30-day mortality compared with VA-ECMO and Impella for the treatment of CS.
Subject(s)
Extracorporeal Membrane Oxygenation/mortality , Heart, Artificial , Intra-Aortic Balloon Pumping/mortality , Shock, Cardiogenic/mortality , Shock, Cardiogenic/therapy , Extracorporeal Membrane Oxygenation/adverse effects , Heart-Assist Devices , Hospital Mortality , Humans , Intra-Aortic Balloon Pumping/adverse effects , Network Meta-Analysis , Observational Studies as Topic , Randomized Controlled Trials as Topic , Risk Assessment , Risk Factors , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/physiopathology , Time Factors , Treatment OutcomeABSTRACT
While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock. The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock and with available on-treatment ADP-induced platelet aggregation measurements. Out of 233 patients, 74 suffered from a severe BARC3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (p < .001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU). An optimal cutoff value of <12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, the use of VA-ECMO (HR 1.972) or coaxial left ventricular pump (HR 2.593), first lactate (HR 1.093 per mmol/l) and thrombocyte count (HR 0.994 per G/l) were independent predictors of BARC≥3 bleedings. In conclusion, lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in cardiogenic shock warrants further investigation.
Subject(s)
Adenosine Diphosphate/metabolism , Blood Platelets/metabolism , Hemorrhage/etiology , Myocardial Infarction/complications , Shock, Cardiogenic/etiology , Acute Disease , Aged , Female , Hemorrhage/physiopathology , Humans , Male , Myocardial Infarction/pathology , Shock, Cardiogenic/physiopathologyABSTRACT
BACKGROUND: Prior studies have shown worse outcomes in patients with cardiogenic shock (CS) who have reduced left ventricular ejection fraction (LVEF), but the association between other transthoracic echocardiogram (TTE) findings and mortality in CS patients remains uncertain. We hypothesized that Doppler TTE measurements would outperform LVEF for risk stratification. METHODS: Retrospective analysis of cardiac intensive care unit patients with an admission diagnosis of CS and a TTE within 1 day of admission. Hospital survivors and inpatient deaths were compared, and multivariable logistic regression was used to analyze the associations between TTE variables and hospital mortality. RESULTS: We included 1,085 patients, with a median age of 69.5 (59.6, 77.5) years; 37% were females and 62% had an acute coronary syndrome. Most patients (66%) had moderate or severe left ventricular (LV) systolic dysfunction, and 48% had moderate or severe right ventricular (RV) systolic dysfunction. Hospital mortality occurred in 31%, and inpatient deaths had a lower median LVEF (29% vs. 35%, Pâ<â0.001). Patients with mild or no LV or RV dysfunction were at lower risk of adjusted hospital mortality (Pâ<â0.01). The LV outflow tract (LVOT) velocity-time integral (VTI) was the single best predictor of hospital mortality. After multivariable adjustment, both the LVEF and LVOT VTI remained strongly associated with hospital mortality (Pâ<â0.001). CONCLUSIONS: Early comprehensive Doppler TTE can provide important prognostic insights in CS patients, highlighting its potential utility in clinical practice. The LVOT VTI, reflecting forward flow, is an important measurement to obtain on bedside TTE.
Subject(s)
Critical Care , Echocardiography, Doppler , Shock, Cardiogenic/mortality , Shock, Cardiogenic/physiopathology , Ventricular Function, Left/physiology , Ventricular Function, Right/physiology , Aged , Female , Hospital Mortality , Humans , Logistic Models , Male , Middle Aged , Predictive Value of Tests , Retrospective Studies , Shock, Cardiogenic/diagnostic imaging , Stroke Volume/physiology , Survival RateABSTRACT
BACKGROUND: Ventricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases. CASE PRESENTATION: A 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2-3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction. CONCLUSIONS: Prolonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.
Subject(s)
Cardiac Catheterization , Inferior Wall Myocardial Infarction/therapy , Intra-Aortic Balloon Pumping/adverse effects , Percutaneous Coronary Intervention , Shock, Cardiogenic/therapy , Ventricular Septal Rupture/therapy , Aged , Drug-Eluting Stents , Humans , Inferior Wall Myocardial Infarction/complications , Inferior Wall Myocardial Infarction/diagnostic imaging , Inferior Wall Myocardial Infarction/physiopathology , Male , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/instrumentation , Recovery of Function , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/etiology , Shock, Cardiogenic/physiopathology , Time Factors , Treatment Outcome , Ventricular Septal Rupture/diagnostic imaging , Ventricular Septal Rupture/etiology , Ventricular Septal Rupture/physiopathologyABSTRACT
IMPORTANCE: Cardiogenic shock affects between 40â¯000 and 50â¯000 people in the US per year and is the leading cause of in-hospital mortality following acute myocardial infarction. OBSERVATIONS: Thirty-day mortality for patients with cardiogenic shock due to myocardial infarction is approximately 40%, and 1-year mortality approaches 50%. Immediate revascularization of the infarct-related coronary artery remains the only treatment for cardiogenic shock associated with acute myocardial infarction supported by randomized clinical trials. The Percutaneous Coronary Intervention Strategies with Acute Myocardial Infarction and Cardiogenic Shock (CULPRIT-SHOCK) clinical trial demonstrated a reduction in the primary outcome of 30-day death or kidney replacement therapy; 158 of 344 patients (45.9%) in the culprit lesion revascularization-only group compared with 189 of 341 patients (55.4%) in the multivessel percutaneous coronary intervention group (relative risk, 0.83 [95% CI, 0.71-0.96]; P = .01). Despite a lack of randomized trials demonstrating benefit, percutaneous mechanical circulatory support devices are frequently used to manage cardiogenic shock following acute myocardial infarction. CONCLUSIONS AND RELEVANCE: Cardiogenic shock occurs in up to 10% of patients immediately following acute myocardial infarction and is associated with mortality rates of nearly 40% at 30 days and 50% at 1 year. Current evidence and clinical practice guidelines support immediate revascularization of the infarct-related coronary artery as the primary therapy for cardiogenic shock following acute myocardial infarction.
Subject(s)
Myocardial Infarction/complications , Myocardial Revascularization/methods , Shock, Cardiogenic/therapy , Cardiotonic Agents/therapeutic use , Extracorporeal Membrane Oxygenation , Heart-Assist Devices , Humans , Percutaneous Coronary Intervention , Shock, Cardiogenic/etiology , Shock, Cardiogenic/mortality , Shock, Cardiogenic/physiopathology , Time-to-TreatmentABSTRACT
BACKGROUND: The value of mechanical circulatory support (MCS) in cardiogenic shock, especially the combination of the ECMELLA approach (Impella combined with ECMO), remains controversial. CASE PRESENTATION: A previously healthy 33-year-old female patient was submitted to a local emergency department with a flu-like infection and febrile temperatures up to 39 °C. The patient was tested positive for type-A influenza, however negative for SARS-CoV-2. Despite escalated invasive ventilation, refractory hypercapnia (paCO2: 22 kPa) with severe respiratory acidosis (pH: 6.9) and a rising norepinephrine rate occurred within a few hours. Due to a Horovitz-Index < 100, out-of-centre veno-venous extracorporeal membrane oxygenation (vv-ECMO)-implantation was performed. A CT-scan done because of anisocoria revealed an extended dissection of the right vertebral artery. While the initial left ventricular function was normal, echocardiography revealed severe global hypokinesia. After angiographic exclusion of coronary artery stenoses, we geared up LV unloading by additional implantation of an Impella CP and expanded the vv-ECMO to a veno-venous-arterial ECMO (vva-ECMO). Clinically relevant bleeding from the punctured femoral arteries resulted in massive transfusion and was treated by vascular surgery later on. Under continued MCS, LVEF increased to approximately 40% 2 days after the initiation of ECMELLA. After weaning, the Impella CP was explanted at day 5 and the vva-ECMO was removed on day 9, respectively. The patient was discharged in an unaffected neurological condition to rehabilitation 25 days after the initial admission. CONCLUSIONS: This exceptional case exemplifies the importance of aggressive MCS in severe cardiogenic shock, which may be especially promising in younger patients with non-ischaemic cardiomyopathy and potentially reversible causes of cardiogenic shock. This case impressively demonstrates that especially young patients may achieve complete neurological restoration, even though the initial prognosis may appear unfavourable.
Subject(s)
Extracorporeal Membrane Oxygenation/methods , Heart-Assist Devices , Influenza A virus/isolation & purification , Influenza, Human , Respiration, Artificial/methods , Respiratory Insufficiency , Ventricular Dysfunction, Left , Adult , COVID-19/diagnosis , Clinical Deterioration , Critical Care/methods , Echocardiography/methods , Female , Heart Failure/physiopathology , Heart Failure/therapy , Humans , Influenza, Human/complications , Influenza, Human/diagnosis , Influenza, Human/physiopathology , Respiratory Insufficiency/etiology , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/therapy , SARS-CoV-2 , Serologic Tests/methods , Severity of Illness Index , Shock, Cardiogenic/etiology , Shock, Cardiogenic/physiopathology , Shock, Cardiogenic/therapy , Treatment Outcome , Ventricular Dysfunction, Left/etiology , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Left/therapyABSTRACT
BACKGROUND: With the high prevalence of COVID-19 infections worldwide, the multisystem inflammatory syndrome in adults (MIS-A) is becoming an increasingly recognized entity. This syndrome presents in patients several weeks after infection with COVID-19 and is associated with thrombosis, elevated inflammatory markers, hemodynamic compromise and cardiac dysfunction. Treatment is often with steroids and intravenous immunoglobulin (IVIg). The pathologic basis of myocardial injury in MIS-A, however, is not well characterized. In our case report, we obtained endomyocardial biopsy that revealed a pattern of myocardial injury similar to that found in COVID-19 cardiac specimens. CASE PRESENTATION: A 26-year-old male presented with fevers, chills, headache, nausea, vomiting, and diarrhea 5 weeks after his COVID-19 infection. His SARS-CoV-2 PCR was negative and IgG was positive, consistent with prior infection. He was found to be in cardiogenic shock with biventricular failure, requiring inotropes and diuretics. Given concern for acute fulminant myocarditis, an endomyocardial biopsy (EMB) was performed, showing an inflammatory infiltrate consisting predominantly of interstitial macrophages with scant T lymphocytes. The histologic pattern was similar to that of cardiac specimens from COVID-19 patients, helping rule out myocarditis as the prevailing diagnosis. His case was complicated by persistent hypoxemia, and a computed tomography scan revealed pulmonary emboli. He received IVIg, steroids, and anticoagulation with rapid recovery of biventricular function. CONCLUSIONS: MIS-A should be considered as the diagnosis in patients presenting several weeks after COVID-19 infection with severe inflammation and multi-organ involvement. In our case, EMB facilitated identification of MIS-A and guided therapy. The patient's biventricular function recovered with IVIg and steroids.
Subject(s)
Anticoagulants/administration & dosage , COVID-19 Drug Treatment , COVID-19 , Myocarditis/diagnosis , Shock, Cardiogenic , Systemic Inflammatory Response Syndrome , Adult , Biopsy/methods , COVID-19/complications , COVID-19/diagnosis , COVID-19/immunology , COVID-19/physiopathology , Cardiotonic Agents/administration & dosage , Diagnosis, Differential , Diuretics/administration & dosage , Electrocardiography/methods , Humans , Immunoglobulins, Intravenous/administration & dosage , Male , Myocardium/pathology , Radiography, Thoracic/methods , SARS-CoV-2 , Shock, Cardiogenic/diagnosis , Shock, Cardiogenic/drug therapy , Shock, Cardiogenic/etiology , Shock, Cardiogenic/physiopathology , Systemic Inflammatory Response Syndrome/diagnosis , Systemic Inflammatory Response Syndrome/drug therapy , Systemic Inflammatory Response Syndrome/physiopathology , Treatment OutcomeABSTRACT
BACKGROUND: Adrenal Insufficiency (AI) is rarely observed in patients with cardiogenic shock (CS). We aimed to identify the prevalence of AI in patients with CS and its effect on their clinical outcomes. AIMS: Our study aimed to determine the prevalence of AI in CS patients who underwent treatments for CS. METHODS: The articles concerning AI in CS were extracted for review from PubMed/Medline, Science Direct, World Wide Science.org, and Pro-Quest. The research articles included patients with CS, post-cardiac-arrest shock, out-of-hospital cardiac arrest, and CS after acute myocardial infarction. RStudio (version 1.0.136) was used for analyzing AI in CS patients. RESULTS: The search revealed 1463 unique publications, including 256 studies identified after screening the titles and the abstracts. Five observational cohort studies met the eligibility criteria for meta-analysis after the preliminary screening. The included studies reported a corticotropin stimulation test for AI diagnosis. The studies reportedly exhibited a low-to-fair quality. The random-effects pooled estimates indicated a 32% AI prevalence in the setting of CS [95% CI; 21%-45%; I2 = 81%]. The outcomes from the included studies were statistically significant for high heterogeneity (P = 0.001). The pooled results confirmed an 11%-51% AI prevalence in CS patients. CONCLUSIONS: This meta-analysis revealed a moderate level prevalence of AI in CS patients.
