RESUMO
BACKGROUND: Calcific mitral stenosis (calcific MS) presents a challenge for surgical treatment and is a contraindication for most contemporary transcatheter mitral valve replacement devices (TMVR), rendering patients with very limited therapeutic options. AIMS: This study aims to assess the clinical and hemodynamic follow-up after mitral valve lithotripsy (MVL). METHODS: All consecutive patients who underwent MVL to treat symptomatic calcific MS at St Michael's Hospital, Toronto, Canada, were included. Patients were deemed unsuitable for mitral surgery or TMVR after heart team assessment. Patients with rheumatic MS or ≥moderate mitral regurgitation (MR) were excluded. The primary endpoint was a reduction in the invasive mitral gradient by ≥50% without significant (≥moderate) MR. RESULTS: Fifteen patients underwent MVL between 2021 and 2023 with a mean age of 74 ± 9 years; 53% were female, with a mean STS score of 10% ± 0.1%. Following MVL, there was a reduction in the invasively measured mean trans-mitral gradient compared to baseline (14 mmHg vs. 6 mmHg; p < 0.05). The primary endpoint was achieved in 8 patients (53%) with no major procedural complications. At follow-up (median 90 days, IQR 58-115 days), 14 (93%) patients reported improved symptoms from New York Heart Association (NYHA) Class III-IV to NYHA Class I-II (p < 0.01) with stable echo-derived mean gradient (7.7 mmHg ± 2 mmHg vs. 8.4 mmHg ± 2.9 mmHg (p = 0.7). CONCLUSIONS: In selected patients with symptomatic inoperable calcific MS, MVL was safe and associated with significant short-term clinical and hemodynamic improvement. MVL may represent a new compassionate therapy for this challenging cohort. Further studies are needed to determine the long-term outcomes and help define the role of IVL technology in treating calcific valvular conditions.
RESUMO
BACKGROUND: Heart failure (HF) is a common reason for admission to the cardiac intensive care unit. We sought to identify the role of an HF consultation service in improving the management of this patient population. METHODS: We identified all adult patients admitted to the cardiac intensive care unit (2014-2015) at the University Health Network with a diagnosis of acute decompensated HF ± cardiogenic shock (CS). Clinical characteristics and course were recorded. We calculated a propensity score-adjusted association between HF consultation and in-hospital mortality. RESULTS: A total of 285 unique patients were identified in our cohort. Of these, 82 (28.7%) died. A total of 150 patients (52.6%) were co-managed by an HF service, and 135 patients (47.3%) were not. Patients who were managed by an HF team were younger (52.5 vs 68.0 years, P < 0.0001), were more likely to be admitted with CS (61.3 vs 41.5%, P < 0.0009), and had higher rates of vasoactive medications during their admission (69.3% vs 52.6%, P < 0.005). At discharge, there were higher rates of discharge to a HF clinic (52.0% vs 27.5%, P < 0.0001) and prescription of guideline-directed medical therapy. In-hospital mortality was lower in those co-managed by a HF team (16.7% vs 42.2%, P < 0.0001). HF consultation reduced the odds of readmission by 76% (odds ratio, 0.24; 95% confidence interval, 0.13-0.47). CONCLUSIONS: Patients managed by a HF team were more likely to be in CS at admission, to survive to discharge from hospital, and to be initiated on guideline-directed medical therapy with HF follow-up.
CONTEXTE: L'insuffisance cardiaque (IC) est un motif fréquent d'admission à l'unité de soins intensifs de cardiologie. Cette étude visait à cerner le rôle d'un service de consultation spécialisé en IC dans l'amélioration de la prise en charge de la population de patients atteinte de cette affection. MÉTHODOLOGIE: Un recensement de tous les patients adultes admis en 2014-2015 à l'unité de soins intensifs de cardiologie du Réseau universitaire de santé et ayant reçu un diagnostic d'IC aiguë décompensée avec ou sans choc cardiogénique a été effectué. Les caractéristiques cliniques et l'évolution de l'atteinte avaient été consignées pour ces patients. L'association, ajustée en fonction du score de propension, entre la consultation pour IC et la mortalité hospitalière a été calculée. RÉSULTATS: Au total, 285 patients uniques ont été recensés dans la cohorte. De ce nombre, 82 (28,7 %) patients sont décédés. Sur les 285 patients, 150 (52,6 %) avaient été pris en charge conjointement par un service spécialisé en IC, tandis que les 135 (47,3 %) autres ne l'avaient pas été. Les patients pris en charge par une équipe spécialisée en IC étaient plus jeunes (52,5 vs 68,0 ans, p < 0,0001), étaient plus susceptibles d'être en proie à un choc cardiogénique à l'admission (61,3 vs 41,5 %, p < 0,0009) et étaient plus nombreux à avoir reçu un agent vasoactif à l'admission (69,3 % vs 52,6 %, p < 0,005). Ils ont aussi été plus nombreux à être orientés vers une clinique spécialisée en IC à leur sortie de l'hôpital (52,0 % vs 27,5 %, p < 0,0001) et à se voir prescrire un traitement médical recommandé dans des lignes directrices. La mortalité hospitalière était plus faible chez les patients qui ont fait l'objet d'une prise en charge conjointe par une équipe spécialisée en IC (16,7 % vs 42,2 %, p < 0,0001). La consultation d'une équipe spécialisée en IC a en outre réduit le risque de réadmission de 76 % (rapport de cotes de 0,24; intervalle de confiance à 95 % : 0,13-0,47). CONCLUSIONS: Les patients pris en charge par une équipe spécialisée en IC étaient plus susceptibles d'être en proie à un choc cardiogénique à l'admission, de survivre à leur sortie de l'hôpital, de se voir prescrire un traitement médical recommandé dans des lignes directrices et de faire l'objet d'un suivi dans une clinique spécialisée en IC.
RESUMO
BACKGROUND: Vasoplegia has been reported in patients receiving angiotensin receptor-neprilysin inhibitors (ARNI) with heart failure with reduced ejection fraction (HFrEF). We present a case of vasoplegic shock after initiation of ARNI in a hospitalized 65-year-old man recovering from cardiogenic shock (CS) and acute kidney injury (AKI). CASE SUMMARY: A 65-year-old man with HFrEF presented to a community hospital with CS with evidence of poor perfusion with a lactate of 5.6 mmol/L and creatinine (Cr) 125 µmol/L. He was treated with intravenous furosemide infusion. Subsequently, his lactate normalized but he developed an AKI with a Cr of 176 µmol/L. He was then started on ARNI and beta blockers. Over the next 24 h, he developed a vasoplegic shock necessitating multiple vasopressors and a transfer to a tertiary academic centre. With supportive therapy, his vasoplegic shock improved and he was discharged home. DISCUSSION: PARADIGM-HF found that the introduction of an ARNI in patients with ambulatory symptomatic HFrEF reduces the risk of death and heart failure hospitalization. Most recently, PIONEER-HF showed that ARNI reduced N-terminal pro-B-type natriuretic peptide levels at 4 and 8 weeks, without significantly different rates of medication-related adverse effects. However, thus far, no clinical trials have examined the role of ARNI in CS. Our case report highlights the risk of vasoplegic shock caused by initiation of ARNI in patients hospitalized with CS especially in whom renal and hepatic impairment is present.
