Predictors of weaning failure in case of VA ECMO implantation.

The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a "weaning test" (ECMO flow < 2 L/min for at least 60 min). ECMO removal was left to the discretion of the medical team blinded to the results. Weaning failure was defined as a patient who died or required a new VA ECMO, heart transplant or LVAD 30 days after ECMO removal. Thirty-six patients (63.2%) were successfully weaned off VA ECMO, of whom 31 (54.4%) after the first weaning test. In case of first test failure, 3 out of 7 patients could be weaned after a 2nd test and 3 out of 4 patients after a 3rd test. Pre-existing ischemic heart disease (OR 9.6 [1.1-83]), pre-test left ventricular ejection fraction (LVEF) ≤ 25% and/or post-test LVEF ≤ 40% (OR 11 [0.98-115]), post-test systolic blood pressure ≤ 120 mmHg (OR 33 [3-385]), or length of ECMO support > 7 days (OR 24 [2-269]) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.

Successful Reversal of Severe Tachycardia-Induced Cardiomyopathy with Cardiogenic Shock by Urgent Rhythm or Rate Control: Only Rhythm and Rate Matter.

Background and objectives Severe forms of Tachycardia-induced cardiomyopathy (TIC) with cardiogenic shock are not well described so far, and efficiency of catheter ablation in this setting is unknown. Methods We retrospectively included consecutive patients admitted to the Intensive Cardiac Care Unit for acute heart failure with cardiogenic shock associated with atrial arrhythmia and managed by ablation. Result Fourteen patients were included, each with cardiogenic shock and two needing the use of extracorporeal membrane oxygenation. Successful ablation was performed in the acute setting or over the following weeks. Two patients experienced relapses of arrhythmias and were treated by new ablation procedures. At 7.5 ± 5 months follow-up, all patient were alive with stable sinus rhythm. The left ventricular Ejection Fraction dramatically improved (21 vs. 54%, p = 0.001) as well as the end-diastolic left ventricular diameter (61 vs. 51 mm, p = 0.01) and NYHA class (class IV in all vs. median 1, p = 0.002). Conclusion Restoration and maintenance of sinus rhythm in severe TIC with cardiogenic shock and atrial arrhythmias lead to a major increase or normalization of LVEF, reduction of ventricular dimensions, and improvement in functional status. Ablation is efficient in long-term maintenance of sinus rhythm and may be proposed early in refractory cases.

Prevalence and Prognosis Impact of Frailty Among Older Adults in Cardiac Intensive Care Units.

BACKGROUND: Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU. METHODS: This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7. RESULTS: A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group. CONCLUSIONS: Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.

CONTEXTE: On ignore si la fragilité, définie comme un syndrome biologique reflétant une diminution des réserves physiologique et une vulnérabilité au stress, impacte le pronostic des sujets âgés admis en unité de soins intensifs cardiologiques (USIC). Notre objectif était de déterminer la prévalence de la fragilité et son impact sur la mortalité chez les sujets âgés de 80 ans ou plus admis en USIC. MÉTHODOLOGIE: Il s'agit d'une étude prospective monocentrique observationnelle conduite sur les patients de 80 ans ou plus admis en USIC dans un centre tertiaire. La fragilité a été évaluée par l'échelle de fragilité d'Edmonton (EFS) qui donne un score allant de 0 (pas fragile) à 17 (très fragile). La population a été divisé en 3 classes : score EFS de 0 à 3, score EFS de 4 à 6, et score EFS de > 7. RÉSULTATS: Cent quatre-vingt-dix-neuf patients ont été inclus avec un suivi médian de 365 jours. L'âge moyen était de 84,8 ans. Cinquante patients (25,1 %) sont décédés au cours de la période de suivi. Quarante-cinq patients (22,6 %) avaient un score EFS de 0 à 3, 60 patients (30,2 %) avaient un score EFS de 4 à 6 et 94 patients (47,2 %) avaient un score EFS de ≥ 7. Les taux de mortalité toutes causes étaient de 4,4 % dans la classe de score EFS de 0 à 3, 27,1 % dans la classe de score EFS de 4 à 6 et 37,2 % dans la classe de score EFS de ≥ 7, (p < 0.001). En analyse multivariée, la fragilité demeurait associée avec la mortalité toutes causes : le rapport de risques instantanés (RRI) était à 2,60 (intervalle de confiance [IC] à 95 % [0,54 - 12,45]) dans la classe de score EFS de 4 à 6, et le RRI était à 5,46 (IC à 95 % [1,23 - 24,08]) dans la classe de score EFS de ≥ 7. CONCLUSION: La fragilité est fortement prévalente dans la population des sujets âgés admis en USIC et constitue un facteur pronostique fort de mortalité toutes causes à un an.