Management of Post-cardiotomy Shock.

Patients undergoing cardiac surgery experience significant physiologic derangements that place them at risk for multiple shock phenotypes. Any combination of cardiogenic, obstructive, hemorrhagic, or vasoplegic shock occurs commonly in post-cardiotomy patients. The approach to the diagnosis and management of these shock states has many facets that are distinct compared to non-surgical cardiac intensive care unit patients.

Optimizing outcomes: Impact of palliative care consultation timing in the cardiovascular intensive care unit.

Background: ICU patients and their families experience significant stress due to illness severity and prognostic uncertainty, making palliative care (PC) integral for symptom management, family support, and end-of-life care goals. The impact of PC in the Cardiac Intensive Care Unit (CICU) remains unstudied.

Objective: We explore the impact of early palliative care consultation (PCC) on patient outcomes in the CICU, including mortality, length of stay, and family meeting frequency.

Management of the peri-intubation period in patients with pulmonary arterial hypertension and respiratory failure.

Purpose Of Review: The endotracheal intubation of patients with pulmonary arterial hypertension (PAH) in respiratory distress is a highly morbid procedure that can precipitate hemodynamic collapse. Here we review our strategy for confronting this difficult clinical situation.

Recent Findings: There are no clinical trials that explore best practices in the management of patients with PAH and respiratory failure.

Shock Teams: A Contemporary Review.

Purpose Of Review: Cardiogenic shock (CS) is a time-sensitive and often fatal condition. To address this issue, many centers have developed multidisciplinary shock teams with a common goal of expediting the recognition and treatment of CS. In this review, we examine the mission, structure, implementation, and outcomes reported by these early shock teams.

Management of Mechanical Prosthetic Heart Valve Thrombosis: JACC Review Topic of the Week.

Mechanical prosthetic heart valves, though more durable than bioprostheses, are more thrombogenic and require lifelong anticoagulation. Mechanical valve dysfunction can be caused by 4 main phenomena: 1) thrombosis; 2) fibrotic pannus ingrowth; 3) degeneration; and 4) endocarditis. Mechanical valve thrombosis (MVT) is a known complication with clinical presentation ranging from incidental imaging finding to cardiogenic shock.

The Role of Echocardiography in Extracorporeal Membrane Oxygenation.

Purpose Of Review: Extracorporeal membrane oxygenation (ECMO) is increasingly used to temporarily support patients in severe circulatory and/or respiratory failure. Echocardiography is a core component of successful ECMO deployment. Herein, we review the role of echocardiography at different phases on extracorporeal support including candidate identification, cannulation, maintenance, complication vigilance, and decannulation.

Critical Care Cardiology Trials Network (CCCTN): a cohort profile.

Aims: The aims of the Critical Care Cardiology Trials Network (CCCTN) are to develop a registry to investigate the epidemiology of cardiac critical illness and to establish a multicentre research network to conduct randomised clinical trials (RCTs) in patients with cardiac critical illness.

Methods And Results: The CCCTN was founded in 2017 with 16 centres and has grown to a research network of over 40 academic and clinical centres in the United States and Canada. Each centre enters data for consecutive cardiac intensive care unit (CICU) admissions for at least 2 months of each calendar year.

Ventilatory Ratio Is a Valuable Prognostic Indicator in an Observational Cohort of Patients With ARDS.

Background: How indices specific to respiratory compromise contribute to prognostication in patients with ARDS is not well characterized in general clinical populations. The primary objective of this study was to identify variables specific to respiratory failure that might add prognostic value to indicators of systemic illness severity in an observational cohort of subjects with ARDS.

Methods: Fifty subjects with ARDS were enrolled in a single-center, prospective, observational cohort.

Impella Management for the Cardiac Intensivist.

The Impella mechanical circulatory support (MCS) system is a catheter-based continuous flow cardiac assist device that is widely used in the treatment of cardiogenic shock in medical and surgical cardiac intensive care units. As with all forms of MCS, device-related complications remain a major concern, the incidence of which can be mitigated by adhering to a few fundamental concepts in device management. The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter.

Management and Outcomes of Cardiogenic Shock in Cardiac ICUs With Versus Without Shock Teams.

Background: Single-center studies suggest that implementation of multidisciplinary cardiogenic shock (CS) teams is associated with improved CS survival.

Objectives: The aim was to characterize practice patterns and outcomes in the management of CS across multiple centers with versus without shock teams.

Methods: The Critical Care Cardiology Trials Network is a multicenter network of cardiac intensive care units (CICUs) in North America.

Pulmonary Dead Space Monitoring: Identifying Subjects With ARDS at Risk of Developing Right Ventricular Dysfunction.

Background: ARDS is a highly morbid condition characterized by diffuse pulmonary inflammation, which results in hypoxemic respiratory failure. Approximately 25% of patients with ARDS develop right ventricular dysfunction, with cor pulmonale being a common final pathway in a significant number of non-survivors. ARDS-related right ventricular dysfunction occurs due to acute elevation in ventricular afterload caused by mechanisms that are associated with increased pulmonary dead space fraction.

Noninvasive estimation of pulmonary vascular resistance improves portopulmonary hypertension screening in liver transplant candidates.

Despite limitations in sensitivity and specificity, estimation of the pulmonary artery systolic pressure (ePASP) on echocardiography is used for portopulmonary hypertension (PoPH) screening in liver transplant (LT) candidates. We proposed that alternative echocardiographic models, such as estimated pulmonary vascular resistance (ePVR), may provide improved testing characteristics in PoPH screening. In a retrospective analysis of 100 LT candidates, we found that the formula ePVR = ePASP/VTI  + 3 if MSN (VTI  = right ventricular outflow tract time velocity integral; MSN = mid-systolic notching of the VTI Doppler signal) significantly improves accuracy of PoPH screening compared to ePASP.

Incidence of new cardiovascular events in patients with and without peripheral arterial disease seen in a vascular surgery clinic.

Background: To investigate the incidence of death and of new cardiovascular events at long-term follow-up of patients with and without PAD seen in a vascular surgery clinic.

Material/methods: We investigated the incidence of death, new stroke/transient ischemic attack, new myocardial infarction, new coronary revascularization, new carotid endarterectomy, new peripheral arterial disease (PAD) revascularization, or at least one of the above outcomes at long-term follow-up of patients with and without PAD followed in a vascular surgery clinic.

Results: At least one of the above outcomes occurred in 259 of 414 patients (63%) with PAD at 33-month follow-up and in 21 of 89 patients (24%) without PAD at 48-month follow-up (p<0.