Houston SHOCK: A Practical Scoring System Incorporating Cardiogenic Shock Dynamic Changes

Cardiogenic shock has an unacceptably high mortality rate and additional tools are needed to improve outcomes. The Society of Cardiovascular Angiography and Interventions (SCAI) shock severity classification has provided a unified definition of shock severity that has proven to be reproducible and predictive of survival. However, cardiogenic shock assessment goes beyond standardizing its severity, and a uniform and practical approach to comprehensive assessment that may guide therapy in a dynamic state is currently lacking. Since cardiogenic shock is a rapidly evolving pathophysiological catastrophe, we propose a new assessment tool – the Houston SHOCK Score – which incorporates dynamic changes. The acronym SHOCK can be used to emphasize five key aspects of patients in cardiogenic shock: Severity, Hemodynamics, Onset, Causes, and Kinetics. We believe this tool provides physicians with vital information that will facilitate appropriate care by incorporating dynamic changes in the patient’s profile

India, Germany and Europe: a Spatial Perspective at SDG 3 on Good Health and Well-Being

Responding to crucial challenges in urban and rural development led the United Nations decide on the New Urban Agenda as well as the 2030 Agenda and the Sustainable Development Goals (SDGs). In order to understand the spatial patterns, which SDGs produce, a national and supranational spatial perspective is taken on SDG 3 “Good health and Well-Being”. Progress in health concomitantly affects several pathways of development in a country. Persistent improvements in the life expectancy at birth ascertain significant progress towards health care in any country. The development in the respective health system is validated by improving health-related indicators, such as institutional deliveries, infant and child mortality rates, full immunisation and nutrition. Sub-goal 3.7 addresses the universal access to sexual and reproductive health care services, including family planning, information and education. Adolescent pregnancy leading to teenage parenthood is an obviously global concern affecting low- and high-income countries in the same way. Alternating maps illustrate the spatial perspective on SDG 3 in India, Germany and Europe by taking manifold national as well as supranational views wherever feasible

India, Germany and Europe: a Spatial Perspective at SDG 4 on Quality Education

Responding to crucial challenges in urban and rural development led the United Nations decide on the New Urban Agenda as well as the 2030 Agenda and the Sustainable Development Goals (SDGs). In order to understand the spatial patterns, which SDGs produce, a national and supranational spatial perspective is taken on SDG 4 "Quality Education". SDG 4 highlights the human right on education and requests institutions to ensure inclusive and equal access to education for all. In many countries, one can note gender differences related to schooling at all levels or at graduation. Education in general and the education of females in particular influences largely the social and economic development of countries, ranging from health and birth control to a higher economic output of enterprises lead by mixed teams. The chapters visualise the spatial analysis of SDG 4, respectively on school graduates, female school graduates and scholar exclusion. Alternating maps illustrate the spatial perspective on SDG 4 in India, Germany and Europe by taking manifold national as well as supranational views wherever feasible

Outcomes of Transcatheter Aortic Valve Replacement in Patients With Cardiogenic Shock

AIMS: The safety and efficacy of transcatheter aortic valve replacement (TAVR) with contemporary balloon expandable transcatheter valves in patients with cardiogenic shock (CS) remain largely unknown. In this study, the TAVRs performed for CS between June 2015 and September 2022 using SAPIEN 3 and SAPIEN 3 Ultra bioprosthesis from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were analysed. METHODS AND RESULTS: CS was defined as: (i) coding of CS within 24 h on Transcatheter Valve Therapy Registry form; and/or (ii) pre-procedural use of inotropes or mechanical circulatory support devices and/or (iii) cardiac arrest within 24 h prior to TAVR. The control group was comprised of all the other patients undergoing TAVR. Baseline characteristics, all-cause mortality, and major complications at 30-day and 1-year outcomes were reported. Landmark analysis was performed at 30 days post-TAVR. Cox-proportional multivariable analysis was performed to determine the predictors of all-cause mortality at 1 year. A total of 309 505 patients underwent TAVR with balloon-expandable valves during the study period. Of these, 5006 patients presented with CS prior to TAVR (1.6%). The mean Society of Thoracic Surgeons score was 10.76 ± 10.4. The valve was successfully implanted in 97.9% of patients. Technical success according to Valve Academic Research Consortium-3 criteria was 94.5%. In a propensity-matched analysis, CS was associated with higher in-hospital (9.9% vs. 2.7%), 30-day (12.9% vs. 4.9%), and 1-year (29.7% vs. 22.6%) mortality compared to the patients undergoing TAVR without CS. In the landmark analysis after 30 days, the risk of 1-year mortality was similar between the two groups [hazard ratio (HR) 1.07, 95% confidence interval (CI) 0.95-1.21]. Patients who were alive at 1 year noted significant improvements in functional class (Class I/II 89%) and quality of life (ΔKCCQ score +50). In the multivariable analysis, older age (HR 1.02, 95% CI 1.02-1.03), peripheral artery disease (HR 1.25, 95% CI 1.06-1.47), prior implantation of an implantable cardioverter-defibrillator (HR 1.37, 95% CI 1.07-1.77), patients on dialysis (HR 2.07, 95% CI 1.69-2.53), immunocompromised status (HR 1.33, 95% CI 1.05-1.69), New York Heart Association class III/IV symptoms (HR 1.50, 95% CI 1.06-2.12), lower aortic valve mean gradient, lower albumin levels, lower haemoglobin levels, and lower Kansas City Cardiomyopathy Questionnaire scores were independently associated with 1-year mortality. CONCLUSION: This large observational real-world study demonstrates that the TAVR is a safe and effective treatment for aortic stenosis patients presenting with CS. Patients who survived the first 30 days after TAVR had similar mortality rates to those who were not in CS

Improved outcomes in the treatment of post-myocardial infarction ventricular septal defect with percutaneous TandemHeart left ventricular mechanical circulatory support

Background Post-myocardial infarction (MI) ventricular septal defect (VSD) is associated with 40% - 50% of peri-procedural mortalities; however, it is amenable to catheter-based therapies. We retrospectively investigated the impact of state-of-the-art bridging percutaneous left ventricular mechanical circulatory support (MCS) using the TandemHeart® (TH) ventricular assist device (VAD) on a patient with post-MI VSD. Results From July 2008 to March 2014, 23 patients were referred for treatment of post-MI VSD. Initially, 18/23 patients required MCS; 12 received an intra-aortic balloon pump (IABP), while 6 received initial TH support. Seven of the IABP patients later required TH support. Catheter-based device VSD closure was performed in 18 of the patients; however, three patients required conversion to conventional open cardiac surgical repair via VSD patch closure due to failure of the catheter-based approach. Five patients with TH underwent planned open cardiac surgical repair due to an anticipated lack of suitability for catheter-based treatment. Results revealed that delayed closure after MI correlated with improved survival. Overall, 30-day and 6-month survival rates were 83% (19/23) and 70% (16/23), respectively. Conclusions Further, Qp/Qs ratios of \u3c2.4 correlated with successful percutaneous VSD repair, and this assessment should be further explored as an assessment to inform clinical judgment in patients with post-MI VSD treatment

Adverse Events in Continuous-Flow LVAD Recipients: Gastrointestinal Bleeding is Still Notable?

Background: The etiology and risk factors associated with gastrointestinal bleeding (GIB) in patients with continuous-flow left ventricular assist devices (CF-LVADs) are currently unknown. Therefore, we sought to assess the risk factors for GIB in these patients. Design and Methods: This was a retrospective, non-randomized, non-controlled study at a single center. Between 2012 and 2014, 65 men and 6 women (mean age = 55 ± 12 years) underwent CF-LVAD implantation at our institution. Overall, 23.9% of patients (17/71) had at least one GIB episode. Endoscopy confirmed GIB in 13/17. Arteriovenous malformation was the major GIB source in 8/13 (61%). There was no significant difference in incidence of GIB with regard to INTERMACS profile, blood type, or device type—HeartWare vs. HeartMateII. All our patients with GIB were men, most had hyperlipidemia, and most likely had ischemic cardiomyopathy (65%) and peripheral vascular disease (24%). The only significant risk factor for GIB was chronic kidney disease (odds ratio= 3.95; 95% confidence interval of 1.21 to 12.84; p=0.02). At the time of the first GIB, mean hemoglobin was 7.38 ± 1.06 g/dl, international normalized ratio was 2.08 ± 0.69 IU, and mean arterial pressure was 75 ± 12 mmHg. Ten patients (59%) required hospital admission for treatment. Conclusion: In our patients GIB was often a single event and often occurred within first month after implantation. Prevention strategies should be focused on this vulnerable period, especially in patients with chronic kidney disease

Clinicopathological correlations in heart transplantation recipients complicated by death or re-transplantation.

Purpose This study aimed to identify and correlate pathological findings with clinical outcomes in patients after orthotopic heart transplantation (OHT) who either died or underwent a re-transplantation. Methodology and study design Single-center retrospective analysis of primary OHT patients who died or were re-transplanted between October 2012 and July 2021. Clinical data were matched with corresponding pathological findings from endomyocardial biopsies on antibody-mediated rejection, cellular rejection, and cardiac allograft vasculopathy. Re-assessment of available tissue samples was performed to investigate acute myocardial injury (AMI) as a distinct phenomenon. These were correlated with clinical outcomes, which included severe primary graft dysfunction. Patients were grouped according to the presence of AMI and compared. Results We identified 47 patients with truncated outcomes after the first OHT. The median age was 59 years, 36 patients (76%) were male, 25 patients (53%) had a prior history of cardiac operation, and 21 patients (45%) were supported with a durable assist device before OHT. Of those, AMI was identified in 22 (47%) patients (AMI group), and 25 patients had no AMI (non-AMI group). Groups were comparable in baseline and perioperative data. Histopathological observations in AMI group included a non-significant higher incidence of antibody-mediated rejection Grade 1 or higher (pAMR ≥ 1) (32% vs. 12%, P = 0.154), and non-significant lower incidence of severe acute cellular rejection (ACR ≥ 2R) (32% vs. 40%, P = 0.762). Clinical observations in the AMI group found a significantly higher occurrence of severe primary graft dysfunction (68% vs. 20%, P = 0.001) and a highly significant shorter duration from transplantation to death or re-transplantation (42 days [IQR 26, 120] vs. 1,133 days [711-1,664], P < 0.0001). Those patients had a significantly higher occurrence of cardiac-related deaths (64% vs. 24%, P = 0.020). No difference was observed in other outcomes. Conclusion In heart transplant recipients with a truncated postoperative course leading to either death or re-transplantation, AMI in endomyocardial biopsies was a common pathological phenomenon, which correlated with the clinical occurrence of severe primary graft dysfunction. Those patients had significantly shorter survival times and higher cardiac-related deaths. The presence of AMI suggests a truncated course after OHT

The emerging spectrum of cardiopulmonary pathology of the coronavirus disease 2019 (COVID-19): Report of 3 autopsies from Houston, Texas, and review of autopsy findings from other United States cities

This paper collates the pathological findings from initial published autopsy reports on 23 patients with coronavirus disease 2019 (COVID-19) from 5 centers in the United States of America, including 3 cases from Houston, Texas. Findings confirm that COVID-19 is a systemic disease with major involvement of the lungs and heart. Acute COVID-19 pneumonia has features of a distinctive acute interstitial pneumonia with a diffuse alveolar damage component, coupled with microvascular involvement with intra- and extravascular fibrin deposition and intravascular trapping of neutrophils, and, frequently, with formation of microthombi in arterioles. Major pulmonary thromboemboli with pulmonary infarcts and/or hemorrhage occurred in 5 of the 23 patients. Two of the Houston cases had interstitial pneumonia with diffuse alveolar damage pattern. One of the Houston cases had multiple bilateral segmental pulmonary thromboemboli with infarcts and hemorrhages coupled with, in nonhemorrhagic areas, a distinctive interstitial lymphocytic pneumonitis with intra-alveolar fibrin deposits and no hyaline membranes, possibly representing a transition form to acute fibrinous and organizing pneumonia. Multifocal acute injury of cardiac myocytes was frequently observed. Lymphocytic myocarditis was reported in 1 case. In addition to major pulmonary pathology, the 3 Houston cases had evidence of lymphocytic pericarditis, multifocal acute injury of cardiomyocytes without inflammatory cellular infiltrates, depletion of splenic white pulp, focal hepatocellular degeneration and rare glomerular capillary thrombosis. Each had evidence of chronic cardiac disease: hypertensive left ventricular hypertrophy (420 g heart), dilated cardiomyopathy (1070 g heart), and hypertrophic cardiomyopathy (670 g heart). All 3 subjects were obese (BMIs of 33.8, 51.65, and 35.2 Kg/

Management of Patients with Refractory Cardiogenic Shock and Cardiointestinal Syndrome with Impella 5.5 as Bridge to Decision: Case Series

Patients with advanced heart failure require multi-system management as a majority succumb to end-organ dysfunction, including gastrointestinal sequelae. Temporizing measures, such as early mechanical circulatory support, can assist in the recovery of patients with acute cardiogenic shock. The temporary support can improve patient characteristics to enable future definitive heart failure therapies such as durable left ventricular assist devices and orthotopic heart transplantation. We present two cases of cardiogenic shock that were successfully bridged with an Impella 5.5 (Abiomed). The management enabled the patients to recover from reversible cardiointestinal syndrome and undergo successful definitive therapies