Impact of Right Ventricular Performance in Patients Undergoing Extracorporeal Membrane Oxygenation Following Cardiac Surgery

Background: Extracorporeal membrane oxygenation following cardiac surgery safeguards end‐organ oxygenation but unfavorably alters cardiac hemodynamics. Along with the detrimental effects of cardiac surgery to the right heart, this might impact outcome, particularly in patients with preexisting right ventricular (RV) dysfunction. We sought to determine the prognostic impact of RV function and to improve established risk‐prediction models in this vulnerable patient cohort. Methods and Results: Of 240 patients undergoing extracorporeal membrane oxygenation support following cardiac surgery, 111 had echocardiographic examinations at our institution before implantation of extracorporeal membrane oxygenation and were thus included. Median age was 67 years (interquartile range 60‐74), and 74 patients were male. During a median follow‐up of 27 months (interquartile range 16‐63), 75 patients died. Fifty‐one patients died within 30 days, 75 during long‐term follow‐up (median follow‐up 27 months, minimum 5 months, maximum 125 months). Metrics of RV function were the strongest predictors of outcome, even stronger than left ventricular function (P<0.001 for receiver operating characteristics comparisons). Specifically, RV free‐wall strain was a powerful predictor univariately and after adjustment for clinical variables, Simplified Acute Physiology Score‐3, tricuspid regurgitation, surgery type and duration with adjusted hazard ratios of 0.41 (95%CI 0.24‐0.68; P=0.001) for 30‐day mortality and 0.48 (95%CI 0.33‐0.71; P<0.001) for long‐term mortality for a 1‐SD (SD=−6%) change in RV free‐wall strain. Combined assessment of the additive EuroSCORE and RV free‐wall strain improved risk classification by a net reclassification improvement of 57% for 30‐day mortality (P=0.01) and 56% for long‐term mortality (P=0.02) compared with the additive EuroSCORE alone. Conclusions: RV function is strongly linked to mortality, even after adjustment for baseline variables and clinical risk scores. RV performance improves established risk prediction models for short‐ and long‐term mortality

Blood count in new onset atrial fibrillation after acute myocardial infarction - A hypothesis generating study

Background & objectives: Atrial fibrillation (AF) is a common complication after acute myocardial infarction (AMI) and associated with increased morbidity and mortality. Previous studies identified high white and red blood cell count as potential risk factors for new onset AF. The objective of this retrospective, nested case-control study was to examine the association of different parameters of the blood count with the development of new onset of AF after AMI. Methods: A total of 66 consecutive patients with new onset AF after AMI and 132 sex and age matched controls were enrolled into the study and analyzed whether parameters of the blood count, including leukocytes, platelets, haemoglobin, haematocrit or erythrocyte count, are associated with the occurrence of AF after AMI. All AMI patients had undergone coronary angiography. Results: Patients with post-AMI AF displayed significantly higher levels of haemoglobin (14.2 g/dl, IQR 12.4-15 vs. 12.9 g/dl, IQR 11.7-13.8; P< 0.001), haematocrit (41.7 %, IQR 36.6-44.3 vs. 38.7 %, IQR 34.7-41.5; P 0.0015), and erythrocyte count (4.6 T/l, IQR 4.1-5 vs. 4.2 T/l, IQR 3.9-4.65; P< 0.001). In the unadjusted and adjusted logistic regression analysis, the blood parameters most strongly associated with the outcome were serum haemoglobin (crude OR 2.20, 95% CI 1.40- 3.47, P 0.001; adjusted OR 3.82, 95% CI 1.71- 8.54, P 0.001) and erythrocyte count (crude OR 2.10, 95% CI 1.36-3.22, P 0.001; adjusted OR 3.79, 95% CI 1.73- 8.33, P 0.001), whereas haematocrit did not reach statistical significance. Interpretation & conclusions: This study shows a significant independent association between serum haemoglobin, haematocrit, erythrocyte count and occurrence of AF after AMI. However, the pathophysiologic mechanism underlying these associations and its potential clinical applicability need to be further elucidated

Patient Selection and Clinical Indication for Chronic Total Occlusion Revascularization—A Workflow Focusing on Non-Invasive Cardiac Imaging

Percutaneous coronary intervention of chronic total occlusion (CTO PCI) is a challenging procedure with high complication rates and, as not yet fully understood long-term clinical benefits. Ischemic symptom relief in patients with high ischemic burden is to date the only established clinical indication to undergo CTO PCI, supported by randomized controlled trials. In this context, current guidelines suggest attempting CTO PCI only in non-invasively assessed viable CTO correspondent myocardial territories, with large ischemic areas. Hence, besides a comprehensive coronary angiography lesion evaluation, the information derived from non-invasive cardiac imaging techniques is crucial to selecting candidates who may benefit from the revascularization of the occluded vessel. Currently, there are no clear recommendations for a non-invasive myocardial evaluation or choice of imaging modality pre-CTO PCI. Therefore, selecting among available options is left to the physician’s discretion. As CTO PCI is strongly recommended to be carried out explicitly in experienced centers, full access to non-invasive imaging for risk-benefit assessment as well as a systematic institutional evaluation process has to be encouraged. In this framework, we opted to review the current myocardial imaging tools and their use for indicating a CTO PCI. Furthermore, based on our experience, we propose a cost-effective systematic approach for myocardial assessment to help guide clinical decision-making for patients presenting with chronic total occlusions

Wiener klinische Wochenschrift / Abnormal maternal echocardiographic findings in triplet pregnancies presenting with dyspnoea

Objective The objective of our study was to evaluate the prevalence of abnormal maternal echocardiographic findings in triplet pregnancies presenting with dyspnoea. Study design Between 2003 and 2013, patients records of 96 triplet pregnancies at our department were analysed including maternal and fetal outcome, echocardiographic parameters and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. After exclusion of triplet pregnancies with fetal demise before 23+0 weeks, selective feticide or missing outcome data, the study population consisted of 60 triplet pregnancies. All women with dyspnoea underwent echocardiography and measurement of NT-proBNP. Results Dyspnoea towards the end of pregnancy was observed in 13.3% (8/60) of all women with triplet pregnancies, and all of these women underwent echocardiography. The prevalence of abnormal echocardiographic findings in women with dyspnoea was 37.5% (3/8) with peripartum cardiomyopathy in one woman. Median serum NT-proBNP was significantly higher in women with abnormal echocardiographic findings compared with those without (1779 ng/ml, range 10456076 ng/ml vs 172 ng/ml, range 50311 ng/ml; p<0.001 by Mann-Whitney-U Test). Conclusion We conclude that triplet pregnancies presenting with dyspnoea show a high prevalence of abnormal echocardiographic findings. Since dyspnoea is a common sign in triplet pregnancies and is associated with a high rate of cardiac involvement, echocardiography and evaluation of maternal NT-proBNP could be considered to improve early diagnosis and perinatal management.(VLID)346205

Left Main Coronary Artery Disease and Outcomes after Percutaneous Coronary Intervention for Chronic Total Occlusions

BACKGROUND Concomitant left main coronary artery (LMCA) disease in patients with chronic total occlusions (CTO) commonly results in referral for coronary artery bypass grafting, although the impact of LMCA in CTO patients remains largely unknown. Nevertheless, patient selection for percutaneous coronary intervention of CTOs (CTO-PCI) or alternative revascularization strategies should be based on precise evaluation of the coronary anatomy to anticipate those patients that most likely benefit from a procedure and not on strict adherence to perpetual clinical practice. Therefore, the aim of this study was to assess the impact of LMCA disease on long-term outcomes in patients undergoing percutaneous coronary intervention for CTO. METHODS We enrolled 3860 consecutive patients undergoing PCI for at least one CTO lesion and investigated the predictive value of concomitant LMCA disease. All-cause mortality was defined as the primary study endpoint. RESULTS We observed that LMCA disease is significantly associated with mortality. In the Cox regression analysis, we observed a crude hazard ratio (HR) 1.59 (95% confidence interval (CI) 1.23-2.04, p < 0.001) for patients with LMCA disease as compared to patients without. Results remained unchanged after bootstrap- or clinical confounder-based adjustment. CONCLUSION LMCA disease is associated with excess mortality in CTO patients. Specifically, anatomical features such as CTO of the circumflex artery represent a high risk patient population