Association between dose of catecholamines and markers of organ injury early after out-of-hospital cardiac arrest

Catecholamines are recommended as first-line drugs to treat hemodynamic instability after out-of-hospital cardiac arrest (OHCA). The benefit-to-risk ratio of catecholamines is dose dependent, however, their effect on metabolism and organ function early after OHCA has not been investigated.The Post-Cardiac Arrest Syndrome (PCAS) pilot study was a prospective, observational, multicenter study. The primary outcomes of this analysis were association between norepinephrine/cumulative catecholamines doses and neuron specific enolase (NSE)/lactate concentration over the first 72 hours after resuscitation. The association was adjusted for proven OHCA mortality predictors and verified with propensity score matching (PSM).Overall 148 consecutive OHCA patients; aged 18-91 (62.9 ± 15.27), 41 (27.7%) being female, were included. Increasing norepinephrine and cumulative catecholamines doses were significantly associated with higher NSE concentration on admission (r = 0.477, p0.001; r = 0.418, p0.001) and at 24 hours after OHCA (r = 0.339, p0.01; r = 0.441, p0.001) as well as with higher lactate concentration on admission (r = 0.404, p0.001; r = 0.280, p0.01), at 24 hours (r = 0.476, p0.00; r = 0.487, p0.001) and 48 hours (r = 0.433, p0.01; r = 0.318, p = 0.01) after OHCA. The associations remained significant up to 48 hours in non-survivors after PSM.Increasing the dose of catecholamines is associated with higher lactate and NSE concentration, which may suggest their importance for tissue oxygen delivery, anaerobic metabolism, and organ function early after OHCA

Low molecular weight heparin in surgical valve procedures: When and how much for an optimal prophylaxis?

Background: Periprocedural antithrombotic prophylaxis in patients undergoing surgical valve procedures (SVP) is insufficiently investigated. Low molecular weight heparin (LMWH) has been considered as an alternative to unfractionated heparin (UFH). However, safety and efficacy of this prophylaxis strategy is unknown. This study aimed to investigate safety and efficacy of periprocedural LMWH prophylaxis and determine optimal dosage and timing for periprocedural cessation and initiation.Methods: The present study is a retrospective, single-center observational analysis of 388 patients who underwent SVP (valve replacement or valvuloplasty) between 2015 and 2016. In-hospital endpoints were bleeding, transfusions, reoperation due to bleeding, and thromboembolic events. Results: Giving the first dose of LMWH on the day of SVP was a risk factor for bleeding (OR 1.07; 95% CI 1.04–1.10; p < 0.001), transfusions (OR 1.04; 95% CI 1.01–1.07; p = 0.008) and reoperation due to bleeding (OR 1.20; 95% CI 1.12–1.28; p < 0.001), with > 40 mg/day as a predictor. A higher dosage of LMWH premedication was an independent risk factor for bleeding (OR 1.02; 95% CI 1.00–1.04; p = 0.03) and transfusion (OR 1.03; 95% CI 1.01–1.05; p = 0.01), with > 60 mg/day as a predictor for these events. LMWH dosed within 24 h prior to SVP increased the risk of transfusion (AUC 0.636; 95% CI 0.496–0.762; p = 0.04).Conclusions: Bleeding is an important early concern after surgical valve procedures. Safety and efficacy of periprocedural prophylaxis with LMWH depends on dosage and the timing of its administration. The most optimal periprocedural prophylaxis in the SVP population appears to be LMWH in dosage of 40–60 mg/day, which is recommended for deep vein thrombosis prophylaxis, ceased at least one day before SV

Association between dose of catecholamines and markers of organ injury early after out-of-hospital cardiac arrest

Background: Catecholamines are recommended as first-line drugs to treat hemodynamic instability after out-of-hospital cardiac arrest (OHCA). The benefit-to-risk ratio of catecholamines is dose dependent, however, their effect on metabolism and organ function early after OHCA has not been investigated. Methods: The Post-Cardiac Arrest Syndrome (PCAS) pilot study was a prospective, observational, multicenter study. The primary outcomes of this analysis were association between norepinephrine/cumulative catecholamines doses and neuron specific enolase (NSE)/lactate concentration over the first 72 hours after resuscitation. The association was adjusted for proven OHCA mortality predictors and verified with propensity score matching (PSM). Results: Overall 148 consecutive OHCA patients; aged 18–91 (62.9 ± 15.27), 41 (27.7%) being female, were included. Increasing norepinephrine and cumulative catecholamines doses were significantly associated with higher NSE concentration on admission (r = 0.477, p < 0.001; r = 0.418, p < 0.001) and at 24 hours after OHCA (r = 0.339, p < 0.01; r = 0.441, p < 0.001) as well as with higher lactate concentration on admission (r = 0.404, p < 0.001; r = 0.280, p < 0.01), at 24 hours (r = 0.476, p < 0.00; r = 0.487, p < 0.001) and 48 hours (r = 0.433, p < 0.01; r = 0.318, p = 0.01) after OHCA. The associations remained significant up to 48 hours in non-survivors after PSM. Conclusions: Increasing the dose of catecholamines is associated with higher lactate and NSE concentration, which may suggest their importance for tissue oxygen delivery, anaerobic metabolism, and organ function early after OHCA

Vascular complications after transcatheter aortic valve implantation (TAVI): risk and long-term results

Vascular complications are the main safety limitations of transcatheter aortic valve implantation (TAVI). The aim of the study was to assess the incidents, predictors, and the impact of early vascular complications on prognosis after TAVI. This was a single-center analysis of vascular complications related to TAVI. Early vascular complications were defined as incidents within 30 days after TAVI and comprised complications related to transvascular: transfemoral/transsubclavian ,and transapical bioprosthesis implantation. Evaluated risk factors were: (1) clinical characteristics, (2) TAVI route, and (3) center experience. In patients with transvascular TAVI the impact of: (1) diameters of access arteries, vascular sheathes and difference between them, (2) arterial wall calcification, and (3) ProStar devices used for access site closure were assessed. Arterial wall calcification and arteries diameters were measured by 64-slice computer tomography. Arterial wall calcification was graded according to 5° scale. Results: between 2009–2011; follow-up 1–23 months (12 ± 15.55), 83 consecutive patients, and 62–91 (81.10 ± 7.20) years, underwent TAVI: 67 (80.72 %) patients had transvascular, and 16 (19.27 %) patients had transapical bioprosthesis implantation. We noted 44 (53.01 %) early vascular complications: 17 (20.48 %) were major and 27 (32.53 %) were minor incidents. Independent predictors of early vascular complications were: history of anaemia (OR 3.497: 95 % CI [1.276–9.581]; p = 0.014), diabetes (OR 0.323: 95 % CI [0.108–0.962]; p = 0.042), percutaneous coronary intervention performed as preparation for TAVI (OR 4.809: 95 % CI [1.172–19.736]; p = 0.029), and arterial wall calcification (OR 1.945: 95 % CI [1.063–3.558]; p = 0.03). Of 6 (7.22 %) in-hospital and 10 (12.98 %) late deaths: 5 (83.33 %) patients and 8 (80 %) patients respectively had post-procedural vascular complications. Vascular complications, which occurred in 30-days after TAVI, predict late mortality (p = 0.036). Conclusions derived were: (1) TAVI patients with history of anaemia and diabetes required careful monitoring for early vascular complications. (2) If coronary intervention before TAVI is required, it should be performed in the time allowing vascular injuries to heal. (3) Calcification of access arteries is an independent predictor of post-procedural vascular complications; therefore, its estimation should be a regular element of preceding computer tomography. (4) Vascular complications seem to be predictors of late mortality after TAVI

Acute respiratory failure and inflammatory response after out-of-hospital cardiac arrest:results of the Post-Cardiac Arrest Syndrome (PCAS) pilot study

Background:Although the lungs are potentially highly susceptible to post-cardiac arrest syndrome injury, the issue of acute respiratory failure after out-of-hospital cardiac arrest has not been investigated. The objectives of this analysis were to determine the prevalence of acute respiratory failure after out-of-hospital cardiac arrest, its association with post-cardiac arrest syndrome inflammatory response and to clarify its importance for early mortality.Methods:The Post-Cardiac Arrest Syndrome (PCAS) pilot study was a prospective, observational, six-centre project (Poland 2, Denmark 1, Spain 1, Italy 1, UK 1), studying patients resuscitated after out-of-hospital cardiac arrest of cardiac origin. Primary outcomes were: (a) the profile of organ failure within the first 72 hours after out-of-hospital cardiac arrest; (b) in-hospital and short-term mortality, up to 30 days of follow-up. Respiratory failure was defined using a modified version of the Berlin acute respiratory distress syndrome definition. Inflammatory response was defined using leukocytes (white blood cells), platelet count and C-reactive protein concentration. All parameters were assessed every 24 hours, from admission until 72 hours of stay.Results:Overall, 148 patients (age 62.9 +/- 15.27 years; 27.7% women) were included. Acute respiratory failure was noted in between 50 (33.8%) and 75 (50.7%) patients over the first 72 hours. In-hospital and short-term mortality was 68 (46.9%) and 72 (48.6%), respectively. Inflammation was significantly associated with the risk of acute respiratory failure, with the highest cumulative odds ratio of 748 at 72 hours (C-reactive protein 1.035 (1.001-1.070); 0.043, white blood cells 1.086 (1.039-1.136); 0.001, platelets 1.004 (1.001-1.007); <0.005). Early acute respiratory failure was related to in-hospital mortality (3.172, 95% confidence interval 1.496-6.725; 0.002) and to short-term mortality (3.335 (1.815-6.129); 0.0001).Conclusions:An inflammatory response is significantly associated with acute respiratory failure early after out-of-hospital cardiac arrest. Acute respiratory failure is associated with a worse early prognosis after out-of-hospital cardiac arrest

Current status and needs for changes in critical care training: the voice of the young cardiologists

Aims The implementation of the 2013 European Society of Cardiology (ESC) Core Curriculum guidelines for acute cardiovascular care (acc) training among European countries is unknown. We aimed to evaluate the current status of acc training among cardiology trainees and young cardiologists (<40 years) from ESC countries.Methods and results The survey (March-July 2019) asked about details of cardiology training, self-confidence in acc technical and nontechnical skills, access to training opportunities, and needs for further training in the field. Overall 614 young doctors, 31 (26-43) years old, 55% males were surveyed. Place and duration of acc training differed between countries and between centres in the same country. Although the majority of the respondents (91%) had completed their acc training, the average self-confidence to perform invasive procedures and to manage acc clinical scenarios was low-44% (27.3-70.4). The opportunities for simulation-based learning were scarce-18% (5.8-51.3), as it was previous leadership training (32%) and knowledge about key teamwork principles was poor (48%). The need for further acc training was high-81% (61.9-94.3). Male gender, higher level of training centres, professional qualifications of respondents, longer duration of acc/intensive care training, debriefings, and previous leadership training as well as knowledge about teamwork were related to higher self-confidence in all investigated aspects.Conclusions The current cardiology training program is burdened by deficits in acc technical/non-technical skills, substantial variability in programs across ESC countries, and a clear gender-related disparity in outcomes. The forthcoming ESC Core Curriculum for General Cardiology is expected to address these deficiencies