Renal Protection and Hemodynamic Improvement by Impella Microaxial Pump in Patients with Cardiogenic Shock

Acute kidney injury is one of the most frequent and prognostically relevant complications in cardiogenic shock. The purpose of this study was to evaluate the potential effect of the Impella® pump on hemodynamics and renal organ perfusion in patients with myocardial infarction complicating cardiogenic shock. Between January 2020 and February 2022 patients with infarct-related cardiogenic shock supported with the Impella® pump were included in this single-center prospective short-term study. Changes in hemodynamics on different levels of Impella® support were documented with invasive pulmonal arterial catheter. As far as renal function is concerned, renal perfusion was assessed by determining the renal resistive index (RRI) using Doppler sonography. A total of 50 patients were included in the analysis. The increase in the Impella® output by a mean of 1.0 L/min improved the cardiac index (2.7 ± 0.86 to 3.3 ± 1.1 p [ 0.001) and increased central venous oxygen saturation (62.6 ± 11.8% to 67.4 ± 10.5% p [ 0.001). On the other side, the systemic vascular resistance (1035 ± 514 N·s/m5 to 902 ± 371 N·s/m5 p = 0.012) and the RRI were significantly reduced (0.736 ± 0.07 to 0.62 ± 0.07 p [ 0.001). Furthermore, in the overall cohort, a baseline RRI ≥ 0.8 was associated with a higher frequency of renal replacement therapy (71% vs. 39% p = 0.04), whereas the consequent reduction of the RRI below 0.7 during Impella® support improved the glomerular filtration rate (GFR) during hospital stay (15 ± 3 days; 53 ± 16 mL/min to 83 ± 16 mL/min p = 0.04). Impella® support in patients with cardiogenic shock seems to improve hemodynamics and renal organ perfusion. The RRI, a well-known parameter for the early detection of acute kidney injury, can be directly influenced by the Impella flow rate. Thus, a targeted control of the RRI by the Impella® pump could mediate renal organ protection

Monitoring a Mystery: The Unknown Right Ventricle during Left Ventricular Unloading with Impella in Patients with Cardiogenic Shock

Background: Right ventricular (RV) dysfunction or failure occurs in more than 30% of patients in cardiogenic shock (CS). However, the importance of timely diagnosis of prognostically relevant impairment of RV function is often underestimated. Moreover, data regarding the impact of mechanical circulatory support like the Impella on RV function are rare. Here, we investigated the effects of the left ventricular (LV) Impella on RV function. Moreover, we aimed to identify the most optimal and the earliest applicable parameter for bedside monitoring of RV function by comparing the predictive abilities of three common RV function parameters: the pulmonary artery pulsatility index (PAPi), the ratio of right atrial pressure to pulmonary capillary wedge pressure (RA/PCWP), and the right ventricular stroke work index (RVSWI). Methods: The data of 50 patients with CS complicating myocardial infarction, supported with different flow levels of LV Impella, were retrospectively analyzed. Results: Enhancing Impella flow (1.5 to 2.5 L/min ± 0.4 L/min) did not lead to a significant variation in PAPi (p = 0.717), RA/PCWP (p = 0.601), or RVSWI (p = 0.608), indicating no additional burden for the RV. PAPi revealed the best ability to connect RV function with global hemodynamic parameters, i.e., cardiac index (CI; p p = 0.005, 95% CI: −6.721–−1.26), central venous pressure (CVP; p 2); p = 0.008, 95% CI: 1.096–7.196). Conclusions: LV Impella does not impair RV function. Moreover, PAPi seems to be to the most effective and valid predictor for early bedside monitoring of RV function

Outcomes after transcatheter aortic valve replacement in older patients

Background!#!The prevalence of aortic valve stenosis is increasing due to the continuously growing geriatric population. Data on procedural success and mortality of very old patients are sparse, raising the question of when this population may be deemed as 'too old even for transcatheter aortic valve replacement (TAVR).' We, therefore, sought to evaluate the influence of age on outcome after TAVR and the impact of direct implantation.!##!Methods!#!The data of 394 consecutive patients undergoing TF-TAVR were analyzed. Patients were divided into four age groups: ≤75 (group 1, n = 28), 76-80 (group 2, n = 107), 81-85 (group 3, n = 148), and >85 (group 4, n = 111) years. Direct implantation was performed when possible according to current recommendations. Survival was evaluated by Kaplan-Meier analysis.!##!Results!#!Mortality at 30 days and 1 year was not significantly different between the four age groups (3.6 vs. 6.7 vs. 5.4 vs. 2.7% and 7.6 vs. 17 vs. 14.5 vs. 13%m respectively, log-rank p = 0.59). Direct implantation without balloon aortic valvuloplasty was more frequently performed on patients aged >85 vs. ≤85 years (33.3 vs. 14.1%, p < 0.001). the incidence of procedural complications frequently associated with advanced age (stroke, vascular complications) was not significantly increased in group 4.!##!Conclusion!#!Outcome after TF-TAVR is comparable among different age cohorts, even in very old patients. Direct implantation simplifies the procedure and could therefore play a role in reducing the incidence of peri-interventional complications in patients of advanced age

Renal Protection and Hemodynamic Improvement by Impella^® Microaxial Pump in Patients with Cardiogenic Shock

Acute kidney injury is one of the most frequent and prognostically relevant complications in cardiogenic shock. The purpose of this study was to evaluate the potential effect of the Impella® pump on hemodynamics and renal organ perfusion in patients with myocardial infarction complicating cardiogenic shock. Between January 2020 and February 2022 patients with infarct-related cardiogenic shock supported with the Impella® pump were included in this single-center prospective short-term study. Changes in hemodynamics on different levels of Impella® support were documented with invasive pulmonal arterial catheter. As far as renal function is concerned, renal perfusion was assessed by determining the renal resistive index (RRI) using Doppler sonography. A total of 50 patients were included in the analysis. The increase in the Impella® output by a mean of 1.0 L/min improved the cardiac index (2.7 ± 0.86 to 3.3 ± 1.1 p p 5 to 902 ± 371 N·s/m5p = 0.012) and the RRI were significantly reduced (0.736 ± 0.07 to 0.62 ± 0.07 p p = 0.04), whereas the consequent reduction of the RRI below 0.7 during Impella® support improved the glomerular filtration rate (GFR) during hospital stay (15 ± 3 days; 53 ± 16 mL/min to 83 ± 16 mL/min p = 0.04). Impella® support in patients with cardiogenic shock seems to improve hemodynamics and renal organ perfusion. The RRI, a well-known parameter for the early detection of acute kidney injury, can be directly influenced by the Impella® flow rate. Thus, a targeted control of the RRI by the Impella® pump could mediate renal organ protection

Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival

Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p 6 mmol/L, vasoactive score > 100 and pH 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels

Ergebnisse nach Transkatheter-Aortenklappenersatz bei älteren Patienten

$\bf Background$ The prevalence of aortic valve stenosis is increasing due to the continuously growing geriatric population. Data on procedural success and mortality of very old patients are sparse, raising the question of when this population may be deemed as "too old even for transcatheter aortic valve replacement (TAVR)". We, therefore, sought to evaluate the influence of age on outcome after TAVR and the impact of direct implantation. $\bf Methods$ The data of 394 consecutive patients undergoing TF-TAVR were analyzed. Patients were divided into four age groups: ≤75 (group 1, $\it n$ = 28), 76–80 (group 2, $\it n$ = 107), 81–85 (group 3, $\it n$ = 148), and >85 (group 4, $\it n$ = 111) years. Direct implantation was performed when possible according to current recommendations. Survival was evaluated by Kaplan–Meier analysis. $\bf Results$ Mortality at 30 days and 1 year was not significantly different between the four age groups (3.6 vs. 6.7 vs. 5.4 vs. 2.7% and 7.6 vs. 17 vs. 14.5 vs. 13%m respectively, log-rank $\it p$ = 0.59). Direct implantation without balloon aortic valvuloplasty was more frequently performed on patients aged >85 vs. ≤85 years (33.3 vs. 14.1%, $\it p$ < 0.001). the incidence of procedural complications frequently associated with advanced age (stroke, vascular complications) was not significantly increased in group 4. \ (\bf Conclusion\) Outcome after TF-TAVR is comparable among different age cohorts, even in very old patients. Direct implantation simplifies the procedure and could therefore play a role in reducing the incidence of peri-interventional complications in patients of advanced age.$\bf Hintergrund$ Die Prävalenz der Aortenklappenstenose steigt durch eine kontinuierlich wachsende geriatrische Bevölkerung. Daten über prozeduralen Erfolg sowie Mortalität von sehr alten Patienten sind gering, sodass sich die Frage stellt, wann diese Population "als bereits zu alt" für einen Transkatheter-Aortenklappenersatz (TAVR) anzusehen wäre. Ziel dieser Studie war es, den Einfluss der direkten Implantation auf die Ergebnisse nach transfemoraler (TF-)TAVR bei Patienten in fortgeschrittenem Alter zu evaluieren. $\bf Methoden$ Dazu wurden die Daten von 394 konsekutiven Patienten nach TF-TAVR ermittelt. Die Patienten wurden in 4 Altersgruppen eingeteilt: ≤75 Jahre (Gruppe 1, $\it n$ = 28), 76–80 Jahre (Gruppe 2, $\it n$ = 107), 81–85 Jahre (Gruppe 3, $\it n$ = 148) und >85 Jahre (Gruppe 4, $\it n$ = 111). Sofern es die aktuellen Empfehlungen erlaubten, wurde eine direkte Implantation durchgeführt. Das Überleben wurde mittels Kaplan–Meier-Analyse evaluiert. $\bf Ergebnisse$ Zwischen den 4 Altersgruppen waren keine signifikanten Unterschiede der Mortalität nach 30 Tagen und nach einem Jahr zu verzeichnen (entsprechend 3,6 vs. 6,7 vs. 5,4 vs. 2,7 % und 7,6 vs. 17 vs. 14,5 vs. 13 %; $\it p$ = 0,59 für Log-Rank-Test). Eine direkte Implantation ohne Ballonvalvuloplastie wurde bei Patienten >85 Jahre häufiger durchgeführt als ≤85 Jahre (33,3 vs. 14,1 %; $\it p$ < 0,001). Die Inzidenz von häufig mit fortgeschrittenem Patientenalter assoziierten prozeduralen Komplikationen (Schlaganfall, vaskuläre Komplikationen) war in der Gruppe 4 nicht signifikant erhöht. $\bf Schlussfolgerung$ In verschiedenen Alterskollektiven zeigen sich vergleichbare Ergebnisse nach TF-TAVR, dies gilt sogar für Patienten sehr hohen Alters. Die direkte Implantation kann die Prozedur vereinfachen und zu einer konsekutiven Reduktion der Inzidenz von periprozeduralen Komplikationen bei Patienten mit fortgeschrittenem Alter führen

Clinical Significance of Germline Cancer Predisposing Variants in Unselected Patients with Pancreatic Adenocarcinoma

Our aim was to determine the prevalence, prognostic and predictive role of germline pathogenic/likely pathogenic variants (P/LPVs) in cancer predisposing genes in patients with pancreatic ductal adenocarcinoma (PDAC). Germline testing of 62 cancer susceptibility genes was performed on unselected patients diagnosed from 02/2003 to 01/2020 with PDAC, treated at Hellenic Cooperative Oncology Group (HeCOG)-affiliated Centers. The main endpoints were prevalence of P/LPVs and overall survival (OS). P/LPVs in PDAC-associated and homologous recombination repair (HRR) genes were identified in 22 (4.0%) and 42 (7.7%) of 549 patients, respectively. P/LPVs were identified in 16 genes, including ATM (11, 2.0%) and BRCA2 (6, 1.1%), while 19 patients (3.5%) were heterozygotes for MUTYH P/LPVs and 9 (1.6%) carried the low-risk allele, CHEK2 p.(Ile157Thr). Patients carrying P/LPVs had improved OS compared to non-carriers (22.6 vs. 13.9 months, p = 0.006). In multivariate analysis, there was a trend for improved OS in P/LPV carriers (p = 0.063). The interaction term between platinum exposure and mutational status of HRR genes was not significant (p-value = 0.35). A significant proportion of patients with PDAC carries clinically relevant germline P/LPVs, irrespectively of age, family history or disease stage. The predictive role of these P/LPVs has yet to be defined. ClinicalTrials.gov Identifier: NCT03982446