Artificial intelligence for clinical decision support for monitoring patients in cardiovascular ICUs: a systematic review

Background: Artificial intelligence (AI) and machine learning (ML) models continue to evolve the clinical decision support systems (CDSS). However, challenges arise when it comes to the integration of AI/ML into clinical scenarios. In this systematic review, we followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), the population, intervention, comparator, outcome, and study design (PICOS), and the medical AI life cycle guidelines to investigate studies and tools which address AI/ML-based approaches towards clinical decision support (CDS) for monitoring cardiovascular patients in intensive care units (ICUs). We further discuss recent advances, pitfalls, and future perspectives towards effective integration of AI into routine practices as were identified and elaborated over an extensive selection process for state-of-the-art manuscripts. Methods: Studies with available English full text from PubMed and Google Scholar in the period from January 2018 to August 2022 were considered. The manuscripts were fetched through a combination of the search keywords including AI, ML, reinforcement learning (RL), deep learning, clinical decision support, and cardiovascular critical care and patients monitoring. The manuscripts were analyzed and filtered based on qualitative and quantitative criteria such as target population, proper study design, cross-validation, and risk of bias. Results: More than 100 queries over two medical search engines and subjective literature research were developed which identified 89 studies. After extensive assessments of the studies both technically and medically, 21 studies were selected for the final qualitative assessment. Discussion: Clinical time series and electronic health records (EHR) data were the most common input modalities, while methods such as gradient boosting, recurrent neural networks (RNNs) and RL were mostly used for the analysis. Seventy-five percent of the selected papers lacked validation against external datasets highlighting the generalizability issue. Also, interpretability of the AI decisions was identified as a central issue towards effective integration of AI in healthcare

The Role of Large Impella Devices in Temporary Mechanical Circulatory Support for Patients Undergoing Heart Transplantation

Large microaxial pump systems (Impella 5.0, or Impella 5.5; i.e., Impella 5+) (Abiomed Inc., Danvers, MA, USA) have gained increasing levels of attendance as valuable tools of mechanical circulatory support (MCS). Patients undergoing heart transplantation (HTX) often need temporary MCS in the perioperative course, either as a preoperative bridge or occasionally in the early post-transplant period. Here we present our experience using Impella 5+ support for patients designated to undergo HTX, describe technical aspects of implantation and removal, and further analyze factors influencing the overall patient outcome. Significant factors are discussed in front of the background of contemporary international literature, and current scientific questions are highlighted

Impact of standardized computed tomographic angiography for minimally invasive mitral and tricuspid valve surgery

Background!#!Femoral cannulation for extracorporeal circulation (ECC) is a standard procedure for minimally invasive cardiac surgery (MICS) of the atrio-ventricular valves. Vascular pathologies may cause serious complications. Preoperative computed tomography-angiography (CT-A) of the aorta, axillary and iliac arteries was implemented at our department.!##!Methods!#!Between July 2017 and December 2018 all MICS were retrospectively reviewed (n = 143), and divided into 3 groups.!##!Results!#!In patients without CT (n = 45, 31.5%) ECC was applied via femoral arteries (91.1% right, 8.9% left). Vascular related complications (dissection, stroke, coronary and visceral ischemia, related in-hospital death) occurred in 3 patients (6.7%). In patients with non-contrast CT (n = 35, 24.5%) only femoral cannulation was applied (94.3% right) with complications in 4 patients (11.4%). CT-angiography (n = 63, 44.1%) identified 12 patients (19.0%) with vulnerable plaques, 7 patients (11.1%) with kinking of iliac vessels, 41 patients (65.1%) with multiple calcified plaques and 5 patients (7.9%) with small femoral artery diameter (d ≤ 6 mm). In 7 patients (11.1%) pathologic findings led to alternative cannulation via right axillary artery, additional 4 patients (6.3%) were cannulated via left femoral artery. Only 2 patients (3.2%) suffered from complications.!##!Conclusions!#!CT-A identifies vascular pathologies otherwise undetectable in routine preoperative preparation. A standardized imaging protocol may help to customize the operative strategy

Coronary artery bypass grafting under sole Impella 5.0 support for patients with severely depressed left ventricular function

Selection of the ideal surgical procedure for coronary revascularization in patients with severe cardiac dysfunction at times may represent a challenge. In recent years, with the advent of surgical large microaxial pumps, e.g., Impella 5.0 (Abiomed Inc., Boston, USA), specific support and effective unloading of the left ventricle has become available. In the interventional field, good results have been achieved with smaller microaxial pumps in the setting of so-called protected percutaneous coronary intervention. In this study, we would like to share our early experience with surgical coronary revascularization under the sole support of Impella 5.0, omitting the use of heart-lung machine in three cases of severe cardiac dysfunction due to complex ischemic heart disease. Effective circulatory support intraoperatively and postoperatively speaks in favor of this technique in selected patients

Synthesis and Characterization of Tunable PEG - Gelatin Methacrylate Hydrogels

Poly(ethylene glycol) (PEG) hydrogels are popular for cell culture and tissue-engineering applications because they are nontoxic and exhibit favorable hydration and nutrient transport properties. However, cells cannot adhere to, remodel, proliferate within, or degrade PEG hydrogels. Methacrylated gelatin (GelMA), derived from denatured collagen, yields an enzymatically degradable, photocrosslinkable hydrogel that cells can degrade, adhere to and spread within. To combine the desirable features of each of these materials we synthesized PEG-GelMA composite hydrogels, hypothesizing that copolymerization would enable adjustable cell binding, mechanical, and degradation properties. The addition of GelMA to PEG resulted in a composite hydrogel that exhibited tunable mechanical and biological profiles. Adding GelMA (5%–15% w/v) to PEG (5% and 10% w/v) proportionally increased fibroblast surface binding and spreading as compared to PEG hydrogels (p<0.05). Encapsulated fibroblasts were also able to form 3D cellular networks 7 days after photoencapsulation only within composite hydrogels as compared to PEG alone. Additionally, PEG-GelMA hydrogels displayed tunable enzymatic degradation and stiffness profiles. PEG-GelMA composite hydrogels show great promise as tunable, cell-responsive hydrogels for 3D cell culture and regenerative medicine applications.National Institutes of Health (U.S.) (DE019024)National Institutes of Health (U.S.) (HL099073)National Institutes of Health (U.S.) (EB012597)National Institutes of Health (U.S.) (AR057837)National Institutes of Health (U.S.) (HL092836)National Science Foundation (U.S.) (CAREER award DMR0847287)United States. Office of Naval ResearchEngineer Research and Development Center (U.S.)Construction Engineering Research Laboratories (U.S.

Optimizing Anastomoses Technique in Orthotopic Heart Transplantation: Comparison of Biatrial, Bicaval and Modified Bicaval Technique

Implantation techniques for orthotopic heart transplantation (HTx) have evolved over the centuries. Recently new approaches of modified bicaval techniques to minimize warm ischemia are gaining popularity in the literature. Between 2010 and 2022 n = 238 patients underwent HTx in our department. The recipients were retrospectively reviewed and divided regarding their anastomoses&rsquo; technique. Anastomoses were sutured either in biatrial (n = 37), bicaval (n = 191) or in a modified bicaval (n = 10) manner with suturing of the superior cava vein and A. pulmonalis anastomosis after removing the aortic cross-clamp during the reperfusion. Warm ischemia was 62 &plusmn; 11 min for biatrial, 66 &plusmn; 15 min for bicaval, but only 48 &plusmn; 10 min for modified bicaval technique (p &lt; 0.001). The incidence of severe primary graft dysfunction (PGD) was comparable between biatrial (27.0%) and bicaval (28.8%) anastomoses. In contrast, in patients with modified bicaval technique PGD occurred only in a single patient (10.0%). The incidence of postoperative pacemaker implantation was 18.2% for biatrial compared to 3.0% for bicaval and 0.0% for modified bicaval technique (p = 0.01). The modified bicaval technique enables to decrease the crucial warm ischemia during HTx compared to both biatrial and regular bicaval techniques. Therefore, we strongly recommend bicaval anastomoses, ideally in a modified manner

Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock

Despite the critical feature of heparin-induced thrombocytopenia (HIT) for patients on mechanical circulatory support, reports on its incidence and outcome are still scarce. Thus, we report on clinical features of HIT in patients under Impella 5.0 or 5.5 (Abiomed Inc., Danvers, MA, USA) (Impella 5+) support for acute cardiogenic shock (CS) by focusing on observed thrombotic events. Between November 2018 and December 2020, a total of 56 consecutive patients were enrolled in a single-center retrospective study. A total of 21 patients (37.5%) were tested for HIT, and 6 (10.7%) proved positive for HIT at 10.5 &plusmn; 2.89 days after the first heparin administration during current admission. Interestingly, thrombocyte counts dropped under Impella support in all groups (all cases, no HIT test, and HIT negative group: p &lt; 0.001, HIT-positive group: p = 0.001). All HIT-positive patients were switched from heparin to argatroban. HIT-associated thrombotic events were observed in two cases resulting in Impella dysfunction due to pump thrombosis (n = 1) and left ventricular (LV) thrombus formation (n = 1). Under large Impella support, the prevalence of HIT was relatively high. Further, thrombocytopenia does not deliver a high specificity in the setting of Impella 5+ support. Considering HIT manifestation, a routine HIT test may be considered to avoid critical thrombotic adverse events