Cardiogenic shock (CS) describes a physiological state of end-organ hypoperfusion characterized by reduced cardiac output in the presence of adequate intravascular volume. Mortality still remains exceptionally high. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has become the preferred device for short-term hemodynamic support in patients with CS. ECMO provides the highest cardiac output, complete cardiopulmonary support. In addition, the device has portable characteristics, more familiar to medical personnel. VA ECMO provides cardiopulmonary support for patients in profound CS as a bridge to myocardial recovery. This review provides an overview of VA ECMO in salvage of CS, emphasizing the indications, management and further direction.
Objective To investigate the predictive value of extracorporeal membrane oxygenation (ECMO) pre-computer multiple scoring systems in the mortality of patients with cardiogenic shock. Methods A retrospective analysis was performed on 100 patients with cardiogenic shock due to various reasons who were treated with veno-arterial ECMO (VA-ECMO) from July 2020 to July 2022. The patients were followed up for 30 days and divided into a survival group (35 cases) and a death group (65 cases) according to whether they survived 30 days after withdrawal. General clinical data, blood biochemistry data within 24 hours before ECMO, ventilator parameters, past medical history and other data were collected, and sequential organ failure score (SOFA) before VA-ECMO, acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), survival after veno-arterial ECMO (SAVE) score and modified SAVE score were calculated. Blood biochemical indicators and clinical scores related to patient prognosis were screened using two-independent sample t test or Man-Whitney U test. The predictive efficacy of each score on short-term prognosis (30-day post-discharge mortality) was evaluated by receiver operating characteristic curve and area under curve (AUC). Results There were significant differences in APACHEⅡ score, SAVE score and modified SAVE score between two groups (P<0.05). The AUC and its 95%CI of APACHEⅡ score was 0.696 (95%CI 0.592 - 0.801), of SAVE score was 0.617 (95%CI 0.498 - 0.736), and of post SAVE score was 0.664 (95%CI 0.545 - 0.782), respectively. All AUCs were relatively low (<0.75). Conclusion SOFA, APACHEⅡ, SAVE score and modified SAVE score have limited clinical value in the prognosis assessment of ECMO patients, and do not show obvious advantages.
Objective To investigate multi-slice spiral CT (MSCT) and MRI features of stasis cirrhosis and the diagnostic value of MSCT and MRI. Methods MSCT and MRI findings of 35 patients with stasis cirrhosis were studied. The size of liver and spleen, the diameter of hepatic vein (HV), enhancement pattern of liver parenchyma, contrast medium reflux in inferior vena cava (IVC) and (or) HV, ascites, number of varices and correlated abnormalities were reviewed. Results The volume index of liver and spleen of 35 patients was 4434.95 cm3 and 621.92 cm3 respectively. The mean diameter of HV of 27 patients (77.1%) was 3.61 cm and HV of other 8 patients (22.9%) were too small to show. Number of patients showed waves of borderline, inhomogeneous pattern of parenchymal contrast enhancement, contrast medium reflux in IVC and (or) HV, varices and ascites was 5 (14.3%), 29 (82.9%), 20 (57.1%), 16 (45.7%), and 6 (17.1%), respectively. Correlated abnormalities included cardiac enlargement 〔4 cases (11.4%)〕, pericardium thickening 〔11 cases (31.4%)〕, and pericardial effusion 〔2 cases (5.7%)〕. Conclusions Stasis cirrhosis mainly demonstrate liver enlargement, inhomogeneous pattern of parenchymal contrast enhancement, contrast medium reflux in IVC and (or) HV, and slight portal hypertension. MSCT and MRI play invaluable roles in diagnosis, differential diagnosis and etiological diagnosis of stasis cirrhosis.
Objective To explore the clinical effects of emergency transcatheter aortic replacement (TAVR) on the treatment of patients with acute refractory heart failure or cardiogenic shock secondary to severe aortic stenosis during hospitalization. Methods The study selected 44 patients from 8 heart valve centers from January 2018 to January 2021. All patients received emergency TAVR treatment. The patients’ baseline clinical data, cardiac ultrasound indicators, and postoperative hospital stay were collected. Paired t-test and McNemar test were used to compare and analyze the preoperative and postoperative cardiac ultrasound indexes, moderate to severe aortic stenosis, and cardiac function. Results The average age of the patients was (72.0±7.9) years. Valve displacement occurred in one patient during the operation, and the surgical success rate was 97.7%. Four cases died during hospitalization, and the mortality rate was 9.1%. The median length of hospital stay was 11.5 d. The postoperative aortic valve area was significantly higher than that before surgery [(0.5±0.2) vs. (3.8±1.6) mm2, P<0.05], the mean transvalvular pressure of the aortic valve was significantly lower than that before operation [(64.0±24.9) vs. (11.3±4.6) mm Hg (1 mm Hg=0.133 kPa), P<0.05], the peak aortic flow velocity was significantly lower than that before operation [(4.5±0.7) vs. (1.9±0.7) m/s, P<0.05], the left ventricular end diastolic inner diameter was lower than that before operation [(59.0±7.2) vs. (56.1±7.3) mm, P<0.05], the left ventricular ejection fraction increased significantly compared with that before operation [(30.1±10.4)% vs. (40.9±11.0)%, P<0.05], and the cardiac function improved significantly compared with that before operation (P<0.05). During the operation, 2 cases (4.5%) underwent valve-in-valve implantation, 11 cases (25.0%) underwent percutaneous coronary intervention during the same period. During the postoperative hospital stay, 1 case (2.3%) developed stroke, 3 cases (6.8%) experienced severe bleeding, 5 cases (11.4%) had severe vascular complications, 2 cases (4.5%) experienced acute myocardial infarction, 30 cases (68.2%) had small or trace paravalvular regurgitation, 3 cases (6.8%) received permanent pacemaker implantation, and 5 cases (11.4%) developed acute kidney injury. Conclustion Emergency TAVR is an effective and feasible treatment plan for patients with acute refractory heart failure or cardiogenic shock secondary to severe aortic stenosis.
Objective To summarize the efficacy and clinical experiences of emergent coronary artery bypass grafting (E-CABG) in patients with acute myocardial infarction (AMI) and to discuss the operative opportunity and procedures. Methods We retrospectively analyzed the clinical data of 21 patients with AMI undergoing E-CABG in Sun Yatsen Cardiovascular Disease Hospital between June 1999 and December 2009. Among the patients, there were 14 males and 7 females with their age ranged from 24 to 81 years (63.9±12.4 years). Six patients were operated within 6 hours after the onset of AMI, 7 patients were operated from 6 hours to 3 days after the onset of AMI, and 8 patients were operated from 3 days to 30 days after the onset of AMI. Eight patients had the cardiogenic shock after AMI, one had rupture of ventricular septum and cardiogenic shock, two had rupture of coronary artery after percutaneous transluminal coronary angioplasty, eight had unstable angina and frequent ventricular arrhythmia, one had ventricular fibrillation and cardiac arrest, and one had cardiac trauma. Ten patients were treated with intraaortic balloon pump (IABP). Conventional CABG was performed for 12 patients, off-pump CABG for 5 patients, and on-pump-beating CABG for 4 patients. Results Five patients died after E-CABG with a mortality of 23.8% which was obviously higher than the overall CABG mortality (23.8% vs. 3.1%, χ2=21.184, P＜0.05). There were respectively 2, 2 and 1 deaths with a mortality of 33.3%, 28.6% and 12.5% respectively for operations within 6 hours, 6 hours to 3 days and 3 to 30 days after the onset of AMI. The mortality of those patients who were operated within 3 days after AMI was obviously lower (P＜0.05). The primary causes of death were low cardiac output syndrome, perioperative acute myocardial infarction after CABG and sapremia. There was one death each for patients operated with off-pump and on-pump-beating CABG. Sixteeen patients were discharged from the hospital. The follow-up was from 6 months to 10 years. There were 6 late deaths among which 5 died of cardiac failure accompanied by pulmonary infection, one died of noncardiac factor. Ten patients survived at present, and the quality of life among 5 patients was unsatisfactory. Conclusion The mortality of E-CABG is obviously higher in patients operated within 3 days of AMI. With the support of IABP, if the operation can be carried out 3 days after the onset of AMI, the surgical success rate will be greatly improved by adopting proper offpump and onpumpbeating procedures.
Objective To investigate the clinical efficacy and safety of intravenous thrombolysis bridging endovascular thrombectomy (EVT) in patients with acute cardioembolic stroke. Methods We retrospectively included patients with cardioembolic stroke who were admitted within 24 h after onset of stroke symptoms and had received EVT in the Department of Neurology, West China Hospital of Sichuan University between January 2017 and December 2021. Based on whether they had received intravenous thrombolysis, the patients were divided into bridging therapy group and direct EVT group. The primary outcome was unfavorable outcome by 3 months, defined as a modified Rankin Scale (mRS) score of 3 to 6. The secondary outcomes included intracranial hemorrhage during hospitalization and 3-month death. Multivariable logistic regression was performed to assess the treatment effect on the primary outcome after adjusting for confounding factors. Results A total of 285 patients were enrolled. Among them, 174 (61.1%) were female, the median age was 74 years (interquartile range 64-80 years), and the median time from stroke onset to admission was 4.0 h (interquartile range 3.0-5.0 h). Compared to patients in the direct EVT group (n=202), patients in the bridging therapy group (n=83) had a lower rate of unfavorable functional outcome (55.4% vs 68.3%, P=0.039) by 3 months, while the incidences of intracranial hemorrhage (47.0% vs. 39.6%, P=0.251) and 3-month death (20.5% vs. 30.7%, P=0.080) were comparable between the two groups. After adjusting for confounding factors, the bridging therapy improved 3-month functional outcomes over direct EVT [odds ratio=0.482, 95% confidence interval (0.249, 0.934), P=0.031]. Conclusion In patients with acute cardioembolic stroke, intravenous thrombolysis bridging endovascular treatment can significantly improve 3-month functional outcomes without increasing the risk of intracranial hemorrhage.
ObjectiveTo systematically review the early clinical prediction value of machine learning (ML) for cardiac arrest (CA).MethodsPubMed, EMbase, WanFang Data and CNKI databases were electronically searched to retrieve all ML studies on predicting CA from January 2015 to February 2021. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. The value of each model was evaluated based on the area under receiver operating characteristic curve (AUC) and accuracy.ResultsA total of 38 studies were included. In terms of data sources, 13 studies were based on public database, and other studies retrospectively collected clinical data, in which 21 directly predicted CA, 3 predicted CA-related arrhythmias, and 9 predicted sudden cardiac death. A total of 51 models had been adopted, among which the most popular ML methods included artificial neural network (n=11), followed by random forest (n=9) and support vector machine (n=5). The most frequently used input feature was electrocardiogram parameters (n=20), followed by age (n=12) and heart rate variability (n=10). Six studies compared the ML models with other traditional statistical models and the results showed that the AUC value of ML was generally higher than that in traditional statistical models.ConclusionsThe available evidence suggests that ML can accurately predict the occurrence of CA, and the performance is significantly superior to traditional statistical model in certain cases.