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Wang Z, Jia E, Sun Z, Zhang P, Chen Y, Feng X. Miniaturized Designs of Implantable and Wireless Hemodynamic Pressure Monitoring Capsules. IEEE Trans Biomed Eng 2025; 72:1585-1595. [PMID: 40030516 DOI: 10.1109/tbme.2024.3513333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2025]
Abstract
OBJECTIVE Hemodynamic pressure (HP) monitoring is critical for managing cardiovascular diseases. Clinical Doppler echocardiography and invasive catheter monitoring cannot realize remote continuous monitoring in daily life. Current implantable wireless equipment depends on custom chips or indirect sensing, presenting challenges in cost-effective and precise applications. Here, we present systematic design strategies for implantable, wireless, and battery-free capsule-like HP monitoring under near and middle-distance circumstances. METHODS The systems were composed of completely non-customized devices, with extremely compact volumes (<0.4 cm3). Near-distance monitoring utilized Near Field Communication with a piezoresistive sensor and foldable circuit designs. Middle-distance monitoring employed dual-winding antennas based on magnetic resonance (∼600 kHz) and Bluetooth. The power feedback circuit was optimized through human model electromagnetic simulations. Validation involved in vitro and in vivo experiments. RESULTS Near-distance system achieved 0.35 mmHg omnidirectional pressure accuracy under 5 mm tissue shielding. Middle-distance system attained the longest wireless power transfer distance (7.5 cm) via electromagnetic fields, supporting a capacitive sensor with 0.4 mmHg accuracy. In vitro tests in artificial tissue demonstrated stable data/energy transfer, accommodating axial misalignments up to ±45°. In vivo experiments on the beagle demonstrated real-time, wireless monitoring of left atrial pressure, whose rhythm synchronized with electrocardiograph recordings. The interatrial septum interventional installation was also validated. CONCLUSION The wireless and implantable capsules enable near and middle-distance hemodynamic pressure monitoring, even in dynamic swinging intracardiac situations. and has been validated in animal experiments. SIGNIFICANCE The designs provide a universal method for in vivo fully-implantable pressure monitor development.
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Luk A, Barker M, Billia P, Fordyce CB, So D, Tsang M, Potter BJ. ECLS-SHOCK and DanGer Shock: Implications for Optimal Temporary Mechanical Circulatory Support Use for Cardiogenic Shock Due to Acute Myocardial Infarction. Can J Cardiol 2025; 41:691-704. [PMID: 39824437 DOI: 10.1016/j.cjca.2025.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Revised: 01/08/2025] [Accepted: 01/08/2025] [Indexed: 01/20/2025] Open
Abstract
Despite concerted efforts to rapidly identify patients with cardiogenic shock complicating acute myocardial infarction (AMI-CS) and provide timely revascularization, early mortality remains stubbornly high. Although artificially augmenting systemic flow by using temporary mechanical circulatory support (tMCS) devices would be expected to reduce the rate of progression to multiorgan dysfunction and thereby enhance survival, reliable evidence for benefit has remained elusive with lingering questions regarding the appropriate selection of both patients and devices, as well as the timing of device implantation relative to other critical interventions. Further complicating matters are the resource-intensive multidisciplinary systems of care that must be brought to bear in this complex patient population. Until recently, studies of tMCS were extremely heterogeneous in design, populations treated, and timing of device implantation with regard to shock onset and revascularization. Attempts at summarizing the available data had resulted in a lack of clear benefit for any type of tMCS modality. On this background, 2 landmark trials of tMCS in the setting of AMI-CS---ECLS-SHOCK and DanGer Shock---have recently been published with divergent results that deserve detailed consideration. Thus, we provide a detailed narrative review of the current state of knowledge regarding tMCS for AMI-CS. The most common types of tMCS and related evidence are presented, as well as evidence for organizational considerations, such as the shock team. We also provide some insight into how this new evidence may be incorporated into practice and influence future research.
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Affiliation(s)
- Adriana Luk
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Madeleine Barker
- Emory University Hospital, Emory School of Medicine, Atlanta, Georgia, USA; Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Phyllis Billia
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Christopher B Fordyce
- Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Derek So
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Tsang
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Brian J Potter
- University of Montréal Hospital Centre, Cardiovascular Centre & Research Centre, University of Montréal, Montréal, Québec, Canada.
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Jaffe AT, Pallarès-López R, Raines JK, Aguirre AD, Anthony BW. Noninvasive Quantitative Compression Ultrasound Central Venous Pressure: A Clinical Pilot Study. BME FRONTIERS 2025; 6:0115. [PMID: 40110344 PMCID: PMC11922486 DOI: 10.34133/bmef.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Revised: 01/03/2025] [Accepted: 02/24/2025] [Indexed: 03/22/2025] Open
Abstract
Objective: This is an initial study to validate central venous pressure (CVP) measurements derived from quantitative compression ultrasound (QCU). Impact Statement: This study is the first gold standard invasive validation of CVP estimation from QCU. Introduction: QCU finds the collapse force-the force required for complete occlusion-of the short axis of the internal jugular vein (IJV) to estimate CVP. Methods: We captured QCU data as well as the noninvasive clinical standard jugular venous pulsation height (JVP) on cardiac intensive care unit (CICU) patients at Massachusetts General Hospital (MGH). We compared these data to ground truth invasive CVP data from the MGH CICU. Results: Using linear regression, we correlated invasive CVP with collapse force (r 2: 0.82, error: 1.08 mmHg) and with JVP (r 2: 0.45, error: 1.39 mmHg). To directly compare our method to JVP, we measured the percentage of patients whose uncertainty estimates for QCU methods and for JVP overlapped with their invasive CVP counterparts. We found that the CVP overlap accuracy of collapse force (77.8%) and of collapse force and hydrostatic offset (88.9%) are higher than that of JVP (12.5%). Finally, we input QCU image segmentation data of the short-axis cross-sections of the IJV and carotid artery into an inverse finite element model to predict the invasive CVP waveform. Conclusion: These results validate the noninvasive technique for estimating CVP, namely, QCU, indicating that it may provide a desirable, middle-ground alternative to invasive catheterization and to visual inspection of the JVP.
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Affiliation(s)
- Alex T Jaffe
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Roger Pallarès-López
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jeffrey K Raines
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Aaron D Aguirre
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian W Anthony
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
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Ataş İ, Yazıcı MM, Hamdioğlu E, Parça N, Kaçan M, Yavaşi Ö, Bilir Ö. Ultrasonographic Evaluation of Hypervolemic and Normovolemic Patients: A Comparison of Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameters and Collapsibility Indices. Cureus 2025; 17:e77488. [PMID: 39958133 PMCID: PMC11827922 DOI: 10.7759/cureus.77488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2025] [Indexed: 02/18/2025] Open
Abstract
Background and objective We aimed to determine the diameters and respiratory variability of the subclavian vein (SCV), internal jugular vein (IJV), and femoral vein (FV), which are more superficial and easier to visualize with point-of-care ultrasound (PoCUS) in the detection of volume overload, and to investigate whether they can be an alternative to analyzing an inferior vena cava (IVC) to determine volume load. Methodology We prospectively evaluated volume-overloaded and normovolemic patients admitted to the emergency department using PoCUS for six months. Inspiratory-expiratory diameters and collapsibility indices (CI) of IVC and SCV, IJV, and FV were evaluated. The correlation between IVC and SCV, IJV, and FV was analyzed. Results A total of 176 patients were included in the study, including 88 volume-overloaded patients in the study group and 88 normovolemic patients in the control group. The median values of the maximum and minimum diameters of the IVC, SCV, IJV, and FV in the study group were statistically higher compared to the control group. A moderate correlation was found between IVC and SCV, IVC and IJV, and IVC and FV for maximum diameters in all patients (p = 0.447, p = 0.515, and p = 450, respectively). There was a very weak correlation between the IVC-CI and the FV-CI in all patients (p = 0.160), and no correlation was found with the other veins. Conclusion The IVC-CI was not correlated with the SCV-CI, the IJV-CI, or the FV-CI in volume-overloaded patients; therefore, superficial venous vessels cannot be an alternative to the IVC.
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Affiliation(s)
- İsmail Ataş
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, TUR
| | - Mümin Murat Yazıcı
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, TUR
| | - Enes Hamdioğlu
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, TUR
| | - Nurullah Parça
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, TUR
| | - Meryem Kaçan
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, TUR
| | - Özcan Yavaşi
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, TUR
| | - Özlem Bilir
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, Rize, TUR
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Callejas Pastor CA, Oh C, Hong B, Ku Y. Machine Learning-Based Cardiac Output Estimation Using Photoplethysmography in Off-Pump Coronary Artery Bypass Surgery. J Clin Med 2024; 13:7145. [PMID: 39685605 DOI: 10.3390/jcm13237145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Revised: 11/06/2024] [Accepted: 11/22/2024] [Indexed: 12/18/2024] Open
Abstract
Background/Objectives: Hemodynamic monitoring is crucial for managing critically ill patients and those undergoing major surgeries. Cardiac output (CO) is an essential marker for diagnosing hemodynamic deterioration and guiding interventions. The gold standard thermodilution method for measuring CO is invasive, prompting a search for non-invasive alternatives. This pilot study aimed to develop a non-invasive algorithm for classifying the cardiac index (CI) into low and non-low categories using finger photoplethysmography (PPG) and a machine learning model. Methods: PPG and continuous thermodilution CO data were collected from patients undergoing off-pump coronary artery bypass graft surgery. The dataset underwent preprocessing, and features were extracted and selected using the Relief algorithm. A CatBoost machine learning model was trained and evaluated using a validation and testing phase approach. Results: The developed model achieved an accuracy of 89.42% in the validation phase and 87.57% in the testing phase. Performance was balanced across low and non-low CO categories, demonstrating robust classification capabilities. Conclusions: This study demonstrates the potential of machine learning and non-invasive PPG for accurate CO classification. The proposed method could enhance patient safety and comfort in critical care and surgical settings by providing a non-invasive alternative to traditional invasive CO monitoring techniques. Further research is needed to validate these findings in larger, diverse patient populations and clinical scenarios.
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Affiliation(s)
- Cecilia A Callejas Pastor
- Research Institute for Medical Sciences, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
| | - Yunseo Ku
- Department of Biomedical Engineering, Chungnam National University College of Medicine, Daejeon 35015, Republic of Korea
- Medical Device Research Center, Department of Biomedical Research Institute, Chungnam National University Hospital, Daejeon 35015, Republic of Korea
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Li Y, Zhu Y, Fu L, Luo L, She Y. Association between intra-arterial catheterization and mortality of acute heart failure patients without shock in ICU: A retrospective study. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 45:100432. [PMID: 39188416 PMCID: PMC11345900 DOI: 10.1016/j.ahjo.2024.100432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/28/2024] [Accepted: 07/22/2024] [Indexed: 08/28/2024]
Abstract
Background Acute heart failure necessitates intensive care, and arterial catheterization is a commonly performed invasive procedure in the intensive care unit (ICU). We aimed to investigate the association between arterial catheterization and outcomes in acute heart failure patients without shock. Methods We utilized MIMIC-IV database records for acute heart failure patients at Beth Israel Deaconess Medical Center from 2008 to 2019. Employing doubly robust estimation, we examined the relationship between arterial catheterization and outcomes, including 28-day, 90-day, in-hospital mortality, and ICU-free days within 28 days. Results Of 6936 patients identified, 2078 met inclusion criteria; 347 underwent arterial catheterization during their ICU stay. We observed no significant difference in 28-day mortality (odds ratio [OR]: 0.61, 95 % confidence interval [CI]: 0.31-1.21, P = 0.155), though catheterization was associated with reduced in-hospital mortality (OR: 0.41, 95 % CI: 0.14-0.65, P = 0.02). No significant effects were observed on 90-day mortality or ICU-free days within 28 days. Conclusion Our findings suggest that arterial catheterization is not associated with 28- and 90-day mortality rates in acute heart failure patients without shock but is linked to lower in-hospital mortality. Additional research and consensus are required to determine the appropriate utilization of arterial catheterization in patients.
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Affiliation(s)
- Yide Li
- Department of Critical Care Medicine, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Yuan Zhu
- Department of Critical Care Medicine, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Le Fu
- Department of Critical Care Medicine, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Liang Luo
- Department of Critical Care Medicine, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Yingfang She
- Neurology Medicine Center, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
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Adhyapak SM, Konda A, K T T, Shivakumar, Varghese K. Right heart catheterization in idiopathic pulmonary hypertension: An all-inclusive necessity. Curr Probl Cardiol 2024; 49:102642. [PMID: 38750992 DOI: 10.1016/j.cpcardiol.2024.102642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 05/12/2024] [Indexed: 05/19/2024]
Abstract
The gold standard for diagnosis of pulmonary hypertension is right heart catheterization. This procedure requires considerable expertise and has its own procedure related complications. If not done properly, it can lead to misinterpretations of its findings. We have highlighted the procedural technique and major pitfalls in the diagnosis of pulmonary hypertension.
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Affiliation(s)
- Srilakshmi M Adhyapak
- Department of Cardiology, St. John's medical College Hospital, Bangalore 560034, India.
| | - Abhilash Konda
- Department of Cardiology, St. John's medical College Hospital, Bangalore 560034, India
| | - Thirumal K T
- Department of Cardiology, St. John's medical College Hospital, Bangalore 560034, India
| | - Shivakumar
- Department of Cardiology, St. John's medical College Hospital, Bangalore 560034, India
| | - Kiron Varghese
- Department of Cardiology, St. John's medical College Hospital, Bangalore 560034, India
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Chinedozi ID, Boskamp E, Darby Z, Kang JK, Rando H, Sair H, Pitt J, Wilcox C, Kim BS, Khanduja S, Whitman G, Cho SM. Point-of-Care Bedside Brain Magnetic Resonance Imaging Is Safe in Extracorporeal Membrane Oxygenation Patients With Swan Ganz Catheters: A Phantom Experiment and Single Center Experience. J Surg Res 2024; 299:290-297. [PMID: 38788465 DOI: 10.1016/j.jss.2024.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION More than 1.2 million pulmonary artery catheters (PACs) are used in cardiac patients per annum within the United States. However, it is contraindicated in traditional 1.5 and 3T magnetic resonance imaging (MRI) scans. We aimed to test preclinical and clinical safety of using this imaging modality given the potential utility of needing it in the clinical setting. METHODS We conducted two phantom experiments to ensure that the electromagnetic field power deposition associated with bare and jacketed PACs was safe and within the acceptable limit established by the Food and Drug Administration. The primary end points were the safety and feasibility of performing Point-of-Care (POC) MRI without imaging-related adverse events. We performed a preclinical computational electromagnetic simulation and evaluated these findings in nine patients with PACs on veno-arterial extracorporeal membrane oxygenation. RESULTS The phantom experiments showed that the baseline point specific absorption rate through the head averaged 0.4 W/kg. In both the bare and jacketed catheters, the highest net specific absorption rates were at the neck entry point and tip but were negligible and unlikely to cause any heat-related tissue or catheter damage. In nine patients (median age 66, interquartile range 42-72 y) with veno-arterial extracorporeal membrane oxygenation due to cardiogenic shock and PACs placed for close hemodynamic monitoring, POC MRI was safe and feasible with good diagnostic imaging quality. CONCLUSIONS Adult ECMO patients with PACs can safely undergo point-of-care low-field (64 mT) brain MRI within a reasonable timeframe in an intensive care unit setting to assess for acute brain injury that might otherwise be missed with conventional head computed tomography.
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Affiliation(s)
| | | | - Zachary Darby
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Jin Kook Kang
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Hannah Rando
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Haris Sair
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland
| | - John Pitt
- Hyperfine Research, Guilford, Connecticut
| | | | - Bo Soo Kim
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Shivalika Khanduja
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sung-Min Cho
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland.
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Bronicki RA, Tume S, Gomez H, Dezfulian C, Penny DJ, Pinsky MR, Burkhoff D. Application of Cardiovascular Physiology to the Critically Ill Patient. Crit Care Med 2024; 52:821-832. [PMID: 38126845 DOI: 10.1097/ccm.0000000000006136] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To use the ventricular pressure-volume relationship and time-varying elastance model to provide a foundation for understanding cardiovascular physiology and pathophysiology, interpreting advanced hemodynamic monitoring, and for illustrating the physiologic basis and hemodynamic effects of therapeutic interventions. We will build on this foundation by using a cardiovascular simulator to illustrate the application of these principles in the care of patients with severe sepsis, cardiogenic shock, and acute mechanical circulatory support. DATA SOURCES Publications relevant to the discussion of the time-varying elastance model, cardiogenic shock, and sepsis were retrieved from MEDLINE. Supporting evidence was also retrieved from MEDLINE when indicated. STUDY SELECTION, DATA EXTRACTION, AND SYNTHESIS Data from relevant publications were reviewed and applied as indicated. CONCLUSIONS The ventricular pressure-volume relationship and time-varying elastance model provide a foundation for understanding cardiovascular physiology and pathophysiology. We have built on this foundation by using a cardiovascular simulator to illustrate the application of these important principles and have demonstrated how complex pathophysiologic abnormalities alter clinical parameters used by the clinician at the bedside.
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Affiliation(s)
- Ronald A Bronicki
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Sebastian Tume
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Hernando Gomez
- Critical Care Medicine Department, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Cameron Dezfulian
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel J Penny
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Michael R Pinsky
- Critical Care Medicine Department, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Gomes FKA, Fagundes AADP, Amorim FF. Cardiac Output and Stroke Volume Assessments by Transthoracic Echocardiography and Pulse index Continuous Cardiac Output Monitor in Critically ill Adult Patients: A Comparative Study. J Intensive Care Med 2024; 39:341-348. [PMID: 37769347 DOI: 10.1177/08850666231204787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
PURPOSE Bedside transthoracic echocardiography (TTEcho) is a noninvasive cardiac output (CO) monitoring method that has grown recently. However, there are questions regarding its accuracy compared to invasive methods. We aimed to evaluate the agreement and correlation of TTEcho and pulse index continuous CO (PiCCO) monitor measurements for CO and systolic volume (SV) in critically ill patients. METHODS This prospective experimental study included consecutive adult patients who required invasive hemodynamic monitoring admitted at an intensive care unit in the Federal District, Brazil, from January/2019 to January/2021. Correlation and agreement between SV and CO measurements by PiCCO and TTEcho were performed using the Spearman correlation and the Bland-Altman analysis. RESULTS The study enrolled 29 patients, with adequate TTEcho evaluations in all patients. There were very strong correlations between CO-TTEcho and CO-PiCCO (r = 0.845, P < .001) and SV-TTEcho and SV-PiCCO (r = 0.800, P < .001). TTEcho estimations for CO and SV were feasible within the limits of agreement in 96.6% (28/29) compared to PiCCO. The mean difference between CO-PiCCO and CO-TTEcho was 0.250 L/min (limits of agreement: -1.083 to 1.583 L/min, percentage error: 21.0%), and between SV-PiCCO and SV-TTEcho was 2.000 mL (limits of agreement: -16.960 to 20.960, percentage error: 24.3%). The reduced cardiac index (CI) measurements by TTEcho showed an accuracy of 89.7% (95% IC: 72.6%-97.8%) and an F1 score of 92.7% (95% IC: 75.0%-98.0%), considering the CI-PiCCO as the gold standard. CONCLUSION Echocardiographic measurements of CO and SV are comparable to measurements by PiCCO. These results reinforce echocardiography as a reliable tool to evaluate hemodynamics in critically ill patients.
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Affiliation(s)
- Flávia K A Gomes
- Graduate Program in Health Sciences, Higher Education School of Health Sciences (ESCS), Brasília, Federal District, Brazil
- Adult Intensive Care Unit, Hospital DF Star, Brasília, Federal District, Brazil
- Adult Intensive Care Unit, Hospital Home, Brasília, Federal District, Brazil
| | | | - Fábio F Amorim
- Graduate Program in Health Sciences, Higher Education School of Health Sciences (ESCS), Brasília, Federal District, Brazil
- Graduate Program in Health Sciences, University of Brasilia (UnB), Brasília, Federal District, Brazil
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Grinstein J. Advanced hemodynamics for prognostication in heart failure: the pursuit of the patient-specific tipping point. Front Cardiovasc Med 2024; 11:1365696. [PMID: 38500751 PMCID: PMC10944906 DOI: 10.3389/fcvm.2024.1365696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
Background Objective tools to define the optimal time for referral for advanced therapies and to help guide escalation and de-escalation of support can improve management decisions and outcomes for patients with advanced heart failure. The current parameters have variable prognostic potential depending on the patient population being studied and often have arbitrary thresholds. Methods Here, a mathematical and physiological framework to define the patient-specific tipping point of myocardial energetics is defined. A novel hemodynamic parameter known as the myocardial performance score (MPS), a marker of power and efficiency, is introduced that allows for the objective assessment of the physiological tipping point. The performance of the MPS and other advanced hemodynamic parameters including aortic pulsatility index (API) and cardiac power output (CPO) in predicting myocardial energetics and the overall myocardial performance was evaluated using a validated computer simulation model of heart failure (Harvi) as well as a proof-of-concept clinical validation using a cohort of the Society for Cardiovascular Angiography and Interventions (SCAI) Stage C cardiogenic shock patients. Results Approximately 1010 discrete heart failure scenarios were modeled. API strongly correlated with the left ventricular coupling ratio (R2 = 0.81) and the strength of association became even stronger under loaded conditions where pulmonary capillary wedge pressure (PCWP) was >20 mmHg (R2 = 0.94). Under loaded conditions, there is a strong logarithmic relationship between MPS and mechanical efficiency (R2 = 0.93) with a precipitous rise in potential energy (PE) and drop in mechanical efficiency with an MPS <0.5. An MPS <0.5 was able to predict a CPO <0.6 W and coupling ratio of <0.7 with sensitivity (Sn) of 87%, specificity (Sp) of 91%, positive predictive value of 81%, and negative predictive value of 94%. In a cohort of 224 patients with SCAI Stage C shock requiring milrinone initiation, a baseline MPS score of <0.5 was associated with a 35% event rate of the composite endpoint of death, left ventricular assist device, or transplant at 30 days compared with 3% for those with an MPS >1 (p < 0.001). Patients who were able to augment their MPS to >1 after milrinone infusion had a lower event rate than those with insufficient reserve (40% vs. 16%, p = 0.01). Conclusions The MPS, which defines the patient-specific power-to-efficiency ratio and is inversely proportional to PE, represents an objective assessment of the myocardial energetic state of a patient and can be used to define the physiological tipping point for patients with advanced heart failure.
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Affiliation(s)
- Jonathan Grinstein
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL, United States
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Esposito C, Tzan K, Machado P, Forsberg F, Dave JK. The Effect of Mixing Iodinated Contrast Media and Ultrasound Contrast Agents on Subharmonic Signals. ULTRASONIC IMAGING 2024; 46:130-134. [PMID: 38318708 DOI: 10.1177/01617346241227971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Subharmonic aided pressure estimation (SHAPE) is a technique that utilizes subharmonic signals from microbubble contrast agents for pressure estimation. Validation of the SHAPE technique relies on synchronous measurements of in vivo pressures using contrast microbubbles and a pressure catheter (reference standard). For the guidance and placement of pressure catheter in vivo, iodinated contrast is used with fluoroscopy. Therefore, during data acquisition for validation studies of the SHAPE technique, both contrast microbubbles and iodinated contrast are present simultaneously within the vasculature. This study aims to elucidate the effects of iodinated contrast (Visipaque, GE HealthCare) on subharmonic signal amplitude from contrast microbubbles (Definity, Lantheus Medical Imaging, Inc.). In an acrylic water tank, 0.06 mL of Definity and varied amounts of Visipaque (0.14, 0.43, 0.85, and 1.70 mL) were added to 425 mL of deionized water. Ultrasound scanning was performed with a SonixTablet scanner (BK Medical Systems) using optimized parameters for SHAPE with Definity (ftransmit/receive = 3.0/1.5 MHz; chirp down pulse). Subharmonic data was acquired and analyzed at 9 different incident acoustic outputs (n = 3). Results showed an increase in subharmonic signal amplitude from Definity microbubbles in the presence of 0.14 mL Visipaque by 2.8 ± 1.3 dB (p < .001), no change with 0.85 mL Visipaque (0.7 ± 1.2 dB; p = .09) and a decrease in subharmonic amplitude in the presence of 1.70 mL Visipaque by 1.9 ± 0.7 dB (p < .001). While statistically significant effect on subharmonic signal amplitude of Definity microbubbles was noted due to the mixture, the magnitude of the effect was minimal (~2.8 dB) and unlikely to impact in vivo SHAPE measurements.
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Affiliation(s)
- Cara Esposito
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kenneth Tzan
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priscilla Machado
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jaydev K Dave
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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13
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Grinstein J, Houston BA, Nguyen AB, Smith BA, Chinco A, Pinney SP, Tedford RJ, Belkin MN. Standardization of the Right Heart Catheterization and the Emerging Role of Advanced Hemodynamics in Heart Failure. J Card Fail 2023; 29:1543-1555. [PMID: 37633442 DOI: 10.1016/j.cardfail.2023.08.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
The accurate assessment of hemodynamics is paramount to providing timely and efficacious care for patients presenting in cardiogenic shock. Recently, the regular use of the pulmonary artery catheter in cardiogenic shock has had a resurgence with emerging data indicating improved survival in the modern era. Optimal multidisciplinary management of advanced heart failure and cardiogenic shock relies on our ability to effectively communicate and understand the complete hemodynamic assessment. Standardization of data acquisition and a renewed focus on the physiological processes, and thresholds driving disease progression, including the coupling ratio and myocardial reserve, are needed to fully understand and interpret the hemodynamic assessment. This State-of-the-Art review discusses best practices in the cardiac catheterization laboratory as well as emerging data on the prognostic role of emerging advanced hemodynamic parameters.
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Affiliation(s)
- Jonathan Grinstein
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois.
| | - Brian A Houston
- Medical University of South Carolina, Department of Medicine, Section of Heart Failure, Charleston, South Carolina
| | - Ann B Nguyen
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
| | - Bryan A Smith
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
| | - Annalyse Chinco
- University of Chicago, Department of Surgery, Chicago, Illinois
| | - Sean P Pinney
- Mount Sinai Hospital, Department of Medicine, Section of Cardiology, New York, New York
| | - Ryan J Tedford
- Medical University of South Carolina, Department of Medicine, Section of Heart Failure, Charleston, South Carolina
| | - Mark N Belkin
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, Illinois
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14
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Grinstein J, Sinha SS, Goswami RM, Patel PA, Cyrille-Superville N, Neyestanak ME, Feliberti JP, Snipelisky DF, Devore AD, Najjar SS, Jeng EI, Rao SD. Variation in Hemodynamic Assessment and Interpretation: A Call to Standardize the Right Heart Catheterization. J Card Fail 2023; 29:1507-1518. [PMID: 37352965 DOI: 10.1016/j.cardfail.2023.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/17/2023] [Accepted: 06/05/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Invasive hemodynamic measurement via right heart catheterization has shown divergent data in its role in the treatment of patients with heart failure (HF) and cardiogenic shock. We hypothesized that variation in data acquisition technique and interpretation might contribute to these observations. We sought to assess differences in hemodynamic acquisition and interpretation by operator subspecialty as well as level of experience. METHODS AND RESULTS Individual-level responses to how physicians both collect and interpret hemodynamic data at the time of right heart catheterization was solicited via a survey distributed to international professional societies in HF and interventional cardiology. Data were stratified both by operator subspecialty (HF specialists or interventional cardiologists [IC]) and operator experience (early career [≤10 years from training] or late career [>10 years from training]) to determine variations in clinical practice. For the sensitivity analysis, we also look at differences in each subgroup. A total of 261 responses were received. There were 141 clinicians (52%) who self-identified as HF specialists, 99 (38%) identified as IC, and 20 (8%) identified as other. There were 142 early career providers (54%) and late career providers (119 [46%]). When recording hemodynamic values, there was considerable variation in practice patterns, regardless of subspecialty or level of experience for the majority of the intracardiac variables. There was no agreement or mild agreement among HF and IC as to when to record right atrial pressures or pulmonary capillary wedge pressures. HF cardiologists were more likely to routinely measure both Fick and thermodilution cardiac output compared with IC (51% vs 29%, P < .001), something mirrored in early career vs later career cardiologists. CONCLUSIONS Significant variation exists between the acquisition and interpretation of right heart catheterization measurements between HF and IC, as well as those early and late in their careers. With the growth of the heart team approach to management of patients in cardiogenic shock, standardization of both assessment and management practices is needed.
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Affiliation(s)
- Jonathan Grinstein
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois.
| | - Shashank S Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Fairfax Virginia
| | - Rohan M Goswami
- Division of Transplant, Research and Innovation, Mayo Clinic in Florida, Jacksonville Florida
| | - Priyesh A Patel
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina
| | | | - Maryam E Neyestanak
- Department of Medicine, Section of Cardiology, University of Chicago, Chicago, Illinois
| | - Jason P Feliberti
- University of South Florida Heart and Vascular Institute, Transplant Cardiology, Tampa, Florida
| | - David F Snipelisky
- Section of Heart Failure & Cardiac Transplant Medicine, Cleveland Clinic Florida, Weston, Florida
| | - Adam D Devore
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Samer S Najjar
- Medstar Heart and Vascular Institute, Baltimore Maryland
| | - Eric I Jeng
- Department of surgery, Division of cardiovascular surgery, University of Florida, Gainesville, Florida
| | - Sriram D Rao
- Medstar Washington Hospital Center, Division of Cardiology, Georgetown University, Department of Medicine, Washington DC
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15
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Pichon J, Roche A, Fauvel C, Boucly A, Mercier O, Ebstein N, Beurnier A, Cortese J, Jevnikar M, Jaïs X, Fartoukh M, Fadel E, Sitbon O, Montani D, Voiriot G, Humbert M, Savale L. Clinical relevance and prognostic value of renal Doppler in acute decompensated precapillary pulmonary hypertension. Eur Heart J Cardiovasc Imaging 2023; 24:1518-1527. [PMID: 37194564 DOI: 10.1093/ehjci/jead104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/23/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023] Open
Abstract
AIMS We aim to evaluate the clinical relevance and the prognostic value of arterial and venous renal Doppler in acute decompensated precapillary pulmonary hypertension (PH). METHODS AND RESULTS The renal resistance index (RRI) and the Doppler-derived renal venous stasis index (RVSI) were monitored at admission and on Day 3 in a prospective cohort of precapillary PH patients managed in intensive care unit for acute right heart failure (RHF). The primary composite endpoint included death, circulatory assistance, urgent transplantation, or rehospitalization for acute RHF within 90 days following inclusion. Ninety-one patients were enrolled (58% female, age 58 ± 16 years). The primary endpoint event occurred in 32 patients (33%). In univariate logistic regression analysis, variables associated with RRI higher than the median value were non-variable parameters (age and history of hypertension), congestion (right atrial pressure and renal pulse pressure), cardiac function [tricuspid annular plane systolic excursion (TAPSE) and left ventricular outflow tract- velocity time integral], systemic pressures and NT-proBNP. Variables associated with RVSI higher than the median value were congestion (high central venous pressure, right atrial pressure, and renal pulse pressure), right cardiac function (TAPSE), severe tricuspid regurgitation, and systemic pressures. Inotropic support was more frequently required in patients with high RRI (P = 0.01) or high RVSI (P = 0.003) at the time of admission. At Day 3, a RRI value <0.9 was associated with a better prognosis after adjusting to the estimated glomerular filtration rate. CONCLUSION Renal Doppler provides additional information to assess the severity of patients admitted to the intensive care unit for acute decompensated precapillary PH.
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Affiliation(s)
- Jérémie Pichon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Anne Roche
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Charles Fauvel
- CHU Rouen, Department of Cardiology, F-76000 Rouen, France
- Université Rouen Normandie, Inserm U1096, F-76000 Rouen, France
| | - Athénais Boucly
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Olaf Mercier
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, 92350 Le Plessis Robinson, France
| | - Nathan Ebstein
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Antoine Beurnier
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Jonathan Cortese
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
- AP-HP, Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, 94276, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Xavier Jaïs
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Muriel Fartoukh
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 75020 Paris, France
- Centre de Recherche Saint-Antoine UMRS_938 INSERM, 75012 Paris, France
| | - Elie Fadel
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, 92350 Le Plessis Robinson, France
| | - Olivier Sitbon
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - David Montani
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Guillaume Voiriot
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Service de Médecine Intensive Réanimation, Hôpital Tenon, 75020 Paris, France
- Centre de Recherche Saint-Antoine UMRS_938 INSERM, 75012 Paris, France
| | - Marc Humbert
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
| | - Laurent Savale
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, 78 rue du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 « Pulmonary Hypertension: Pathophysiology and Novel Therapies », Hôpital Marie Lannelongue, 92350 Le Plessis-Robinson, France
- Université Paris-Saclay, Faculté de Médecine, 94276 Le Kremlin Bicêtre, France
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16
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Berg DD, Kaur G, Bohula EA, Baird-Zars VM, Alviar CL, Barnett CF, Barsness GW, Burke JA, Chaudhry SP, Chonde M, Cooper HA, Daniels LB, Dodson MW, Gerber DA, Ghafghazi S, Gidwani UK, Goldfarb MJ, Guo J, Hillerson D, Kenigsberg BB, Kochar A, Kontos MC, Kwon Y, Lopes MS, Loriaux DB, Miller PE, O’Brien CG, Papolos AI, Patel SM, Pisani BA, Potter BJ, Prasad R, Roswell RO, Shah KS, Sinha SS, Smith TD, Solomon MA, Teuteberg JJ, Thompson AD, Zakaria S, Katz JN, van Diepen S, Morrow DA. Prognostic significance of haemodynamic parameters in patients with cardiogenic shock. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:651-660. [PMID: 37640029 PMCID: PMC10599641 DOI: 10.1093/ehjacc/zuad095] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/17/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
AIMS Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. METHODS AND RESULTS The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018-2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th-75th percentile, 1.6-2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66-86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. CONCLUSION In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.
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Affiliation(s)
- David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Carlos L Alviar
- Leon H Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - James A Burke
- Division of Cardiology, Lehigh Valley Heart Network, Allentown, PA, USA
| | | | - Meshe Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard A Cooper
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Shahab Ghafghazi
- Cardiovascular Medicine, University of Louisville, Louisville, KY, USA
| | - Umesh K Gidwani
- Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Benjamin B Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ajar Kochar
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Younghoon Kwon
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Mathew S Lopes
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Connor G O’Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | - Rajnish Prasad
- Division of Cardiology, Wellstar Health System, Marietta, GA, USA
| | - Robert O Roswell
- Division of Cardiology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine, New York, NY, USA
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA
| | - Timothy D Smith
- Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea D Thompson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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17
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Truesdell AG, Alkalbani M, Isseh I. Editorial: Moving from clinical intuition to clinical evidence in cardiogenic shock. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 55:66-67. [PMID: 37380504 DOI: 10.1016/j.carrev.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, Falls Church, VA, USA; Inova Heart and Vascular Institute, Falls Church, VA, USA.
| | | | - Iyad Isseh
- Inova Heart and Vascular Institute, Falls Church, VA, USA.
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18
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Yoo TK, Miyashita S, Davoudi F, Imahira U, Al-Obaidi A, Chweich H, Huggins GS, Kimmelstiel C, Kapur NK. Clinical impact of pulmonary artery catheter in patients with cardiogenic shock: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 55:58-65. [PMID: 37100652 DOI: 10.1016/j.carrev.2023.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/28/2023] [Accepted: 04/10/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The clinical utility of the pulmonary artery catheter (PAC) for the management of cardiogenic shock (CS) remains controversial. We performed a systematic review and meta-analysis exploring the association between PAC use and mortality among patients with CS. METHODS Published studies of patients with CS treated with or without PAC hemodynamic guidance were retrieved from MEDLINE and PubMed databases from January 1, 2000, to December 31, 2021. The primary outcome was mortality, which was defined as a combination of in-hospital mortality and 30-day mortality. Secondary outcomes assessed 30-day and in-hospital mortality separately. To assess the quality of nonrandomized studies, the Newcastle-Ottawa Scale (NOS), a well-established scoring system was used. We analyzed outcomes for each study using NOS with a threshold value of >6, indicating high quality. We also performed analyses based on the countries of the studies conducted. RESULTS Six studies with a total of 930,530 patients with CS were analyzed. Of these, 85,769 patients were in the PAC-treated group, and 844,761 patients did not receive a PAC. PAC use was associated with a significantly lower risk of mortality (PAC: 4.6 % to 41.5 % vs control: 18.8 % to 51.0 %) (OR 0.63, 95 % CI: 0.41-0.97, I2 = 0.96). Subgroup analyses demonstrated no difference in the risk of mortality between NOS ≥ 6 studies and NOS < 6 studies (p-interaction = 0.57), 30-day and in-hospital mortality (p-interaction = 0.83), or the country of origin of studies (p-interaction = 0.08). CONCLUSIONS The use of PAC in patients with CS may be associated with decreased mortality. These data support the need for a randomized controlled trial testing the utility of PAC use in CS.
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Affiliation(s)
- Tae Kyung Yoo
- Department of Medicine, MetroWest Medical Center, Framingham, MA, USA
| | - Satoshi Miyashita
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, MA, USA
| | - Farideh Davoudi
- Department of Medicine, Mass General Brigham-Salem Hospital, Salem, MA, USA
| | - Ubumi Imahira
- Department of Psychiatry, Tufts Medical Center, MA, USA
| | | | - Haval Chweich
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center and Tufts University School of Medicine, MA, USA
| | - Gordon S Huggins
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, MA, USA
| | - Carey Kimmelstiel
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, MA, USA
| | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center and Tufts University School of Medicine, MA, USA.
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Fox WE, Marshall M, Walters SM, Mangunta VR, Ragosta M, Kleiman AM, McNeil JS. Bedside Clinician's Guide to Pulmonary Artery Catheters. Crit Care Nurse 2023; 43:9-18. [PMID: 37524367 DOI: 10.4037/ccn2023133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Pulmonary artery catheters provide important information about cardiac function, mixed venous oxygenation, and right-sided pressures and potentially provide temporary pacing ability. OBJECTIVE To provide bedside clinicians with guidance for techniques to insert right heart monitors and devices, describe risk factors for difficult insertion and contraindications to placement, and provide updates on new technologies that may be encountered in the intensive care unit. METHODS An extensive literature review was performed. Experienced clinicians were asked to identify topics not addressed in the literature. RESULTS Advanced imaging techniques such as transesophageal echocardiography or fluoroscopy can supplement traditional pressure waveform-guided insertion when needed, and several other techniques can be used to facilitate passage into the pulmonary artery. Caution is warranted when attempting insertion in patients with right-sided masses or preexisting conduction abnormalities. New technologies include a pacing catheter that anchors to the right ventricle and a remote monitoring device that is implanted in the pulmonary artery. DISCUSSION Bedside clinicians should be aware of risk factors such as atrial fibrillation with dilated atria, decreased ventricular function, pulmonary hypertension, and right-sided structural abnormalities that can make pulmonary artery catheter insertion challenging. Clinicians should be familiar with advanced techniques and imaging options to facilitate placement. CONCLUSION The overall risk of serious complications with right heart catheter placement and manipulation is low and often outweighed by its benefits, specifically pressure monitoring and pacing.
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Affiliation(s)
- W Everett Fox
- W. Everett Fox is an anesthesiology resident, Department of Anesthesiology, University of Virginia Health System (UVA Health), Charlottesville, Virginia
| | - Michael Marshall
- Michael Marshall is a charge and bedside registered nurse, coronary care unit, UVA Health
| | - Susan M Walters
- Susan M. Walters is a cardiothoracic anesthesiologist and an assistant professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - Venkat R Mangunta
- Venkat R. Mangunta is a cardiothoracic and intensive care anesthesiologist and an assistant professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - Michael Ragosta
- Michael Ragosta is a professor of cardiology and the Medical Director of the cardiac catheterization laboratory and interventional cardiology fellowship, Cardiology Division, Department of Internal Medicine, UVA Health
| | - Amanda M Kleiman
- Amanda M. Kleiman is a cardiothoracic anesthesiologist and an associate professor of anesthesiology, Department of Anesthesiology, UVA Health
| | - John S McNeil
- John S. McNeil is a cardiothoracic anesthesiologist and an associate professor of anesthesiology, Department of Anesthesiology, UVA Health
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20
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Kadosh BS, Berg DD, Bohula EA, Park JG, Baird-Zars VM, Alviar C, Alzate J, Barnett CF, Barsness GW, Burke J, Chaudhry SP, Daniels LB, DeFilippis A, Delicce A, Fordyce CB, Ghafghazi S, Gidwani U, Goldfarb M, Katz JN, Keeley EC, Kenigsberg B, Kontos MC, Lawler PR, Leibner E, Menon V, Metkus TS, Miller PE, O'Brien CG, Papolos AI, Prasad R, Shah KS, Sinha SS, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, Toole J, van Diepen S, Morrow DA, Roswell RO. Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit. JACC. HEART FAILURE 2023; 11:903-914. [PMID: 37318422 PMCID: PMC10527413 DOI: 10.1016/j.jchf.2023.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The appropriate use of pulmonary artery catheters (PACs) in critically ill cardiac patients remains debated. OBJECTIVES The authors aimed to characterize the current use of PACs in cardiac intensive care units (CICUs) with attention to patient-level and institutional factors influencing their application and explore the association with in-hospital mortality. METHODS The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Between 2017 and 2021, participating centers contributed annual 2-month snapshots of consecutive CICU admissions. Admission diagnoses, clinical and demographic data, use of PACs, and in-hospital mortality were captured. RESULTS Among 13,618 admissions at 34 sites, 3,827 were diagnosed with shock, with 2,583 of cardiogenic etiology. The use of mechanical circulatory support and heart failure were the patient-level factors most strongly associated with a greater likelihood of the use of a PAC (OR: 5.99 [95% CI: 5.15-6.98]; P < 0.001 and OR: 3.33 [95% CI: 2.91-3.81]; P < 0.001, respectively). The proportion of shock admissions with a PAC varied significantly by study center ranging from 8% to 73%. In analyses adjusted for factors associated with their placement, PAC use was associated with lower mortality in all shock patients admitted to a CICU (OR: 0.79 [95% CI: 0.66-0.96]; P = 0.017). CONCLUSIONS There is wide variation in the use of PACs that is not fully explained by patient level-factors and appears driven in part by institutional tendency. PAC use was associated with higher survival in cardiac patients with shock presenting to CICUs. Randomized trials are needed to guide the appropriate use of PACs in cardiac critical care.
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Affiliation(s)
- Bernard S Kadosh
- Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA; Lenox Hospital, Northwell Health, New York, New York, USA.
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Alviar
- Department of Medicine at New York University Grossman School of Medicine, Bellevue Hospital, New York, New York, USA
| | - James Alzate
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, Pennsylvania, USA
| | | | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | | | | | - Christopher B Fordyce
- University of British Columbia, University of British Columbia Centre for Cardiovascular Innovation, Cardiovascular Health Program, University of British Columbia Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Umesh Gidwani
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Evan Leibner
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, Georgia, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph Toole
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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21
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Dayani A, Faritous SZ, Amniati S, Bakhshande H, Zamani A, Ghanbari M. Anesthesia Management for the Patient with Chronic Decompensated Heart Failure and Low Cardiac Output Undergoing CABG with Advanced Cardiac Monitoring: A Case Report. Anesth Pain Med 2023; 13:e133796. [PMID: 37404260 PMCID: PMC10317024 DOI: 10.5812/aapm-133796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 07/06/2023] Open
Abstract
Introduction Heart failure (HF) is a complex clinical syndrome caused by a structural or functional heart disorder. One of the most important challenges for anesthesiologists is the management of anesthesia in patients with severe heart failure, which has been facilitated by advanced monitoring systems. Case Presentation The patient was a 42-year-old man with a history of hypertension (HTN) and HF with involvement of the three coronary arteries (3VD) with ejection fraction (EF) 15%. He was also a candidate for elective CABG. In addition to the insertion of arterial line in the left radial artery and the Swan-Ganz catheter in the pulmonary artery, the patient was also monitored by the Edwards Lifesciences Vigilance II for cardiac index (CI) and intravenous mixed blood oxygenation (ScvO2). Hemodynamic changes during and after surgery, as well as during inotrope infusion, were controlled, and the amount of fluid therapy was calculated by gold direct therapy (GDT) method. Conclusions Using PA catheter with advanced monitoring and GDT-based fluid therapy guaranteed a safe anesthesia in this patient with severe heart failure and EF < 20%. Moreover, the postoperative complications and duration of ICU stays were significantly reduced.
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Affiliation(s)
- Abdolreza Dayani
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Zahra Faritous
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saied Amniati
- Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran
| | - Hooman Bakhshande
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Afarin Zamani
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Ghanbari
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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22
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Central venous pressure estimation with force-coupled ultrasound of the internal jugular vein. Sci Rep 2023; 13:1500. [PMID: 36707658 PMCID: PMC9883282 DOI: 10.1038/s41598-022-22867-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/20/2022] [Indexed: 01/29/2023] Open
Abstract
We estimate central venous pressure (CVP) with force-coupled ultrasound imaging of the internal jugular vein (IJV). We acquire ultrasound images while measuring force applied over the IJV by the ultrasound probe imaging surface. We record collapse force, the force required to completely occlude the vein, in 27 healthy subjects. We find supine collapse force and jugular venous pulsation height (JVP), the clinical noninvasive standard, have a linear correlation coefficient of r2 = 0.89 and an average absolute difference of 0.23 mmHg when estimating CVP. We perturb our estimate negatively by tilting 16 degrees above supine and observe decreases in collapse force for every subject which are predictable from our CVP estimates. We perturb venous pressure positively to values experienced in decompensated heart failure by having subjects perform the Valsalva maneuver while the IJV is being collapsed and observe an increase in collapse force for every subject. Finally, we derive a CVP waveform with an inverse three-dimensional finite element optimization that uses supine collapse force and segmented force-coupled ultrasound data at approximately constant force.
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23
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Gonzalez LS, Coghlan C, Alsatli RA, Alsatli O, Tam CW, Kumar SR, Thalappillil R, Chaney MA. The Entrapped Pulmonary Artery Catheter. J Cardiothorac Vasc Anesth 2022; 36:4198-4207. [PMID: 35843773 DOI: 10.1053/j.jvca.2022.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Laura S Gonzalez
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Colleen Coghlan
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Raed A Alsatli
- Department of Anesthesiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ola Alsatli
- Kenneth Jansz Medicine Professional Corporation, Burlington, Ontario, Canada
| | - Christopher W Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Shreyajit R Kumar
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Richard Thalappillil
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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24
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Kubisa B, Kubisa A, Piotrowska M, Safranow K, Grodzki T, Peregud-Pogorzelska M. Right Heart Echocardiography Parameters and Other Predictors to Evaluate Mechanical Cardiac Support Necessity During Lung Transplantation. Transplant Proc 2022; 54:2307-2312. [PMID: 36180254 DOI: 10.1016/j.transproceed.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 07/21/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lung transplantation (LuTx) is a challenge when right heart function fails. Mechanical circulatory support (MCS) is then necessary. METHODS We aimed to investigate whether preoperative transthoracic echocardiography (TTE) can predict MCS use and help to exclude the sickest patients. Between 2011 and 2018, 52 patients at our institution received LuTx and qualified for this study: 35 bilateral, 16 single, 1 lobar [1] and 1 retransplantation procedure. Of these, 22 were operated using MCS and 30 without MCS. The patients were aged between 18 and 65 years, and 23 were women. The indications were lung fibrosis for 18 patients, chronic obstructive lung disease for 16, cystic fibrosis for 15, primary pulmonary hypertension for 2 and bronchiectasis for 1. TTE was performed up to 30 days before treatment and 1 to 7 days after. RESULTS Patients undergoing MCS versus patients not undergoing MCS: preoperative right ventricular systolic pressure 56.5 (30) vs 37.8 (11.5) mm Hg (P = .03); tricuspid regurgitation pressure gradient 48.7 (27) vs 30.2 (10.8) mm Hg (P = .015); tricuspid annular plane systolic excursion 17.8 (4.3) vs 19.9 (2.8) mm Hg (P = .04); pulmonary artery diameter 27.5 (5.2) vs 23.9 (4.1) mm (P = .004); age 41.9 (14.1) vs 54.3 (11.8) years (P = .001). Patients who were Dead versus patients who were alive pulmonary valve acceleration time of 82.8 (24.1) vs 104.9 (27.2) ms (hazard ratio [HR] = 0.959, 95% confidence interval [CI] = 0.923-0.996 per ms, P = .02) and pulmonary artery diameter of 28.9 (5.8) vs 24.4 (4.1) mm HR = 1.225, 95% CI = 1.028-1.460 per 1 mm, P = .016 were predictors of death. CONCLUSIONS Preoperative TTE parameters: right ventricular systolic pressure, tricuspid regurgitation pressure gradient, tricuspid annular plane systolic excursion, and pulmonary artery diameter predicted MCS use during LuTx. Certain values of valve acceleration time and pulmonary artery diameter could help discern LuTx qualification.
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Affiliation(s)
- Bartosz Kubisa
- Thoracic Surgery and Transplantation Department, Pomeranian Medical University of Szczecin, Szczecin, Poland.
| | - Anna Kubisa
- Internal Medicine Ward, SPWSZ Hospital Szczecin-Zdunowo, Szczecin, Poland
| | - Maria Piotrowska
- Thoracic Surgery and Transplantation Department, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Tomasz Grodzki
- Thoracic Surgery and Transplantation Department, Pomeranian Medical University of Szczecin, Szczecin, Poland
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25
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review various contemporary cardiac output (CO) measurement technologies available and their utility in critically ill patients. RECENT FINDINGS CO measurement devices can be invasive, minimally invasive, or noninvasive depending upon their method of CO measurement. All devices have pros and cons, with pulmonary artery catheter (PAC) being the gold standard. The invasive techniques are more accurate; however, their invasiveness can cause more complications. The noninvasive devices predict CO via mathematical modeling with several assumptions and are thus prone to errors in clinical situations. Recently, PAC has made a comeback into clinical practice especially in cardiac intensive care units (ICUs). Critical care echocardiography (CCE) is an upcoming tool that not only provides CO but also helps in differential diagnosis. Lack of proper training and nonavailability of equipment are the main hindrances to the wide adoption of CCE. SUMMARY PAC thermodilution for CO measurement is still gold standard and most suitable in patients with cardiac pathology and with experienced user. CCE offers an alternative to thermodilution and is suitable for all ICUs; however, structural training is required.
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Affiliation(s)
- Virendra K Arya
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Sridharan A, Dehn MM, Cooper C, Madineedi VS, Ordway LJ, DeNofrio D, Patel AR. Accuracy of echocardiographic estimations of right heart pressures in adult heart transplant recipients. Clin Cardiol 2022; 45:752-758. [PMID: 35451518 PMCID: PMC9286333 DOI: 10.1002/clc.23835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/27/2022] [Accepted: 04/07/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Accurate assessment of right atrial pressure (RAP) and pulmonary artery systolic pressure (PASP) is critical in the management of heart transplant recipients. The accuracy of echocardiography in estimating these pressures has been debated. OBJECTIVE To assess the correlation and agreement between echocardiographic estimations of right heart pressures with those of respective invasive hemodynamic measurements by right heart catheterization (RHC) in adult heart transplant recipients. METHODS This is a prospective evaluation of 84 unique measurements from heart transplant recipients who underwent RHC followed by standard echocardiographic evaluation within 159 ± 64 min with no intervening medication changes. The relationship between noninvasive pressure estimations and invasive hemodynamic measurements was examined. RESULTS Mean RAP was 7 ± 5 mmHg and mean PASP was 33 ± 8 mmHg by RHC. There was no significant correlation between echocardiographic estimation of RAP and invasive RAP (Spearman's rho = -0.05, p = .7), and no significant agreement between these two variables (weighted kappa = -0.1). There was a modest correlation between echocardiographic estimation of PASP and invasive PASP (r = .39, p = .002). Bland-Altman analysis showed a mean bias of 2.1 ± 9 mmHg (limits of agreement = -15 to 20 mmHg). CONCLUSION In heart transplant recipients, there is no significant correlation or agreement between echocardiographic RAP estimation and invasively determined RAP. Noninvasive PASP estimation correlates significantly but modestly with invasively measured PASP. Further refinement of echocardiographic methods for assessment of RAP is warranted in this unique patient population.
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Affiliation(s)
- Aadhavi Sridharan
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Monica M Dehn
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Craig Cooper
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Vidya S Madineedi
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA
| | - Linda J Ordway
- Heart Failure and Cardiac Transplant Program, Tufts Medical Center, Boston, Massachusetts, USA
| | - David DeNofrio
- Heart Failure and Cardiac Transplant Program, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ayan R Patel
- Cardiovascular Imaging and Hemodynamic Laboratory, Tufts Medical Center, Boston, Massachusetts, USA.,Heart Failure and Cardiac Transplant Program, Tufts Medical Center, Boston, Massachusetts, USA
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27
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Josan E, Pastis N, Shaman Z. Ultrasound guided pulmonary artery catheter insertion: An alternative to fluoroscopic guidance. Respir Med Case Rep 2022; 38:101678. [PMID: 35656092 PMCID: PMC9151730 DOI: 10.1016/j.rmcr.2022.101678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/19/2022] [Indexed: 11/01/2022] Open
Abstract
Pulmonary artery catheters (PACs) can provide extremely valuable objective data in select patients. They are usually advanced by floatation of balloon tip along the normal blood flow and their placement is confirmed under pressure waveform guidance. Imaging such as fluoroscopy is often employed in low flow states and in cardiac catheterization suite to reduce the failure rate and time to wedge; but is not readily available at bedside. In critically ill patient, bedside insertion is feasible but can be complicated by repeated attempts to float the balloon tip through various cardiac chambers. Point of care ultrasound can be used to visualize the balloon tip of PAC inside the cardiac chambers alongside the confirmatory pressure waveform changes.
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28
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Durack JC, Chen LL, Imran S, Halpern NA. A Tale of Two Pulmonary Artery Catheters. Crit Care Nurs Q 2022; 45:8-12. [PMID: 34818292 PMCID: PMC9911303 DOI: 10.1097/cnq.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Innovative catheter-based therapies are increasingly being used for the treatment of patients with submassive pulmonary embolism. These patients may be monitored in the intensive care unit following insertion of specialized pulmonary artery catheters. However, the infusion catheters utilized in catheter-based therapies differ greatly from traditional pulmonary artery catheters designed for hemodynamic monitoring. As such, the critical care team will have to be familiar with the monitoring and management of these novel catheters. Important distinctions between the catheters are illustrated using a clinical case report.
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Affiliation(s)
- Jeremy C Durack
- Interventional Radiology Service, Department of Radiology (Dr Durack), and Critical Care Center and Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine (Drs Chen, Imran, and Halpern), Memorial Sloan Kettering Cancer Center, New York City, New York
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Figueiro-Filho EA, Robinson NTS, Carvalho J, Keunen J, Robinson M, Maxwell C. Hemodynamic Assessment of Pregnant People with and without Obesity by Noninvasive Bioreactance: A Pilot Study. AJP Rep 2022; 12:e69-e75. [PMID: 35141039 PMCID: PMC8816622 DOI: 10.1055/s-0041-1742270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to identify cardiovascular differences between pregnant people with and without obesity for trimester-specific changes in hemodynamic parameters using noninvasive cardiac output monitoring (NICOM). Study Design This study is a pilot prospective comparative cohort between pregnant people with and without obesity. Hemodynamic assessment was performed with NICOM (12-14, 21-23, and 34-36 weeks) during pregnancy. Results In first trimester, pregnant people with obesity had higher blood pressure, stroke volume (SV), total peripheral resistance index (TPRI), and cardiac output (CO). Pregnant people with obesity continued to have higher SV and cardiac index (second and third trimesters). During the first trimester, body mass index (BMI) positively correlated with SV, TPRI, and CO. Fat mass showed a strong correlation with TPRI. BMI positively correlated with CO during the second trimester and fat mass was positively associated with CO. During the third trimester, TPR negatively correlated with BMI and fat mass. Conclusion Fat mass gain in the period between the first and second trimesters in addition to the hemodynamic changes due to obesity and pregnancy contribute to some degree of left ventricular diastolic dysfunction which was manifested by lower SVs. Future work should investigate the possible causative role of obesity in the cardiovascular changes identified in people with obesity.
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Affiliation(s)
- Ernesto A Figueiro-Filho
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.,Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Na T S Robinson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, Queen Elizabeth Hospital, Barbados
| | - Jose Carvalho
- Department of Anaesthesia, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Johannes Keunen
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Monique Robinson
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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Kim DW, Chung S, Kang WS, Kim J. Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 12:diagnostics12010049. [PMID: 35054215 PMCID: PMC8774961 DOI: 10.3390/diagnostics12010049] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/22/2021] [Accepted: 12/22/2021] [Indexed: 01/08/2023] Open
Abstract
This systematic review and meta-analysis aimed to investigate the ultrasonographic variation of the diameter of the inferior vena cava (IVC), internal jugular vein (IJV), subclavian vein (SCV), and femoral vein (FV) to predict fluid responsiveness in critically ill patients. Relevant articles were obtained by searching PubMed, EMBASE, and Cochrane databases (articles up to 21 October 2021). The number of true positives, false positives, false negatives, and true negatives for the index test to predict fluid responsiveness was collected. We used a hierarchical summary receiver operating characteristics model and bivariate model for meta-analysis. Finally, 30 studies comprising 1719 patients were included in this review. The ultrasonographic variation of the IVC showed a pooled sensitivity and specificity of 0.75 and 0.83, respectively. The area under the receiver operating characteristics curve was 0.86. In the subgroup analysis, there was no difference between patients on mechanical ventilation and those breathing spontaneously. In terms of the IJV, SCV, and FV, meta-analysis was not conducted due to the limited number of studies. The ultrasonographic measurement of the variation in diameter of the IVC has a favorable diagnostic accuracy for predicting fluid responsiveness in critically ill patients. However, there was insufficient evidence in terms of the IJV, SCV, and FV.
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Affiliation(s)
- Do-Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju 61469, Korea;
| | - Seungwoo Chung
- Department of Critical Care Medicine, Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Wu-Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Korea;
- Correspondence:
| | - Joongsuck Kim
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, Jeju 63127, Korea;
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Endo Y, Hirokawa T, Miyasho T, Takegawa R, Shinozaki K, Rolston DM, Becker LB, Hayashida K. Monitoring the tissue perfusion during hemorrhagic shock and resuscitation: tissue-to-arterial carbon dioxide partial pressure gradient in a pig model. J Transl Med 2021; 19:390. [PMID: 34774068 PMCID: PMC8590759 DOI: 10.1186/s12967-021-03060-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/27/2021] [Indexed: 11/20/2022] Open
Abstract
Background Despite much evidence supporting the monitoring of the divergence of transcutaneous partial pressure of carbon dioxide (tcPCO2) from arterial partial pressure carbon dioxide (artPCO2) as an indicator of the shock status, data are limited on the relationships of the gradient between tcPCO2 and artPCO2 (tc-artPCO2) with the systemic oxygen metabolism and hemodynamic parameters. Our study aimed to test the hypothesis that tc-artPCO2 can detect inadequate tissue perfusion during hemorrhagic shock and resuscitation. Methods This prospective animal study was performed using female pigs at a university-based experimental laboratory. Progressive massive hemorrhagic shock was induced in mechanically ventilated pigs by stepwise blood withdrawal. All animals were then resuscitated by transfusing the stored blood in stages. A transcutaneous monitor was attached to their ears to measure tcPCO2. A pulmonary artery catheter (PAC) and pulse index continuous cardiac output (PiCCO) were used to monitor cardiac output (CO) and several hemodynamic parameters. The relationships of tc-artPCO2 with the study parameters and systemic oxygen delivery (DO2) were analyzed. Results Hemorrhage and blood transfusion precisely impacted hemodynamic and laboratory data as expected. The tc-artPCO2 level markedly increased as CO decreased. There were significant correlations of tc-artPCO2 with DO2 and COs (DO2: r = − 0.83, CO by PAC: r = − 0.79; CO by PiCCO: r = − 0.74; all P < 0.0001). The critical level of oxygen delivery (DO2crit) was 11.72 mL/kg/min according to transcutaneous partial pressure of oxygen (threshold of 30 mmHg). Receiver operating characteristic curve analyses revealed that the value of tc-artPCO2 for discrimination of DO2crit was highest with an area under the curve (AUC) of 0.94, followed by shock index (AUC = 0.78; P < 0.04 vs tc-artPCO2), and lactate (AUC = 0.65; P < 0.001 vs tc-artPCO2). Conclusions Our observations suggest the less-invasive tc-artPCO2 monitoring can sensitively detect inadequate systemic oxygen supply during hemorrhagic shock. Further evaluations are required in different forms of shock in other large animal models and in humans to assess its usefulness, safety, and ability to predict outcomes in critical illnesses.
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Affiliation(s)
- Yusuke Endo
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Taku Hirokawa
- School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan
| | - Taku Miyasho
- School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan
| | - Ryosuke Takegawa
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | - Koichiro Shinozaki
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Daniel M Rolston
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Lance B Becker
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA.,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.,Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Kei Hayashida
- The Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Drive, Manhasset, NY, 11030, USA. .,Department of Emergency Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.
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Echocardiography-Based Hemodynamic Monitoring Use on Inpatients Listed for Heart Transplantation Under 2018 Allocation Policy in United States. Transplant Proc 2021; 53:3036-3038. [PMID: 34728079 DOI: 10.1016/j.transproceed.2021.08.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/01/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND One notable change to the 2018 United Network for Organ Sharing listing criteria was to allow for the use of noninvasive hemodynamic monitoring for inpatients listed as status 3 for heart transplantation. We wanted to explore the feasibility of performing daily focused echocardiograms in place of invasive monitoring in this population. METHODS On retrospective chart review of inpatients listed for transplantation at our institution, 8 patients in the invasive monitoring group listed as status 1A (October 2016 to October 2018) and 9 patients in the echocardiographic group listed as status 3 (October 2018 to February 2020) were identified. RESULTS There were no significant differences between the 2 cohorts in the average measured/estimated right atrial, pulmonary artery systolic, and wedge pressures, although the echo cohort had lower cardiac index (P = .001). There were 2 patients with positive blood cultures treated with Swan exchange in Swan cohort and a total of 14 Swan exchanges. There were no infections in the noninvasive group. CONCLUSION We present our experience with the use of noninvasive daily hemodynamic assessment using focused echocardiograms to manage patients undergoing heart transplantation listing as status 3 under the new United Network for Organ Sharing allocation system. This approach appears safe and feasible; however, it requires validation in larger cohorts.
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Hemodynamic Monitoring in Patients With Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. J Neurosurg Anesthesiol 2021; 33:285-292. [PMID: 32011413 DOI: 10.1097/ana.0000000000000679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/29/2019] [Indexed: 11/25/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) often causes cardiopulmonary dysfunction. Therapeutic strategies can be guided by standard (invasive arterial/central venous pressure measurements, fluid balance assessment), and/or advanced (pulse index continuous cardiac output, pulse dye densitometry, pulmonary artery catheterization) hemodynamic monitoring. We conducted a systematic review and meta-analysis of the literature to determine whether standard compared with advanced hemodynamic monitoring can improve patient management and clinical outcomes after aSAH. A literature search was performed for articles published between January 1, 2000 and January 1, 2019. Studies involving aSAH patients admitted to the intensive care unit and subjected to any type of hemodynamic monitoring were included. A total of 14 studies were selected for the qualitative synthesis and 3 randomized controlled trials, comparing standard versus advanced hemodynamic monitoring, for meta-analysis. The incidence of delayed cerebral ischemia was lower in the advanced compared with standard hemodynamic monitoring group (relative risk [RR]=0.71, 95% confidence interval [CI]=0.52-0.99; P=0.044), but there were no differences in neurological outcome (RR=0.83, 95% CI=0.64-1.06; P=0.14), pulmonary edema onset (RR=0.44, 95% CI=0.05-3.92; P=0.46), or fluid intake (mean difference=-169 mL; 95% CI=-1463 to 1126 mL; P=0.8) between the 2 groups. In summary, this systematic review and meta-analysis found only low-quality evidence to support the use of advanced hemodynamic monitoring in selected aSAH patients. Because of the small number and low quality of studies available for inclusion in the review, further studies are required to investigate the impact of standard and advanced hemodynamic monitoring-guided management on aSAH outcomes.
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Mora B, Roth D, Bernardi MH, Base E, Weber U. Estimation of pulmonary artery pressure with transesophageal echocardiography: An observer-blinded test accuracy study. Medicine (Baltimore) 2021; 100:e26988. [PMID: 34414978 PMCID: PMC8376331 DOI: 10.1097/md.0000000000026988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/26/2021] [Indexed: 01/04/2023] Open
Abstract
With the declining use of the pulmonary artery catheter (PAC), transesophageal echocardiography (TEE) has become an appealing alternative to obtain pulmonary artery pressure non-invasively using the simplified Bernoulli equation. The validation of this method in the perioperative setting has been scarce with no clear recommendations about which view is the most accurate to estimate right ventricular systolic pressure (RVSP).Therefore, we performed a prospective, observer-blinded, diagnostic test accuracy study to assess the difference in systolic pulmonary artery pressure (sysPAP) measuring both, invasively sysPAP and estimated RVSP with TEE in 3 different views: the mid-esophageal (ME) 4Chamber, the ME right ventricular (RV) inflow-outflow and the ME modified bicaval view.To show a clinically significant difference of at least 10% in RVSP, we included 40 cardiac surgical patients divided into 3 subgroups: Patients with mild to moderate tricuspid regurgitation (TR) and mean PAP <25 mm Hg, patients with mild to moderate TR and mean PAP≥ 25 mm Hg, and patients with severe TR.For the whole cohort, bias of estimated RVSP compared to measured sysPAP was 5.27 mm Hg, precision was 7.96 mm Hg, limits of agreement were -10.66 to 21.19 mm Hg. The best agreement between the 2 methods was found in patients with severe TR and in the ME RV inflow-outflow and the modified bicaval view. Good Doppler signals were available in 35% and 46% in these views, and in 20% in the ME 4 chamber view.The estimation of the sysPAP by TEE cannot be considered reliable in the clinical perioperative setting. Only measurements that provide a full Doppler envelope show sufficient precision to provide accurate estimations.
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Affiliation(s)
- Bruno Mora
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Dominik Roth
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin H. Bernardi
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Base
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Ulrike Weber
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
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35
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Grand J, Kjaergaard J, Hassager C, Møller JE, Bro-Jeppesen J. Comparing Doppler Echocardiography and Thermodilution for Cardiac Output Measurements in a Contemporary Cohort of Comatose Cardiac Arrest Patients Undergoing Targeted Temperature Management. Ther Hypothermia Temp Manag 2021; 12:159-167. [PMID: 34415801 DOI: 10.1089/ther.2021.0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Measuring cardiac output is used to guide treatment during postresuscitation care. The aim of this study was to compare Doppler echocardiography (Doppler-CO) with thermodilution using pulmonary artery catheters (PAC-CO) for cardiac output estimation in a large cohort of comatose out-of-hospital cardiac arrest (OHCA) patients undergoing targeted temperature management (TTM). Single-center substudy of 141 patients included in the TTM trial randomly assigned to 33 or 36°C for 24 hours after OHCA. Per protocol, PAC-CO and Doppler-CO were measured simultaneously shortly after admission and again at 24 and 48 hours. Linear correlation was assessed between methods and positive predictive value (PPV) and negative predictive value (NPV) of Doppler to estimate low cardiac output (<3.5 L/min) was calculated. A total of 301 paired cardiac output measurements were available. Average cardiac output was 5.28 ± 1.94 L/min measured by thermodilution and 4.06 ± 1.49 L/min measured by Doppler with a mean bias of 1.22 L/min (limits of agreements -1.92 to 4.36 L/min). Correlation between methods was moderate (R2 = 0.36). Using PAC-CO as the gold standard, PPV of a low cardiac output measurement (<3.5 L/min) by Doppler was 33%. However, the NPV was 92%. Hypothermia at 33°C did not negatively affect the correlations of CO methods. In the lowest quartile of Doppler, 13% had elevated lactate (>2 mmol/L). In the lowest quartile of thermodilution, 36% had elevated lactate (>2 mmol/L). In ventilated OHCA patients, the two methods for estimating cardiac output correlated moderately and there was a consistent underestimation of Doppler-CO. Absolute cardiac output values from Doppler-CO should be interpreted with caution. However, Doppler can be used to exclude low cardiac output with high accuracy. TTM at 33°C did not negatively affect the correlation or bias of cardiac output measurements. ClinicalTrials.gov ID: NCT01020916.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - John Bro-Jeppesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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36
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Estimation of Pulmonary Artery Occlusion Pressure Using Doppler Echocardiography in Mechanically Ventilated Patients. Crit Care Med 2021; 48:e943-e950. [PMID: 32885942 DOI: 10.1097/ccm.0000000000004512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Evaluation of left atrial pressure is frequently required for mechanically ventilated critically ill patients. The objective of the present study was to evaluate the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for assessment of the pulmonary artery occlusion pressure (a frequent surrogate of left atrial pressure) in this population. DESIGN A pooled analysis of three prospective cohorts of patients simultaneously assessed with a pulmonary artery catheter and echocardiography. SETTINGS Medical-surgical intensive care department of two university hospitals in France. PATIENTS Mechanically ventilated critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 98 included patients (males: 67%; mean ± SD age: 59 ± 16; and mean Simplified Acute Physiology Score 2: 54 ± 20), 53 (54%) experienced septic shock. Using the 2016 American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines, the predicted pulmonary artery occlusion pressure was indeterminate in 48 of the 98 patients (49%). Of the 24 patients with an elevated predicted left atrial pressure (grade II/III diastolic dysfunction), only 17 (71%) had a pulmonary artery occlusion pressure greater than or equal to 18 mm Hg. Similarly, 20 of the 26 patients (77%) with a normal predicted left atrial pressure (grade I diastolic dysfunction) had a measured pulmonary artery occlusion pressure less than 18 mm Hg. The sensitivity and specificity of American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines for predicting elevated pulmonary artery occlusion pressure were both 74%. The agreement between echocardiography and the pulmonary artery catheter was moderate (Cohen's Kappa, 0.48; 95% CI, 0.39-0.70). In a proposed alternative algorithm, the best echocardiographic predictors of a normal pulmonary artery occlusion pressure were a lateral e'-wave greater than 8 (for a left ventricular ejection fraction ≥ 45%) or an E/A ratio less than or equal to 1.5 (for a left ventricular ejection fraction < 45%). CONCLUSIONS The American Society of Echocardiography and the European Association of Cardiovascular Imaging guidelines do not accurately assess pulmonary artery occlusion pressure in ventilated critically ill patients. Simple Doppler measurements gave a similar level of diagnostic performance with less uncertainly.
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Pecchiari M, Pontikis K, Alevrakis E, Vasileiadis I, Kompoti M, Koutsoukou A. Cardiovascular Responses During Sepsis. Compr Physiol 2021; 11:1605-1652. [PMID: 33792902 DOI: 10.1002/cphy.c190044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sepsis is the life-threatening organ dysfunction arising from a dysregulated host response to infection. Although the specific mechanisms leading to organ dysfunction are still debated, impaired tissue oxygenation appears to play a major role, and concomitant hemodynamic alterations are invariably present. The hemodynamic phenotype of affected individuals is highly variable for reasons that have been partially elucidated. Indeed, each patient's circulatory condition is shaped by the complex interplay between the medical history, the volemic status, the interval from disease onset, the pathogen, the site of infection, and the attempted resuscitation. Moreover, the same hemodynamic pattern can be generated by different combinations of various pathophysiological processes, so the presence of a given hemodynamic pattern cannot be directly related to a unique cluster of alterations. Research based on endotoxin administration to healthy volunteers and animal models compensate, to an extent, for the scarcity of clinical studies on the evolution of sepsis hemodynamics. Their results, however, cannot be directly extrapolated to the clinical setting, due to fundamental differences between the septic patient, the healthy volunteer, and the experimental model. Numerous microcirculatory derangements might exist in the septic host, even in the presence of a preserved macrocirculation. This dissociation between the macro- and the microcirculation might account for the limited success of therapeutic interventions targeting typical hemodynamic parameters, such as arterial and cardiac filling pressures, and cardiac output. Finally, physiological studies point to an early contribution of cardiac dysfunction to the septic phenotype, however, our defective diagnostic tools preclude its clinical recognition. © 2021 American Physiological Society. Compr Physiol 11:1605-1652, 2021.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Emmanouil Alevrakis
- 4th Department of Pulmonary Medicine, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Maria Kompoti
- Intensive Care Unit, Thriassio General Hospital of Eleusis, Magoula, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
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Internal barriers to efficiency: why disinvestments are so difficult. Identifying and addressing internal barriers to disinvestment of health technologies. HEALTH ECONOMICS, POLICY, AND LAW 2021; 16:473-488. [PMID: 33563362 DOI: 10.1017/s1744133121000037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Although efficiency is a core concept in health economics, its impact on health care practice still is modest. Despite an increased pressure on resource allocation, a widespread use of low-value care is identified. Nonetheless, disinvestments are rare. Why is this so? This is the key question of this paper: why are disinvestments not more prevalent and improving the efficiency of the health care system, given their sound foundation in health economics, their morally important rationale, the significant evidence for a long list of low-value care and available alternatives? Although several external barriers to disinvestments have been identified, this paper looks inside us for mental mechanisms that hamper rational assessment, implementation, use and disinvestment of health technologies. Critically identifying and assessing internal inclinations, such as cognitive biases, affective biases and imperatives, is the first step toward a more rational handling of health technologies. In order to provide accountable and efficient care we must engage in the quest against the figments of our minds; to disinvest in low-value care in order to provide high-value health care.
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Meani P, Lorusso R, Pappalardo F. ECPella: Concept, Physiology and Clinical Applications. J Cardiothorac Vasc Anesth 2021; 36:557-566. [PMID: 33642170 DOI: 10.1053/j.jvca.2021.01.056] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/24/2021] [Accepted: 01/29/2021] [Indexed: 02/06/2023]
Abstract
Addition of Impella on top of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has gained wide interest as it might portend improved outcomes in patients with cardiogenic shock. This has been consistently reported in retrospective propensity-matched studies, case series, and meta-analyses. The pathophysiologic background is based on the mitigation of ECMO-related side effects and the additive benefit of myocardial unloading. In this perspective, thorough knowledge of these mechanisms is required to optimize the management of mechanical circulatory support with this approach and introduce best practices, as the interplay between the two devices and the implantation-explantation strategies are key for success.
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Affiliation(s)
- P Meani
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy; ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - R Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - F Pappalardo
- Department of Anaesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy
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40
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Sharma S, Lupera MA, Chan A, Nurok M, Ansryan LZ, Coleman B. Safety First: An Ambulation Protocol for Patients With Pulmonary Artery Catheters. Crit Care Nurse 2021; 41:45-52. [PMID: 33560433 DOI: 10.4037/ccn2021957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients with indwelling pulmonary artery catheters have historically been excluded from participating in early mobility programs because of the concern for catheter-related complications. However, this practice conflicts with the benefits accrued from early mobilization. OBJECTIVE The purposes of this quality improvement project were to develop and implement a standardized ambulation protocol for patients with a pulmonary artery catheter in a cardiac surgery intensive care unit and to assess and support safe ambulation practices while preventing adverse events in patients with pulmonary artery catheters. METHODS From October 2016 through October 2017, this single-center quality improvement project developed and analyzed the implementation of a safe patient ambulation protocol in the cardiac surgery intensive care unit. Frontline nursing staff and the interdisciplinary team were educated on a standardized protocol that facilitated patient ambulation. Data analyzed included distance of ambulation, catheter migration, presence of cardiac dysrhythmias, and adverse events during ambulation. RESULTS During this 1-year project, 41 patients participated in 94 walks for a total distance of 13 676.38 m. There were no reported episodes of cardiac dysrhythmia, accidental occlusion of the pulmonary artery, catheter migration, or pulmonary artery rupture related to ambulation with a pulmonary artery catheter. CONCLUSIONS The use of a standardized ambulation protocol can successfully result in safe mobilization of patients with indwelling pulmonary artery catheters.
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Affiliation(s)
- Stephanie Sharma
- Stephanie Sharma is a nurse practitioner in the cardiac surgery intensive care unit at Cedars-Sinai Medical Center, Los Angeles, California
| | - Ma Andrea Lupera
- Ma Andrea Lupera is a registered nurse in the cardiac surgery intensive care unit at Cedars-Sinai Medical Center
| | - Alice Chan
- Alice Chan is an associate nursing director in the cardiac surgery intensive care unit at Cedars-Sinai Medical Center
| | - Michael Nurok
- Michael Nurok is medical director of the cardiac surgery intensive care unit and a professor of cardiac surgery in the Smidt Heart Institute at Cedars-Sinai Medical Center
| | - Lianna Z Ansryan
- Lianna Z. Ansryan is a clinical nurse specialist in the Nursing Research Department at Cedars-Sinai Medical Center
| | - Bernice Coleman
- Bernice Coleman is director of the Nursing Research Department, research scientist III, nurse practitioner, and assistant professor of biomedical sciences and medicine at Cedars-Sinai Medical Center
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Yano K, Toyama Y, Iida T, Hayashi K, Takahashi K, Kanda H. Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter. J Cardiothorac Vasc Anesth 2020; 35:1663-1669. [PMID: 33268041 DOI: 10.1053/j.jvca.2020.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE. DESIGN Prospective observational. SETTING Cardiac operating room at a single university hospital. PARTICIPANTS All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements. CONCLUSION A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.
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Affiliation(s)
- Kiichi Yano
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan.
| | - Yuki Toyama
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takafumi Iida
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kentaro Hayashi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Keiya Takahashi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
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43
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Basmaji J, Ball I, Jones P, Rochwerg B, Arntfield R. Critical care ultrasonography in shock management: the elephant in Canadian intensive care units. Can J Anaesth 2020; 67:1119-1123. [PMID: 32651852 DOI: 10.1007/s12630-020-01747-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/11/2020] [Accepted: 03/24/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
| | - Ian Ball
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Philip Jones
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Robert Arntfield
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Jacobzon E, Hasin T, Lifschitz A, Bogot N, Farkash A, Tager S, Silberman S. Is There a Need for a Pulmonary Artery Catheter in Cardiac Surgery Today? Semin Cardiothorac Vasc Anesth 2020; 25:29-33. [PMID: 32847478 DOI: 10.1177/1089253220951322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pulmonary artery catheters are a useful tool for hemodynamic monitoring in high-risk patients during surgery and while in intensive care. However, there are major risks inherent to the device, and with modern day technology, their routine use has decreased. We discuss the need for routine insertion of pulmonary artery catheters in cardiac surgery. We also present a case of a left ventricular assist device implantation complicated by serious pulmonary hemorrhage due to pulmonary artery catheter insertion, highlighting the potentially life-threatening risks involved.
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Affiliation(s)
- Ehud Jacobzon
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tal Hasin
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avital Lifschitz
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Naama Bogot
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adam Farkash
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Salis Tager
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shuli Silberman
- Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Takeda C, Takeuchi M, Mizota T, Yonekura H, Nahara I, Joo WJ, Dong L, Kawasaki Y, Kawakami K. The association between arterial pulse waveform analysis device and in-hospital mortality in high-risk non-cardiac surgeries. Acta Anaesthesiol Scand 2020; 64:928-935. [PMID: 32236951 DOI: 10.1111/aas.13584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/23/2020] [Accepted: 03/06/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Perioperative goal-directed fluid therapy is used for haemodynamic optimization in high-risk surgeries. Cardiac output monitoring can be performed by a specialized pressure transducer for arterial pulse waveform analysis (S-APWA). No study has assessed whether real-world use of S-APWA is associated with post-operative outcomes; therefore, using a Japanese administrative claims database, we retrospectively investigated whether S-APWA use is associated with in-hospital mortality among patients undergoing high-risk surgery under general anaesthesia. METHODS Adult patients who underwent high-risk surgery under general anaesthesia and arterial catheterization between 2014 and 2016 were divided into S-APWA and conventional arterial pressure transducer groups, then compared regarding baseline factors and outcomes. Logistic regression analysis was performed to compare in-hospital mortality. Subgroup analyses evaluated S-APWA efficacy and outcomes based on the type of surgery and patients' comorbidity. RESULTS S-APWA was used in 6859 of 23 655 (29.0%) patients; the crude in-hospital mortality rate was 3.5%. Adjusted analysis showed no significant association between S-APWA use and in-hospital mortality rate (adjusted odds ratio [aOR] = 0.91; 95% confidence interval [CI]: 0.76-1.07; P = .25). S-APWA use was associated with significantly lower in-hospital mortality in patients undergoing vascular surgery (aOR = 0.67; 95% CI: 0.49-0.94), and significantly higher in-hospital mortality in patients undergoing lower limb amputation (aOR = 2.63; 95% CI: 1.32-5.22). S-APWA use and in-hospital mortality were not significantly associated with other subgroups. CONCLUSION S-APWA use was not associated with in-hospital mortality in the entire study population. However, S-APWA was associated with decreased in-hospital mortality among vascular surgery and increased in-hospital mortality among lower limb amputation.
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Affiliation(s)
- Chikashi Takeda
- Department of Pharmacoepidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
- Department of Anesthesia Kyoto University Hospital Kyoto Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
| | | | - Hiroshi Yonekura
- Department of Clinical Anesthesiology Mie University Hospital Mie Japan
| | - Isao Nahara
- Department of Pharmacoepidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
| | - Woo J. Joo
- Department of Pharmacoepidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
| | - Li Dong
- Department of Anesthesia Kyoto University Hospital Kyoto Japan
| | - Yohei Kawasaki
- Clinical Research Center Chiba University Hospital Chiba Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology Graduate School of Medicine and Public Health Kyoto University Kyoto Japan
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Kim JH, Sunkara A, Varnado S. Management of Cardiogenic Shock in a Cardiac Intensive Care Unit. Methodist Debakey Cardiovasc J 2020; 16:36-42. [PMID: 32280416 DOI: 10.14797/mdcj-16-1-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Cardiogenic shock (CS) is a complex condition characterized by end-organ hypoperfusion and requiring pharmacologic and/or mechanical circulatory support. It is caused by a decline in cardiac output due to a primary cardiac disorder. CS is frequently complicated by multiorgan system dysfunction that requires a multidisciplinary approach in a critical care setting. Appropriate use of diagnostic data using tools available in a modern cardiac intensive care unit should guide optimal management incorporating both pharmacologic and nonpharmacologic therapies to minimize morbidity and mortality.
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Affiliation(s)
- Ju H Kim
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Anusha Sunkara
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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Nakayama A, Iwama K, Makise N, Domoto Y, Ishida J, Morita H, Komuro I. Use of a Non-invasive Cardiac Output Measurement in a Patient with Low-output Dilated Cardiomyopathy. Intern Med 2020; 59:1525-1530. [PMID: 32132339 PMCID: PMC7364242 DOI: 10.2169/internalmedicine.4271-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
A 49-year-old man was diagnosed with acute cardiac insufficiency based on evidence of congestive heart failure. The non-invasive measurement of the cardiac output using an AESCULON® mini showed low cardiac output (CO, 3.9 L/min). We administered an intravenous diuretic for cardiac edema and dobutamine drip for low cardiac output. Soon after starting dobutamine at 3.2 γ (microg/kg/min), the CO improved to 6.8 L/min. Combination therapy of diuretic and dobutamine resolved the heart failure. CO measurement by an AESCULON® mini was safe, cost-effective, and convenient. Data output correlates with the CO by Swan-Ganz catheterization. The non-invasive measurement of the CO permitted a smooth recovery without recurrence in this patient.
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Affiliation(s)
- Atsuko Nakayama
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Kentaro Iwama
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Naohiro Makise
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Yukako Domoto
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
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Shen J, Ma L, Huang H. Difficult removal: a Swan-Ganz catheter coiled on the central venous catheter. J Cardiothorac Surg 2020; 15:103. [PMID: 32430008 PMCID: PMC7236472 DOI: 10.1186/s13019-020-01149-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Swan-Ganz catheter plays an important role in gaining understanding of cardiac pathophysiology and in the hemodynamic monitoring of critically ill patients. Difficult removal of the Swan-Ganz catheter is a rare but serious complication. CASE PRESENTATION This case presents the difficult removal of a Swan-Ganz catheter in a 28-year-old female patient after cardiac surgery. Fluoroscopy and chest X-ray revealed that a portion of the Swan-Ganz catheter was coiled on the central venous catheter at the level of the superior vena cava. Under X-ray guidance, the central venous catheter was first removed, and then the Swan-Ganz catheter was successfully withdrawn through the percutaneous introducer sheath. CONCLUSIONS This case report provides an unreported reason for difficult removal and describes a successful solution. This report suggests that X-ray examinations may be necessary before removing the Swan-Ganz catheter.
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Affiliation(s)
- Jian Shen
- Department of Anesthesiology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, Jiangsu Province, 210029, PR China
| | - Luyao Ma
- Department of Cardiovascular Surgery, First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - He Huang
- Department of Anesthesiology, First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, Jiangsu Province, 210029, PR China.
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Leurent G, Delmas C, Auffret V, Bonnefoy E, Puymirat E, Roubille F. The 50-year-old pulmonary artery catheter: the tale of a foretold death? ESC Heart Fail 2020; 7:783-785. [PMID: 32314540 PMCID: PMC7261538 DOI: 10.1002/ehf2.12702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/24/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Guillaume Leurent
- Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, Univ Rennes 1, F-35000, Rennes, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Department of Cardiology, Rangueil University Hospital; INSERM 1048 Metabolic and Cardiovascular Disease Institute, 31059, Toulouse, France
| | - Vincent Auffret
- Department of Cardiology, CHU Rennes, Inserm, LTSI-UMR 1099, Univ Rennes 1, F-35000, Rennes, France
| | - Eric Bonnefoy
- Department of Cardiac Critical Care, Hospices Civils de Lyon, Lyon, France
| | - Etienne Puymirat
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP); Hôpital Européen Georges Pompidou (HEGP), Paris, France.,Université de Paris, Paris, France
| | - FranÇois Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, CHU de Montpellier, France
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50
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Gorrasi J, Pazos A, Florio L, Américo C, Lluberas N, Parma G, Lluberas R. Cardiac output measured by transthoracic echocardiography and Swan-Ganz catheter. A comparative study in mechanically ventilated patients with high positive end-expiratory pressure. Rev Bras Ter Intensiva 2020; 31:474-482. [PMID: 31967221 PMCID: PMC7008993 DOI: 10.5935/0103-507x.20190073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/16/2019] [Indexed: 01/18/2023] Open
Abstract
Objective To compare cardiac output measurements by transthoracic echocardiography and a pulmonary artery catheter in mechanically ventilated patients with high positive end-expiratory pressure. To evaluate the effect of tricuspid regurgitation. Methods Sixteen mechanically ventilated patients were studied. Cardiac output was measured by pulmonary artery catheterization and transthoracic echocardiography. Measurements were performed at different levels of positive end-expiratory pressure (10cmH2O, 15cmH2O, and 20cmH2O). The effect of tricuspid regurgitation on cardiac output measurement was evaluated. The intraclass correlation coefficient was studied; the mean error and limits of agreement were studied with the Bland-Altman plot. The error rate was calculated. Results Forty-four pairs of cardiac output measurements were obtained. An intraclass correlation coefficient of 0.908 was found (p < 0.001). The mean error was 0.44L/min for cardiac output values between 5 and 13L/min. The limits of agreement were 3.25L/min and -2.37L/min. With tricuspid insufficiency, the intraclass correlation coefficient was 0.791, and without tricuspid insufficiency, 0.935. Tricuspid insufficiency increased the error rate from 32% to 52%. Conclusions In patients with high positive end-expiratory pressure, cardiac output measurement by transthoracic echocardiography is comparable to that with a pulmonary artery catheter. Tricuspid regurgitation influences the intraclass correlation coefficient. In patients with high positive end-expiratory pressure, the use of transthoracic echocardiography to measure cardiac output is comparable to invasive measures.
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Affiliation(s)
- José Gorrasi
- Cátedra de Medicina Intensiva y Centro de Tratamiento Intensivo, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay.,Departamento y Cátedra de Emergencia, Hospital de Clínicas, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - Arturo Pazos
- Cátedra de Cardiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - Lucia Florio
- Cátedra de Cardiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - Carlos Américo
- Cátedra de Cardiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - Natalia Lluberas
- Cátedra de Cardiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - Gabriel Parma
- Cátedra de Cardiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - Ricardo Lluberas
- Cátedra de Cardiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
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