Search Results (719)

Echocardiographic assessment is essential for evaluating patients with cardiogenic shock (CS) and determining their potential need for mechanical circulatory support (MCS) implantation. The use of Impella devices has increased significantly in recent years, paralleling the growing recognition of their hemodynamic benefits in selected patient populations. As the clinical experience with these devices has expanded, the need for a more standardized imaging approach has emerged. Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) play complementary roles in guiding the pre-implantation evaluation, placement procedure, and post-implantation management of Impella devices. Currently, no comprehensive guidelines exist concerning the echocardiographic evaluation of Impella devices throughout their entire clinical course, from initial patient selection and device implantation to ongoing monitoring and eventual weaning. This gap in standardized guidance has led to significant variability in clinical practice across different institutions and healthcare systems. This comprehensive review examines the role of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in managing patients on Impella support across five distinct phases: candidate identification and pre-implantation assessment, intraoperative procedural guidance and device positioning, postoperative monitoring and haemodynamic optimisation, complication detection and troubleshooting, and weaning strategies with post-explantation surveillance. Both left-sided devices (Impella CP, CP Smart Assist, and Impella 5.5) and right-sided support (Impella RP) are covered, including combined configurations with VA-ECMO (ECPella). For each phase, we detail the recommended echocardiographic views, essential measurements and their evidence-based thresholds, signs of device malposition, and practical corrective strategies. A level-of-evidence approach is adopted throughout, specifying whether proposed thresholds derive from randomised trials, observational studies, expert consensus, or manufacturer recommendations. Summary tables and a bedside workflow are provided to facilitate immediate clinical application. Full article

Background/Objectives: Acute hemodynamic collapse is a rare but deadly complication of transcatheter aortic valve replacement (TAVR) that can require temporary mechanical circulatory support (tMCS). Using a statewide collaborative, we conducted a focused analysis on the incidence and outcomes associated with the use of tMCS during TAVR as hemodynamic rescue. Methods: We identified adult patients who underwent TAVR between September 2012 and September 2024 within the statewide collaborative and stratified them based on if tMCS was needed. Baseline patient characteristics and risk factors associated with tMCS use were analyzed as well as the impact of tMCS on outcomes. Results: We identified 7735 patients who underwent TAVR. A total of 44 (0.57%) patients required tMCS. Patients requiring tMCS were more likely to have histories that included diabetes, concurrent mitral regurgitation, prior MI, or NYHA class III or IV. These patients also experienced more emergent procedures and were more likely to require inotropic support. Patients experienced significantly worse outcomes following tMCS rescue during TAVR, with 18% requiring conversion to surgical approach (vs. 1%, p < 0.001) and 37% of tMCS patients experiencing cardiac arrest, compared to 1% of those who did not need tMCS (p < 0.001). Thirty-day mortality was worse for patients requiring tMCS (p < 0.001). MCS usage was independently associated with the need for further procedures. Conclusions: Unplanned, emergent tMCS during TAVR as hemodynamic rescue represents significant risk of complications and should be utilized judiciously in cases of acute hemodynamic collapse. Full article

Background: Unfractionated heparin (UFH) remains the standard anticoagulant for extracorporeal membrane oxygenation (ECMO), despite complications, such as heparin resistance, heparin-induced thrombocytopenia, bleeding and variable pharmacokinetics. This has prompted the search for alternative and novel anticoagulation strategies, including pharmacologic agents, circuit modifications, and monitoring approaches. This scoping review aimed to map the breadth and characteristics of evidence on ECMO anticoagulation strategies beyond UFH. Methods: A comprehensive search of peer-reviewed and gray literature was conducted across PubMed, Cochrane, Clinical Trials, WHO Trials Registry, and conference abstracts through manual searches in key journals. Clinical, pre-clinical, and gray literature studies evaluating pharmacologic agents, anticoagulation-free or heparin-sparing, biocompatible circuits, and monitoring innovations were included. Data were charted and synthesized descriptively to identify trends, gaps, and emerging directions. Results: A total of 269 records were included. Evidence was highly heterogeneous among study designs, populations, ECMO modalities, and outcome definitions. Most clinical studies were retrospective cohorts and adult-centered, with limited multicenter randomized controlled trials and underrepresentation of neonatal and pediatric populations. Direct thrombin inhibitors were frequently studied and clinically implemented alternatives to UFH. Other agents, including nafamostat mesylate, prostaglandin E1, and factor pathway inhibitors remain early in clinical investigation. Anticoagulation-free strategies and biocompatible circuit technologies were mostly supported through pre-clinical and single-center studies. Monitoring and modeling innovations, like TEG, ROTEM, real-time imaging, and machine learning, are quickly emerging. Conclusions: ECMO anticoagulation is transitioning from UFH reliance toward diversified and personalized strategies. Future research should prioritize multicenter randomized controlled trials, standardize protocols, expand to neonatal and pediatric investigation, and integrate strategies. Full article

Background/Objectives: Heart rate variability (HRV) and cerebral autoregulation (CAR) reflect physiologic processes that may influence neurological injury in children supported with extracorporeal membrane oxygenation (ECMO). Although abnormalities in both have been associated with adverse neurological outcomes, their physiologic relationship during ECMO remains unclear. Methods: This retrospective single-center study evaluated the association between HRV and CAR during the first 24 h of ECMO support and assessed their independent relationships with neurological outcome. Patients with at least two hours of simultaneous HRV and CAR monitoring within 24 h of ECMO initiation were included. HRV metrics were derived from artifact-free NN intervals across time, frequency, and nonlinear domains, while CAR was quantified using the cerebral oximetry index (COx), with impaired CAR defined as COx > 0.3. Associations between HRV indices and COx were examined using Spearman correlations at hourly and 24 h resolutions. Unfavorable outcome was defined as death or a Pediatric Cerebral Performance Category (PCPC) score ≥3 at discharge with deterioration from baseline. Results: Eighty-nine patients met inclusion criteria, and 16% demonstrated impaired CAR. HRV measures were reduced relative to age-adjusted norms in both CAR groups without significant differences between groups. Correlations between HRV indices and COx were consistently weak. Overall, 50% experienced unfavorable neurological outcomes. In adjusted logistic regression models, NN skewness and COx were independently associated with outcome, although only NN skewness remained significant in interaction analyses. Conclusions: HRV and CAR exhibited limited physiological coupling during early ECMO support, while each measure provided independent prognostic information with respect to neurological outcome. Full article

Background/Objectives: While caregiver burden in Inflammatory Bowel Disease (IBD) is well documented, the association between informal support and patient-reported outcomes (PROs), particularly health-related quality of life (QoL) and psychological well-being, remains underexplored. This systematic review synthesizes evidence on the association of informal caregiving on patient-reported QoL and psychosocial outcomes and maps the available evidence on clinical outcomes. Methods: Following international reporting guidelines and prospective protocol registration, a systematic search was conducted across five electronic databases between May and October 2025. Observational studies in adults with IBD assessing informal support and patient-reported or psychosocial outcomes were included. Owing to substantial heterogeneity in constructs and outcome measures, results were synthesised using a structured Synthesis Without Meta-analysis (SWiM) approach. Methodological quality was assessed using standardised critical appraisal checklists. Results: Six cross-sectional studies involving 1036 patients and 417 informal caregivers met the inclusion criteria. All studies reported a positive direction of association between higher levels or better quality of informal caregiver support and improved patient-reported QoL. Several studies identified psychological and relational factors, such as lower patient psychological distress and caregiver-related positive feelings and caring ability, as mechanisms statistically associated with this relationship. Conclusions: Available cross-sectional evidence suggests a positive association between informal support and patient-reported QoL/psychological outcomes in IBD, but causality cannot be inferred. Priorities include longitudinal dyadic studies and caregiver-inclusive interventions, alongside standardised definitions and measures of support. Full article

Heparin remains a foundational parenteral anticoagulant across both acute and chronic care settings. This narrative review summarizes clinical indications and dosing of unfractionated (UFH) and low-molecular-weight heparin (LMWH). It also details laboratory monitoring using activated partial thromboplastin (APTT), anti-factor Xa (anti-Xa), activated clotting time (ACT) and viscoelastic testing (VET), including common pitfalls and interferences. We provide considerations for specific populations as well as complications including heparin resistance, heparin-induced thrombocytopenia (HIT) and heparin reversal strategies. Future research directions include harmonization of therapeutic ranges, mitigation of assay interference and prospective evaluation on monitoring, particular in extracorporeal membrane oxygenation (ECMO), pregnancy and cardiac surgical settings. Full article

Background: Carinal resections remain a challenging and demanding surgical technique for both the patient and medical professionals. The most common indications are adenoid cystic carcinoma and bronchogenic carcinoma. There have been no randomized controlled trials because of the low incidence of pathologic processes suited to carinal resections and the difficulties associated with designing such studies. Methods: The known data are limited to a few single-institutional, retrospective studies over the last several decades. In this review article, we focus on the available data regarding surgical techniques and the types of ventilation that can help in the construction of the anastomosis—the most crucial part of the operation. Important issues regarding carinal resections are discussed in detail. Results: The available literature is reviewed in detail regarding indications, surgical techniques and approaches, types of ventilation, the rates of morbidity and mortality, and 5-year survival. The authors present their experience with two patients, where they utilized ECMO and crossfield ventilation. The role of minimally invasive surgery in carinal resections is also discussed. Conclusions: Carinal resections are complex surgical procedures, but acceptable mortality and morbidity rates can be achieved in carefully selected patients. Excellent cooperation between the surgeon and anesthesiologist is essential in the construction of the anastomosis. Various types of airway management, especially ECMO, help to reduce complication rates and facilitate secure airway reconstruction. Full article

Background: Human serum albumin (HSA), the most abundant plasma protein, is essential for oncotic pressure, endothelial protection, drug binding, and immune modulation. Despite its widespread clinical use since the 1940s, its therapeutic benefit in critically ill patients remains debated. This narrative review summarizes current evidence on HSA use in common intensive care scenarios. Clinical Applications: In hepatorenal syndrome (HRS), albumin combined with vasoconstrictors like terlipressin improves renal function and survival. In spontaneous bacterial peritonitis (SBP), albumin lowers the risk of acute kidney injury and mortality, particularly in high-risk cirrhotic patients. Post-paracentesis albumin reduces circulatory dysfunction and may enhance survival in cirrhosis. For septic shock, trials show no overall mortality benefit over crystalloids, though albumin may offer hemodynamic advantages in specific subgroups. In acute respiratory distress syndrome (ARDS), albumin improves oxygenation in hypoalbuminemic patients, without survival benefits. During major cardiac or abdominal surgery, albumin reduces fluid needs and postoperative complications, especially in hypoalbuminemic individuals. In acute brain injury, albumin’s role is controversial: it may aid recovery after cerebral hemorrhage, but can worsen outcomes in traumatic brain injury. In trauma and ECMO patients, albumin may stabilize hemodynamics and improve outcomes in selected cases. Conclusions: Inappropriate albumin use remains common, and evidence on its optimal concentration, dose, timing, and patient selection is limited. HSA is safe and beneficial in specific situations. Routine use should follow evidence-based guidelines. Future research must identify patients who are most likely to benefit and clarify optimal dosing strategies, concentrations, and therapeutic goals. Full article

Background: To address organ shortage and reduce waitlist mortality, the use of extended criteria donors (ECDs) in heart transplantation is increasing. Methods: We retrospectively analysed outcomes in 236 heart transplant recipients: 140 received standard donor (SD) hearts and 96 received ECD hearts. Results: No significant differences were found in early or mid-term survival between the SD and ECD groups with a 30-day mortality rates of 13% vs. 10% (p = 0.662) and estimated 1-year survival of 75% (95% CI: 62.3–78.3%) and 71% (95% CI: 55.3–76.2%) (p = 0.556), respectively. Mechanical ventilation prior to transplant (p < 0.001), ischemic time (p = 0.022), peripheral vascular disease (p = 0.011), and chronic obstructive pulmonary disease (p = 0.022) were the only independent predictors of mortality. Conclusions: In our cohort, heart transplantation using ECD was not associated with increased early or mid-term adverse events. This approach may help expand the donor pool without compromising post-transplant outcomes. Full article

Background/Objectives: Extracorporeal membrane oxygenation (ECMO) use has increased worldwide, yet in-hospital mortality among adult recipients remains substantial. Large-scale evidence examining patient- and treatment-related factors associated with mortality in real-world settings is still limited. This study aimed to quantify in-hospital mortality and identify factors associated with mortality among adults receiving ECMO using a nationwide cohort in Taiwan. Methods: We conducted a retrospective nationwide cohort study using Taiwan’s National Health Insurance Research Database, including adults (≥18 years) who received ECMO during hospitalization between 2011 and 2020. ECMO indication groups were defined using ICD-9-CM (before 2016) and ICD-10-CM (2016 onward) codes and further classified into four mutually exclusive categories. Multivariable logistic regression was used to examine factors associated with in-hospital mortality. Results: Among 15,151 adults treated with ECMO, 9657 (63.7%) died during hospitalization. In multivariable analyses, higher odds of in-hospital mortality were associated with older age, higher comorbidity burden (Charlson Comorbidity Index ≥3), and use of multiple ECMO machines (≥2). Compared with patients without cardiopulmonary indications, those classified as cardiogenic shock alone or combined respiratory failure and cardiogenic shock had lower adjusted odds of in-hospital mortality. Longer hospital length of stay was inversely associated with in-hospital mortality, reflecting differing care trajectories among ECMO recipients. Conclusions: In this nationwide real-world cohort of adult ECMO recipients, in-hospital mortality was high, and mortality risk was associated with patient age, comorbidity burden, ECMO treatment complexity, and diagnosis-based indication classification. These findings provide population-level insight into mortality patterns and may inform risk communication and system-level planning for ECMO care. Full article

Background: Since 2018, the number of left ventricular assist devices (LVAD) implantations in Korea has been steadily increasing. Consequently, an increasing number of LVAD patients are presenting for non-cardiac surgery (NCS) of varying complexity. However, recent data on the perioperative management and clinical course of these patients remain limited. We share our investigation on patient and perioperative risk factors, as well as perioperative adverse outcomes, including mortality, in LVAD patients undergoing NCS. Methods: We retrospectively reviewed medical records of 36 LVAD patients who underwent NCS at our tertiary care center between 2018 and 2024. Patients requiring VA-ECMO were excluded. The primary end point was in-hospital mortality. The secondary end point was a composite of complications, including postoperative pulmonary complications, acute kidney injury, cerebrovascular accident, postoperative bleeding or thrombosis, and hemodynamic instability. Using univariable and multivariable logistic regression analysis, we examined the correlation between perioperative factors and adverse outcomes. Results: A total of 53 NCS index cases across 40 hospitalizations were analyzed. General surgery was the most common specialty (n = 19, 35.8%), followed by thoracic surgery (n = 13, 24.5%), plastic surgery (n = 7, 13.2%), and neurosurgery (n = 4, 7.5%). Thirteen procedures (24.5%) were classified as major surgeries. Postoperative complications occurred in 24 patients (66.7%), and 8 patients (20%) experienced mortality. Multivariable regression analysis identified major surgery (adjusted odds ratio [aOR] 1.44; 95% CI 1.11–1.86; p = 0.010), and intraoperative transfusion of ≥3 units of packed red blood cells (aOR 1.47; 95% CI 1.05–2.04; p = 0.029) as significant predictors of in-hospital mortality. Undergoing NCS within 180 days after LVAD implantation was associated with an increased risk of composite complications (aOR 1.86; 95% CI 1.53–2.27; p < 0.001). Conclusions: LVAD patients undergoing non-cardiac surgery frequently experience postoperative complications. Major surgeries, significant intraoperative transfusions, and early surgery following LVAD implantation are key predictors of poor outcomes. Careful risk assessment and tailored perioperative management are essential in this population. Full article

Cardiogenic shock (CS) remains a life-threatening syndrome characterized by reduced cardiac output and end-organ hypoperfusion, most commonly resulting from acute myocardial infarction (AMI). Despite advances in early revascularization and increasing use of percutaneous mechanical circulatory support (MCS), short-term mortality in AMI-related CS (AMI-CS) remains high. This review summarizes the contemporary evidence on short-term percutaneous MCS in AMI-CS, with a focus on intra-aortic balloon pump (IABP), Impella microaxial flow pumps, and venoarterial extracorporeal membrane oxygenation (VA-ECMO), and provides insights into device selection and implementation in clinical practice. We performed a comprehensive analysis of the most relevant randomized controlled trials and key guideline recommendations from European and North American societies concerning the use of MCS. Despite its long-standing, IABP has not demonstrated a mortality benefit in contemporary trials and is no longer recommended for routine use in AMI-CS without mechanical complications. Nevertheless, it remains widely used due to its simplicity, safety profile, and broad availability. In contrast, Impella devices provide active left ventricular unloading and have shown promising hemodynamic effects, with the DanGer Shock trial suggesting a potential survival benefit in carefully selected patients, at the expense of higher complication rates. VA-ECMO offers full cardiopulmonary support but is associated with the highest complication rates and increases left ventricular afterload, often requiring adjunctive unloading with devices such as Impella (ECPELLA). However, recent randomized trials have not demonstrated a clear survival advantage for VA-ECMO, and concerns regarding its complications persist. In conclusion, CS continues to pose major therapeutic challenges, and no single MCS device has consistently shown a survival benefit across all AMI-CS patient populations. Individualized, phenotype-driven strategies that incorporate hemodynamic profiling and timely escalation of support are essential. Further randomized studies are urgently needed to define optimal device selection, the timing of placement, and appropriate patient selection criteria. Institutional protocols guided by clinical stage, etiology, and available expertise will be pivotal in improving outcomes. Full article

Neuron-specific enolase (NSE) is a marker used to assess neurological impairment. Notwithstanding, the release of NSE into the circulation can also originate from erythrocytes and thrombocytes, signifying that even mild instances of hemolysis have the potential to induce heightened serum NSE levels. The present study addresses the question of whether the serum NSE level is a reliable parameter for assessing potential brain damage in patients undergoing extracorporeal membrane oxygenation (ECMO). To this end, NSE values of all non-resuscitated ECMO patients treated at our clinic from January 2020 to March 2022 were retrospectively evaluated. Serum NSE levels were found to be median 35.95 µg/L, with significant intrapersonal variability during ECMO therapy. A comparative analysis in ECMO patients with and without diagnosed brain damage revealed no statistically significant differences. In contrast, the concurrent measurement of serum LDH and NSE levels exhibited a significant positive correlation (Spearman Rho 0.69), indicating that the elevated serum NSE levels exhibited by patients devoid of cerebral impairment were attributable to the occurrence of ECMO-induced hemolysis. Consequently, the prognostic value of serum NSE levels in patients undergoing ECMO is restricted. The data also demonstrate that individual measurements of serum NSE levels in ECMO patients should be regarded as snapshots with only limited significance. Full article

Background: Therapeutic prone positioning is widely used to improve oxygenation in patients with acute respiratory distress syndrome but is associated with an increased risk of pressure injuries, particularly affecting facial and anterior body regions. Methods: This systematic review was conducted according to PRISMA 2020 and Joanna Briggs Institute guidelines and was prospectively registered in PROSPERO (CRD42023442604). PubMed, CINAHL, Web of Science, Scopus, and the Cochrane Library were searched from inception to June 2025, including grey literature. Primary studies involving adult, mechanically ventilated patients undergoing therapeutic prone positioning and evaluating pressure injury prevention strategies were included. Methodological quality was assessed using JBI critical appraisal tools. Owing to clinical and methodological heterogeneity, findings were synthesized using a Synthesis Without Meta-analysis (SWiM) approach. Results: Eight studies with heterogeneous designs were included. Preventive interventions mainly comprised prophylactic dressings, repositioning and support devices, and comprehensive care bundles. Most strategies were associated with a reduction in pressure injury incidence, particularly in facial and anterior anatomical areas. Greater effectiveness was observed when interventions were implemented within structured protocols supported by staff training and multidisciplinary coordination. Conclusions: Preventive strategies appear effective in reducing pressure injuries associated with prone positioning in critically ill patients. The implementation of standardized, bundled prevention protocols may improve patient safety in intensive care settings. Full article

Excessive right heart load imposes an acute or chronic injury on the right ventricle (RV), predisposing critically ill neonates and cardiac surgical patients to RV failure, low cardiac output syndrome, and death. Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator that improves ventilation–perfusion matching and unloads the RV without systemic hypotension; nonetheless, its application beyond established neonatal indications remains contentious. Our review synthesizes current mechanistic, translational, and clinical evidence regarding iNO use in three major settings characterized by excessive RV load: (1) neonatal pulmonary hypertension, particularly PPHN; (2) acute and chronic RV overload in older children and adults, including secondary pulmonary hypertension, acute respiratory distress syndrome (ARDS), and acute pulmonary embolism; and (3) perioperative and post-cardiopulmonary bypass (CPB) management in congenital and adult cardiac surgery. In term and near-term infants with hypoxic respiratory failure, pivotal randomized trials show that iNO consistently improves oxygenation and reduces extracorporeal membrane oxygenation (ECMO) use, but this has little effect on survival and long-term neurodevelopment. In ARDS and other adult critical-care indications, iNO provides transient improvements in gas exchange and RV performance without reducing mortality or ventilator duration, and meta-analyses signal an increased risk of acute kidney injury, particularly with prolonged use. In contrast, perioperative studies around CPB demonstrate that prophylactic postoperative iNO and intra-CPB nitric oxide administration can attenuate pulmonary hypertensive crises, facilitate separation from CPB, shorten ventilation and intensive care stay, and, in selected high-risk cohorts, may reduce cardiac surgery-associated acute kidney injury, although survival benefits remain unproven. Across these scenarios, iNO should be used judiciously and in a pathophysiology-driven manner as a time-limited, targeted adjunct to stabilize patients with documented or anticipated RV strain rather than a disease-modifying therapy. Future work should refine patient selection, timing, dosing, and weaning strategies, and define the long-term safety and cost-effectiveness of iNO within contemporary multimodal RV support pathways. Full article