Search Results (67)

Background and Objectives: Effective myocardial protection is essential for successful cardiac surgery outcomes, especially in complex and prolonged procedures. To this end, Del Nido (DN) and histidine-tryptophan-ketoglutarate (HTK) cardioplegia solutions are widely used; however, their comparative efficacy in adult surgeries with prolonged aortic cross-clamp (ACC) times remains unclear. This study aimed to compare the efficacy and safety of DN and HTK for myocardial protection during prolonged ACC times in adult cardiac surgery and to define clinically relevant thresholds. Materials and Methods: This retrospective study included a total of 320 adult patients who underwent cardiac surgery under cardiopulmonary bypass (CPB) with an aortic cross-clamp time ≥ 90 min. Data were collected from the medical records of elective adult cardiac surgery cases performed at a single center between 2019 and 2025. Patients were categorized into two groups based on the type of cardioplegia received: Del Nido (n = 160) and HTK (n = 160). The groups were compared using 1:1 propensity score matching. Clinical and biochemical outcomes—including troponin I (TnI), CK-MB, lactate levels, incidence of low cardiac output syndrome (LCOS), and need for mechanical circulatory support—were analyzed between the two cardioplegia groups. Subgroup analyses were performed according to ACC duration (90–120, 120–150, 150–180 and >180 min). The predictive threshold of ACC duration for each complication was determined by ROC analysis, followed by the analysis of independent predictors of each endpoint by multivariate logistic regression. Results: Intraoperative cardioplegia volume and transfusion requirements were lower in the DN group (p < 0.05). HTK was associated with lower TnI levels and less intra-aortic balloon pump (IABP) requirement at ACC times exceeding 180 min. Markers of myocardial injury were lower in patients with an ACC duration of 120–150 min in favor of HTK. The propensity for ventricular fibrillation after ACC was significantly lower in the DN group. Significantly lower postoperative sodium levels were observed in the HTK group. Prolonged ACC duration was an independent risk factor for LCOS (odds ratio [OR]: 1.023, p < 0.001), VIS > 15 (OR, 1.015; p < 0.001), IABP requirement (OR: 1.020, p = 0.002), and early mortality (OR: 1.016, p = 0.048). Postoperative ejection fraction (EF), troponin I, and CK-MB levels were associated with the development of LCOS and a VIS > 15. Furthermore, according to ROC analysis, HTK cardioplegia was able to tolerate ACC for up to a longer duration in terms of certain complications, suggesting a higher physiological tolerance to ischemia. Conclusions: ACC duration is a strong predictor of major adverse outcomes in adult cardiac surgeries. Although DN cardioplegia is effective and economically advantageous for shorter procedures, HTK may provide superior myocardial protection in operations with long ACC duration. This study supports the need to individualize cardioplegia choice according to ACC duration. Further prospective studies are needed to establish standard dosing protocols and to optimize cardioplegia selection according to surgical duration and complexity. Full article

Background/Objectives: High-risk percutaneous coronary interventions (HR-PCIs) often require mechanical circulatory support (MCS) to maintain hemodynamic stability. Intra-aortic balloon pump (IABP) and percutaneous left ventricular assist device (PLVAD) are two commonly used MCS devices that differ in their mechanisms. We aimed to evaluate and compare the clinical outcomes associated with IABP and PLVAD use in HR-PCIs without cardiogenic shock. Methods: We conducted a search of PubMed, Scopus, Cochrane, Mendeley, Web of Science, and Embase to identify relevant randomized controlled trials and cohort studies, and we included 13 studies for the systematic review and meta-analysis. The primary goal was to define the difference in early mortality (in-hospital and 30-day mortality), major bleeding, and major adverse cardiovascular event (MACE) components (cardiogenic shock, acute kidney injury (AKI), and stroke/TIA) in IABP and PLVAD. We used a random-effects model with the Mantel–Haenszel statistical method to estimate odds ratios (ORs) and 95% confidence intervals. Results: Among 1 trial and 12 cohort studies (35,554 patients; 30,351 IABP and 5203 PLVAD), HR-PCI with IABP was associated with a higher risk of early mortality (OR = 1.53, 95% CI [1.21, 1.94]) and cardiogenic shock (OR = 2.56, 95% CI [1.98, 3.33]) when compared to PLVAD. No significant differences were found in the rates of arrhythmia, major bleeding, AKI, stroke/TIA, or hospital length of stay. Conclusions: In high-risk PCIs, PLVAD use is associated with lower early mortality and cardiogenic shock risk compared to IABP, with no significant differences in other major outcomes. Full article

Background: Intra-aortic balloon pump (IABP) augments coronary perfusion during high-risk percutaneous coronary interventions (PCI). We sought to identify patients who benefited from prophylactic IABP (P-IABP) compared to rescue-IABP (R-IABP). Methods: All consecutive non-cardiogenic shock patients undergoing high-risk PCI with IABP support at Ulm University Hospital, Germany, between 2012 and 2020 were grouped based on the timing of IABP insertion in the pre-interventional P-IABP or peri-interventional R-IABP group. We compared the primary endpoint peri-interventional high-sensitivity Troponin T (hsTnT) increase, sought baseline characteristics associated with the endpoint in the R-IABP group, and compared their correlation strengths between the groups. Results: Interventional outcomes of 44 patients with P-IABP implantation were compared with those of 15 patients with R-IABP implantation. P-IABP was associated with a lower peri-interventional hsTnT increase (p = 0.008, r = 0.390). In the R-IABP group, the presence of ST-segment elevation (p = 0.037, r = 0.631), low systolic blood pressure (RRsyst) (p = 0.007, r = 0.893 (inverse correlation)), and elevated NT-proBNP levels (p < 0.001, r = 0.953) were associated with higher hsTnT increases. HsTnT increase was significantly smaller in the P-IABP group in patients with low RRsyst (IZI = 2.6) and high NT-proBNP levels (IZI = 3.36). Patients with RRsyst < 120 mmHg (p = 0.007) and NT-proBNP levels ≥ 900 pg/mL (Cohen’s d = 0.70, respectively 1.17 for ≥5000 pg/mL and 5.01 for ≥10,000 pg/mL) showed lower peri-interventional hsTnT increase when treated with P-IABP compared to R-IABP, while patients with NT-proBNP levels < 900 pg/mL showed a contrary effect (Cohen’s d = −0.90). Cox regression analysis showed that a high peri-interventional hsTnT increase was significantly associated with a shorter survival time (p = 0.046). Conclusions: P-IABP use in high-risk PCI was associated with reduced peri-interventional myocardial injury, as measured by lower hsTnT increase, which was associated with improved survival in patients with low systolic blood pressure and elevated NT-proBNP levels. Thus, these conditions should be considered for indicating P-IABP. Full article

Heart failure is a heterogeneous disorder that can lead to cardiogenic shock. Mechanical circulatory support (MCS) devices can replace the cardiac function in an attempt to bridge patients to transplant or they can serve as destination therapy to improve overall patient functionality and in turn quality of life. Currently utilized MCS devices include devices such as Left Ventricular Assist Devices (LVADs), Biventricular Assist Devices (BiVADs), Impella, Total Artificial Hearts (TAHs), and extracorporeal membrane oxygenation (ECMO). This literature review examines a range of studies, case reports, and meta-analyses to present current approaches to mechanical circulatory support (MCS), along with the challenges and limitations of existing devices, common complications, and overall survival and long-term outcomes following MCS therapy. Full article

Background and Clinical Significance: Ventricular septal defect (VSD) is a rare but serious complication following myocardial infarction (MI) that can lead to cardiogenic shock and carries a high mortality rate. Acute mitral regurgitation (MR) is another severe complication of MI with additional risks of mortality. The optimal timing of surgical intervention for VSD with MR is still being debated, and delaying surgery in medically manageable patients has been associated with improved survival. However, managing these patients in the intensive care unit (ICU) presents unique challenges. Case Presentation: In this paper, we present the case of a 52-year-old male with comorbidities who developed post-MI VSD with severe MR and underwent successful delayed surgical repair and mitral valve replacement. Our aim is to highlight the clinical characteristics, diagnostic approach, and management strategies of this rare complication in the critical care setting. The patient presented in cardiogenic shock and acute pulmonary edema. After stabilization using an intra-aortic balloon pump, pre- and afterload reducing pharmacotherapy and non-invasive mechanical ventilation, a watchful waiting strategy was employed, and surgery was performed on day 21 after hospital admission. Surgery was performed under general anesthesia, and the patient did not develop any complications related to the intra-aortic balloon pump or novel organ dysfunction. Conclusions: This case highlights the importance of a multidisciplinary approach to managing post-MI VSD with MR and emphasizes the need for careful patient selection and timing of surgical intervention in the critical care setting. Clinicians should be aware of the potential benefits of delaying surgical intervention in medically manageable patients, while also considering the unique challenges of managing these patients in the ICU. Full article

We investigated echocardiographic and hemodynamic effects of intraaortic balloon pump (IABP) in 26 patients with cardiogenic shock on veno-arterial membrane oxygenation (VA ECMO). Our study demonstrated an 8.1% increase in left ventricular velocity time integral (p = 0.023) without reduction in left ventricular diameters and 4.7% decrease in right ventricular end diastolic base diameter (p = 0.05) when using IABP 1:1 mode compared to no augmentation. This was associated with a 3.2% decrease in heart rate (p < 0.001) and a 3.0% increase in mixed venous oxygen saturation (p = 0.057). Since the magnitude of the documented favorable changes is rather small, the clinical relevance of concomitant IABP in patients with cardiogenic shock on VA ECMO remains questionable. Full article

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the management of refractory cardiogenic shock (CS) has been widely used in recent years. Increased left ventricular (LV) afterload induced by retrograde flow remains a limiting factor, which is particularly evident during peripheral VA ECMO support. The concomitant use of the intra-aortic balloon pump (IABP) is an established strategy to achieve LV unloading during VA ECMO support. Nevertheless, there remains controversy about the combined use of IABP during central or peripheral VA ECMO in terms of beneficial effects and outcome. We developed a simulation setting to study left ventricular unloading with IABP during peripheral and central VA ECMO using CARDIOSIM©, an established software simulator of the cardiovascular system. The aim was to quantitatively evaluate potential differences between the two VA ECMO configurations and ascertain the true beneficial effects compared to VA ECMO alone. The combined use of central VA ECMO and IABP decreased left ventricular end systolic volume and left ventricular end diastolic volume by 5–10%; right ventricular end systolic volume and right ventricular end diastolic volume by 10–20%; left atrial end systolic volume and left atrial end diastolic volume by 5–10%. Up to 25% reduction in mean left atrial pressure, up to 15% reduction in pulmonary capillary wedge pressure and up to 25% reduction in mean pulmonary arterial pressure was observed. From an energetic point of view, left ventricular external work decreased by 10–15% whilst up to 40%vreduction in right ventricular external work was observed. The findings make central VA ECMO plus IABP the most appropriate combination for left and right ventricle unloading. Full article

Myocardial Bridging (MB) is typically a benign congenital coronary anomaly. MB can infrequently result in complications such as myocardial ischemia, arrhythmias, and sudden cardiac death. Recent studies suggest an underlying genetic component for MB involving DES, FBN1, SCN2B, or NOTCH1. The role of percutaneous coronary intervention (PCI) in managing MB, compared to optimal medical therapy (OMT), remains uncertain. Our study used the National Inpatient Sample (NIS) Database to identify patients aged 18 or older with myocardial bridging who were managed with PCI versus medical therapy. We compared the outcomes between both groups including in-hospital mortality, the trend of management of MB and other in-hospital outcomes or complications. Our results showed no statistically significant difference between both subgroups when comparing in-hospital mortality and secondary outcomes of cardiac arrest and the development of an acute kidney injury (AKI). Patients with myocardial bridging treated with PCI had a higher risk of developing cardiogenic shock, requiring LVAD, and requiring the use of intra-aortic balloon pump (IABP) compared to the medical therapy subgroup. Our study suggests the decision to perform PCI in myocardial bridging patients should be individualized such as in patients with refractory symptoms despite medical therapy or those with known high-risk features. Full article

Background and Clinical Significance: Takotsubo cardiomyopathy (TCM), an acute stress-induced left ventricular dysfunction, stems from catecholaminergic surges leading to transient myocyte stunning, calcium overload, and microvascular dysregulation. Although most cases resolve spontaneously, roughly 10% deteriorate into fulminant cardiogenic shock, warranting mechanical circulatory support (MCS). Impella^® provides direct transvalvular LV unloading but carries elevated risks of hemolysis, vascular compromise, and thrombogenicity. Conversely, the intra-aortic balloon pump (IABP) enhances diastolic coronary perfusion and marginally reduces afterload via counterpulsation, albeit with less potent LV decompression. Optimal MCS selection in TCM-associated shock therefore hinges on balancing hemodynamic benefits against procedural morbidity. Case Presentation: A 72-year-old female with coronary artery disease, paroxysmal atrial fibrillation (status post–left atrial appendage occlusion), and stage 3 chronic kidney disease presented with anterior ST-segment elevations (V2–V4) and troponin I >1000 ng/L, progressing rapidly to cardiogenic shock and respiratory failure. Coronary angiography revealed mild luminal irregularities, while echocardiography demonstrated severely reduced ejection fraction (5–10%) with characteristic apical ballooning. Refractory elevations in pulmonary capillary wedge pressure, despite escalating inotropes and vasopressors, prompted IABP insertion for partial LV offloading. Over one week, her ejection fraction improved to 35%, facilitating weaning from pressor support, extubation, and discharge on guideline-directed medical therapy. Conclusions: In TCM complicated by shock, meticulous MCS selection is paramount. Although Impella confers more robust unloading, heightened device-related complications may be unjustified in a largely reversible disease. IABP can sufficiently stabilize hemodynamics, enable myocardial recovery, and mitigate morbidity, underscoring the importance of individualized decision-making in TCM-related shock. Importantly, no trial has shown that MCS confers a proven long-term mortality benefit beyond initial hemodynamic rescue. Full article

Background/Objectives: Brain ischemia is a frequent complication in patients undergoing veno-arterial extracorporeal membrane oxygenation (va-ECMO) therapy due to hypoperfusion, low oxygenation, and thromboembolism. While concomitant intra-aortic balloon pump (IABP) therapy may improve the perfusion of the supra-aortic branches, it may also favor thromboembolism. This retrospective study aimed to evaluate the effects of combined va-ECMO and IABP therapy on procedural brain infarction compared to va-ECMO therapy alone, with a specific focus on analyzing the types of infarctions. Methods: Cranial computed tomography (CCT) scans of consecutive patients receiving va-ECMO therapy were analyzed retrospectively. Subgroups were formed for patients with combined therapy (ECMO and IABP) and va-ECMO therapy only. The types of infarctions and the potential impacts of va-ECMO vs. combined therapy with IABP on stroke were investigated. Results: Overall, 146 patients (36 female, 110 male, mean age 61 ± 13.3 years) were included, with 69 undergoing combined therapy and 77 patients receiving va-ECMO therapy alone. In total, 14 stroke events occurred in 11 patients in the ECMO-only group and there were 12 events in 12 patients in the ECMO + IABP-group, showing no significant difference (p = 0.61). The majority of infarctions were of thromboembolic (n = 23; 88%) origin, with 14 stroke-events in 12 patients in the ECMO + IABP-group and 9 stroke events in the ECMO-only group. The survival rate within 30 days of treatment was 29% in the ECMO-only group and 32% in the ECMO + IABP group. Conclusions: The results of this retrospective study show that concomitant IABP therapy appears to be neither protective nor more hazardous in relation to ECMO-related stroke. Thus, the indication for additional IABP therapy should be assessed independently from the procedural risk of brain ischemia. Thromboembolic infarctions seem to represent the most common type of infarction in ECMO, especially within the first 48 h of treatment. Full article

Background and Objectives: The coronavirus disease 2019 pandemic presented unprecedented challenges in balancing infection control measures with the timely management of ST-segment elevation myocardial infarction (STEMI), a time-sensitive condition. This study investigates the pandemic’s effects on STEMI management times and outcomes at a high-volume medical center in Taiwan. Materials and Methods: A retrospective analysis of 1309 STEMI patients was conducted at Chang Gung Memorial Hospital between 2017 and 2022. Patients were divided into pre-pandemic and pandemic groups. Measurement outcomes include in-hospital mortality rate, management times (e.g., door-to-balloon time), the rates of intra-aortic balloon pump (IABP) and/or veno-arterial extracorporeal membrane oxygenation (VA-ECMO) usage, mechanical ventilation, inotropic support, and the length of intensive care unit (ICU) and hospital stay. Kaplan–Meier survival analysis and statistical comparisons were performed to assess temporal trends and prognostic outcomes. Results: No significant difference in in-hospital mortality was observed between pre-pandemic (5.85%) and pandemic (7.03%) groups (p = 0.45). The pandemic group experienced longer management times, including door-to-cath arrival (p = 0.0335) and door-to-balloon time (p = 0.014), although all times remained below the 90 min threshold. Quality improvements during the first outbreak allowed the institution to handle higher case volumes during subsequent waves without further delays. Ninety-day survival analysis showed no significant disparity between groups (p = 0.3655). Conclusions: Pandemic-related delays in STEMI management were effectively mitigated through workflow optimization, preventing significant increases in mortality rates. This study highlights the adaptability of healthcare systems in responding to crises while maintaining quality care for time-sensitive emergencies. Future multicenter studies could provide broader insights into global STEMI management strategies under pandemic conditions. Full article

Background and Objectives: In-hospital mortality associated with myocardial infarction complicated by cardiogenic shock (MI-CS) remains critically high. A particularly challenging form, mixed shock (MS), combines features of cardiogenic shock (CS) with distributive elements such as vasodilation and reduced vascular resistance. MS is associated with elevated mortality rates and presents unique diagnostic and therapeutic challenges. This study aimed to analyze the clinical, historical, instrumental, and laboratory characteristics of the primary phenotypes of MI-CS, stratified according to the Society for Cardiovascular Angiography and Interventions (SCAI) shock severity scale. Materials and Methods: In this single-center, retrospective observational study, we reviewed the medical records of 1289 patients admitted to the emergency cardiology department from 1 January to 12 December 2020. Among them, 117 patients were identified as having MI-CS and were divided into two groups: MS (n = 48) and isolated CS (n = 69). The data were analyzed using the SCAI shock classification. Logistic regression analysis was employed to identify predictors of mortality and improved survival outcomes. Results: Patients with MS were older (80 years [71.0; 83.0] vs. 73 years [64.0; 81.0], p = 0.035). The overall mortality rate was significantly higher in the MS group (68% vs. 53%, RR = 1.438, 95% CI: 1.041–1.986, p = 0.03). Logistic regression identified mechanical ventilation (OR = 8.33, 95% CI: 2.54–22.80, p = 0.012), elevated lactate levels (OR = 1.20, 95% CI: 1.02–1.41, p = 0.026), and cardiopulmonary resuscitation (CPR) (OR = 7.97, 95% CI: 2.51–24.40, p < 0.0001) as independent predictors of mortality. Conversely, the use of an intra-aortic balloon pump (IABP) (OR = 0.22, 95% CI: 0.06–0.80, p = 0.021) and a higher body mass index (BMI) (OR = 0.91, 95% CI: 0.84–0.99, p = 0.038) were associated with reduced mortality risk. Conclusions: MS in the context of MI-CS represents a distinct clinical phenotype with specific hemodynamic features and significantly worsened outcomes. The identification of mortality predictors, such as mechanical ventilation, elevated lactate levels, and CPR, alongside protective factors like IABP use and a higher BMI, underscores the importance of early and tailored therapeutic interventions. These findings highlight the need for further studies to refine treatment protocols and improve outcomes in this high-risk population. Full article

Over 10% of patients undergoing aortic endograft implantation experience endoleaks within a few years. In the case of type 1a endoleaks, a crack forms between the aorta and the prosthesis collar, allowing blood to pass. This blood fills the aneurysmal sac and can lead to its rupture. None of the strategies, such as prostheses with barbs and hooks or ad hoc pharmacological therapies, can prevent the phenomenon. An alternative approach is to reduce diameter oscillations due to pulsating pressure to improve the endoprosthesis adhesion to the internal vessel walls during the initial post-implantation phases. To reach this objective, we propose to use a passive intra-aortic balloon pump (PIABP) inserted and then maintained inside the vessel immediately after the surgical procedure. We tested our hypothesis in a mechanical mock of the cardiovascular system. A silicon aorta with physiological behavior was created for this purpose. The PIABP was inflated to increasing pressures between systolic and diastolic values (120/80 mmHg). For each aorta and each condition, the variations in aortic diameter between systole and diastole, and the pressure variations, were measured. For the normal aorta, with a PIABP pressure of 110 mmHg, the variations in diameter were reduced by 38%. Assuming an endoprosthesis with a diameter of 30 mm (oversized by 5% compared to the diastolic diameter), the time the oscillations are higher than 30 mm is also reduced by 36%. The results are positive and suggest the usefulness of a biomechanical approach to the problem of type 1a endoleaks. Further in silico and clinical trials are necessary to validate the method. Full article

This work investigates the conditions for net flow generation by a straight tube with a cross-sectional area harmonically varying in time that connects two tanks—a problem that is mainly found in the design of impedance pumps. By assuming a quasi-one-dimensional flow and applying continuity and momentum equations, a first-order differential equation with respect to the flow rate is derived and presented for the first time, including a nonlinear term that is responsible for net flow rate generation. Namely, the net flow rate is found to be nonzero (as is the nonlinear term) if the cross-sectional areas of the two tanks are unequal and one of them is smaller than that of the straight tube. In this case, the flow is directed from the smaller to the larger tank and the net flow rate increases with the frequency of the tube’s cross-sectional area variation. In contrast, when the tanks’ cross-sections are equal, the net flow is generated only if a valve is installed, e.g., at one end of the tube, due to the large asymmetries imposed in the hydraulic losses with respect to the tube mid-length. Compared with constant valve opening, the net flow rate is augmented significantly if the valve opening is time-dependent. By employing the same equation, the flow rate of an intra-aortic counter-pulsating balloon pump is also examined, in which the valve (representing the aortic valve) opens during the shrinkage of the tube, and it is shown that the net flow rate increases with the frequency and amplitude of the tube’s cross-sectional area. Conclusively, the harmonic oscillation in time of a tube’s wall can cause unidirectional flow only if asymmetric losses are present with respect to its mid-length. Full article

Background: This study aims to assess the outcomes and complications of patients who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP) support after cardiac surgery at Ankara University Heart Center between 2000 and 2023. Methods: We have carried out a retrospective analysis that included 255 patients. Among them, 98 received IABP, 103 received VA-ECMO, and 54 received both VA-ECMO and IABP. Preoperative and postoperative assessments were carried out, including evaluations of left ventricular function and serum creatinine levels. Primary outcomes included 30-day survival and successful VA-ECMO weaning. Complications such as bleeding, sepsis, liver failure, wound infection, and peripheral ischemia were also assessed. Results: The weaning rate from VA-ECMO was significantly higher in the combined VA-ECMO and IABP group (81.4%) compared with the other groups (p = 0.004). One-year survival was also higher in the combined group (75.9%) (p = 0.002). Complications or renal function did not differ significantly among the groups. The primary indication for mechanical support was coronary artery bypass grafting. Conclusions: In conclusion, the combined use of VA-ECMO and IABP therapy led to improved weaning and survival rates without increasing the risk of complications. These findings suggest that a combined approach may be beneficial for selected patients with severe cardiac dysfunction post surgery. Full article