Faculty Bibliography

BACKGROUND/UNASSIGNED:The paucity of data to guide selection of specific vasoactive agents in patients with cardiogenic shock (CS) may lead to variability in practice patterns. The level of variability and specific factors that are associated with the use of vasoactive medications and inodilators have not been previously described. METHODS/UNASSIGNED:The CCCTN (Critical Care Cardiology Trials Network) is an international, multicenter network of cardiac intensive care units (CICUs) coordinated by the TIMI Study Group. This analysis included CICU admissions for CS from 2019 to 2023. Variation in the use of inodilator treatment (dobutamine/milrinone) was assessed with multivariable mixed-effects logistic modeling. RESULTS/UNASSIGNED:increase). No individual measurable institution-level factors (eg, transplant center) were associated with variability in inodilator use. In mixed-effects logistic modeling, 45.7% of variation in inodilator use was attributed to patient-level factors and 22.7% to the random effect of individual CICU centers. Similarly, 35.3% of variation in the use of dobutamine versus milrinone was attributed to patient-level factors and 32.6% to the random effect of individual CICU centers. CONCLUSIONS/UNASSIGNED:There is significant variation in vasoactive treatment and inodilator use in CS. Variation in inodilator use was associated with patient-level factors and with substantial individual CICU practice variation. Such variability underscores the need for additional high-quality evidence to guide vasoactive treatment strategies in CS.

BACKGROUND:Consensus documents classify cardiogenic shock (CS) centers on the basis of percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), and cardiothoracic surgery (CTS) capabilities, but outcomes data remain limited. OBJECTIVES/OBJECTIVE:This study sought to assess the association between CS center tiers and outcomes. METHODS:Adults (aged ≥18 years) hospitalized with CS were identified from the Nationwide Readmissions Database (2016-2022). Hospitals were stratified into the following categories: level 3 (non-PCI, non-MCS, non-CTS, intensive care unit only), level 2 (level 3 in addition to PCI, intra-aortic balloon pump, percutaneous left ventricular assist device capable), level 1A (level 2 in addition to extracorporeal membrane oxygenation, nonpercutaneous ventricular assist device, CTS capable), and level 1 (level 1A in addition to durable left ventricular assist device/cardiac transplantation capable). Outcomes included in-hospital mortality, length of stay, and costs (in all patients), as well as 30-day readmissions (only in survivors). Multinomial overlap propensity to adjust for baseline characteristics and hierarchical regression models were used. RESULTS:Among 623,835 CS admissions, the distribution of hospital levels was consistent over the 7-year period (7% level 1, 27%-36% level 1A, 19%-21% level 2, and 38%-40% level 3). Compared with level 1, the odds of receiving MCS were 38% lower at level 1A (adjusted OR [aOR]: 0.62 [95% CI: 0.59-0.65]) and 73% lower at level 2 (aOR: 0.27 [95% CI: 0.25-0.28]). In the propensity-matched analysis, compared with level 1 (29.5%), patients admitted to other levels had higher in-hospital mortality (level 1A: 38.4%, aOR: 1.33 [95% CI: 1.29-1.38]; level 2: 41.1%, aOR: 1.44 [95% CI: 1.38-1.50]; level 3: 45.2%, aOR: 1.63 [95% CI: 1.54-1.71]; all P < 0.001). The survival benefit of level 1 centers persisted across age, cardiac arrest, MCS use, location, and insurance subgroups. Compared with level 1, 30-day readmissions were lower by 4% at level 1A (OR: 0.96 [95% CI: 0.94-0.98]) and 1% at level 3 (OR: 0.99 [95% CI: 0.94-0.98]) centers, with no significant difference at level 2 centers (OR: 1.02 [95% CI: 0.99-1.06]). Length of stay and costs were higher at levels 1 and 1A. CONCLUSIONS:Tiered CS care was associated with a stepwise improvement in survival outcome at advanced centers despite greater acuity of illness.

Durable left ventricular assist devices (dLVAD) remain a lifesaving therapy in patients with stage D heart failure that is refractory to conventional medical therapies. Owing to improvements in technology and patient outcomes, the number of patients supported with dLVADs has increased over the past decade. Despite this growing population, there are few resources for cardiovascular intensivists that integrate epidemiology, diagnostic workup and multidisciplinary medical management of acute emergencies in patients supported with dLVADs.

Iron deficiency has been reported in up to 50% of patients with heart failure (HF), irrespective of the presence of anemia. Although no formally validated definition for iron deficiency in patients with HF exists, both the American and European Heart Failure Guidelines define iron deficiency as a serum ferritin of < 100 ng/ml, or a ferritin of 100-299 ng/ml, provided that the transferrin saturation (TSAT) is less than 20%. The presence of iron deficiency has been associated with poor patient-oriented outcomes, prompting the assessment of intravenous (IV) iron as a treatment for iron deficiency. This review summarizes the totality of the evidence on the diagnosis, evaluation and treatment of patients with iron deficiency. In addition, we highlight our approach to patients with HF with reduced ejection fraction and highlight areas for both clinical improvement and research.

OBJECTIVES/OBJECTIVE:To evaluate the efficacy of intraoperative hemoadsorption (HA) during cardiopulmonary bypass (CPB) in reducing acute kidney injury (AKI) and other major postoperative complications in patients undergoing cardiac surgery. DESIGN/METHODS:Systematic review and meta-analysis of randomized controlled trials (RCTs) conducted in accordance with PRISMA guidelines, with a protocol registered in PROSPERO (CRD42025638656). SETTING/METHODS:Multicountry, multi-institutional hospital-based studies of patients undergoing cardiac surgery with CPB. PARTICIPANTS/METHODS:A total of 1133 patients from 16 RCTs comparing CPB with versus without intraoperative HA. INTERVENTIONS/METHODS:Intraoperative HA using sorbent-based devices (e.g., CytoSorb, oXiris, Jafron HA 380). MEASUREMENTS AND MAIN RESULT/RESULTS:Primary outcomes included AKI incidence, renal replacement therapy requirement, and mortality. Secondary outcomes included intensive care unit/hospital length of stay, postoperative delirium, stroke, sepsis, and reoperation. HA significantly reduced the incidence (RR 0.75; 95% CI 0.59-0.96; p = 0.020). No significant differences were observed for renal replacement therapy (RR 0.64; p = 0.58) or mortality (RR 0.96; p = 0.861). No significant effects were found for secondary outcomes. CONCLUSIONS:Intraoperative HA during CPB reduces the risk of AKI but does not significantly affect other major postoperative outcomes. Further studies are needed to determine its clinical relevance and optimal patient selection.

BACKGROUND:The ARIES-HM3 trial demonstrated the safety and effectiveness of aspirin elimination from the antithrombotic regimen after HeartMate 3 (HM3) LVAD implantation. We explored the interaction of atrial fibrillation, diabetes mellitus and obesity [AF/DM/Ob] with aspirin elimination on hemocompatibility-related adverse events (HRAE) at 1 year post-implant. METHODS:level suppression. RESULTS:levels. CONCLUSION/CONCLUSIONS:Among ARIES-HM3 trial patients with AF/DM/Ob, either comorbidity alone or in combination, did not alter the safety or observed effect size on bleeding reduction with aspirin elimination in patients implanted with the HM3 LVAD.