Faculty Bibliography

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.

BACKGROUND:In patients with tricuspid valve infective endocarditis, percutaneous debulking is a treatment option. However, the outcomes of this approach are less well known. METHODS:We performed a retrospective analysis of all patients who underwent percutaneous vegetation debulking for tricuspid valve infective endocarditis from August 2020 to November 2022 at a large academic tertiary care public hospital. The primary efficacy outcome was procedural success defined by clearance of blood cultures. The primary safety outcome was any procedural complication. For the composite outcome of in-hospital mortality or heart block, outcomes were compared (sequential noninferiority and superiority) with published surgical outcomes data. RESULTS:=0.016). CONCLUSIONS:Percutaneous debulking is feasible, effective, and safe in treating patients with tricuspid valve infective endocarditis refractory to medical therapy.

BACKGROUND:Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS. METHODS:We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups. RESULTS:<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%. CONCLUSIONS:Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.

The clinical course of patients with a previous coronary artery bypass graft surgery (CABG) presenting with non-ST-elevation myocardial infarction (NSTEMI) is not well defined. We aimed to compare the management and outcomes of patients with and without previous CABG who present with an NSTEMI. Patients hospitalized with an NSTEMI between 2002 and 2018 were identified from the National Inpatient Sample. The baseline characteristics and outcomes of patients with and without a previous CABG were compared. The outcomes included the rates of invasive procedures (defined as coronary angiography, percutaneous coronary intervention [PCI], or CABG), and its individual components, and in-hospital mortality. A total of 1,445,545 cases of NSTEMI were found, of which 133,691 (9.3%) had a previous CABG. Patients with a previous CABG were older (72.4 vs 68.6 years, p <0.001), more likely men (68.8% vs 56.9%, p <0.001), and of White race (79.7% vs 74.8%, p <0.001). The previous CABG cohort had lower rates of invasive procedures (50.4% vs 65.6%, p <0.001), PCI (23.7% vs 32.0%, p <0.001), or CABG (1.2% vs 10.6%; p <0.001) in the unmatched analysis. The results were consistent in the propensity score-matched analysis with the previous CABG group less likely to receive any invasive procedures (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.47 to 0.49), including coronary angiography (OR 0.54, 95% CI 0.53 to 0.55), PCI (OR 0.66, 95% CI 0.64 to 0.67), or repeat CABG (OR 0.11, 95% CI 0.10 to 0.12). Moreover, the risk of in-hospital mortality was higher in the previous CABG group (OR 1.15, 95% CI 1.10 to 1.21). In the subset of patients who were revascularized in both groups, this excess mortality was no longer observed (OR 0.82, 95% CI 0.66 to 1.03). In conclusion, a previous CABG in patients who present with NSTEMI is associated with lower rates of invasive procedures and revascularization and higher in-hospital mortality than patients without a previous CABG.

Targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) has been a focus of debate in an attempt to improve post-arrest outcomes. Contemporary trials examining the role of TTM after cardiac arrest suggest that targeting normothermia should be the standard of care for initially comatose survivors of cardiac arrest. Differences in patient populations have been demonstrated across trials, and important subgroups may be under-represented in clinical trials compared with real-world registries. In this review, we aimed to describe the populations represented in international OHCA registries and to propose a pathway to integrate clinical trial evidence into practice. The patient case mix among registries including survivors to hospital admission was similar to the pivotal trials (shockable rhythm, witnessed arrest), suggesting reasonable external validity. Therefore, for the majority of OHCA, targeted normothermia should be the strategy of choice. There remains conflicting evidence for patients with a nonshockable rhythm, with no clear evidence-based justification for mild hypothermia over targeted normothermia.

BACKGROUND:Little is known about the prevalence and post-surgical outcomes associated with cardiac intensive care unit (CICU) therapeutics among CICU patients referred for cardiac surgery. OBJECTIVES/OBJECTIVE:The purpose of this study was to investigate the clinical characteristics and outcomes of CICU patients referred for cardiac surgery from the intensive care unit. METHODS:We analyzed characteristics and outcomes of CICU admissions referred from the CICU for cardiac surgery during 2017 to 2020 across 29 centers. The primary outcome was in-hospital mortality. RESULTS:Among 10,321 CICU admissions, 887 (8.6%) underwent cardiac surgery, including 406 (46%) coronary artery bypass graftings, 201 (23%) transplants or ventricular assist devices, 171 (19%) valve surgeries, and 109 (12%) other procedures. Common indications for CICU admission included shock (33.5%) and respiratory insufficiency (24.9%). Preoperative CICU therapies included vasoactive therapy in 52.2%, mechanical circulatory support in 35.9%, renal replacement in 8.2%, mechanical ventilation in 35.7%, and 17.5% with high-flow nasal cannula or noninvasive positive pressure ventilation. In-hospital mortality was 11.7% among all CICU admissions and 9.1% among patients treated with cardiac surgery. After multivariable adjustment, pre-op mechanical circulatory support and renal replacement therapy were associated with mortality, while respiratory support and vasoactive therapy were not. CONCLUSIONS:Nearly 1 in 12 contemporary CICU patients receive cardiac surgery. Despite high preoperative disease severity, CICU admissions undergoing cardiac surgery had a comparable mortality rate to CICU patients overall; highlighting the ability of clinicians to select higher acuity patients with a reasonable perioperative risk.