Harefield Hospital is a health institution in Harefield, London Borough of Hillingdon, England. It is managed by the Guy's and St Thomas' NHS Foundation Trust.
AIMS:Out-of-hospital cardiac arrest (OHCA) has high mortality, and outcomes remain heterogeneous despite guidelines recommending universal conveyance to cardiac arrest centres. Early pre-hospital risk stratification may identify patients most likely to benefit. The pre-hospital utility of MIRACLE2 is unknown, so we evaluated the feasibility of rapid point-of-care testing to enable calculation of the MIRACLE2 score after return of spontaneous circulation (ROSC). METHODS AND RESULTS:RAPID-MIRACLE was a prospective, multi-centre observational study conducted across London with the London Ambulance Service. Adult patients with suspected cardiac aetiology OHCA achieving sustained ROSC were enrolled. Pre-hospital point-of-care venous blood-gas sampling was performed with results blinded to receiving hospitals. We evaluated ROSC-MIRACLE2 incorporating post-ROSC pH, compared with a modified MIRACLE2 excluding pH (pre-MIRACLE2) and standard MIRACLE2 calculated on hospital admission. The primary outcome was poor neurological outcome at 30 days, defined as cerebral performance category (CPC) 3-5. Among 292 patients, 48% had poor neurological outcome. ROSC-MIRACLE2 demonstrated excellent discrimination [area under the receiver operating characteristic curve (AUC) 0.89 (95% CI 0.85-0.92)], comparable to pre-MIRACLE2 [AUC 0.88 (95% CI 0.84-0.92)], and admission MIRACLE2 [AUC 0.89 (95% CI 0.85-0.92)]. For ROSC-MIRACLE2, a threshold 0-2, the negative predictive value for good outcome was 0.89 (0.82-0.94). At a threshold ≥5, the positive predictive value was 0.88 (0.82-0.94). In a multi-variable regression model, post-ROSC pH was independently associated with poor neurological outcome and less than 3% of patients with a ROSC pH <7.00 had good neurological outcome. CONCLUSION:In this study, pre-hospital application of ROSC-MIRACLE2 enables early neurological risk stratification following resuscitated OHCA. Point-of-care pH improves prognostic precision, but is constrained by feasibility, whilst the simplified pre-MIRACLE2 score is more practical with comparable performance. Integration into OHCA care pathways may improve patient stratification and resource utilization but requires further study.
OBJECTIVES:The optimal conduit strategy for coronary artery bypass grafting (CABG) in patients with moderate left ventricular dysfunction (LVEF 30-49%) remains debated. While total arterial grafting (TAG) has shown benefits in broader populations, its role in this higher-risk subgroup is unclear. This study aimed to compare short-term outcomes and long-term survival between single arterial grafting (SAG) and TAG in patients with moderate LV dysfunction undergoing CABG. METHODS:A retrospective analysis of 1866 patients was performed, with 640 patients matched using propensity scores (320 SAG vs. 320 TAG). Preoperative, intraoperative, and postoperative variables were assessed. Survival was evaluated using Kaplan-Meier analysis and Cox regression. RESULTS:Matched cohorts were well balanced across baseline characteristics. Long-term survival at 10 and 15 years was numerically higher in the TAG group (85.8% and 79.7%) compared to SAG (81.7% and 74.2%), though not statistically significant (log-rank p = 0.862). Multivariate Cox regression identified age (HR 1.045, p < 0.001), NYHA class (NYHA III HR 0.610, p = 0.003), previous cardiac surgery (HR 0.501, p = 0.006), and off-pump CABG (HR 1.521, p < 0.001) as independent predictors of mortality. Grafting strategy (TAG vs. SAG) was not independently associated with long-term mortality (HR 1.005, p = 0.966). CONCLUSION:TAG is safe and feasible in patients with moderate LV dysfunction undergoing isolated CABG, with comparable short-term outcomes. Although unadjusted analyses suggested improved long-term survival, this difference was not observed after propensity matching or multivariable adjustment, and grafting strategy was not independently associated with mortality.
Cardiogenic shock (CS) is the most lethal complication of acute myocardial infarction (AMI), with a 30-day mortality of approximately 40-50% despite early revascularization. Temporary mechanical circulatory support (tMCS) devices, including the intra-aortic balloon pump (IABP), microaxial flow pumps (MAFP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO), are used as adjunctive therapy in refractory shock, but evidence of a survival benefit is limited and often conflicting. The IABP-SHOCK II trial found no 30-day mortality reduction with IABP, supporting a Class III (no benefit) recommendation, whereas the DanGer Shock trial reported a 12.7% absolute mortality reduction at 180 days with the MAFP Impella CP in highly selected patients. In contrast, the ECLS-SHOCK and ECMO-CS trials showed no improvement in survival with early VA-ECMO and noted high complication rates. Real-world data reveal significant disparities between trial populations and clinical practice, highlighting limitations of current evidence, since many AMI-CS patients are older, in more advanced shock or have multiple comorbidities and would not meet typical randomized controlled trial (RCT) inclusion criteria. In clinical practice, in-hospital mortality with IABP or VA-ECMO often exceeds 50-60%. Given the heterogeneity of AMI-CS, rapid identification of appropriate tMCS candidates and personalized therapy are essential. Management guided by individual patient profile, hemodynamic stage and neurological status, supported by multidisciplinary shock teams, may improve timely triage, device selection and outcomes. This review emphasizes the need for individualized, protocol-driven care within structured shock systems to optimize tMCS use in AMI-CS.
BACKGROUND:Surgical ventricular reconstruction (SVR) is not always feasible in patients with ischaemic cardiomyopathy and left ventricular (LV) aneurysm, due to high surgical risk. The Revivent-TC Transcatheter Ventricular Enhancement System is a less invasive alternative option. METHODS:We conducted a systematic literature search using PubMed, Ovid Medline and Google Scholar between January 2013 up to May 2025 to assess the effectiveness and safety of Revivent-TC System. Inclusion criteria included symptomatic patients with ischaemic left ventricular (LV) systolic impairment and anterior or anteroseptal scar, with appropriate anatomy confirmed by cardiac magnetic resonance (CMR), who were treated with the device. Outcomes included echocardiographic parameters, procedural data, adverse events and survival. RESULTS:Eight studies (276 patients) were included: seven observational and the prospective non-randomised dual-arm ALIVE trial. Mean age was 61.8 years; 73% were male with LV ejection fraction (EF) ranging from 22.8% to 35.6%. Procedural success ranged from 96 to 100%, with procedure-related mortality of 2.5%. Conversion to full median sternotomy was required in 1.4% due to complications such as right ventricular (RV) perforation, acute mitral regurgitation and right ventricular (RV) failure. Surgical re-intervention was required in 4.3% of patients. Overall mortality during follow-up was 6.5%. Statistically significant improvement in LVEF and LV volumes was observed across observational studies, persisting up to 5 years post-operatively. Improvements in exercise tolerance, NYHA functional class and quality of life were also observed. However, the ALIVE trial did not demonstrate a significant clinical benefit over guideline-directed medical therapy (win ratio 1.13; p = 0.32), with cardiovascular mortality and HF hospitalisation numerically favouring the control group. CONCLUSIONS:The Revivent-TC system is associated with LV volume reduction and functional improvements in selected patients, offering a less invasive alternative to surgical ventricular reconstruction. However, the evidence base consists predominantly of small observational studies, and the only controlled trial did not demonstrate significant benefit on hard clinical endpoints. Longer-term randomised data, including a guideline-directed medical therapy comparator arm, are needed before definitive conclusions about efficacy can be drawn.
