BACKGROUND: Temporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network. METHODS: Prospective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centers organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality. RESULTS: Two hundred and forty-six patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95% CI:0.65-1.26). Patients with mechanical assistance had a higher rate of complications than others

BACKGROUND:Microcirculatory alterations have been observed at the early phase of sepsis, although macrocirculation seems preserved. The aim of this study was to analyze the effect of crystalloid fluid therapy on mesenteric microcirculation, assessed by using the confocal laser endomicroscope Cellvizio®, in an endotoxic porcine model.METHODS:It is a prospective endotoxic shock (lipopolysaccharide infusion) experimental trial. Piglets were divided into 3 groups: 6 in the sham group (no LPS injection, no fluid), 9 in the control group (LPS infusion, no fluid), and 6 in the crystalloids group (LPS infusion and fluid resuscitation with crystalloids). Fluid resuscitation consisted in a fluid bolus of 20 mL/kg 0.9% saline over 30 min followed by a 10 mL/kg/h fluid rate over 4 h. Mesenteric microcirculation was assessed using a confocal laser endomicroscope (Cellvizio®). Blood flow within capillaries was visually assessed according to the point of care microcirculation (POEM) score.RESULTS:At baseline, the 3 groups were similar regarding hemodynamic, biological, and microcirculatory parameters. At T360, the POEM score significantly decreased in the control and crystalloids groups, whereas it remained unchanged in the sham group (respectively, 1.62 ± 1.06, 1.2 ± 0.45, and 5.0 ± 0, p = 0.011). There was no significant difference in cardiac output at T360 between the sham and crystalloids groups (3.1 ± 0.8 vs. 2.3 ± 0.6, p = 0.132) or between the control and crystalloids groups (2.0 ± 0.6 vs. 2.3 ± 0.6, p = 0.90).CONCLUSION:There was no significant improvement of microcirculatory alterations after crystalloids resuscitation despite improvement in macrocirculatory parameters in early experimental sepsis.

Abstract Background: Encouraging results in several series of patients on refractory cardiogenic shock (CS) led to the consideration of including temporary mechanical circulatory support (TMCS) in the guidelines for CS management. Benefit on survival might be improved when TMCS devices are initiated early. This study assessed early TMCS for CS in the real-world condition of a cardiac assistance regional network. Methods: We examined the clinical features and outcomes of patients treated with TMCS, using data from a prospective cohort of patients admitted for CS in a cardiac assistance regional network. Patients were eligible when CS included systolic blood pressure (SBP) <90 mmHg despite adequate filling pressure or need of catecholamine to maintain SPB>90 mmHg, signs of congestion or tissue hypo-perfusion or blood lactate >2mmol/L. TMCS indication, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or percutaneous left ventricle assistance (Impella) was based on the initial severity of CS or if shock was refractory to medical treatment. To estimate the effect of early TMCS on mortality, we emulated a target trial of TMCS implantation versus no TMCS within 24 hours of ICU admission. Patients were followed until hospital discharge, death, or 180 days. Inverse probability of treatment weighting with propensity score was used to adjust for confounders. Results: Among 372 patients, 246 were included in the study: 121 treated by early TMCS (TMCS group) and 125 not treated by early TMCS (controls). Median age was 59.5 years, 71.9% were male, and the main etiologies were acute myocardial infraction (MI) (46.8%) and decompensated heart failure (27.2%). Crude in-hospital mortality was 38% (46/121) in the TMCS group and 22.4% (28/125) in the control group. After emulation, in-hospital mortality was not different between the TMCS group and the control group (HR=0.91, 95%CI:0.65-1.26). In sub-group analyses, in-hospital mortality was not different among patients with MI (HR=0.82, 95%CI:0.52-1.32), with other etiology than MI (HR=1.19, 95%CI:0.70-2.04), and with VA-ECMO only (HR=0.87, 95%CI:0.62-1.22). TMCS patients had two-fold longer hospital stays, and a higher rate of complications than controls. Conclusion: In this emulated target trial from real-world data, patients with CS treated with early TMCS had no improvement in survival compared to controls. Trial registration number: NCT03528291, registered trials May 18, 2017

espanolObjetivos. La ecografia cardiopulmonar puede ser util para diagnosticar insuficiencia cardiaca aguda (ICA). Se evaluo el rendimiento diagnostico de un algoritmo basado en ecografia cardiopulmonar a la cabecera del paciente (POCUS) para el diagnostico de ICA en pacientes que consultan en urgencias por disnea aguda. Metodo. Se evaluo prospectivamente una muestra de conveniencia de pacientes con disnea aguda en dos servicios de urgencias hospitalarios (SUH). El algoritmo POCUS incluia la ecografia pulmonar y tres mediciones ecocardiograficas realizadas en un plano apical de cuatro camaras. Se midio el MAPSE (desplazamiento sistolico del plano del anillo mitral), doppler de flujo mitral y doppler tisular en el anillo mitral lateral. El diagnostico final fue asignado por dos medicos ciegos entre si y a los hallazgos ecograficos. Resultados. Se incluyeron 103 pacientes adultos, la edad media fue 73 (12) anos, 51 (50%) mujeres. El diagnostico final fue ICA en 42 (41%) pacientes. La concordancia entre asignadores fue buena para el diagnostico de ICA (k = 0,82). El algoritmo asigno un diagnostico en 76 (74%) pacientes, 57 (85%) estaban en ritmo sinusal. El rendimiento diagnostico del algoritmo de los 76 pacientes categorizados mostro un area bajo la curva de 0,94 (IC 95%: 0,88-1,00), sensibilidad 96% (IC 95%: 78-100%), especificidad 93% (IC 95%: 8-98%), valor predictivo positivo 85% (IC 95%: 67-100%), valor predictivo negativo 98% (IC 95%: 88-100%). Conclusion. El rendimiento de un algoritmo basado en ecografia cardiopulmonar POCUS fue bueno para diagnosticar ICA en pacientes que consultan en urgencias por disnea aguda. EnglishBackground and objective. Cardiopulmonary ultrasound imaging can be useful for diagnosing acute heart failure (AHF). We aimed to evaluate the diagnostic performance of an algorithm based on point-of-care ultrasound (POCUS) in patients coming to the emergency department with acute dyspnea. Methods. Prospective analysis of a convenience sample of patients with acute dyspnea in 2 hospital emergency departments. The POCUS algorithm included lung ultrasound findings and 3 echocardiographic measurements taken from an apical view of 4 chambers: mitral annular plane systolic excursion, Doppler mitral flow velocity, and tissue Doppler imaging of the lateral mitral annulus. The definitive diagnosis was made by 2 physicians blinded to the POCUS findings. Results. A total of 103 adult patients with a mean (SD) age of 73 (12) years were included; about half (51 patients) were women. Forty-two patients (41%) were finally diagnosed with AHF. Interindividual agreement on the physicians’ diagnoses was good (k = 0.82). The POCUS algorithm assigned an AHF diagnosis to 76 patients (74%); 56 of them (85%) were in sinus rhythm. The diagnostic performance indicators for the algorithm were as follows: area under the receiver operating characteristic curve, 0.94 (95% CI, 0.88–1.00); sensitivity 96% (95% CI, 78%–100%); specificity, 93% (95% CI, 8%–98%); positive predictive value, 85% (95% CI, 67%–100%); negative predictive value, 98% (95% CI, 88%–100%). Conclusion. The POCUS-based algorithm for diagnosing AHF performed well in patients coming to the emergency department with acute yspnea.

OBJECTIVES:Cardiopulmonary ultrasound imaging can be useful for diagnosing acute heart failure (AHF). We aimed to evaluate the diagnostic performance of an algorithm based on point-of-care ultrasound (POCUS) in patients coming to the emergency department with acute dyspnea.MATERIAL AND METHODS:Prospective analysis of a convenience sample of patients with acute dyspnea in 2 hospital emergency departments. The POCUS algorithm included lung ultrasound findings and 3 echocardiographic measurements taken from an apical view of 4 chambers: mitral annular plane systolic excursion, Doppler mitral flow velocity, and tissue Doppler imaging of the lateral mitral annulus. The definitive diagnosis was made by 2 physicians blinded to the POCUS findings.RESULTS:A total of 103 adult patients with a mean (SD) age of 73 (12) years were included; about half (51 patients) were women. Forty-two patients (41%) were finally diagnosed with AHF. Interindividual agreement on the physicians' diagnoses was good (k = 0.82). The POCUS algorithm assigned an AHF diagnosis to 76 patients (74%); 56 of them (85%) were in sinus rhythm. The diagnostic performance indicators for the algorithm were as follows: area under the receiver operating characteristic curve, 0.94 (95% CI, 0.88-1.00); sensitivity 96% (95% CI, 78%-100%); specificity, 93% (95% CI, 8%-98%); positive predictive value, 85% (95% CI, 67%-100%); negative predictive value, 98% (95% CI, 88%-100%).CONCLUSION:The POCUS-based algorithm for diagnosing AHF performed well in patients coming to the emergency department with acute dyspnea.

Our main objective was to describe the course of GLS during the first days of septic shock and to assess the agreement between GLS values and longitudinal strain measured in apical four chambers. A prospective observational single centre study was conducted at the Nimes University Hospital’s ICU. All patients admitted for a diagnosis of septic shock without pre-existing heart disease were eligible. Echocardiography (LVEF and GLS) was performed on the first day, and repeated once between day 3 and day 5 then once between day 6 and day 8. We enrolled 40 consecutive patients. Four patients were excluded. In overall population, GLS at T1 was impaired (− 11.0%, IQR(interquartile range) [− 15; − 10]). On T2 exams, a significant improvement of the GLS (− 11% vs − 16% p = 0.02) was observed whereas LVEF remained stable over time. A good agreement between GLS and longitudinal strain measured on a four chambers view was found. Based on the Bland and Altman method, the mean of differences for T1 exams was 0.1 (95% CI [− 0.6; 0.8]) with limits of agreement ranging from − 4 to 4. Myocardial strain is depressed at the early phase of septic shock and improves over time. A single measurement of LS4C view appears sufficient at bedside.