Cardiogenic shock has a high mortality rate. Even with the use of the Impella device, there are certain number of cases require further escalation therapy, although the predictive factors have not been fully elucidated. In this study, we aimed to estimate the acute mortality rate and the rate of requiring escalation therapy, as well as evaluate the predictors of the need for escalation therapy, including electrocardiographic parameters. In this retrospective study, we analyzed the patients with cardiogenic shock on Impella support between April 2018 and June 2021. Electrocardiogram, serum lactate levels, and pulmonary artery catheterization parameters were assessed 12 h after Impella implantation. Patients who died or required escalation therapy within 30 days of Impella implantation were defined as the deteriorated group and the remaining as the recovered group. A total of 67 patients with cardiogenic shock (66 ± 16 years; 46 men) with Impella were evaluated. The 30-day mortality rate and rate of requiring escalation therapy were 24

BACKGROUND:This study aimed to describe hemodynamic trends in patients with cardiogenic shock who received either isolated microaxial flow pump (mAFP) support or additional mAFP on venoarterial extracorporeal membrane oxygenation support (ie, VA-ECMO + mAFP). Trends also were analyzed by hospital survival in each group. METHODS:Using mixed-effect models, we analyzed hemodynamic indices from pre-, post-, and 24 hours after mAFP installation to immediately before device explantation in patients from the UNLOADERS-PVAD (UNLoading and heart recOvery with ADvanced mEchanical ciRculatory Support: optimal management of Percutaneous Ventricular Assist Device) Registry, a Japanese multicenter registry of patients with cardiogenic shock receiving mAFP. RESULTS:Hemodynamic indices from 409 patients (mean age 67 years, 75% male; 206 with isolated mAFP and 203 with VA-ECMO + mAFP) were analyzed. From immediately before mAFP installation to immediately before mAFP explantation, the mAFP group achieved an 11.8-mm Hg decrease in pulmonary artery wedge pressure, a 5.8-mm Hg decrease in right atrial pressure, and a 1.32 L/min increase in cardiac output (COPAC). Similarly, the ECMO + mAFP group showed a 2.8 L/min and 0.4 W increase in COPAC and cardiac power output, respectively. Changing patterns of hemodynamic indices were comparable between survivors and nonsurvivors with isolated mAFP support. In the ECMO + mAFP group, survivors demonstrated additional increases in COPAC, aortic pulsatility index, and myocardial performance score as well as reductions in pulmonary artery wedge pressure and diastolic pulmonary arterial pressure after VA-ECMO explantation. CONCLUSIONS:Patients with mAFP for cardiogenic shock exhibited progressive decreases in atrial pressures and increases in cardiac output, with distinct patterns in survivors receiving mAFP in addition to VA-ECMO. Hemodynamic monitoring may help determine the extent of cardiac recovery during combination therapy.

BACKGROUND:This study aimed to identify the most influential factors affecting severe respiratory failure requiring respiratory assist devices (RADs), including mechanical ventilation and non-invasive positive pressure ventilation, in patients with uncomplicated acute Stanford Type B aortic dissection (TBAD). METHODS AND RESULTS:Ninety-seven patients were retrospectively analyzed and categorized into RAD (n=15) and non-RAD (n=82) groups. The mean (±SD) time to RAD initiation was 2.1±1.2 days, with a PaO2to fraction of inspired oxygen (FiO2) ratio of 116±53 at initiation. Compared with the non-RAD group, patients in the RAD group were younger (56.8±13.6 vs. 70.2±12.1 years; P<0.001), had higher body mass index (27.2±7.0 vs. 23.4±3.9 kg/m2; P=0.003), more frequently had a completely patent false lumen (47% vs. 11%; P<0.001), and showed significantly higher white blood cell (WBC) counts the day after admission (12,580±2,899 vs. 9,589±2,917/μL; P<0.001). Multivariable logistic regression identified a WBC count ≥11,100/μL on the day after admission as an independent predictor of RAD requirement (odds ratio 6.17; 95% confidence interval 1.71-25.74; P=0.007). Structural equation modeling further supported the central role of an elevated WBC count (regression coefficient=0.184; P<0.05). CONCLUSIONS:An elevated WBC count appears to be the most influential factor associated with respiratory failure requiring RAD in patients with uncomplicated acute TBAD.

BACKGROUND:We examined the association between cerebral tissue oxygen saturation (SctO2) at each patient's first defibrillation after in-hospital monitoring began and return of spontaneous circulation (ROSC) after that defibrillation in patients requiring continued resuscitation after out-of-hospital cardiac arrest (OHCA). METHODS:We included adult patients with out-of-hospital cardiac arrest who underwent SctO2 monitoring during ongoing CPR and received in-hospital defibrillation for ventricular fibrillation or pulseless ventricular tachycardia. The first monitored defibrillation per patient was analyzed using multivariable Firth penalized logistic regression. All 194 monitored defibrillations were analyzed secondarily using a logistic generalized linear mixed-effects model (GLMM) with a patient-level random intercept. Both models adjusted for site. RESULTS:Nineteen patients achieved ROSC after the first monitored defibrillation. Median SctO2 was 48.8% [interquartile range, 47.2-53.6] with ROSC and 38.1% [33.8-41.8] without ROSC. After adjusting for site, arrest-to-defibrillation time, and epinephrine within 2 min, the odds ratio (OR) was 1.48 for each 1% increase in SctO2 (95% confidence interval [CI], 1.22-1.80; P<0.001). The area under the receiver operating characteristic curve was 0.961 (95% CI, 0.917-0.991). At an SctO2 cut-off of 44.5%, the sensitivity was 94.7% (18/19; 95% CI, 74.0%-99.9%) and the specificity was 89.7% (61/68; 95% CI, 79.9%-95.8%). In the adjusted GLMM of all 194 defibrillations (41 followed by ROSC), the association remained consistent (OR, 1.56; 95% CI, 1.34-1.82; P<0.001). CONCLUSIONS:In this selected population, higher SctO2 at defibrillation was associated with ROSC. This indirect marker and exploratory cutoff need external validation and should not delay guideline-directed defibrillation.

BACKGROUND:Right ventricular dysfunction (RVD) is common in cardiogenic shock and associated with poor outcomes. However, early RVD trajectories after initiation of percutaneous ventricular assist device (PVAD) support and their prognostic implications remain unclear. OBJECTIVES:The objectives of the study was to characterize the trajectory of hemodynamic RVD (hRVD) during the first 24 hours after PVAD initiation and evaluate its association with outcomes. METHODS:This study included patients with cardiogenic shock treated with PVAD from the UNLOADERS-PVAD registry. RVD was hemodynamically defined by an elevated right atrial pressure ≥15 mm Hg and/or a low pulmonary artery pulsatility index <0.9. Hemodynamic assessments were performed pre-PVAD, early post-PVAD, and 24 h post-PVAD. The primary endpoint was a composite of all-cause mortality or reintroduction of mechanical circulatory support after PVAD discontinuation within 30 days. RESULTS:Among 463 patients with available data, hRVD was present in 52% (63/121) pre-PVAD, decreased to 48% (211/443) early post-PVAD, and further to 39% (169/436) at 24 h post-PVAD. hRVD trajectories were heterogeneous, with improvement predominating over deterioration. The median follow-up from PVAD implantation was 27 (12-30) days. Persistent or worsening hRVD at 24 h post-PVAD was associated with a higher risk of the primary endpoint. Elevated right atrial pressure was associated with adverse outcomes only at 24 h post-PVAD, whereas low pulmonary artery pulsatility index was consistently associated with adverse outcomes across all time points. CONCLUSIONS:In patients with cardiogenic shock supported by PVAD, the early trajectory of hRVD provides prognostic information. Persistent or worsening hRVD at 24 hours identifies high-risk patients and may guide timely escalation of right-heart-targeted therapies. (UNLOADERS-PVAD [Unloading and Heart Recovery with Advanced Mechanical Circulatory Support: Optimal Management of Percutaneous Ventricular Assist Device] UMIN000052966).

IntroductionCardiogenic shock (CS) with severe aortic stenosis (AS) is a drug-resistant hemodynamically unstable condition with high mortality. We report three cases of CS with severe AS that were successfully managed with balloon aortic valvuloplasty (BAV), followed by left ventricular (LV) unloading using Impella as a bridge therapy for transcatheter aortic valve replacement (TAVR). We call this therapeutic approach “BAV-PELLA-TAVR”.Case presentationCase 1: A 92-year-old Japanese female presented with CS due to low-flow, low-gradient severe AS and multivessel coronary artery disease. After emergent BAV and Impella 2.5 support, the patient's hemodynamics stabilized. Percutaneous coronary intervention was performed on the right coronary and left anterior descending arteries with Impella 2.5 support. Subsequently, her heart failure (HF) improved and elective TAVR was performed. Case 2: An 89-year-old Japanese female presented with CS due to severe AS. Despite administration of high-dose catecholamines, the patient developed exacerbation of CS due to reduced cardiac output, corresponding to Stage D according to the Society for Cardiovascular Angiography and Interventions (SCAI) classification. Consequently, BAV was performed, which reduced the aortic valve pressure gradient (PG). However, due to persistent hemodynamic instability, Impella 2.5 support was initiated. This procedure resulted in hemodynamic improvement and elective TAVR was performed. Case 3: An 86-year-old Japanese female developed CS with pulmonary edema due to severe AS. Emergent BAV was performed. However, there was no improvement in the PG and hemodynamics, and the initial mild aortic regurgitation worsened to a moderate degree. Therefore, an Impella CP was implanted, which resulted in improved hemodynamics. Following the removal of the Impella CP device, and sub-emergent TAVR was successfully performed.DiscussionIn all cases, emergent BAV and subsequent hemodynamic support from the Impella were provided as the initial treatment for CS at Stage C/D according to the SCAI classification. This approach improved CS, enabling interventions for concomitant ischemic heart disease, multidisciplinary heart team evaluation, and TAVR with reduced perioperative risk.

Anemia can worsen the prognosis of patients with acute cardiovascular (CV) disease; however, the effect of red blood cell (RBC) transfusion on mid-term outcomes in such patients requiring intensive care remains unclear. Therefore, this study investigated the association between RBC transfusions during hospitalization and subsequent CV events (all-cause mortality, non-fatal myocardial infarction or stroke, admission for acute heart failure [AHF], unstable angina, and other CV events) after hospital discharge in patients admitted to the cardiovascular intensive care unit (CICU). We retrospectively enrolled 517 patients with emergent admission to the CICU for suspected acute CV disease between January and December 2018. After excluding 41 patients who died or developed CV events during hospitalization, the remaining 476 patients (44.3

Background:Prognostic models for cardiovascular death, but not all-cause death, after transcatheter aortic valve implantation (TAVI) have not been established yet. Methods and Results:In 252 patients with aortic stenosis (AS) who underwent TAVI (men/women 83/169; mean age 85 years), we explored predictive models by machine learning for cardiovascular death using 62 candidates. During the follow-up period (mean 1,135 days), 13 (5.2%) patients died of cardiovascular disease. The least absolute shrinkage and selection operator (LASSO) feature selection identified 8 features as important candidates, including old myocardial infarction, triglycerides/high-density lipoprotein cholesterol (TG/HDL-C) ratio, Society of Thoracic Surgeons predicted risk of mortality score (STS-PROM), pulse rate, left atrium volume index, stroke volume index, estimated glomerular filtration rate, and albumin. Cox regression analyses with adjustment for age and sex showed that old myocardial infarction, high levels of TG/HDL-C, STS-PROM, and pulse rate, as well as low levels of glomerular filtration rate and albumin, were independent risk factors for cardiovascular death. Models of logistic regression (LR) and random survival forest (RSF) using the LASSO-selected features, except for STS-PROM, significantly improved predictive abilities for cardiovascular death compared with LR analysis using STS-PROM alone. Conclusions:Machine learning models of prediction for cardiovascular death of LR and RSF using the LASSO-selected features are superior to a LR model using STS-PROM alone in patients with severe AS who underwent TAVI.

BACKGROUND:Alcohol septal ablation (ASA) is used to treat drug-refractory hypertrophic obstructive cardiomyopathy (HOCM). Intraprocedural echocardiography is essential for identifying the septal area perfused by each septal branch; however, its role in determining the procedural endpoint of ASA remains unclear. This retrospective study aimed to evaluate the impact of intraprocedural echocardiographic findings on clinical outcomes and left ventricular pressure gradient (LVPG) after ASA. METHODS:Overall, 120 patients with HOCM who underwent ASA at a single center were divided into two groups based on the presence of optimal ablation. Optimal ablation was defined as the ablated area fully covering the targeted septal myocardium from the point of contact with the onset of the accelerated flow to the basal septum and dense acoustic shadowing accompanying the ablated area. Clinical outcomes and LVPG changes were evaluated using inverse probability of treatment weighting. RESULTS:Significantly more patients showed a New York Heart Association (NYHA) functional class improvement of ≥2 stages or achievement of class I in the optimal ablation group (n = 74) than in the non-optimal ablation group (94 % vs. 62 %; p < 0.001). The optimal ablation group had a significantly greater percentage reduction in LVPG at 1-year after ASA (82 ± 18 % vs. 64 ± 18 %; p = 0.001). Multivariate analyses revealed that optimal ablation was an independent predictor of a NYHA functional class improvement of ≥2 stages or achievement of class I (odds ratio, 11.3; 95 % confidence interval, 3.43-39.1; p < 0.001) and a percentage reduction in LVPG (p = 0.001). CONCLUSIONS:Intraprocedural echocardiographic findings of optimal ablation were associated with favorable clinical outcomes and a significant reduction in LVPG.

BACKGROUND:Standardized protocols with optimal hemodynamic targets for percutaneous ventricular assist device (PVAD) management remain undefined. We aimed to evaluate the proportion of phase-specific hemodynamic criteria achieved during PVAD support and their association with outcomes in patients with cardiogenic shock. METHODS:This multicenter retrospective study enrolled patients with cardiogenic shock requiring PVAD (Impella). Patients were evaluated at 24 hours post-PVAD, venoarterial extracorporeal membrane oxygenation weaning, and PVAD weaning. Hemodynamic criteria consisted of key targets, including mean arterial pressure ≥60 mm Hg, lactate <2.0 mmol/L, right atrial pressure <15 mm Hg, pulmonary artery wedge pressure <20 mm Hg, pulmonary artery pulsatility index ≥1.0, and cardiac power output ≥0.6 W. The primary outcome was a composite of 30-day all-cause mortality and unplanned mechanical circulatory support reintroduction. RESULTS:A total of 501 patients were enrolled: 206 (41%) with PVAD alone and 295 (59%) with PVAD and venoarterial extracorporeal membrane oxygenation. The majority of patients were supported with Impella CP (406, 81%). Fulfillment of criteria was observed in 37%, 52%, and 45% at 24 hours post-PVAD, venoarterial extracorporeal membrane oxygenation weaning, and PVAD weaning, respectively. Patients with unfulfilled criteria at each evaluation point were at high risk for the primary outcome (hazard ratio, 3.2 [95% CI, 2.1-4.8]; hazard ratio, 2.1 [1.2-3.7]; and hazard ratio, 2.0 [95% CI, 1.1-3.6]). Hemodynamic criteria achievement consistently stratified the risk of the primary outcome across different subgroups, including shock cause, shock stage, and concomitant use of venoarterial extracorporeal membrane oxygenation. CONCLUSIONS:Phase-specific hemodynamic criteria are often unmet and are associated with significantly higher risks of short-term fatal events.

Alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) can lead to complex hemodynamic challenges. This report describes a case of a 79-year-old woman who developed mixed cardiogenic and distributive shock following ASA. Cardiogenic shock occurred due to complete atrioventricular block with insufficient cardiac output despite temporary right ventricular pacing. Concurrently, distributive shock developed secondary to bacterial pneumonia and exacerbation of polymyositis-associated interstitial lung disease. Fluid resuscitation, antibiotics, vasopressors, and hydrocortisone were ineffective. Inotropes, intra-aortic balloon pump, and veno-arterial extracorporeal membrane oxygenation were contraindicated because of the risk of worsening left ventricular outflow tract obstruction. An Impella 2.5 (Abiomed Inc., Danvers, MA, USA) was deployed, achieving hemodynamic stabilization without worsening left ventricular outflow tract obstruction. The patient recovered successfully through comprehensive intensive care and was discharged. This case highlights the potential efficacy of Impella support in managing complex mixed shock states after ASA. It emphasizes the multiple challenges in HOCM management, including addressing hemodynamic complexities due to left ventricular outflow tract obstruction, managing ASA-related complications, and simultaneously treating concurrent distributive shock. This comprehensive approach is crucial for developing effective individualized management strategies for patients with HOCM when dealing with postprocedural complications. Learning objective This case illustrates complex hemodynamic complications following alcohol septal ablation for hypertrophic obstructive cardiomyopathy. It emphasizes the importance of recognizing and managing mixed cardiogenic and distributive shock when standard treatments fail. The case highlights the potential role of Impella (Abiomed Inc., Danvers, MA, USA) support in stabilizing hemodynamics without exacerbating left ventricular outflow tract obstruction.

Background It is unclear whether an intra‐aortic balloon pump (IABP) or percutaneous ventricular assist device (Impella) in combination with extracorporeal membrane oxygenation (ECMO) is better. Methods Using the Japanese Diagnosis Procedure Combination database from September 2016 to March 2022, we identified inpatients who received an Impella or IABP in combination with ECMO (ECPella or ECMO+IABP group, respectively). The primary outcome was in‐hospital mortality, and the secondary outcomes included the length of hospital stay, length of ECMO, total hospitalization cost, complications, and durable mechanical circulatory support implantations. Propensity score matching was performed to compare the outcomes between the groups. Results Of 14 319 eligible patients, 590 (4.1%) received ECPella and 13 729 (96%) received ECMO+IABP. The mean age of patients was 65 years, 77% were men, and 57% had acute coronary syndrome. After propensity score matching, the patient characteristics were well balanced between the groups. The 14‐day mortality rate was lower in the ECPella group than in the ECMO+IABP group (28.0% versus 36.8%; risk difference, −8.2% [95% CI, −13.8 to −2.7]), whereas there was no significant difference in in‐hospital mortality between the groups (58.3% versus 56.6%; risk difference, 2.4% [95% CI, −3.5 to 8.2]). The ECPella group had a higher total hospitalization cost, increased renal replacement therapy during hospitalization, and more durable mechanical circulatory support implantations than the ECMO+IABP group. Conclusions This nationwide inpatient database study showed no significant difference in in‐hospital mortality between the groups, but ECPella was associated with a higher total hospitalization cost, increased renal replacement therapy during hospitalization, and more durable mechanical circulatory support implantations than ECMO+IABP.

BACKGROUND:Limited data are available on risk stratification in patients undergoing weaning from percutaneous ventricular assist devices (PVADs). We aimed to identify factors associated with adverse events following PVAD weaning and to construct a predictive scoring system. METHODS:This study was a secondary analysis of the UNLOADERS-PVAD study, an observational registry involving three participating institutions in Japan. Consecutive patients with cardiogenic shock who received PVAD support were analyzed for 13 clinical and nine hemodynamic factors assessed immediately prior to PVAD explantation, using the least absolute shrinkage and selection operator (LASSO) method. Risk factors associated with 30-day events, defined as all-cause mortality or reintroduction of mechanical circulatory support after PVAD weaning, were identified. RESULTS:Among 304 patients, four clinical factors (female sex, renal replacement therapy, use of multiple vasopressors and/or inotropes, and elevated lactate levels) and three hemodynamic factors (elevated heart rate, elevated pulmonary artery wedge pressure, and lower cardiac power output) immediately prior to PVAD explantation were selected to construct a predictive scoring system for 30-day event risk. This score stratified 30-day event risk linearly and demonstrated good predictive accuracy (area under the curve: 0.786; 95% CI 0.712-0.860). CONCLUSIONS:Four clinical and three hemodynamic factors were significantly associated with 30-day events following PVAD weaning, leading to the development of the UNLOADERS-PVAD Weaning Score. This scoring system facilitates accurate risk stratification before PVAD weaning, guiding clinical decisions regarding further interventions. TRIAL REGISTRATION:UMIN000052966.

Abstract Background The micro-axial flow pump Impella, a new mechanical circulatory device for cardiogenic shock, is still only available in a limited number of hospitals, due to the facility certification requirements and insufficient evidence of the benefit of introducing Impella in hospitals. This study aimed to evaluate the impact of introducing Impella in hospitals on in-hospital mortality of patients treated with extracorporeal membrane oxygenation (ECMO). Methods Using a nationwide Japanese inpatient database, we identified patients who received ECMO during hospitalization between 1 April 2014 and 31 March 2021. A hospital-level propensity score–matched cohort was created matching hospitals that introduced Impella (exposure group) to those that did not introduce Impella (control group). The inclusion period in each hospital was divided into two time periods according to the time of Impella introduction in the exposure group and the corresponding hospital in the control group (before and after exposure). The primary outcome was in-hospital mortality. Uncontrolled and controlled interrupted time-series analyses involved before–after exposure comparison and exposure–control comparison. Results Out of 34,379 eligible patients, we created a matched cohort of 8351 patients from 86 hospitals with Impella introduction (exposure group) and 7230 patients from 86 hospitals without Impella introduction (control group). In-hospital mortality before and after exposure was 62.5% and 59.3, respectively, in the exposure group; and 66.8% and 63.7%, respectively, in the control group. Uncontrolled interrupted time-series analysis showed no significant level change or trend change in the before–after exposure comparison in both the exposure and the control groups. Controlled interrupted time-series analysis also showed no significant level change (−0.01%; 95% confidence intervals −5.36% to + 5.33%) or trend change (+ 0.10%, −0.30% to + 0.40%) after exposure in the exposure–control comparison. Conclusions This nationwide inpatient database study showed no association between Impella introduction in hospitals and in-hospital mortality of patients who underwent ECMO. Because this study confined itself to analze of the impact of the introduction of Impella solely at the hospital level, further detailed studies are warranted to assess its efficacy at the patient level.

Aim: To investigate the factors associated with favourable neurological outcomes in adult patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out -of -hospital cardiac arrest (OHCA). Methods: This retrospective observational study used secondary analysis of the SAVE -J II multicentre registry data from 36 institutions in Japan. Between 2013 and 2018, 2157 patients with OHCA who underwent ECPR were enrolled in SAVE -J II. A total of 1823 patients met the study inclusion criteria. Adult patients (aged >= 18 years) with OHCA, who underwent ECPR before admission to the intensive care unit, were included in our secondary analysis. The primary outcome was a favourable neurological outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 or 2. We used a multivariate logistic regression model to examine the association between factors measured at the incident scene or upon hospital arrival and favourable neurological outcomes. Results: Multivariable analysis revealed that shockable rhythm at the scene [odds ratio (OR); 2.11; 95% confidence interval (CI), 1.16-3.95] and upon hospital arrival (OR 2.59; 95% CI 1.60-4.30), bystander CPR (OR 1.63; 95% CI 1.03-1.88), body movement during resuscitation (OR 7.10; 95% CI 1.79-32.90), gasping (OR 4.33; 95% CI 2.57-7.28), pupillary reflex on arrival (OR 2.93; 95% CI 1.73-4.95), and male sex (OR 0.43; 95% CI 0.24-0.75) significantly correlated with neurological outcomes. Conclusions: Shockable rhythm, bystander CPR, body movement during resuscitation, gasping, pupillary reflex, and sex were associated with favourable neurological outcomes in patients with OHCA treated with ECPR.

Background In some cases of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR), negative pupillary light reflex (PLR) and mydriasis upon hospital arrival serve as common early indicator of poor prognosis. However, in certain patients with poor prognoses inferred by pupil findings upon hospital arrival, pupillary findings improve before and after the establishment of ECPR. The association between these changes in pupillary findings and prognosis remains unclear. This study aimed to clarify the association of pupillary examinations before and after the establishment of ECPR in patients with OHCA showing poor pupillary findings upon hospital arrival with their outcomes. To this end, we analysed retrospective multicentre registry data involving 36 institutions in Japan, including all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. We selected patients with poor prognosis inferred by pupillary examinations, negative pupillary light reflex (PLR) and pupil mydriasis, upon hospital arrival. The primary outcome was favourable neurological outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Multivariable logistic regression analysis was performed to evaluate the association between favourable neurological outcome and pupillary examination after establishing ECPR. Results Out of the 2,157 patients enrolled in the SAVE-J II study, 723 were analysed. Among the patients analysed, 74 (10.2%) demonstrated favourable neurological outcome at hospital discharge. Multivariable analysis revealed that a positive PLR at ICU admission (odds ration [OR] = 11.3, 95% confidence intervals [CI] = 5.17–24.7) was significantly associated with favourable neurological outcome. However, normal pupil diameter at ICU admission (OR = 1.10, 95%CI = 0.52–2.32) was not significantly associated with favourable neurological outcome. Conclusion Among the patients with OHCA who underwent ECPR and showed poor pupillary examination findings upon hospital arrival, 10.2% had favourable neurological outcome at hospital discharge. A positive PLR after the establishment of ECPR was significantly associated with favourable neurological outcome.

Background Previous studies have suggested that left ventricular (LV) unloading with an intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (Impella) in combination with extracorporeal membrane oxygenation (ECMO) is associated with lower mortality; however, it is unclear which is better. This study aimed to evaluate the effectiveness of LV unloading with an Impella versus IABP on in-hospital mortality and other clinical outcomes.Methods Using the Japanese Diagnosis Procedure Combination database from September 28, 2016, to March 31, 2022, we identified inpatients who received an Impella or IABP in combination with ECMO (ECPella or ECMO+IABP group, respectively). The primary outcome was in-hospital mortality and the secondary outcomes were the length of hospital stay, length of ECMO, total hospitalization cost, and complications. Propensity score matching was performed to compare the outcomes between the groups.Results Of 14,525 eligible patients, 603 (4.2%) received ECPella and 13,922 (96%) received ECMO+IABP. After propensity score matching, there was no significant difference in in-hospital mortality between the two groups (58.9% versus 56.6%; risk difference, 2.3%; 95% confidence interval, −3.9% to 8.5%). The ECPella group had a longer hospital stay, higher total hospitalization cost, and more frequent major bleeding, vascular complications, and renal replacement therapy during hospitalization than the ECMO+IABP group.Conclusions This nationwide inpatient database study showed that ECPella was not associated with a survival benefit but was associated with a longer hospital stay, higher total hospitalization cost, and more complications than ECMO+IABP.### Competing Interest StatementDrs. Nishimoto and Nakata received lecture fees from Abiomed Japan. All other authors declare that they have no conflict of interest.### Clinical TrialN/A### Funding StatementThis research was funded by grants from the Ministry of Health, Labour and Welfare, Japan, grant numbers 23AA2003 and 22AA2003.### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This study was performed in accordance with the amended Declaration of Helsinki, and the Institutional Review Board of The University of Tokyo approved this study (approval number: 3501-(3); 25 December 2017).I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.Yes

Hypertrophic cardiomyopathy is characterized by significant left ventricular wall thickening, often leading to obstructive symptoms. Alcohol septal ablation (ASA) has emerged as an effective treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM) who remain symptomatic despite maximal medical therapy. However, the detailed long-term effects of ASA in Japanese patients with HOCM remain unclear. Therefore, this study aimed to investigate the long-term effects of ASA for HOCM by evaluating changes in symptoms, pressure gradient, hemodynamics, prognosis, and predictive factors for cardiovascular events over time. In this retrospective study, we examined 239 highly symptomatic patients (age, 64 ± 13 years; median follow-up, 6.9 years) treated with ASA for drug-refractory HOCM between 1998 and 2021. Patients were assessed using transthoracic echocardiography, magnetic resonance imaging, and cardiac catheterization. Follow-up evaluations included clinical assessments, electrocardiography, and echocardiography. Data analysis included descriptive statistics, Kaplan–Meier analysis, and multivariate regression. ASA reduced the left ventricular outflow tract gradient from 90.5 ± 52.8 to 14.4 ± 17.1 mmHg (P < 0.01) and New York Heart Association (NYHA) class from 3 [2.5–3] to 1 [1–2] at 10 years after ASA (P < 0.01). The 30-day mortality rate following ASA was 1