CANCARE RESEARCH
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Preoperative levels of biomarkers of coagulation to predict massive bleeding after surgical repair for acute type A aortic dissection: a retrospective cohort study.
Clinical takeaway Preoperative APTT was associated with massive postoperative bleeding after type A dissection repair. Its usefulness for prospective risk stratification remains unvalidated.
Summary & abstract
Study summary
This single-center retrospective cohort included 474 patients undergoing surgery for acute type A aortic dissection between January 2005 and May 2023. Massive postoperative bleeding occurred in 87 patients (18%), who were compared with 387 patients without massive bleeding. In multivariable analysis, preoperative APTT above 34.5 seconds was associated with massive bleeding (OR 2.95, 95% CI 1.60–5.47). Higher preoperative creatinine, hypertension, and longer cardiopulmonary bypass duration were also independently associated with bleeding. Patients with massive bleeding experienced more postoperative complications.
Study limitation: The retrospective, single-center design limits generalizability, and the abstract does not report the definition of massive bleeding or predictive performance.
Published abstract
BACKGROUND: Acute type A aortic dissection is a highly emergent condition with a high mortality rate. The condition poses an imminent risk of serious complications such as coagulopathy with massive bleeding. This increases the risk of mortality even after surgical repair. Procoagulant drugs are routinely administered but some patients still suffer postoperative massive bleeding that can be fatal. The study aimed to investigate whether massive bleeding after surgical treatment for type A aortic dissection can be predicted preoperatively through routine coagulation tests such as APTT, PT (INR), fibrinogen, D-dimer, and platelets. METHODS: The study was a retrospective, single-center, cohort study performed at a tertiary cardiac surgery unit. A total of 474 patients who underwent surgery for type A aortic dissection at our department between January 2005 and May 2023 were included in the study. Of these, 87 patients had massive postoperative bleeding after surgery for type A aortic dissection and were compared to 387 patients who did not have massive postoperative bleeding. Uni- and multivariable analyses were performed using logistic regression. The multivariable model included predictors of massive bleeding. Bleeding-related routine lab variables were then forced into the model. RESULTS: Patients with massive bleeding (18%) had higher preoperative activated partial thromboplastin time (APTT) (33 s vs 29 s, p<0.01), and creatinine (97 µmol/L vs 87 µmol/L, p<0.01), as well as lower preoperative platelet counts (172 × 109/L vs 187 × 109/L, p=0.03) compared to patients without massive bleeding. Patients with massive bleeding also had longer duration of cardiopulmonary bypass (CPB) (221 min vs 170 min, p<0.01) and suffered more postoperative complications. Multivariable logistic regression identified preoperative APTT per mmol increment (OR 1.04 (95% CI 1.01-1.07, p=0.01), preoperative APTT > 34.5 s (OR 2.95 (95% CI 1.60-5.47), p<0.01), preoperative creatinine > 82.5 µmol/L (OR 2.16 (95% CI 1.15-4.06), p=0.02), hypertension (OR 1.83 (95% CI 1.01-3.32), p<0.05) and CPB time per 10 min increment (OR 1.09 (95% CI 1.05-1.13, p<0.01)) as independent predictors of massive bleeding. CONCLUSION: Preoperative APTT exceeding 34.5 s was independently associated with massive bleeding after type A aortic dissection repair and may, pending prospective validation, help identify patients who could potentially benefit from earlier hemostatic intervention.
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Clinical outcomes of sacubitril/valsartan in patients with mildly reduced or preserved ejection fraction and acute heart failure: a multi-institutional study.
Clinical takeaway Sacubitril/valsartan initiation was not associated with fewer HF rehospitalizations or cardiovascular deaths than ARB therapy in this cohort. The confidence interval does not establish equivalence.
Summary & abstract
Study summary
This observational cohort included 9,107 patients hospitalized for acute heart failure with mildly reduced or preserved ejection fraction and used propensity score overlap weighting. Comparing in-hospital sacubitril/valsartan initiation with ARB therapy, rates of HF rehospitalization or cardiovascular death were 39.7 versus 40.3 per 100 person-years (hazard ratio 0.97; 95% confidence interval 0.79–1.20). Associations were consistent across kidney-function strata, including dialysis. Greater NT-proBNP reduction in a biomarker subcohort did not translate into an observed reduction in clinical events, and limited sample size prevented conclusions of therapeutic equivalence.
Study limitation: The observational design leaves potential residual confounding despite overlap weighting, and limited sample size precludes definitive equivalence conclusions.
Published abstract
BACKGROUND: The long-term real-world effectiveness and safety of in-hospital initiation of sacubitril/valsartan in patients hospitalized for acute heart failure (HF) with mildly reduced or preserved left ventricular ejection fraction (HFmrEF or HFpEF) remain uncertain, particularly among patients with advanced chronic kidney disease or dialysis, who are often underrepresented in randomized trials. PATIENTS/MATERIALS AND METHODS: We identified 9,107 patients with HFmrEF or HFpEF hospitalized for acute HF from the Chang Gung Research Database between January 1, 2016, and June 30, 2023. Propensity score weighting with overlap weights was applied to balance baseline characteristics between treatment groups. Risks of fatal and nonfatal outcomes were analyzed using Cox proportional hazards and Fine-Gray subdistribution hazard models, respectively. RESULTS: After overlap weighting, the incidence rates of the composite endpoint of HF rehospitalization and cardiovascular (CV) death were 39.7 and 40.3 per 100 person-years in the angiotensin receptor neprilysin inhibitor (ARNI) and angiotensin receptor blocker (ARB) groups, respectively (Hazard ratio, 0.97; 95% confidence interval, 0.79-1.20). In analyses stratified by chronic kidney disease stage, the association between treatment group and the primary endpoint was consistent among patients with eGFR ≥60, 30-59, <30 mL/min/1.73 m2, or dialysis. CONCLUSIONS: In this multi-institutional real-world cohort of patients hospitalized for acute HF with left ventricular ejection fraction (LVEF) >40%, in-hospital initiation of sacubitril/valsartan was not associated with lower risks of HF rehospitalization or CV death compared with ARB therapy, despite greater NT-proBNP reduction in a biomarker subcohort. Limited sample size precludes definitive conclusions regarding therapeutic equivalence.
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A Robust Educational Initiative for EMS Clinicians Focusing on Pit-Crew CPR Improves Neurologically Intact Survival.
Clinical takeaway The training initiative was associated with gradually improving neurologically intact survival, but not improved overall discharge survival. The observational design does not establish that training caused these changes.
Summary & abstract
Study summary
A retrospective before-and-after study evaluated pit-crew CPR training across 27 EMS agencies in 1,917 adults with non-traumatic out-of-hospital cardiac arrest. In interrupted time series analysis, survival to discharge with good neurological function increased gradually after implementation (adjusted odds ratio 1.20 per four-month interval; 95% confidence interval 1.01–1.44). Sustained return of spontaneous circulation increased at intervention onset (adjusted odds ratio 1.41; 95% confidence interval 1.1–1.81). Overall survival to hospital discharge showed no change before, at, or after implementation, distinguishing the neurological outcome association from the absence of an observed overall survival improvement.
Study limitation: The retrospective before-and-after design remains vulnerable to confounding and concurrent changes in resuscitation care despite statistical adjustment.
Published abstract
OBJECTIVES: To evaluate whether the implementation of a region-wide pit-crew cardiopulmonary resuscitation (CPR) initiative was associated with improved survival to hospital discharge with good neurological function among adults with non-traumatic out-of-hospital cardiac arrest (OHCA) in a heterogenous, multi-agency emergency medical services (EMS) system in south-central Connecticut. METHODS: We conducted a retrospective, before-and-after observational study using the Cardiac Arrest Registry to Enhance Survival (CARES). The pit-crew CPR intervention, comprising structured didactic and hands-on simulation-based training was delivered across 27 EMS agencies from September 28, 2021 through August 2, 2022. The primary outcome was survival to hospital discharge with good neurological function (Cerebral Performance Category 1-2). Secondary outcomes included survival to hospital discharge and sustained return of spontaneous circulation (ROSC). We performed an interrupted time series analysis using the beginning of our intervention (September 28, 2021) as the interruption to model. Multivariable logistic regression models were adjusted for age, sex, race, shockable initial rhythm, witnessed arrest, arrest location, and bystander CPR. RESULTS: A total of 1917 adult non-traumatic OHCA patients (922 pre-intervention; 995 post-intervention) were resuscitated by EMS clinicians in the study period. In progression since intervention, there was a significant increase in neurologically intact survival per 4-month interval (adjusted odds ratio [OR] 1.20; 95% confidence interval [CI], 1.01-1.44), suggesting a gradual improvement in outcomes over time after protocol implementation. At intervention start, there was a significant increase in ROSC (aOR 1.41; 95% CI, 1.1-1.81). There was no change in survival to hospital discharge prior to the intervention, at the time of the intervention, or following the intervention. CONCLUSIONS: Implementation of a pit-crew CPR model across a heterogenous, multi-agency EMS system was associated with a significant gradual increase in neurologically intact survival in the post-intervention period, as well as a significant immediate improvement in ROSC at the time of protocol implementation. These findings support structured, team-based resuscitation as a feasible and effective strategy to improve cardiac arrest outcomes within existing EMS systems.
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Hemodynamic trajectory phenotypes may modify associations between corticosteroid timing and outcomes in septic shock.
Clinical takeaway Haemodynamic trajectories may identify heterogeneity in associations between corticosteroid timing and septic-shock outcomes. These observational findings do not establish a benefit from delaying corticosteroids.
Summary & abstract
Study summary
This retrospective study examined corticosteroid timing in adults with vasopressor-treated septic shock across three ICU cohorts, identifying deteriorated and improved phenotypes from 168-hour haemodynamic trajectories. Early administration was defined as within six hours of sepsis onset, versus later administration. In the MIMIC-IV deteriorated phenotype, late corticosteroids were associated with lower 28-day mortality (HR 0.88 [0.78–0.98]) and shorter ventilation duration (HR 0.65 [0.58–0.73]). The mortality association was not consistently replicated in validation cohorts; the improved phenotype showed no consistent mortality or hospital length-of-stay association with later treatment.
Study limitation: Retrospective treatment comparisons remain vulnerable to confounding, and the mortality association was not consistently replicated across validation cohorts.
Published abstract
Corticosteroid trials in septic shock show conflicting results, with patient heterogeneity and treatment timing as likely contributors. We evaluated whether associations between corticosteroid timing and clinical outcomes differed by hemodynamic trajectory phenotype defined by dynamic time warping clustering of Blood Pressure-Vasopressor Index (BPRI) trajectories across three ICU cohorts. We conducted a retrospective cohort study using MIMIC-IV as the derivation cohort and eICU-CRD and PINES as validation cohorts. Adult patients with septic shock receiving vasopressors were included. Hemodynamic phenotypes were identified from 168-h BPRI trajectories. Corticosteroid timing was classified as early (≤ 6 h) or late (> 6 h) after sepsis onset. In MIMIC-IV, inverse probability of treatment weighting with cause-specific Cox regression was used to estimate associations between timing and 28-day mortality, hospital length of stay, and ventilation duration within each phenotype. Validation cohorts were analyzed using multivariable Cox regression, and cohort-specific estimates were summarized using random-effects meta-analysis with I2. Two phenotypes were identified in MIMIC-IV: Deteriorated (N=2,082, 38%), with declining hemodynamics and higher mortality, and Improved (N=3,361, 62%), with stable or rising trajectories. Similar trajectory patterns were observed in eICU-CRD and PINES. In the Deteriorated phenotype, late corticosteroids were associated with lower 28-day mortality in MIMIC-IV (HR 0.88 [0.78-0.98]) and shorter ventilation duration (HR 0.65 [0.58-0.73]) compared with early administration. The mortality association was not consistently replicated in validation cohorts, whereas the ventilation association was observed in PINES Deteriorated patients. In the Improved phenotype, late steroids showed no consistent mortality or hospital length-of-stay association. Exploratory hemodynamic response analysis showed a more favorable BPRI slope for late versus early steroids in the Deteriorated phenotype. Hemodynamic trajectory phenotypes identified clinically meaningful variation in the relationship between corticosteroid timing and outcomes in septic shock. In the Deteriorated phenotype, delayed corticosteroid initiation was associated with lower 28-day mortality and shorter recovery, whereas the Improved phenotype showed no mortality advantage from delayed treatment. These findings support incorporating dynamic hemodynamic trajectories into future studies of corticosteroid timing in septic shock.
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Immunonutritional status and survival after cardiac arrest: prognostic value of the prognostic nutritional index, the cholesterol-modified prognostic nutritional index, and the controlling nutritional status score in post-cardiopulmonary resuscitation intensive care patients.
Clinical takeaway These routine laboratory-derived indices were associated with ICU mortality after cardiac arrest, but their modest discrimination and retrospective evaluation leave their clinical prognostic utility uncertain.
Summary & abstract
Study summary
This single-center retrospective study evaluated immunonutritional indices measured within 24 hours of ICU admission in 444 adults after return of spontaneous circulation following out-of-hospital cardiac arrest. Non-survivors had lower Prognostic Nutritional Index (PNI), higher cholesterol-modified PNI (CPNI), and higher Controlling Nutritional Status (CONUT) scores than survivors. In separate adjusted models, mortality odds ratios were 0.64 per 10-point PNI increase, 1.25 per 10-point CPNI increase, and 1.24 per one-point CONUT increase. Discrimination for ICU mortality was modest, with AUCs of 0.689 for PNI, 0.631 for CPNI, and 0.681 for CONUT.
Study limitation: The single-center retrospective design limits generalizability; the abstract reports no confidence intervals for adjusted associations.
Published abstract
BACKGROUND: Patients achieving return of spontaneous circulation (ROSC) after cardiac arrest experience marked systemic inflammation, metabolic stress, and nutritional impairment, all of which contribute to high mortality. Practical prognostic indices reflecting immunonutritional status may facilitate early risk stratification in this population. AIM: To evaluate the prognostic value of immunonutritional indices for predicting mortality in patients with ROSC after out-of-hospital cardiac arrest. METHODS: This single-center, retrospective cohort study included adult patients admitted to the intensive care unit after ROSC following out-of-hospital cardiac arrest between January 2015 and January 2025. Prognostic Nutritional Index (PNI), cholesterol-modified Prognostic Nutritional Index (CPNI), and Controlling Nutritional Status (CONUT) scores were calculated from laboratory parameters obtained within the first 24 h of ICU admission. Patients were classified as survivors or non-survivors based on ICU outcome. Associations with mortality were evaluated using univariate and multivariate logistic regression analyses, and discriminatory performance was assessed using receiver operating characteristic curve analysis. RESULTS: Among 444 post-ROSC patients, non-survivors had lower PNI (43.66 ± 15.47 vs. 55.06 ± 17.21) and higher CPNI (81.10 ± 13.70 vs. 66.90 ± 18.25) and CONUT scores (4.27 ± 3.04 vs. 2.43 ± 2.43; all p < 0.001). In separate stepwise multivariable models, PNI (aOR 0.64 per 10-point increase), CPNI (aOR 1.25 per 10-point increase), and CONUT (aOR 1.24 per 1-point increase) remained independently associated with mortality. AUCs were 0.689, 0.631, and 0.681, respectively; PNI showed the highest sensitivity (86.3%) at a cut-off of ≤ 59.90. CONCLUSION: PNI, CPNI, and CONUT were significantly associated with ICU mortality after out-of-hospital cardiac arrest. These indices may reflect systemic inflammation, immune dysfunction, metabolic stress, and nutritional reserve rather than nutritional status alone. Their availability from routine laboratory parameters may support early risk stratification. Further prospective studies are needed to confirm their prognostic value and clinical applicability.
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Exploratory Sex-Stratified Associations of Postoperative Visual and Auditory Hallucinations After Cardiac Surgery: Insights from the VAACS Study.
Clinical takeaway Hallucinations were reported during the first week after cardiac surgery in both sexes. The exploratory associations do not establish causation or justify changes to perioperative medication use.
Summary & abstract
Study summary
A prospective cohort followed 1,331 adults undergoing isolated coronary bypass or valve surgery at 10 Palestinian centers for postoperative hallucinations through day 7. Visual hallucinations occurred in 155 patients (11.6%) and auditory hallucinations in 92 (6.9%), with similar rates in males and females. In exploratory sex-stratified models, postoperative noradrenaline requirement was associated with auditory hallucinations among females (adjusted HR 4.35, 95% CI 2.18–8.68), but this model included only 22 events. The authors emphasized that these findings require confirmation in studies incorporating structured delirium assessment.
Study limitation: Sex-stratified associations are hypothesis-generating; the female auditory-hallucination model included only 22 events, and structured delirium assessment is needed.
Published abstract
Background Postoperative hallucination experiences are distressing but under-recognized complications of cardiac surgery. This study investigated whether sex differences exist in their incidence and in the factors associated with postoperative visual and auditory hallucination experiences. Methods We conducted a prospective multicenter cohort study of 1,331 adults (1,000 males and 331 females) undergoing isolated coronary artery bypass grafting or isolated valve surgery at 10 cardiac surgery centers in the West Bank, Palestine (September 2022-May 2025). Postoperative visual (VH) and auditory hallucination (AH) experiences were assessed using daily QPE interviews through postoperative day 4, followed by clinical checks or telephone follow-up through day 7, with QPE-based confirmation of newly reported experiences. Sex-stratified multivariable Cox proportional hazards models evaluated associated factors within an exploratory, hypothesis-generating framework. This study was conducted as part of the VAACS Study (https://www.isrctn.com/ISRCTN18368253). Results Within the first postoperative week, 155 patients (11.6%) experienced visual hallucination experiences (11.2% of males vs. 13.0% of females), and 92 (6.9%) experienced auditory hallucination experiences (7.0% vs. 6.6%). Among males, lower body mass index (adjusted HR 0.91; 95% CI 0.83-0.99; P = 0.034), higher EuroSCORE II (adjusted HR 1.03; 95% CI 1.02-1.04; P < 0.001), higher serum creatinine (adjusted HR 1.21; 95% CI 1.15-1.27; P < 0.001), and postoperative blood transfusion (adjusted HR 1.65; 95% CI 1.20-2.28; P = 0.002) were associated with visual hallucination experiences. Among females, higher EuroSCORE II (adjusted HR 1.05; 95% CI 1.04-1.06; P < 0.001) and longer postoperative ventilation duration (adjusted HR 0.93; 95% CI 0.89-0.97; P < 0.001) were associated with visual hallucination experiences. Higher EuroSCORE II (adjusted HR 1.07; 95% CI 1.04-1.10; P < 0.001) and longer postoperative ventilation duration (adjusted HR 0.91; 95% CI 0.83-0.99; P = 0.029) were associated among males; intraoperative fentanyl exposure did not reach statistical significance (adjusted HR 0.51; 95% CI 0.26-1.02; P = 0.057). Among females, lower age (adjusted HR 0.98; 95% CI 0.97-1.00; P = 0.007), higher EuroSCORE II (adjusted HR 1.08; 95% CI 1.07-1.10; P < 0.001), and postoperative noradrenaline requirement (adjusted HR 4.35; 95% CI 2.18-8.68; P < 0.001) were associated with auditory hallucination experiences; this model included only 22 events. Conclusions Postoperative hallucination experiences captured by the QPE occurred at similar rates in male and female patients after cardiac surgery, but exploratory sex-stratified association patterns differed by hallucination modality. These findings should be interpreted irrespective of delirium status and require confirmation in future studies incorporating structured delirium assessment.
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Early post-ROSC laboratory phenotypes and clinical outcomes after out-of-hospital cardiac arrest: a 10-year national cohort study.
Clinical takeaway Early laboratory phenotypes were associated with neurological and mortality outcomes after resuscitated cardiac arrest. These exploratory associations warrant external validation before any phenotype-guided clinical application.
Summary & abstract
Study summary
This retrospective Singapore cohort classified 1,514 adults resuscitated after presumed cardiac out-of-hospital arrest using 14 laboratory variables within six hours of ROSC. Three phenotypes emerged: multi-organ dysfunction, homeostatic, and immune-dysregulated. Compared with multi-organ dysfunction, adjusted odds of poor neurological recovery at discharge were lower for homeostatic (0.50, 95% CI 0.30–0.78) and immune-dysregulated phenotypes (0.46, 0.26–0.78). Adjusted 30-day mortality hazard ratios were 0.71 (95% CI 0.61–0.83) and 0.78 (0.64–0.94), respectively; lower mortality hazards also persisted at three years.
Study limitation: Retrospective associations adjusted only for age, sex and initial rhythm remain vulnerable to residual confounding; validation was internal.
Published abstract
BACKGROUND: Prior phenotyping in out-of-hospital cardiac arrest (OHCA) relied predominantly on prehospital indicators, which neither describe nor grade the underlying ischemia-reperfusion injury. We aimed to derive laboratory-based phenotypes and describe their clinical characteristics and outcome associations. METHODS: We conducted a retrospective cohort study of adult resuscitated OHCA patients of presumed cardiac etiology between 01/02/2011 and 01/01/2022, linking Singapore's national OHCA and cardiovascular databases. Unsupervised latent class analysis (LCA) was applied to 14 laboratory variables within six hours post-return of spontaneous circulation (ROSC). Stability was confirmed through split-sample validation. Logistic regression and Cox proportional hazards model, adjusted for age, sex and initial cardiac rhythm, assessed poor neurological recovery at hospital discharge, 30-day and 3-year mortality. RESULTS: Among 1514 eligible patients (median age 65.0 years, 73.6% males), LCA identified three distinct phenotypes: multi-organ dysfunction (MOD, N = 286), homeostatic (HOM, N = 967), and immune-dysregulated (IMD, N = 261), independently reproduced in derivation (entropy = 0.817) and replication (entropy = 0.892) subsamples. The most discriminative variables were creatinine, eosinophil and lymphocyte. Compared to MOD, both HOM (aOR: 0.50, 95% CI 0.30-0.78, p = 0.004) and IMD (aOR: 0.46, 95% CI 0.26-0.78, p = 0.005) phenotypes had significantly lower odds of poor neurological recovery. This pattern was consistent for 30-day mortality (HOM aHR: 0.71, 95% CI 0.61-0.83; IMD aHR: 0.78, 95% CI 0.64-0.94) and 3-year mortality (HOM aHR: 0.70, 95% CI 0.60-0.82; IMD aHR: 0.74, 95% CI 0.62-0.90), all p ≤ 0.01. CONCLUSION: Early post-ROSC laboratory data identified three prognostically distinct phenotypes among resuscitated OHCA patients. These exploratory findings support external validation and investigation of phenotype-guided therapies.
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Early-Phase Computed Tomography Bowel Diameter and Neurological Outcomes Post-Extracorporeal Cardiopulmonary Resuscitation.
Clinical takeaway Early CT bowel diameter showed weak overall discrimination for unfavorable neurological outcomes after ECPR. Higher subgroup estimates remain exploratory and do not establish clinical prognostic utility.
Summary & abstract
Study summary
This single-centre observational study examined early abdominal CT bowel diameter in 181 patients undergoing ECPR for out-of-hospital cardiac arrest. The primary endpoint was unfavorable neurological outcome at one month, defined as Cerebral Performance Category 3–5. Overall discrimination was weak: AUC 0.58 (95% confidence interval, 0.47–0.70). Exploratory subgroup AUCs were higher in patients aged 65 years or older (0.83; 95% confidence interval, 0.69–0.96) and those with initial nonshockable rhythms (0.69; 95% confidence interval, 0.47–0.91). Bowel diameter was measured by an investigator blinded to outcomes.
Study limitation: The single-centre observational design and exploratory subgroup findings limit generalizability and confidence in prognostic performance.
Published abstract
AIM: We aimed to conduct an exploratory investigation on the association between bowel diameter on early-phase abdominal computed tomography (CT) and neurological outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). METHODS: This observational study included patients who underwent ECPR for OHCA and abdominal CT before intensive care unit admission between January 2015 and December 2021 at a tertiary emergency medical center. Maximum bowel diameter was measured with a picture archiving and communication system by an investigator blinded to outcomes. The primary endpoint was unfavorable neurological outcomes at 1 month, defined as Cerebral Performance Category 3-5. The discriminatory ability of bowel diameter was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: Data from 181 patients were analyzed (median age, 57 years; 84.5% male). Bowel diameter demonstrated a weak ability to predict unfavorable neurological outcomes, with an AUC of 0.58 (95% confidence interval [CI], 0.47-0.70). However, higher discriminatory performance was observed in subgroups of patients aged ≥ 65 years (AUC, 0.83; 95% CI, 0.69-0.96) and those with initial nonshockable rhythms (AUC, 0.69; 95% CI, 0.47-0.91). CONCLUSION: The results of this exploratory investigation suggest that bowel diameter may represent a potential adjunctive marker associated with functional outcomes post-ECPR for OHCA.
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Neurologic complications in venoarterial versus venovenous extracorporeal membrane oxygenation: A propensity score-matched retrospective cohort study.
Clinical takeaway VA ECMO recipients had greater observed ischemic and hypoxic-ischemic neurologic burden than matched VV recipients. These associations do not establish that ECMO configuration caused the differences.
Summary & abstract
Study summary
This retrospective TriNetX study compared 30-day neurologic outcomes in adults receiving VA versus VV ECMO during 2015–2024, with 6,944 patients per group after propensity matching. Cerebral infarction occurred in 7.04% versus 5.13%, respectively (OR 1.40, 95% CI 1.22–1.61). VA ECMO was also associated with higher odds of seizures, hypoxic-ischemic encephalopathy and brain death; hemorrhagic stroke showed no statistically clear difference (OR 0.83, 95% CI 0.66–1.04). The authors emphasized that hypoxic-ischemic endpoints could not be separated from the indication for VA support and reflected burden rather than modality effect.
Study limitation: Retrospective propensity matching cannot separate hypoxic-ischemic outcomes from the indication for VA support or establish a causal modality effect.
Published abstract
BACKGROUND: Neurologic complications are among the most devastating events associated with extracorporeal membrane oxygenation (ECMO), yet propensity-balanced comparisons of mode-specific neurologic risk between venoarterial (VA) and venovenous (VV) configurations remain limited. OBJECTIVES: To compare the 30-day incidence of five discrete neurologic outcomes: ischemic stroke, hemorrhagic stroke, seizures, hypoxic-ischemic encephalopathy (HIE), and brain death, between adult VA and VV ECMO patients. METHODS: In this retrospective cohort study using the TriNetX federated network, adults undergoing VA or VV ECMO (2015-2024) were identified by ICD-10-PCS codes and 1:1 propensity score matched on demographics, comorbidities, and antithrombotic exposures. Odds ratios (OR), risk ratios, and hazard ratios (HR) with 95% confidence intervals (CI) were estimated within 30 days; multivariable Cox regression was performed for each outcome. RESULTS: After matching (6944 per cohort), VA ECMO was associated with higher 30-day rates of cerebral infarction (7.04%vs 5.13%; OR 1.40, 95% CI 1.22-1.61), seizures (OR 1.15, 1.002-1.324), HIE (OR 2.17, 1.82-2.58), and brain death (OR 2.63, 1.67-4.14). Hemorrhagic stroke did not differ (OR 0.83, 0.66-1.04). Cox models concordantly showed higher hazard for all outcomes except hemorrhagic stroke (brain death adjusted HR 2.37, 1.58-3.57); heparin exposure was associated with lower hazard of cerebral infarction and HIE. CONCLUSION: VA ECMO was associated with higher 30-day ischemic and hypoxic-ischemic neurologic risk than VV ECMO, while hemorrhagic risk did not differ. The hypoxic-ischemic endpoints are not separable from the indication for VA support and reflect burden rather than modality effect. These findings motivate prospective evaluation of mode-specific neurologic surveillance.
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Outcomes Following Impedance Threshold Device Use During Out-of-Hospital Cardiac Arrest.
Clinical takeaway ITD use was associated with better early resuscitation outcomes but lower survival to discharge. These observational findings do not establish benefit or harm, particularly given incomplete disposition data.
Summary & abstract
Study summary
This observational study included 97,439 adult non-traumatic out-of-hospital cardiac arrest records, comparing ITD alone, ITD with active compression-decompression, and neither device. ITD alone was associated with higher return of spontaneous circulation than neither device (26.7% versus 23.8%; adjusted odds ratio 1.09 [1.04, 1.14]). However, survival to discharge was lower with ITD alone (23.9% versus 32.0%; adjusted odds ratio 0.68 [0.61, 0.76]). Discharge home, used as the favorable neurologic outcome, showed a similar adverse association. Disposition outcomes were available for only 13,026 patients, limiting interpretation of longer-term associations.
Study limitation: Incomplete disposition follow-up and potential residual confounding limit causal interpretation; discharge home was the proxy for favorable neurologic outcome.
Published abstract
BACKGROUND: Existing work is equivocal regarding the benefit of impedance threshold device (ITD) use among patients experiencing out-of-hospital cardiac arrest (OHCA). We examined the association of ITD use with prehospital outcomes and longer-term dispositions in a nationally representative sample of OHCA patients. METHODS: We included adult, non-traumatic, OHCA scene runs from the 2024 ESO Data Collaborative. We compared patients treated with (a) ITD only; (b) ITD and active compression-decompression device (ITD+ACD); and (c) neither device (no ITD). Prehospital outcomes included return of spontaneous circulation (ROSC) and survival to hospital arrival (SHA); disposition outcomes included survival to hospital discharge and favorable neurologic outcome (i.e., discharge to home). We used multivariate logistic regression to examine the association of treatment group with outcomes, adjusting for demographics and several potential confounders. RESULTS: We included 97,439 patient records (85.3% no ITD; 13.1% ITD only; 1.6% ITD+ACD). Disposition outcomes were available for 13,026 patients (23.3%). ROSC was higher for patients treated with ITD only (26.7%) than those treated with no ITD (23.8%; aOR=1.09 [1.04, 1.14]); a similar pattern emerged for SHA. Conversely, survival to discharge was lower for patients treated with ITD only (23.9%) than those treated with no ITD (32.0%; aOR=0.68, [.61, .76]); a similar pattern emerged for favorable neurologic outcome. The ITD+ACD group showed more extreme versions of the trends observed for ITD only. CONCLUSIONS: ITD use was associated with improved prehospital outcomes but worsened dispositional outcomes among patients experiencing OHCA, suggesting this device may prove beneficial early in resuscitation of OHCA patients.
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CS-MORT-6: A mortality score that refines risk within EHR-derived SCAI stages in cardiogenic shock.
Clinical takeaway CS-MORT-6 showed moderate external discrimination and differentiated mortality risk within EHR-derived SCAI stages. These findings support further prognostic evaluation, not score-directed treatment decisions.
Summary & abstract
Study summary
CS-MORT-6 was developed in adults with cardiogenic shock to predict subsequent in-hospital mortality at a 24-hour landmark; 892 deaths occurred among 2694 ICU survivors at that landmark. External validation included 1047 patients from 117 hospitals. The integer score had an external AUROC of 0.759 (95% CI, 0.729–0.790), but overpredicted mortality on average. Within EHR-derived SCAI stages, mortality differed by 20–47 percentage points between the lowest and highest score tertiles in MIMIC-IV, with a similar pattern in eICU, suggesting additional risk stratification beyond stage alone.
Study limitation: Predictions apply to patients alive in the ICU at 24 hours; repeated scoring and real-time performance require prospective evaluation.
Published abstract
BACKGROUND: Cardiogenic shock carries high in-hospital mortality, and the ordinal SCAI classification does not rank risk within a stage. Existing scores generally require imaging, procedural, or support-dependent data. METHODS: We identified 3103 adults with documented cardiogenic shock in MIMIC-IV. Six predictors (lactate, urine output, cardiac arrest, age, blood urea nitrogen, red cell distribution width) were selected by bootstrap LASSO screening and clinical review. CS-MORT-6 was derived as two continuous ridge logistic models (lactate or anion gap) fitted at a 24-h landmark and a 0-to-15-point integer score. The primary outcome was subsequent in-hospital death among patients alive in the ICU at the landmark (n = 2694; 892 deaths). The models were externally validated in 1047 patients from 117 eICU hospitals. RESULTS: The integer score's AUROC was 0.727 (95% CI, 0.706-0.747) on cross-validation and 0.759 (0.729-0.790) externally; corresponding values were 0.734 and 0.759 (lactate model) and 0.726 and 0.748 (anion-gap model). Externally, the integer score over-predicted on average (calibration-in-the-large -0.22, slope 1.15). Within EHR-derived SCAI stages, mortality differed by 20 to 47 percentage points between the lowest and highest score tertiles in MIMIC-IV, with a similar pattern in eICU. Adding the anion-gap model to stage increased apparent AUROC by 0.139 (0.116-0.162) in MIMIC-IV and 0.141 (0.101-0.178) in eICU. Compared with BOS,MA2 (654 eICU patients scorable by both), the anion-gap model's AUROC difference was 0.004 (-0.039 to 0.046). CONCLUSIONS: At 24 h, CS-MORT-6 distinguished mortality risk within EHR-derived SCAI stages and retained moderate discrimination externally. Repeated scoring and real-time performance require prospective evaluation.
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The association between cardiac surgery - associated acute kidney injury and elevated liver function tests. A single-center cohort study.
Clinical takeaway Admission liver enzymes offered limited discrimination for postoperative kidney injury. The stronger predictive signal for renal replacement therapy at 12 hours warrants further validation before clinical application.
Summary & abstract
Study summary
This single-center cohort included 3,415 adult cardiac surgery patients over six years and evaluated liver enzymes as predictors of postoperative acute kidney injury. Overall, 65.4% developed acute kidney injury, 37.4% had stage ≥2 injury, and 3.8% received renal replacement therapy. Admission AST normalized to the upper limit of normal showed weak discrimination for acute kidney injury: AUC 0.587 (95% CI 0.570–0.604). AST measured 12 hours after ICU admission was the strongest reported predictor of renal replacement therapy, with an AUC of 0.751 (95% CI 0.733–0.768).
Study limitation: The single-center observational design limits generalizability and cannot establish that liver enzyme elevations cause kidney injury.
Published abstract
INTRODUCTION: Acute kidney injury after cardiac surgery (CSA-AKI) is common and associated with worse outcome. Venous congestion contributes to CSA-AKI and liver dysfunction. We hypothesized that elevated liver enzymes may serve as early markers for CSA-AKI. METHODS: In a single-center cohort study we included adult cardiac surgery patients during a 6-year period. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were measured at ICU admission, 12 h and 24 h. The primary objective was to assess whether liver enzymes at ICU admission, normalized to their upper limits of normal (ULN), predicted CSA-AKI. Secondary outcomes included prediction of CSA-AKI severity, use of renal replacement therapy (RRT), and the association between central venous pressure (CVP) and liver enzymes. RESULTS: Among 3415 patients, 65.4% developed CSA-AKI, 37.4% had AKI stage ≥2 and 3.8% received RRT. AST/ULN and ALT/ULN at ICU admission predicted CSA-AKI [AUC-ROC (95% CI; resp. 0.587 (0.570-0.604); 0.534 (0.517-0.551); both p < 0.001)], with AST performing better (p < 0.001). The discriminating power of AST/ULN and ALT/ULN at ICU admission for AKI ≥2 were respectively AUC-ROC (95% CI); 0.594 (0.577-0.610) and 0.541 (0.524-0.585) (both p < 0.001). AST/ULN 12 h after ICU admission was the strongest predictor for RRT [AUC-ROC (95% CI; 0.751 (0.733-0.768); p < 0.001)], with a 4-fold increased RRT risk when AST exceeded 1.6 times the ULN. AST and ALT 24 h post ICU admission were weakly associated with CVP (respectively: R2 = 0.007; p = 0.003 and ALT: R2 = 0.006; p = 0.004). CONCLUSION: AST activity may have potential as a predictor of CSA-AKI and use of RRT, although liver enzymes demonstrated a weak association with CSA-AKI.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.