CANCARE RESEARCH
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Spectral characteristics and parameters of pulse oximetry waveforms for assessing resuscitation status.
Clinical takeaway Pulse oximetry waveform analysis may help recognize ROSC during ongoing compressions, but these retrospective diagnostic findings do not establish improved resuscitation outcomes.
Summary & abstract
Study summary
This retrospective study evaluated pulse oximetry plethysmography in 451 adults with cardiac arrest across 497 CPR episodes at 14 Chinese tertiary hospitals. A hybrid spectral pattern during ongoing compressions with spontaneous circulation identified clinically documented return of spontaneous circulation (ROSC) with 100% specificity and positive predictive value of 1.000. During compression-only periods, waveform area was higher in stable than unstable ROSC groups (3232.2 versus 2769.6 PVPG; P=0.007). Disappearance of the plethysmography waveform despite a concurrent ECG signal identified pulseless electrical activity with 100% specificity.
Study limitation: The abstract reports no sensitivity estimates or confidence intervals for diagnostic performance, limiting interpretation of the reported perfect specificity.
Published abstract
BACKGROUND: Real-time assessment of physiological resuscitation status is critical for guiding personalised cardiopulmonary resuscitation (CPR) and avoiding unnecessary harm from prolonged chest compressions. Non-invasive, objectively trackable tools for this purpose remain limited. METHODS: This multicentre retrospective study (2013-2018) included 451 adult patients with cardiac arrest (497 CPR episodes) from 14 Chinese tertiary hospitals, comprising 158 Out-of-Hospital Cardiac Arrest (OHCA) episodes with prehospital SpO2/ECG monitoring continued upon ED arrival and full pulse oximetry plethysmography (POP)/ECG/end-tidal carbon dioxide (ETCO2) monitoring established in the ED, and 339 In-Hospital Cardiac Arrest (IHCA) episodes occurring in the ED. We analysed POP waveforms across four statuses: compression-only (CC), chest compression with return of spontaneous circulation (CC + ROSC, spontaneous circulation during ongoing compressions), non-compression without ROSC, and spontaneous circulation-only (SC). Time-domain (area under the POP curve [POPAUC]) and frequency-domain spectral features were evaluated against clinically documented ROSC. RESULTS: A frequency-domain "hybrid" pattern during the CC + ROSC identified ROSC with 100% specificity (PPV 1.000). In CC status, POPAUC was higher in stable-ROSC than unstable-ROSC (3232.2 ± 1008.2 vs. 2769.6 ± 1013.0 PVPG, P = 0.007). The POPAUC was lower in CC + ROSC status than in SC status for stable-ROSC (2768.2 ± 997.8 vs. 3335.8 ± 842.4 PVPG, P = 0.001), but the reverse was observed for unstable-ROSC (2697.5 ± 941.0 vs. 1338.1 ± 952.6 PVPG, P < 0.001). POP waveforms disappearance with concurrent ECG presence identified pulseless electrical activity with 100% specificity. CONCLUSION: Pulse oximetry plethysmography waveform analysis-using signals already available on standard monitors-may provide a non-invasive, real-time approach that may help identify ROSC during ongoing compressions and distinguish between stable and unstable circulation.
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Beyond hemodynamic failure: a distinct inflammatory cytokine profile in cardiogenic shock complicating acute coronary syndrome.
Clinical takeaway ACS-related cardiogenic shock was associated with a distinct inflammatory profile, but these exploratory associations do not establish causality or demonstrate clinical utility for cytokine testing.
Summary & abstract
Study summary
This observational study compared 76 patients with acute coronary syndrome, including 38 with cardiogenic shock and 38 without shock. Patients with shock had lower blood pressure, reduced ejection fraction, and higher markers of myocardial injury and inflammation. Five cytokines were elevated in unadjusted analyses; IL-8, IL-18 and IL-1β remained significantly associated with shock after adjustment for age, sex and STEMI status. Mortality was numerically higher in the shock group. The authors characterized these inflammatory findings as exploratory and requiring confirmation in larger prospective studies.
Study limitation: The small observational cohort and limited adjustment leave residual confounding; mortality effect sizes and uncertainty were not reported.
Published abstract
OBJECTIVE: To compare the clinical, hemodynamic, metabolic and inflammatory profiles of patients with acute coronary syndrome (ACS) with and without cardiogenic shock (CS) and to identify biomarkers associated with disease severity. METHODS: In this observational study, 76 patients with ACS (38 with CS and 38 without CS) were enrolled. Clinical characteristics, laboratory parameters, cardiac biomarkers, lipid profile and 13 circulating cytokines were assessed. Continuous variables were compared using Welch's t-test or the Mann-Whitney U test and categorical variables using the chi-square or Fisher's exact test. Exploratory multivariable analyses adjusted for age, sex and STEMI status were performed for selected cytokines. RESULTS: Compared with patients without CS, those with CS had significantly lower blood pressure, higher shock index, reduced ejection fraction and higher CK-MB, troponin I, BNP, D-dimer, CRP, LDH, urea and liver enzyme levels. IL-8, IL-1β, IL-18, TNF-α and GM-CSF were significantly elevated in unadjusted analyses. After adjustment for age, sex and STEMI status, IL-8, IL-18 and IL-1β remained significantly associated with CS. Mortality was numerically higher in the CS group. CONCLUSION: ACS complicated by CS was associated with profound hemodynamic impairment, greater myocardial injury and an enhanced inflammatory response. These exploratory findings warrant confirmation in larger prospective studies.
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Prognostic implications of complications during VA-ECMO for cardiogenic shock.
Clinical takeaway Complication type and timing were associated with mortality during VA-ECMO for cardiogenic shock. These findings provide prognostic context but do not establish that complications caused the observed excess mortality.
Summary & abstract
Study summary
An ELSO Registry analysis included 22,547 adults receiving VA-ECMO for cardiogenic shock during 2017–2024; 54% died in hospital. Complications occurred in 74% of nonsurvivors versus 54% of survivors. Neurologic complications were associated with a mortality hazard ratio of 3.6 (95% confidence interval 3.4–3.8). Multistate analysis estimated 30-day mortality risk at 48.6% without complications and 93.1% with a neurologic complication. Among patients surviving to three weeks, those without complications during that period had the highest conditional survival. Neurologic and pulmonary complications were associated with the greatest mortality risk.
Study limitation: Observational registry associations cannot establish causality; the three-week landmark findings apply only to patients surviving to that point.
Published abstract
PURPOSE: Veno-arterial extracorporeal oxygenation (VA-ECMO) provides comprehensive cardiopulmonary support in patients with cardiogenic shock (CS), but may result in complications. While complications rates are known, their impact on risk of death remains largely unknown. METHODS: Using the Extracorporeal Life Support Organization (ELSO) Registry to identify adults with a diagnosis of CS treated with VA-ECMO (2017-2024), we analyzed the association between timing and type of complication and in-hospital mortality using three methodologies: 1) Cox proportional hazards analysis, treating complications as time-dependent covariates; 2) Multi-State Model (MSM) analysis, treating complications as transient states and estimating the differential mortality rate from each of these states; and 3) landmark Kaplan Meier survival analysis, estimating conditional survival curves, given survival to 3 weeks, based on count and timing of complications. RESULTS: Among 22,547 patients (31.7% female), 12,094 (54%) died during index hospitalization. More non-survivors experienced complications than survivors (74% vs 54%), with all sub-types occurring more frequently. Neurologic complications increased the hazard of mortality by 3.6 (95% C.I 3.4 - 3.8). MSM analysis indicated that the absolute 30-day risk of mortality was greater if a patient had a complication, increasing from 48.6% (0 complications) to 93.1% with a neurologic complication. Landmark survival analysis demonstrated that patients without complications within the first 3 weeks had the highest conditional survival. CONCLUSION: Complications on VA-ECMO have a significant and cumulative effect on in-hospital mortality, with a higher number associated with increased risk of death. Neurologic and pulmonary complications were associated with the greatest mortality risk.
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Short and long-term outcomes of intermediate-high risk pulmonary embolism treated with catheter-directed reperfusion therapy versus anticoagulation.
Clinical takeaway Catheter-directed intervention was associated with lower mortality and post-discharge morbidity, but this observational comparison does not establish benefit. Randomized trials with long-term patient-centred outcomes are needed.
Summary & abstract
Study summary
This retrospective US cohort compared catheter-directed intervention with anticoagulation for hospitalized intermediate-high risk pulmonary embolism, including 50,614 patients in short-term analyses. After overlap weighting, intervention was associated with lower 30-day mortality (adjusted HR 0.70; 95% CI 0.66–0.73). Among discharge survivors, intervention was associated with fewer heart-failure readmissions (aHR 0.79; 95% CI 0.75–0.83), respiratory-failure readmissions (0.85; 0.81–0.90), and less chronic oxygen use (0.69; 0.65–0.74). Post-discharge analyses included 49,122 patients; the abstract did not specify the duration of long-term follow-up.
Study limitation: Residual confounding may explain associations despite weighting; bleeding results and the duration of post-discharge follow-up were not reported.
Published abstract
BACKGROUND: Treatment of intermediate-high risk pulmonary embolism (PE) with catheter directed therapy remains a topic of controversy. It is unknown if long-term post-hospitalization outcomes of these patients are improved compared to anticoagulation. RESEARCH QUESTION: What is the comparative effectiveness of catheter-directed reperfusion therapy versus conventional anticoagulation on both short- and long-term outcomes among patients with intermediate-high risk PE? STUDY DESIGN AND METHODS: This was a retrospective cohort study of hospitalized patients in the United States with intermediate-high risk pulmonary embolism between 2010 and 2024 from a multi-institutional aggregated electronic health record database. Patients were categorized as receiving catheter-directed intervention (CDI) or conventional anticoagulation and followed for 30-day mortality, bleeding and procedural complications (short-term outcomes) and, among those who survived discharge, for readmission related to heart failure or respiratory failure, oxygen dependence, and pulmonary hypertension related diagnosis (long-term outcomes). Overlap weighting was used to balance characteristics between patients in both groups and weighted hazard ratios were calculated. RESULTS: After application of a specific phenotype definition integrating diagnosis codes, vital signs, and laboratory biomarkers to identify patients with intermediate high-risk PE in a large-scale data set, a total of 50,614 patients were included in the analysis of short-term outcomes and 49,122 were included in the analysis of post-discharge outcomes. CDI was associated with a lower hazard of death in both crude (HR 0.56; 95% CI 0.53-0.59, p < 0.001) and adjusted comparisons (aHR 0.70; 95% CI 0.66-0.73, p < 0.001). Although there was no increase in CTEPH rates (aHR 1.05; 95% CI 1.00-1.10, p = 0.057), long-term outcomes favored CDI including lower rates of readmission for heart failure (aHR 0.79; 95% CI 0.75-0.83, p < 0.001), readmission for respiratory failure (aHR 0.85; 95% CI 0.81-0.90, p < 0.001), and lower chronic oxygen usage (aHR 0.69; 95% CI 0.65-0.74, p < 0.001). INTERPRETATION: Among patients with intermediate-high risk pulmonary embolism, CDI was associated with improved short- and long-term survival compared to anticoagulation alone. These findings suggest a potential benefit of CDI in intermediate-high risk PE and support the need for randomized trials powered for long-term, patient-centered outcomes.
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Prehospital prognostication after out-of-hospital cardiac arrest in tertiary care centers: the R-EDByUS score in the JAAM-OHCA registry.
Clinical takeaway The score showed strong overall discrimination for one-month neurological outcomes in tertiary-center OHCA patients. These findings support risk stratification, not certainty about an individual patient’s outcome.
Summary & abstract
Study summary
This external validation included 29,345 adults with presumed cardiogenic OHCA transported to tertiary care centers, predicting unfavorable neurological outcome at one month. R-EDByUS discrimination was good in prehospital ROSC and ongoing CPR cohorts, with areas under the curve of 0.906 and 0.913, respectively. Calibration was good in the prehospital ROSC cohort, but discrimination was lower among ongoing CPR patients receiving PCI, TTM, or ECMO. Among patients with predicted risk ≥99%, unfavorable outcomes occurred in 112/112 with prehospital ROSC and 20,560/20,588 with ongoing CPR.
Study limitation: Performance varied across intervention subgroups, and good calibration was reported only for the prehospital ROSC cohort.
Published abstract
AIM: The R-EDByUS score predicts unfavorable neurological outcomes after out-of-hospital cardiac arrest (OHCA) using prehospital variables alone, with separate models based on return of spontaneous circulation (ROSC) status at hospital arrival. However, whether the score remains valid in patients transported to tertiary care centers is uncertain. We therefore aimed to validate it externally in this setting. METHODS: Using the JAAM-OHCA Registry, we analyzed adult patients with presumed cardiogenic OHCA transported to tertiary care centers. The regression-based R-EDByUS score was applied to predict unfavorable neurological outcome (Cerebral Performance Category 3-5) at 1 month in the prehospital ROSC and ongoing cardiopulmonary resuscitation (CPR) cohorts. Discrimination and calibration were assessed, and score performance was examined across in-hospital intervention subgroups (percutaneous coronary intervention, targeted temperature management, and extracorporeal membrane oxygenation). We also assessed the proportion of patients with unfavorable outcomes among those with a predicted probability ≥99%. RESULTS: Of 29,345 patients, 3305 were classified into the prehospital ROSC cohort and 26,040 into the ongoing CPR cohort. The score showed good discrimination, with areas under the curve of 0.906 and 0.913, and good calibration in the prehospital ROSC cohort. Discrimination was lower among patients who received PCI, TTM, or ECMO in the ongoing CPR cohort. Among patients with a predicted probability ≥99%, 100% (112/112; prehospital ROSC) and 99.9% (20,560/20,588; ongoing CPR) had unfavorable outcomes. CONCLUSION: The R-EDByUS score showed good discrimination in the JAAM-OHCA Registry, supporting its use for early risk stratification in cardiogenic OHCA even in tertiary care centers.
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Amiodarone after conversion from a non-shockable to a shockable rhythm in out-of-hospital cardiac arrest: A propensity score-matched analysis from the German resuscitation registry.
Clinical takeaway Amiodarone use was associated with greater discharge survival in this rhythm-conversion population, but a neurologically favourable survival benefit remains uncertain. The observational findings do not establish causality.
Summary & abstract
Study summary
This retrospective German registry study compared amiodarone with no amiodarone during resuscitation in adults with non-traumatic out-of-hospital cardiac arrest, an initially non-shockable rhythm, and at least two subsequent defibrillations. Among 1,843 propensity-matched pairs, amiodarone was associated with higher survival to hospital discharge (6.5% versus 4.2%; OR 1.58, 95% CI 1.18–2.12). Favourable neurological outcome at discharge was not significantly different (3.7% versus 2.9%; OR 1.31, 95% CI 0.91–1.89), leaving uncertainty about whether the observed survival association extends to neurologically favourable survival.
Study limitation: Retrospective propensity matching cannot exclude residual confounding, and the neurological outcome estimate remains imprecise.
Published abstract
BACKGROUND: Amiodarone should be administered after three shocks according the current ERC ALS guidelines. However, its effect in out-of-hospital cardiac arrest (OHCA) patients with an initial non-shockable rhythm who subsequently convert to a shockable rhythm is not established. METHODS: We performed a retrospective observational cohort study using data from the German Resuscitation Registry. Adult patients with non-traumatic OHCA, having an initial non-shockable rhythm and subsequently received at least two defibrillations were included. Propensity-score-matched patient pairs (1:1) were analysed to compare outcomes between patients who received amiodarone during resuscitation and those who did not. The primary outcome was survival to hospital discharge. Secondary outcomes included hospital admission with return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge, and favourable neurological outcome at hospital discharge. RESULTS: Of 5535 patients included 3181 received amiodarone and 2354 did not. After propensity-score matching, 1843 patients remained in each group. Amiodarone administration was associated with higher rates of hospital admission with ROSC (26.7% vs. 23.0%; OR 1.22, 95% confidence interval 1.05-1.42), 24-h survival (21.4% vs. 14.7%; OR 1.58, 95% CI 1.33-1.87), and survival to hospital discharge (6.5% vs. 4.2%; OR 1.58, 95% CI 1.18-2.12). Favourable neurological outcome at hospital discharge was not statistically significant (3.7% vs. 2.9%; OR 1.31, 95% CI 0.91-1.89). CONCLUSIONS: In OHCA patients with an initial non-shockable rhythm who subsequently converted to a shockable rhythm, amiodarone administration was associated with improved short-term and long-term survival, but not with a statistically significant improved favourable neurological outcome. Future controlled studies might define the proper (earlier) time of amiodarone administration.
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Acute deoxygenation during M-TEER: a note of caution.
Clinical takeaway These findings suggest that right ventricular dysfunction and adverse atrial pressure relationships may help identify patients vulnerable to acute right-to-left shunting after M-TEER. They do not establish a validated prediction strategy.
Summary & abstract
Study summary
This retrospective study compared patients requiring emergency closure of an iatrogenic atrial septal defect after successful M-TEER with the remaining cohort. Among 444 consecutive patients, six (1.3%) required emergency closure for right-to-left shunting and acute deoxygenation. All six had severe tricuspid regurgitation, right ventricular dilatation and impaired right ventricular function; right atrial pressure exceeded left atrial pressure after M-TEER in five. Compared with controls, affected patients had lower tricuspid annular plane systolic excursion, fractional area change and right ventricular free wall strain magnitude. One patient developed cardiogenic shock.
Study limitation: The retrospective design and only six emergency closure events limit the reliability and generalizability of risk-factor associations.
Published abstract
AIMS: Right-to-left (R-L) shunting through an iatrogenic atrial septal defect (iASD) after mitral transcatheter edge-to-edge repair (M-TEER) is a rare but potentially life-threatening complication. We aimed to identify factors associated with clinically relevant R-L shunting requiring emergency iASD closure. METHODS AND RESULTS: We retrospectively analysed 444 consecutive patients undergoing successful M-TEER between 2017 and 2026. Clinical, echocardiographic, and invasive haemodynamic parameters were compared between patients requiring emergency iASD closure and the remaining cohort. Six patients (1.3%) required emergency iASD closure due to R-L shunting and acute deoxygenation. All presented with severe tricuspid regurgitation, RV dilatation, and impaired RV function. Following M-TEER, right atrial pressure exceeded left atrial pressure in five patients. Compared with controls, affected patients demonstrated reduced tricuspid annular plane systolic excursion (15 ± 2 vs. 19 ± 4 mm), fractional area change (FAC) (27 ± 5% vs. 43 ± 6%), and RV free wall strain (-13 ± 2% vs. -22 ± 5%). Echocardiography underestimated invasively measured systolic pulmonary artery pressure (25.8 vs. 40.3 mmHg; P = 0.035). Oxygen saturation decreased by 3-8%, with one patient developing cardiogenic shock. CONCLUSION: Severe tricuspid regurgitation, RV dysfunction, and elevated right atrial pressure may identify patients at risk for clinically relevant R-L shunting after M-TEER. Comprehensive RV assessment, including FAC and strain, combined with invasive hemodynamic evaluation, may improve risk stratification and facilitate timely iASD closure.
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Association between early intravenous magnesium sulfate administration and mortality according to systemic immune-inflammation index in critically ill patients with acute heart failure: A retrospective cohort study.
Clinical takeaway Early intravenous magnesium was associated with lower mortality in this ICU acute heart failure cohort. The observational findings do not establish benefit, and interaction testing did not support differential associations across inflammatory-index strata.
Summary & abstract
Study summary
This retrospective MIMIC-IV cohort included 4,293 critically ill patients with acute heart failure; 1,561 received intravenous magnesium sulfate. Early administration meant initiation from six hours before to 24 hours after ICU admission. Compared with no early administration, magnesium was associated with lower 30-day mortality (adjusted hazard ratio 0.68, 95% confidence interval 0.56–0.82) and 90-day mortality (0.74, 0.63–0.86). Associations appeared strongest at the extremes of the systemic immune-inflammation index, but formal interaction testing was not significant. These subgroup findings are hypothesis-generating and require prospective validation.
Study limitation: Retrospective exposure comparisons remain vulnerable to confounding; exploratory subgroup patterns were not supported by significant interaction testing.
Published abstract
BACKGROUND: Magnesium sulfate is commonly administered in acute heart failure (AHF). We investigated the association between early intravenous magnesium sulfate and mortality across baseline systemic immune-inflammation index (SII) strata in critically ill patients with AHF. METHODS: We conducted a retrospective study using the MIMIC-IV database of critically ill patients with AHF. Early intravenous magnesium sulfate was defined as treatment initiated from 6 h before to 24 h after intensive care unit admission. SII was categorized into quartiles. The primary and secondary outcomes were 30-day and 90-day all-cause mortality. Multivariable Cox regression, restricted cubic spline, and sensitivity analyses were performed. RESULTS: Among 4293 patients, 1561 (36.4%) received intravenous magnesium sulfate. Magnesium sulfate administration was associated with lower 30-day (adjusted hazard ratio [aHR] 0.68, 95% CI 0.56-0.82) and 90-day mortality (aHR 0.74, 95% CI 0.63-0.86). For 30-day mortality, multivariable Cox regression demonstrated significant associations in the lowest (aHR 0.64, 95% CI 0.43-0.95) and highest (aHR 0.52, 95% CI 0.36-0.75) SII quartiles, whereas no significant associations were identified in the intermediate quartiles. Comparable patterns were observed for 90-day mortality. Restricted cubic spline analyses showed visual separation between treatment groups at the extremes of the SII distribution, although formal interaction testing was not significant. Sensitivity analyses consistently reproduced the association in the highest SII quartile. CONCLUSIONS: Stratified analyses suggested that the association between early magnesium sulfate administration and lower mortality was most evident in the highest SII quartile and less consistent in the lowest quartile. These findings are hypothesis-generating and require prospective validation. TRIAL REGISTRATION: Not applicable.
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Derivation and Validation of Operational Definitions From Claims Data for Identifying Cardiogenic Shock.
Clinical takeaway The algorithm may support cardiogenic-shock surveillance and long-term outcome research using Korean claims data. These findings concern case identification rather than treatment effectiveness.
Summary & abstract
Study summary
This diagnostic accuracy study evaluated a claims-based cardiogenic shock definition against clinically adjudicated standards in two Korean clinical cohorts. The algorithm combined diagnostic codes with treatment-based criteria reflecting haemodynamic support, including mechanical circulatory support or vasoactive therapy. Among 10,156 cardiac ICU registry patients, sensitivity was 0.89, specificity 0.90, and accuracy 0.90; sensitivity was 0.95 in the 1,247-patient RESCUE registry. Nationwide application identified 207,419 patients with cardiogenic shock, with cumulative mortality of 37.9% at 12 months, 49.9% at five years, and 61.7% at ten years.
Study limitation: The abstract reports neither uncertainty intervals for diagnostic performance nor specificity in the RESCUE validation cohort.
Published abstract
OBJECTIVES: To derive and validate a claims-based operational definition for cardiogenic shock (CS) using administrative data against clinically adjudicated reference standards. DESIGN: Diagnostic accuracy study. SETTING: Two independent clinical cohorts, a single-center cardiac ICU (CICU) registry and a multicenter CS registry (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock [RESCUE]), and a nationwide administrative database from the Korean National Health Insurance Service. PATIENTS: A total of 10,156 patients from the CICU registry and 1,247 patients from the RESCUE registry. For population-level application, 207,419 patients were identified from the national claims database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A claims-based algorithm defined CS using the International Classification of Diseases, 10th Revision code R57.0 or cardiac disease codes combined with treatment-based criteria reflecting hemodynamic support, including mechanical circulatory support or vasoactive therapy. In the CICU cohort, the algorithm demonstrated a sensitivity of 0.89 and specificity of 0.90, with an overall accuracy of 0.90. In the RESCUE cohort, sensitivity was 0.95. When applied to the nationwide database, 207,419 patients with CS were identified. The cumulative mortality rates were 37.9% at 12 months, 49.9% at 5 years, and 61.7% at 10 years. CONCLUSIONS: A claims-based definition combining diagnostic codes with treatment-based criteria demonstrated high diagnostic performance for identifying CS. This approach enables reliable large-scale epidemiologic studies and long-term outcome assessments using administrative data and may facilitate system-level evaluation of critical care delivery in patients with CS.
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Physiological response following inhaled nitric oxide administration during one-lung ventilation in minimally invasive cardiac surgery: an exploratory prospective cohort study.
Clinical takeaway Nitric oxide administration was followed by improved oxygenation in this selected surgical cohort. These physiological observations do not establish comparative efficacy or patient-centred benefit.
Summary & abstract
Study summary
This exploratory prospective cohort enrolled 63 consecutive patients undergoing minimally invasive cardiac surgery and evaluated physiological responses to inhaled nitric oxide. Thirty patients (47.6%) received nitric oxide for post-bypass hypoxemia with pulmonary hypertension during one-lung ventilation. After administration, PaO2/FiO2 increased from 70 [61–80] to 85 [72–102] (P=0.011), while mean pulmonary artery pressure did not change significantly, from 24 [23–26] to 25 [22–28] mmHg (P=0.564). Female sex, higher body mass index, and longer bypass time were associated with nitric oxide initiation in multivariable analysis.
Study limitation: The small exploratory cohort lacked a randomized comparator and reported physiological responses rather than patient-centred outcomes.
Published abstract
OBJECTIVE: This study aimed to evaluate the physiological responses following inhaled nitric oxide (iNO) administration in patients with one-lung ventilation (OLV)-related hypoxemia accompanied by pulmonary hypertension in minimally invasive cardiac surgery (MICS). METHODS: This exploratory prospective cohort study enrolled 63 consecutive patients who underwent MICS. Patients who developed post-cardiopulmonary bypass (CPB) OLV-related hypoxemia with pulmonary hypertension received iNO. The evaluation included changes in PaO2/FiO2 and mean pulmonary artery pressure (mPAP). Additionally, multivariable logistic regression analysis was performed to examine clinical factors associated with iNO initiation. RESULTS: Overall, 30 patients (47.6%) received iNO. PaO2/FiO2 significantly increased following iNO administration (70 [61-80] to 85 [72-102], P = 0.011), while mPAP remained unchanged (24 [23-26] to 25 [22-28] mmHg, P = 0.564). Multivariable analysis identified female sex (odds ratio [OR]: 5.00), higher body mass index (OR: 1.36), and prolonged CPB time (OR: 1.03) as associated factors for iNO initiation (area under the curve: 0.822). All patients with a second aortic clamp or pre-CPB hypoxemia met the initiation criteria and received iNO. CONCLUSIONS: Post-CPB OLV-related hypoxemia accompanied by pulmonary hypertension occurs frequently during MICS. The observed increase in oxygenation following iNO administration suggests its potential utility for respiratory management in MICS, warranting future large-scale, multicenter investigations.
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Early Lower Pulmonary Arterial Diastolic Pressure Monitored With Pulmonary Arterial Catheters Is Associated With Improved Survival During VA ECMO for Patients With Acute Cardiogenic Shock: A Propensity-Matched Study.
Clinical takeaway Early on-support pulmonary artery diastolic pressure may provide prognostic information during VA ECMO. These observational findings do not establish that lowering pressure or using a catheter improves survival.
Summary & abstract
Study summary
This registry study examined 7,654 adults receiving VA ECMO for cardiogenic shock; 3,077 were managed with pulmonary arterial catheters. Haemodynamics were assessed at 24 hours, and the primary outcome was 30-day in-hospital mortality. Catheter use was not significantly associated with lower in-hospital mortality (adjusted OR 0.95, 95% CI 0.897–1.006). Among patients surviving 24 hours, pulmonary artery diastolic pressure above 18 mm Hg was associated with greater in-hospital mortality within 30 days (HR 1.29, 95% CI 1.13–1.46), with consistent associations in subgroups receiving left ventricular mechanical unloading.
Study limitation: Observational associations remain vulnerable to confounding; the pressure analysis was restricted to patients surviving 24 hours.
Published abstract
BACKGROUND: Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is used to support refractory cardiogenic shock (CS) but may increase peripheral afterload. Invasive hemodynamic measurement and cardiopulmonary congestion during VA ECMO may correlate with survival, but the precise mechanisms underlying this benefit are uncertain. OBJECTIVES: The aim of this study was to determine whether invasive hemodynamic monitoring with a pulmonary arterial catheter (PAC) and early on-support pulmonary artery diastolic pressure (PAD) are associated with survival during VA ECMO. METHODS: Adult patients with CS from the ELSO (Extracorporeal Life Support Organization) Registry from 2015 to 2020 were analyzed. Invasive hemodynamic status was assessed at 24 hours of ECMO. The primary outcome was 30-day in-hospital mortality. The association between the use of left ventricular mechanical unloading (LVMU) and both 24-hour on-support invasive hemodynamic status and in-hospital mortality was examined using landmark adjustment. RESULTS: In total, 7,654 patients treated with VA ECMO for CS were identified, of whom 3,077 were managed with PACs. PAC use during VA ECMO was not significantly associated with lower in-hospital mortality, with an adjusted OR of death of 0.95 (95% CI: 0.897-1.006; P = 0.077). Among patients who survived 24 hours, higher single early values of on-support PAD at 24 hours (>18 mm Hg) were associated with greater in-hospital mortality within 30 days (HR: 1.29; 95% CI: 1.13-1.46; P < 0.001), which remained consistent within subgroups receiving concomitant LVMU (peripherally inserted ventricular assist device or intra-aortic balloon pump). CONCLUSIONS: There is a significant, graded relationship between higher single measures of 24-hour on-support PAD and death. Patient survival is greatest when 24-hour PAD is <18 mm Hg. PAD decreased at 24 hours among all comers, but 47% of patients received LVMU devices to support this reduction.
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Comparable rates of severe primary graft dysfunction after heart transplantation in recipients with prior LVAD or other cardiac surgery: The burden of surgical reentry.
Clinical takeaway Prior surgical history may help contextualize graft dysfunction risk after transplantation. These findings do not establish equivalence between LVAD and other prior-surgery recipients or prove that surgical reentry causes the excess risk.
Summary & abstract
Study summary
A retrospective registry cohort compared severe primary graft dysfunction after heart transplantation in 3,406 recipients with durable LVADs, other prior cardiac surgery, or no prior surgery. Severe graft dysfunction occurred in 11.1% versus 10.9% of LVAD and other prior-surgery recipients (adjusted OR 0.81, 95% CI 0.50–1.32), versus 4.2% without prior surgery (LVAD adjusted OR 2.17, 95% CI 1.50–3.13). Mortality at 180 days was 8.5% in both prior-surgery groups (adjusted HR 0.98, 95% CI 0.58–1.65), versus 4.2% without prior surgery (LVAD adjusted HR 2.13, 95% CI 1.46–3.13).
Study limitation: Retrospective registry comparisons remain vulnerable to residual confounding; the contribution of surgical reentry cannot be isolated causally.
Published abstract
INTRODUCTION: The use of durable left ventricular assist device (dLVAD) as a bridge to heart transplantation (HTx) is a risk factor for severe primary graft dysfunction (sPGD). Whether the intrinsic properties of the device itself or mediastinal reentry at the time of HTx are responsible for this deadly complication remains unknown. METHODS: We conducted a retrospective cohort study using the United Network for Organ Sharing database from September 2023 through May 2025 comparing patients with a dLVAD to those with prior non-dLVAD cardiac surgery and no prior cardiac surgery. The primary outcome was development of severe PGD; secondary outcomes included non-sPGD complications and 180-day survival. Multivariable logistic regression, multivariable Cox models, and propensity score matching were used for analysis. RESULTS: In sum, 3,406 patients were included. A total of 219 (6.4%) recipients experienced sPGD. Rates were similarly elevated among those with dLVAD and prior non-dLVAD cardiac surgery (11.1 vs 10.9%, adjusted odds ratio (aOR) 0.81 [95% CI 0.50-1.32]) but significantly higher than those with no prior surgery (11.1 vs 4.2%, aOR 2.17 [95% CI 1.50-3.13]). Rates of post-operative dialysis were similar between dLVAD and prior non-dLVAD cardiac surgery (21.5 vs 22.5%, aOR 0.93, [95% CI 0.65-1.33]), but significantly higher than those with no prior surgery (21.5 vs 13.7%, aOR 1.83 [95% CI 1.44-2.32]). 180-day mortality was comparable between dLVAD and prior non-dLVAD cardiac surgery (8.5 vs 8.5%, adjusted hazard ratio (aHR) 0.98 [95% CI 0.58-1.65]) but significantly higher than those with no prior cardiac surgery (8.5 vs 4.2%, aHR 2.13 [95% CI 1.46-3.13]). Propensity score matching confirmed these results. CONCLUSIONS: Recipients bridged with dLVAD display phenotypic similarity to those with prior non-dLVAD cardiac surgery postoperatively, indicating that mediastinal reentry likely plays a large role in the pathophysiology of sPGD in bridging with dLVAD.
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