CANCARE RESEARCH
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An automated research-discovery feed. Summaries are based on published abstracts and are not clinical recommendations.
Predictors of extubation failure during ongoing VA-ECMO support after cardiac surgery.
Clinical takeaway Extubation failure was common in this postoperative VA-ECMO cohort and associated with adverse outcomes. These findings identify potential risk markers, rather than establish criteria for extubation decisions.
Summary & abstract
Study summary
This retrospective single-centre study included 186 adults extubated during ongoing VA-ECMO after cardiac surgery. Unplanned reintubation within seven days occurred in 44 patients (23.6%), mainly because of acute respiratory failure or neurological impairment. Extubation failure was associated with fewer ventilator-free days, longer ICU stay, and higher short- and long-term mortality. Renal replacement therapy during ICU stay was independently associated with failure (adjusted odds ratio 3.209, 95% confidence interval 1.418–7.467); older age and massive intraoperative transfusion were also associated with failure, while effective post-extubation cough was associated with success.
Study limitation: The retrospective, single-centre design limits generalisability and cannot establish whether extubation failure caused the associated adverse outcomes.
Published abstract
BACKGROUND: As earlier extubation strategies expand during VA-ECMO support, data on predictors of extubation failure remain scarce. OBJECTIVES: We aimed to identify factors associated with extubation failure in cardiac surgery patients extubated during ongoing VA-ECMO support. METHODS: We conducted a retrospective single-center study including all adult patients extubated while receiving VA-ECMO between January 2016 and December 2020. The primary outcome was extubation failure, defined as unplanned reintubation within 7 days. Secondary outcomes included ventilator-free days, ICU and hospital length of stay, and mortality at 28 days and 1 year. RESULTS: A total of 186 patients were included. Median VA-ECMO duration was 9 days [6-14]. Extubation failure occurred in 44 patients (23.6%), mainly due to acute respiratory failure or neurological impairment. Extubation failure was associated with fewer ventilator-free days, longer ICU stay, and higher short- and long-term mortality. In multivariable analysis, older age (aOR 1.053, 95% CI 1.017-1.094; p = 0.006), renal replacement therapy during ICU stay (aOR 3.209, 95% CI 1.418-7.467; p = 0.006), and massive intraoperative transfusion (aOR 4.091, 95% CI 1.753-10.212; p = 0.002) were independently associated with extubation failure, whereas effective post-extubation cough was associated with success (aOR 0.116, 95% CI 0.033-0.368; p < 0.001). CONCLUSIONS: Extubation failure during ongoing VA-ECMO was frequent and associated with adverse outcomes. Markers of global vulnerability and airway protection may be more informative than conventional respiratory and hemodynamic parameters when assessing the risk of extubation failure in this population.
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Clinical, electrographic, and imaging predictors of absent somatosensory evoked potentials in comatose survivors of cardiac arrest: A retrospective cohort study.
Clinical takeaway Clinical examination, EEG reactivity, and MRI patterns were associated with absent SSEPs in this selected cohort. These associations do not establish that the markers can replace SSEP testing or independently predict patient-centred outcomes.
Summary & abstract
Study summary
This retrospective cohort included 76 comatose adult cardiac-arrest survivors who underwent somatosensory evoked potential testing and brain MRI. Extensor or absent motor responses, absent EEG background reactivity, and combined cortical-subcortical MRI involvement were independently associated with absent cortical SSEPs, with odds ratios of 7.78, 5.98, and 8.52, respectively. The model had an AUC of 0.804, increasing to 0.866 with the addition of sex. These findings describe associations with an electrophysiological prognostic marker rather than directly measuring neurological recovery or survival.
Study limitation: The retrospective, 76-patient cohort selected patients undergoing both SSEP testing and MRI; the abstract reports no uncertainty intervals for model estimates.
Published abstract
BACKGROUND: Absence of cortical somatosensory evoked potentials (SSEPs) in comatose survivors of cardiac arrest is a proven predictor of poor neurological outcome, yet this test is not widely available or used. The correlation between absent cortical SSEPs and other clinical, electrophysiologic, and electroencephalographic (EEG) markers in this population remains incompletely defined. METHODS: We conducted a retrospective cohort study of comatose adult patients after cardiac arrest who underwent SSEPs and brain MRI, collecting clinical, neurologic, MRI, and EEG data. We classified MRI findings as cortical, subcortical, or combined. We compared variables by SSEP status using appropriate statistical tests, and logistic regression identified predictors of bilateral absence of N20 responses. We assessed model performance using the AUC. RESULTS: We included 76 comatose patients after cardiac arrest. Absence of SSEPs was associated with higher neuron-specific enolase, abnormal brainstem reflexes, upward gaze, extensor or absent motor responses, and generalized myoclonus. Combined cortical-subcortical MRI involvement and absence of EEG background reactivity were also more frequent. In multivariable analysis, extensor or absent motor response (OR 7.78), absent EEG reactivity (OR 5.98), and combined MRI involvement (OR 8.52) were independently associated with absent SSEPs. The model showed good discrimination (AUC 0.804), improving with addition of sex (AUC 0.866). CONCLUSION: Absence of EEG background reactivity, extensor or absent motor response, and combined cortical-subcortical MRI abnormalities are independently associated with absent SSEPs. These widely available markers may provide complementary prognostic information when SSEP testing is unavailable and contribute to multimodal prognostication in comatose survivors of cardiac arrest.
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More vasopressor, lower pressure: the refractory phenotype in cardiac-surgery AKI.
Clinical takeaway Escalating vasopressor exposure alongside low achieved pressure identified a high-risk postoperative phenotype. These associations do not establish vasopressor kidney toxicity, a blood-pressure target, or benefit from dose reduction.
Summary & abstract
Study summary
Two separately analysed cardiac-surgery cohorts included 9,969 and 3,292 patients, with CSA-AKI occurring in 7.1% and 5.8%, respectively. The endpoint was creatinine/RRT-defined KDIGO stage 2–3 AKI within seven days, with death treated as a competing event. Higher first-24-hour vasopressor dose-load was associated with AKI: adjusted odds ratios per standard deviation were 1.25 (95% CI 1.16–1.35) and 2.96 (2.23–3.92). Greater vasopressor exposure accompanied lower achieved mean arterial pressure in both cohorts, and the highest-dose, lowest-pressure phenotype had the greatest adjusted absolute excess kidney risk.
Study limitation: Achieved pressure was measured after treatment, and illness severity may explain the associations rather than a causal effect of vasopressors.
Published abstract
BACKGROUND: Cardiac-surgery-associated acute kidney injury (CSA-AKI) is common and irreversible. Heavier early vasopressor use is linked to it; whether risk reflects achieved pressure or delivered dose is unclear. We describe these associations in two cohorts. METHODS: Two cohorts were analysed separately (not pooled): primary (n=9,969, 705 CSA-AKI, 7.1%) and replication (n=3,292, 190, 5.8%). Exposure was cumulative first-24h vasopressor dose-load (norepinephrine-equivalent); achieved mean arterial pressure (MAP) is post-treatment. Outcome was creatinine/renal replacement therapy (RRT)-defined KDIGO stage 2-3 within 7 days, death competing. RESULTS: More vasopressor accompanied lower achieved MAP (rho -0.20 and -0.59). Higher dose-load was associated with CSA-AKI (adjusted OR per SD 1.25 [95% CI 1.16-1.35] and 2.96 [2.23-3.92]), persisting with exposure and outcome windows separated (landmark 1.22 and 3.29). Risk rose as achieved MAP fell (adjusted OR per SD 0.89 and 0.55). The highest-dose, lowest-pressure group - a descriptive high-risk haemodynamic phenotype ("refractory") - carried the greatest adjusted absolute excess (6.1% [3.0-9.6] and 9.9% [3.2-17.8]). Dose-load also predicted 28-day mortality, a non-renal outcome (OR 1.47 and 2.48), supporting its interpretation primarily as a marker of illness severity rather than evidence of direct kidney toxicity. CONCLUSIONS: More vasopressor was not accompanied by higher achieved pressure; the patient whose dose climbs while pressure falls signals high kidney risk. These descriptive findings support recognising and monitoring this phenotype and enriching prospective trials; they establish no blood-pressure target (including 65 mmHg) and no case for dose reduction.
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Using CK-MB and hs-cTnT to Predict 30-Day Mortality After CABG: A Combined Biomarker Risk-Stratification Approach.
Clinical takeaway Postoperative CK-MB and hs-cTnT provided prognostic information after isolated CABG. Their combined pattern may support risk stratification, but this study does not establish that biomarker-guided surveillance improves outcomes.
Summary & abstract
Study summary
This multicentre cohort included 9,856 patients undergoing isolated coronary artery bypass grafting. Thirty-day all-cause mortality was 2.0%. Each doubling of postoperative CK-MB and hs-cTnT was associated with higher mortality independently of EuroSCORE II: adjusted HRs were 1.95 (95% CI 1.79–2.12) and 1.71 (95% CI 1.61–1.82), respectively. Discrimination was similar for CK-MB and hs-cTnT (AUC 0.787 versus 0.784; P = 0.99). In the combined analysis, increased mortality risk was identified only when CK-MB was in the top tertile alongside middle- or top-tertile hs-cTnT.
Study limitation: Observational associations do not establish clinical utility, and the abstract reports no external validation of the combined biomarker approach.
Published abstract
BACKGROUND: Accurate diagnosis of perioperative myocardial infarction after coronary artery bypass grafting remains challenging due to uncertainty over postoperative cardiac biomarker interpretation. OBJECTIVES: The authors aimed to evaluate the prognostic value and performance of postoperative creatine kinase-myocardial band (CK-MB) and high-sensitivity cardiac troponin T (hs-cTnT) and explore a combined approach to identify patients at risk of early death. METHODS: This multicenter cohort study involved 9,856 patients undergoing isolated coronary artery bypass grafting at hospitals in Innsbruck, Freiburg, Gothenburg, and Reykjavik. A combined biomarker matrix was created to assess synergistic effects. Associations of biomarkers with 30-day all-cause mortality were evaluated using multivariable Cox regression (adjusted HR) and area under the receiver-operating curve (AUC) analysis. RESULTS: Thirty-day all-cause mortality was 2.0%. Median peak values within 72 hours postsurgery were 2.24 (Q1-Q3: 1.66-3.36) × upper reference limit for CK-MB and 52.06 (Q1-Q3: 29.79-90.00) × upper reference limit for hs-cTnT. Both postoperative CK-MB (adjusted HR: 1.95; 95% CI: 1.79-2.12; P < 0.001) and hs-cTnT (adjusted HR: 1.71; 95% CI: 1.61-1.82; P < 0.001) were associated with higher mortality risk per doubling in concentration independent of EuroSCORE II. Predictive accuracy of CK-MB and hs-cTnT was similar (AUC: 0.787 vs 0.784; P = 0.99), yet stratification using Youden-derived thresholds identified distinct patient subgroups with limited overlap. In a combined analysis, mortality risk was increased only when CK-MB was in the top tertile and hs-cTnT in the mid (adjusted HR: 4.34; 95% CI: 1.78-10.62; P < 0.001) or top tertile (adjusted HR: 14.78; 95% CI: 6.85-31.88; P < 0.001). CONCLUSIONS: The combined use of CK-MB and hs-cTnT enables a simple and robust risk-stratification strategy for early postoperative mortality, with direct implications for clinical surveillance and future cardiac surgery trials.
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Sex differences in epidemiology, care, and outcomes in patients with out-of-hospital cardiac arrest in China.
Clinical takeaway Female patients had better adjusted early resuscitation outcomes, but no clear survival or neurological advantage at later assessment. These observational findings support examining disparities across the full resuscitation pathway rather than inferring equivalent longer-term outcomes.
Summary & abstract
Study summary
This prospective multicentre Chinese cohort included 33,650 EMS-treated out-of-hospital cardiac arrests in 2020; 32.1% were female. Despite less favorable resuscitation characteristics and prehospital care, females had higher adjusted odds of prehospital return of spontaneous circulation (OR 1.21, 95% CI 1.06–1.38) and survival to hospital admission (OR 1.33, 95% CI 1.15–1.55). There was no statistically significant sex difference in survival to hospital discharge or 30 days (adjusted OR 0.85, 95% CI 0.66–1.10) or favorable neurological outcome (adjusted OR 0.84, 95% CI 0.62–1.14).
Study limitation: Observational adjustment cannot exclude residual confounding; the abstract does not report absolute survival or neurological outcome rates.
Published abstract
BACKGROUND: Data on sex differences in out-of-hospital cardiac arrest (OHCA) are well described in developed countries, but scarce in developing countries. METHODS: This prospective, multicenter, population-based observational cohort study used data from the Baseline Investigation of Out-of-hospital Cardiac Arrest (BASIC-OHCA) study collected between January 1, 2020, and December 31, 2020. Differences in outcomes were assessed using multivariable hierarchical logistic regression, with prespecified subgroup analyses and interaction tests. RESULTS: The age-standardized incidence rate of emergency medical system (EMS)-treated OHCA was higher in males than in females (48.1 vs 20.8 per 100,000 person-years, IRR = 2.31, 95% CI: 2.26-2.36) in China. Among 33,650 EMS-treated OHCA patients, 10,793 (32.1%) were females. Females had less favorable resuscitation characteristics and prehospital care than males. In multivariable models, females had significantly higher odds of prehospital return of spontaneous circulation (adjusted odds ratio [OR] = 1.21, 95% CI: 1.06-1.38) and survival to hospital admission (adjusted OR = 1.33, 95% CI: 1.15-1.55). However, no significant sex difference was observed for survival to hospital discharge or 30 days (adjusted OR = 0.85, 95% CI: 0.66-1.10), or favorable neurological outcome (adjusted OR = 0.84, 95% CI: 0.62-1.14). In subgroup analyses, females had lower odds of survival and favorable neurological outcome than males among patients aged ≥50 years, those with shockable rhythm, and those without prehospital epinephrine administration. CONCLUSIONS: In China, females demonstrated better prehospital resuscitation outcomes. However, this early advantage was lost by discharge. These findings highlight the need for integrated evaluation across prehospital and in-hospital care to inform disparity-reduction strategies.
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Rescue-breathing versus chest compression-only bystander cardiopulmonary resuscitation in non-cardiac out-of-hospital cardiac arrest: a nationwide retrospective cohort study.
Clinical takeaway The small overall associations favoring rescue-breathing CPR did not translate into clear differences in adult or elderly subgroups. These observational findings do not establish a causal benefit.
Summary & abstract
Study summary
This Japanese nationwide retrospective cohort compared rescue-breathing with compression-only bystander CPR in 154,137 patients with non-cardiac out-of-hospital cardiac arrest during 2012–2023. Rescue-breathing CPR was associated with modestly lower 30-day mortality (adjusted RR 0.98, 95% CI 0.98–0.99) and unfavorable neurological outcomes (adjusted RR 0.99, 95% CI 0.99–0.99). However, no clear differences were observed among adult or elderly patients, while pediatric patients had lower risks of both outcomes. Associations were strongest in pediatric patients and drowning-related arrests, making the overall findings less directly informative for adult cardiac critical care.
Study limitation: The cohort included pediatric patients; adult-specific effect estimates and uncertainty were not reported in the abstract, and residual confounding remains possible.
Published abstract
BACKGROUND: The role of rescue-breathing cardiopulmonary resuscitation (RB-CPR) remains controversial following guideline recommendations emphasizing chest compression-only CPR (CO-CPR). This study evaluated the associations of bystander-performed RB-CPR with mortality and unfavorable neurological outcomes in Japanese patients with non-cardiac out-of-hospital cardiac arrest (OHCA). METHODS: This retrospective nationwide cohort study included patients identified in the All-Japan Utstein Registry with non-cardiac OHCA between 2012 and 2023. Patients with a cardiac etiology or traumatic cause and those in whom resuscitation was not initiated were excluded. The analysis was restricted to patients who received bystander CPR with documented chest compressions and available information on rescue breathing. Adjusted risk ratios (RRs) were estimated using modified Poisson regression with robust variance. Prespecified subgroup and sensitivity analyses were performed. RESULTS: Among 154,137 patients, 20,124 (13.1%) received RB-CPR and 134,013 (86.9%) received CO-CPR. RB-CPR was associated with modestly lower risks of both 30-day mortality (adjusted RR 0.98, 95% CI 0.98-0.99) and 30-day unfavorable neurological outcomes (adjusted RR 0.99, 95% CI 0.99-0.99). RB-CPR was associated with lower risks of both outcomes in pediatric patients but no clear differences were observed among adult or elderly patients. Associations were strongest for pediatric patients and drowning-related arrests and modest in patients with asphyxia. CONCLUSIONS: Thirty-day mortality and unfavorable neurological outcomes were lower after RB-CPR than after CO-CPR for non-cardiac OHCA, particularly in pediatric patients. Although CO-CPR remains important in bystander CPR, rescue breathing may still have benefit, particularly in pediatric patients and those with cardiac arrest related to drowning or asphyxia.
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Emergency medical services agency-level variation in non-initiation of resuscitation and termination of resuscitation in out-of-hospital cardiac arrest.
Clinical takeaway Resuscitation initiation and termination varied substantially between EMS agencies despite adjustment. These findings support further investigation of decision-making consistency, but do not establish which agency practices are appropriate or improve outcomes.
Summary & abstract
Study summary
This retrospective cohort examined EMS-agency variation in resuscitation decisions for non-traumatic out-of-hospital cardiac arrest using 2018–2024 data. Resuscitation was not initiated in 76,859 of 560,240 encounters (13.7%). Among 309,048 encounters eligible for the Universal termination-of-resuscitation rule, 175,826 (56.9%) underwent termination. After adjustment, substantial agency-level variation remained: median odds ratios were 2.30 (95% confidence interval 2.21–2.38) for non-initiation and 4.13 (3.87–4.26) for termination, representing the median increase in odds between similar encounters treated by two randomly selected agencies.
Study limitation: Residual confounding may explain some variation; the abstract does not report survival or assess the appropriateness of individual decisions.
Published abstract
BACKGROUND: Variations in the decisions to initiate and terminate resuscitation for out-of-hospital cardiac arrest (OHCA) likely differ across emergency medical services (EMS) systems. We evaluated EMS-agency variation in non-initiation of resuscitation for EMS-assessed OHCA and applying termination of resuscitation (TOR) for those meeting the Universal TOR rule. METHODS: We conducted a retrospective cohort study of patients with non-traumatic OHCA using the 2018-2024 ESO Data Collaborative. Our outcomes were non-initiation of resuscitation and TOR. For each outcome, we quantified the extent of agency-level variation using the median odds ratio (MOR), which represents the median increase in odds when comparing similar encounters treated by two randomly selected EMS agencies, calculated from mixed-effects models that incorporated demographic, arrest, scene, agency, and EMS care variables. RESULTS: Among 560,240 encounters, resuscitation was not initiated in 76,859 (13.7%). Of the 309,048 encounters eligible for the Universal TOR rule, 175,826 (56.9%) underwent TOR. After adjustment for encounter-level factors, the median agency-specific rates were 13.6% (IQR, 11.0-16.7%) for non-initiation and 54.3% (IQR, 35.5-67.4%) for TOR. The MOR for non-initiation of resuscitation was 2.30 (95% CI 2.21-2.38), and the MOR for TOR was 4.13 (95% CI 3.87-4.26). CONCLUSION: Even after adjustment for measured patient and agency characteristics, we observed substantial between-agency variation in non-initiation of resuscitation and TOR. Findings highlight the need for further evaluation of prehospital decision-making processes and opportunities to identify and reduce unwarranted variation and improve consistency, equity, and quality of prehospital care.
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The post-ROSC ECG: morphological spectrum of non-ST-elevation occlusion and prognostic markers after cardiac arrest.
Clinical takeaway Post-ROSC ECG morphology and PR-segment duration may offer diagnostic and prognostic information. These observational findings do not establish that angiography improves survival in patients with non-ST-elevation occlusion patterns.
Summary & abstract
Study summary
This retrospective single-centre study examined first post-ROSC ECGs in 214 cardiac arrest survivors admitted to a tertiary ICU; 101 had angiographically confirmed occlusive myocardial infarction. Non-ST-elevation occlusion patterns were more prevalent than STEMI patterns overall (35% versus 24%), but angiography was less frequent (78% versus 98%; p=0.002). Patients with non-ST-elevation occlusion patterns who did not undergo angiography had the highest 30-day mortality (75%; p=0.005). After multivariable adjustment, PR-segment prolongation was associated with lower 30-day survival (adjusted odds ratio 0.977, reported interval 0.956–0.998; p=0.032).
Study limitation: Retrospective single-centre data and nonrandom angiography selection limit causal interpretation of mortality differences.
Published abstract
BACKGROUND: Occlusive myocardial infarction (OMI) frequently presents without ST-elevation (NST-OMI) after return of spontaneous circulation (ROSC), complicating triage decisions. Aim of this study was to (i) characterise the distribution of NST-OMI patterns post-ROSC and (ii) determine whether quantitative ECG features are associated with survival. METHODS: In this retrospective single-centre analysis, the first post-ROSC ECG of cardiac arrest survivors admitted to a tertiary ICU (2020-2025) was evaluated for STEMI and NST-OMI patterns and for quantitative intervals (PQ, PR, P-wave, QRS, QTc). Coronary angiography (CAG) served as the reference standard for OMI. RESULTS: Of 214 patients, 101 had CAG-confirmed OMI, wherein left-main equivalent and Smith-modified Sgarbossa criteria were the most prevalent NST-OMI patterns (each 8%), followed by Aslanger pattern (5%), lateral OMI, shark-fin sign and hyperacute t-wave (each 4%). NST-OMI patterns were more prevalent both overall (35% vs. 24%) and among CAG-confirmed OMI cases (48% vs. 44%) yet underwent CAG less frequently (78% vs. 98%; p = 0.002), with the highest 30-day mortality among NST-OMI patients not undergoing CAG (75%; p = 0.005). Regarding ECG features, non-survivors had longer PR-segment (74 vs. 57 ms; p = 0.008) and QRS-duration (130 vs. 108 ms; p = 0.003), and shorter P-wave duration (105 vs. 108 ms; p = 0.027). After multivariable adjustment, PR-segment prolongation was independently associated with reduced 30-day survival (aOR 0.977 [0.956-0.998]; p = 0.032). CONCLUSIONS: On the first post-ROSC ECG, angiographically confirmed occlusion concentrated around a small number of NST-OMI morphologies - findings of crucial importance for identification and appropriate management. PR-segment prolongation predicted reduced 30-day survival - indicating prognostic information beyond ischaemia detection.
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Disparities in the management of cardiogenic shock complicating acute myocardial infarction: a questionnaire survey in Beijing.
Clinical takeaway This survey identifies gaps in reported cardiogenic-shock infrastructure and monitoring across Beijing hospitals. It does not establish whether these differences affect patient outcomes.
Summary & abstract
Study summary
A questionnaire survey analyzed 142 Beijing hospitals to assess variation in care for cardiogenic shock complicating acute myocardial infarction. PCI capability was absent in 33.1% of hospitals, while 26.0% offered temporary or durable mechanical circulatory support. Pulmonary artery catheter monitoring was uncommon across hospital levels, and continuous lactate monitoring varied significantly between levels. Shock teams were available in 71.9% of Level 1 and 44.4% of Level 2 hospitals, while only 31.9% of Level 3 hospitals had established referral networks.
Study limitation: Hospital questionnaire responses describe reported practices rather than patient-level care; no patient outcomes were reported.
Published abstract
OBJECTIVE: To investigate disparities in the management of cardiogenic shock complicating acute myocardial infarction (AMI-CS) across different hospital levels in Beijing. METHODS: A standardized questionnaire was electronically distributed to 61 hospitals through the Beijing Cardiovascular Internal Medicine Quality Control and Improvement Center and the Beijing Extracorporeal Life Support Quality Control and Improvement Center. A multistage sampling method was also used to survey hospitals in eight Beijing districts that were not included in these quality control networks. Hospitals were categorized as Level 1 hospitals, Level 2 hospitals, or Level 3 hospitals according to international standards and the domestic context. RESULTS: A total of 142 hospitals were analyzed. All participating hospitals were capable of managing cardiovascular diseases. 33.1% of hospitals did not have percutaneous coronary intervention (PCI) capability; 40.8% provided only intra-aortic balloon pump and PCI, whereas 26.0% offered temporary or durable mechanical circulatory support. Level 3 hospitals often lacked established protocols for AMI-CS management. Level 1 hospitals (59.4%) and Level 2 hospitals (56.5%) were more likely to maintain a minimum mean arterial pressure target of 65 mmHg, whereas Level 3 hospitals more commonly accepted a lower target (45.5%). Pulmonary artery catheter monitoring was infrequently used across all hospital levels. Continuous lactate monitoring also differed significantly (Level 3, 39.1% vs. Level 2, 74.6% vs. Level 1, 84.4%; overall p < 0.001). Among the 61 hospitals participating in the quality control network, only 3.6% adopted the Society for Cardiovascular Angiography and Interventions shock stage classification. Shock teams were available in 71.9% of Level 1 hospitals and 44.4% of Level 2 hospitals. Furthermore, only 31.9% of Level 3 hospitals had established referral networks. CONCLUSION: Significant disparities exist in the diagnosis and management of AMI-CS across different hospital levels in Beijing. There is an urgent need to enhance the understanding and management of AMI-CS, especially in Level 2 and Level 3 hospitals.
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Out-of-hospital cardiac arrest management in the Swiss canton of Valais: a retrospective study on first responders' response and automated external defibrillator efficacy.
Clinical takeaway Public responders frequently arrived before EMS, but this study did not establish a survival advantage. The non-significant survival comparisons should not be interpreted as equivalence.
Summary & abstract
Study summary
This retrospective study included 107 consecutive out-of-hospital cardiac arrest cases in Valais, Switzerland, from January 2021 through December 2023. Public responders arrived first in 68% of cases and had a shorter emergency-call-to-arrival interval than EMS (p = 0.019). Survival on hospital arrival was 19% in the public responder group versus 24% in the EMS group; survival to discharge was 9.6% versus 15%, respectively, with neither difference statistically significant. The FRED-PA1 AED rhythm recognition algorithm was judged effective and consistent with current recommendations.
Study limitation: The small retrospective cohort limits causal inference and precision of survival comparisons; the abstract provides no confidence intervals or adjusted estimates.
Published abstract
STUDY AIMS: Cardiac arrest is a condition with a high mortality rate, with most cases occurring outside hospital. First responders (defined as public responders in our study) play an increasingly important role in management through the early initiation of cardiopulmonary resuscitation and defibrillation. Several studies have shown that the involvement of public responders can result in faster initiation of resuscitation and increased survival. This study evaluated the management of out-of-hospital cardiac arrest by public responders and the effectiveness of the FRED-PA1 automated external defibrillator (AED) available in the canton of Valais, Switzerland. METHODS: This was a retrospective study including consecutive cases of out-of-hospital cardiac arrest occurring between January 2021 and December 2023 in the canton of Valais. Response times of public responders and emergency medical services (EMS) were evaluated, along with initial rhythms, survival, and the performance and safety of the available AEDs. RESULTS: A total of 107 patients were included in the study. In 68% of cases, a public responder arrived at the scene first, with a significantly shorter interval between emergency call and on-site arrival compared with EMSs (p = 0.019). Ventricular fibrillation was more frequent in the EMS group than the public responders group (35 vs 23%) (non-significant [NS]). Survival on arrival at hospital was 19% in the public responder group and 24% in the EMS group (NS). Survival to hospital discharge was 9.6% in the public responder group and 15% in the EMS group (NS). Concerning the AEDs, the rhythm recognition algorithm was deemed to be effective and consistent with current recommendations. CONCLUSION: This retrospective study demonstrates the key role played by public responders, who are frequently the first to arrive at the scene of out-of-hospital cardiac arrests. The FRED-PA1 AED algorithm meets the standards in the literature. However, ongoing prospective studies will highlight and optimise the role of public responders in out-of-hospital cardiac arrests.
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Time-Dependent Effects of Inotropic Exposure During Venoarterial Extracorporeal Membrane Oxygenation Support on the Probability of Extracorporeal Membrane Oxygenation Weaning Failure.
Clinical takeaway Greater cumulative inotropic exposure during VA ECMO was associated with worse outcomes, but this observational study does not establish that reducing inotropes improves recovery or survival.
Summary & abstract
Study summary
This observational cohort included 440 adults with severe cardiogenic shock receiving VA ECMO at six Dutch hospitals. ECMO weaning failure occurred in 235 patients (53.4%). This endpoint comprised death, ongoing ECMO support, or heart replacement therapy up to 30 days. In adjusted joint models, higher cumulative inotropic exposure was associated with greater risks of weaning failure (HR 1.04; 95% CI 1.00–1.07) and 30-day mortality (HR 1.04; 95% CI 1.01–1.08). Inotropic support remained largely unchanged in the days after VA ECMO initiation.
Study limitation: Residual confounding by illness severity and treatment indication may explain the associations; the abstract does not specify the exposure increment underlying hazard ratios.
Published abstract
OBJECTIVES: During venoarterial extracorporeal membrane oxygenation (VA ECMO), organ perfusion no longer entirely depends on native cardiac output, which may reduce the therapeutic advantage of inotropic drugs relative to their risks. We hypothesized that, in this setting, higher cumulative inotropic exposure would be associated with impaired cardiac recovery. DESIGN: Observational cohort study on the effects of longitudinal inotropic exposure during VA ECMO support. Temporal changes in inotropic support during VA ECMO support were evaluated. Cumulative inotropic exposure per day during VA ECMO support was calculated using the area under the curve of a standardized inotropic score. These cumulative inotropic scores were associated with the risk of ECMO weaning failure up to 30 days (a composite of death, ongoing need for ECMO support, or the need for heart replacement therapy), mortality, and complications, using joint modeling techniques. SETTING: Six hospitals in the Netherlands. PATIENTS: Adult patients with severe cardiogenic shock (CS) receiving VA ECMO support between 2018 and 2024. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 440 patients with various causes of CS, 235 patients (53.4%) developed ECMO weaning failure. Inotropic support remained largely unchanged in the days following VA ECMO initiation. Adjusted joint models showed that a higher cumulative inotropic exposure during VA ECMO support was associated with an increased risk for ECMO weaning failure (hazard ratio [HR], 1.04; 95% CI, 1.00-1.07), 30-day mortality (HR, 1.04; 95% CI, 1.01-1.08), arrhythmias (HR, 1.05; 95% CI, 1.01-1.08), and protracted lactate clearance (HR, 0.96; 95% CI, 0.92-0.99). CONCLUSIONS: In patients requiring VA ECMO support for refractory CS, inotropic support is often maintained at similar levels after ECMO initiation. Higher cumulative inotropic exposure was associated with an increased risk for ECMO weaning failure. Prospective studies are needed to investigate whether inotropes can be tapered or even stopped and whether such a strategy could improve cardiac recovery.
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Clinical features and outcomes of unsuccessful mechanical aspiration thrombectomy in acute pulmonary embolism.
Clinical takeaway Unsuccessful thrombectomy was associated with chronic thrombus, a less acute presentation, and higher in-hospital PE-related mortality. These observational findings do not establish that procedural failure caused the mortality difference.
Summary & abstract
Study summary
A retrospective tertiary-centre case-series analysis compared successful versus unsuccessful mechanical aspiration thrombectomy for presumed acute pulmonary embolism. Chronic thrombus accounted for 79% of unsuccessful cases. Unsuccessful cases had longer symptom duration (p = 0.04) and a lower presenting Shock Index (0.78 versus 1.10; p = 0.0005). Preprocedure pulmonary artery systolic pressure was numerically higher with unsuccessful thrombectomy (57 versus 48 mmHg; p = 0.06). In-hospital PE-related mortality was higher in the unsuccessful group (36% versus 0%; p = 0.01).
Study limitation: The retrospective, single-centre comparison is vulnerable to confounding; sample size and confidence intervals are not reported in the abstract.
Published abstract
BACKGROUND: Large-bore mechanical aspiration thrombectomy (MAT) for acute pulmonary embolism (PE) is thought to be less effective in patients with a component of subacute or chronic thrombus, though no studies directly compare successful and unsuccessful MAT patients. We hypothesized that unsuccessful MAT would be associated with a more subacute or chronic clinical presentation due to the presence of chronic thrombus, and that a subset of unsuccessful MAT patients would suffer unfavorable outcomes. METHODS: Retrospective case-series analysis of patients treated at a tertiary care center who underwent MAT for presumed acute PE. Clinical features including duration of symptoms, presenting vitals, laboratory results, imaging, and procedural findings were compared between the successful and unsuccessful MAT patients. Adverse outcomes including in-hospital PE-related mortality were also compared. RESULTS: The majority of unsuccessful MAT cases (79%) were attributed to chronic thrombus. Unsuccessful MAT patients presented with a longer duration of symptoms (Fisher's exact test p = 0.04), less severe vital sign abnormalities (Shock Index 0.78 vs 1.10, p = 0.0005), and higher preprocedure pulmonary artery systolic pressure (57 vs 48 mmHg, p = 0.06). In-hospital PE-related mortality was higher in the unsuccessful MAT group (36% vs 0%, p = 0.01). CONCLUSION: Unsuccessful MAT was mostly attributed to chronic thrombus and was associated with a less acute clinical presentation. A subset of patients that undergo unsuccessful MAT may be high risk for in-hospital mortality. A high index of suspicion for chronic thrombus is crucial when considering patients for MAT. Further study is needed to identify the patients most likely to benefit from this procedure, and those with a thrombus not amenable to MAT.
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