Markus Ferrari

Acute microflow changes after stop and restart of intra-aortic balloon pump in cardiogenic shock

BackgroundThe intra-aortic balloon counter pulsation (IABP) is the most frequently used method of mechanical cardiac support in cardiogenic shock (CS). Microcirculatory impairment correlates with outcome in critically ill patients. We therefore investigated the acute influence of IABP therapy on sublingual microflow in patients with CS.MethodsSidestream darkfield intravitalmicroscopy was used in 13 patients with severe CS. The sublingual microvascular bed (10–100xa0μm) was examined according to current guidelines. We measured microflow in means of microvascular flow index at baseline and after intentional stop of IABP support. A computerized model was used for blinded off-line analysis.ResultsMicroflow in vessels 10–50xa0μm in diameter was improved during IABP support (Pxa0<xa00.001). Norepinephrine had a negative effect on the response to IABP related microflow improvement. Cardiac Perfusion Index (product of Cardiac Power index and microflow) correlated best with blood lactate levels.ConclusionsIt was the aim of this study to evaluate the acute influence of IABP therapy on microflow in vivo. In this setting we found that IABP therapy improves sublingual microflow. Future studies should investigate Cardiac Perfusion Index under such conditions with respect to clinical decision making.

Endothelial progenitor cells in adolescents: impact of overweight, age, smoking, sport and cytokines in younger age

Background and aimsEndothelial progenitor cells (EPCs) are bone marrow derived pluripotent vascular progenitor cells capable to contribute to reendothelialization and neovascularization. The number of circulating EPCs has been established as a biomarker of cardiovascular risk and is known to decrease with age. We determined the number of EPCs in teenagers and evaluated the influence of traditional risk factors focusing on overweight.Methods79 male adolescents were enrolled (age 13–17xa0years; 42 of normal weight: 64.1xa0±xa07.6xa0kg; 37 above the 90th BMI-percentile: 96.9xa0±xa020.5xa0kg). 41 healthy adults served as controls. EPCs were counted by flow cytometry (CD34+/−CD133/KDR). Besides traditional risk factors, cholesterol, and high sensitive CRP different cytokines were determined.ResultsOverweight adolescents have a higher systolic blood pressure, higher hsCRP, higher HbA(1c) and lower HDL. The number of CD34-negative EPCs, but not CD34-positive EPCs is higher in overweight adolescents. The overall level of EPCs is lower in adolescents compared to adults.ConclusionsOverweight in adolescents influences EPCs in early life. CD34-negative EPCs might be more sensitive to the early risk profile and may represent a biological marker of occult vascular damage. Beginning insulin resistance, endothelial damage and elevation of EPCs could indicate the higher risk for future cardiovascular disease in obese teenagers.

Microcirculation in cardiogenic shock: from scientific bystander to therapy target

Despite diagnostic and therapeutic improvements, mortality rates in patients with cardiogenic shock remain relatively high. Several studies showed that cardiogenic shock is associated with alterations in the microvascular circulation. These alterations may be reversed by extracorporeal support devices. A study by Munsterman and colleagues adds to the body of evidence showing that in patients deemed ready for discontinuing intra-aortic balloon pump (IABP) support, microcirculatory flow in small vessels increases after ceasing IABP therapy. This study not only highlights the need for optimal timing of weaning from IABP support but also supports recent findings that global hemodynamics do not necessarily result in changes of microvascular perfusion. All modalities of modern treatment in cardiogenic shock need to be evaluated for their effect on the microcirculation. Microcirculatory evaluations should be part of randomized controlled trial protocols. More effort is needed to improve outcomes and understand the microcirculation as a therapy target and not as a silent bystander.

Microvascular tissue perfusion is impaired in acutely decompensated heart failure and improves following standard treatment

Acutely decompensated heart failure (ADHF) leads to neurohumoral activation potentially affecting vascular tone and organ perfusion and may be linked to unfavourable outcome. Global haemodynamic, clinical, and laboratory parameters may severely underestimate tissue hypoperfusion. Therefore, the purpose of this study was to evaluate microvascular flow index (MFI) in patients with ADHF and to assess the effect of standard pharmacological therapy using Sidestream Dark Field (SDF) imaging.

Combined Impella and intra-aortic ballon pump support to improve macro- and microcirculation: a clinical case

aortic ballon pump (IABP), the IABP cannot independently support the systemic circulation in case of low cardiac output. Some patients in need of hemodynamic support do not respond to IABP therapy. Hemodynamic stability can then be obtained by a more potent cardiac assist device, like Impella catheter pump, which can independently assist the systemic circulation. This small transvalvular rotary actively pumps blood from the left ventricle (LV) into the ascending aorta [4]. An animal study was able to show that the combination of Impella and IABP support improved systemic, carotid, and coronary perfusion compared to baseline. Both assist devices provided an improvement in perfusion flow, and the combination of both caused a higher perfusion flow than each individually. Furthermore, IABP caused a significant increase of mean arterial pressure and mean carotid artery flow [5]. We investigated the microcirculation in a patient with severe cardiogenic shock supported by Impella and IABP using orthogonal polarization spectral (OPS) intravitalmicroscope. This recently developed imaging technique can non-invasively investigate the human microvasculature. It was developed for the assessment of the human microcirculation without using fluorescent dyes in clinical practice. Briefly, diodes emit green light with a wavelength of 540 ± 50 nm, which is depolarized by hemoglobin and therefore illuminates the tissue microcirculation in a small camera (for review see [3]).

Prognostic relevance of heart rate at rest for survival and the quality of life in patients with dilated cardiomyopathy

ObjectivesReduction of resting heart rate (HR) has been suggested as a novel therapeutic approach in patients with chronic heart failure because it has been shown to prolong survival and also to improve health-related quality of life (Hr-QoL). The purpose of this analysis was to assess the prognostic impact of resting HR in patients with dilated cardiomyopathy (DCM).Methods217 patients with DCM confirmed by endomyocardial biopsy were investigated (age 49xa0±xa011xa0years, 20.7xa0% were female). The study population was divided into two groups according to the median of the resting HR. After a median follow-up time of 7.4xa0years overall survival and health-related quality of life (Hr-QoL) were compared in both groups. Survival was compared using Kaplan–Meier method and Hr-QoL was assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ).ResultsElevated resting HR was associated with poor 1-year survival (pxa0=xa00.03). In contrast, long-term survival was not affected by HR (pxa0=xa00.20). Patients with lower HR at rest scored significantly lower on the MLHFQ (20 vs. 36, pxa0=xa00.03), indicating that higher resting HR is associated with an impairment of Hr-QoL.ConclusionsIncreased HR might be used as a diagnostic tool to identify patients at risk. Reduction of resting HR in patients with DCM might be a therapeutic option to improve Hr-QoL and therefore merits further investigation in future studies.

Better outcome after cardiopulmonary resuscitation using percutaneous emergency circulatory support in non-coronary patients compared to those with myocardial infarction

Background & Objectives: Mobile heart-lung-machines applied by percutaneous cannulation are mostly used in patients suffering from acute myocardial infarction (AMI). Whether patients with non-coronary reasons for circulatory arrest benefit of percutaneous emergency circulatory support (PECS) in the same way is still unclear. Methods: We included 22 consecutive patients who were treated by PECS during a registry period of two years. Primary study endpoint was 30-day mortality rate. Results: Circulatory arrest was caused by AMI in 14 patients (64%). The remaining 8 patients suffered from cardiomyopathy/myocarditis, 4; pulmonary embolism, 2; acute pulmonary failure, 1; and tumor lysis syndrome, 1. Revascularization rate was 93% in the AMI group under PECS support. Overall survival rate was 36.4% at one month: it reached 62.5% among non-coronary patients, but only 21.4% in the AMI group (P = 0.02). Weaning was possible by direct heart transplantation in two patients. Additional two patients required implantation of a left ventricular assist device. Pumpless extracorporeal lung assist was used in one case. Conclusion: In this small retrospective study percutaneous emergency circulatory support provided sufficient hemodynamic stabilization in emergency situations. One fifth of AMI patients were saved by immediate restoration of circulation and causal treatment when other means of resuscitation failed. Higher survival rates were noted in non-coronary patients.

Providing macro- and microcirculatory support with the Lifebridge System during high-risk PCI in cardiogenic shock.

High-risk percutaneous procedures are necessary in patients with contraindications to surgery in whom the inherent risk of the underlying disease is very high. Circulatory support may be provided with an intra-aortic balloon pump. If active cardiac support is required different devices have been successfully used. We report the case of a 75-year-old patient admitted in cardiogenic shock with a severe coronary three-vessel disease with distal left main stenosis. The ejection fraction was 23%. The high-risk PCI of the distal left main coronary artery and left circumflex artery PCI as the main supplying vessel was supported by Lifebridge (Lifebridge Medizintechnik GmbH, Ampfing, Germany), a new portable mechanical circulatory support system. During the procedure we evaluated the macro- and microcirculation. The complex procedure succeeded with a flow of 2-2.5l providing both adequate macro- and microcirculation.

Impact of diabetes mellitus on quality of life in patients with congestive heart failure

ObjectivesCongestive heart failure (CHF) and diabetes mellitus (DM) are increasing in prevalence. There are conflicting data regarding the crosstalk of DM and CHF with respect to the prognostic impact for the patients. Health-related quality of life (Hr-QoL) has been reported to be useful for risk stratification. The purpose of this study was to investigate the impact of DM on Hr-QoL in a CHF population.Methods325 consecutive patients with CHF were retrospectively analyzed (age 49xa0±xa012xa0years, 74.2% male, 18% had diabetes). After a median follow-up time of 7.4xa0years, we compared Hr-QoL of patients with and without DM. Hr-QoL was assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Kaplan–Meier curves were used to compare survival.ResultsThe presence of DM reduced Hr-QoL in patients with CHF, indicated by a higher overall MLHFQ score (43.5 vs. 21, Pxa0=xa00.013). Kaplan–Meier survival curves showed a significant survival difference (Pxa0=xa00.024). Survival rates of both groups differed significantly after 3 (Pxa0=xa00.031), 5 (Pxa0=xa00.006), and 10xa0years (Pxa0=xa00.047) favoring the group without DM.ConclusionsIn patients with CHF, the coexistence of DM is associated with a reduced Hr-QoL and a particularly poor long-term survival. Our results indicate that CHF patients with DM are at increased risk.

Optimal prosthesis sizing in transcatheter aortic valve implantation by exclusive use of three-dimensional transoesophageal echocardiography

The assessment of aortic annular size is critical, and inappropriate sizing is thought to be a main reason of paravalvular aortic regurgitation. Multidetector computed tomograph is associated with the risk of contrast nephropathy. For optimal evaluation of the complex structure of the aortic annulus, three‐dimensional (3D)‐methods should be used. We therefore sought to determine the value of 3D‐transoesophageal echocardiography (3D‐TEE) for appropriate sizing.