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Aims
From the various mechanical cardiac assist devices and indications available, the use of the percutaneous intraventricular Impella CP pump is usually restricted to acute ischaemic shock or prophylactic indications in high‐risk interventions. In the present study, we investigated clinical usefulness of the Impella CP device in patients with non‐ischaemic cardiogenic shock as compared with acute ischaemia.
Methods and results
In this retrospective single‐centre analysis, patients who received an Impella CP at the University Hospital Würzburg between 2013 and 2017 due to non‐ischaemic cardiogenic shock were age‐matched 2:1 with patients receiving the device due to ischaemic cardiogenic shock. Inclusion criteria were therapy refractory haemodynamic instability with severe left ventricular systolic dysfunction and serum lactate >2.0 mmol/L at implantation. Basic clinical data, indications for mechanical ventricular support, and outcome were obtained in all patients with non‐ischaemic as well as ischaemic shock and compared between both groups. Continuous variables are expressed as mean ± standard deviation or median (quartiles). Categorical variables are presented as count and per cent. Twenty‐five patients had cardiogenic shock due to non‐ischaemic reasons and were compared with 50 patients with cardiogenic shock due to acute myocardial infarction. Resuscitation rates before implantation of Impella CP were high (32 vs. 42%; P = 0.402). At implantation, patients with non‐ischaemic cardiogenic shock had lower levels of high‐sensitive troponin T (110.65 [57.87–322.1] vs. 1610 [450.8–3861.5] pg/mL; P = 0.001) and lactate dehydrogenase (377 [279–608] vs. 616 [371.3–1109] U/L; P = 0.007), while age (59 ± 16 vs. 61.7 ± 11; P = 0.401), glomerular filtration rate (43.5 [33.2–59.7] vs. 48 [35.75–69] mL/min; P = 0.290), C‐reactive protein (5.17 [3.27–10.26] vs. 10.97 [3.23–17.2] mg/dL; P = 0.195), catecholamine index (30.6 [10.6–116.9] vs. 47.6 [11.7–90] μg/kg/min; P = 0.663), and serum lactate (2.6 [2.2–5.8] vs. 2.9 [1.3–6.6] mmol/L; P = 0.424) were comparable between both groups. There was a trend for longer duration of Impella support in the non‐ischaemic groups (5 [2–7.5] vs. 3 [2–5.25] days, P = 0.211). Rates of haemodialysis (52 vs. 47%; P = 0.680) and transition to extracorporeal membrane oxygenation (13.6 vs. 22.2%; P = 0.521) were comparable. No significant difference was found regarding both 30 day survival (48 vs. 30%; P = 0.126) and in‐hospital mortality (66.7 vs. 74%; P = 0.512), although there was a trend for better survival in the non‐ischaemic group.
Conclusions
These data suggest that temporary use of the Impella CP device might be a useful therapeutic option for bridge to recovery not only in ischaemic but also in non‐ischaemic cardiogenic shock.
Die Rolle der B-Linien gestützten Lungensonographie in der Differentialdiagnostik der akuten Dyspnoe
(2018)
Die akute Dyspnoe ist ein häufiger Aufnahmegrund für Patienten in einer internistischen Notaufnahme. Die für eine schnelle Behandlung notwendige Differenzierung zwischen pulmonalen Ursachen wie einer akut exazerbierten COPD und kardialen Ursachen wie der akuten, dekompensierten Herzinsuffizienz ist dabei initial oftmals nicht sicher möglich. Weit verbreitet in der Diagnostik ist das Röntgenbild des Thorax, welches jedoch einige Zeit in Anspruch nimmt und oftmals nicht unmittelbar nach Aufnahme durchgeführt werden kann. Weitere Instrumente, wie die körperliche Untersuchung und genaue Anamnese sind wichtig, oft aber auch nicht eindeutig. Nicht zuletzt leiden zahlreiche Patienten an mehreren Krankheiten gleichzeitig. Insbesondere bei COPD- Patienten zeigen sich häufig gleichzeitig auch kardiale Symptomatiken.
Eine Möglichkeit zur schnellen Differenzierung zwischen pulmonalen und kardialen Dyspnoeursachen stellt die Lungensonographie mit der Frage nach dem Vorhandensein und der Anzahl von B-Linien dar. Dabei handelt es sich um Ultraschallartefakte, die vermutlich an den Grenzflächen von Wasser und Luft entstehen und ein Hinweis auf Flüssigkeit in der Lunge darstellen. In der hier vorliegenden Untersuchung konnten durch den Autor in der internistischen Notaufnahme der Universitätsklinik Würzburg 39 Patienten, die mit einer Dyspnoesymptomatik aufgenommen wurden, mittels Lungensonographie untersucht werden. Dafür wurde ein kleines, tragbares Gerät mit Sektorschallkopf benutzt. Die Ergebnisse der Lungensonographie wurden mit den Ergebnissen der Röntgenbilder und der Abschlussdiagnose im Entlassbrief verglichen. Es zeigte sich, dass Patienten mit pulmonaler Dyspnoeursache in der Regel keine bzw. nur sehr vereinzelt auftretende B-Linien aufweisen, während kardial dekompensierte Patienten meist zahlreiche und in verschiedenen Schallpositionen vorkommende Artefakte zeigen.
Daneben handelt es sich bei der Lungensonographie um eine leicht zu erlernende, schnell und einfach durchführbare Methode, die schon in der internistischen Notaufnahme direkt beim Patienten anwendbar ist.
Background
Aortic valve stenosis is a common finding diagnosed with high sensitivity in transthoracic echocardiography, but the examiner often finds himself confronted with uncertain results in patients with moderate pressure gradients and concomitant systolic heart failure. While patients with true-severe low-gradient aortic valve stenosis with either reduced or preserved left ventricular systolic function are primarily candidates for valve replacement, there is a relevant proportion of patients with pseudo-severe aortic valve stenosis anticipated not to benefit but actually rather deteriorate by interventional therapy or surgery.
Case presentation
In this article we present a case report of a male patient with pseudo-severe aortic valve stenosis due to cardiac amyloidosis highlighting the diagnostic schedule. The patient underwent stress echocardiography because of discrepant findings in transthoracic echocardiography and cardiac catheterization regarding the severity of aortic valve stenosis. After evaluation of the results, it became clear that he had a need for optimum heart failure medication and implantation of a cardiac resynchronization therapy defibrillator.
Conclusion
Due to the pitfalls in conventional as well as invasive diagnostics at rest, Stress echocardiography should be considered part of the standard optimum diagnostic spectrum in all unclear or borderline cases in order to confirm the correct diagnosis and constitute optimal therapy.
Background. Fast progression of the transaortic mean gradient (P-mean) is relevant for clinical decision making of valve replacement in patients with moderate and severe aortic stenosis (AS) patients. However, there is currently little knowledge regarding the determinants affecting progression of transvalvular gradient in AS patients. Methods. This monocentric retrospective study included consecutive patients presenting with at least two transthoracic echocardiography examinations covering a time interval of one year or more between April 2006 and February 2016 and diagnosed as moderate or severe aortic stenosis at the final echocardiographic examination. Laboratory parameters, medication, and prevalence of eight known cardiac comorbidities and risk factors (hypertension, diabetes, coronary heart disease, peripheral artery occlusive disease, cerebrovascular disease, renal dysfunction, body mass index >= 30 Kg/m(2), and history of smoking) were analyzed. Patients were divided into slow (P-mean < 5 mmHg/year) or fast (P-mean >= 5 mmHg/year) progression groups. Results. A total of 402 patients (mean age 78 +/- 9.4 years, 58% males) were included in the study. Mean follow-up duration was 3.4 +/- 1.9 years. The average number of cardiac comorbidities and risk factors was 3.1 +/- 1.6. Average number of cardiac comorbidities and risk factors was higher in patients in slow progression group than in fast progression group (3.3 +/- 1.5 vs 2.9 +/- 1.7; P = 0.036). Patients in slow progression group had more often coronary heart disease (49.2% vs 33.6%; P = 0.003) compared to patients in fast progression group. LDL-cholesterol values were lower in the slow progression group (100 +/- 32.6 mg/dl vs 110.8 +/- 36.6 mg/dl; P = 0.005). Conclusion. These findings suggest that disease progression of aortic valve stenosis is faster in patients with fewer cardiac comorbidities and risk factors, especially if they do not have coronary heart disease. Further prospective studies are warranted to investigate the outcome of patients with slow versus fast progression of transvalvular gradient with regards to comorbidities and risk factors.