Damage control approach to refractory neurogenic shock: a new proposal to a well-established algorithm

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is commonly used as an adjunct to resuscitation and bridge to definitive control of non-compressible torso hemorrhage in patients with hemorrhagic shock. It has also been performed for patients with neurogenic shock to support the central aortic pressure necessary for cerebral, coronary and spinal cord perfusion. Although volume replacement and vasopressors are the cornerstones of the management of neurogenic shock, we believe that a REBOA can be used as an adjunct in carefully selected cases to prevent prolonged hypotension and the risk of further anoxic spinal cord injury. This manuscript aims to propose a new damage control algorithmic approach to refractory neurogenic shock that includes the use of a REBOA in Zone 3. There are still unanswered questions on spinal cord perfusion and functional outcomes using a REBOA in Zone 3 in trauma patients with refractory neurogenic shock. However, we believe that its use in these case scenarios can be beneficial to the overall outcome of these patients.

Prospective Clinical Trial Comparing IV Esmolol to IV Metoprolol in CT Coronary Angiography: Effect on Hemodynamic, Technical Parameters and Cost

Background: Intravenous [IV] esmolol, an alternative to IV metoprolol for coronary computed tomography angiography [CCTA], has shorter half-life that decreases the risk of prolonged hypotension. The primary aim was to prospectively compare IV esmolol alone to IV metoprolol alone for effectiveness in achieving heart rate [HR] of 60 beats per minute[bpm] during CCTA. The secondary aim was to compare hemodynamic response, image quality, radiation dose and cost. Materials and Methods: Institutional Review Board approved prospective randomized study of 28 CCTA patients medicated in a 1:1 blinded match with IV esmolol or IV metoprolol to achieve HR of 60 bpm. Serial hemodynamic response was measured at 6 specified times. Two cardiac radiologists independently scored the image quality. Results: Both IV esmolol and IV metoprolol achieved the target HR. IV esmolol resulted in significantly less profound and shorter duration of reduction in systolic blood pressure [BP] than IV metoprolol with a difference of -10, -14 and -9 mm Hg compared to -20, -26 and -25 mmHg at 2, 15 & 30 min respectively. No significant difference in HR at image acquisition, exposure window, radiation dose and image quality. Although IV esmolol was expensive, the overall cost of care was comparable to IV metoprolol due to shortened post CCTA observation period consequent to faster restoration of hemodynamic status. Conclusion: Comparison of IV esmolol and IV metoprolol demonstrate that both are effective in achieving the target HR but significantly faster recovery of HR and BP in patients who receive IV esmolol was found.

Surgical Outcomes in the Pheochromocytoma Surgery. Results From the PHEO-RISK STUDY.

Purpose: To identify presurgical and surgical risk factors for postsurgical complications in the pheochromocytoma surgery.Methods: A retrospective study of pheochromocytomas submitted to surgery in ten Spanish hospitals between 2011 and 2021. Postoperative complications were classified according to Clavien-Dindo scale.Results: One hundred and sixty-two surgeries (159 patients) were included. Preoperative antihypertensive blockade was performed in 95.1% of the patients, being doxazosin in monotherapy (43.8%) the most frequent regimen. Patients pre-treated with doxazosin required intraoperative hypotensive treatment more frequently (49.4% vs 25.0%, P=0.003) than patients treated with phenoxybenzamine, but no differences in the rate of intraoperative and postsurgical complications were observed. However, patients treated with phenoxybenzamine had a longer hospital stay (12.2±11.16 vs 6.2±6.82, P<0.001) than those treated with doxazosin. Hypertension resolution was observed in 78.7% and biochemical cure in 96.6% of the patients. Thirty-one patients (19.1%) had postsurgical complications. Prolonged hypotension was the most common, in 9.9% (n=16), followed by hypoglycaemia in 6 patients and acute renal failure in 4 patients. 13.0% of complications had a score ≥3 in the Clavien-Dindo scale. Postsurgical complications were more common in in patients with diabetes, cerebrovascular disease, higher plasma glucose levels, higher urinary free metanephrine and norepinephrine, and with pheochromocytomas larger than 5 cm.Conclusion: Preoperative medical treatment and postsurgical monitoring of pheochromocytoma should be especially careful in patients with diabetes, cerebrovascular disease, higher levels of plasma glucose and urine free metanephrine and norepinephrine, and with pheochromocytomas >5 cm, due to the higher risk of postsurgical complications.

Safety and feasibility of retrograde INOUE-BALLOON for balloon aortic valvuloplasty without rapid ventricular pacing during transcatheter aortic valve replacement

Rapid ventricular pacing (RVP) is commonly employed during transcatheter aortic valve replacement (TAVR); however, frequent TAVR is associated with worse prognoses. The retrograde INOUE-BALLOON® (IB) allows balloon aortic valvuloplasty (BAV) without RVP. The aim of this study was to evaluate the feasibility of retrograde IB for TAVR preparation. The study population included 178 consecutive patients (mean age, 84 ± 5 years; male, 47%) who underwent retrograde BAV before prosthetic valve replacement via the transfemoral approach. Patients were divided into a retrograde IB group without RVP (n = 74) and a conventional balloon (CB) group with RVP (n = 104). The primary endpoint was prolonged hypotension after BAV (reduced systolic pressure < 80 mmHg for over 1 min or vasopressor drug requirement). The incidence of prolonged hypotension after BAV was significantly lower in the IB group compared with the CB group (4% vs. 16%, p = 0.011). Balloons were able to penetrate and expand the aortic valve in both groups. RVP was used less for total TAVR in the IB group compared with the CB group. The aortic valve area-index after BAV was not significantly different between the two groups (0.72 ± 0.14 cm2/m2 vs. 0.71 ± 0.12 cm2/m2; p = 0.856). Multivariate analysis demonstrated that IB use was associated with avoidance of prolonged hypotension (OR, 0.27 [0.059–0.952]; p = 0.041). In conclusion, BAV using retrograde IB without RVP is both safe and feasible. More stable hemodynamics were achieved using retrograde IB by avoiding RVP during TAVR.

Safety and feasibility of retrograde inoue balloon for balloon aortic valvuloplasty without rapid ventricular pacing during transcatheter aortic valve implantation

Background Although rapid ventricular pacing (RVP) is commonly performed for preparation of transcatheter aortic valve implantation (TAVI). It has been reported that multiple and / or prolonged RVP is associated with adverse clinical outcomes of TAVI. Retrograde Inoue-Balloon was designed for balloon aortic valvuloplasty (BAV) without RVP to prevent slip of balloon by way of central waist during biphasic inflation. Purpose The purpose of this study was to evaluate safety and feasibility of Retrograde Inoue-Balloon for TAVI preparation. Methods From December 2013 to December 2019, 427 consecutive patients who performed TAVI for severe aortic valve stenosis, were retrospectively enrolled in Iwate Medical University. Of them, 227 (53%) patients (mean age 83±5 years, male 41%), underwent retrograde BAV before prosthetic valve implantation, comprised this study population. Retrograde BAV procedures were divided into two groups; patients used Inoue-Balloon without RVP and those did conventional balloon with RVP. The primary endpoint was defined as combined adverse events of 30-day mortality, cerebral infarction, and critical complications after BAV (aortic dissection, aortic rupture and cardiopulmonary arrest). The secondary endpoint was set as prolonged hypotension after BAV. Result Inoue-Balloon (IB) and conventional balloon (CB) were used for 73 patients (32%) and 154 (68%) patients, respectively. Both balloons were succeeded to through and expand of aortic valve in all cases. In the CB group, cardiopulmonary arrest occurred in 2.0% after BAV, cerebral infarction was observed in 3.9%, and 30-day death in 3.3%. On the other hand, no major complications were observed except one aortic dissection in the IB group. In logistic regression analysis adjusted by sex and age, the incidence of combined adverse events was significantly lower in the IB group (OR 0.17, 95% CI 0.009–0.917, P=0.037). Furthermore, the IB group had significantly a lower incidence of prolonged hypotension following BAV compared with CB group (4.1% vs 19.5%, p=0.002). Conclusion Balloon aortic valvuloplasty using retrograde Inoue-balloon without rapid ventricular pacing is safe and feasible, and may improve clinical outcomes of TAVI. Funding Acknowledgement Type of funding source: None

Salvage DC ablation of ventricular tachycardia following failed RF attempts

Background Ablation of ventricular tachycardia (VT) is a frequent clinical necessity. Modification of ventricular substrate can usually be achieved by radiofrequency ablation (RF). We present 4 cases of failed RF for recurrent VT. Two patients had multiple RF failures, one patient had in-procedure failure, and one patient had multiple RF attempts and a failed alcohol ablation (pt4). Objective To evaluate success of DC ablation after failed RF Methods A 6 Fr 4mm tip steerable ablation catheter, was placed at the site felt to be critical for the circuit following mapping (earliest activation, mid-diastolic, fractionated, site of concealed entrainment, or ventricular breakout). Two connection cables were utilized, one to the recording/mapping system, and one connected to an external biphasic defibrillator (DC). The DF was connected with one pad anterior chest and the other connected by the cable to electrode pins 1 and 2 folded within the second pad. The electrodes were secured by placing a hemostat on the pad. DC energy (360j) was delivered synchronized by electrodes 1–2 Results During follow-up 3 months to 1 year, no recurrent VT was observed. 3 patients received a total of 4 DC pulses, while the pt4 received 16 (RV and LV septum), complicated by prolonged hypotension. No other complications were observed. Figure shows broad RV breakout from the septum in pt4. Conclusion In patients with RF refractory VT, DC ablation may be safely used and in this limited series, provides long-term success. Interestingly, biphasic energy did not induce transient hypotension in 3 of 4 pts. DC ablation should be considered following failed RF, especially when mid-myocardial origin suspected. Funding Acknowledgement Type of funding source: None

Amlodipine poisoning management

Amlodipine is a commonly used calcium-channel blocker (CCB) used in the treatment of hypertension. Severe CCB toxicity is highly lethal, as a result of cardiovascular collapse. Amlodipine overdose can lead to prolonged hypotension and potent vasodilatation which can result in fatality. Early identification of CCB overdose can save lives and reduce the risk of complications. The management of CCB intoxication will be reviewed.

Potential risks in using midodrine for persistent hypotension after cardiac surgery: a comparative cohort study

Background Persistent hypotension is a frequent complication after cardiac surgery with cardiopulmonary bypass (CPB). Midodrine, an orally administered alpha agonist, could potentially reduce intravenous vasopressor use and accelerate ICU discharge of otherwise stable patients. The main objective of this study was to explore the clinical impacts of administering midodrine in patients with persistent hypotension after CPB. Our hypothesis was that midodrine would safely accelerate ICU discharge and be associated with more days free from ICU at 30 days. Results We performed a retrospective cohort study that included all consecutive patients having received midodrine while being on vasopressor support in the ICU within the first week after cardiac surgery with CPB, between January 2014 and January 2018 at the Montreal Heart Institute. A contemporary propensity score matched control group that included patients who presented similarly prolonged hypotension after cardiac surgery was formed. After matching, 74 pairs of patients (1:1) fulfilled inclusion criteria for the study and control groups. Midodrine use was associated with fewer days free from ICU (25.8 [23.7–27.1] vs 27.2 [25.9–28] days, p = 0.002), higher mortality (10 (13.5%) vs 1 (1.4%), p = 0.036) and longer ICU length of stay (99 [68–146] vs 68 [48–99] hours, p = 0.001). There was no difference in length of intravenous vasopressors (63 [40–87] vs 44 [26–66] hours, p = 0.052), rate of ICU readmission (6 (8.1%) vs 2 (2.7%), p = 0.092) and occurrence of severe kidney injury (11 (14.9%) vs 10 (13.5%) patients, p = 0.462) between groups. Conclusion The administration of midodrine for sustained hypotension after cardiac surgery with CPB was associated with fewer days free from ICU and higher mortality. Routine prescription of midodrine to hasten ICU discharge after cardiac surgery should be used with caution until further prospective studies are conducted.