Risultati per: Circulation

Circulation, Volume 150, Issue Suppl_1, Page ASa1006-ASa1006, November 12, 2024. Introduction:Maintaining cerebral blood flow during cardiopulmonary resuscitation (CPR) is vital, yet establishing a dynamic indicator of cerebral blood flow during CPR remains challenging. Near-infrared spectroscopy (NIRS) is a non-invasive technique capable of continuously detecting changes in cerebral blood volume and has the potential to assess cerebral blood flow in real-time during cardiac arrest. Despite its potential, limited research exists on cerebral perfusion indexes measured by NIRS during CPR and their clinical outcomes.Research Questions:Can assessing cerebral perfusion indices (CPI) using NIRS during CPR in out-of-hospital cardiac arrest patients serve as a prognostic indicator?Aims:To evaluate the association between increased CPI measured by NIRS during CPR by EMS personnel on-scene and return of spontaneous circulation (ROSC) after adult out-of-hospital cardiac arrest (OHCA).Methods:Between January 2021 and March 2023, we included consecutive out-of-hospital cardiac arrest patients due to internal causes who were attempted resuscitation by emergency medical services (EMS) in Sapporo city, Japan. EMS placed a NIRS monitor probe (NIRO 200-NX; Hamamatsu Photonics, Japan) on the patient’s forehead and began measurements simultaneously upon contact with the patient. Patients treated with a mechanical chest compression device were excluded. We focused on the change of NIRS pulse waves during CPR at the scene and analyzed the values of NIRS pulse waves at two points: patient contact and scene departure by EMS. NIRS technology measures changes in total hemoglobin (ΔcHb) and oxygenated hemoglobin (ΔO2Hb) concentrations. Patients were divided into groups based on whether their ΔcHb and ΔO2Hb levels increased or decreased between patient contact and scene departure. The primary outcome was prehospital ROSC, and no cases of ROSC were observed at the scene.Results:During the study period, 91 patients were included. The prehospital ROSC rate was 16.4% (11/67) in the group with an increasing ΔcHb trend, compared to 0% (0/24) in the group with no increasing trend (p = 0.034). Regarding ΔO2Hb, the rate was 14.7% (10/68) in the group with an increasing trend and 4.3% (1/23) in the group with no increasing trend (p = 0.279).Conclusion:The increase in CPI measured by NIRS during CPR on-scene was associated with ROSC. Further research is warranted to determine whether CPI can aid in predicting the prognosis of cardiac arrest patients.

Circulation, Volume 150, Issue Suppl_1, Page A4140558-A4140558, November 12, 2024. Background:Single ventricle congenital heart disease such as hypoplastic left heart syndrome (HLHS) with a Fontan circulation constitute the largest group of children hospitalized with circulation failure, experiencing an in-hospital mortality rate of 20-50%. We investigated the mechanisms leading to circulation failure so as to identify novel therapeutic targets.Methods:Blood was collected from patients with HLHS s/p Fontan and controls with normal cardiac anatomy and function (N=6/group). Plasma microvesicles (MV) were isolated, and proteomics assessed using data independent acquisition mass spectroscopy. Dysregulated proteins with a fold change >1.5 or < -1.5, p

Circulation, Volume 150, Issue Suppl_1, Page A4139481-A4139481, November 12, 2024. Background:The physiology of the Fontan circulation is consistent with chronic heart failure, characterized by elevated central venous pressure and reduced cardiac output. In adults with conventional heart failure, iron deficiency is common and is associated with increased morbidity and mortality. However, data is lacking on the prevalence of iron deficiency and its relationship with cardiovascular outcomes in pediatric patients with Fontan circulation.Aim:To characterize the relationship between iron profiles and measures of cardiovascular health in pediatric patients with Fontan circulation.Hypothesis:Iron deficiency is associated with worse measures of cardiovascular health.Methods:Cross-sectional study comprising patients with Fontan circulation who had iron labs measured from 2010 – 2024 at a single urban center. Exclusion criteria were hematologic disease other than iron deficiency, acute bleeding, and acute illness other than heart failure. Cardiovascular health was evaluated with NYHA or Ross class, echocardiogram, and cardiac MRI. Kruskal-Wallis tests and linear regression were used to analyze associations between iron labs and measures of cardiovascular health. Indexed oxygen delivery (iDO2) was calculated from cardiac index measured by cardiac MRI, pulse oximetry, and hemoglobin.Results:100 patients (mean 12.5±4.7 years, 46% female) were included. Iron deficiency was present in 45% or 51% based on conventional criteria of transferrin saturation (TSAT)

Circulation, Volume 150, Issue Suppl_1, Page ASa1001-ASa1001, November 12, 2024. Introduction:Epinephrine is the mainstay of drug treatment during cardiac arrest and it is firmly established that it promotes Return of Spontaneous Circulation (ROSC). In this study we aimed to describe the effect and occurrence of ROSC after administering epinephrine to hospitalized patients with primary pulseless electrical activity (PEA), i.e., administered during PEA as the first recorded arrest rhythm.Method:We investigated 78 episodes of primary PEA registered between Aug. 2018 and Oct. 2022 at St. Olav University Hospital (Trondheim, Norway). In 36 episodes, the first dose of epinephrine was administered during primary PEA and registered with minute precision. We created different time dependent covariate profiles for the effect of epinephrine, starting at 0 (time of administration), rising linearly to 1 (presumed maximum effect) and decreasing to 0 immediately thereafter. Time to presumed maximum effect started at 5 seconds (s) after administration and increased in steps of 5s until 300s. We entered each of these different covariate profiles into separate Cox regression models using time to ROSC as outcome obtaining in total 60 Hazard ratios (HR) from all the models.Results:Median time to epinephrine administration was 185s (range 80 to 310) after start of resuscitation. In total, 23 patients obtained ROSC after the administration of epinephrine and 15 patients obtained ROSC without epinephrine. The different hazard ratios (y-axis) were plotted against the location of the maximum point of the covariate profile (x-axis) in Fig. 1. HR peaked twice, at 70 and 155s, 11.4(p< 0.001) and 4.1(p= 0.013), respectively.Discussion:This study indicates a strong effect of epinephrine during primary PEA 1-2 min after administration. This information may provide the treating team with useful insight on what to expect after administering epinephrine. In addition, the actual effect may be even larger, as the sickest patients (expected to respond less well to epinephrine) are more often monitored and thus recieve epinephrine earlier.

Circulation, Volume 150, Issue Suppl_1, Page ASa902-ASa902, November 12, 2024. Introduction:Patients who regain return of spontaneous circulation (ROSC) after in-hospital cardiac arrest are often critically ill and at risk of re-arrest. However, re-arrest is insufficiently studied. Pre-hospital data indicate a re-arrest rate ranging from 3% to 39%. Our study aims to assess the immediate hazard of re-arrest after ROSC, depending on whether the patient’s last observed rhythm before ROSC was shockable or not.Methods:We analyzed defibrillator recordings and clinical data from 763 cardiac arrest episodes at four different hospitals. ROSC was defined as an organized ECG rhythm compatible with a pulse, accompanied by the absence of chest compressions for at least one minute. An organized rhythm with a QRS frequency ≥ 12 was categorized as pulseless electrical activity (PEA). Conversely, a QRS frequency < 12 or a flat line represented asystole. Ventricular fibrillation or tachycardia (VF/VT) was identified based on its distinct morphology. We further stratified ROSC based on whether the preceding rhythm was shockable or not. After comparing four different parametric time-to-event models, we chose the most useful one and estimated the immediate hazard of re-arrest along the timeline of resuscitation.Results:After the initial event of cardiac arrest, we observed 316 re-arrests. Among these, 68% relapsed to PEA, 25% relapsed to VF/VT, and 7% relapsed to asystole. Summarized in the figure, the initial hazard of re-arrest from ROSC after PEA or asystole to a non-shockable rhythm was 0.02 per minute. By the 9th minute, this hazard decreased to 0.01 per minute. Meanwhile, the hazard for re-arrest to a shockable rhythm remained constant at 0.01 per minute. For re-arrest from ROSC after VF/VT back to VF/VT, the hazard was 0.05 per minute initially, decreasing to 0.03 per minute by the 12th minute. The corresponding hazard for re-arrest to PEA or asystole remained at 0.01 per minute.Conclusion:The hazard of re-arrest after return of spontaneous circulation (ROSC) to either pulseless electrical activity (PEA), asystole, or ventricular fibrillation/tachycardia (VF/VT) varies by the last observed state before ROSC. Notably, re-arrest to VF/VT following ROSC after previous VF/VT poses the highest risk. This understanding can assist healthcare professionals in anticipating events during the critical minutes following successful resuscitation and adjusting treatment accordingly.

Circulation, Volume 150, Issue Suppl_1, Page A4142224-A4142224, November 12, 2024. Introduction:Right heart failure under the support of a left ventricular assist device (LVAD) presents a life-threatening condition characterized by organ edema and limited LVAD support. Implementing an inferior vena cava-pulmonary artery (IVC-PA) bypass graft may mitigate these complications by reducing central venous pressure (CVP) and improving LVAD support efficiency. This study aimed to elucidate an adequate graft diameter for an IVC-PA bypass in terms of CVP reduction during LVAD-assisted circulation using an in vitro biventricular pulsatile circulatory system.Methods:We developed a biventricular pulsatile circulation system capable of providing circulatory assistance via an LVAD (centrifugal pump) connected to the apex of a left ventricular model （Fig）. A representative condition of cardiogenic shock was produced by adjusting LV systolic pressure, aortic pressure, and CVP to 80 mmHg, 80/40 mmHg, and 7.5 mmHg, respectively. A right heart failure model was produced by adjusting LV systolic pressure, aortic pressure, and CVP to 45 mmHg, 70 mmHg, and 16 mmHg, respectively, under LVAD support at 1700 rpm. Then, an adequate IVC-PA bypass diameter was investigated in terms of reducing CVP and increasing bypass flow support among 4mm and 18 mm with 2mm interval. The diameters of PA and IVC, and systolic PA pressure were set to 19 mm, 19 mm, and 18 mmHg, respectively. Elastic LV and RV models were driven by pneumatic positive and negative pressures.Results:We found a linearly increasing trend of bypass flow and a decreasing trend of CVP with increasing bypass diameters from 4 to 12 mm. When applying the bypass graft over 12mm diameter, bypass flow and CVP plateaued at 3.4 L/min and 7.5 mmHg, respectively (Fig).Conclusion:Our sophisticated in vitro biventricular circulation study suggests that in scenarios of right heart failure under LVAD support, implementing a bypass graft from the IVC to the PA is effective for decreasing CVP and reducing right ventricular preload. This study indicates that the optimal bypass diameter for reducing CVP is 12 mm when the diameters of the IVC and PA are 19 mm. These findings encouraged us to evaluate the efficacy in in vivo clinical settings.

Circulation, Volume 150, Issue Suppl_1, Page ASa202-ASa202, November 12, 2024. Background:During cardiopulmonary resuscitation (CPR), identifying the return of spontaneous circulation (ROSC) is challenging. Methods such as manual palpation, end-tidal carbon dioxide, and point-of-care ultrasound to detect ROSC are inaccurate, time-consuming, or intermittent. They may also require halting or prolonging no-compression time to identify signs of circulation. Maintaining a high compression fraction is associated with an increased likelihood of achieving ROSC.Aim:This study aimed to investigate if using a novel continuous hands-free carotid Doppler system (RescueDoppler (RD)) could identify ROSC during chest compressions by distinguishing between spontaneous and chest compression-generated carotid blood flow velocity.Methods:We used a porcine cardiac arrest model to investigate the RD. The RD probe was positioned and fixated over the carotid artery. An invasive blood pressure catheter was inserted in the contralateral carotid artery. An implantable cardioverter defibrillator (ICD) was utilized to induce sequences of ventricular fibrillation followed by defibrillation and chest compressions (cardiac arrest sequences). Compressions were administered manually at a rate of 100 or 50 compressions per minute or using a mechanical chest compression device (LUCAS). Doppler blood flow velocity curves were retrospectively analyzed for signs of ROSC by examining both spontaneous and/or compression-generated velocities (Fig. 1,2). We combined color M-mode and Doppler spectrum (Fig. 1) to differentiate between chest compression and spontaneous velocities.Results:Data from eight animals (mean weight 30 kg) and 56 cardiac arrest sequences were included. In the analysis, chest compressions were identified as tissue movements through the whole spectrum of the color M-mode, in the spectral display (Fig. 1), or both. Spontaneous velocities were identified in a specific carotid depth of the color M-mode and between compression-generated peak velocities in the Doppler specter (Fig. 1). ROSC was confirmed by pausing chest compressions and evaluating ECG and invasive blood pressure. We identified spontaneous circulation during manual and mechanical chest compressions in 55 of 56 sequences.Conclusions:In a porcine cardiac arrest model, with ROSC, we could differentiate between spontaneous circulation and chest compression-generated blood flow velocity of the carotid artery using RescueDoppler.

Circulation, Volume 150, Issue Suppl_1, Page A4141869-A4141869, November 12, 2024. Introduction:Over 290,000 in-hospital cardiac arrests occur annually in the United States. Survival is about 25% with significant variation across the country. Evidence supports high-quality chest compressions as a vital factor to achieving return of spontaneous circulation (ROSC) and improving outcomes after cardiac arrest. Research illustrates a propensity for healthcare professionals to provide chest compressions at a rate outside the American Heart Association guideline of 100-120 compressions/minute.Goal/Hypothesis:The team hypothesized greater compliance with chest compression rate guidelines would increase ROSC. The goal of this initiative was to increase CC rate compliance from a facility baseline of 15-64% toward the published benchmark of 80%, and to positively impact ROSC.Method:An interdisciplinary team focused on optimizing CC rate compliance. The Plan, Do, Study, Act methodology provided structure and a systematic approach to data informed improvements. Rate data was collected, then shared on a Power BI dashboard and in a facility specific report. The impact of the awareness campaign was assessed at the end of each quarterly cycle for 9 facilities.Results/Outcomes:Data for 2023 included 487 code events and 6,315 minutes of CPR. At year end, improvements were found at 5 facilities (12, 12, 14, 17,&7%) over baseline, and 2 facilities achieved the benchmark. Statistical analysis was conducted to evaluate CC rate compliance in correlation with ROSC. Cases were sorted into 2 groups: Group 1 (compliance 80% or greater) or Group 2 (compliance less than 31.6% – calculated first quartile). Three hundred two cases met inclusion criteria. Cochran’s formula was used (95% CI) to calculate sample size (Group 1:111 cases; Group 2:107cases). A Chi-squared test showed a significant difference in achieving ROSC between the groups (p=0.0223). Group 1 achieved ROSC 20% more frequently than Group 2.Conclusions:Chest compression rate compliance was positively associated with improved rate of ROSC in this project. Project findings prompted the system resuscitation committee to require facilities to set a goal for CC rate compliance improvement. Improvement can be achieved without financial or educational burden. Other performance-based quality metrics to improve clinical outcomes should be included in future research with consideration of co-morbidities.

Circulation, Volume 150, Issue Suppl_1, Page A4146967-A4146967, November 12, 2024. Objectives:Physically active lifestyles are important for patients with congenital heart disease, including Fontan. This study aims to establish the effect of an active lifestyle in paediatric Fontan patients, determine its relationship with body composition, exercise capacity, ventricle function and quality of life.Methods:30 Fontan patients were recruited. Mean age of 14.8±2 years.Cardiopulmonary exercise tests, bio-impedance analyser, echocardiography and PedsQL questionnaires, generic (V4.0) and cardiac modules (V3.0) were performed. Physical activity level includes structured sports participation, daily stepcounts, and active-zone-minute, AZM (minute spend doing activity ≥ moderate intensity) measured by accelerometer (Fitbit Inspire3).Patients were considered active if they met 2 of the 3 criteria:1/ Structured sports training ≥ 2 per week (moderate-vigorous intensity >30 minutes)2/ Daily steps ≥ 10k3/ AZM ≥ 60 minutes per dayResults:60% of patients were considered active, predominantly male, mean age of 14.1 years old. Overall BMI was normal, however 17% (5 of 30) were overweight or obese (Table 1).The less active Fontan had higher fat% (24.8±8.7 vs 16.6±5.2%; p=0.003), lower percentage appendicular skeletal muscle mass, SMMa%(29.8±3.6 vs 33.7±3.1%; p=0.004), and muscle to fat ratio, MFR (1.4±0.8 vs 2.3±0.9; p=0.015).The less active group had lower peak oxygen consumption, VO2peak(23.5±7.2mL/kg/min vs 35.1±3.96mL/kg/min; p < 0.001), lower peak oxygen pulse (7.9±1.2 vs 10.01±2.9) ml/beat; (p=0.024). No statistical significant differences observed in the ventricle function.Higher self-report PedQL V4.0 scores noted in the active group, indicated better HRQOL (child’s QOL 88.26±8.6 vs 72.89±17.2%; p=0.003 and parent’s QOL 87.22±10.8 vs 71.6±23.4%; p=0.020).Higher physical activity level is associated with lower body fat% (r=– 0.521, p=0.003), greater SMMA% (r=0.513, p=0.004), higher peak and submaximal VO2, [VO2/kg peak (r=0.787, p < 0.001) VO2 at ventilatory threshold 1, VT1 (r=0.451, p=0.012)], peak O2pulse (r=0.411, p=0.024), and importantly, higher HRQOL reported [child’s QOL V4.0 (r=0.524,p=0.003), parent’s QOL V4.0 (r=0.423, p=0.020)].Conclusions:Higher physical activity levels in paediatric Fontan patients are associated with normal skeletal muscle mass, higher exercise capacity and better HRQOL. Conversely, lower physical activity levels are associated with skeletal muscle mass deficit, increased adiposity and reduced exercise capacity.

Circulation, Volume 150, Issue Suppl_1, Page ASu204-ASu204, November 12, 2024. Introduction:International guidelines support use of end-tidal carbon dioxide (ETCO2) for monitoring resuscitation in out-of-hospital cardiac arrest (OHCA). Specific ETCO2cutoffs have been proposed for termination of resuscitation, though data on rates of ROSC based on changes in ETCO2is limited. We aimed to evaluate the relationship between change in ETCO2in OHCA and its relationship to return of spontaneous circulation (ROSC) using a US national database.Methods:This retrospective analysis of National Emergency Medical Services Information System (NEMSIS) datasets from 2020 to 2022 evaluated all adult patients who underwent resuscitation for OHCA and had multiple ETCO2measurements. We excluded cases with missing data. The highest difference between two sequential ETCO2measurements (MΔETCO2) and total difference between minimum and maximum ETCO2measurements [TΔETCO2] were calculated for each case. ΔETCO2groups were stratified into 10-unit increments and we compared rates of ROSC between groups. We then used multivariable logistic regression to evaluate the association between each 5 unit increase in ΔETCO2and ROSC. We adjusted for age, sex, location, witness status, initial shockable rhythm, and CPR or AED prior to EMS arrival.Results:We included 274,516 total patients with 1,686,390 ETCO2measurements. The median number of ETCO2measurements was 5 (IQR 3-8). Median age was 65, 62.8% were male, 60.1% had witnessed arrests, and 78.3% received CPR and 32.3% received AED placement prior to EMS arrival. ROSC rates based on MΔETCO2were 0-10 mmHg [33.3%], 10-20 mmHg [42.3%], 20-30 mmHg [49.7%], 30-40 mmHg [53.2%], and >40 mmHg [56.6%]. ROSC rates for TΔETCO2were 0-10 mmHg [29.6%], 10-20 mmHg [36.7%], 20-30 mmHg [43.5%], 30-40 mmHg [48.9%], and >40 mmHg [54.6%]. Adjusted odds of ROSC per 10 mmHg increase in MΔETCO2was 1.21 [1.21-1.22] and TΔETCO2was 1.19 [1.19-1.19].Conclusions:Increasing max and overall ΔETCO2was associated with increased rates and odds of ROSC for OHCA.

Circulation, Volume 150, Issue Suppl_1, Page ASu1001-ASu1001, November 12, 2024. Background:Progressive post-cardiac arrest syndrome (PCAS) ensues within seconds of an out-of-hospital cardiac arrest (OHCA) and results in damage over days, yet longitudinal changes in blood biomarkers during PCAS are poorly understood. We characterize novel biomarkers at early time points after return of spontaneous circulation (ROSC) and determine associations with survival.Methods:Blood plasma samples from OHCA patients were collected at 1, 6, 24, 48, 72 hours and 7 days after ROSC. Samples were analyzed using a Meso Scale Diagnostics 40-plex assay which included proinflammatory, cytokine, chemokine, angiogenesis, and vascular injury panels. The data distribution was heavily skewed, requiring log-transformation. Biomarkers were compared between survivors and non-survivors at each follow-up time point using a two-sample t-test. Mixed-effect and Generalized Estimation Equation models were used to examine the association between biomarkers and survival and assess trends over time.Results:Thirty-three patients were included, of which 54% (N=18) were males, the mean age was 57 (+/-15) years, and 54% (N=18) survived to discharge. Six out of the 40 biomarkers had a statistically significant difference in biomarker levels between survivors and non-survivors at one or more time points. At the 1-hour, macrophage derived chemokine (MDC) and thymus and activation-regulated chemokine (TARC) were significantly higher in survivors. At 6-hour, interleukin-13 (IL-13) was the only pro-inflammatory biomarker that was significantly higher in non-survivors. At 24-hour, pro-inflammatory biomarkers interleukin-12p70 (IL-12p70) and IL-13 were higher in non-survivors, whereas vascular endothelial growth factor A (VEGF-A) was significantly higher in survivors. At 48-hours, VEGF-A was also significantly higher in survivors. At 72 hours, interleukin-8 was the only biomarker with significantly higher levels in non-survivors. Overall, IL-12p70, IL-13, and MDC levels decreased over time (p=0.02, p=0.003, p=0.01, respectively) for both survivors and non-survivors. Survivors had a lower average level for IL-12p70 (p=0.03) and for IL-13 (p=0.04), but higher average level for MDC (p=0.01) than non-survivors at discharge.Conclusion:This pilot investigation extends prior biomarker work by highlighting new biomarkers, their longitudinal changes during PCAS, and their relation to survival. Future analysis will explore differences in biomarkers for neurological outcomes after OHCA.

Circulation, Volume 150, Issue Suppl_1, Page ASu304-ASu304, November 12, 2024. Objective:The optimal timing for defibrillation attempts in out-of-hospital cardiac arrest (OHCA) patients with recurrent shockable rhythms [ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT)] is uncertain. This study examined the association between “time to DC shock” and the return of spontaneous circulation (ROSC) in OHCA patients with recurrent shockable rhythms.Methods:This was a retrospective analysis of data from the Salt Lake City Fire Department (SLCFD) from 2012 to 2023. Rhythm-filtering technology, used since 2012, enabled real-time and accurate interpretation of cardiac rhythms during CPR, with local protocols allowing early defibrillation for recurrent VF/ pulseless VT cases. Patients who experienced four or five episodes of shockable rhythms and received defibrillation were included. Generalized estimating equation (GEE) analysis was used to evaluate the association between time to shock preceding recurrent defibrillation and ROSC.Results:A total of 142 patients were included, with a mean age of 59.7 ± 15 years; 105 (73.9%) were male, 63 (44.4%) arrested in public locations, and 101 (71.1%) had witnessed arrests. Adjusted GEE analysis revealed that longer time to shock was associated with lower odds of achieving ROSC (OR: 0.81, 95% CI: 0.72–0.93, p = 0.005). Every one-minute delay in defibrillation is predicted to decrease the likelihood of achieving ROSC by 19%.Conclusion:In patients with recurrent shockable rhythms, every one-minute delay in delivering a shock was associated with a statistically significant 19% reduction in the chance of achieving ROSC. This finding highlights the importance of reducing the time to defibrillation in managing recurrent shockable rhythms and suggests reevaluating the current recommendation of two-minute intervals for rhythm check and shock delivery.

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Circulation, Volume 150, Issue 18, Page 1469-1474, October 29, 2024.

Circulation, Volume 150, Issue 17, Page 1307-1307, October 22, 2024.

Circulation, Volume 150, Issue 12, Page 966-970, September 17, 2024.