Canadian Journal of Cardiology最新文献

{"title":"The “Small” Clinical Trial: Methods, Analysis, and Interpretation in Acute Care Cardiology","authors":"Fernando G. Zampieri MD, PhD ,&nbsp;Justin A. Ezekowitz MD, Msc","doi":"10.1016/j.cjca.2024.11.010","DOIUrl":"10.1016/j.cjca.2024.11.010","url":null,"abstract":"<div><div>Clinical trials in acute care settings, particularly those involving small populations or high mortality contexts, present unique challenges in design and analysis. In this review we explore novel statistical approaches and methodological considerations for such trials, with a focus on cardiovascular therapies. We discuss the concept of “small” sample sizes and their limitations and cover various analytical frameworks, including frequentist and Bayesian approaches, and emphasize their implications for result interpretation and reproducibility. We examine end points such as “days alive and free specific to disease state,” which combines mortality and morbidity measures, the win ratio for hierarchical end points, and ordinal scales that capture detailed patient outcomes. These methods potentially increase statistical power and provide more clinically relevant measures compared with traditional binary outcomes; an extensive use of simulations is used to clarify this point. The use of longitudinal ordinal models is presented as a promising method to capture complex patient trajectories over time, offering insights into treatment effects at various disease stages. We also address the potential of adaptive platform trials for rare conditions, allowing for more efficient use of limited patient populations. In this overview we aim to guide researchers and clinicians in selecting optimal trial designs and analytical strategies, to ultimately improve the quality, efficiency, and interpretability of evidence in acute care cardiology.</div></div>","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 656-668"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615272","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mechanical Circulatory Support for Septic Shock in Children and Adults: Different But Similar","authors":"Roberto Chilletti MD, CICM ,&nbsp;Joshua Ihle BMed, FRACP, FCICM, DDU ,&nbsp;Warwick Butt MB, BS, FRACP, FCICM","doi":"10.1016/j.cjca.2024.12.031","DOIUrl":"10.1016/j.cjca.2024.12.031","url":null,"abstract":"<div><div>Although extracorporeal membrane oxygenation (ECMO) for circulatory support in patients with severe septic shock commenced in newborn infants and children in the late 1980s, ECMO has remained a controversial treatment for adults with refractory septic shock (RSS). This is fundamentally because of differences in the predominant hemodynamic response to sepsis. In newborn infants and very young children ventricular failure, low cardiac output syndrome (LCOS) is the major hemodynamic response whereas adolescents and adults mainly have vasoplegic shock. ECMO is a very effective treatment for cardiogenic shock even shock caused by sepsis, with a survival that has varied from 40% to 70%; vasoplegic shock, however, requires vasopressors rather than ECMO, and hence survival of these patients with ECMO was poor (&lt; 20%). However, since the early 2000s, sepsis- induced cardiomyopathy (SCM) with ventricular failure (identical to LCOS in children) has been increasingly described in adults, and the occurrence of cardiogenic shock caused by septic shock is treatable with ECMO. In the last 6 years, increasing publications of series of adults with RSS and cardiogenic shock receiving ECMO and ∼70+% surviving has led to increased use of VA ECMO for RSS.</div></div>","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 605-612"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142920864","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcome Complexity With Microaxial Flow Pump for Circulatory Support in Patients with Cardiogenic Shock: A Meta-Analysis and Trial Sequential Analysis","authors":"Alireza Oraii MD, MSc ,&nbsp;William F. McIntyre MD, PhD ,&nbsp;Sean van Diepen MD, MSc ,&nbsp;Michael B. Tsang MD ,&nbsp;Faizan Amin MD ,&nbsp;Emilie P. Belley-Côté MD, PhD","doi":"10.1016/j.cjca.2025.02.023","DOIUrl":"10.1016/j.cjca.2025.02.023","url":null,"abstract":"","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 789-791"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143476424","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Venoarterial Extracorporeal Membrane Oxygenation in Adults With Septic Shock: Hope or Hype?","authors":"Thin Xuan Vo MD, MSc ,&nbsp;Diego Peña MD ,&nbsp;John Landau MD, MSc ,&nbsp;A. Dave Nagpal MD, MSc","doi":"10.1016/j.cjca.2025.01.025","DOIUrl":"10.1016/j.cjca.2025.01.025","url":null,"abstract":"<div><div>Septic shock is associated with significant morbidity and mortality, but a subset of patients with sepsis will experience transient myocardial depression, termed sepsis-associated cardiomyopathy, which markedly increases observed mortality. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support in medically refractory sepsis, survival in patients with VA-ECMO for sepsis has been historically poor. Concerns regarding numerous potential harms associated with VA-ECMO, including further seeding of infection, exacerbation of inflammation and vasoplegia, bleeding, thrombosis, and distal limb ischemia have further tempered enthusiasm in the setting of sepsis. However, there may be a subset of patients with profound sepsis refractory to medical therapy that could potentially derive some benefit from VA-ECMO. This review provides an overview of the pathophysiology, diagnosis, and treatment of sepsis-associated cardiomyopathy and then focuses on the utility of VA-ECMO in this patient population. A summary of the scant published outcomes of VA-ECMO in sepsis-associated cardiomyopathy is provided, followed by a discussion of important management considerations to optimize outcomes in these extremely sick patients, and finally the pros and cons of VA-ECMO in the setting of sepsis are presented. Using available published data and current state-of-the-art practice, we conclude that VA-ECMO may be a reasonable consideration in highly selected patients with low ejection fraction sepsis-associated cardiomyopathy and refractory hypoperfusion in appropriately equipped health care systems, but more supportive data are required before VA-ECMO can be generally recommended in patients with septic shock.</div></div>","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 705-717"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143073996","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Prediction Score for Successful Liberation from Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients","authors":"Stefania Sacchi MD, PhD ,&nbsp;Angela Venuti MD ,&nbsp;Francesca Maria Gobbi MD ,&nbsp;Alessia Gambaro MD ,&nbsp;Luca Baldetti MD ,&nbsp;Francesco Calvo MD ,&nbsp;Mario Gramegna MD ,&nbsp;Vittorio Pazzanese MD ,&nbsp;Beatrice Peveri MD ,&nbsp;Lorenzo Cianfanelli MD ,&nbsp;Giovanni Lino Cardillo MD ,&nbsp;Flavio Luciano Ribichini MD ,&nbsp;Silvia Ajello MD ,&nbsp;Anna Mara Scandroglio MD","doi":"10.1016/j.cjca.2025.02.009","DOIUrl":"10.1016/j.cjca.2025.02.009","url":null,"abstract":"<div><h3>Background</h3><div>In cardiogenic shock (CS) patients requiring temporary mechanical circulatory support (tMCS), assessing cardiac recovery vs the need for heart replacement therapy is critical. We developed and validated a new clinical score aimed at predicting successful tMCS liberation.</div></div><div><h3>Methods</h3><div>A cohort of 80 CS patients treated with Impella support between January 2018 and December 2020 was analyzed. Hemodynamic, echocardiographic, and laboratory data were collected at baseline, 24 hours, 48 hours, and 96 hours after device insertion. Patients were classified as successfully or unsuccessfully liberated from tMCS, based on recovery vs progression to death, left ventricular assist device implantation, or heart transplant. The W score, derived using independent predictors of successful liberation, was validated in 2 cohorts: 86 CS patients at our center and 23 patients from an external center.</div></div><div><h3>Results</h3><div>Among the 80 patients (mean age 62.5 ± 11.8 years, 63.7% acute myocardial infarction CS), 47.5% achieved successful tMCS liberation. Independent predictors included left ventricular ejection fraction, N-terminal pro–brain natriuretic peptide, and inotropic score at 24 hours, along with creatinine and lactate at 96 hours (area under the curve [AUC] ≥ 0.7, <em>P</em> &lt; 0.05). The W score, using a cutoff of ≥7, demonstrated good diagnostic accuracy (AUC 0.92, sensitivity 80%, specificity 85%, <em>P</em> &lt; 0.001). In validation cohorts, a score ≥7 predicted successful liberation with AUCs of 0.80 (<em>P</em> &lt; 0.001) and 0.72 (<em>P</em> &lt; 0.015) at the internal and external centers, respectively.</div></div><div><h3>Conclusions</h3><div>The W score, based on key parameters at 24 and 96 hours post-tMCS, effectively supports clinicians in identifying CS patients likely to achieve successful tMCS liberation.</div></div>","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 730-739"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143412842","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reply to Cheseks et al.—Expert Opinions For Refractory Cardiac Arrest: Double Sequential External Defibrillation, Vector Change, and eCPR","authors":"Sean van Diepen MD, MSc,&nbsp;Michel R. le May MD,&nbsp;Patricia Alfaro RN, MSc,&nbsp;Michael J. Goldfarb MD, MSc,&nbsp;Adriana Luk MD, MSc,&nbsp;Rebecca Mathew MD,&nbsp;Maude Peretz-Larochelle MDCM,&nbsp;Erin Rayner-Hartley MD,&nbsp;Juan J. Russo MD,&nbsp;Janek M. Senaratne MD, MSc,&nbsp;Craig Ainsworth MD,&nbsp;Emilie Belley-Côté MD, PhD,&nbsp;Christopher B. Fordyce MD, MHS, MSc,&nbsp;Julie Kromm MD,&nbsp;Christopher B. Overgaard MD,&nbsp;Gregory Schnell MD,&nbsp;Graham C. Wong MD, MPH","doi":"10.1016/j.cjca.2024.05.030","DOIUrl":"10.1016/j.cjca.2024.05.030","url":null,"abstract":"","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Page 793"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141330435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Left Ventricular Assist Device as a Bridge-to-Recovery Strategy in Alcoholic Cardiomyopathy: A Case Series","authors":"Federica Valente MD ,&nbsp;Matteo Pozzi MD, PhD ,&nbsp;Laurent Sebbag MD, PhD ,&nbsp;Guillaume Baudry MD, PhD","doi":"10.1016/j.cjca.2024.08.278","DOIUrl":"10.1016/j.cjca.2024.08.278","url":null,"abstract":"","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 764-767"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142092252","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Extracorporeal Membrane Oxygenation for Patients With Electrical Storm or Refractory Ventricular Arrhythmias: Management and Outcomes","authors":"Reha Kumar MD ,&nbsp;Jennifer M. Amadio MD, MEHP ,&nbsp;Adriana C. Luk MD ,&nbsp;Abhishek Bhaskaran FRACP, PhD ,&nbsp;Andrew C.T. Ha MD, MSc","doi":"10.1016/j.cjca.2024.12.018","DOIUrl":"10.1016/j.cjca.2024.12.018","url":null,"abstract":"<div><div>Patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at high risk for ventricular arrhythmias due to derangements in myocardial perfusion, hemodynamics, and heightened catecholamine states. Existing data on the management and outcomes of patients with electrical storm or refractory ventricular tachycardia/fibrillation (VT/VF) treated with VA-ECMO are primarily derived from retrospective observational studies. Typical survival rates are in the range of 40%-50%, with 15%-20% of patients undergoing VT ablation and 30%-40% of patients requiring advanced heart failure therapies (cardiac transplant or durable left ventricular assist device). Similarly, there is a paucity of published data on VT/VF management for patients while on VA-ECMO, as these data are largely extrapolated from patients with electrical storm. Although many of the treatment principles (identifying reversible causes, antiarrhythmic drugs, VT ablation, and reduction of adrenergic tone) are translatable, several aspects require special consideration when managing VT/VF in the VA-ECMO patient population. Among carefully selected patients on VA-ECMO who underwent VT ablation, reported recurrence rates were ∼ 30% and a sizeable proportion of them (30%-40%) required advanced heart failure therapy as an exit strategy. In addition, there are specific issues that require consideration for patients on VA-ECMO who undergo VT ablation, such as vascular access, ECMO access site complications, and bleeding due to systemic anticoagulation. Optimal management of VT/VF in this patient population requires ongoing reassessment and dialogue among electrophysiology, heart failure, and critical care specialists. Additional research is needed to better inform the care of this very high-risk patient population.</div></div>","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 645-655"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142863436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"CJCA_ANN_Call for Original Papers_Endo","authors":"","doi":"10.1016/S0828-282X(25)00214-4","DOIUrl":"10.1016/S0828-282X(25)00214-4","url":null,"abstract":"","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages A11-A12"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143807686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"From Escalate to Elevate: A New Paradigm for Comprehensive Cardiogenic Shock Management","authors":"Darshan H. Brahmbhatt MB BChir, MD(Res) ,&nbsp;Sanjog Kalra MD, MSc ,&nbsp;Adriana Luk MD, MSc ,&nbsp;Filio Billia MD, PhD","doi":"10.1016/j.cjca.2024.12.036","DOIUrl":"10.1016/j.cjca.2024.12.036","url":null,"abstract":"<div><div>Patients with cardiogenic shock (CS) present with critical hemodynamic compromise with low cardiac output (CO) resulting in end-organ dysfunction. Prognosis is closely related to the severity of shock, and treatment of patients with CS is resource intensive. In this review, we consider the current treatment paradigms alongside the evidence that underpins them. The current standard of treatment relies on a feedback mechanism, where small changes in treatment are assessed to see if clinical improvement occurs. This leads to delays that increase time in the shock state. The novel approach described proposes immediate treatment to ameliorate the shock state to \"break” the shock spiral as quickly and decisively as possible, suggesting new metrics to measure performance.</div></div>","PeriodicalId":9555,"journal":{"name":"Canadian Journal of Cardiology","volume":"41 4","pages":"Pages 630-644"},"PeriodicalIF":5.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142969634","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}