Previous Articles of the Month

June 2025

Routine cerebral embolic protection (CEP) during TAVI - The BHF PROTECT-TAVI Trial.

Routine Cerebral Embolic Protection during Transcatheter Aortic-Valve Implantation | NEJM

Transcatheter aortic-valve implantation (TAVI) is associated with procedure-related stroke. Cerebral embolic protection (CEP) devices may reduce embolization to the cerebral circulation and hence t...

www.nejm.org

This study in NEJM enrolled patients from 33 centres in the UK in a 1:1 ratio. Disabling stroke occurred in 1.2% of patients in the CEP arm vs 1.4% in the control arm. Other secondary outcomes including access complications were similar between groups.

May 2025

Management of vasoplegic shock

Vasoplegic shock is common, contributing up to two-thirds of cases of shock admitted to the ICU.1,2 For the two most common causes of vasoplegic shock—septic shock and vasoplegic shock after cardiopulmonary bypass (CPB)—mortality is 25–50%.2–4

www.bjaed.org

BJA education describing novel strategies for managing vasoplegic shock.

April 2025

Prothrombin Complex Concentrate vs Frozen Plasma in Cardiac Surgery

This clinical trial compares the efficacy and safety of prothrombin complex concentrate with frozen plasma in patients requiring coagulation factor replacement for bleeding during cardiac surgery.

jamanetwork.com

The FARES-II Multicenter RCT (Canada and the US) published this month in JAMA:

538 patients of which 420 underwent analysis. 207 entered the FFP group (3u FFP if <60kg, 4u FFP if > 60kg) and 213 entered the PCC group. PCC showed improvements in:

• “Haemostatic effectiveness”,
• Blood product administration (6.6units with PCC vs 9.3 units with FFP)
• Adverse events (36% vs 47%)
• AKI (10% vs 18%)

Importantly this trail used higher doses of PCC (24u/kg) than previous studies, perhaps explaining some of the benefits seen (which were not identified in similar, albeit smaller trials previously) Incidence of thrombotic events was not increased with PCC vs FFP.

March 2025

Catheter Ablation or Antiarrhythmic Drugs for Ventricular Tachycardia | NEJM

Patients with ventricular tachycardia and ischemic cardiomyopathy are at high risk for adverse outcomes. Catheter ablation is commonly used when antiarrhythmic drugs do not suppress ventricular tac...

www.nejm.org

NEJM article comparing ablation therapy to medical management in ischaemic cardiomyopathy and associated VT.

February 2025

Preoperative Levosimendan in Patients With Severe Left Ventricular Dysfunction Undergoing Isolated Coronary Artery Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials

Meta-analysis JCVA article reviewing the use of Levosimendan pre-operatively in patients with LVEF <35%. Overall there was a mortality benefit (RR 0.31; 95% CI 0.16-0.60) in the intervention group with secondary benefits of post-operative AKI, LCOS and AF also seen.

January 2025

Use of intravenous albumin

CHEST review article outlining indications for IV albumin. Of relevance to cardiac intensive care medicine were 2 out of 14 recommendations which state:

1. In adult patients undergoing cardiovascular surgery, intravenous albumin is not suggested for priming the cardiovascular bypass circuit or volume replacement
2. In pediatric patients undergoing cardiovascular surgery, intravenous albumin is not suggested for priming the cardiovascular bypass circuit or volume replacement

December 2024

Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis

Article from October outlining benefit of TAVR vs surveillance in the studied population. Primary end-point (death, stroke or unplanned hospitalisation) occured in 26.8% in TAVR group vs 46.3% in the surveillance group. The major difference was seen in unplanned hospitalisation frequency (20.9% vs 40.7%) although there were signifiant differences in death (8.4% vs 9.2%) and stroke (4.2% vs 6.7%) as well. Of note 87% of patients assigned to the surveillance group underwent TAVR during the 3.8 year follow up period.

Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis | NEJM

For patients with asymptomatic severe aortic stenosis and preserved left ventricular ejection fraction, current guidelines recommend routine clinical surveillance every 6 to 12 months. Data from ra...

www.nejm.org

November 2024

Comprehensive non-invasive haemodynamic assessment in acute decompensated heart failure-related cardiogenic shock: a step towards echodynamics.

Excellent article reviewing the correlation between echo-derived parameters and gold standard PAC-derived parameters in patients with cardiogenic shock. Most validating studies prior to this reviewed stable patients in elective scenarios to establish echo-PAC correlation, this study adds real-world value to echo-assessment of patients with cardiogenic shock.

Comprehensive non-invasive haemodynamic assessment in acute decompensated heart failure-related cardiogenic shock: a step towards echodynamics

AbstractAims. Haemodynamic assessment can be determinant in phenotyping cardiogenic shock (CS) and guiding patient management. Aim of this study was to eva

academic.oup.com

October 2024

EHJ article detailing the role of 3D echo in the identification and characterisation of endocarditis. Some beautiful 3D images and great summary of the role of 3D echo vs 2D TTE in these cases.

Role of 3D transoesophageal echocardiography in the study of infective endocarditis. Demonstration in a case collection

Abstract. Infective endocarditis (IE) is a condition that predominantly affects native or prosthetic heart valves, which is currently on the rise due to th

academic.oup.com

September 2024

SMART Trial

Self-Expanding or Balloon-Expandable TAVR in Patients with a Small Aortic Annulus

NEJM article comparing balloon expandable vs self-expandable TAVI devices in patients with small aortic annulus size (defined as aortic annulus area of 430mm2 or less) 716 patients were enrolled across 13 countries and randomised in a 1:1 fashion. Self-expanding valves were found to be non-inferior to balloon-expandable valves for the primary outcome measures (death, disabling stroke or readmission with HF within 12 months) Self-expandable TAVI was found to be superior in the secondary outcome measure of bioprosthetic valve dysfunction at 12 months (9.4% vs 41.6%)

[Article originally from April 2024]

Self-Expanding or Balloon-Expandable TAVR in Patients with a Small Aortic Annulus | NEJM

Patients with severe aortic stenosis and a small aortic annulus are at risk for impaired valvular hemodynamic performance and associated adverse cardiovascular clinical outcomes after transcatheter...

www.nejm.org

August 2024

HERACLES Trial

2020 Single-centre double-blinded RCT from Bern, Switzerland looking at hypertonic saline vs normal saline as fluid replacement following cardiac surgery. Hypertonic saline used was 5ml/kg of 7.3% saline administered over 60 minutes on arrival to the CICU. Overall urine output was increased and fluid balance was less positive in the intervention arm but with no difference in absolute fluid volume administered.

Hypertonic saline for fluid resuscitation in ICU patients post-cardiac surgery (HERACLES): a double-blind randomized controlled clinical trial

Intensive Care Medicine - Recent evidence questions a liberal approach to fluid resuscitation in intensive care unit (ICU) patients. Here, we assess whether use of hypertonic saline applied as...

link.springer.com

July 2024

DACAB Trial evaluating DAPT post CABG

Antiplatelet therapy after coronary artery bypass surgery: five year follow-up of randomised DACAB trial

Objective To assess the effect of different antiplatelet strategies on clinical outcomes after coronary artery bypass grafting. Design Five year follow-up of randomised Different Antiplatelet Therapy Strategy After Coronary Artery Bypass Grafting (DACAB) trial. Setting Six tertiary hospitals in China; enrolment between July 2014 and November 2015; completion of five year follow-up from August 2019 to June 2021. Participants 500 patients aged 18-80 years (including 91 (18.2%) women) who had elective coronary artery bypass grafting surgery and completed the DACAB trial. Interventions Patients were randomised 1:1:1 to ticagrelor 90 mg twice daily plus aspirin 100 mg once daily (dual antiplatelet therapy; n=168), ticagrelor monotherapy 90 mg twice daily (n=166), or aspirin monotherapy 100 mg once daily (n=166) for one year after surgery. After the first year, antiplatelet therapy was prescribed according to standard of care by treating physicians. Main outcome measures The primary outcome was major adverse cardiovascular events (a composite of all cause death, myocardial infarction, stroke, and coronary revascularisation), analysed using the intention-to-treat principle. Time-to-event analysis was used to compare the risk between treatment groups. Multiple post hoc sensitivity analyses examined the robustness of the findings. Results Follow-up at five years for major adverse cardiovascular events was completed for 477 (95.4%) of 500 patients; 148 patients had major adverse cardiovascular events, including 39 in the dual antiplatelet therapy group, 54 in the ticagrelor monotherapy group, and 55 in the aspirin monotherapy group. Risk of major adverse cardiovascular events at five years was significantly lower with dual antiplatelet therapy versus aspirin monotherapy (22.6% v 29.9%; hazard ratio 0.65, 95% confidence interval 0.43 to 0.99; P=0.04) and versus ticagrelor monotherapy (22.6% v 32.9%; 0.66, 0.44 to 1.00; P=0.05). Results were consistent in all sensitivity analyses. Conclusions Treatment with ticagrelor dual antiplatelet therapy for one year after surgery reduced the risk of major adverse cardiovascular events at five years after coronary artery bypass grafting compared with aspirin monotherapy or ticagrelor monotherapy. Trial registration NCT03987373ClinicalTrials.gov [NCT03987373][1]. All data that underlie the results reported in this article will be provided on reasonable request. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03987373&atom=%2Fbmj%2F385%2Fbmj-2023-075707.atom

www.bmj.com

June 2024

SEQUOIA HCM

Aficamten for Symptomatic Obstructive Hypertrophic Cardiomyopathy

An interesting NEJM article describing a phase-2 RCT looking at the efficacy of Aficamten at reducing LVOT gradients in patients with HCM.

142 patients in the intervention group and 140 in the placebo group.

The mean baseline gradient was 55mmHg and outcomes were assessed after 24 weeks. Overall the intervention group had a reduction in LVOT gradient of 45mmHg. All 10 of the other secondary end-points were also statistically better in the intervention group.

May 2024

Finding the optimal tidal volume in ARDS.

Mariangela Pellegrini, Lorenzo Del Sorbo & V. Marco Ranieri 

Open access journal in ICM detailing how simply dialling in 6ml/kg may not be the optimal strategy in all patients in a heterogenous condition like ARDS.

https://link.springer.com/article/10.1007/s00134-024-07440-5#:~:text=Consequently%2C 6 ml%2Fkg normalized,as a fixed cut-off.

April 2024

DanGer Shock Trial review - NEJM evaluating Impella microaxial pump device in patients with cardiogenic shock following acute MI (AMI-CS) showing a statistically significant benefit in the intervention group.

Mechanical Circulatory Support in Cardiogenic Shock — Persistence and Progress | NEJM

Acute myocardial infarction–related cardiogenic shock (AMI-CS) is characterized by systemic hypoperfusion due to cardiomyocyte necrosis and ventricular dysfunction.1 Cardiogenic shock affects 5 to ...

www.nejm.org

March 2024

Review article highlighting key concepts in the management of pulmonary hypertension and RV failure in the cardiac ICU.

December 2023

Recent BJA education article from Dr M.Gilham in New Zealand eloquently explaining some of the commonly misunderstood aspects of epicardial pacing following cardiac surgery in an excellent review article:

November 2023

JCVA review article concerning PCC’s - a useful read prior to launch of our new haemorrhage in cardiac surgery protocol:

Prothrombin Complex Concentrates in Cardiac Surgery—Is it Time to Call the Pharmacy Instead of the Blood Bank?

PERIOPERATIVE COAGULOPATHY and bleeding in patients undergoing cardiac surgery are common, particularly among those undergoing complex surgery. The etiology of microvascular bleeding in some patients is complex and related to blood exposure to cardiopulmonary bypass components, surgical, and/or patient-specific factors. Treatment of clinically significant microvascular bleeding requires laboratory evaluation to help guide targeted therapy. When coagulation factor deficiency–associated bleeding is the culprit, historic therapy has been with allogeneic plasma transfusion.

www.jcvaonline.com