Trials and guidelines in cardiothoracic ICU

This collection of links is intended as a resource for CICM Second Part Exam candidates trying to figure out how to supplement or replace the previously effective practice of preparing for this exam on the basis of doing past paper SAQs. Most of the trials have come from Critical Care Reviews and The Bottom Line. Wherever possible, the original paper is linked from the name of the study, and the Bottom Line review is linked from the year of publication.


Cardiac surgery

SYNTAX - 2009 - PCI vs CABG for triple vessel disease. n=1800 in Europe and the US. Composite cardiac badness was much worse with PCI (17.8% vs. 12.4%), stroke more likely with CABG (2.2% vs. 0.6%). Mortality was no different.

TRACS - 2010 - what if we aim for a lower Hb in cardiac surgery? n=502 in Brazil.  Hb was 91 in the restrictive and 105 in the liberal groups. Composite outcome endpoint was no different (10% vs 11%).

EASE - 2012 - why not intervene early for infective endocarditis? n=76; enrolled if vegetation were >10mm, and severe valve disease. Primary endpoint (death and emboli) was much more likely with conservative management (23% vs 3%).

Transcatheter valves

PARTNER-A - 2011 - what if TAVR instead, if surgical mortality risk is >15%? n=699 all over the world. Mortality ended up being 3.4% for TAVR and 6.5%  for surgery.

COAPT - 2018 - mitral clip vs. conservative management. n=614. Mortality much better with clipping ( 29.1%  vs 46.1% at 48 months).

PARTNER-3 - 2019 - what if TAVR if surgical mortality risk low? n=1000. Composite endpoint was much better for TAVR (8.5% vs. 15.1%)

SOLVE-TAVI - 2020 - what if TAVR under local? n=447; there was no difference in composite endpoints ( 27.2% vs 26.4%)


GUSTO-I - 1997 - small (n=62) IABP subgroup in a huge (n=41,021) trial of thrombolysis for MI. Statistically insignificant mortality benefit (47% vs 60%)

SHOCK - 2000 - emergency PCI for cardiogenic shock, of whom some had IABP. n=1126; mortality improved (50% vs 72%)

IABP-SHOCK2 - 2012 - IABP or just inotropes for MI with cardiogenic shock;  n=600 in Germany. No difference in mortality (39.7% vs. 41.3%).


When things are going right in CTICU

When things are going wrong in CTICU:

Transcatheter valves


Serruys, Patrick W., et al. "Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease." New England journal of medicine 360.10 (2009): 961-972.

Smith, Craig R., et al. "Transcatheter versus surgical aortic-valve replacement in high-risk patients." New England Journal of Medicine 364.23 (2011): 2187-2198.

Mack, Michael J., et al. "Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients." New England Journal of Medicine 380.18 (2019): 1695-1705.

Stone, Gregg W., et al. "Transcatheter mitral-valve repair in patients with heart failure." New England Journal of Medicine 379.24 (2018): 2307-2318.

Thiele, Holger, et al. "General versus local anesthesia with conscious sedation in transcatheter aortic valve implantation: the randomized SOLVE-TAVI trial." Circulation 142.15 (2020): 1437-1447.

Hajjar, Ludhmila A., et al. "Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.Jama 304.14 (2010): 1559-1567.

Kang, Duk-Hyun, et al. "Early surgery versus conventional treatment for infective endocarditis." New England Journal of Medicine 366.26 (2012): 2466-2473.

Karcher, Christian, et al. "The Australasian ANZSCTS/ANZICS guidelines on cardiothoracic advanced life support (CALS-ANZ)." Critical Care and Resuscitation 24.3 (2022): 218-223.

Engelman, Daniel T., et al. "Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations." JAMA surgery 154.8 (2019): 755-766.

Fordyce, Christopher B., et al. "Prevention of complications in the cardiac intensive care unit: a scientific statement from the American Heart Association." Circulation 142.22 (2020): e379-e406.

Carl, M., et al. "S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system." GMS German Medical Science 8 (2010).

Mertes, Paul-Michel, et al. "Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump." Anaesthesia Critical Care & Pain Medicine 41.3 (2022): 101059.

Dunning, Joel, et al. "Joint British Societies’ guideline on management of cardiac arrest in the cardiac catheter laboratory.Heart 108.12 (2022): e1-e18.

Agnihotri, Arvind. "2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement: Executive summary." The Journal of Thoracic and Cardiovascular Surgery 144.3 (2012): 534-537.