Effects of Escalating Temporary Mechanical Circulatory Support in Patients With Worsening Cardiogenic Shock

BackgroundCardiogenic shock–related mortality is substantial, and temporary mechanical circulatory support (MCS) devices are frequently used. The authors aimed to describe patient characteristics and outcomes in patients with worsening cardiogenic shock requiring escalation of temporary MCS devices.MethodsWorsening cardiogenic shock was defined as persistent hypotension, increasing doses of vasopressors/inotropes, worsening hypoperfusion, or worsening invasive hemo-dynamics. Escalation of temporary MCS devices was defined as adding or exchanging an existing MCS device. Variables were evaluated by logistic regression models and receiver operating characteristic curves.ResultsFrom July 1, 2016, to July 1, 2018, a total of 81 consecutive patients experienced worsening cardiogenic shock requiring temporary MCS escalation. The etiology of cardiogenic shock was heterogeneous (33.3% acute myocardial infarction and 61.7% decompen-sated heart failure). Younger age (<62 years), lower body mass index (<28.7 kg/m²), lower preescalation lactate levels (<3.1 mmol/L), higher postescalation blood pressure (>85 mm Hg), and lower postescalation lactate levels (<2.9 mmol/L) were associated with greater odds of survival. The presence of a pulmonary artery catheter at the time of escalation was associated with greater odds of survival (P = .05). Escalation of temporary MCS in Society for Cardiovascular Angiography and Interventions stage E shock was associated with 100% mortality (P = .05). The rate of overall survival to discharge was 32%.ConclusionPatients requiring temporary MCS escalation represent a high-risk cohort. Further work is needed to improve outcomes in this patient population.     

Mechanical Circulatory Support Following Out-of-Hospital Cardiac Arrest: Insights From the National Cardiogenic Shock Initiative

BackgroundEvidence is limited regarding the role of mechanical circulatory support (MCS) in patients with acute coronary syndromes (ACS) complicated by cardiogenic shock (CGS). In particular, the role of MCS in patients with out-of-hospital cardiac arrest (OHCA) is unknown.MethodsThe National Cardiogenic Shock Initiative (NCSI) is a multicenter United States registry of patients with ACS complicated by CGS treated with MCS. We compared the rate of survival to hospital discharge among patients with OHCA, in-hospital cardiac arrest (IHCA), or no cardiac arrest. We subsequently used multivariable analyses to determine independent predictors of OHCA survival.ResultsSurvival to hospital discharge occurred in 85.7% (42/49) of OHCA, 72.4% (50/69) of IHCA, and 74.5% (111/149) of non-cardiac arrest patients. By multivariable analysis, pre-procedural predictors of survival included younger age, female sex, fewer diseased vessels, left anterior descending coronary artery culprit, lower troponin, higher lactate, and delayed initiation of MCS. Procedural and post-procedural predictors of survival included fewer vessels treated, complete revascularization, higher post-MCS cardiac power output, and fewer inotropic medications required.ConclusionsThis study demonstrates that excellent outcomes may be achieved following OHCA when MCS is employed for patients appropriately selected by prognostic demographic, anatomic, and health status characteristics. A larger study population, currently being enrolled, is needed to validate the observation further.     

心源性休克的机械循环辅助装置治疗进展

机械循环辅助在心源性休克的救治中起着日益重要的作用,可纠正患者的血流动力学紊乱状态,保障再灌注治疗的实施.其中主动脉内球囊反搏最常用也最为成熟;心室辅助装置在逆转休克的血流动力学和代谢参数方面优于标准主动脉内球囊反搏治疗,近年来,经皮左室辅助装置逐渐应用于临床,其创伤小且无需体外循环,是今后的发展方向;目前体外膜氧合器多用在爆发性心肌炎或心脏外科术后支持,其应用于急性心肌梗死并发心源性休克治疗的证据不足,有待于更大规模的临床研究验证.未来循环辅助装置的发展方向是体积小、微创、植入和撤除方便、组织相容性好、辅助效果确切.     

Acute Mechanical Circulatory Support for Fulminant Myocarditis Complicated by Cardiogenic Shock

In fulminant myocarditis complicated by cardiogenic shock, early mechanical circulatory support (MCS) may prevent cardiomyopathy and death. We sought to examine the outcomes of patients with fulminant myocarditis supported with MCS. A retrospective review of patients with acute cardiogenic shock treated with MCS from 2007 to 2013 was conducted, and patients with a diagnosis of fulminant myocarditis were included in this series. At our center, 260 patients received MCS for acute cardiogenic shock, and 11 were implanted for fulminant myocarditis. Eight received the Centrimag biventricular assist device (BIVAD), and three received veno-arterial extracorporeal membrane oxygenator (VA ECMO), though 1 VA ECMO-supported patient was transitioned to BIVAD due to refractory shock. The mean acute support time was 14.7?±?4.4 days. Two patients required long-term left ventricular assist devices and were further supported for 55 and 112 days. Eight patients recovered with a mean ejection fraction of 54?±?7 %, and one was successfully transplanted. Eight patients survived to discharge (73 %) with mean follow-up: 292.6?±?306.8 days. All three deaths were due to neurologic complications. MCS should be considered in patients with fulminant myocarditis complicated by shock. With aggressive medical therapy, early utilization of MCS carries promising outcomes.     

Positive Pressure Ventilation in Cardiogenic Shock: Review of the Evidence and Practical Advice for Patients With Mechanical Circulatory Support

Cardiogenic shock (CS) is often complicated by respiratory failure, and more than 80% of patients with CS require respiratory support. Elevated filling pressures from left-ventricular (LV) dysfunction lead to alveolar pulmonary edema, which impairs both oxygenation and ventilation. The implementation of positive pressure ventilation (PPV) improves gas exchange and can improve cardiovascular hemodynamics by reducing preload and afterload of the LV, reducing mitral regurgitation and decreasing myocardial oxygen demand, all of which can help augment cardiac output and improve tissue perfusion. In right ventricular (RV) failure, however, PPV can potentially decrease preload and increase afterload, which can potentially lead to hemodynamic deterioration. Thus, a working understanding of cardiopulmonary interactions during PPV in LV and RV dominant CS states is required to safely treat this complex and high-acuity group of patients with respiratory failure. Herein, we provide a review of the published literature with a comprehensive discussion of the available evidence on the use of PPV in CS. Furthermore, we provide a practical framework for the selection of ventilator settings in patients with and without mechanical circulatory support, induction, and sedation methods, and an algorithm for liberation from PPV in patients with CS.     

The Impella Microaxial Flow Catheter Is Safe and Effective for Treatment of Myocarditis Complicated by Cardiogenic Shock: An Analysis From the Global cVAD Registry

Background

Myocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella transvalvular microaxial flow catheters in the setting of myocarditis with cardiogenic shock.

Impella Mechanical Circulatory Support for Takotsubo Syndrome With Shock: A Retrospective Multicenter Analysis

ObjectivesTo analyze the characteristics and outcome of Impella mechanical circulatory support (MCS) for Takotsubo syndrome (TS) with cardiogenic shock.BackgroundTS is an acute heart failure syndrome characterized by transient severe reduction of left ventricular (LV) systolic function, with cardiogenic shock occurring in around 10% of patients. Since inotropes should be avoided due to their role in TS pathogenesis and aggravation of LV outflow tract obstruction, the use of MCS as treatment is a viable treatment option, however, studies are lacking.MethodsThe catheter-based ventricular assist device (cVAD) registry and local MCS databases were screened for TS patients with cardiogenic shock (TS-CS) supported with an Impella percutaneous ventricular assist device (pVAD). Patient and treatment characteristics and in-hospital outcomes were retrospectively analyzed.ResultsAt 10 US and European centers, 16 TS-CS patients supported with an Impella pVAD were identified between December 2013 and May 2018 (mean age, 61.8 ± 15.5 years; 87.5% women). LV ejection fraction (LVEF) at presentation was severely reduced (mean, 19.4 ± 8.3%). Prior to MCS, 13 patients (81.3%) were mechanically ventilated, 4 patients (25.0%) had been resuscitated, and mean serum lactate was 4.7 ± 3.5 mmol/L. Mean duration of Impella support was 1.9 ± 1.0 days (range, 1–4 days). Thirteen patients (81.3%) survived to discharge, and all survivors experienced cardiac recovery with significant improvement of LVEF at discharge compared to baseline (20.4 ± 8.8 vs. 52.9 ± 12.0, P < 0.001).ConclusionsThis is the first series of TS-CS patients supported with an Impella pVAD. Mortality was low, and LV systolic function recovered in all survivors. Prospective studies of Impella support in this special condition are warranted.     

Efficacy of Mechanical Circulatory Support Used Before Versus After Primary Percutaneous Coronary Intervention in Patients with Cardiogenic Shock From ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis

BackgroundOptimal timing to initiate mechanical circulatory support (MCS) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) remains unclear with studies showing conflicting results on whether to start before or after primary percutaneous coronary intervention (PPCI). This study aims to examine the association between mortality and MCS initiated before vs after PPCI in patients with STEMI complicated by CS.MethodsWe systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to October 2021. Studies were included if they evaluated the association of mortality in patients who initiated MCS (specifically intra-aortic balloon pump (IABP), Impella, and venoarterial extracorporeal membrane oxygenation (VA-ECMO)) before PPCI versus after PPCI, specifically in patients with STEMI complicated by CS. Data were integrated using the random-effects models.ResultsTen studies involving 1,352 patients (956, 203, and 193 patients underwent IABP, Impella, and VA-ECMO respectively) with STEMI complicated by CS were included. There was no difference in mortality using IABP before or after PPCI ([OR] 1.77, 95% CI 0.77–1.61, I2 = 27%, p = 0.57). Nevertheless, Impella and VA-ECMO started before PPCI were significantly associated with a reduced risk of mortality compared to that started after PPCI ([OR] 0.49, 95% CI 0.26–0.92, I2 = 0%, p = 0.03 and [OR] 0.29, 95% CI 0.14–0.62, I2 = 0%, p = 0.001, respectively).ConclusionsIn patients with STEMI complicated by CS undergoing PPCI, the use of IMPELLA or VA-ECMO prior to PPCI significantly decreased mortality, in contrast to IABP, in which no difference in mortality was found between using it before or after PPCI. More rigorous studies are needed to clarify this association.     

An Unusual Case of Cardiogenic Shock: Common Cause From Uncommon Etiology

Mechanical complications of an acute coronary syndrome can lead to hemodynamic instability out of proportion to the degree of left ventricular dysfunction. We present the case of a patient with cardiogenic shock secondary to severe mitral regurgitation in the setting of an acutely occluded obtuse marginal artery. Echocardiography and pathologic findings revealed an uncommon cause of anterolateral papillary muscle rupture. Using the unique features of this case, we present a clinical self-assessment exercise highlighting the challenges involved in the management of this type of patient.