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Buda KG, Hryniewicz K, Eckman PM, Basir MB, Cowger JA, Alaswad K, Mukundan S, Sandoval Y, Elliott A, Brilakis ES, Megaly MS. Early vs. delayed mechanical circulatory support in patients with acute myocardial infarction and cardiogenic shock. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:390-397. [PMID: 38502888 DOI: 10.1093/ehjacc/zuae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 03/21/2024]
Abstract
AIMS Despite increased temporary mechanical circulatory support (tMCS) utilization for acute myocardial infarction complicated by cardiogenic shock (AMI-CS), data regarding efficacy and optimal timing for tMCS support are limited. This study aimed to describe outcomes based on tMCS timing in AMI-CS and to identify predictors of 30-day mortality and readmission. METHODS AND RESULTS Patients with AMI-CS identified in the National Readmissions Database were grouped according to the use of tMCS and early (<24 h) vs. delayed (≥24 h) tMCS. The correlation between tMCS timing and inpatient outcomes was evaluated using linear regression. Multivariate logistic regression was used to identify variables associated with 30-day mortality and readmission. Of 294 839 patients with AMI-CS, 109 148 patients were supported with tMCS (8067 veno-arterial extracorporeal membrane oxygenation, 33 577 Impella, and 79 161 intra-aortic balloon pump). Of patients requiring tMCS, patients who received early tMCS (n = 79 906) had shorter lengths of stay (7 vs. 15 days, P < 0.001) and lower rates of ischaemic and bleeding complications than those with delayed tMCS (n = 32 241). Patients requiring tMCS had higher in-hospital mortality [odds ratio (95% confidence interval)] [1.7 (1.7-1.8), P < 0.001]. Among patients requiring tMCS, early support was associated with fewer complications, lower mortality [0.90 (0.85-0.94), P < 0.001], and fewer 30-day readmissions [0.91 (0.85-0.97), P = 0.005] compared with patients with delayed tMCS. CONCLUSION Among patients receiving tMCS for AMI-CS, early tMCS was associated with fewer complications, shorter lengths of stay, lower hospital costs, and fewer deaths and readmissions at 30 days.
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Affiliation(s)
- Kevin G Buda
- Allina Health-Minneapolis Heart Institute, 800 E 28th St, Heart Hospital, Minneapolis, MN 55407, USA
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, 730 S. 8th St, Minneapolis, MN 55415, USA
| | - Katarzyna Hryniewicz
- Allina Health-Minneapolis Heart Institute, 800 E 28th St, Heart Hospital, Minneapolis, MN 55407, USA
| | - Peter M Eckman
- Allina Health-Minneapolis Heart Institute, 800 E 28th St, Heart Hospital, Minneapolis, MN 55407, USA
| | - Mir B Basir
- Heart and Vascular Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48208, USA
| | - Jennifer A Cowger
- Heart and Vascular Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48208, USA
| | - Khaldoon Alaswad
- Heart and Vascular Institute, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48208, USA
| | - Srini Mukundan
- Knight Cardiovascular Institute, Oregon Health and Science University, 3303 S Bond Ave, Building 1, 7th Floor, Portland, OR 97239, USA
| | - Yader Sandoval
- Allina Health-Minneapolis Heart Institute, 800 E 28th St, Heart Hospital, Minneapolis, MN 55407, USA
- Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 100, Minneapolis, MN 55407, USA
| | - Andrea Elliott
- Division of Cardiology, University of Minnesota, 401 E River Pkwy, Minneapolis, MN 55455, USA
| | - Emmanouil S Brilakis
- Allina Health-Minneapolis Heart Institute, 800 E 28th St, Heart Hospital, Minneapolis, MN 55407, USA
- Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, 920 East 28th Street, Suite 100, Minneapolis, MN 55407, USA
| | - Michael S Megaly
- Division of Cardiology, Willis Knighton Heart Institute, 2400 Hospital Drive #350, Shreveport, LA 71111, USA
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Chien SC, Wang CA, Liu HY, Lin CF, Huang CY, Chien LN. Comparison of the prognosis among in-hospital survivors of cardiogenic shock based on etiology: AMI and Non-AMI. Ann Intensive Care 2024; 14:74. [PMID: 38735891 PMCID: PMC11089020 DOI: 10.1186/s13613-024-01305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Current data on post-discharge mortality and rehospitalization is still insufficient among in-hospital survivors of cardiogenic shock (CS), including acute myocardial infarction (AMI) and non-AMI survivors. METHODS Patients with CS who survived after hospital discharge were selected from the Taiwan National Health Insurance Research Database. Each patient was followed up at 3-year intervals. Mortality and rehospitalization were analyzed using Kaplan-Meier curves and Cox regression models. RESULTS There were 16,582 eligible patients. Of these, 42.4% and 57.6% were AMI-CS and non-AMI-CS survivors, respectively. The overall mortality and rehospitalization rates were considerably high, with reports of 7.0% and 22.1% at 30 days, 24.5% and 58.2% at 1 year, and 38.9% and 73.0% at 3 years, respectively, among in-hospital CS survivors. Cardiovascular (CV) problems caused approximately 40% mortality and 60% rehospitalization. Overall, the non-AMI-CS group had a higher mortality burden than the AMI-CS group owing to older age and a higher prevalence of comorbidities. In multivariable models, the non-AMI-CS group exhibited a lower risk of all-cause mortality (adjusted hazard ratio [aHR] 0.69, 95% confidence interval [CI] 0.60 to 0.78) and CV mortality (aHR 0.65, 95% CI 0.54 to 0.78) compared to the AMI-CS group. However, these risks diminished and even reversed after one year (aHR 1.13, 95% CI 1.03 to 1.25 for all-cause mortality; aHR 1.27, 95% CI 1.09 to 1.49 for CV mortality).This reversal was not observed in all-cause and CV rehospitalization. For rehospitalization, AMI-CS was associated with the risk of CV rehospitalization in the entire observation period (aHR:0.80, 95% CI:0.76-0.84). CONCLUSIONS In-hospital AMI-CS survivors had an increased risk of CV rehospitalization and 30-day mortality, whereas those with non-AMI-CS had a greater mortality risk after 1-year follow-up.
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Affiliation(s)
- Shih-Chieh Chien
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheng-An Wang
- Division of Cardiology, Department of Internal Medicine, Taipei Medical University Wan Fang Hospital, Taipei, Taiwan
| | - Hung-Yi Liu
- Health and Clinical Research Data Center, Office of Data Center, Taipei Medical University, Taipei, Taiwan
| | - Chao-Feng Lin
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chun-Yao Huang
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan.
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Lin W, Yip ACL, Cherian R, Chan SP, Evangelista LKM, Sari NY, Ling HS, Lim YC, Wong RCC, Tung BWL, Tan LL, Low AF, Ambhore AA, Lim SL. Predictors of Mortality in Acute Myocardial Infarction Complicated by Cardiogenic Shock despite Intra-Aortic Balloon Pump: Opportunities for Advanced Mechanical Circulatory Support in Asia. Life (Basel) 2024; 14:577. [PMID: 38792598 PMCID: PMC11122050 DOI: 10.3390/life14050577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/21/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024] Open
Abstract
Introduction: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) mortality remains high despite revascularization and the use of the intra-aortic balloon pump (IABP). Advanced mechanical circulatory support (MCS) devices, such as catheter-based ventricular assist devices (cVAD), may impact mortality. We aim to identify predictors of mortality in AMI-CS implanted with IABP and the proportion eligible for advanced MCS in an Asian population. Methods: We retrospectively analyzed a cohort of Society for Cardiovascular Angiography and Intervention (SCAI) stage C and above AMI-CS patients with IABP implanted from 2017-2019. We excluded patients who had IABP implanted for indications other than AMI-CS. Primary outcome was 30-day mortality. Binary logistic regression was used to calculate adjusted odds ratios (aOR) for patient characteristics. Results: Over the 3-year period, 242 patients (mean age 64.1 ± 12.4 years, 88% males) with AMI-CS had IABP implanted. 30-day mortality was 55%. On univariate analysis, cardiac arrest (p < 0.001), inotrope/vasopressor use prior to IABP (p = 0.004) was more common in non-survivors. Non-survivors were less likely to be smokers (p = 0.001), had lower ejection fraction, higher creatinine/ lactate and lower pH (all p < 0.001). On multi-variate analysis, predictors of mortality were cardiac arrest prior to IABP (aOR 4.00, CI 2.28-7.03), inotrope/vasopressor prior to IABP (aOR 2.41, CI 1.18-4.96), lower arterial pH (aOR 0.02, CI 0.00-0.31), higher lactate (aOR 2.42, CI 1.00-1.19), and lower hemoglobin (aOR 0.83, CI 0.71-0.98). Using institutional MCS criteria, 106 patients (44%) would have qualified for advanced MCS. Conclusions: Early mortality in AMI-CS remains high despite IABP. Many patients would have qualified for higher degrees of MCS.
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Affiliation(s)
- Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Alfred Chung Lum Yip
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
| | - Robin Cherian
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Siew Pang Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
- Cardiovascular Research Institute, National University Heart Centre, Singapore 119074, Singapore
| | - Lauren Kay Mance Evangelista
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- De La Salle Medical and Health Sciences Institute, Dasmarinas 4114, Philippines
- Department of Cardiology, University of the Philippines—Philippine General Hospital, Manilla 1000, Philippines
| | - Novi Yanti Sari
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Dr Mohammad Hoesin General Hospital Palembang, South Sumatra, Kota Palembang 30126, Indonesia
| | - Hwei Sung Ling
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Department of Medicine, Faculty of Medicine and Health Science, Universiti Malaysia Sarawak, Kota Samarahan 94300, Malaysia
- Department of Cardiology, Sarawak Heart Centre, Kota Samarahan 94300, Malaysia
| | - Yoke Ching Lim
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Raymond Ching Chiew Wong
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Benjamin Wei Liang Tung
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
| | - Li-Ling Tan
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Adrian F. Low
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Anand Adinath Ambhore
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore (R.C.); (L.K.M.E.); (H.S.L.); (A.F.L.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore;
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Schupp T, Rusnak J, Egner-Walter S, Ruka M, Dudda J, Bertsch T, Müller J, Mashayekhi K, Tajti P, Ayoub M, Akin I, Behnes M. Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry. Clin Res Cardiol 2024; 113:626-641. [PMID: 37093246 DOI: 10.1007/s00392-023-02196-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/28/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI). BACKGROUND Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients. METHODS Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching. RESULTS 273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528). CONCLUSION AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Bad Neustadt a. d. Saale, Germany
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, Budapest, Hungary
| | - Mohammed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum-Bad, Oeynhausen, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, First Department of Medicine, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany.
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Ghahremani-Nasab L, Toufan-Tabrizi M, Javanshir E, Rahimi M. Assessing cardiac power output values in a healthy adult population. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:517-526. [PMID: 38085404 DOI: 10.1007/s10554-023-03019-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 11/21/2023] [Indexed: 03/20/2024]
Abstract
Cardiac power output (CPO), which combines pressure and flow capacities, directly measures the heart's pumping capability. It is proposed as a superior alternative to ejection fraction in assessing cardiac function. However, there is a lack of data on CPO in healthy individuals, prompting a study to determine the cardiac power output in healthy adults in the Iranian population. This cross-sectional descriptive study investigated cardiac power in a sample of healthy individuals. Participants were recruited from healthy individuals referred to the Echocardiography department using convenience sampling. In this study, we examined the echocardiographic parameters in 173 individuals, of which 52% were men. Men exhibited significantly higher values for stroke volume, cardiac output, and cardiac power output (CPO) in both ventricles, as well as larger body surface area (BSA) and systemic mean arterial pressure (MAP), compared to women. Individuals under the age of 40 had significantly higher BSA and right ventricular cardiac output compared to those aged 40 or above. Multivariate analysis revealed that MAP, left ventricular (LV) cardiac output, LVCPO, pulmonary MAP, right ventricular (RV) CPO, and RV cardiac power index (CPI) were significant predictors of LVCPI changes. Our findings emphasize the importance of cardiac power output as a comprehensive measure of cardiac function, complementing the traditional use of ejection fraction. Further research is warranted to validate these results, establish accurate reference ranges, and explore the clinical implications of cardiac power output in various patient populations.
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Affiliation(s)
- Leila Ghahremani-Nasab
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran
| | - Mehrnoush Toufan-Tabrizi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran.
| | - Elnaz Javanshir
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran
| | - Mehran Rahimi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran
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Kim BS, Jang WJ, Choi KH, Kim SH, Yu CW, Jeong JO, Lee HJ, Gwon HC, Kim HJ, Yang JH. Differential Prognostic Impact of IABP-SHOCK II Scores According to Treatment Strategy in Cardiogenic Shock Complicating Acute Coronary Syndrome: From the RESCUE Registry. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:183. [PMID: 38276062 PMCID: PMC10818598 DOI: 10.3390/medicina60010183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024]
Abstract
Background: Early risk stratification is necessary for optimal determination of the treatment strategy in cardiogenic shock (CS) complicating acute coronary syndrome (ACS). Therefore, we evaluated the prognostic impact of an intra-aortic balloon pump on the cardiogenic shock (IABP-SHOCK) II score according to the treatment strategies in ACS complicated by CS using the RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock) registry. Methods: The RESCUE registry contains multicenter observational retrospective and prospective cohorts that include 1247 patients with CS from 12 centers in Korea. A total of 865 patients with ACS complicated by CS were selected and stratified into low-, intermediate- and high-risk categories according to their IABP-SHOCK II scores and then according to treatment: non-mechanical support, IABP, and extracorporeal membrane oxygenators (ECMOs). The primary outcome was all-cause mortality during follow-up. Results: The observed mortality rates for the low-, intermediate-, and high-IABP-SHOCK II score risk categories were 28.8%, 52.4%, and 69.8%, respectively (p < 0.01). Patients in the non-mechanical support and IABP groups showed an increasingly elevated risk of all-cause mortality as their risk scores increased from low to high. In the ECMO group, the risk of all-cause mortality did not differ between the intermediate- and high-risk categories (HR = 1.21, 95% CI: 0.81-1.81, p = 0.33). The IABP-SHOCK II scores for the non-mechanical support and IABP groups showed a better predictive performance (area under curve [AUC] = 0.70, 95% CI: 0.65-0.76) for mortality compared with the EMCO group (AUC = 0.61, 95% CI 0.54-0.67; p-value for comparison = 0.02). Conclusions: Risk stratification using the IABP-SHOCK II score is useful for predicting mortality in ACS complicated by CS when patients are treated with non-mechanical support or IABP. However, its prognostic value may be unsatisfactory in severe cases where patients require ECMOs.
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Affiliation(s)
- Bum Sung Kim
- Division of Cardiology, Department of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (B.S.K.); (S.H.K.)
| | - Woo Jin Jang
- Department of Cardiology, Ewha Woman’s University Seoul Hospital, Ehwa Woman’s University School of Medicine, Seoul 07804, Republic of Korea;
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (K.H.C.); (H.-C.G.)
| | - Sung Hea Kim
- Division of Cardiology, Department of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (B.S.K.); (S.H.K.)
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul 02841, Republic of Korea;
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Republic of Korea;
| | - Hyun Jong Lee
- Division of Cardiology, Department of Medicine, Sejong General Hospital, Bucheon 14754, Republic of Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (K.H.C.); (H.-C.G.)
| | - Hyun-Joong Kim
- Division of Cardiology, Department of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (B.S.K.); (S.H.K.)
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea; (K.H.C.); (H.-C.G.)
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Bloom JE, Wong N, Nehme E, Dawson LP, Ball J, Anderson D, Cox S, Chan W, Kaye DM, Nehme Z, Stub D. Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:89-98. [PMID: 36808236 DOI: 10.1093/ehjqcco/qcad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 02/04/2023] [Indexed: 02/19/2023]
Abstract
AIMS The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS). METHODS AND RESULTS This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100 000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0 vs. highest quintile 9.7 per 100 000 person-years, P-trend < 0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile. CONCLUSION This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.
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Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Nathan Wong
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - David Anderson
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
- Department of Intensive Care, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shelley Cox
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ziad Nehme
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
- Department of Paramedicine, Monash University, McMahons Road, Frankston, VIC 3199, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
- Department of Research and Evaluation, Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
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8
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Schupp T, Rusnak J, Forner J, Dudda J, Bertsch T, Behnes M, Akin I. Platelet Count During Course of Cardiogenic Shock. ASAIO J 2024; 70:44-52. [PMID: 37831815 DOI: 10.1097/mat.0000000000002066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023] Open
Abstract
The study investigates the prognostic value of the platelet count in patients with cardiogenic shock (CS). Limited data regarding the prognostic value of platelets in patients suffering from CS is available. Consecutive patients with CS from 2019 to 2021 were included at one institution. Firstly, the prognostic value of the baseline platelet count was tested for 30-day all-cause mortality. Thereafter, the prognostic impact of platelet decline during course of intensive care unit (ICU) hospitalization was assessed. A total of 249 CS patients were included with a median platelet count of 224 × 10 6 /ml. No association of the baseline platelet count with the risk of 30-day all-cause mortality was found (log-rank p = 0.563; hazard ratio [HR] = 0.879; 95% confidence interval [CI] 0.557-1.387; p = 0.579). In contrast, a decrease of platelet count by ≥ 25% from day 1 to day 3 was associated with an increased risk of 30-day all-cause mortality (55% vs. 39%; log-rank p = 0.045; HR = 1.585; 95% CI 0.996-2.521; p = 0.052), which was still evident after multivariable adjustment (HR = 1.951; 95% CI 1.116-3.412; p = 0.019). Platelet decrease during the course of ICU hospitalization but not the baseline platelet count was associated with an increased risk of 30-day all-cause mortality in CS patients.
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Affiliation(s)
- Tobias Schupp
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jan Forner
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Dudda
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Michael Behnes
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- From the Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
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9
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Aboal J, Pascual J, Loma-Osorio P, Nuñez M, Badosa E, Martín C, Ferrero M, Moral S, Ballesteros E, Pedraza J, Tapia S, Brugada R. Impact of a Cardiogenic Shock Program on Mortality in a Non-Transplant Hospital. Heart Lung Circ 2024; 33:38-45. [PMID: 38151398 DOI: 10.1016/j.hlc.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 10/29/2023] [Accepted: 11/14/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Cardiogenic shock is associated with high in-hospital morbidity and mortality. Improvements in this care process could lead to better outcomes. METHODS This retrospective study of patients with cardiogenic shock compared two periods: no specific program to address cardiogenic shock and implementation of a cardiogenic shock program. This program included the establishment of a multidisciplinary team (shock team), early alert to the transplant hospital, initiation of a ventricular assist extracorporeal membrane oxygenation (ECMO) program, and extension of continuous care by acute cardiovascular care specialists. The primary objective was to analyse whether there were differences between in-hospital mortality and mortality during follow-up. Predictors of in-hospital mortality were examined as a secondary objective. RESULTS A total of 139 patients were enrolled: 69 of them in the previous period and 70 in the cardiogenic shock program period. There was a significant reduction in in-hospital mortality (55.1% vs 37.1%; p=0.03) and mortality during follow-up (62.7% vs 44.6%; p=0.03) in the second period. Diabetes mellitus, ejection fraction, out-of-hospital cardiac arrest, and implementation of the cardiogenic shock program were independent predictors of in-hospital mortality. CONCLUSIONS The implementation of a comprehensive cardiogenic shock program in a non-transplanting hospital improved in-hospital and follow-up mortality of patients in cardiogenic shock.
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Affiliation(s)
- Jaime Aboal
- University Hospital Dr. Josep Trueta, Girona, Spain.
| | | | | | - Maria Nuñez
- University Hospital Dr. Josep Trueta, Girona, Spain
| | | | | | | | - Sergio Moral
- University Hospital Dr. Josep Trueta, Girona, Spain
| | - Esther Ballesteros
- Territorial Management of Radiology and Nuclear Medicine of Girona, Girona, Spain; Biomedical Research Institute, Girona (IdIBGi), Girona, Spain
| | | | - Simón Tapia
- University Hospital Dr. Josep Trueta, Girona, Spain
| | - Ramon Brugada
- University Hospital Dr. Josep Trueta, Girona, Spain; Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain; Biomedical Research Institute, Girona (IdIBGi), Girona, Spain
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10
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Basir MB, Lemor A, Gorgis S, Patel KC, Kolski BC, Bharadwaj AS, Todd JW, Tehrani BN, Truesdell AG, Lasorda DM, Lalonde TA, Kaki A, Schrieber TL, Patel NC, Senter SR, Gelormini JL, Marso SP, Rahman AM, Federici RE, Wilkins CE, Thomas McRae A, Nsair A, Caputo CP, Khuddus MA, Chahin JJ, Dupont AG, Goldsweig AM, Lim MJ, Kapur NK, Wohns DHW, Zhou Y, Hacala MJ, O'Neill WW. Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative. J Am Heart Assoc 2023; 12:e031401. [PMID: 38014676 PMCID: PMC10727311 DOI: 10.1161/jaha.123.031401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/24/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Amir Kaki
- Ascension St. John HospitalDetroitMI
| | | | | | | | | | | | | | | | | | | | - Ali Nsair
- Ronald Reagan UCLA Medical CenterLos AngelesCA
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11
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Delmas C, Laine M, Schurtz G, Roubille F, Coste P, Leurent G, Hraiech S, Pankert M, Gonzalo Q, Dabry T, Letocart V, Loubière S, Resseguier N, Bonello L. Rationale and design of the ULYSS trial: A randomized multicenter evaluation of the efficacy of early Impella CP implantation in acute coronary syndrome complicated by cardiogenic shock. Am Heart J 2023; 265:203-212. [PMID: 37657594 DOI: 10.1016/j.ahj.2023.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/03/2023]
Abstract
CONTEXT Despite 20 years of improvement in acute coronary syndromes care, patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) remains a major clinical challenge with a stable incidence and mortality. While intra-aortic balloon pump (IABP) did not meet its expectations, percutaneous mechanical circulatory supports (pMCS) with higher hemodynamic support, large availability and quick implementation may improve AMICS prognosis by enabling early hemodynamic stabilization and unloading. Both interventional and observational studies suggested a clinical benefit in selected patients of the IMPELLAⓇ CP device within in a well-defined therapeutic strategy. While promising, these preliminary results are challenged by others suggesting a higher rate of complications and possible poorer outcome. Given these conflicting data and its high cost, a randomized clinical trial is warranted to delineate the benefits and risks of this new therapeutic strategy. DESIGN The ULYSS trial is a prospective randomized open label, 2 parallel multicenter clinical trial that plans to enroll patients with AMICS for whom an emergent percutaneous coronary intervention (PCI) is intended. Patients will be randomized to an experimental therapeutic strategy with pre-PCI implantation of an IMPELLAⓇ CP device on top of standard medical therapy or to a control group undergoing PCI and standard medical therapy. The primary objective of this study is to compare the efficacy of this experimental strategy by a composite end point of death, need to escalate to ECMO, long-term left ventricular assist device or heart transplantation at 1 month. Among secondary objectives 1-year efficacy, safety and cost effectiveness will be assessed. CLINICAL TRIAL REGISTRATION NCT05366452.
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Affiliation(s)
- Clement Delmas
- Department of Cardiology, Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France; INSERM U1048, I2MC, Toulouse, France; REICATRA, Institut Saint Jacques, Toulouse, France.
| | - Marc Laine
- Aix-Marseille Université, F-13385 Marseille, France; Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, F-13385 Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
| | - Guillaume Schurtz
- Department of Cardiology, Intensive Cardiac Care Unit, Lille University Hospital, Lille, France
| | - Francois Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, CHU de Montpellier, France
| | - Pierre Coste
- Cardiology Department, Bordeaux University Hospital, Pessac, France
| | - Guillaume Leurent
- Intensive Cardiac Care Unit, Cardiology Department, Rennes University Hospital, Rennes, France
| | - Sami Hraiech
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | | | | | - Vincent Letocart
- Department of Cardiology, Nantes Université, CHU Nantes, l'institut du thorax, Nantes, France
| | - Sandrine Loubière
- Department of Epidemiology and Health Economics, APHM, Marseille, France; CEReSS-Health Service Research and Quality of Life Center, School of Medicine Aix-Marseille University Marseille France
| | - Noémie Resseguier
- Department of Epidemiology and Health Economics, APHM, Marseille, France; CEReSS-Health Service Research and Quality of Life Center, School of Medicine Aix-Marseille University Marseille France
| | - Laurent Bonello
- Aix-Marseille Université, F-13385 Marseille, France; Intensive Care Unit, Department of Cardiology, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, F-13385 Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France
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12
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Aslam MI, Gruslova AB, Almomani A, Nolen D, Elliott JJ, Jani VP, Kottam A, Porterfield J, Heighten C, Anderson AS, Valvano JW, Feldman MD. Modification of a Transvalvular Microaxial Flow Pump for Instantaneous Determination of Native Cardiac Output and Volume. J Card Fail 2023; 29:1369-1379. [PMID: 37105397 DOI: 10.1016/j.cardfail.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The current Impella cardiopulmonary (CP) pump, used for mechanical circulatory support in patients with cardiogenic shock (CS), cannot assess native cardiac output (CO) and left ventricular (LV) volumes. These data are valuable in facilitating device management and weaning. Admittance technology allows for accurate assessment of cardiac chamber volumes. OBJECTIVES This study tested the ability to engineer admittance electrodes onto an existing Impella CP pump to assess total and native CO as well as LV chamber volumes in an instantaneous manner. METHODS Impella CP pumps were fitted with 4 admittance electrodes and were placed in the LVs of adult swine (n = 9) that were subjected to 3 different hemodynamic conditions, including Impella CP speed adjustments, administration of escalating doses of dobutamine and microsphere injections into the left main artery to result in cardiac injury. CO, according to admittance electrodes, was calculated from LV volumes and heart rate. In addition, CO was calculated in each instance via thermodilution, continuous CO measurement, the Fick principle, and aortic velocity-time integral by means of echocardiography. RESULTS Modified Impella CP pumps were placed in swine LVs successfully. CO, as determined by admittance electrodes, was similar by trend to other methods of CO assessment. It was corrected for pump speed to calculate native CO, and calculated LV chamber volumes trended as expected in each experimental protocol. CONCLUSIONS We report, for the first time, that an Impella CP pump can be fitted with admittance electrodes and used to determine total and native CO in various hemodynamic situations. CONDENSED ABSTRACT Transvalvular mechanical circulatory support devices such as the Impella CP do not have the ability to provide real-time information on native cardiac output (CO) and left ventricular (LV) volumes. This information is critical in device management and in weaning in patients with cardiogenic shock. We demonstrate, for the first time, that Impella CP pumps coupled with admittance electrodes are able to determine native CO and LV chamber volumes in multiple hemodynamic situations such as Impella pump speed adjustments, escalating dobutamine administration and cardiac injury from microsphere injection.
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Affiliation(s)
- M Imran Aslam
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Aleksandra B Gruslova
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ahmed Almomani
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Drew Nolen
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - James J Elliott
- Department of Laboratory Animal Resources, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Vivek P Jani
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anil Kottam
- BridgeSource Medical Corporation, Austin, Texas
| | | | | | - Allen S Anderson
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Jonathan W Valvano
- Department of Electrical Engineering, University of Texas at Austin, Austin, Texas
| | - Marc D Feldman
- Department of Medicine, Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas.
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13
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Ismayl M, Hussain Y, Aboeata A, Walters RW, Naidu SS, Messenger JC, Basir MB, Rao SV, Goldsweig AM, Altin SE. Pulmonary Artery Catheter Use and Outcomes in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock Treated With Impella (a Nationwide Analysis from the United States). Am J Cardiol 2023; 203:304-314. [PMID: 37517125 DOI: 10.1016/j.amjcard.2023.06.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/24/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023]
Abstract
The role of continuous hemodynamic assessment with pulmonary artery (PA) catheter placement in cardiogenic shock (CS) remains debated. We aimed to assess the association between PA catheter placement and clinical outcomes in patients with CS secondary to ST-elevation myocardial infarction (STEMI) treated with an intravascular microaxial flow pump. We identified patients hospitalized with STEMI complicated by CS on mechanical circulatory support with an intravascular microaxial flow pump (Impella, Abiomed, Danvers, Massachusetts) using the National Inpatient Sample database and compared the outcomes in those treated with and without PA catheters. The primary outcome was in-hospital mortality. The secondary outcomes included in-hospital complications, hospital length of stay, inpatient costs, and temporal trends. The total cohort included 14,635 hospitalizations for STEMI complicated by CS treated with Impella between 2016 and 2020, of whom 5,505 (37.6%) received PA catheters. Over the study period, the use of PA catheters increased significantly from 25.9% to 41.8% (ptrend <0.01). Similarly, the use of Impella increased from 9.9% to 18.9% (ptrend <0.01). After adjustment for baseline characteristics using a multivariate logistic regression analysis, PA catheter use was associated with lower in-hospital mortality (adjusted odds ratio 0.80, 95% confidence interval 0.67 to 0.96, p = 0.01) and similar cardiovascular, neurologic, renal, and hematologic complications; length of stay; and inpatient costs compared with no PA catheter use. In conclusion, PA catheter use in patients with STEMI complicated by CS treated with Impella is associated with reduced in-hospital mortality and similar complication rates. Given the mortality benefit, further research is necessary to optimize PA catheter use in patients with STEMI with CS.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota.
| | - Yasin Hussain
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ahmed Aboeata
- Department of Cardiovascular Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Ryan W Walters
- Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, Nebraska
| | - Srihari S Naidu
- Department of Cardiovascular Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - John C Messenger
- Department of Cardiovascular Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Mir B Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Sunil V Rao
- Department of Cardiovascular Medicine, NYU Langone Health System, New York, New York
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center and University of Massachusetts-Baystate, Springfield, Massachusetts
| | - S Elissa Altin
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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14
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Nakamura M, Imamura T, Ueno H, Kinugawa K. Impact of the elevated angiopoietin-2 levels during Impella support on the short-term prognosis. J Artif Organs 2023; 26:184-191. [PMID: 35932355 DOI: 10.1007/s10047-022-01347-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/06/2022] [Indexed: 10/15/2022]
Abstract
Elevated serum angiopoietin-2 levels in patients with acute myocardial infarction-related cardiogenic shock with and without intra-aortic balloon pump as well as acute decompensated heart failure are associated with short-term mortality. However, its prognostic impact in patients with cardiogenic shock supported by Impella-incorporated mechanical circulatory support (MCS) remains unknown. Patients who received temporary MCS (Impella alone or Impella and veno-arterial extracorporeal membrane oxygenation) in our institute between August 2018 and January 2022 were included in this prospective study. The serum levels of angiopoietin-2 were measured just before and following the initiation of temporary MCS therapy. Association between the levels of serum angiopoietin-2 and 30-day mortality was investigated. A total of 38 patients (median 72 years old, 63% men) were included. The median levels of serum angiopoetin-2 tended to decrease from baseline to 4 days following the initiation of temporary MCS from 5.2 (3.3, 10.5) ng/mL to 4.8 (2.7, 6.8) ng/mL (p = 0.132). A higher angiopoietin-2 (> 6.8 ng/mL) following the initiation of temporary MCS was associated with higher 30-day mortality (89.7% versus 44.4%, p = 0.0048) with an odds ratio 18.946 (95% confidence interval 1.624-218.695, p = 0.018) adjusted for potential confounders. A higher serum angiopoietin-2 level following the initiation of Impella-incorporated temporary MCS, instead of baseline angiopoetin-2 level, was associated with higher short-term mortality.
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Affiliation(s)
- Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama, 930-0194, Japan.
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama, 930-0194, Japan
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15
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Epps KC, Tehrani BN, Rosner C, Bagchi P, Cotugno A, Damluji AA, deFilippi C, Desai S, Ibrahim N, Psotka M, Raja A, Sherwood MW, Singh R, Sinha SS, Tang D, Truesdell AG, O’Connor C, Batchelor W. Sex-Related Differences in Patient Characteristics, Hemodynamics, and Outcomes of Cardiogenic Shock: INOVA-SHOCK Registry. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100978. [PMID: 38504778 PMCID: PMC10950300 DOI: 10.1016/j.jscai.2023.100978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Background Little is known about sex-related differences in outcomes of patients with cardiogenic shock (CS) treated within a standardized team-based approach (STBA). Methods We evaluated 520 consecutive patients (151 women and 369 men) with CS due to acute myocardial infarction (AMI) and heart failure (HF) in a single-center registry (January 2017-December 2019) and examined outcomes according to sex and CS phenotype. The primary outcome was in-hospital mortality. Secondary outcomes included major adverse cardiac events, 30-day mortality, major bleeding, vascular complications, and stroke. Results Women with AMI-CS had higher baseline acuity (CardShock score: female [F]: 5.5 vs male [M]: 4.0; P = .04). Women with HF-CS more often presented with cardiac arrest (F: 12.4% vs M: 2.4%; P< .01) and had higher rates of vasopressor use (F: 70.8% vs M: 58.0%; P = .04) and mechanical circulatory support (F: 46.1% vs M: 32.5%; P = .04). There were no sex-related differences in in-hospital mortality for AMI-CS (F: 45.2% vs M: 36.9%; P = .28) and HF-CS (F: 28.1% vs M: 24.5%; P = .56). Women with HF-CS experienced higher rates of major bleeding (F: 25.8% vs M: 13.7%; P = .02) and vascular complications (F: 15.7% vs M: 6.1%; P = .01). However, female sex was not an independent predictor of these complications. No sex differences in survival were noted at 1 year. Conclusions Within an STBA, although women with AMI-CS and HF-CS presented with higher acuity, they experienced similar in-hospital mortality, major adverse cardiac events, 30-day mortality, stroke, and 30-day readmissions as men. Further research is needed to better understand the extent to which historical differences in CS outcomes can be mitigated by an STBA.
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Affiliation(s)
- Kelly C. Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Pramita Bagchi
- Department of Statistics, George Mason University, Fairfax, Virginia
| | - Annunziata Cotugno
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Institute of Cardiology, University of Brescia, Brescia, Italy
| | | | | | - Shashank Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Anika Raja
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Daniel Tang
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Alexander G. Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia
- Virginia Heart, Falls Church, Virginia
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16
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Takagi K, Shojima T, Kono T, Kikusaki S, Homma T, Shibata T, Otsuka M, Fukumoto Y, Tayama E. ECPELLA as the bridge to surgery in patients with cardiogenic shock due to post-infarct papillary muscle rupture: management of mechanical circulatory support during operation. J Artif Organs 2023; 26:237-241. [PMID: 36112331 DOI: 10.1007/s10047-022-01365-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 08/31/2022] [Indexed: 11/27/2022]
Abstract
Papillary muscle rupture is a fatal complication with a high operative mortality. Most patients experience cardiogenic shock and hypoxia due to pulmonary edema caused by severe mitral regurgitation. Although preoperative stabilization using a mechanical assist device potentially improves surgical outcomes, an appropriate strategy has not yet been established. ECPELLA, combining venoarterial extracorporeal membrane oxygenation and Impella, has the potential to stabilize preoperative status and improve outcome in patients with refractory cardiogenic shock due to papillary muscle rupture. Herein, we present 3 cases involving the efficacy of ECPELLA and our tips of surgical and ECPELLA management in patients with papillary muscle rupture.
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Affiliation(s)
- Kazuyoshi Takagi
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan.
| | - Takahiro Shojima
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Takanori Kono
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Satoshi Kikusaki
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Takehiro Homma
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Maki Otsuka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Eiki Tayama
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
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17
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Schupp T, Rusnak J, Forner J, Weidner K, Ruka M, Egner-Walter S, Dudda J, Bertsch T, Kittel M, Behnes M, Akin I. Cardiac Troponin I but Not N-Terminal Pro-B-Type Natriuretic Peptide Predicts Outcomes in Cardiogenic Shock. J Pers Med 2023; 13:1348. [PMID: 37763116 PMCID: PMC10532680 DOI: 10.3390/jpm13091348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/16/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023] Open
Abstract
This study investigates the prognostic value of cardiac troponin I (cTNI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients with cardiogenic shock (CS). Data regarding the prognostic value of cardiac biomarkers in CS is scarce, furthermore, most studies were restricted to CS patients with acute myocardial infarction (AMI). Therefore, consecutive patients with CS from 2019 to 2021 were included. Blood samples were retrieved from day of disease onset (day 1) and on days 2, 3 and 4 thereafter. The prognostic value of cTNI and NT-proBNP levels was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, Kaplan-Meier analyses and multivariable Cox proportional regression analyses. A total of 217 CS patients were included with an overall rate of all-cause mortality of 56% at 30 days. CTNI was able to discriminate 30-day non-survivors (area under the curve (AUC) = 0.669; p = 0.001), whereas NT-proBNP (AUC = 0.585; p = 0.152) was not. The risk of 30-day all-cause mortality was higher in patients with cTNI levels above the median (70% vs. 43%; log rank p = 0.001; HR = 2.175; 95% CI 1.510-3.132; p = 0.001), which was observed both in patients with (71% vs. 49%; log rank p = 0.012) and without AMI-related CS (69% vs. 40%; log rank p = 0.005). The prognostic impact of cTNI was confirmed after multivariable adjustment (HR = 1.915; 95% CI 1.298-2.824; p = 0.001). In conclusion, cTNI-but not NT-proBNP-levels discriminated 30-day all-cause mortality in CS patients.
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Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Maximilian Kittel
- Institute for Clinical Chemistry, Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemastaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 69117 Heidelberg, Germany (M.B.)
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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18
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Fishkin T, Isath A, Naami E, Aronow WS, Levine A, Gass A. Impella devices: a comprehensive review of their development, use, and impact on cardiogenic shock and high-risk percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2023; 21:613-620. [PMID: 37539790 DOI: 10.1080/14779072.2023.2244874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/02/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Impella devices have emerged as a critical tool for temporary mechanical circulatory support (TMCS) in the management of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (PCI). The purpose of this review is to examine the history of the different Impella devices, their hemodynamic profiles, and how the data supports their use. AREAS COVERED This review covers the development and specifications of the Impella 2.5, Impella CP, Impella 5.0/Left Direct (LD), Impella RP, and Impella 5.5 devices. This review also covers the clinical trials that illuminate the Impella devices' use in their appropriate clinical contexts. These studies examine the effectiveness of Impella devices and have begun to yield promising results, demonstrating improved survival rates when compared to the historically high mortality rates associated with CS. It is important to weigh the benefits of Impella devices in light of their contraindications. A literature search was conducted by searching the PubMed database for reviews, meta-analyses, and clinical trials pertinent to Impella devices. EXPERT OPINION Impella devices are a crucial tool for management of patients undergoing high-risk PCI and those with CS. There is evidence that early Impella implantation is beneficial in the treatment of patients presenting with CS. Further randomized controlled trials are needed to better elucidate the benefits of Impella devices in various clinical settings.
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Affiliation(s)
- Tzvi Fishkin
- Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Edmund Naami
- Departments of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Avi Levine
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Alan Gass
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Singhvi A, Punnen J. Acute mechanical circulatory support for cardiogenic shock in India. Indian J Thorac Cardiovasc Surg 2023; 39:47-62. [PMID: 37525701 PMCID: PMC10387029 DOI: 10.1007/s12055-023-01530-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 08/02/2023] Open
Abstract
Cardiogenic shock continues to have high morbidity and mortality, despite advances in the field. Temporary mechanical circulatory support (TMCS) devices, if instituted in a timely fashion, can help stabilize critically ill patients with cardiogenic shock from various aetiologies and cardiac arrest, and provide time for organ recovery or till durable support or transplantation can be achieved. Currently, several options for TMCS devices exist. In this review, we discuss indications, contraindications, characteristics of the various available devices, and important issues pertaining to their management.
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Affiliation(s)
- Aditi Singhvi
- Narayana Institute of Cardiac Sciences, Narayana Health, Bommasandra Industrial Area, Bengaluru, Karnataka 560099 India
| | - Julius Punnen
- Narayana Institute of Cardiac Sciences, Narayana Health, Bommasandra Industrial Area, Bengaluru, Karnataka 560099 India
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20
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Kochan A, Lee T, Moghaddam N, Milley G, Singer J, Cairns JA, Wong GC, Jentzer JC, van Diepen S, Alviar C, Fordyce CB. Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without Cardiogenic Shock. Circ Cardiovasc Interv 2023; 16:e012810. [PMID: 37339233 DOI: 10.1161/circinterventions.122.012810] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/18/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS. METHODS We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups. RESULTS 2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0-145.0) and 103.0 (interquartile range, 85.0-130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%. CONCLUSIONS Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.
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Affiliation(s)
- Andrew Kochan
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - Nima Moghaddam
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Grace Milley
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - John A Cairns
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (J.C.J.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Canada (S.v.D.)
| | - Carlos Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NY (C.A.)
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
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21
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Ardito V, Sarucanian L, Rognoni C, Pieri M, Scandroglio AM, Tarricone R. Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses. J Cardiovasc Dev Dis 2023; 10:jcdd10040158. [PMID: 37103037 PMCID: PMC10142129 DOI: 10.3390/jcdd10040158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.
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Affiliation(s)
- Vittoria Ardito
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Lilit Sarucanian
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
- Department of Social and Political Science, Bocconi University, 20136 Milan, Italy
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22
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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23
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Polyzogopoulou E, Bezati S, Karamasis G, Boultadakis A, Parissis J. Early Recognition and Risk Stratification in Cardiogenic Shock: Well Begun Is Half Done. J Clin Med 2023; 12:2643. [PMID: 37048727 PMCID: PMC10095596 DOI: 10.3390/jcm12072643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Cardiogenic shock is a complex syndrome manifesting with distinct phenotypes depending on the severity of the primary cardiac insult and the underlying status. As long as therapeutic interventions fail to divert its unopposed rapid evolution, poor outcomes will continue challenging health care systems. Thus, early recognition in the emergency setting is a priority, in order to avoid delays in appropriate management and to ensure immediate initial stabilization. Since advanced therapeutic strategies and specialized shock centers may provide beneficial support, it seems that directing patients towards the recently described shock network may improve survival rates. A multidisciplinary approach strategy commands the interconnections between the strategic role of the ED in affiliation with cardiac shock centers. This review outlines critical features of early recognition and initial therapeutic management, as well as the utility of diagnostic tools and risk stratification models regarding the facilitation of patient trajectories through the shock network. Further, it proposes the implementation of precise criteria for shock team activation and the establishment of definite exclusion criteria for streaming the right patient to the right place at the right time.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Sofia Bezati
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - Grigoris Karamasis
- Second Department of Cardiology, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Antonios Boultadakis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, Rimini 1, Chaidari, 12462 Athens, Greece
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24
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Glazier MM, Kaki A. Treatment of Cardiogenic Shock and Refractory Ventricular Fibrillation: Pulling Out All the Stops. Int J Angiol 2023. [DOI: 10.1055/s-0043-1764461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
AbstractWe report the case of a 62-year-old woman who presented with an acute inferior wall myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation. Following prolonged resuscitation in the emergency room, she was transferred to the cardiac catheterization laboratory where, as a first step, mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (ECMO) was established. Next, a right heart catheterization study was performed, followed by coronary angiography and angioplasty of the infarct-related artery. Promptly on transfer to the intensive care unit, a hypothermia protocol was initiated. By postprocedure day 1, the patient's ventricular fibrillation had resolved, mean arterial pressure was >65 mm Hg, and pulmonary artery diastolic pressure was 10 mm Hg. Echocardiography demonstrated complete recovery of left ventricular systolic function. Lactate levels had fallen from 11.0 mmol/L (pre-ECMO) to 1.2 mmol/L. The patient was successfully weaned off pressor and ECMO support within 24 hours of the percutaneous coronary intervention procedure. She was extubated on postprocedure day 2 and discharged home on day 6. At 26-month follow-up, she remains well, angina free, neurologically intact, and without evidence of heart failure. The treatment algorithm used in this case should be considered favorably in the management of patients presenting with acute myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation.
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Affiliation(s)
| | - Amir Kaki
- Division of Cardiology, St John University Hospital, Detroit, Michigan
- Department of Medicine, Wayne State University, Detroit, Michigan
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25
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De Luca L, Mistrulli R, Scirpa R, Thiele H, De Luca G. Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction. J Clin Med 2023; 12:2184. [PMID: 36983185 PMCID: PMC10051785 DOI: 10.3390/jcm12062184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/26/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023] Open
Abstract
Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
- Faculty of Medicine and Dentistry, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
| | - Raffaella Mistrulli
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
| | - Riccardo Scirpa
- Department of Cardio-Thoracic and Vascular Medicine and Surgery, Division of Cardiology, A.O. San Camillo-Forlanini, 00152 Rome, Italy
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, 04289 Leipzig, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant’Ambrogio, 20161 Milan, Italy
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26
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Guddeti RR, Sanina C, Jauhar R, Henry TD, Dehghani P, Garberich R, Schmidt CW, Nayak KR, Shavadia JS, Bagai A, Alraies C, Mehra A, Bagur R, Grines C, Singh A, Patel RA, Htun WW, Ghasemzadeh N, Davidson L, Acharya D, Kabour A, Hafiz AM, Amlani S, Wasserman HS, Smith T, Kapur NK, Garcia S. Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction. Am J Cardiol 2023; 187:76-83. [PMID: 36459751 PMCID: PMC9706494 DOI: 10.1016/j.amjcard.2022.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/26/2022] [Accepted: 09/30/2022] [Indexed: 11/30/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n = 71] COVID-19+/MCS positive [MCS+] vs 12.4% [n = 98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p = 0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p = 0.001) because of very high in-hospital mortality (59% vs 28%; p = 0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.
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Affiliation(s)
- Raviteja R. Guddeti
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Cristina Sanina
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Rajiv Jauhar
- North Shore University Hospital, Manhasset, New York
| | - Timothy D. Henry
- The Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | | | - Ross Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Keshav R. Nayak
- Department of Cardiology, Scripps Mercy Hospital, San Diego, California
| | - Jay S. Shavadia
- Royal University Hospital, University of Saskatchewan Saskatoon, Saskatchewan, Canada
| | | | | | - Aditya Mehra
- Jersey Shore University Medical Center, Neptune, New Jersey
| | - Rodrigo Bagur
- London Health Sciences Centre, London, Ontario, Canada
| | - Cindy Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
| | - Avneet Singh
- North Shore University Hospital, Manhasset, New York
| | - Rajan A.G. Patel
- Ochsner Health, University of Queensland Ochsner Clinical School, New Orleans, Louisiana
| | | | | | | | - Deepak Acharya
- University of Arizona Sarver Heart Center, Tuczon, Arizona
| | | | - Abdul Moiz Hafiz
- Southern Illinois University School of Medicine. Springfiled, Illinois
| | - Shy Amlani
- William Osler Health System, Ontario, Canada
| | | | - Timothy Smith
- The Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | | | - Santiago Garcia
- The Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio.
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Funamoto M, Kunavarapu C, Kwan MD, Matsuzaki Y, Shah M, Ono M. Single center experience and early outcomes of Impella 5.5. Front Cardiovasc Med 2023; 10:1018203. [PMID: 36926047 PMCID: PMC10011692 DOI: 10.3389/fcvm.2023.1018203] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/13/2023] [Indexed: 03/08/2023] Open
Abstract
Background Acute decompensated heart failure (HF) and cardiogenic shock (CS) frequently are refractory to conservative treatment and require mechanical circulatory support (MCS). We report our early clinical experience and evaluate patient outcomes with the newer generation surgical Impella 5.5. Methods Seventy patients that underwent Impella 5.5 implantation between October 2019 and December 2021 at a single center were enrolled in this study. Pre-operative characteristics, peri-operative clinical course information, and post-operative outcomes were retrospectively collected. Results Fifty-seven (81%) patients survived to discharge, and 51 (76%) patients survived at the time of the first 30 days post-discharge visit. Thirty-one patients (44%) received Impella support for a bridge to advanced surgical heart failure therapy (transplant or durable left ventricular assist device [LVAD]), 27 (39%) cases were used for a bridge to recovery/decision and 12 (17.1%) cases was used for planned perioperative support for high-risk cardiac surgery procedure. Conclusion Our results suggest that Impella 5.5 provides favorable survival in the management of HF and CS, particularly used for a bridge to heart transplant or LVAD. Early extubation and mobilization with high flow circulatory support allowed effective tailoring of MCS approaches from peri-operative support for high-risk cardiac surgery, bridge to recovery, and to advanced surgical heart failure therapy.
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Affiliation(s)
- Masaki Funamoto
- Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, TX, United States
| | - Chandra Kunavarapu
- Advanced Heart Failure and Transplant Cardiology, Methodist Hospital, San Antonio, TX, United States
| | - Michael D Kwan
- Advanced Heart Failure and Transplant Cardiology, Methodist Hospital, San Antonio, TX, United States
| | - Yuichi Matsuzaki
- Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, TX, United States
| | - Mahek Shah
- Advanced Heart Failure and Transplant Cardiology, Methodist Hospital, San Antonio, TX, United States
| | - Masahiro Ono
- Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, TX, United States
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Dangl M, Albosta M, Butros H, Loebe M. Temporary Mechanical Circulatory Support: Left, Right, and Biventricular Devices. Curr Cardiol Rev 2023; 19:27-42. [PMID: 36918790 PMCID: PMC10518886 DOI: 10.2174/1573403x19666230314115853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 03/16/2023] Open
Abstract
Temporary mechanical circulatory support (MCS) encompasses a wide array of invasive devices, which provide short-term hemodynamic support for multiple clinical indications. Although initially developed for the management of cardiogenic shock, indications for MCS have expanded to include prophylactic insertion prior to high-risk percutaneous coronary intervention, treatment of acute circulatory failure following cardiac surgery, and bridging of end-stage heart failure patients to more definitive therapies, such as left ventricular assist devices and cardiac transplantation. A wide variety of devices are available to provide left ventricular, right ventricular, or biventricular support. The choice of a temporary MCS device requires consideration of the clinical scenario, patient characteristics, institution protocols, and provider familiarity and training. In this review, the most common forms of left, right, and biventricular temporary MCS are discussed, along with their indications, contraindications, complications, cannulations, hemodynamic effects, and available clinical data.
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Affiliation(s)
- Michael Dangl
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Michael Albosta
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Hoda Butros
- Department of Medicine, Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Matthias Loebe
- Department of Surgery, Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
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Muacevic A, Adler JR, Upadhyay HV, Konat A, Zalavadia P, Padaniya A, Patel P, Patel N, Prajjwal P, Sharma K. Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock. Cureus 2023; 15:e33372. [PMID: 36751242 PMCID: PMC9898582 DOI: 10.7759/cureus.33372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.
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Acosta ME, Belkin MN, Nathan S. Selection of percutaneous mechanical circulatory support in cardiogenic shock: patient-specific considerations and insights from contemporary clinical data. Curr Opin Cardiol 2023; 38:47-53. [PMID: 36200273 DOI: 10.1097/hco.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW Cardiogenic shock remains a complex and variable disease process requiring early recognition and prompt, multidisciplinary treatment. Available data link usage of high-dose and/or multiple vasopressors in cardiogenic shock to increased mortality. This review proposes a structured approach to escalation of percutaneous mechanical circulatory support (pMCS) in cardiogenic shock, based on the hemodynamic and metabolic parameters highlighted in the revised SCAI Shock Classification, and supported by the available clinical data. RECENT FINDINGS Intra-aortic balloon pumps (IABP) may improve hemodynamics in early cardiogenic shock (stage B) but offer little benefit in stage C-E shock where percutaneous ventricular assist devices (pVAD) improve cardiac power/index and may improve survival in certain subsets. In stage D-E shock, escalation from standalone pVADs to devices in combination is often appropriate. Left ventricular venting, with IABP or Impella, in conjunction with VA ECMO, appears to be beneficial. SUMMARY Graded escalation of pMCS support should be considered in SCAI stage B shock patients onwards, with the choice of support allowable by local expertise, matched to the degree and anticipated trajectory of hemodynamic and metabolic compromise. Additional clinical data are required before timing, and escalation of pMCS initiation may be integrated into a single treatment algorithm.
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Affiliation(s)
| | - Mark N Belkin
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Sandeep Nathan
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
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Vallabhajosyula S, Verghese D, Henry TD, Katz JN, Nicholson WJ, Jaber WA, Jentzer JC. Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction. Mayo Clin Proc 2022; 97:2333-2354. [PMID: 36464466 DOI: 10.1016/j.mayocp.2022.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 06/08/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022]
Abstract
Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Dhiran Verghese
- Section of Advanced Cardiac Imaging, Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA; Department of Cardiovascular Medicine, NCH Heart Institute, Naples, FL, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, OH, USA
| | - Jason N Katz
- Divisions of Cardiovascular Diseases and Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Abusnina W, Ismayl M, Al-Abdouh A, Ganesan V, Mostafa MR, Hallak O, Peterson E, Abdou M, Goldsweig AM, Aboeata A, Dahal K. IMPELLA VERSUS EXTRACORPOREAL MEMBRANE OXYGENATION IN CARDIOGENIC SHOCK: A SYSTEMATIC REVIEW AND META-ANALYSIS. Shock 2022; 58:349-357. [PMID: 36445229 DOI: 10.1097/shk.0000000000001996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
ABSTRACT Background: Cardiogenic shock (CS) carries high mortality. The roles of specific mechanical circulatory support (MCS) systems are unclear. We compared the clinical outcomes of Impella versus extracorporal membrane oxygenation (ECMO) in patients with CS. Methods: This is a systematic review and meta-analysis that was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. We searched PubMed, Cochrane Central Register, Embase, Web of Science, Google Scholar, and ClinicalTrials.gov (inception through May 10, 2022) for studies comparing the outcomes of Impella versus ECMO in CS. We used random-effects models to calculate risk ratios (RRs) with 95% confidence interval (CIs). End points included in-hospital, 30-day, and 12-month all-cause mortality, successful weaning from MCS, bridge to transplant, all reported bleeding, stroke, and acute kidney injury. Results: A total of 10 studies consisting of 1,827 CS patients treated with MCS were included in the analysis. The risk of in-hospital all-cause mortality was significantly lower with Impella compared with ECMO (RR, 0.80; 95% CI, 0.65-1.00; P = 0.05), whereas there was no statistically significant difference in 30-day (RR, 0.97, 95% CI, 0.82-1.16; P = 0.77) and 12-month mortality (RR, 0.90; 95% CI, 0.74-1.11; P = 0.32). There were no significant differences between the two groups in terms of successful weaning (RR, 0.97; 95% CI, 0.81-1.15; P = 0.70) and bridging to transplant (RR, 0.88; 95% CI, 0.58-1.35; P = 0.56). There was less risk of bleeding and stroke in the Impella group compared with the ECMO group. Conclusions: In patients with CS, the use of Impella is associated with lower rates of in-hospital mortality, bleeding, and stroke than ECMO. Future randomized studies with adequate sample sizes are needed to confirm these findings.
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Affiliation(s)
- Waiel Abusnina
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Mahmoud Ismayl
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Ahmad Al-Abdouh
- Department pf medicine, University of Kentucky, Lexington, Kentucky
| | - Vaishnavi Ganesan
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | | | - Osama Hallak
- Division of Cardiology, Kettering Medical Center, Dayton, Ohio
| | - Emily Peterson
- Creighton University School of Medicine, Omaha, Nebraska
| | - Mahmoud Abdou
- Division of Cardiology, Emory University, Atlanta, Georgia
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ahmed Aboeata
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Khagendra Dahal
- Department of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
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Tan SR, Low CJW, Ng WL, Ling RR, Tan CS, Lim SL, Cherian R, Lin W, Shekar K, Mitra S, MacLaren G, Ramanathan K. Microaxial Left Ventricular Assist Device in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12101629. [PMID: 36295065 PMCID: PMC9605512 DOI: 10.3390/life12101629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Microaxial left ventricular assist devices (LVAD) are increasingly used to support patients with cardiogenic shock; however, outcome results are limited to single-center studies, registry data and select reviews. We conducted a systematic review and meta-analysis, searching three databases for relevant studies reporting on microaxial LVAD use in adults with cardiogenic shock. We conducted a random-effects meta-analysis (DerSimonian and Laird) based on short-term mortality (primary outcome), long-term mortality and device complications (secondary outcomes). We assessed the risk of bias and certainty of evidence using the Joanna Briggs Institute and the GRADE approaches, respectively. A total of 63 observational studies (3896 patients), 6 propensity-score matched (PSM) studies and 2 randomized controlled trials (RCTs) were included (384 patients). The pooled short-term mortality from observational studies was 46.5% (95%-CI: 42.7–50.3%); this was 48.9% (95%-CI: 43.8–54.1%) amongst PSM studies and RCTs. The pooled mortality at 90 days, 6 months and 1 year was 41.8%, 51.1% and 54.3%, respectively. Hemolysis and access-site bleeding were the most common complications, each with a pooled incidence of around 20%. The reported mortality rate of microaxial LVADs was not significantly lower than extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumps (IABP). Current evidence does not suggest any mortality benefit when compared to ECMO or IABP.
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Affiliation(s)
- Shien Ru Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Wei Lin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119228, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Robin Cherian
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD 4032, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
| | - Saikat Mitra
- Intensive Care Unit, Dandenong and Casey Hospital, Monash Health, Melbourne, VIC 3175, Australia
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
- Correspondence:
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Ranard LS, Guber K, Fried J, Takeda K, Kaku Y, Karmpaliotis D, Sayer G, Rabbani L, Burkhoff D, Uriel N, Kirtane AJ, Masoumi A. Comparison of Risk Models in the Prediction of 30-Day Mortality in Acute Myocardial Infarction–Associated Cardiogenic Shock. STRUCTURAL HEART 2022. [DOI: 10.1016/j.shj.2022.100116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Comparison of Clinical Outcomes after Non-ST-Segment and ST-Segment Elevation Myocardial Infarction in Diabetic and Nondiabetic Populations. J Clin Med 2022; 11:jcm11175079. [PMID: 36079008 PMCID: PMC9456669 DOI: 10.3390/jcm11175079] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/25/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
Using a new-generation drug-eluting stent, we compared the 2-year clinical outcomes of patients with diabetes mellitus (DM) and non-DM concomitant with a non-ST-segment elevation myocardial infarction (NSTEMI) and an ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention. A total of 11,798 patients with acute myocardial infarction were classified into two groups: DM (NSTEMI, n = 2399; STEMI, n = 2693) and non-DM (NSTEMI, n = 2694; STEMI, n = 4012). The primary clinical outcome was the occurrence of major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction, or any coronary repeat revascularization. The secondary outcome was the occurrence of definite or probable stent thrombosis. In all the patients, both multivariable and propensity score-adjusted analyses revealed that the incidence rates of MACE (adjusted hazard ratio (aHR), 1.214; p = 0.006 and aHR, 1.298; p = 0.002, respectively), all-cause death, cardiac death (CD), and non-CD rate were significantly higher in the NSTEMI group than in the STEMI group. Additionally, among patients with NSTEMI, there was a higher non-CD rate (aHR, 2.200; p = 0.007 and aHR, 2.484; p = 0.004, respectively) in the DM group and a higher CD rate (aHR, 2.688; p < 0.001 and 2.882; p < 0.001, respectively) in the non-DM group. In this retrospective study, patients with NSTEMI had a significantly higher 2-year mortality rate than those with STEMI did. Furthermore, strategies to reduce the non-CD rate in patients with DM and the CD rate in patients without DM could be beneficial for those with NSTEMI.
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Geller BJ, Sinha SS, Kapur NK, Bakitas M, Balsam LB, Chikwe J, Klein DG, Kochar A, Masri SC, Sims DB, Wong GC, Katz JN, van Diepen S. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e50-e68. [PMID: 35862152 DOI: 10.1161/cir.0000000000001076] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.
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Prognostic Role of Cardiac Power in a Large Cohort of Patients with Normal Ejection Fraction Referred for Dobutamine Stress Echocardiography. J Am Soc Echocardiogr 2022; 35:1139-1145.e3. [PMID: 35863546 DOI: 10.1016/j.echo.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cardiac power reflects cardiac performance in terms of energy transferred by the left ventricle (LV) to the aorta per unit time. Peak stress cardiac power has been shown to predict outcome in patients with reduced LV ejection fraction (EF), and more recently, in patients with normal EF referred for exercise stress echocardiography. We sought to evaluate the prognostic significance of cardiac power in patients with normal EF referred for dobutamine stress test (DSE). METHODS We studied data from 15,576 patients with EF ≥50% and no significant valvular or right ventricular dysfunction, undergoing DSE. Cardiac power at rest and peak stress and power reserve (peak stress minus rest power) were calculated and normalized to LV mass. Outcome endpoints were all-cause mortality and new-onset heart failure (HF). RESULTS The mean age was 66±13 years and 49% patients were females. Resting and peak stress power/mass were 0.7±0.2 and 1.6±0.6 W/100 g of LV myocardium, respectively. During follow-up [median 3.3 (IQR 0.7-7.3) years], 2,278 patients died and 2,137 developed HF. After adjusting for age, sex, comorbidities, and stress test results, lower peak stress power/mass was independently associated with mortality [adjusted hazard ratio (HR), highest vs. lowest quartile, 0.84, 95% confidence intervals (CI) 0.74-0.95, P=0.004] and HF at follow-up [adjusted HR 0.67, 95% CI 0.59-0.76, P<0.0001]. Power reserve showed similar associations with outcomes. CONCLUSION Assessment of cardiac power during DSE in patients with normal EF provides valuable prognostic information regarding risk of mortality and future HF, in addition to stress test results. It is an important research tool to study cardiac performance and development of risk scores incorporating this novel index could be considered after further validation in prospective studies.
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Krittanawong C, Rivera MR, Shaikh P, Kumar A, May A, Mahtta D, Jentzer J, Civitello A, Katz J, Naidu SS, Cohen MG, Menon V. SKey Concepts Surrounding Cardiogenic Shock. Curr Probl Cardiol 2022; 47:101303. [PMID: 35787427 DOI: 10.1016/j.cpcardiol.2022.101303] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 11/03/2022]
Abstract
Cardiogenic shock (CS) is the final common pathway of impaired cardiovascular performance that results in ineffective forward cardiac output producing clinical and biochemical signs of organ hypoperfusion. CS represents the most common cause of shock in the cardiac intensive care unit (CICU) and accounts for a substantial proportion of CICU patient deaths. Despite significant advances in revascularization techniques, pharmacologic therapeutics and mechanical support devices, CS remains associated with a high mortality rate. Indeed, the prevalence of CS within the CICU appears to be increasing. CS can be differentiated as phenotypes reflecting different metabolic, inflammatory, and hemodynamic profiles, depending also on anatomic substrate and congestion profile. Future prospective studies and clinical trials may further characterize these phenotypes and apply targeted intervention for each phenotype and SCAI SHOCK stage rather than a one-size-fits-all approach. Overall, there are 8 key concepts of CS; 1) the mortality associated with CS; 2) Shock attributed to AMI may be declining in both incidence and associated mortality; 3) providers should think about hemodynamic, metabolic, inflammation and cardiac function in totality to assess CS; 4) CS is a dynamic process; 5) no randomized trials evaluating use of the PAC in patients with CS; 6) most data supporting neosynephrine as first line agent in CS; 7) most registries suggest that almost half of CS patients do not have any mechanical support, and the vast majority of the remainder utilize the IABP; and 8) patients with AMI CS should receive emergent PCI of the culprit vessel.
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Affiliation(s)
- Chayakrit Krittanawong
- Section of Cardiology, Baylor College of Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, TX.
| | - Mario Rodriguez Rivera
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease. Barnes-Jewish Hospital/Washington University in St.Louis School of Medicine
| | - Preet Shaikh
- John T. Milliken Department of Medicine, Barnes-Jewish Hospital/Washington University in St.Louis School of Medicine
| | - Anirudh Kumar
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Adam May
- John T. Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Critical Care Cardiology. Barnes-Jewish Hospital/Washington University in St.Louis School of Medicine
| | - Dhruv Mahtta
- Section of Cardiology, Baylor College of Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, TX
| | - Jacob Jentzer
- Department of Cardiovascular Medicine; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew Civitello
- Section of Cardiology, Baylor College of Medicine, Baylor St. Luke's Medical Center, Texas Heart Institute, Houston, TX
| | - Jason Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC
| | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Centre, New York Medical College, Valhalla, NY
| | - Mauricio G Cohen
- Cardiovascular Division, University of Miami Miller School of Medicine, FL, USA
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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Masiero G, Cardaioli F, Tarantini G. Mechanical circulatory support in cardiogenic shock: a critical appraisal. Expert Rev Cardiovasc Ther 2022; 20:443-454. [PMID: 35587216 DOI: 10.1080/14779072.2022.2078702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encounter in patients with multivessel coronary artery disease (MVD). AREAS COVERED Despite prompt revascularization, in particular percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for CS related to AMI remains high. Differently from hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested in AMI-CS patients, based on the results of a recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have raised as a key therapeutic option in CS, especially in case of an early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of current evidences on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of MCS devices, and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes. EXPERT OPINION Emerging observational experience suggested that an early implantation of MCS (prior to PCI), the performance of an extensive revascularization and the implementation of shock teams and networks are key factors for improving clinical outcomes.
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Affiliation(s)
- Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
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Saito R, Koyama K, Kongoji K, Soejima K. Acute myocardial infarction with simultaneous total occlusion of the left anterior descending artery and right coronary artery successfully treated with percutaneous coronary intervention. BMC Cardiovasc Disord 2022; 22:206. [PMID: 35538416 PMCID: PMC9088105 DOI: 10.1186/s12872-022-02652-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Simultaneous thrombosis in more than one coronary artery is an uncommon angiographic finding in patients with acute ST-segment elevation myocardial infarction. It is difficult to identify using 12-lead electrocardiography and usually leads to cardiogenic shock and fatal outcomes, including sudden cardiac death. Therefore, immediate revascularization and adequate mechanical circulatory support are required. CASE PRESENTATION We report the case of a 58-year-old man who presented with vomiting and chest pain complicated by cardiogenic shock and complete atrioventricular block. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V1-V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery and right coronary artery. The patient successfully underwent primary percutaneous coronary intervention with ballooning and stenting for both arteries. An Impella CP was inserted during the procedure. Fifty-seven days after admission, he had New York Heart Association class II heart failure and was transferred to a rehabilitation hospital. CONCLUSIONS Acute double-vessel coronary thrombosis, a serious event with a high mortality rate, requires prompt diagnosis and management to prevent complications such as cardiogenic shock and ventricular arrhythmias. A combination of judicious medical treatment, efficient primary percutaneous coronary intervention, and early mechanical support device insertion is crucial to improve the survival rate of patients with this disease.
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Affiliation(s)
- Ryuhei Saito
- Department of Cardiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Kohei Koyama
- Department of Cardiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-8611, Japan.
| | - Ken Kongoji
- Department of Cardiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
| | - Kyoko Soejima
- Department of Cardiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-8611, Japan
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 593] [Impact Index Per Article: 296.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock. Curr Opin Cardiol 2022; 37:241-249. [PMID: 35612936 DOI: 10.1097/hco.0000000000000967] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide. RECENT FINDINGS Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection. SUMMARY Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.
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Khalid N, Ahmad SA. Shifting gears from early revascularization to early hemodynamic support: Are we there yet? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:84-85. [DOI: 10.1016/j.carrev.2022.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/03/2022]
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Abstract
ABSTRACT Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.
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Bertaina M, Galluzzo A, Morici N, Sacco A, Oliva F, Valente S, D’Ascenzo F, Frea S, Sbarra P, Petitti E, Brach Prever S, Boccuzzi G, Zanini P, Attisani M, Rametta F, De Ferrari GM, Noussan P, Iannaccone M. Pulmonary Artery Catheter Monitoring in Patients with Cardiogenic Shock: Time for a Reappraisal? Card Fail Rev 2022; 8:e15. [PMID: 35541286 PMCID: PMC9069264 DOI: 10.15420/cfr.2021.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/19/2022] [Indexed: 12/20/2022] Open
Abstract
Cardiogenic shock represents one of the most dramatic scenarios to deal with in intensive cardiology care and is burdened by substantial short-term mortality. An integrated approach, including timely diagnosis and phenotyping, along with a well-established shock team and management protocol, may improve survival. The use of the Swan-Ganz catheter could play a pivotal role in various phases of cardiogenic shock management, encompassing diagnosis and haemodynamic characterisation to treatment selection, titration and weaning. Moreover, it is essential in the evaluation of patients who might be candidates for long-term heart-replacement strategies. This review provides a historical background on the use of the Swan-Ganz catheter in the intensive care unit and an analysis of the available evidence in terms of potential prognostic implications in this setting.
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Affiliation(s)
- Maurizio Bertaina
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | | | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; IRCCS S Maria Nascente – Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Alice Sacco
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Serafina Valente
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Simone Frea
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pierluigi Sbarra
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Elisabetta Petitti
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Silvia Brach Prever
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Giacomo Boccuzzi
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Paola Zanini
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Matteo Attisani
- Department of Cardiac Surgery, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | | | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Patrizia Noussan
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
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Lüsebrink E, Kellnar A, Krieg K, Binzenhöfer L, Scherer C, Zimmer S, Schrage B, Fichtner S, Petzold T, Braun D, Peterss S, Brunner S, Hagl C, Westermann D, Hausleiter J, Massberg S, Thiele H, Schäfer A, Orban M. Percutaneous Transvalvular Microaxial Flow Pump Support in Cardiology. Circulation 2022; 145:1254-1284. [PMID: 35436135 DOI: 10.1161/circulationaha.121.058229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Impella device (Impella, Abiomed, Danvers, MA) is a percutaneous transvalvular microaxial flow pump that is currently used for (1) cardiogenic shock, (2) left ventricular unloading (combination of venoarterial extracorporeal membrane oxygenation and Impella concept), (3) high-risk percutaneous coronary interventions, (4) ablation of ventricular tachycardia, and (5) treatment of right ventricular failure. Impella-assisted forward blood flow increased mean arterial pressure and cardiac output, peripheral tissue perfusion, and coronary blood flow in observational studies and some randomized trials. However, because of the need for large-bore femoral access (14 F for the commonly used Impella CP device) and anticoagulation, the incidences of bleeding and ischemic complications are as much as 44% and 18%, respectively. Hemolysis is reported in as many as 32% of patients and stroke in as many as 13%. Despite the rapidly growing use of the Impella device, there are still insufficient data on its effect on outcome and complications on the basis of large, adequately powered randomized controlled trials. The only 2 small and also underpowered randomized controlled trials in cardiogenic shock comparing Impella versus intra-aortic balloon pump did not show improved mortality. Several larger randomized controlled trials are currently recruiting patients or are in preparation in cardiogenic shock (DanGer Shock [Danish-German Cardiogenic Shock Trial; NCT01633502]), left ventricular unloading (DTU-STEMI [Door-To-Unload in ST-Segment-Elevation Myocardial Infarction; NCT03947619], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO], and REVERSE [A Prospective Randomised Trial of Early LV Venting Using Impella CP for Recovery in Patients With Cardiogenic Shock Managed With VA ECMO; NCT03431467]) and high-risk percutaneous coronary intervention (PROTECT IV [Impella-Supported PCI in High-Risk Patients With Complex Coronary Artery Disease and Reduced Left Ventricular Function; NCT04763200]).
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Affiliation(s)
- Enzo Lüsebrink
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Antonia Kellnar
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Kathrin Krieg
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Leonhard Binzenhöfer
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Clemens Scherer
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Germany (S.Z.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, and German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck (B.S.)
| | - Stephanie Fichtner
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Tobias Petzold
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Daniel Braun
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Sven Peterss
- Herzchirurgische Klinik und Poliklinik (S.P., C.H.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Stefan Brunner
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik (S.P., C.H.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany (D.W.)
| | - Jörg Hausleiter
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Steffen Massberg
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Germany (H.T.)
| | - Andreas Schäfer
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Germany (A.S.)
| | - Martin Orban
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
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Ahmed AM, Tabi M, Wiley BM, Vallabhajosyula S, Barsness GW, Bell MR, Jentzer JC. Outcomes Associated With Cardiac Arrest in Patients in the Cardiac Intensive Care Unit With Cardiogenic Shock. Am J Cardiol 2022; 169:1-9. [PMID: 35045934 DOI: 10.1016/j.amjcard.2021.12.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022]
Abstract
Cardiac arrest (CA) is common and has been associated with adverse outcomes in patients with cardiogenic shock (CS). We sought to determine the prevalence, patient characteristics, and outcomes of CA in cardiovascular intensive care unit patients with CS. We queried cardiovascular intensive care unit admissions from 2007 to 2018 with an admission diagnosis of CS and compared patients with and without CA. Temporal trends were assessed using linear regression. The primary and secondary outcomes of in-hospital and 1-year mortality were analyzed using logistic regression and Cox proportional-hazards analysis, respectively. We included 1,498 patients, and CA was present in 510 patients (34%), with 258 (50.6% of patients with CA) having ventricular fibrillation (VF). Mean age was 68 ± 14 years, and 37% were females. The prevalence of CA decreased over time (from 43% in 2007 to 24% in 2018, p <0.001). Hospital mortality was 33.3% and decreased over time in patients without CA (from 30% in 2007 to 22% in 2018, p = 0.05), but not in patients with CA (p = 0.71). CA was associated with a higher risk of hospital mortality (51.0% vs 24.2%, adjusted odds ratio 2.15, 95% confidence interval [CI] 1.52 to 3.05, p <0.001), with no difference between VF CA and non-VF CA (p = 0.64). CA was associated with higher 1-year mortality (adjusted hazard ratio 1.53, 95% CI 1.24 to 1.89, p <0.001). In conclusion, CA is present in 1 of 3 of CS hospitalizations and confers a substantially higher risk of hospital and 1-year mortality with no improvement during our 12-year study period contrary to prevailing trends.
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Affiliation(s)
- Abdelrahman M Ahmed
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine
| | - Meir Tabi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jacob C Jentzer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Patel SM. Percutaneous repositioning of Impella RP: the Snare–Manoeuvre–Prolapse technique—a case report. Eur Heart J Case Rep 2022; 6:ytac085. [PMID: 35620061 PMCID: PMC9128371 DOI: 10.1093/ehjcr/ytac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/12/2021] [Accepted: 02/07/2022] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Impella RP (Abiomed, Danvers, MA, USA) is indicated for right ventricular failure after left ventricular assist device insertion or biventricular shock. Once the peel-away sheath is removed, Impella RP repositioning can only be achieved with manual manipulation of the catheter itself. This method does not always accomplish appropriate positioning of the catheter and can result in continued haemodynamic instability.
Case summary
A young male presented to our institution with recurrent ventricular fibrillation and ST-elevation myocardial infarction that underwent emergent coronary intervention but was in progressive cardiogenic shock requiring implantation of Impella 5.0 and Impella RP. After insertion of the right ventricular support, the patient stabilized transiently then became unstable once more, and repeat fluoroscopy demonstrated that the Impella RP had ‘fallen back’ into the right ventricle. Due to continued instability, we improvised a previously undescribed method of repositioning of the Impella RP catheter with the use of a goose-neck snare.
Discussion
The snare–manoeuvre–prolapse method of Impella RP repositioning is a relatively novel approach at the management of Impella RP retrograde migration into the right ventricle and prevents the need for large-bore venous closure and re-access and the use of a new Impella RP catheter while providing rapid improvement of haemodynamics.
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Affiliation(s)
- Sandeep M Patel
- The Structural Heart and Interventional Center, Department of Cardiology, St. Rita’s Medical Center, BonSecours-Mercy Health, 730 West Market Street, 2K Tower, Lima, OH 45801, USA
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 687] [Impact Index Per Article: 343.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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