Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock

Comparison of a direct vs consultative advanced heart failure role in the outcomes of extracorporeal membrane oxygenation patients

BACKGROUND

Advanced heart failure and transplant (AHFTC) teams are crucial in the management of patients in cardiogenic shock. We sought to explore the impact of AHFTC physicians on outcomes in patients receiving extracorporeal membrane oxygenation (ECMO) support.

AIM

To determine whether outcomes differ in the care of ECMO patients when AHFTC physicians serve in a primary vs consultative role.

METHODS

We conducted a retrospective cohort study of 51 patients placed on veno-venous (VV) and veno-arterial (VA) ECMO between January 2015 and February 2023 at our institution. We compared ECMO outcomes between teams managed primarily by intensivists vs teams where AHFTC physicians played a direct role in ECMO management, including patient selection. Our primary outcome measure was survival to 30 days post hospital discharge.

RESULTS

For combined VA and VV ECMO patients, survival to 30 days post discharge in the AHFTC cohort was significantly higher (67% vs 30%, P = 0.01), largely driven by a significantly increased 30-day post discharge survival in VA ECMO patients in the AHFTC group (64% vs 20%, P = 0.05).

CONCLUSION

This study suggests that patients in shock requiring VA ECMO support may have improved survival 30 days after hospital discharge when an AHFTC team serves in a direct role in the selection and management of patients. Further studies are needed to validate this impact.

Acute Hemodynamic and Echocardiographic Consequences of Impella 5.5 Placement in Patients With Advanced Cardiogenic Shock

We sought to investigate the hemodynamic and echocardiographic consequences of the Impella 5.5 during the acute perioperative period. A retrospective analysis of patients who underwent device implantation at our institution between January 2021 and June 2023 was performed. Hemodynamic and echocardiographic changes were modeled as linear mixed models with random intercepts for patient and fixed as well as random effects of time. Of 87 patients identified, most were male (72, 83%) with nonischemic cardiomyopathy (44, 51%). In the first two postoperative days, the median cardiac output increased by 1.2 L/min (p < 0.05), although the median Impella flow remained at 4.1 L/min. Mean pulmonary artery pressures (32 vs. 27 mm Hg, p < 0.05) and vasoactive inotrope scores (5.6 vs. 3.7, p < 0.01) were modestly reduced. Significant echocardiographic improvement was noted in 61% and 71% of patients with significant preoperative mitral or tricuspid regurgitation, respectively. However, no changes in ejection fraction, left ventricle (LV) diameter, or right ventricular function were noted (all p > 0.05). At 30 days, 27 (31%) patients were transplanted and 13 (15%) were bridged to a durable left ventricular assist device (LVAD). We conclude that in the acute phase following Impella implantation, LV offloading, reductions in pulmonary artery pressures, and improvement in valvular regurgitation are seen without changes to ventricular geometry.

Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association

Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.

The Role of a Cardiogenic Shock Team in Decision Making Surrounding Mechanical Circulatory Support

Cardiogenic shock (CS) confers high mortality rates and remains a challenge for cardiovascular specialists. The difficulty in treating CS lies in its complexity, phenotypic heterogeneity, and the need for expedient treatment. Emerging evidence suggests that cardiogenic shock teams (CS teams), consisting of multiple specialists working in tandem with set protocols and care pathways to offer standardized team-based care, may reduce mortality and morbidity in patients with CS. A key reason for improved outcomes may be the team's decisions surrounding the use of temporary mechanical support devices (tMCS). CS teams expedite the identification of patients who require tMCS and determine the most appropriate device based on patient factors, including shock phenotype. The CS team ensures that tMCS best practices are followed and assists in determining the timing of device escalation or de-escalation. This article will discuss the rationale and role of CS teams. The evidence behind CS teams and their impact on tMCS decision making will be reviewed. Recent trial evidence for the use of tMCS in CS secondary to acute myocardial infarction (AMI) will be examined. Considerations for creating and optimizing an AMI-CS team will be highlighted. Finally, we will examine the current use of CS teams, potential challenges, and future directions for establishing CS teams in Canada.

Differences in Care and Outcomes in Cardiogenic Shock in Cardiac Intensive Care Units in the United States and Canada: CCCTN Registry Insights

BACKGROUND

Mortality in cardiogenic shock (CS) remains high. Significant interhospital heterogeneity in critical care therapies has been described, which reflects the lack of high-quality evidence to guide optimal treatment. We aimed to describe differences in practices and clinical outcomes among patients with CS in the United States and Canada.

METHODS

The Critical Care Cardiology Trials Network (CCCTN) is a research network of tertiary cardiac intensive care units (CICUs). Data collection spanned from 2017 to 2022. The analysis included 34 American and 8 Canadian sites. The outcomes of interest included baseline clinical differences, use of critical care monitoring and therapies, and all-cause in-hospital mortality between patients with CS in the United States and Canada admitted to CICUs.

RESULTS

Among 23,299 admissions, 19% had CS (n = 4336, 88% United States vs 12% Canada). The proportion of patient who received invasive hemodynamics (United States: 80.8% vs Canada: 74.8%, P = 0.0015), vasoactive medications (United States: 88.9% vs Canada: 82.1%, P < 0.0001), temporary mechanical circulatory support (tMCS) (United States: 39.4% vs Canada: 23.1%, P < 0.0001) were more frequent in US centres. Intra-aortic balloon pump was the most common tMCS device in both countries. After multivariable adjustment, in-hospital mortality was higher in Canada vs United States (37.1% vs 29.4%, odds ratio [OR]: 1.47; 95% confidence interval [CI], 1.18-1.83).

CONCLUSIONS

In a contemporary registry, management of CS was heterogenous between the United States and Canada, with higher use of invasive monitoring and MCS in the US. Although adjusted mortality was lower in the United States, the effects of these treatments cannot be reliably determined without randomized trial data.

ECLS-SHOCK and DanGer Shock: Implications for Optimal Temporary Mechanical Circulatory Support Use for Cardiogenic Shock Due to Acute Myocardial Infarction

Despite concerted efforts to rapidly identify patients with cardiogenic shock complicating acute myocardial infarction (AMI-CS) and provide timely revascularization, early mortality remains stubbornly high. Although artificially augmenting systemic flow by using temporary mechanical circulatory support (tMCS) devices would be expected to reduce the rate of progression to multiorgan dysfunction and thereby enhance survival, reliable evidence for benefit has remained elusive with lingering questions regarding the appropriate selection of both patients and devices, as well as the timing of device implantation relative to other critical interventions. Further complicating matters are the resource-intensive multidisciplinary systems of care that must be brought to bear in this complex patient population. Until recently, studies of tMCS were extremely heterogeneous in design, populations treated, and timing of device implantation with regard to shock onset and revascularization. Attempts at summarizing the available data had resulted in a lack of clear benefit for any type of tMCS modality. On this background, 2 landmark trials of tMCS in the setting of AMI-CS---ECLS-SHOCK and DanGer Shock---have recently been published with divergent results that deserve detailed consideration. Thus, we provide a detailed narrative review of the current state of knowledge regarding tMCS for AMI-CS. The most common types of tMCS and related evidence are presented, as well as evidence for organizational considerations, such as the shock team. We also provide some insight into how this new evidence may be incorporated into practice and influence future research.

Cardiogenic Shock Teams: Past, Present, and Future Directions

Cardiogenic shock (CS) remains a significant challenge in cardiovascular medicine, characterized by substantial morbidity and mortality. Historically, patient outcomes in CS have been varied, highly dependent on the timeliness of interventions and the expertise available at treating centers. Emerging evidence indicates that structured, team-based approaches significantly improve survival rates and diminish complications linked to CS. However, several challenges for implementing a team-based approach persist, including optimizing team composition and resource distribution. This article delves into the evolution, current implementations, and future directions of CS teams, emphasizing their crucial role in enhancing patient outcomes. We advocate for the adoption of standardized protocols to ensure uniformity of care across institutions, highlighting the critical need for prompt recognition and management strategies that integrate invasive hemodynamic monitoring and early mechanical circulatory support. Looking ahead, we propose the extension of CS team models into regional networks, broadening their impact through education, telemedicine and collaborative protocols. We also emphasize the importance of continuous research and data sharing via national registries to refine CS team strategies and substantiate their effects on patient outcomes. Ultimately, this review highlights the imperative for ongoing innovation and standardization in CS team operations to improve care delivery and enhance survival rates in CS scenarios.

Evolution of Critical Care Cardiology: An Update on Structure, Care Delivery, Training, and Research Paradigms: A Scientific Statement From the American Heart Association

Critical care cardiology refers to the practice focus of and subspecialty training for the comprehensive management of life-threatening cardiovascular diseases and comorbid conditions that require advanced critical care in an intensive care unit. The development of coronary care units is often credited for a dramatic decline in mortality rates after acute myocardial infarction throughout the 1960s. As the underlying patient population became progressively sicker, changes in organizational structure, staffing, care delivery, and training paradigms lagged. The coronary care unit gradually evolved from a focus on rapid resuscitation from ventricular arrhythmias in acute myocardial infarction into a comprehensive cardiac intensive care unit designed to care for the sickest patients with cardiovascular disease. Over the past decade, the cardiac intensive care unit has continued to transform with an aging population, increased clinical acuity, burgeoning cardiac and noncardiac comorbidities, technologic advances in cardiovascular interventions, and increased use of temporary mechanical circulatory support devices. Herein, we provide an update and contemporary expert perspective on the organizational structure, staffing, and care delivery in the cardiac intensive care unit; examine the challenges and opportunities present in the education and training of the next generation of physicians for critical care cardiology; and explore quality improvement initiatives and scientific investigation, including multicenter registry initiatives and randomized clinical trials, that may change clinical practice, care delivery, and the research landscape in this rapidly evolving discipline.

Profiling of Cardiogenic Shock: Incorporating Machine Learning Into Bedside Management

Cardiogenic shock (CS) is a complex clinical syndrome with various etiologies and clinical presentations. Despite advances in therapeutic options, mortality remains high, and clinical trials in the field are complicated in part by the heterogeneity of CS patients. More individualized targeted therapeutic approaches might improve outcomes in CS, but their implementation remains challenging. The present review discusses current and emerging machine learning-based approaches, including unsupervised and supervised learning methods that use real-world clinical data to individualize therapeutic strategies for CS patients. We will discuss the rationale for each approach, potential advantages and disadvantages, and how these strategies can inform clinical trial design and management decisions.

Protocolised Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock in Australia-Initial Experience From a Hub-and-Spoke Model

BACKGROUND

Acute myocardial infarction complicated by cardiogenic shock (AMICS) confers short-term mortality of 40%-50%. Protocolised network management of AMICS patients as part of a hub-and-spoke model supported by upstream mechanical circulatory support (MCS) is gaining traction globally to treat AMICS.

METHOD

We conducted a prospective multicenter study in Melbourne, Australia describing our 5-year experience utilizing a protocolised hub-and-spoke model of care for patients with AMICS supported by planned upstream use of Impella CP (Abiomed, Danvers, MA).

RESULTS

From December 2019 to August 2024, 31 patients were treated for AMICS with Impella MCS support. Median age was 60 years and 87% were males. ST-elevation myocardial infarction accounted for 84% of presentations, and 29% were complicated by cardiac arrest. The majority of patients treated were in SCAI-CSWG stage D (52%), and stage C (26%) shock. Upstream Impella prior to PCI occurred in 84% of patients. The 30-day survival rate was 74%. An adverse event occurred in 39% of patients. Device-related complications were due to hemolysis (32%) and arrhythmia (3%). Escalation of MCS support was required in five patients (16%). Multivariate analysis identified patients requiring transfer to the hub center prior to revascularisation as an independent predictor of mortality (OR 13.2 [1.34-129.3] p = 0.027).

CONCLUSION

In this first protocolised hub-and-spoke model of care for AMICS supported by planned upstream use of Impella in Australia, 30-day survival was high compared to published historical rates. Patient and device-related complication rates were low. Expansion of the hub-and-spoke model for the treatment of AMICS appears warranted.

Informing Management of Patients Developing Cardiogenic Shock at a Spoke and Being Transferred to a Hub

BACKGROUND

Multidisciplinary teams and regionalized care systems have been suggested to improve cardiogenic shock (CS) outcomes. We sought to identify clinical factors associated with successful outcomes for patients developing CS at an outside healthcare facility (spoke) and being transferred to a quaternary medical center (hub).

METHODS AND RESULTS

Consecutive patients with CS were evaluated (N=1162). Our study cohort comprised 412 patients developing CS at a spoke. Our primary end point was native heart survival (NHS) defined as survival to discharge without receiving advanced heart failure therapies. Secondary end points were survival to discharge, 30-day and 1-year survival after discharge, and adverse events. Association of clinical data with NHS was analyzed using logistic regression. Overall, 246 (59.7%) patients achieved NHS, 125 (30.3%) died, and 41 (10.0%) were discharged after advanced heart failure therapies. Of the 287 patients who were discharged (69.7%), 276 (67.0%) were alive at 30 days, and 250 (60.7%) at 1 year. Patients with NHS less commonly had bleeding or vascular complications or acute kidney injury requiring renal replacement therapy compared with patients who died or received advanced heart failure therapies. Significant multivariable factors associated with NHS likelihood included younger age; shorter length of stay and transfer from a secondary compared with a tertiary/quaternary level of care spoke; absence of cardiac arrest, intubation, or type 3 bleeding; lower vasoactive-inotropic score; higher left ventricular ejection fraction at admission to the hub; and shorter CS onset-to-temporary mechanical circulatory support deployment time.

CONCLUSIONS

We identified clinical factors reflecting disease severity and management practices including length of stay and spoke level of care, inotrope/vasopressor utilization, and CS onset-to-temporary mechanical circulatory support deployment time, that might inform the management of patients developing CS at a spoke.

Early Escalation to CentriMag for Acute Myocardial Infarction-Induced Out-of-Hospital Cardiac Arrest With Refractory to Extracorporeal Membrane Oxygen Support

OBJECTIVES

The mortality rate of acute myocardial infarction (AMI)-related refractory cardiogenic shock (rCS) remains high, particularly in patients experiencing cardiac arrest with extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to evaluate the outcomes of early escalation to CentriMag for AMI-induced out-of-hospital cardiac arrest (OHCA) with ECPR.

METHODS

Patients with AMI-induced OHCA with refractory to ECMO support after ECPR were enrolled. Clinical data were analyzed to identify predictive factors for mortality and survival benefits.

RESULTS

Eighty-nine patients were enrolled, of whom 26 underwent CentriMag implantation. The 1-year survival rate for those with the implantation was 34.6%. In contrast, those without implantation showed a survival rate of 7.9%. The average time from the initiation of ECPR to CentriMag implantation was 22.5 ± 14.6 h. The surgical mortality group exhibited a larger body surface area, longer intervals from CPR to ECPR, shorter duration of CentriMag support, and higher preoperative serum creatinine and postoperative day 1 serum aspartate aminotransferase levels. A prolonged interval from CPR to ECPR was identified as an independent risk factor for mortality. Extended duration of CentriMag support was associated with improved survival outcomes.

CONCLUSIONS

Early CentriMag implantation rescues patients experiencing AMI-related OHCA with rCS and refractory to ECMO support after ECPR. This intervention provides a critical time window, serving as a safe bridge to decision.

Haemodynamic effects of intra-aortic balloon pumps stratified by baseline pulmonary artery pulsatility index

AIMS

Intra-aortic balloon pump (IABP) devices are commonly used in patients with heart failure related cardiogenic shock (HF-CS), including those with out-of-proportion right ventricular (RV) dysfunction. Pulmonary artery pulsatility index (PAPi) is a haemodynamic surrogate for RV performance. We aimed to assess short-term haemodynamic changes in patients with HF-CS following IABP support stratified by baseline PAPi.

METHODS AND RESULTS

This is a single-centre study of 67 consecutive patients with HF-CS who underwent IABP placement between 2020 and 2022. The primary aim was haemodynamic changes of specific variables on pulmonary artery catheter monitoring over 72 h following IABP placement. Secondary aims were clinically significant changes in diuretic regimens, changes in inotropes or vasopressors at 72 h following IABP, along with clinical outcomes. Prior to IABP placement, 57% of the total cohort (median age 59 years [48, 69], 31% female) had Society of Cardiovascular Angiography and Interventions Stage C HF-CS. Thirty-eight (56%) patients had a PAPi <2.0. Following 72 h of IABP support, the PAPi <2.0 group had an observed significant decrease in central venous pressure (CVP; 20 to 12 mmHg, P < 0.001) and mean pulmonary artery pressure (mPAP; 37.5 to 28.5 mmHg, P = 0.001), and an increase in PAPi (1 to 1.6, P = 0.001). No significant change in cardiac index (CI; 2 to 2.1 L/min/m2, P = 0.31) was observed. The PAPi ≥2.0 group (N = 29) had no observed significant change in CVP (10 to 8 mmHg, P = 0.47), or PAPi (2.6 to 2.8, P = 0.92), but there was a significant improvement in CI (1.9 to 2.5 L/min/m2, P = 0.004) along with reduction in mPA (37 to 29 mmHg, P = 0.03). The PAPi <2.0 group had a significant increase in diuretic requirement (52.6% vs. 20.7%, P = 0.01) and numerically greater addition of inotropes/vasopressors (47.3% vs. 34.4%, P = 0.07) compared with the PAPi ≥2.0 group at 72 h following IABP placement. Significantly more patients in the PAPi ≥2.0 group underwent left ventricular assist device (55.2% vs. 26.3%, P = 0.02), with no overall significant differences observed in escalation to veno-arterial extracorporeal membrane oxygenation, 30-day mortality, renal replacement therapy post-IABP, or rates of heart transplantation.

CONCLUSIONS

IABP devices in those with HF-CS and low or abnormal PAPi may provide modest short-term haemodynamic benefits without significant improvement in CI, along with greater need for adjustment in medical therapeutics to achieve haemodynamic optimization.

The processes of care and long-term mortality of acute myocardial infarction with cardiogenic shock survivors: A nationwide cohort study

BACKGROUND

Acute myocardial infarction with cardiogenic shock (AMI-CS) carries a significant risk of inpatient mortality compared with AMI alone, although it is unclear what the longer-term outcomes of AMI-CS survivors is, and whether the inpatient quality of care received influences this.

METHODS

Using the Myocardial Ischaemia National Audit Project (MINAP) registry, linked to Office for National Statistics (ONS) mortality data, we analyzed 330,517 UK AMI patients; 3330 (1 %) with CS. Patients dying within thirty-days of admission were excluded. Median follow-up for patients included was 1642 days. Cox regression models were fitted, adjusting for demographics and management strategy.

RESULTS

AMI-CS survivors were younger (median years) (67 vs. 69, p < 0.001), less often female (29 % vs. 32 %, p < 0.001) and more likely to present with STEMI (81 % vs. 37 %, p < 0.001). Mortality risk was highest at one-year for AMI-CS survivors compared to patients that did not suffer CS (adjusted hazard ratio [HR] 1.85; 95 % CI; 1.68-2.04, p < 0.001), and remained elevated at five-years (HR 1.55; 95 % CI; 1.43-1.68, p < 0.001). 'Excellent-care' according to mean opportunity-based quality indicator (OBQI) score compared to 'Poor-care', showed reduced risk of long-term mortality with AMI-CS (HR: 0.46, CI; 0.39-0.54, P < 0.001). Of patients that received "Excellent-care", AMI-CS survivors had elevated risk of long-term mortality (HR 1.45, 95 % CI; 1.34-1.57, P < 0.001).

CONCLUSION

AMI-CS survivors have elevated risk long-term mortality risk when compared with AMI patients, which persists beyond five years. AMI-CS patients that receive higher-quality inpatient care have better longer-term survival compared to those with poorer inpatient care.

Clinical outcomes following shock team implementation for cardiogenic shock: a systematic review

BACKGROUND

Cardiogenic shock is a critical cardiac condition characterized by low cardiac output leading to end-organ hypoperfusion and associated with high in-hospital mortality rates. It can manifest following acute myocardial infarction or acute exacerbation of chronic heart failure. Despite advancements, mortality rates remain elevated, prompting interest in multidisciplinary approaches to improve outcomes. This manuscript presents a review focused on the concept of a cardiogenic shock team and its potential impact on patient management and outcomes.

METHODS

A comprehensive search was performed on March 19, 2023, covering PubMed, Web of Science, Scopus, Embase, and Cochrane Library. We included primary studies (prospective and retrospective) only and evaluated their quality using the Newcastle-Ottawa Quality Scale. This review was registered in PROSPERO (CRD42023440354).

RESULTS

Six relevant studies with 2066 cardiogenic shock patients were included, of which 1071 were managed by shock teams and 995 received standard care. Findings from the reviewed studies indicated the favorable outcomes associated with implementing cardiogenic shock teams. Patients managed by these teams exhibited higher 30-day and in-hospital survival rates compared to those without team intervention. The implementation of cardiogenic shock teams was linked to reduced in-hospital and intensive care unit mortality rates. Additionally, shock team involvement was associated with shorter door-to-balloon times.

CONCLUSION

The findings suggest that cardiogenic shock teams play a crucial role in improving patient outcomes through earlier detection and timely interventions. Despite challenges in team implementation, their potential to reduce mortality and improve efficiency in patient care warrants further research and greater integration of multidisciplinary strategies into clinical practice.

Defining the Cross-Volume Effect of Extracorporeal Life Support on Outcomes of Cardiogenic Shock

BACKGROUND

Cardiogenic shock (CS) remains a leading cause of mortality despite advancements in mechanical circulatory support and other management strategies. In particular, venoarterial extracorporeal membrane oxygenation (ECMO) requires expertise in cardiac surgery, cardiology, and critical care. The benefits of such expertise may extend beyond patients undergoing ECMO.

METHODS

Hospitalizations in adults (aged ≥18 years) with a primary diagnosis of CS who were not undergoing ECMO, cardiac operations, durable left ventricular assist device therapy, or heart transplantation were abstracted from the 2016-2020 Nationwide Readmissions Database. Multivariable regression models were developed to assess the association of cardiac surgical and ECMO institutional caseload with clinical and financial outcomes.

RESULTS

Of an estimated 70,339 patients with CS identified for study, 33,643 (47.8%) were treated at a high-volume hospital for ECMO (HVH-ECMO). HVH-ECMO was associated with decreased odds of in-hospital mortality (adjusted odds ratio [aOR], 0.85; 95% CI, 0.75-0.95), respiratory complications (aOR, 0.86; 95% CI, 0.79-0.94), and nonhome discharge (aOR, 0.86; 95% CI, 0.79-0.94). However, HVH-ECMO was associated with a longer length of stay by 1.7 days (95% CI, 1.3-2.1) and higher inpatient costs by $9170 (95% CI, $6,490-$12,060). Although ECMO volume was inversely associated with the predicted risk of in-hospital mortality, institutional volume of cardiac operations was not significantly associated with mortality.

CONCLUSIONS

Our findings suggest improved outcomes for patients with CS who were treated at an HVH-ECMO. Multidisciplinary care pathways, including those among surgery, cardiology, and critical care, may influence CS management. Further studies are needed to characterize long-term outcomes of regionalization and ensure equitable access for all populations.

Impacts of Hospital Volume and Patient-Hospital Distances on Outcomes of Older Adults Receiving Percutaneous Microaxial Ventricular Assist Devices for Cardiogenic Shock

BACKGROUND

Percutaneous microaxial ventricular assist devices (pVADs) have the potential to reduce mortality of patients with cardiogenic shock (CS). However, the association between the distribution of pVAD-performing centers and outcomes of CS has not been explored.

METHODS

This observational study included Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD for CS from 2016 to 2020. It examined the associations between patient outcomes and 2 exposure variables: hospitals' procedure volumes of pVAD and patient-hospital distances (in quintiles [Qn]). We developed Cox proportional hazards regression for 180-day mortality and heart failure readmission rates, and multivariable logistic regression for in-hospital outcomes, adjusting for patient demographics, comorbidities, concomitant treatments, and hospital characteristics, including CS volume, teaching status, and the ability to perform extracorporeal membrane oxygenation.

RESULTS

A total of 6637 patients with CS underwent pVAD at 1041 hospitals, with the annualized hospital volume ranging widely from 0.3 to 55.6 cases/year. Patients treated at higher-volume centers experienced lower 180-day mortality compared with those treated at lower-volume centers (Qn1=reference; Qn2: adjusted hazard ratio [aHR], 0.88 [95% CI, 0.79-0.97]; Qn3: aHR, 0.88 [95% CI, 0.79-0.98]; Qn4: aHR, 0.88 [95% CI, 0.78-0.99]; Qn5: aHR, 0.84 [95% CI, 0.74-0.95]; P for trend, 0.026), while we found no evidence that patient-hospital distances were associated with mortality (Qn1=reference; Qn2: aHR, 0.99 [95% CI, 0.89-1.09]; Qn3: aHR, 0.94 [95% CI, 0.85-1.04]; Qn4: aHR, 1.01 [95% CI, 0.92-1.11]; Qn5: aHR, 0.91 [95% CI, 0.82-1.01]; P for trend, 0.160). We found no evidence that the hospital volume and patient-hospital distances were associated with in-hospital bleeding, intracranial hemorrhage, or renal replacement therapy initiation.

CONCLUSIONS

Hospital volume was more strongly associated with mortality than patient-hospital distances, suggesting that rational distribution of pVAD-performing centers while ensuring adequate procedure volumes may optimize patient mortality.

Blueprint for Building and Sustaining a Cardiogenic Shock Program: Qualitative Survey of 12 US Programs

Background

Multidisciplinary cardiogenic shock (CS) programs have been associated with improved outcomes, yet practical guidance for developing a CS program is lacking.

Methods

A survey on CS program development and operational best practices was administered to 12 institutions in diverse sociogeographic regions and practice settings. Common steps in program development were identified.

Results

Key steps for program development were identified: measuring baseline outcomes; identifying subspecialty champions; gaining leadership and team buy-in; developing institution-specific CS protocols; educating staff and referring providers; consulting with external experts; and developing quality assessment and process improvement.

Conclusions

An assessment of 12 US CS programs highlights a blueprint for establishing and maintaining a successful, multidisciplinary shock program.

The Price We Pay for Progression in Shock Care: Economic Burden, Accessibility, and Adoption of Shock-Teams and Mechanical Circulatory Support Devices

PURPOSE OF REVIEW

Cardiogenic shock (CS) is associated with high in-hospital and long-term mortality and morbidity that results in significant socio-economic impact. Due to the high costs associated with CS care, it is important to define the short- and long-term burden of this disease state on resources and review strategies to mitigate these.

RECENT FINDINGS

In recent times, the focus on CS continues to be on improving short-term outcomes, but there has been increasing emphasis on the long-term morbidity. In this review we discuss the long-term outcomes of CS and the role of hospital-level and system-level disparities in perpetuating this. We discuss mitigation strategies including developing evidence-based protocols and systems of care, improvement in risk stratification and evaluation of futility of care, all of which address the economic burden of CS. CS continues to remain the pre-eminent challenge in acute cardiovascular care, and a combination of multi-pronged strategies are needed to improve outcomes in this population.

Multidisciplinary Care Teams in Acute Cardiovascular Care: A Review of Composition, Logistics, Outcomes, Training, and Future Directions

As cardiovascular care continues to advance and with an aging population with higher comorbidities, the epidemiology of the cardiac intensive care unit has undergone a paradigm shift. There has been increasing emphasis on the development of multidisciplinary teams (MDTs) for providing holistic care to complex critically ill patients, analogous to heart teams for chronic cardiovascular care. Outside of cardiovascular medicine, MDTs in critical care medicine focus on implementation of guideline-directed care, prevention of iatrogenic harm, communication with patients and families, point-of-care decision-making, and the development of care plans. MDTs in acute cardiovascular care include physicians from cardiovascular medicine, critical care medicine, interventional cardiology, cardiac surgery, and advanced heart failure, in addition to nonphysician team members. In this document, we seek to describe the changes in patients in the cardiac intensive care unit, health care delivery, composition, logistics, outcomes, training, and future directions for MDTs involved in acute cardiovascular care. As a part of the comprehensive review, we performed a scoping of concepts of MDTs, acute hospital care, and cardiovascular conditions and procedures.

Clinical Characteristics and Outcomes of Patients Suffering Acute Decompensated Heart Failure Complicated by Cardiogenic Shock

BACKGROUND

Cardiogenic shock (CS) can stem from multiple causes and portends poor prognosis. Prior studies have focused on acute myocardial infarction-CS; however, acute decompensated heart failure (ADHF)-CS accounts for most cases. We studied patients suffering ADHF-CS to identify clinical factors, early in their trajectory, associated with a higher probability of successful outcomes.

METHODS

Consecutive patients with CS were evaluated (N=1162). We studied patients who developed ADHF-CS at our hospital (N=562). Primary end point was native heart survival (NHS), defined as survival to discharge without receiving advanced HF therapies. Secondary end points were adverse events, survival, major cardiac interventions, and hospital readmissions within 1 year following index hospitalization discharge. Association of clinical data with NHS was analyzed using logistic regression.

RESULTS

Overall, 357 (63.5%) patients achieved NHS, 165 (29.2%) died, and 41 (7.3%) were discharged post advanced HF therapies. Of 398 discharged patients (70.8%), 303 (53.9%) were alive at 1 year. Patients with NHS less commonly suffered cardiac arrest, underwent intubation or pulmonary artery catheter placement, or received temporary mechanical circulatory support, had better hemodynamic and echocardiographic profiles, and had a lower vasoactive-inotropic score at shock onset. Bleeding, hemorrhagic stroke, hemolysis in patients with mechanical circulatory support, and acute kidney injury requiring renal replacement therapy were less common compared with patients who died or received advanced HF therapies. After multivariable adjustments, clinical variables associated with NHS likelihood included younger age, history of systemic hypertension, absence of cardiac arrest or acute kidney injury requiring renal replacement therapy, lower pulmonary capillary wedge pressure and vasoactive-inotropic score, and higher tricuspid annular plane systolic excursion at shock onset (all P<0.05).

CONCLUSIONS

By studying contemporary patients with ADHF-CS, we identified clinical factors that can inform clinical management and provide future research targets. Right ventricular function, renal function, pulmonary artery catheter placement, and type and timing of temporary mechanical circulatory support warrant further investigation to improve outcomes of this devastating condition.

Cardiogenic Shock Challenges and Priorities: A Clinician Survey

BACKGROUND

Cardiogenic shock (CS) is common and survival outcomes have not substantially improved. Australia's geography presents unique challenges in the management of CS. The challenges and research priorities for clinicians pertaining to CS identification and management have yet to be described.

METHOD

We used an exploratory sequential mixed methods design. Semi-structured interviews were conducted with 10 clinicians (medical and nursing) to identify themes for quantitative evaluation. A total of 143 clinicians undertook quantitative evaluation through online survey. The interviews and surveys addressed current understanding of CS, status of cardiogenic systems and future research priorities.

RESULTS

There were 143 respondents: 16 (11%) emergency, cardiology 22 (16%), 37 (26%) intensive care, 54 (38%) nursing. In total, 107 (75%) believe CS is under-recognised. Thirteen (13; 9%) of respondents indicated their hospital had existing CS teams, all from metropolitan hospitals, and 40% thought additional access to mechanical circulatory support devices was required. Five (5; 11%) non-tertiary hospital respondents had not experienced a delay in transfer of a patient in CS. All respondents felt additional research, particularly into the management of CS, was required.

CONCLUSIONS

Clinicians report that CS is under-recognised and further research into CS management is required. Access to specialised CS services is still an issue and CS protocolised pathways may be of value.

Building a cardiogenic shock response team: key considerations necessary to improve outcomes

PURPOSE OF REVIEW

This review provides key information about cardiogenic shock (CS) teams, including published evidence and practical recommendations to create a CS team and program.

RECENT FINDINGS

CS is a complex disease process with a high in-hospital mortality rate ranging from 30% to 70% according to recent registries and randomized studies. The explanation for the elevated rates is likely multifactorial, including the various etiologies of cardiogenic shock as well as delays in recognition and deployment of appropriate therapies. Accordingly, the use of cardiogenic shock team has been implemented with the aim of improving outcomes in these patients. The CS team typically consists of members with critical care or cardiac critical care expertise, heart failure, cardiothoracic surgery, and interventional cardiology. A number of retrospective studies have now supported the benefits of a CS team, particularly in selecting the appropriate candidates for tailored mechanical circulatory support therapies and providing interventions in a timely manner, which have translated into improved outcomes.

SUMMARY

CS teams provides a platform for expedited recognition of CS and timely, standardized, and multidisciplinary discussions regarding appropriate management and care.

Transcatheter Structural Heart Interventions in the Acute Setting: An Emerging Indication

Structural heart disease is increasingly prevalent in the general population, especially in patients of increased age. Recent advances in transcatheter structural heart interventions have gained a significant following and are now considered a mainstay option for managing stable valvular disease. However, the concept of transcatheter interventions has also been tested in acute settings by several investigators, especially in cases where valvular disease comes as a result of acute ischemia or in the context of acute decompensated heart failure. Tested interventions include both the mitral and aortic valve, mostly evaluating mitral transcatheter edge-to-edge repair and transcatheter aortic valve implantation, respectively. This review is going to focus on the use of acute structural heart interventions in the emergent setting, and it will delineate the available data and provide a meaningful discussion on the optimal patient phenotype and future directions of the field.

Cardiogenic shock diagnosis and management in general intensive care: a nationwide survey

BACKGROUND

the epidemiology of cardiogenic shock has evolved over the years: in the last decades an increasing prevalence of cardiogenic shock related to acute decompensated heart failure was observed. Therefore, treatment bundles should be updated according to the underlying pathophysiology. No data exist regarding the diagnostic/therapeutic strategies in general intensive care units.

METHODS

A 27-questions survey was spread through the GiViTi (Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The results were then divided according to level of hospitals (1st-2nd versus 3rd).

RESULTS

Sixty-nine general intensive care units replied to the survey. The shock team is present in 13% of institutions; Society for Cardiovascular Angiography and Interventions shock classification is applied only in 18.8%. Among the ICUs, 94.2% routinely use a cardiac output monitoring device (pulmonary artery catheter more frequently in 3rd level centers). The first-line adrenergic drug are vasopressors in 27.5%, inotrope in 21.7% or their combination in 50.7%; 79.7% applies fluid challenge. The first vasopressor of choice is norepinephrine (95.7%) (maximum dosage tolerated higher than 0.5 mcg/kg/min in 29%); the first line inotrope is dobutamine (52.2%), followed by epinephrine in 36.2%. The most frequently used mechanical circulatory supports are intra-aortic balloon pump (71%), Impella (34.8%) and VA-ECMO (33.3%); VA-ECMO is the first line strategy in refractory cardiogenic shock (60.8%).

CONCLUSIONS

According to this survey, there is no standardized approach to cardiogenic shock amongst Italian general intensive care units. The application of shock severity stratification and the treatment bundles may play a key role in improving the outcome.

EPidemiology Of Cardiogenic sHock in Scotland (EPOCHS): A multicentre, prospective observational study of the prevalence, management and outcomes of cardiogenic shock in Scotland

Background

Despite high rates of cardiovascular disease in Scotland, the prevalence and outcomes of patients with cardiogenic shock are unknown.

Methods

We undertook a prospective observational cohort study of consecutive patients with cardiogenic shock admitted to the intensive care unit (ICU) or coronary care unit at 13 hospitals in Scotland for a 6-month period. Denominator data from the Scottish Intensive Care Society Audit Group were used to estimate ICU prevalence; data for coronary care units were unavailable. We undertook multivariable logistic regression to identify factors associated with in-hospital mortality.

Results

In total, 247 patients with cardiogenic shock were included. After exclusion of coronary care unit admissions, this comprised 3.0% of all ICU admissions during the study period (95% confidence interval [CI] 2.6%-3.5%). Aetiology was acute myocardial infarction (AMI) in 48%. The commonest vasoactive treatment was noradrenaline (56%) followed by adrenaline (46%) and dobutamine (40%). Mechanical circulatory support was used in 30%. Overall in-hospital mortality was 55%. After multivariable logistic regression, age (odds ratio [OR] 1.04, 95% CI 1.02-1.06), admission lactate (OR 1.10, 95% CI 1.05-1.19), Society for Cardiovascular Angiographic Intervention stage D or E at presentation (OR 2.16, 95% CI 1.10-4.29) and use of adrenaline (OR 2.73, 95% CI 1.40-5.40) were associated with mortality.

Conclusions

In Scotland the prevalence of cardiogenic shock was 3% of all ICU admissions; more than half died prior to discharge. There was significant variation in treatment approaches, particularly with respect to vasoactive support strategy.

The Intra-aortic Balloon Pump: A Focused Review of Physiology, Transport Logistics, Mechanics, and Complications

Critical care transport medicine (CCTM) teams are playing an increasing role in the care of patients in cardiogenic shock requiring mechanical circulatory support devices. Hence, it is important that CCTM providers are familiar with the pathophysiology of cardiogenic shock, the role of mechanical circulatory support, and the management of these devices in the transport environment. The intra-aortic balloon pump is a widely used and accessible cardiac support device capable of increasing cardiac output and reducing work on the left ventricle through diastolic augmentation and counterpulsation. This article reviews essential CCTM-based considerations for patients supported by intra-aortic balloon pump, including indications for placement, mechanics and physiology, potential issues during transport, and associated complications.

Cardiogenic shock as a health issue. Physiology, classification, and detection

Cardiogenic shock (CS) is a heterogeneous syndrome with high mortality and a growing incidence. It is characterized by an imbalance between the tissue oxygen demands and the capacity of the cardiovascular system to meet these demands, due to acute cardiac dysfunction. Historically, acute coronary syndromes have been the primary cause of CS. However, non-ischemic cases have seen a rise in incidence. The pathophysiology involves ischemic damage of the myocardium and a sympathetic, renin-angiotensin-aldosterone system and inflammatory response, perpetuating the situation of tissue hypoperfusion and ultimately leading to multiorgan dysfunction. The characterization of CS patients through a triaxial assessment and the widespread use of the Society for Cardiovascular Angiography and Interventions (SCAI) scale has allowed standardization of the severity stratification of CS; this, coupled with early detection and the "hub and spoke" approach, could contribute to improving the prognosis of these patients.

Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center

Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis

BACKGROUND

Consensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of "spoke" centers to tertiary/"hub" centers with higher capabilities. However, outcomes associated with such transfers are largely unknown beyond those reported in individual health networks.

OBJECTIVES

To analyze a contemporary, multicenter CS cohort with the aim of comparing characteristics and outcomes of patients between transfer (between spoke and hub centers) and nontransfer cohorts (those primarily admitted to a hub center) for both acute myocardial infarction (AMI-CS) and heart failure-related HF-CS. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality.

METHODS

The Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high-volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016-2020.

RESULTS

Of 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these patients, 528 (58.1%) had heart failure-related CS (HF-CS), and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stages C and D, when compared to nontransfer patients. Transfer patients had higher mortality rates (37% vs 29%, < 0.001) than nontransfer patients; the differences were driven primarily by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer or within 24 hours of arrival was associated with decreased mortality rates. Among transfer AMI-CS patients, BMI > 28 kg/m2, worsening renal failure, lactate > 3 mg/dL, and increasing numbers of vasoactive drugs were associated with increased mortality rates.

CONCLUSION

More than half of patients with CS managed at high-volume CS centers were transferred from another hospital. Although transfer patients had higher mortality rates than those who were admitted primarily to hub centers, the outcomes and their predictors varied significantly when classified by HF-CS vs AMI-CS.

Association between intensive care unit nursing grade and mortality in patients with cardiogenic shock and its cost-effectiveness

BACKGROUND

Despite the high workload of cardiac intensive care unit (ICU), there is a paucity of evidence on the association between nurse workforce and mortality in patients with cardiogenic shock (CS). This study aimed to evaluate the prognostic impact of the ICU nursing grade on mortality and cost-effectiveness in CS.

METHODS

A nationwide analysis was performed using the K-NHIS database. Patients diagnosed with CS and admitted to the ICU at tertiary hospitals were enrolled. ICU nursing grade was defined according to the bed-to-nurse ratio: grade1 (bed-to-nurse ratio < 0.5), grade2 (0.5 ≤ bed-to-nurse ratio < 0.63), and grade3 (0.63 ≤ bed-to-nurse ratio < 0.77) or above. The primary endpoint was in-hospital mortality. Cost-effective analysis was also performed.

RESULTS

Of the 72,950 patients with CS, 27,216 (37.3%) were in ICU nursing grade 1, 29,710 (40.7%) in grade 2, and 16,024 (22.0%) in grade ≥ 3. The adjusted-OR for in-hospital mortality was significantly higher in patients with grade 2 (grade 1 vs. grade 2, 30.6% vs. 37.5%, adjusted-OR 1.14, 95% CI1.09-1.19) and grade ≥ 3 (40.6%) with an adjusted-OR of 1.29 (95% CI 1.23-1.36) than those with grade 1. The incremental cost-effectiveness ratio of grade1 compared with grade 2 and ≥ 3 was $25,047/year and $42,888/year for hospitalization and $5151/year and $5269/year for 1-year follow-up, suggesting that grade 1 was cost-effective. In subgroup analysis, the beneficial effects of the high-intensity nursing grade on mortality were more prominent in patients who received CPR or multiple vasopressors usage.

CONCLUSIONS

For patients with CS, ICU grade 1 with a high-intensity nursing staff was associated with reduced mortality and more cost-effectiveness during hospitalization compared to grade 2 and grade ≥ 3, and its beneficial effects were more pronounced in subjects at high risk of CS.

Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices

Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.

Clinical profile, management and outcomes of patients with cardiogenic shock undergoing transfer between centers in Spain

INTRODUCTION AND OBJECTIVES

The aim of this study was to analyze the clinical profile, management, and prognosis of ST segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) requiring interhospital transfer, as well as the prognostic impact of structural variables of the treating centers in this setting.

METHODS

This study included patients with STEMI-CS treated at revascularization-capable centers from 2016 to 2020. The patients were divided into the following groups: group A: patients attended throughout their admission at hospitals with interventional cardiology without cardiac surgery; group B: patients treated at hospitals with interventional cardiology and cardiac surgery; and group C: patients transferred to centers with interventional cardiology and cardiac surgery. We analyzed the association between the volume of STEMI-CS cases treated, the availability of cardiac intensive care units (CICU), and heart transplant with hospital mortality.

RESULTS

A total of 4189 episodes were included: 1389 (33.2%) from group A, 2627 from group B (62.7%), and 173 from group C (4.1%). Transferred patients were younger, had a higher cardiovascular risk, and more commonly underwent revascularization, mechanical circulatory support, and heart transplant during hospitalization (P<.001). The crude mortality rate was lower in transferred patients (46.2% vs 60.3% in group A and 54.4% in group B, (P<.001)). Lower mortality was associated with a higher volume of care and CICU availability (OR, 0.75, P=.009; and 0.80, P=.047).

CONCLUSIONS

The proportion of transfers in patients with STEMI-CS in our setting is low. Transferred patients were younger and underwent more invasive procedures. Mortality was lower among patients transferred to centers with a higher volume of STEMI-CS cases and CICU.

Consensus statements from the International Society for Heart and Lung Transplantation consensus conference: Heart failure-related cardiogenic shock

The last decade has brought tremendous interest in the problem of cardiogenic shock. However, the mortality rate of this syndrome approaches 50%, and other than prompt myocardial revascularization, there have been no treatments proven to improve the survival of these patients. The bulk of studies have been in patients with acute myocardial infarction, and there is little evidence to guide the clinician in those patients with heart failure cardiogenic shock (HF-CS). An International Society for Heart and Lung Transplant consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals) with vast clinical and published experience in CS, representing 42 centers worldwide. This consensus report summarizes the results of a premeeting survey answered by participants and the breakout sessions where predefined clinical issues were discussed to achieve consensus in the absence of robust data. Key issues discussed include systems for CS management, including the "hub-and-spoke" model vs a tier-based network, minimum levels of data to communicate when considering transfer, disciplines that should be involved in a "shock team," goals for mechanical circulatory support device selection, and optimal flow on such devices. Overall, the document provides expert consensus on some important issues facing practitioners managing HF-CS. It is hoped that this will clarify areas where consensus has been reached and stimulate future research and registries to provide insight regarding other crucial knowledge gaps.

Heart failure related cardiogenic shock: An ISHLT consensus conference content summary

In recent years, there have been significant advancements in the understanding, risk-stratification, and treatment of cardiogenic shock (CS). Despite improved pharmacologic and device-based therapies for CS, short-term mortality remains as high as 50%. Most recent efforts in research have focused on CS related to acute myocardial infarction, even though heart failure related CS (HF-CS) accounts for >50% of CS cases. There is a paucity of high-quality evidence to support standardized clinical practices in approach to HF-CS. In addition, there is an unmet need to identify disease-specific diagnostic and risk-stratification strategies upon admission, which might ultimately guide the choice of therapies, and thereby improve outcomes and optimize resource allocation. The heterogeneity in defining CS, patient phenotypes, treatment goals and therapies has resulted in difficulty comparing published reports and standardized treatment algorithms. An International Society for Heart and Lung Transplantation (ISHLT) consensus conference was organized to better define, diagnose, and manage HF-CS. There were 54 participants (advanced heart failure and interventional cardiologists, cardiothoracic surgeons, critical care cardiologists, intensivists, pharmacists, and allied health professionals), with vast clinical and published experience in CS, representing 42 centers worldwide. State-of-the-art HF-CS presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues, including but not limited to models of CS care delivery, patient presentations in HF-CS, and strategies in HF-CS management. This consensus report summarizes the contemporary literature review on HF-CS presented in the first half of the conference (part 1), while the accompanying document (part 2) covers the breakout sessions where the previously agreed upon clinical issues were discussed with an aim to get to a consensus.

The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation

Extracorporeal membrane oxygenation (ECMO) was first started for humans in early 1970s by Robert Bartlett. Since its inception, there have been numerous challenges with extracorporeal circulation, such as coagulation and platelet activation, followed by consumption of coagulation factors and platelets, and biocompatibility of tubing, pump, and oxygenator. Unfractionated heparin (heparin hereafter) has historically been the defacto anticoagulant until recently. Also, coagulation monitoring was mainly based on bedside activated clotting time and activated partial thromboplastin time. In the past 50 years, the technology of ECMO has advanced tremendously, and thus, the survival rate has improved significantly. The indication for ECMO has also expanded. Among these are clinical conditions such as postcardiopulmonary bypass, sepsis, ECMO cardiopulmonary resuscitation, and even severe coronavirus disease 2019 (COVID-19). Not surprisingly, the number of ECMO cases has increased according to the Extracorporeal Life Support Organization Registry and prolonged ECMO support has become more prevalent. It is not uncommon for patients with COVID-19 to be on ECMO support for more than 1 year until recovery or lung transplant. With that being said, complications of bleeding, thrombosis, clot formation in the circuit, and intravascular hemolysis still remain and continue to be major challenges. Here, several clinical ECMO experts, including the "Father of ECMO"-Dr. Robert Bartlett, describe the history and advances of ECMO.

Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting

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.

The Successful Rotor Wing Transport of 2 Patients Requiring Biventricular Impella Support: A Case Series and Review

Despite many advances in care, the mortality rate for cardiogenic shock remains high. Because the medical management of patients with cardiogenic shock is limited, many patients often require mechanical circulatory support. As such, cardiogenic shock patients requiring percutaneous ventricular support devices such as the Impella (Abiomed, Danvers, MA) may be encountered by critical care transport crews with increasing frequency. Recently, biventricular Impella support has been described as a mechanical support strategy for biventricular failure. This case series describes the successful rotor wing transport of 2 patients with severe cardiogenic shock requiring biventricular Impella support and presents a review of Impella RP (Abiomed) and biventricular Impella support devices for the critical care transport medicine clinician.

Protocolised Management of Cardiogenic Shock and Shock Teams: A Narrative Review

Despite advances in therapy, the incidence of cardiogenic shock continues to increase, with significant mortality that has improved minimally over time. Treatment options for cardiogenic shock are complex and time-, resource-, and case volume-dependent, and involve multiple medical specialties. To provide early, more equitable, and standardised access to cardiogenic shock expertise with advanced therapies, cardiogenic shock teams with a protocolised treatment approach have been proposed. These processes have been applied across hospitals into integrated cardiogenic shock networks. This narrative review evaluates the role of cardiogenic shock teams, protocolised and regionalised shock networks, and the main individual components of protocolised shock management approaches.

[Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest]

Objectives

Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown.

Objective

We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA.

Materials and methods

. We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume.

Results

Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups.

Conclusions

After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.

Trends and Outcomes of Cardiogenic Shock in Patients With End-Stage Renal Disease: Insights From USRDS Database

BACKGROUND

There is a paucity of data regarding epidemiology, temporal trends, and outcomes of patients with cardiogenic shock (CS) and end-stage renal disease (chronic kidney disease stage V on hemodialysis).

METHODS

This is a retrospective cohort study using the United States Renal Data System database from January 1, 2006 to December 31, 2019. We analyzed trends of CS, percutaneous mechanical support (intraaortic balloon pump, percutaneous ventricular assist device [Impella and Tandemheart], and extracorporeal membrane oxygenation) utilization, index mortality, 30-day mortality, and 1-year all-cause mortality in end-stage renal disease patients.

RESULTS

A total of 43 825 end-stage renal disease patients were hospitalized with CS (median age, 67.8 years [IQR, 59.4-75.8] and 59.1% men). From 2006 to 2019, the incidence of CS increased from 275 to 578 per 100 000 patients (Ptrend<0.001). The index mortality rate declined from 54.1% in 2006 to 40.8% in 2019 (Ptrend=0.44), and the 1-year all-cause mortality decreased from 63% in 2006 to 61.8% in 2018 (Ptrend=0.73), but neither trend was statistically significant. There was a significantly decreased utilization of intra-aortic balloon pumps from 17 832 to 7992 (Ptrend<0.001), increased utilization of percutaneous ventricular assist device from 137 to 5201 (Ptrend<0.001) and increase in extracorporeal membrane oxygenation use from 69 to 904 per 100 000 patients (Ptrend<0.001). After adjusting for covariates, there was no significant difference in index mortality between CS patients requiring percutaneous mechanical support versus those not requiring percutaneous mechanical support (odds ratio, 0.97 [CI, 0.91-1.02]; P=0.22). On multivariable regression analysis, older age, peripheral vascular disease, diabetes, and time on dialysis were independent predictors of higher index mortality.

CONCLUSIONS

The incidence of CS in end-stage renal disease patients has doubled without significant change in the trend of index mortality despite the use of percutaneous mechanical support.

Prevention and management of critical care complications in cardiogenic shock: a narrative review

BACKGROUND

Cardiogenic shock (CS) is a common cause of morbidity and mortality in cardiac intensive care units (CICUs), even in the contemporary era.

MAIN TEXT

Although mechanical circulatory supports have recently become widely available and used in transforming the management of CS, their routine use to improve outcomes has not been established. Transportation to a high-volume center, early reperfusion, tailored mechanical circulatory supports, regionalized systems of care with multidisciplinary CS teams, a dedicated CICU, and a systemic approach, including preventing noncardiogenic complications, are the key components of CS treatment strategies.

CONCLUSIONS

This narrative review aimed to discuss the challenges of preventing patients from developing CS-related complications and provide a comprehensive practical approach for its management.

Relationship between the volume of cases and in-hospital mortality in patients with cardiogenic shock receiving short-term mechanical circulatory support

BACKGROUND

We examined the relationship between annual case volume at each hospital and outcome in cardiogenic shock (CS) patients receiving mechanical circulatory support (MCS) devices.

METHODS

This cross-sectional study used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients, 3 subcohorts were created; the intra-aortic balloon pump (IABP) alone (n = 48,643), the extracorporeal membrane oxygenation (ECMO) (n = 16,871), and the Impella cohorts (n = 696).

RESULTS

The median annual case volume was 13.5 (7.4-22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0-10.7) in the Impella cohort. The highest quintile for the volume of cases in the IABP alone and ECMO had the lowest in-hospital mortality (IABP alone, 25.1% in quintile 1 vs 15.2% in quintile 5; ECMO, 73.7% in quintile 1 in 67.4% in quintile 5). Adjusted ORs for in-hospital mortality decreased as case volume increased (IABP alone, 0.63 [0.58-0.68] in quintile 5; ECMO, 0.73 [0.65-0.82] in quintile 5, with the lowest quintile as reference) but did not decrease significantly in the Impella (0.90 [0.58-1.39] in tertile 3, with the lowest tertile as reference). In the continuous models with the case volume as a continuous variable, adjusted ORs for in-hospital mortality decreased to 28 IABP cases/year and 12 ECMO cases/year. They did not decrease or became almost flat above that.

CONCLUSIONS

Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline. Centralizing patients with refractory CS in a particular hospital might improve patient outcomes in each region.

Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without Cardiogenic Shock

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.

Cardiogenic Shock Classification and Associated Mortality Risk

The Society for Cardiovascular Angiography and Interventions (SCAI) Shock Classification was developed to create standardized language describing the severity of cardiogenic shock (CS). The purposes of this review were to evaluate short-term and long-term mortality rates at each SCAI shock stage for patients with or at risk for CS, which has not been studied previously, and to propose using the SCAI Shock Classification to develop algorithms for clinical status monitoring. A detailed literature search was conducted for articles published from 2019 through 2022 in which the SCAI shock stages were used to assess the mortality risk. In total, 30 articles were reviewed. The SCAI Shock Classification at hospital admission revealed a consistent and reproducible graded association between shock severity and mortality risk. Furthermore, shock severity correlated incrementally with mortality risk even after patients were stratified for diagnosis, treatment modalities, risk modifiers, shock phenotype, and underlying cause. The SCAI Shock Classification system can be used to evaluate mortality across populations of patients with or at risk for CS including those with different causes, shock phenotypes, and comorbid conditions. We propose an algorithm that uses clinical parameters incorporating the SCAI Shock Classification into the electronic health record to continually reassess and reclassify the presence and severity of CS across time throughout hospitalization. The algorithm has the potential to alert the care team and a CS team, leading to earlier recognition and stabilization of the patient, and may facilitate the use of treatment algorithms and prevent CS deterioration, leading to improved outcomes.