2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices in Cardiovascular Care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of Value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention)

Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy

Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.

Understanding long-term risk in Percutaneous Coronary Intervention (PCI) in the Australian contemporary era with a focus on defining Complex Revascularisation in High-Risk Indicated Patients (CHIP)

BACKGROUND

Complex Revascularisation in High-Risk Indicated Patients (CHIP) is emerging in Percutaneous Coronary Intervention (PCI). We document the frequency and outcomes following CHIP PCI in the Australian population, to understand risk and guide clinical decision-making. We propose a scoring system to define CHIP procedures.

METHODS

Patients undergoing PCI from Melbourne Intervention Group registry between 2005 and 2018 were analysed. Patients were stratified based on the number of high-risk features defined as 1)presence of ≥3 patient factors including age > 75yo, COPD, diabetes, renal impairment (eGFR<60 mL/min/1.73 m2), PVD, and 2)LVEF<30 %, and/or 3)having one complex coronary anatomical feature such as LMCA PCI, ACC/AHA B2/C lesion PCI, presence of multi-vessel disease or CTO PCI. National Death Index linkage was performed for long-term mortality analysis. Outcomes were analysed according to 4 risk categories - low risk(score 0), intermediate risk(score 1), high-risk(score 2), and very high-risk(score 3).

RESULTS

20,973patients were analysed. Majority of patients underwent intermediate-risk procedures(71.7 %), with low rates of high-risk(6.6 %), and very high-risk(0.2 %). Lesion success inversely correlates with risk; low-risk(99.4 %), intermediate-risk(95.1 %), high-risk(94.3 %), very high-risk(92.5 %),p < 0.001. In-hospital and 30-day death correlates with risk; low-risk(0.0 %/0.1 %), intermediate-risk(0.3 %/0.5 %), high-risk(1.5 %/2.9 %), very high-risk(2.4 %/7.1 %),p < 0.001. Long-term mortality correlates with risk; low-risk(12.3 %), intermediate-risk(15.8 %), high-risk(49.3 %), very high-risk(76.2 %),p < 0.001. On multivariate analysis, increasing risk correlates with long-term mortality; intermediate-risk(HR1.41), high-risk(HR6.42), and very high-risk(14.05).

CONCLUSION

In the Australian practice, proportion of patients undergoing high and very high-risk PCI procedures are low. Despite good procedural success and in-hospital outcomes, long-term mortality is poor. Further research into appropriate patient selection, and direct comparison of CHIP PCI to those treated medically and surgically should be considered.

Association of Preprocedural SYNTAX Score With Outcomes in Impella-Assisted High-Risk Percutaneous Coronary Intervention

Background

Patients with complex coronary artery disease, as defined by high SYNTAX scores, undergoing percutaneous coronary intervention (PCI) have poorer outcomes when compared with patients with lower SYNTAX I scores. This study aimed to assess if mechanical circulatory support using Impella mitigates the effect of the SYNTAX I score on outcomes after high-risk percutaneous coronary intervention (HRPCI).

Methods

Using data from the PROTECT III study, patients undergoing Impella-assisted HRPCI between March 2017 and March 2020 were divided into 3 cohorts based on SYNTAX I score-low (≤22), intermediate (23-32), and high (≥33). Procedural and clinical outcomes out to 90 days were compared between groups. Multivariable regression analysis was used to assess the impact of SYNTAX I score on major adverse cardiovascular and cerebrovascular events (MACCE) at 90 days.

Results

A total of 850 subjects with core laboratory-adjudicated SYNTAX I scores were identified (low: n = 310; intermediate: n = 256; high: n = 284). Patients with high SYNTAX I scores were older than those with low or intermediate SYNTAX I scores (72.7 vs 69.7 vs 70.1 years, respectively; P < .01). After adjustment for covariates, high SYNTAX I score remained a significant predictor of 90-day MACCE (hazard ratio [HR], 2.14; 95% CI, 1.42-3.69; P < .01 vs low), whereas intermediate SYNTAX I score was not (HR, 0.92; 95% CI, 0.47-1.77; P = .80 vs low). These findings persisted after adjustment for post-PCI SYNTAX I score.

Conclusions

A high SYNTAX I score was associated with higher rates of 90-day MACCE in patients who underwent Impella-assisted HRPCI. Further research is needed to understand the patient and procedural factors driving this finding.

Peripheral artery disease and extracorporeal membrane oxygenation: Examining a high-risk cohort over time

OBJECTIVE

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a resource-intensive approach for the management of refractory cardiogenic shock. Within this population exists a substantial cohort of patients with peripheral artery disease (PAD), which independently increases the risk of complications and all-cause mortality. We studied 10-year national trends of the impact of PAD among VA-ECMO recipients to better understand the prevalence of PAD and implications on outcomes in this vulnerable population.

METHODS

This 10-year retrospective, propensity score-matched study identified all adult patients (≥18) who underwent VA-ECMO between 2009 and 2018, from a large US database (National Inpatient Sample). Patients with an ICD diagnosis of PAD were identified. The primary endpoints of in-hospital mortality, bleeding complications and major limb loss (above- or below-knee amputation) were compared between patients with PAD to those without.

RESULTS

A total of 6768 patients were identified, of which 342 (5.3%) had PAD. The median age at admission was significantly higher in PAD patients [64 years vs. 55 years; p < .01], as was male gender [71% vs. 64%; p < .01]. Patients with PAD had higher rates of smoking (38.9% vs. 23.3%), hypertension (71.1% vs. 50%), diabetes (37.4% vs. 27.0%), chronic kidney disease (30.1% vs. 18.0%), coronary artery disease (76.0% vs. 35.0%) and dyslipidemia (76.0% vs. 35.0); all p < .01. After propensity-matching 2:1 for comorbidities, PAD patients were found to have significantly greater overall complications, including in-hospital mortality, bleeding, surgical wound infections, pseudoaneurysms, and major adverse limb events [71.9% vs. 63.9%; p < .01]. Subgroup analysis revealed greater in-hospital mortality [62.2% vs. 55.3%; p < .05], major amputations [4.1% vs. 0.3%; p < .01] and blood transfusions [32.2% vs. 26.2%; p < .05] in PAD patients. Over 2014-2018, the non-PAD group demonstrated statistically discernable trends in a 51.1% decrease in overall complications and a 28.1% increase in survival to discharge (all p < .01). Over the same time period the PAD cohort experienced a modest, nonsignificant, decrease in complications [7.0%, p = .40] and a decrease in those surviving to discharge [47.1% vs. 40.5%, p = .91].

CONCLUSION

Patients with PAD on VA-ECMO are sicker at baseline and experience significantly greater major amputations and higher in-hospital mortality. They have not benefitted from the considerable decrease in complication rates and increase in survival to discharge over time as compared to their non-PAD counterparts. These findings demonstrate the substantial frailty of the PAD population within an already high-risk cohort, and highlight the need for better procedural approaches and innovative technologies.

Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

Racial, Ethnic, Socioeconomic, and Geographic Inequities in Access to Mechanical Circulatory Support

Background

Hospital admissions for cardiogenic shock have increased in the United States. Temporary mechanical circulatory support (tMCS) can be used to acutely stabilize patients. We sought to evaluate the presence of racial, ethnic, and socioeconomic inequities in access to MCS in the United States among patients with cardiogenic shock.

Methods

Medicare data were used to identify patients with cardiogenic shock admitted to hospitals with advanced tMCS (microaxial left ventricular assist device [mLVAD] or extracorporeal membranous oxygenation [ECMO]) capabilities within the 25 largest core-based statistical areas, all major metropolitan areas. We modeled the association between patient race, ethnicity, and socioeconomic status and use of mLVAD or ECMO.

Results

After adjusting for age and clinical comorbidities, dual eligibility for Medicaid was associated with a 19.9% (95% CI, 11.5%-27.4%) decrease in odds of receiving mLVAD in a patient with cardiogenic shock (P < .001). After adjusting for age, clinical comorbidities, and dual eligibility for Medicaid, Black race was associated with 36.7% (95% CI, 28.4%-44.2%) lower odds of receiving mLVAD in a patient with cardiogenic shock. Dual eligibility for Medicaid was associated with a 62.0% (95% CI, 60.8%-63.1%) decrease in odds of receiving ECMO in a patient with cardiogenic shock (P < .001). Black race was associated with 36.0% (95% CI, 16.6%-50.9%) lower odds of receiving ECMO in a patient with cardiogenic shock, after adjusting for Medicaid eligibility.

Conclusions

We identified large and significant racial, ethnic, and socioeconomic inequities in access to mLVAD and ECMO among patients presenting with cardiogenic shock to metropolitan hospitals with active advanced tMCS programs. These findings highlight systematic inequities in access to potentially lifesaving therapies.

Intra-aortic balloon pump versus percutaneous Impella© in emergency revascularisation for myocardial infarction and cardiogenic shock: systematic review

OBJECTIVES

Mortality rates in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) remain persistently high despite advances over the past decade in percutaneous mechanical circulatory support. This systematic review aims to analyse the existing literature to compare mortality outcomes in patients mechanically supported by intra-aortic balloon pump or percutaneous Impella 2.5/CP© for AMI-CS undergoing emergency revascularisation.

METHODS

The following MeSH terms were applied to the databases Ovid Medline, Ovid Embase, Cochrane and Web of Science: 'Intra-aortic balloon pump', 'Impella', 'Cardiogenic shock', 'Myocardial Infarction' and 'Mortality'. This yielded 2643 studies. Using predefined inclusion and exclusion criteria, the studies were initially screened by title and abstract before full text analysis.

RESULTS

Fourteen studies met eligibility criteria: two randomised controlled trials (RCTs) and 12 observational studies. Data from a total of 21,006 patients were included across the studies. Notably, one study claimed reduced mortality with IABP versus control, and one study concluded that Impella© improved survival rates over the IABP. The average 30-day all-cause mortality in patients supported by IABP was 38.1%, 54.3% in Impella© groups and 39.4% in control groups.

CONCLUSION

AMI-CS presents an important cohort of patients in whom conducting RCTs is difficult. As a result, the literature is limited. Analysis of the available literature suggests that there is insufficient evidence to support superior survival in those supported by IABP or Impella© when compared to control despite suggestions that the Impella© offers superior haemodynamic support. Limitations of the studies have been discussed to outline suggestions for future research.

Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management

Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.

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.

Role of Mechanical Circulatory Support in Acute MI Management

Cardiogenic shock complicating acute MI carries high mortality and morbidity in many cases. Mechanical circulatory support devices are often used in these cases, aimed at improving patient-centered outcomes, although there is a lack of large randomized clinical trial-based evidence for many of such devices. Various circulatory support devices are available with their associated risks and benefits. Ideal circulatory support device intends to unload the myocardium, halt the spiral of ischemia, provide support for revascularization, and/or allow time for myocardial recovery. In this review paper, the commonly used mechanical circulatory support devices available for use in acute myocardial infarction settings are discussed, and the pros and cons of these devices are examined, considering the contemporary data for each. While this is an evolving field, the authors believe this paper can be helpful to review the current status of the use of mechanical support devices in the setting of acute MI and highlight some of the unmet needs in this field.

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery

In the United States, about one million people are seen to visit the operating theater for cardiac surgery annually. However, nearly half of these visits result in complications such as renal, neurological, and cardiac injury of varying degrees. Historically, many mechanisms and approaches have been explored in attempts to reduce injuries associated with cardiac surgery and percutaneous procedures. Devices such as cardioplegia, mechanical circulatory support, and other methods have shown promising results in managing and preventing life-threatening cardiac-surgery-related outcomes such as heart failure and cardiogenic shock. Comparably, cardioprotective devices such as TandemHeart, Impella family devices, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) have also been proven to show significant cardioprotection through mechanical support. However, their use as interventional agents in the prevention of hemodynamic changes due to cardiac surgery or percutaneous interventions has been correlated with adverse effects. This can lead to a rebound increased risk of mortality in high-risk patients who undergo cardiac surgery. Further research is necessary to delineate and stratify patients into appropriate cardioprotective device groups. Furthermore, the use of one device over another in terms of efficacy remains controversial and further research is necessary to assess device potential in different settings. Clinical research is also needed regarding novel strategies and targets, such as transcutaneous vagus stimulation and supersaturated oxygen therapy, aimed at reducing mortality among high-risk cardiac surgery patients. This review explores the recent advances regarding the use of cardioprotective devices in patients undergoing percutaneous procedures and cardiac surgery.

Pulmonary artery flotation catheter (PAFC) combined with pump-controlled retrograde trial off (PCRTO) as a trial for weaning VA-ECMO patients: A retrospective study

OBJECTIVES

Pump-controlled retrograde trial off (PCRTO) has been recently proposed as an effective and safe VA-ECMO weaning method. However, reports of haemodynamic monitoring during PCRTO are rare. Therefore, the purpose of this study was to investigate the changes in the left and right heart function during the PCRTO process combined with a pulmonary artery flotation catheter (PAFC).

METHODS

Between March 2019 and May 2021, 20 adult VA-ECMO patients who underwent PCRTO in combination with PAFC were enrolled in this study. The patients' general characteristics, PCRTO results, haemodynamic parameters during PCRTO progression, complications, and clinical prognoses were analysed. Those who survived for 48 h after withdrawal and did not require ECMO assistance were defined as the success group, and those who did not survive for 48 h after withdrawal or who required ECMO assistance were defined as the failure group.

RESULTS

Of the 20 patients, 13 (65%) were included in the success group, and 7 (35%) were included in the failure group. Compared with the success group, the heart rate (HR) of the failure group was significantly increased 30 min after PCRTO (p < .01), and the pulmonary artery wedge pressure (PAWP) was significantly higher at all time points (p < .01). Compared with pre-PCRTO in the success group, the HR at 2 min in the success group was significantly increased, but decreased to the baseline levels at 15 min and 30 min. The PAWP was also significantly increased at 2 min, but decreased at 15 min and dropped to the baseline level at 30 min in the success group. Compared with pre-PCRTO in the failure group, the HR and PAWP increased significantly at 2 min, 15 min and 30 min in the failure group. No new embolism-related complications were found in the success group after the withdrawal from ECMO.

CONCLUSIONS

PCRTO is a safe and reliable VA-ECMO weaning method. Combined with haemodynamic monitoring through PAFC, PCRTO can better assess the cardiac reserve function.

Prophylactic ECMO Support during Elective Coronary Percutaneous Interventions in High-Risk Patients: A Single-Center Experience

Introduction

Evidence regarding the impact of prophylactic implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for elective high-risk percutaneous coronary intervention (PCI) is limited. The purpose of this paper is to evaluate the outcome during index hospitalization and 3 years after interventions.

Methods

This is an observational retrospective study including all patients undergoing elective, high-risk PCI and receiving VA-ECMO for cardiopulmonary support. Primary endpoints were in-hospital and 3- year major adverse cardiovascular and cerebrovascular event (MACCE) rates. Secondary endpoints were vascular complications, bleeding, and procedural success.

Results

Nine patients were included in total. All patients were considered inoperable by the local heart team, and 1 patient had a previous coronary artery bypass graft (CABG). All patients were hospitalized for an acute heart failure episode 30 days before the index procedure. Severe left ventricular dysfunction was present in 8 patients. The main target vessel was the left main coronary artery in 5 cases. Complex PCI techniques were used: bifurcations with 2 stents in 8 patients, rotational atherectomy was performed in 3, and coronary lithoplasty in 1 case. PCI was successful in all of the patients with revascularization of all target and additional lesions. Eight of the 9 patients survived for at least 30 days after the procedure, and 7 patients survived for 3 years after the procedure. Regarding the complication rate, 2 patients suffered from limb ischemia and were treated by an antegrade perfusion, 1 patient had a femoral perforation that needed surgical repair, 6 patients had a hematoma, 5 patients had a significant drop in hemoglobin of more than 2 g/dl and received blood transfusions, 2 patients were treated for septicemia, and 2 patients needed hemodialysis.

Conclusions

Prophylactic use of VA-ECMO in elective patients is an acceptable strategy for revascularization by high-risk coronary percutaneous interventions with good long-term outcomes for patients considered inoperable when a clear clinical benefit is expected. Regarding the potential risk of complications due to a VA-ECMO system, the selection of candidates in our series was based on a multiparameter analysis. The two main triggers in favor of prophylactic VA-ECMO in our studies were the presence of a recent heart failure episode and the high probability of periprocedural prolonged impairment of the coronary flow through the major epicardial artery.

Temporary Mechanical Circulatory Support: Left, Right, and Biventricular Devices

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.

Mechanical Circulatory Support for Right Ventricular Failure

Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated as high as 70–75%. RV failure may occur following cardiac surgery in conjunction with left ventricular failure, or may be isolated in certain circumstances, such as inferior MI with RV infarction, pulmonary embolism or following left ventricular assist device placement. Medical management includes volume optimisation and inotropic and vasopressor support, and a subset of patients may benefit from mechanical circulatory support for persistent RV failure. Increasingly, percutaneous and surgical mechanical support devices are being used for RV failure. Devices for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow RV assist devices, surgically implanted RV assist devices and veno-arterial extracorporeal membrane oxygenation. In this review, the authors discuss the indications, candidate selection, strategies and outcomes of mechanical circulatory support for RV failure.

A Comprehensive Review of Mechanical Circulatory Support Devices

Treatment strategies to combat cardiogenic shock (CS) have remained stagnant over the past decade. Mortality rates among patients who suffer CS after acute myocardial infarction (AMI) remain high at 50%. Mechanical circulatory support (MCS) devices have evolved as novel treatment strategies to restore systemic perfusion to allow cardiac recovery in the short term, or as durable support devices in refractory heart failure in the long term. Haemodynamic parameters derived from right heart catheterization assist in the selection of an appropriate MCS device and escalation of mechanical support where needed. Evidence favouring the use of one MCS device over another is scant. An intra-aortic balloon pump is the most commonly used short-term MCS device, despite providing only modest haemodynamic support. Impella CP® has been increasingly used for CS in recent times and remains an important focus of research for patients with AMI-CS. Among durable devices, Heartmate® 3 is the most widely used in the USA. Adequately powered randomized controlled trials are needed to compare these MCS devices and to guide the operator for their use in CS. This article provides a brief overview of the types of currently available MCS devices and the indications for their use.

Device profile of the Impella 5.0 and 5.5 system for mechanical circulatory support for patients with cardiogenic shock: overview of its safety and efficacy

INTRODUCTION

Trans-valvular micro-axial flow pumps such as Impella are increasingly utilized in patients with cardiogenic shock [CS]. A number of different Impella devices are now available providing a wide range of cardiac output. Among these, the Impella 5.0 and recently introduced Impella 5.5 pumps can provides 5.55 L/min of flow, enabling complete left ventricular support with more favorable hemodynamic effects on myocardial oxygen consumption and left ventricular unloading. These devices require placement of a surgical conduit graft for endovascular delivery, but are increasingly being used in patients with CS due to acutely decompensated heart failure [ADHF], acute myocardial infarction [AMI] and after cardiac surgery as a bridge to transplant or durable ventricular assist device surgery or myocardial recovery.

AREAS COVERED

This review focuses on the device profile and use of the Impella 5.0 and 5.5 systems in patients with CS. Specifically; we reviewed the published literature for Impella 5.0 device to summarize data regarding safety and efficacy.

EXPERT OPINION

The Impella 5.0 and 5.5 are trans-valvular micro-axial flow pumps for which the current data suggest excellent safety and efficacy profiles as approaches to provide circulatory support, myocardial unloading, and axillary placement enabling patient mobilization and rehabilitation.

ABBREVIATIONS

pMCS, Percutaneous mechanical circulatory support devices; CS, Cardiogenic shock; ADHF, Acute decompensated heart failure; AMI, Acute myocardial infarction; LVAD, Left ventricular assist deviceI; ABP, Intra-aortic balloon pump; VA-ECLS, Veno-arterial extracorporeal life support.

Left Heart Decompression on Veno-Arterial Extracorporeal Membrane Oxygenation in Children With Dilated Cardiomyopathy and Myocarditis: An Extracorporeal Life Support Organization Registry Review

OBJECTIVES

To describe the association between left heart decompression on veno-arterial extracorporeal membrane oxygenation and survival in patients with myocarditis and dilated cardiomyopathy. The secondary outcome is to study association of left heart decompression with survival in children with myocarditis compared with those with dilated cardiomyopathy.

DESIGN

Retrospective study of a multicenter registry database.

SETTING

Data reported to Extracorporeal Life Support Organization from international extracorporeal membrane oxygenation centers.

PATIENTS

Patients less than or equal to 18 years old with a diagnosis of myocarditis or dilated cardiomyopathy receiving extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 1,438 pediatric extracorporeal membrane oxygenation runs were identified. Thirty-seven percent of the patients had myocarditis (n = 532), whereas the rest had dilated cardiomyopathy. Survival to hospital discharge was 63%. Median extracorporeal membrane oxygenation duration was 148 hours with interquartile range (84-248 hr). Nineteen percent of patients (n = 274) had left heart decompression. Multivariable analysis revealed using left heart decompression (adjusted odds ratio, 1.42; 95% CI, 1.06-1.89; p = 0.02), e-cardiopulmonary resuscitation (adjusted odds ratio, 0.63; 95% CI, 0.51-0.79; p < 0.001), higher pH (adjusted odds ratio, 3.69; 95% CI, 1.80-7.53; p < 0.001), and diagnosis of myocarditis (adjusted odds ratio, 1.69; 95% CI, 1.35-2.08; p < 0.001) were associated with greater odds of survival. In the multivariable analysis for patients with dilated cardiomyopathy, left heart decompression failed to reveal a significant association with survival (20% among survivors vs 17% among nonsurvivors, 95% CI, -2.2% to 8.0%). Meanwhile in patients with myocarditis, the multivariable analysis failed to exclude the possibility that left heart decompression was associated with up to a three-fold greater odds of survival (adjusted odds ratio, 1.77; 95% CI, 0.99-.15).

CONCLUSIONS

Retrospective review of the Extracorporeal Life Support Organization registry revealed an association between left heart decompression and greater odds of survival in children with myocarditis and dilated cardiomyopathy on extracorporeal membrane oxygenation. When comparing patients with dilated cardiomyopathy against those with myocarditis, we could not exclude a three-fold greater odds of survival associated with the use of left heart decompression. This finding warrants further prospective evaluation.

Adverse Events of Percutaneous Microaxial Left Ventricular Assist Devices-A Retrospective, Single-Centre Cohort Study

Worldwide, the left ventricular assist device Impella^® (Abiomed, Danvers, MA, USA) is increasingly implanted in patients with acute cardiogenic shock or undergoing high-risk cardiac interventions. Despite its long history of use, few studies have assessed its safety and possible complications associated with its use. All patients treated with a left-sided Impella^® device at the University Hospital of Basel from 1 January 2011 to 31 December 2019 were enrolled. The primary endpoint was the composite rate of mortality and adverse events (bleeding, acute kidney injury, and limb ischemia). Out of 281 included patients, at least one adverse event was present in 262 patients (93%). Rates of in-hospital, 90-day, and one-year mortality were 48%, 47%, and 50%, respectively. BARC type 3 bleeding (62%) and hemolysis (41.6%) were the most common complications. AKI was observed in 50% of all patients. Renal replacement therapy was required in 97 (35%) of all patients. Limb ischemia occurred in 13% of cases. Bleeding and hemolysis are common Impella^®-associated complications. Additionally, we found a high rate of AKI. A careful selection of patients receiving microaxial LV support and defining the indication for its use are essential measures to be taken for the benefits to outweigh potential complications.

Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock

BACKGROUND

Cardiogenic shock is associated with substantial morbidity and mortality. Although inotropic support is a mainstay of medical therapy for cardiogenic shock, little evidence exists to guide the selection of inotropic agents in clinical practice.

METHODS

We randomly assigned patients with cardiogenic shock to receive milrinone or dobutamine in a double-blind fashion. The primary outcome was a composite of in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, transient ischemic attack or stroke diagnosed by a neurologist, or initiation of renal replacement therapy. Secondary outcomes included the individual components of the primary composite outcome.

RESULTS

A total of 192 participants (96 in each group) were enrolled. The treatment groups did not differ significantly with respect to the primary outcome; a primary outcome event occurred in 47 participants (49%) in the milrinone group and in 52 participants (54%) in the dobutamine group (relative risk, 0.90; 95% confidence interval [CI], 0.69 to 1.19; P = 0.47). There were also no significant differences between the groups with respect to secondary outcomes, including in-hospital death (37% and 43% of the participants, respectively; relative risk, 0.85; 95% CI, 0.60 to 1.21), resuscitated cardiac arrest (7% and 9%; hazard ratio, 0.78; 95% CI, 0.29 to 2.07), receipt of mechanical circulatory support (12% and 15%; hazard ratio, 0.78; 95% CI, 0.36 to 1.71), or initiation of renal replacement therapy (22% and 17%; hazard ratio, 1.39; 95% CI, 0.73 to 2.67).

CONCLUSIONS

In patients with cardiogenic shock, no significant difference between milrinone and dobutamine was found with respect to the primary composite outcome or important secondary outcomes. (Funded by the Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario; ClinicalTrials.gov number, NCT03207165.).

Herzinsuffizienz-Netzwerke – Struktur, Organisation, Ziele

Die zunehmende Inzidenz der Herzinsuffizienz, als häufigste zur Krankenhausaufnahme führende Gesundheitsstörung, bedarf in einer demografisch alternden Gesellschaft eines optimierten und ressourcensparenden Diagnostik- und Therapieplans in hierfür spezialisierten sektorenübergreifenden Herzinsuffizienz-Netzwerken (HF-NET), wo nicht nur die häufigen Komorbiditäten und Komplikationen, sondern auch die zunehmende Anzahl zur Verfügung stehender medikamentöser und interventioneller Therapiemöglichkeiten einen interdisziplinären und intersektoralen Versorgungsansatz bei limitierten Ressourcen ermöglicht. Insbesondere vor dem Hintergrund, dass der Verlauf der Herzinsuffizienz durch rezidivierende Dekompensation (meist Volumenretention etc.) charakterisiert ist, ermöglichen die im HF-NET optimierten Versorgungs- und Kommunikationsstrukturen der bei Herzinsuffizienz betroffenen Leistungserbringer, drohende Dekompensationen frühzeitiger und prognostisch relevant zu erkennen und zu behandeln.

The Effect of Clinical Characteristics and Stent Parameters on Left Ventricular Mechanical Dyssynchrony

Aim. To study short term effect of stent size and number on left ventricular mechanical dyssynchrony after elective percutaneous coronary intervention (PCI) to left anterior descending (LAD) artery.

Materials and methods. the study included 150 adult patients with LAD lesion treated with PCI using drug-eluting stent. Patients were evaluated pre PCI then 1 month and 3 months post PCI for evaluation of mechanical dyssynchrony using tissue synchronization image (TSI).

Results. Before revascularization mean left ventricular ejection fraction was 51.2±5.7 %, mean time to peak TSI was 213.6±10.9 ms; 1 month after PCI TSI improved significantly to 163.7±17.6 ms (p<0.001), 3 months after PCI showed more improvement to 120.7±26.9 ms (p<0.001). After 3m; 61 patients (40.7%) showed recovery to normal TSI value. The predictors of non-improvement of time to peak TSI after 3 months were diabetes mellitus (p=0.007), dyslipidemia (p=0.001) and stent length (p=0.001), number of stents (p=0.004). There were strong negative correlation between stent length and improvement of the time to peak TSI at 1 month (r=-0.352, p<0.001) and at 3 months (r=-0.509, p<0.001),and also with number of stent at 1 month (r= -0.173, p=0.034) and at 3 months (r=-0.499, p<0.001), but the correlation between stent diameter and improvement of the TSI wasn’t significant neither at 1 month nor at 3 months (r=0.055, p=0.504 and r= -0.018, p=0.827) respectively.

Conclusion. Increased number and length of the implanted stents were predictors to non-improvement of mechanical dyssynchrony, while stent diameter didn’t affects the recovery.

Comparison of anticoagulated versus non-anticoagulated patients with intra-aortic balloon pumps

Background

There is limited guidance regarding the use of anticoagulation in patients on intra-aortic balloon pumps (IABP). The purpose of this study is to compare the safety outcomes in anticoagulated versus non-anticoagulated patients with an IABP.

Methods

This was a single center, retrospective chart review of patients admitted to the coronary care unit or cardiac surgery unit who received an IABP from May 2015 to July 2018. Patients who were anticoagulated with heparin while on an IABP were compared to those who were not anticoagulated. Major endpoints included a composite of thrombotic events and a composite of bleeding events. The major composite endpoint of thrombotic events included the incidence of ischemic stroke, any venous thromboembolism, device thrombosis, and limb ischemia. The major composite endpoint of bleeding events included major access site bleeding, minor access site bleeding, major non-access site bleeding, and minor non-access site bleeding. Minor endpoints included any major endpoint events occurring within 24 and 48 h of IABP insertion, hospital length of stay, intensive care unit length of stay, and in-hospital mortality.

Results

A total of 185 patients were evaluated for inclusion and 147 were included in the final analysis. There were 82 and 65 patients in the heparin and non-heparin groups, respectively. The composite endpoint of thrombotic events occurred in 7.3 and 7.7% in the heparin and non-heparin groups, respectively (p = 1). The composite bleeding endpoint occurred in 20.7 and 20.0% in the heparin and non-heparin groups, respectively (p = 0.91). There were no differences found in minor endpoints between groups.

Conclusion

There were no significant differences found in major endpoints of bleeding and thrombotic events in patients who received anticoagulation while on an IABP versus those who did not receive anticoagulation.

Fondaparinux During Intra-Aortic Balloon Pump Counterpulsation in Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Although anticoagulation with unfractionated heparin (UFH) is commonly used during intra-aortic balloon pump (IABP) counterpulsation to prevent thromboembolic events, no data or guidelines exist to support this strategy, especially in the setting of acute myocardial infarction (AMI). This study sought to compare the short-term outcome of UFH vs fondaparinux in AMI patients who underwent successful percutaneous coronary intervention (PCI) and IABP insertion.

METHODS

The anticoagulation therapy of revascularised AMI patients who received IABP counterpulsation and admitted to a tertiary hospital in the last decade was retrospectively evaluated. The primary outcome was the occurrence of all-cause mortality, stroke or transient ischaemic attack, reinfarction, unplanned revascularisation, major or minor limb ischaemia, and any bleeding at 1 month. Propensity score matching was performed to compare the primary outcome between UFH and fondaparinux.

RESULTS

Of 1,355 AMI survivors at 2 days after hospital admission and who underwent successful PCI, an IABP was inserted in 197 (14.5%): 72 (36.5%) were treated with UFH and 125 (63.5%) with fondaparinux (2.5 mg o.d.). At clinical follow-up, completed in 98.5% of cases, the incidence of the primary outcome was 22.5% in UFH and 5.7% in fondaparinux groups (p=0.0009). More than two-thirds of the events included in the primary outcome were related to early bleeding complications. In the matched cohort of 62 patients, the primary outcome occurred in 14 (45.2%) patients in the UFH and two (6.5%) in the fondaparinux group (p=0.01).

CONCLUSIONS

This study suggested that fondaparinux is safer, by reducing early bleeding complications at one month, than UFH in the management of IABP.

Effectiveness of fondaparinux vs unfractionated heparin following percutaneous coronary intervention in survivors of out-of-hospital cardiac arrest due to acute myocardial infarction

AIM

There is no specific evidence on the antithrombotic management of survivors of out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI). We sought to compare the short-term outcome of unfractioned heparin (UFH) vs fondaparinux in OHCA survivors due to AMI admitted in our Institution in the last decade.

METHODS

We performed a retrospective cohort study on survivors of OHCA due to AMI managed with UFH or fondaparinux during the hospitalization. The primary outcome was the occurrence of any bleeding, all-cause mortality, cerebrovascular accidents, re-MI, and unplanned revascularization at 1 month. A propensity-score matching was performed to compare the outcome between UFH and fondaparinux.

RESULTS

Out of 2083 AMI patients undergoing successful PCI, OHCA was present in 94 (4.5%): 41 (43.6%) treated with UFH and 53 (56.4%) with fondaparinux. At clinical follow-up, the incidence of the primary outcome was 65.9% in UFH and 35.8% in fondaparinux group (p = 0.007). More than half of the events included in the primary outcome were related to bleeding complications. In the matched cohort of 56 patients, the primary outcome occurred in 46.4% and 25.0% (p = 0.16), while bleeding was present in 32.1% and 7.1% (p = 0.04), in the UFH and fondaparinux group, respectively.

CONCLUSIONS

The present analysis suggests that fondaparinux is safer than UFH in the management of OHCA due to AMI by reducing early bleeding complications at one month.

ECPella: Concept, Physiology and Clinical Applications

Addition of Impella on top of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has gained wide interest as it might portend improved outcomes in patients with cardiogenic shock. This has been consistently reported in retrospective propensity-matched studies, case series, and meta-analyses. The pathophysiologic background is based on the mitigation of ECMO-related side effects and the additive benefit of myocardial unloading. In this perspective, thorough knowledge of these mechanisms is required to optimize the management of mechanical circulatory support with this approach and introduce best practices, as the interplay between the two devices and the implantation-explantation strategies are key for success.

Impella support versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A meta-analysis

BACKGROUND

Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with high mortality rates. Data has shown that intra-aortic balloon pump (IABP) support does not provide a survival benefit over optimal medical therapy in AMICS. Despite lack of supportive evidence, IABP is still commonly used in these clinical situations. The Impella percutaneous ventricular assist device (PVAD) (Abiomed, Denver, MA) rapidly deploys superior mechanical circulatory support (MCS) in patients with AMICS. However, the safety and efficacy of Impella in AMICS is a matter of ongoing investigation, and its role in AMICS management is not yet fully established.

METHODS

The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to March 2020. Relevant randomized trials and observational studies comparing Impella versus IABP in AMICS were identified and a meta-analysis was performed using the random effect model. The efficacy endpoint of interest was short-term mortality (defined as in-hospital or 30-day mortality). The safety endpoints of interest were major bleeding, limb complications, stroke and hemolysis.

RESULTS

A total of 2 randomized trials and 5 observational studies with 3921 patients were included. No difference in short-term mortality between the two groups [RR 1.08, 95% CI 0.87-1.33, P = 0.49] was found. For safety endpoints, Impella was associated with significantly higher incidence of major bleeding [RR: 2.03, 95% CI 1.56-2.64, P < 0.0001], limb complications [RR: 3.67, 95% CI 1.56-8.65, P = 0.003] as well as hemolysis [RR: 9.46, 95% CI 1.75-51.22, P = 0.009] compared with IABP. No significant difference was observed for the incidence of stroke [RR: 1.07 95% CI 0.34-3.31 P = 0.91].

CONCLUSION

Impella support in AMICS patients was associated with a significantly increased risk of bleeding, limb complications and hemolysis without an improved short-term survival advantage compared with IABP.

Mechanical circulatory support in the management of life-threatening arrhythmia

Life-threatening refractory unstable ventricular arrhythmias in presence of advanced heart failure (HF) may determine haemodynamic impairment. Haemodynamic mechanical support (HMS) in this setting has a relevant role to restore end-organ perfusion. Catheter ablation (CA) of ventricular tachycardia (VT) is effective at achieving rhythm stabilization, allowing patient's weaning from HMS, or bridging to permanent HF treatments. Acute heart decompensation during CA at anaesthesia induction in presence of advanced heart disease, in selected cases requires a preemptive HMS to prevent periprocedure adverse outcomes. Substrate ablation during sinus rhythm (SR) might be an effective strategy of ablation in presence of unstable VTs; however, in a minority of patients, it might have some limitations and might be unfeasible in some settings, including the case of the mechanical induction of several unstable VTs and the absence of ablation targets. In case of the persistent induction of unstable VTs after a previous failure of a substrate-based ablation in SR, a feasible alternative strategy of ablation might be VT activation/entrainment mapping supported by HMS. Multiple devices are available for HMS in the low-output states related to electrical storm and during CA of VT. The choice of the device is not standardized and it is based on the centres' expertise. The aim of this article is to provide an up-to-date review on HMS for the management of life-threatening arrhythmias, in the context of catheter ablation and discussing our approach to manage critical VT patients.

Impella percutaneous left ventricular assist device as mechanical circulatory support for cardiogenic shock: A retrospective analysis from a tertiary academic medical center

OBJECTIVES

To describe hemodynamic efficacy and clinical outcomes of Impella percutaneous left ventricular assist device (pLVAD) in patients with cardiogenic shock (CS).

BACKGROUND

Percutaneous LVADs are increasingly used in CS management. However, device-related outcomes and optimal utilization remain active areas of investigation.

METHODS

All CS patients receiving pLVAD as mechanical circulatory support (MCS) between 2011 and 2017 were identified. Clinical characteristics and outcomes were analyzed. A multivariable logistic regression model was created to predict MCS escalation despite pLVAD. Outcomes were compared between early and late implantation.

RESULTS

A total of 115 CS patients (mean age 63.6 ± 13.8 years; 69.6% male) receiving pLVAD as MCS were identified, the majority with CS secondary to acute myocardial infarction (AMI; 67.0%). Patients experienced significant cardiac output improvement (median 3.39 L/min to 3.90 L/min, p = .002) and pharmacological support reduction (median vasoactive-inotropic score [VIS] 25.4 to 16.4, p = .049). Placement of extracorporeal membrane oxygenation (ECMO) occurred in 48 (41.7%) of patients. Higher pre-pLVAD VIS was associated with subsequent MCS escalation in the entire cohort and AMI subgroup (OR 1.27 [95% CI 1.02-1.58], p = .034 and OR 1.72 [95% CI 1.04-2.86], p = .035, respectively). Complications were predominantly access site related (bleeding [9.6%], vascular injury [5.2%], and limb ischemia [2.6%]). In-hospital mortality was 57.4%, numerically greater survival was noted with earlier device implantation.

CONCLUSIONS

Treatment with pLVAD for CS improved hemodynamic status but did not uniformly obviate MCS escalation. Mortality in CS remains high, though earlier device placement for appropriately selected patients may be beneficial.

Hemodynamic adaptation of heart failure to percutaneous venoarterial extracorporeal circulatory supports

Extracorporeal life support (ECLS) is a treatment modality that provides prolonged blood circulation, gas exchange and can partially support or fully substitute functions of heart and lungs in patients with severe but potentially reversible cardiopulmonary failure refractory to conventional therapy. Due to high-volume bypass, the extracorporeal flow is interacting with native cardiac output. The pathophysiology of circulation and ECLS support reveals significant effects on arterial pressure waveforms, cardiac hemodynamics, and myocardial perfusion. Moreover, it is still subject of research, whether increasing stroke work caused by the extracorporeal flow is accompanied by adequate myocardial oxygen supply. The left ventricular (LV) pressure-volume mechanics are reflecting perfusion and loading conditions and these changes are dependent on the degree of the extracorporeal blood flow. By increasing the afterload, artificial circulation puts higher demands on heart work with increasing myocardial oxygen consumption. Further, this can lead to LV distention, pulmonary edema, and progression of heart failure. Multiple methods of LV decompression (atrial septostomy, active venting, intra-aortic balloon pump, pulsatility of flow) have been suggested to relieve LV overload but the main risk factors still remain unclear. In this context, it has been recommended to keep the rate of circulatory support as low as possible. Also, utilization of detailed hemodynamic monitoring has been suggested in order to avoid possible harm from excessive extracorporeal flow.

Cardiac intensive care management of high-risk percutaneous coronary intervention using the venoarterial ECMO support

The emerging concept of high-risk percutaneous coronary intervention (HR-PCI) has required the adoption of a multidisciplinary team approach. Venoarterial ECMO (VA-ECMO) has been introduced as a temporary mechanical circulatory support (MCS) for HR-PCI patients in order to provide an adequate systemic perfusion during the procedure. Both patient's complexity and technological evolutions have catalyzed the development of critical care cardiology; however, ECMO therapy faces several challenges. Indeed, the management of patients on ECMO remains complex; moreover, the lack of specific recommendation for HR-PCI patients further complicates the management of these patients. In this narrative review, we give a reappraisal for the management of HR-PCI patients supported with VA-ECMO according to the available data published in current literature.

Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock

BACKGROUND

Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI).

OBJECTIVE

We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI.

METHODS

We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation.

RESULTS

Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs.

CONCLUSIONS

Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.

Prophylactic veno-arterial extracorporeal membrane oxygenation in patients undergoing high-risk percutaneous coronary intervention

PURPOSE

Complex high-risk percutaneous coronary intervention (PCI) is challenging and frequently accompanied by haemodynamic instability. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide cardiopulmonary support in high-risk PCI. However, the outcome is unclear.

METHODS

A two-centre, retrospective study was performed of all patients undergoing high-risk PCI and receiving VA-ECMO for cardiopulmonary support.

RESULTS

A total of 14 patients (92% male, median age 69 (53-83) years), of whom 50% had previous coronary artery disease in the form of a coronary artery bypass graft (36%) and a PCI (14%) underwent high-risk PCI and received VA-ECMO support. The main target lesion was a left main coronary artery in 78%, a left anterior descending artery in 14%, a right coronary artery in 7%, and 71% underwent multi-vessel PCI in addition to main target vessel PCI. The median SYNTAX score was 27.2 (8-42.5) and in 64% (9/14) there was a chronic total occlusion. Left ventricular function was mildly impaired in 7% (1/14), moderately impaired in 14% (2/14) and severely impaired in 64% (9/14). Cannulation was femoral-femoral in all patients. Median ECMO run was 2.57 h (1-4). Survival was 93% (13/14). One patient died during hospitalisation due to refractory cardiac failure. All other patients survived to discharge. Complications occurred in 14% (2/14), with one patient developing a transient ischaemic attack post-ECMO and one patient developing a thrombus in the femoral vein used for ECMO cannulation.

CONCLUSION

VA-ECMO in high-risk PCI is feasible with a good outcome. It can be successfully used for cardiopulmonary support in selected patients.

Impact of left-ventricular end-diastolic pressure as a predictor of periprocedural hemodynamic deterioration in patients undergoing Impella supported high-risk percutaneous coronary interventions

BACKGROUND

An increasing number of high-risk percutaneous coronary interventions (PCI) are performed with mechanical circulatory support (MCS) to minimize the risk of periprocedural hemodynamic compromise. Prior studies have demonstrated that an elevated left-ventricular end-diastolic pressure (LVEDP) is associated with worse outcome after acute myocardial infarction or cardiac surgery. Although LVEDP is frequently measured, little is known about the usefulness for predicting periprocedural hemodynamic deterioration in high-risk PCI. The objective of this study is to assess the impact of preprocedural measured LVEDP in non-shock patients undergoing high-risk PCI with MCS on periprocedural hemodynamic deterioration.

METHODS AND RESULTS

We reviewed the PCI protocol and the Automated Impella Controller in a consecutive series of 64 patients (mean age 73 years, 80% male), who underwent high-risk PCI with Impella MCS (period 01/2017-12/2018). LVEDP (17 ± 8 mm Hg) was measured in all cases before Impella insertion and start of PCI. Periprocedural hemodynamic deterioration was defined as: systolic blood pressure (SBP) drop (decrease ≥20 mm Hg or ≤90 mm Hg), or transient loss of arterial pressure pulsatility. Hemodynamic deterioration occurred in 33% (n = 21) of all patients but did not lead to a hemodynamic compromise due to the Impella support. Regression analysis of LVEDP for periprocedural hemodynamic deterioration or in-hospital major adverse cardiac and cerebrovascular events (MACCE) showed no significant results.

CONCLUSION

LVEDP was not associated with periprocedural hemodynamic deterioration or a higher rate of in-hospital MACCE. Our data propose that LVEDP may not be used as a risk stratification variable for MCS usage in non-shock patients undergoing high-risk PCI.

Mechanical circulatory support in cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock remains a complex clinical syndrome with high morbidity and mortality. The purpose of this article is to review important landmark trials as well as the relevant recent literature for percutaneous mechanical circulatory support following acute myocardial infarction.

RECENT FINDINGS

The sole use of intraaortic balloon pumps for cardiogenic shock following acute myocardial infarction continues to be questioned with downgrading of its recommendation in recent years, there however may remain a role in patients with mechanical complications of their myocardial infarction. The combined use of extracorporeal circulatory support and a ventricular unloading device appears to be promising with increasing data supporting this strategy.

SUMMARY

Given the complex and heterogeneous nature of cardiogenic shock there remains somewhat limited robust data to guide clinical practice. Ongoing research is needed to help guide improvements in patient outcomes.

Haemodynamic efficacy of microaxial left ventricular assist device in cardiogenic shock: a systematic review and meta-analysis

The Impella percutaneous mechanical circulatory support device is designed to augment cardiac output and reduce left ventricular wall stress and aims to improve survival in cases of cardiogenic shock. In this meta-analysis we investigated the haemodynamic effects of the Impella device in a clinical setting. We systematically searched all articles in PubMed/Medline and Embase up to July 2019. The primary outcomes were cardiac power (CP) and cardiac power index (CPI). Survival rates and other haemodynamic data were included as secondary outcomes. For the critical appraisal, we used a modified version of the U.S. Department of Health and Human Services quality assessment form. The systematic review included 12 studies with a total of 596 patients. In 258 patients the CP and/or CPI could be extracted. Our meta-analysis showed an increase of 0.39 W [95% confidence interval (CI): 0.24, 0.54], (p = 0.01) and 0.22 W/m² (95% CI: 0.18, 0.26), (p < 0.01) for the CP and CPI, respectively. The overall survival rate was 56% (95% CI: 0.50, 0.62), (p = 0.09). The quality of the studies was moderate, mostly due to the presence of confounders. Our study suggests that in patients with cardiogenic shock, Impella support seems effective in augmenting CP(I). This study merely investigates the haemodynamic effectiveness of the Impella device and does not reflect the complete clinical impact for the patient.

Mechanical circulatory support device-heart hysteretic interaction can predict left ventricular end diastolic pressure

The full potential of mechanical circulatory systems in the treatment of cardiogenic shock is impeded by the lack of accurate measures of cardiac function to guide clinicians in determining when to initiate and how to optimally titrate support. The left ventricular end diastolic pressure (LVEDP) is an established metric of cardiac function that refers to the pressure in the left ventricle at the end of ventricular filling and immediately before ventricular contraction. In clinical practice, LVEDP is typically only inferred from, and poorly correlates with, the pulmonary capillary wedge pressure (PCWP). We leveraged the position of an indwelling percutaneous ventricular assist device and advanced data analysis methods to obtain LVEDP from the hysteretic operating metrics of the device. We validated our hysteresis-derived LVEDP measurement using mock flow loops, an animal model of cardiac dysfunction, and data from a patient in cardiogenic shock to show greater measurement precision and correlation with actual pressures than traditional inferences via PCWP. Delineation of the nonlinear relationship between device and heart adds insight into the interaction between ventricular support devices and the native heart, paving the way for continuous assessment of underlying cardiac state, metrics of cardiac function, potential closed-loop automated control, and rational design of future innovations in mechanical circulatory support systems.

Effects of Impella on Coronary Perfusion in Patients With Critical Coronary Artery Stenosis

BACKGROUND

Mechanical circulatory support devices are used to maintain hemodynamic stability during high-risk percutaneous coronary interventions. Little is known on the effects of such devices on coronary hemodynamics in patients with significant coronary stenosis. We sought to investigate whether mechanical circulatory support in the form of Impella (Abiomed Inc, Danvers, MA) can improve coronary hemodynamics in the presence of a critical coronary stenosis.

METHODS AND RESULTS

We examined coronary perfusion pressures and coronary pressure distal to a critical stenosis using a coronary pressure wire in 11 patients (12 coronary lesions) undergoing high-risk percutaneous coronary interventions with the use of mechanical circulatory support. Systemic, ventricular, and coronary hemodynamics were obtained at both minimum and maximum support levels before high-risk percutaneous coronary interventions. All patients had obstructive lesions with angiographically estimated diameter stenosis between 70% and 99% and distal coronary artery pressure to aortic pressure ratios between 0.44 and 0.88. When compared with minimum support, maximum support resulted in a decrease in the left ventricular end-diastolic pressure (27.3±8.6 versus 21.5±5.2 mm Hg; P=0.002) and increases in the mean systemic blood pressure (77.6±13.5 versus 88.2±12.2 mm Hg; P<0.001) and mean distal coronary pressure (51.8±20.2 versus 60.8±18.1 mm Hg; P<0.001). Effective coronary perfusion pressure (mean aortic pressure-left ventricular end-diastolic pressure) significantly increased with maximum support (49.8±15.7 versus 67.2±13.6 mm Hg; P<0.001). Diastolic perfusion pressure (diastolic blood pressure-left ventricular end-diastolic pressure) also significantly increased with maximum support (32.9±13.4 versus 52.0±11.6 mm Hg; P<0.001).

CONCLUSIONS

Mechanical circulatory support with Impella can improve distal coronary pressure and coronary perfusion pressures in the presence of critical coronary stenosis.

Mechanical circulatory support in cardiogenic shock from acute myocardial infarction: Impella CP/5.0 versus ECMO

Background:

Short-term mechanical circulatory support devices are increasingly used in cardiogenic shock after acute myocardial infarction. As no randomised evidence is available, the choice between high-output Impella or extra-corporeal membrane oxygenation (ECMO) is still a matter of debate. Real-life data are necessary to assess adverse outcomes and to help guide the treatment decision between the different devices. The purpose of this study was to compare characteristics and clinical outcomes of Impella CP/5.0 with ECMO support in patients with cardiogenic shock from myocardial infarction.

Methods:

A retrospective, two-centre study was performed on all cardiogenic shock from myocardial infarction patients with Impella CP/5.0 or ECMO support, from 2006 until 2018. The primary outcome was 30-day mortality. Potential baseline imbalance between the groups was adjusted using inverse probability treatment weighting, and survival analysis was performed with an adjusted log-rank test. Secondarily, the occurrence of device-related complications (limb ischaemia, access site-related bleeding, access site-related infection) was evaluated.

Results:

A total of 128 patients were included (Impella, N=90; ECMO, N=38). The 30-day mortality was similar for both groups (53% vs. 49%, P=0.30), also after adjustment for potential baseline imbalance between the groups (weighted log-rank P=0.16). Patients with Impella support had significantly fewer device-related complications than patients treated with ECMO (respectively, 17% vs. 40%, P<0.01).

Conclusions:

Patients treated with Impella CP/5.0 or ECMO for cardiogenic shock after myocardial infarction did not differ in 30-day mortality. More device-related complications occurred with ECMO compared to Impella support.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Nutritional support in patients with extracorporeal life support and ventricular assist devices

PURPOSE OF REVIEW

Extracorporeal life support (ECLS) including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VAD) provide mechanical pulmonary and circulatory support, respectively, in patients with acute pulmonary or cardiovascular failure. This review discusses recently published data regarding specific topics of nutritional support in patients with ECLS and VAD.

RECENT FINDINGS

ECLS may aggravate loss of endogenous and exogenous micronutrients and macronutrients. Observational studies have shown that enteral nutrition is feasible and most commonly used in patients with ECLS. Indirect calorimetry may be feasible for measuring energy expenditure during ECLS. Specific tools are available to assess malnutrition or nutrition risk in patients with VAD but require further validation in the perioperative setting. If parenteral nutrition is indicated, the use of intravenous lipid emulsions may be associated with membrane oxygenator dysfunction of the ECLS device or increased infectious risk in patients with VAD.

SUMMARY

Despite the exponential use of ECLS and VAD over the last decade, the role of nutrition on clinical outcome in this patient population remains an important but yet underinvestigated field.

Volume-Outcome Relationships in Extracorporeal Membrane Oxygenation: Retrospective Analysis of Administrative Data From Pennsylvania, 2007-2015

This article seeks to understand whether a volume-outcome relationship exists in adult extracorporeal membrane oxygenation (ECMO). We examined primary administrative discharge data from the Pennsylvanian Health Care Cost Containment Council for all 2,948 consecutive adults treated with ECMO in Pennsylvania between January 1, 2007, and December 31, 2015. We used a well-fitting backwards stepwise logistic regression to obtain patient-level predicted mortality. Number of cases and risk-adjusted mortality was aggregated by calendar quarter and by hospital. Graphical and correlation analysis was used to understand the volume-outcome relationship, focusing separately on the impact of a hospital's current scale (annual volume of adult ECMO) and a hospital's cumulative experience (total cumulative volume of adult ECMO since starting operations). We found that more than 9 years, there was essentially no reduction in overall risk-adjusted mortality in the state. For individual hospitals, once institutions had as few as 50 cases' total experience or performed just 10 cases annually, there was no clear improvement in outcomes. Patients in hospitals with fewer than 50 cases ever performed appeared objectively less sick compared with patients in hospital with more experience. We conclude that there is little evidence of volume-outcome relationships in adult ECMO in this state, although we acknowledge that the absence of clinical chart data limits these conclusions.

Identification of Hypotensive Emergency Department Patients with Cardiogenic Etiologies

OBJECTIVE

Identify predictors of cardiogenic etiology among emergency department (ED) patients with hypotension, and use these predictors to create a clinical tool to discern cardiogenic etiology of hypotension.

METHODS

This secondary analysis evaluated a prospective cohort of consecutive patients with hypotension in an urban, academic, tertiary care ED from November 2012 to September 2013. We included adults with hypotension, defined as a new vasopressor requirement, systolic blood pressure (SBP) < 90 mm Hg after at least 1 L of crystalloid or 2 units packed red blood cells, or SBP < 90 mm Hg and fluids withheld due to concern for fluid overload. The primary outcome was cardiogenic etiology, adjudicated by two physician chart review, with 25% paired chart review (kappa = 0.92). We used multivariable logistic regression to predict cardiogenic etiology, utilizing clinical data abstracted from the electronic medical record. We created a prediction score from significant covariates and calculated its test characteristics for cardiogenic hypotension.

RESULTS

Of 700 patients with hypotension, 107 (15.3%, 95% CI: 12.6%-18.0%) had cardiogenic etiology. Independent predictors of cardiogenic etiology were shortness of breath (OR 4.1, 95% CI: 2.5-6.7), troponin > 0.1 ng/mL (37.5, 7.1-198.2), electrocardiographic ischemia (8.9, 4.0-19.8), history of heart failure (2.0, 1.1-3.3), and absence of fever (4.5, 2.3-8.7) (area under the curve [AUC] = 0.83). The prediction score created from these predictors yielded 78% sensitivity and 77% specificity for cardiogenic etiology (AUC = 0.827).

CONCLUSIONS

Clinical predictors offer reasonable ED screening sensitivity for cardiogenic hypotension, while demonstrating sufficient specificity to facilitate early cardiac interventions.