Pulmonary Artery Catheter Usage and Impact on Mortality in Patients With Cardiogenic Shock: Results From a Canadian Single-Centre Registry

From Escalate to Elevate: A New Paradigm for Comprehensive Cardiogenic Shock Management

Patients with cardiogenic shock (CS) present with critical hemodynamic compromise with low cardiac output (CO) resulting in end-organ dysfunction. Prognosis is closely related to the severity of shock, and treatment of patients with CS is resource intensive. In this review, we consider the current treatment paradigms alongside the evidence that underpins them. The current standard of treatment relies on a feedback mechanism, where small changes in treatment are assessed to see if clinical improvement occurs. This leads to delays that increase time in the shock state. The novel approach described proposes immediate treatment to ameliorate the shock state to "break" the shock spiral as quickly and decisively as possible, suggesting new metrics to measure performance.

The Comparative Epidemiology, Pathophysiology and Management of Cardiogenic Shock Associated With Acute Myocardial Infarction and Advanced Heart Failure

Cardiogenic shock (CS) results from low cardiac output caused by myocardial dysfunction, coupled with systemic end-organ tissue hypoperfusion and elevated ventricular filling pressures, along a spectrum of shock severity. This narrative review aims to compare the epidemiology, pathophysiology, and contemporary management of 2 common etiologies of CS caused by acute myocardial infarction (AMI-CS) and advanced heart failure (HF-CS). CS complicates up to 14% of AMI and 5% of HF admissions. Rapid therapeutic intervention after prompt recognition of CS etiology is the mainstay toward improving clinical outcomes and mitigating end-organ sequelae and death. In AMI-CS, persistent hypotension often leads to subsequent hypoperfusion and congestion, and early culprit coronary artery lesion revascularization is critical. In HF-CS, congestion often precedes hypoperfusion and hypotension, and targeting the underlying nonischemic cause of myocardial dysfunction is key. Tailoring of hemodynamic strategies with vasoactive agents and temporary mechanical circulatory and end-organ support to manage the predominant ventricular failure, hemometabolic phenotypes, and shock severity associated with each etiology is discussed. Given the limited evidence-base in CS care, we also highlight potential knowledge gaps ripe for future exploration.

Toward a Universal Definition for Right Heart Failure: A Work in Progress

BACKGROUND

Broadly speaking, right heart failure (RHF) can be defined as a clinical syndrome with signs and symptoms of heart failure resulting from right ventricular dysfunction, as evidenced by abnormal structure or function. The heterogeneity of conditions associated with RHF combined with the challenges of characterizing the structural and functional relationships of the right ventricle make a singular definition of RHF elusive. We performed a concise scoping review of the literature that provides knowledge synthesis of RHF in different clinical populations, and extracted the recommended criteria to define the syndrome.

METHODS

Searches were conducted to identify reviews, guidelines, consensus statements, systematic reviews, meta-analyses, and consensus statements concerning right heart or right ventricular failure in well-described adult human disease populations from the previous 10 years. After removal of case reports and duplicates, publications describing syndromes in the context of left-sided heart disease were also removed. Data extracted from selected manuscripts included the patient population and quantitative criteria to define RHF, categorized based on diagnostic modalities.

RESULTS

Of 9487 articles initially identified, 71 were selected for full text review. We found that the majority of the reviewed literature offered multifaceted diagnostic approaches, including clinical, echocardiographic, hemodynamic, and therapeutic characteristics, with unique additions or omissions depending on the clinical contexts. Nomenclature for RHF was variable, and only 40% of articles articulated a narrative definition.

CONCLUSIONS

At this time, development of consistent criteria and a universal definition for RHF remains a work in process.

Age-specific differences of Impella support in Japanese patients: The Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD) registry analysis on outcomes and adverse events

BACKGROUND

The association between the clinical significance and prognostic impact of catheter-based micro-axial ventricular assist device Impella (Abiomed, Danvers, MA, USA) support and age has not been sufficiently investigated.

METHODS AND RESULTS

A total of 5282 patients treated with Impella were analyzed from the Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD). Patients were categorized into four age groups: <50 years old (Group A, n = 670), 50-69 years old (Group B, n = 2009), 70-79 years old (Group C, n = 1716), and ≥80 years old (Group D, n = 887). Kaplan-Meier curve analysis demonstrated that the prognosis, including 30-day all-cause mortality, was significantly poorer in Group D compared to the other groups. A multivariate Cox regression model identified Group D as an independent predictor of 30-day all-cause death (HR: 2.173, 95 % CI: 1.699-2.779) relative to Group A. The multivariate logistic regression analysis indicated that estimated glomerular filtration rate, lactate levels, and systolic blood pressure were independently associated with 30-day mortality across all age categories. The presence of more than two major adverse events was independently associated with 30-day mortality specifically in the cohort aged ≥80 years (OR: 1.492, 95 % CI: 1.037-2.148, p = 0.031).

CONCLUSION

Increasing age was identified as a significant factor associated with higher 30-day mortality rates in J-PVAD. While the incidence of major adverse events did not differ significantly across age categories, the occurrence of two or more additional adverse events was linked to increased 30-day mortality among older individuals. Therefore, an appropriate mechanical support strategy may be necessary for elderly Japanese patients based on their age.