1
|
Masi P, Gendreau S, Moyon Q, Leguyader M, Lebreton G, Ropers J, Dangers L, Sitruk S, Bréchot N, Pineton de Chambrun M, Chommeloux J, Schmidt M, Luyt CE, Leprince P, Combes A, Frere C, Hékimian G. Bleeding complications, coagulation disorders, and their management in acute myocardial infarction-related cardiogenic shock rescued by veno-arterial ECMO: A retrospective cohort study. J Crit Care 2024; 82:154771. [PMID: 38471248 DOI: 10.1016/j.jcrc.2024.154771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 02/21/2024] [Accepted: 03/05/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Management of dual antiplatelet therapy (DAPT) in patients on venoarterial-extracorporeal membrane (VA-ECMO) after acute myocardial infarction (AMI) is challenging. Our objective was to describe the frequency, management and outcomes of severe bleeding complications and determine their occurrence risk factors. MATERIAL AND METHODS We conducted a retrospective observational cohort study including post-AMI cardiogenic shock patients requiring VA-ECMO. Severe bleeding was defined based on the Bleeding Academic Research Consortium classification. We calculated multivariable Fine-Gray models to assess factors associated with risk of severe bleeding. RESULTS From January 2015 to July 2019, 176 patients received VA-ECMO after AMI and 132 patients were included. Sixty-five (49%) patients died. Severe bleeding occurred in 39% of cases. Severe thrombocytopenia (< 50 G/L) and hypofibrinogenemia (<1,5 g/L) occurred in respectively 31% and 19% of patients. DAPT was stopped in 32% of patients with a 6% rate of stent thrombosis. Anticoagulation was stopped in 39% of patients. Using a multivariate competing risk model, female sex, time on ECMO, troponin at admission and Impella® implantation were independently associated with severe bleeding. CONCLUSIONS Bleeding complications and coagulation disorders were frequent and severe in patients on VA-ECMO after AMI, leading of antiplatelet therapy withdrawal in one third of patients.
Collapse
Affiliation(s)
- Paul Masi
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France.
| | - Ségolène Gendreau
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France
| | - Quentin Moyon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Maxence Leguyader
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France
| | - Guillaume Lebreton
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Cardiothoracic surgery department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Jacques Ropers
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique des Hôpitaux Universitaires Pitié Salpêtrière -Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | - Laurence Dangers
- Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Samuel Sitruk
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique des Hôpitaux Universitaires Pitié Salpêtrière -Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | - Nicolas Bréchot
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Juliette Chommeloux
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Charles Edouard Luyt
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Pascal Leprince
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Cardiothoracic surgery department, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Alain Combes
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Corinne Frere
- Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Department of Hematology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, F-75013 Paris, France
| | - Guillaume Hékimian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive Réanimation, Paris, France; Sorbonne Université, Inserm, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| |
Collapse
|
2
|
Fisher T, Hill N, Kalakoutas A, Lahlou A, Rathod K, Proudfoot A, Warren A. Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis. Crit Care 2024; 28:192. [PMID: 38845019 PMCID: PMC11157877 DOI: 10.1186/s13054-024-04973-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/27/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock. MAIN BODY Cochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support. Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26-1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06-1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57-0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71-0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71-0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51-1.33, p = 0.42). CONCLUSION Even when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.
Collapse
Affiliation(s)
- Thomas Fisher
- North Bristol NHS Trust, Southmead Rd, Bristol, BS10 5NB, UK
| | - Nicole Hill
- Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, Avon, BA1 3NG, UK
| | | | - Assad Lahlou
- Barts Health Library Services, W Smithfield, London, EC1A 7BE, UK
| | - Krishnaraj Rathod
- Barts Health NHS Trust, W Smithfield, London, EC1A 7BE, UK
- William Harvey Research Institute, Barts and The London Faculty of Medicine and Dentistry, Queen Mary University of London, W Smithfield, London, EC1A 7BE, UK
| | - Alastair Proudfoot
- Barts Health NHS Trust, W Smithfield, London, EC1A 7BE, UK
- Critical Care and Perioperative Medicine Group, School of Medicine and Dentistry, Queen Mary University London, W Smithfield, London, EC1A 7BE, UK
| | - Alex Warren
- Barts Health NHS Trust, W Smithfield, London, EC1A 7BE, UK.
- Critical Care and Perioperative Medicine Group, School of Medicine and Dentistry, Queen Mary University London, W Smithfield, London, EC1A 7BE, UK.
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| |
Collapse
|
3
|
Vandenbriele C, M'Pembele R, Dannenberg L, Metzen D, Zako S, Helten C, Mourikis P, Ignatov D, Huhn R, Balthazar T, Adriaenssens T, Vanassche T, Meyns B, Panoulas V, Monteagudo-Vela M, Arachchillage D, Janssens S, Scherer C, Orban M, Petzold T, Horn P, Jung C, Zeus T, Price S, Westenfeld R, Kelm M, Polzin A. Heparin dosing in patients with Impella-supported cardiogenic shock. Int J Cardiol 2024; 399:131690. [PMID: 38160912 DOI: 10.1016/j.ijcard.2023.131690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Impella™ is increasingly used in cardiogenic shock. However, thromboembolic and bleeding events are frequent during percutaneous mechanical circulatory support (pMCS). OBJECTIVE Therefore, we aimed to explore the optimal anticoagulation regime for pMCS to prevent thromboembolism and bleedings. METHODS This hypothesis-generating multi-center cohort study investigated 170 patients with left-Impella™ support. We (A) compared bleeding/thrombotic events in two centers with therapeutic range (TR-aPTT) activated partial thromboplastin time (60-80s) and (B) compared events of these centers with one center with intermediate range aPTT (40-60s). RESULTS After matching, there were no differences in patients' characteristics. In centers aiming at TR-aPTT, major bleeding was numerically lower with aPTT <60s within 48 h of left-Impella™ support, versus patients that achieved the aimed aPTT of ≥60s [aPTT ≥60s: 22 (37.3%) vs. aPTT<60s 14 (23.7%); Hazard ratio [HR], 0.62 (95%) CI, 0.28-1.38; p = 0.234]. Major cardiovascular and cerebrovascular adverse events (MACCE) did not differ between groups. In comparison of centers, TR-aPTT strategy showed higher major bleeding rates [TR: 8 (47.1%) vs. intermediate range: 1 (5.9%); HR, 0.06 (95%) CI, 0.01-0.45; p = 0.006]. MACCE were lower in the intermediate range aPTT group as well [TR 12 (70.6%) vs. intermediate range 5 (29.4%) HR, 0.32 (95%) CI, 0.11-0.92; p = 0.034]. CONCLUSION This pilot analysis showed that lowering UFH-targets in left-Impella™ supported CS patients seems to be a safe and promising strategy for reducing major bleedings without increasing MACCE. This needs to be validated in larger, randomized clinical trials.
Collapse
Affiliation(s)
| | - René M'Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Germany
| | - Lisa Dannenberg
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Daniel Metzen
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Saif Zako
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Carolin Helten
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Philipp Mourikis
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Denis Ignatov
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Germany
| | - Tim Balthazar
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of cardiac surgery, University Hospitals Leuven, Belgium
| | - Vasileios Panoulas
- Department of Adult Intensive Care, Royal Brompton and Harefield Hospitals, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Maria Monteagudo-Vela
- Department of Adult Intensive Care, Royal Brompton and Harefield Hospitals, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Deepa Arachchillage
- Centre for haematology, Department of Immunology and Inflammation, Imperial College London, London, UK; Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Stefan Janssens
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Clemens Scherer
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Martin Orban
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Patrick Horn
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Christian Jung
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Tobias Zeus
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Susanna Price
- Department of Adult Intensive Care, Royal Brompton and Harefield Hospitals, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ralf Westenfeld
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Malte Kelm
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Amin Polzin
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
| |
Collapse
|
4
|
Thiele H. Cardiac ECMO: changing role in times of Impella and ventricular assist devices? Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01121-3. [PMID: 38456998 DOI: 10.1007/s00063-024-01121-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/01/2024] [Indexed: 03/09/2024]
Abstract
Mortality in infarct-related as well as heart failure-associated cardiogenic shock remains high, reaching 40-50% depending on the etiology and severity of cardiogenic shock. Percutaneous active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and microaxial left ventricular mechanical circulatory support devices are rapidly evolving in their use. However, evidence of VA-ECMO therapy has only recently emerged and showed no benefit for mortality, with an associated higher complication rate. Evidence for microaxial left ventricular mechanical circulatory support devices such as the Impella pump (Abiomed, Danvers/MA, USA) is limited. The current article aims to give an overview of the basics of VA-ECMO therapy and microaxial left ventricular mechanical circulatory support devices, the current evidence, ongoing trials, patient selection, and potential complications. This article is freely available.
Collapse
Affiliation(s)
- Holger Thiele
- Leipzig Heart Science, Leipzig, Germany.
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at Leipzig University, Strümpellstr. 39, 04289, Leipzig, Germany.
| |
Collapse
|
5
|
van Diepen S, Zheng Y, Senaratne JM, Tyrrell BD, Das D, Thiele H, Henry TD, Bainey KR, Welsh RC. Reperfusion in Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times. Circ Cardiovasc Interv 2024; 17:e013415. [PMID: 38293830 DOI: 10.1161/circinterventions.123.013415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/09/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND In patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the preferred revascularization option. Little is known about the efficacy and safety of a pharmacoinvasive approach for patients with cardiogenic shock presenting to a non-PCI hospital with prolonged interhospital transport times. METHODS In a retrospective analysis of geographically extensive ST-segment-elevation myocardial infarction network (2006-2021), 426 patients with cardiogenic shock and ST-segment-elevation myocardial infarction presented to a non-PCI-capable hospital and underwent reperfusion therapy (53.8% pharmacoinvasive and 46.2% pPCI). The primary clinical outcome was a composite of in-hospital mortality, renal failure requiring dialysis, cardiac arrest, or mechanical circulatory support, and the primary safety outcome was major bleeding defined as an intracranial hemorrhage or bleeding that required transfusion was compared in an inverse probability weighted model. The electrocardiographic reperfusion outcome of interest was the worst residual ST-segment-elevation. RESULTS Patients with pharmacoinvasive treatment had longer median interhospital transport (3 hours versus 1 hour) and shorter median symptom-onset-to-reperfusion (125 minute-to-needle versus 419 minute-to-balloon) times. ST-segment resolution ≥50% on the postfibrinolysis ECG was 56.6%. Postcatheterization, worst lead residual ST-segment-elevation <1 mm (57.3% versus 46.3%; P=0.01) was higher in the pharmacoinvasive compared with the pPCI cohort, but no differences were observed in the worst lead ST-segment-elevation resolution ≥50% (77.4% versus 81.8%; P=0.57). The primary clinical end point was lower in the pharmacoinvasive cohort (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26-0.72]; P<0.01) compared with patients who received pPCI. An interaction between interhospital transfer time and reperfusion strategy with all-cause mortality was observed, favoring a pharmacoinvasive approach with transfer times >60 minutes. The incidence of the primary safety outcome was 10.1% in the pharmacoinvasive arm versus 18.7% in pPCI (adjusted odds ratio, 0.41 [95% CI, 0.14-1.09]; P=0.08). CONCLUSIONS In patients with ST-segment-elevation myocardial infarction presenting with cardiogenic shock and prolonged interhospital transport times, a pharmacoinvasive approach was associated with improved electrocardiographic reperfusion and a lower rate of death, dialysis, or mechanical circulatory support without an increase in major bleeding.
Collapse
Affiliation(s)
- Sean van Diepen
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Janek M Senaratne
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | | | - Debraj Das
- CK Hui Heart Center, Edmonton, Alberta, Canada (B.D.T., D.D.)
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Germany (H.T.)
| | - Timothy D Henry
- Carl and Edyth Lindner Research Center at the Christ Hospital, Cincinnati, OH (T.D.H.)
| | - Kevin R Bainey
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Robert C Welsh
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| |
Collapse
|
6
|
Bartlett R, Arachichilage DJ, Chitlur M, Hui SKR, Neunert C, Doyle A, Retter A, Hunt BJ, Lim HS, Saini A, Renné T, Kostousov V, Teruya J. The History of Extracorporeal Membrane Oxygenation and the Development of Extracorporeal Membrane Oxygenation Anticoagulation. Semin Thromb Hemost 2024; 50:81-90. [PMID: 36750217 DOI: 10.1055/s-0043-1761488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
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.
Collapse
Affiliation(s)
- Robert Bartlett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Deepa J Arachichilage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College, Healthcare NHS Trust, London, United Kingdom
| | - Meera Chitlur
- Division of Hematology/Oncology, Central Michigan University School of Medicine, Children's Hospital of Michigan, Michigan
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Cindy Neunert
- Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Hoong Sern Lim
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Arun Saini
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Vadim Kostousov
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| |
Collapse
|
7
|
Droppa M, Geisler T. Optimal Antithrombotic Strategies in Cardiogenic Shock. J Clin Med 2024; 13:277. [PMID: 38202284 PMCID: PMC10779586 DOI: 10.3390/jcm13010277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/22/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
Cardiogenic shock (CS) represents a critical condition with a high mortality rate. The most common cause of CS is coronary artery disease, and patients typically present with myocardial infarction, necessitating immediate treatment through percutaneous coronary intervention (PCI) and often requiring mechanical circulatory support. CS is associated with a prothrombotic situation, while on the other hand, there is often a significant risk of bleeding. This dual challenge complicates the selection of an optimal antithrombotic strategy. The choice of antithrombotic agents must be personalized, taking into consideration all relevant conditions. Repeated risk assessment, therapeutic monitoring, and adjusting antithrombotic therapy are mandatory in these patients. This review article aims to provide an overview of the current evidence and practical guidance on antithrombotic strategies in the context of CS.
Collapse
Affiliation(s)
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital of Tuebingen, 72076 Tuebingen, Germany
| |
Collapse
|
8
|
Nishihira K, Honda S, Takegami M, Kojima S, Takahashi J, Itoh T, Watanabe T, Yamashita J, Saji M, Tsujita K, Takayama M, Sumiyoshi T, Kimura K, Yasuda S. Percutaneous coronary intervention for ST-elevation myocardial infarction complicated by cardiogenic shock in a super-aging society. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:847-855. [PMID: 37724765 DOI: 10.1093/ehjacc/zuad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/07/2023] [Accepted: 09/14/2023] [Indexed: 09/21/2023]
Abstract
AIMS ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMICS) is associated with substantial mortality. As life expectancy increases, percutaneous coronary intervention (PCI) is being performed more frequently, even in elderly patients with acute myocardial infarction (AMI). This study sought to investigate the characteristics and impact of PCI on in-hospital mortality in patients with STEMICS. METHODS AND RESULTS The Japan AMI Registry (JAMIR) is a retrospective, nationwide, real-world database. Among 46 242 patients with AMI hospitalized in 2011-2016, 2760 patients with STEMICS (median age, 72 years) were studied. We compared 2396 (86.8%) patients who underwent PCI with 364 (13.2%) patients who did not. The percentage of mechanical circulatory support use in patients with STEMICS was 69.3% and in-hospital mortality was 34.6%. Compared with patients who did not undergo PCI, patients undergoing PCI were younger and had a higher rate of intra-aortic balloon pump use. A higher proportion was male or current smokers. In-hospital mortality was significantly lower in the PCI group than in the no-PCI group (31.3% vs. 56.0%, P < 0.001). Percutaneous coronary intervention was independently associated with lower in-hospital mortality [adjusted odds ratio (OR), 0.508; 95% confidence interval (CI), 0.347-0.744]. In 789 (28.6%) patients aged ≥80 years, PCI was associated with fewer in-hospital cardiac deaths (adjusted OR, 0.524; 95% CI, 0.281-0.975), but was not associated with in-hospital mortality (adjusted OR, 0.564; 95% CI, 0.300-1.050). CONCLUSION In Japan, PCI was effective in reducing in-hospital cardiac death in elderly patients with STEMICS. Age alone should not preclude potentially beneficial invasive therapy.
Collapse
Affiliation(s)
- Kensaku Nishihira
- Department of Cardiology, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki 880-2102, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Public Health and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sunao Kojima
- Department of Cardiology, Sakura-jyuji Yatsushiro Rehabilitation Hospital, Kumamoto, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomonori Itoh
- Division of Community Medicine, Department of Medical Education/Division of Cardiology, Department of Medicine, Iwate Medical University, Morioka, Japan
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Jun Yamashita
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | | | | | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
9
|
Sandoval Y, Basir MB, Lemor A, Lichaa H, Alasnag M, Dupont A, Hirst C, Kearney KE, Kaki A, Smith TD, Vallabhajosyula S, Kayssi A, Firstenberg MS, Truesdell AG. Optimal Large-Bore Femoral Access, Indwelling Device Management, and Vascular Closure for Percutaneous Mechanical Circulatory Support. Am J Cardiol 2023; 206:262-276. [PMID: 37717476 DOI: 10.1016/j.amjcard.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/30/2023] [Accepted: 08/05/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Alejandro Lemor
- Department of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Hady Lichaa
- Ascension Saint Thomas Heart, Ascension Saint Thomas Rutherford, Murfreesboro, Tennessee
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | | | - Colin Hirst
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | | | - Amir Kaki
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | |
Collapse
|
10
|
Zeymer U, Freund A, Hochadel M, Ostadal P, Belohlavek J, Rokyta R, Massberg S, Brunner S, Lüsebrink E, Flather M, Adlam D, Bogaerts K, Banning A, Sabaté M, Akin I, Jobs A, Schneider S, Desch S, Thiele H. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials. Lancet 2023; 402:1338-1346. [PMID: 37643628 DOI: 10.1016/s0140-6736(23)01607-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with cardiogenic shock despite the lack of evidence from adequately powered randomised clinical trials. Three trials reported so far were underpowered to detect a survival benefit; we therefore conducted an individual patient-based meta-analysis to assess the effect of VA-ECMO on 30-day death rate. METHODS Randomised clinical trials comparing early routine use of VA-ECMO versus optimal medical therapy alone in patients presenting with infarct-related cardiogenic shock were identified by searching MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and trial registries until June 12, 2023. Trials were included if at least all-cause death rate 30 days after in-hospital randomisation was reported and trial investigators agreed to collaborate (ie, providing individual patient data). Odds ratios (ORs) as primary outcome measure were pooled using logistic regression models. This study is registered with PROSPERO (CRD42023431258). FINDINGS Four trials (n=567 patients; 284 VA-ECMO, 283 control) were identified and included. Overall, there was no significant reduction of 30-day death rate with the early use of VA-ECMO (OR 0·93; 95% CI 0·66-1·29). Complication rates were higher with VA-ECMO for major bleeding (OR 2·44; 95% CI 1·55-3·84) and peripheral ischaemic vascular complications (OR 3·53; 95% CI 1·70-7·34). Prespecified subgroup analyses were consistent and did not show any benefit for VA-ECMO (pinteraction ≥0·079). INTERPRETATION VA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted. FUNDING Foundation Institut für Herzinfarktforschung.
Collapse
Affiliation(s)
- Uwe Zeymer
- Institut für Herzinfarktforschung, Ludwigshafen, Germany; Klinikum Ludwigshafen, Ludwigshafen, Germany.
| | - Anne Freund
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Petr Ostadal
- Department of Cardiology, Na Homolce Hospital, Department of Cardiology and University Hospital Motol and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Belohlavek
- Department of Medicine II, General University Hospital and 1st Medical School, Charles University, Prague, Czech Republic
| | - Richard Rokyta
- Cardiology Department, University Hospital and Faculty of Medicine Pilsen, Charles University, Czech Republic
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
| | - Stefan Brunner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
| | - Enzo Lüsebrink
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich, Germany
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Kris Bogaerts
- KU Leuven, Department of Public Health and Primary Care, I-BioStat, Leuven and UHasselt, Hasselt, Belgium
| | - Amerjeet Banning
- Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Manel Sabaté
- Consorci Institut D'Investigacions Biomediques August Pi I Sunyer, Cardiovascular Institute, Hospital Clinic, Barcelona, Spain
| | - Ibrahim Akin
- University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Alexander Jobs
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Steffen Desch
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany.
| |
Collapse
|
11
|
Thiele H, Zeymer U, Akin I, Behnes M, Rassaf T, Mahabadi AA, Lehmann R, Eitel I, Graf T, Seidler T, Schuster A, Skurk C, Duerschmied D, Clemmensen P, Hennersdorf M, Fichtlscherer S, Voigt I, Seyfarth M, John S, Ewen S, Linke A, Tigges E, Nordbeck P, Bruch L, Jung C, Franz J, Lauten P, Goslar T, Feistritzer HJ, Pöss J, Kirchhof E, Ouarrak T, Schneider S, Desch S, Freund A. Extracorporeal Life Support in Infarct-Related Cardiogenic Shock. N Engl J Med 2023; 389:1286-1297. [PMID: 37634145 DOI: 10.1056/nejmoa2307227] [Citation(s) in RCA: 128] [Impact Index Per Article: 128.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Extracorporeal life support (ECLS) is increasingly used in the treatment of infarct-related cardiogenic shock despite a lack of evidence regarding its effect on mortality. METHODS In this multicenter trial, patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early ECLS plus usual medical treatment (ECLS group) or usual medical treatment alone (control group). The primary outcome was death from any cause at 30 days. Safety outcomes included bleeding, stroke, and peripheral vascular complications warranting interventional or surgical therapy. RESULTS A total of 420 patients underwent randomization, and 417 patients were included in final analyses. At 30 days, death from any cause had occurred in 100 of 209 patients (47.8%) in the ECLS group and in 102 of 208 patients (49.0%) in the control group (relative risk, 0.98; 95% confidence interval [CI], 0.80 to 1.19; P = 0.81). The median duration of mechanical ventilation was 7 days (interquartile range, 4 to 12) in the ECLS group and 5 days (interquartile range, 3 to 9) in the control group (median difference, 1 day; 95% CI, 0 to 2). The safety outcome consisting of moderate or severe bleeding occurred in 23.4% of the patients in the ECLS group and in 9.6% of those in the control group (relative risk, 2.44; 95% CI, 1.50 to 3.95); peripheral vascular complications warranting intervention occurred in 11.0% and 3.8%, respectively (relative risk, 2.86; 95% CI, 1.31 to 6.25). CONCLUSIONS In patients with acute myocardial infarction complicated by cardiogenic shock with planned early revascularization, the risk of death from any cause at the 30-day follow-up was not lower among the patients who received ECLS therapy than among those who received medical therapy alone. (Funded by the Else Kröner Fresenius Foundation and others; ECLS-SHOCK ClinicalTrials.gov number, NCT03637205.).
Collapse
Affiliation(s)
- Holger Thiele
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Uwe Zeymer
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ibrahim Akin
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Michael Behnes
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tienush Rassaf
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Amir Abbas Mahabadi
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ralf Lehmann
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ingo Eitel
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tobias Graf
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tim Seidler
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Andreas Schuster
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Carsten Skurk
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Daniel Duerschmied
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Peter Clemmensen
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Marcus Hennersdorf
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Stephan Fichtlscherer
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Ingo Voigt
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Melchior Seyfarth
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Stefan John
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Sebastian Ewen
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Axel Linke
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Eike Tigges
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Peter Nordbeck
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Leonhard Bruch
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Christian Jung
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Jutta Franz
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Philipp Lauten
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Tomaz Goslar
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Hans-Josef Feistritzer
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Janine Pöss
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Eva Kirchhof
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Taoufik Ouarrak
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Steffen Schneider
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Steffen Desch
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| | - Anne Freund
- From Heart Center Leipzig at University of Leipzig (H.T., H.-J.F., J.P., S.D., A.F.) and Helios Health Institute (E.K.), Leipzig, Institut für Herzinfarktforschung (U.Z., T.O., S.S.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim (I.A., M.B., D.D.), the West German Heart and Vascular Center, University Hospital Essen (T.R., A.A.M.), and Contilia Elisabeth-Krankenhaus, Essen (I.V.), Essen, Asklepios Clinic Langen, Langen (R.L.), University Heart Center Lübeck and German Center for Cardiovascular Research, Partner Site Hamburg-Kiel-Lübeck, Lübeck (I.E., T. Graf), Heart Center Göttingen, University Medicine Göttingen, Göttingen (T.S., A.S.), Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine (C.S.), and Unfallkrankenhaus Berlin (L.B.), Berlin, University Heart and Vascular Center Hamburg (P.C.) and Asklepios Clinic St. Georg (E.T.), Hamburg, SLK Kliniken Heilbronn, Heilbronn (M.H.), University Heart and Vascular Center Frankfurt, Frankfurt (S.F.), Heart Center Wuppertal, Witten-Herdecke University, Wuppertal (M.S.), Paracelsus Private University, Clinic Nuremberg South, Nuremberg (S.J.), Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg (S.E.), Technische Universität Dresden, Heart Center, Dresden (A.L.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Düsseldorf, Düsseldorf (C.J.), Clinic Winnenden, Winnenden (J.F.), and Zentralklinik Bad Berka, Bad Berka (P.L.) - all in Germany; and University Medical Center Ljubljana, Ljubljana, Slovenia (T. Goslar)
| |
Collapse
|
12
|
Schupp T, Behnes M, Rusnak J, Dudda J, Forner J, Ruka M, Egner-Walter S, Bertsch T, Müller J, Akin I. The prothrombin time/international normalized ratio predicts prognosis in cardiogenic shock. Coron Artery Dis 2023; 34:395-403. [PMID: 37139569 DOI: 10.1097/mca.0000000000001241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVE The study investigates the prognostic impact of the prothrombin time/international normalized ratio (PT/INR) in patients with cardiogenic shock. BACKGROUND Despite ongoing improvements regarding the treatment of cardiogenic shock patients, intensive care unit (ICU)-related mortality in cardiogenic shock patients remains unacceptably high. Limited data regarding the prognostic value of the PT/INR during the course of cardiogenic shock treatment is available. METHODS All consecutive patients with cardiogenic shock from 2019 to 2021 were included at one institution. Laboratory values were collected from the day of disease onset (day 1) and days 2, 3, 4 and 8. The prognostic impact of the PT/INR was tested for 30-day all-cause mortality, as well as the prognostic role of PT/INR changes during course of ICU hospitalization. Statistical analyses included univariable t -test, Spearman's correlation, Kaplan-Meier analyses, C-Statistics and Cox proportional regression analyses. RESULTS Two hundred twenty-four cardiogenic shock patients were included with a rate of all-cause mortality at 30 days of 52%. The median PT/INR on day 1 was 1.17. The PT/INR on day 1 was able to discriminate 30-day all-cause mortality in cardiogenic shock patients [area under the curve 0.618; 95% confidence interval (CI), 0.544-0.692; P = 0.002). Patients with PT/INR > 1.17 were associated with an increased risk of 30-day mortality [62% vs. 44%; hazard ratio (HR) = 1.692; 95% CI, 1.174-2.438; P = 0.005], which was still evident after multivariable adjustment (HR = 1.551; 95% CI, 1.043-2.305; P = 0.030). Furthermore, especially patients with an increment of the PT/INR by ≥10% from day 1 to day 2 were associated with an increased risk of 30-day all-cause mortality (64% vs. 42%; log-rank P = 0.014; HR = 1.833; 95% CI, 1.106-3.038; P = 0.019). CONCLUSION Baseline PT/INR and an increase of the PT/INR during the course of ICU treatment were associated with the risk of 30-day all-cause mortality in cardiogenic shock patients.
Collapse
Affiliation(s)
- Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Jonas Dudda
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg
| | - Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, Bad Neustadt a. d. Saale
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim
| |
Collapse
|
13
|
Epps KC, Tehrani BN, Rosner C, Bagchi P, Cotugno A, Damluji AA, deFilippi C, Desai S, Ibrahim N, Psotka M, Raja A, Sherwood MW, Singh R, Sinha SS, Tang D, Truesdell AG, O’Connor C, Batchelor W. Sex-Related Differences in Patient Characteristics, Hemodynamics, and Outcomes of Cardiogenic Shock: INOVA-SHOCK Registry. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100978. [PMID: 38504778 PMCID: PMC10950300 DOI: 10.1016/j.jscai.2023.100978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Background Little is known about sex-related differences in outcomes of patients with cardiogenic shock (CS) treated within a standardized team-based approach (STBA). Methods We evaluated 520 consecutive patients (151 women and 369 men) with CS due to acute myocardial infarction (AMI) and heart failure (HF) in a single-center registry (January 2017-December 2019) and examined outcomes according to sex and CS phenotype. The primary outcome was in-hospital mortality. Secondary outcomes included major adverse cardiac events, 30-day mortality, major bleeding, vascular complications, and stroke. Results Women with AMI-CS had higher baseline acuity (CardShock score: female [F]: 5.5 vs male [M]: 4.0; P = .04). Women with HF-CS more often presented with cardiac arrest (F: 12.4% vs M: 2.4%; P< .01) and had higher rates of vasopressor use (F: 70.8% vs M: 58.0%; P = .04) and mechanical circulatory support (F: 46.1% vs M: 32.5%; P = .04). There were no sex-related differences in in-hospital mortality for AMI-CS (F: 45.2% vs M: 36.9%; P = .28) and HF-CS (F: 28.1% vs M: 24.5%; P = .56). Women with HF-CS experienced higher rates of major bleeding (F: 25.8% vs M: 13.7%; P = .02) and vascular complications (F: 15.7% vs M: 6.1%; P = .01). However, female sex was not an independent predictor of these complications. No sex differences in survival were noted at 1 year. Conclusions Within an STBA, although women with AMI-CS and HF-CS presented with higher acuity, they experienced similar in-hospital mortality, major adverse cardiac events, 30-day mortality, stroke, and 30-day readmissions as men. Further research is needed to better understand the extent to which historical differences in CS outcomes can be mitigated by an STBA.
Collapse
Affiliation(s)
- Kelly C. Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Pramita Bagchi
- Department of Statistics, George Mason University, Fairfax, Virginia
| | - Annunziata Cotugno
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Institute of Cardiology, University of Brescia, Brescia, Italy
| | | | | | - Shashank Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Anika Raja
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Daniel Tang
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Alexander G. Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia
- Virginia Heart, Falls Church, Virginia
| | | | | |
Collapse
|
14
|
Thiele H. [ECMO-CS trial-is this the end of ECMO?]. Med Klin Intensivmed Notfmed 2023; 118:156-159. [PMID: 36418473 DOI: 10.1007/s00063-022-00977-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Holger Thiele
- Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig - Universität Leipzig, Strümpellstr. 39, 04289, Leipzig, Deutschland.
| |
Collapse
|
15
|
Ostadal P, Rokyta R, Karasek J, Kruger A, Vondrakova D, Janotka M, Naar J, Smalcova J, Hubatova M, Hromadka M, Volovar S, Seyfrydova M, Jarkovsky J, Svoboda M, Linhart A, Belohlavek J. Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial. Circulation 2023; 147:454-464. [PMID: 36335478 DOI: 10.1161/circulationaha.122.062949] [Citation(s) in RCA: 112] [Impact Index Per Article: 112.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used for circulatory support in patients with cardiogenic shock, although the evidence supporting its use in this context remains insufficient. The ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) aimed to compare immediate implementation of VA-ECMO versus an initially conservative therapy (allowing downstream use of VA-ECMO) in patients with rapidly deteriorating or severe cardiogenic shock. METHODS This multicenter, randomized, investigator-initiated, academic clinical trial included patients with either rapidly deteriorating or severe cardiogenic shock. Patients were randomly assigned to immediate VA-ECMO or no immediate VA-ECMO. Other diagnostic and therapeutic procedures were performed as per current standards of care. In the early conservative group, VA-ECMO could be used downstream in case of worsening hemodynamic status. The primary end point was the composite of death from any cause, resuscitated circulatory arrest, and implementation of another mechanical circulatory support device at 30 days. RESULTS A total of 122 patients were randomized; after excluding 5 patients because of the absence of informed consent, 117 subjects were included in the analysis, of whom 58 were randomized to immediate VA-ECMO and 59 to no immediate VA-ECMO. The composite primary end point occurred in 37 (63.8%) and 42 (71.2%) patients in the immediate VA-ECMO and the no early VA-ECMO groups, respectively (hazard ratio, 0.72 [95% CI, 0.46-1.12]; P=0.21). VA-ECMO was used in 23 (39%) of no early VA-ECMO patients. The 30-day incidence of resuscitated cardiac arrest (10.3.% versus 13.6%; risk difference, -3.2 [95% CI, -15.0 to 8.5]), all-cause mortality (50.0% versus 47.5%; risk difference, 2.5 [95% CI, -15.6 to 20.7]), serious adverse events (60.3% versus 61.0%; risk difference, -0.7 [95% CI, -18.4 to 17.0]), sepsis, pneumonia, stroke, leg ischemia, and bleeding was not statistically different between the immediate VA-ECMO and the no immediate VA-ECMO groups. CONCLUSIONS Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02301819.
Collapse
Affiliation(s)
- Petr Ostadal
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic (P.O., A.K., D.V., M.J., J.N.)
| | - Richard Rokyta
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic (R.R., M. Hromadka, S.V., M. Seyfrydova)
| | - Jiri Karasek
- Hospital Liberec, Liberec, Czech Republic (J.K.)
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Liberec, Czech Republic (J.K., J.S., M. Hubatova, A.L., J.B.)
| | - Andreas Kruger
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic (P.O., A.K., D.V., M.J., J.N.)
| | - Dagmar Vondrakova
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic (P.O., A.K., D.V., M.J., J.N.)
| | - Marek Janotka
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic (P.O., A.K., D.V., M.J., J.N.)
| | - Jan Naar
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic (P.O., A.K., D.V., M.J., J.N.)
| | - Jana Smalcova
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Liberec, Czech Republic (J.K., J.S., M. Hubatova, A.L., J.B.)
| | - Marketa Hubatova
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Liberec, Czech Republic (J.K., J.S., M. Hubatova, A.L., J.B.)
| | - Milan Hromadka
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic (R.R., M. Hromadka, S.V., M. Seyfrydova)
| | - Stefan Volovar
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic (R.R., M. Hromadka, S.V., M. Seyfrydova)
| | - Miroslava Seyfrydova
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University, Pilsen, Czech Republic (R.R., M. Hromadka, S.V., M. Seyfrydova)
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic (J.J., M. Svoboda)
| | - Michal Svoboda
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic (J.J., M. Svoboda)
- Institute of Biostatistics and Analyses, Ltd, Brno, Czech Republic (M. Svoboda)
| | - Ales Linhart
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Liberec, Czech Republic (J.K., J.S., M. Hubatova, A.L., J.B.)
| | - Jan Belohlavek
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Liberec, Czech Republic (J.K., J.S., M. Hubatova, A.L., J.B.)
| |
Collapse
|
16
|
Leick J, Grottke O, Oezkur M, Mangner N, Sanna T, Al Rashid F, Vandenbriele C. What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention? Eur Heart J Suppl 2022; 24:J17-J24. [PMCID: PMC9731207 DOI: 10.1093/eurheartjsupp/suac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Interest in the use of percutaneous left ventricular assist devices (p-LVADs) for patients undergoing high-risk percutaneous coronary intervention (PCI) is growing rapidly. The Impella™ (Abiomed Inc.) is a catheter-based continuous micro-axial flow pump that preserves haemodynamic support during high-risk PCI. Anticoagulation is required to counteract the activation of the coagulation system by the patient’s procoagulant state and the foreign-body surface of the pump. Excessive anticoagulation and the effect of dual antiplatelet therapy (DAPT) increase the risk of bleeding. Inadequate anticoagulation leads to thrombus formation and device dysfunction. The precarious balance between bleeding and thrombosis in patients with p-LVAD support is often the primary reason that patients’ outcomes are jeopardized. In this chapter, we will discuss anticoagulation strategies and anticoagulant management in the setting of protected PCI. This includes anticoagulant therapy with unfractionated heparin, direct thrombin inhibitors, DAPT, purge blockage prevention by bicarbonate-based purge solution, and monitoring by activated clotting time, partial thromboplastin time, as well as anti-factor Xa levels. Here, we provide a standardized approach to the management of peri-interventional anticoagulation in patients undergoing protected PCI.
Collapse
Affiliation(s)
- Jürgen Leick
- Corresponding author. Tel: +49 651208981911, Fax: 00496512082786,
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, University Hospital Mainz, 55131 Mainz, Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universitaet Dresden, Dresden, Germany
| | - Tommaso Sanna
- Institute of Cardiology, Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Fadi Al Rashid
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, 45147 Essen, Germany
| | | |
Collapse
|
17
|
Damluji AA, Tehrani B, Sinha SS, Samsky MD, Henry TD, Thiele H, West NEJ, Senatore FF, Truesdell AG, Dangas GD, Smilowitz NR, Amin AP, deVore AD, Moazami N, Cigarroa JE, Rao SV, Krucoff MW, Morrow DA, Gilchrist IC. Position Statement on Vascular Access Safety for Percutaneous Devices in AMI Complicated by Cardiogenic Shock. JACC Cardiovasc Interv 2022; 15:2003-2019. [PMID: 36265932 PMCID: PMC10312149 DOI: 10.1016/j.jcin.2022.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 01/09/2023]
Abstract
In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.
Collapse
Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Behnam Tehrani
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Marc D Samsky
- New York University School of Medicine, New York, New York, USA
| | - Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education, Christ Hospital, Cincinnati, Ohio, USA
| | - Holger Thiele
- Heart Center Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | | | - Fortunato F Senatore
- Division of Cardiology and Nephrology, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Alexander G Truesdell
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - George D Dangas
- Division of Cardiology, Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | | | - Amit P Amin
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Adam D deVore
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nader Moazami
- New York University School of Medicine, New York, New York, USA
| | | | - Sunil V Rao
- New York University School of Medicine, New York, New York, USA
| | | | - David A Morrow
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ian C Gilchrist
- Penn State Heart and Vascular Institute, Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
18
|
Manual compression versus MANTA device for access management after impella removal on the ICU. Sci Rep 2022; 12:14060. [PMID: 35982200 PMCID: PMC9388691 DOI: 10.1038/s41598-022-18184-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 08/08/2022] [Indexed: 11/08/2022] Open
Abstract
To compare the safety and efficacy of manual compression versus use of the MANTA closure device for access management after Impella removal on the intensive care unit (ICU). The number of patients treated with percutaneous left ventricular assist devices (pLVAD), namely Impella and ECMO, for complex cardiac procedures or shock, is growing. However, removal of pLVAD and large bore arteriotomy closure among such patients on the ICU remains challenging, since it is associated with a high risk for bleeding and vascular complications. Patients included in a prospective registry between 2017 and 2020 were analyzed. Bleeding and vascular access site complications were assessed and adjudicated according to VARC-2 criteria. We analyzed a cohort of 87 consecutive patients, who underwent access closure after Impella removal on ICU by using either the MANTA device or manual compression. The cohort´s mean age was 66.1 ± 10.7 years and 76 patients (87%) were recovering from CS. Mean support time was 40 h (interquartile range 24–69 h). MANTA was used in 31 patients (35.6%) and manual compression was applied in 56 patients (64.4%). Overall access related bleedings were significantly lower in the MANTA group (6.5% versus 39.3% (odds ratio (OR) 0.10, 95% CI 0.01–0.50; p = 0.001), and there was no significant difference in vascular complications between the two groups (p = 0.55). Our data suggests that the application of the MANTA device directly on the ICU is safe. In addition, it seems to reduce access related bleeding without increasing the risk of vascular complications.
Collapse
|
19
|
Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:1949-1962. [PMID: 35550692 DOI: 10.1016/j.jacc.2022.02.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
Interest in the use of mechanical circulatory support for patients presenting with cardiogenic shock is growing rapidly. The Impella (Abiomed Inc), a microaxial, continuous-flow, short-term, ventricular assist device (VAD), requires meticulous postimplantation management. Because systemic anticoagulation is needed to prevent pump thrombosis, patients are exposed to increased bleeding risk, further aggravated by sepsis, thrombocytopenia, and high shear stress-induced acquired von Willebrand syndrome. The precarious balance between bleeding and thrombosis in percutaneous VAD-supported cardiogenic shock patients is often the main reason that patient outcomes are jeopardized, and there is a lack of data addressing optimal anticoagulation management strategies during percutaneous VAD support. Here, we present a parallel anti-Factor Xa/activated partial thromboplastin time-guided anticoagulation algorithm and discuss pitfalls of heparin monitoring in critically ill patients. This review will guide physicians toward a more standardized (anti)coagulation approach to tackle device-related morbidity and mortality in this critically ill patient group.
Collapse
|
20
|
Extracorporeal Membrane Oxygenation in Infarct-Related Cardiogenic Shock. J Clin Med 2022; 11:jcm11051256. [PMID: 35268347 PMCID: PMC8910965 DOI: 10.3390/jcm11051256] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/18/2022] Open
Abstract
Mortality in infarct-related cardiogenic shock (CS) remains high, reaching 40–50%. In refractory CS, active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are rapidly evolving. However, supporting evidence of VA-ECMO therapy in infarct-related CS is low. The current review aims to give an overview on the basics of VA-ECMO therapy, current evidence, ongoing trials, patient selection and potential complications.
Collapse
|
21
|
Tehrani BN, Damluji AA, Batchelor WB. Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories. Curr Cardiol Rev 2022; 18:e251121198293. [PMID: 34823461 PMCID: PMC9413732 DOI: 10.2174/1573403x17666211125090929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/07/2021] [Accepted: 07/28/2021] [Indexed: 11/22/2022] Open
Abstract
Despite advances in early reperfusion and a technologic renaissance in the space of Mechanical Circulatory Support (MCS), Cardiogenic Shock (CS) remains the leading cause of in-hospital mortality following Acute Myocardial Infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patients without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive, evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated into the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trials designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.
Collapse
Affiliation(s)
- Behnam N Tehrani
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
| | - Abdulla A Damluji
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States.,Department of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Wayne B Batchelor
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
| |
Collapse
|
22
|
Thiele H, de Waha-Thiele S, Freund A, Zeymer U, Desch S, Fitzgerald S. Management of cardiogenic shock. EUROINTERVENTION 2021; 17:451-465. [PMID: 34413010 PMCID: PMC9724885 DOI: 10.4244/eij-d-20-01296] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Despite the rapidly evolving evidence base in modern cardiology, progress in the area of cardiogenic shock remains slow, with short-term mortality still reaching 40-50%, relatively unchanged in recent years. Despite advances with an increase in the number of clinical trials taking place in this admittedly difficult-to-study area, the evidence base on which we make day-to-day decisions in clinical practice remains relatively sparse. With only definitive evidence for early revascularisation and the relative ineffectiveness of intra-aortic balloon pumping, most aspects of patient management are based on expert consensus, rather than randomised controlled trials. This updated 2020 review will outline the management of CS mainly after acute myocardial infarction with major focus on state-of-the-art treatment based on randomised clinical trials or matched comparisons if available.
Collapse
Affiliation(s)
- Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Strümpellstr. 39, 04289 Leipzig, Germany
| | | | - Anne Freund
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany,Leipzig Heart Institute, Leipzig, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany,Leipzig Heart Institute, Leipzig, Germany
| | - Sean Fitzgerald
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| |
Collapse
|
23
|
Josiassen J, Møller JE, Holmvang L, Hassager C. Interventional treatment of acute myocardial infarction-related cardiogenic shock. Curr Opin Crit Care 2021; 27:433-439. [PMID: 33929343 DOI: 10.1097/mcc.0000000000000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Acute revascularization is with some evidence the only intervention proven to improve the prognosis in myocardial infarction-related cardiogenic shock but several interventions are continuously being investigated in order to increase survival among these patients. In this review, several aspects related to the interventional treatment of cardiogenic shock are discussed chronologically from symptom debut to leaving the cardiac catheterization laboratory. RECENT FINDINGS In the randomized CULPRIT-SHOCK trial, a culprit-only revascularization strategy was reported superior to immediate complete revascularization among patients with multivessel disease. Recent large-scale observational data underline the marked prognostic importance of time from medical contact to revascularization in acute myocardial infarction-related cardiogenic shock. Moreover, studies suggest a potential beneficial effect of a transradial vascular access as well as early initialization of mechanical circulatory support in carefully selected patients. This, however, needs further validation. SUMMARY Acute revascularization remains a crucial part of the initial management of acute myocardial infarction-related cardiogenic shock. Among cardiogenic shock patients presenting with multivessel disease, a culprit-only approach should be the routine strategy. Time to revascularization plays a crucial role in the setting of cardiogenic shock, why prehospital optimization and triaging may be the most important factors in order to improve prognosis in AMI-related cardiogenic shock.
Collapse
Affiliation(s)
- Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet.,Department of Cardiology, Odense University Hospital, Odense
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
24
|
Bloom JE, Andrew E, Nehme Z, Dinh DT, Fernando H, Shi WY, Vriesendorp P, Nanayakarra S, Dawson LP, Brennan A, Noaman S, Layland J, William J, Al-Fiadh A, Brooks M, Freeman M, Hutchinson A, McGaw D, Van Gaal W, Willson W, White A, Prakash R, Reid C, Lefkovits J, Duffy SJ, Chan W, Kaye DM, Stephenson M, Bernard S, Smith K, Stub D. Pre-hospital heparin use for ST-elevation myocardial infarction is safe and improves angiographic outcomes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1140-1147. [PMID: 34189566 DOI: 10.1093/ehjacc/zuab032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 11/12/2022]
Abstract
AIMS This study aims to evaluate if pre-hospital heparin administration by paramedics is safe and improves clinical outcomes. METHODS AND RESULTS Using the multicentre Victorian Cardiac Outcomes Registry, linked with state-wide ambulance records, we identified consecutive patients undergoing primary percutaneous coronary intervention for STEMI between January 2014 and December 2018. Information on thrombolysis in myocardial infarction (TIMI) flow at angiography was available in a subset of cases. Patients receiving pre-hospital heparin were compared to those who did not receive heparin. Findings at coronary angiography and 30-day clinical outcomes were compared between groups. Propensity-score matching was performed for risk adjustment. We identified a total of 4720 patients. Of these, 1967 patients had TIMI flow data available. Propensity-score matching in the entire cohort yielded 1373 matched pairs. In the matched cohort, there was no observed difference in 30-day mortality (no-heparin 3.5% vs. heparin 3.0%, P = 0.25), MACCE (no-heparin 7% vs. heparin 6.2%, P = 0.44), and major bleeding (no-heparin 1.9% vs. heparin 1.4%, P = 0.64) between groups. Propensity-score analysis amongst those with TIMI data produced 552 matched pairs. The proportion of cases with TIMI 0 or 1 flow in the infarct-related artery (IRA) was lower among those receiving pre-hospital heparin (66% vs. 76%, P < 0.001) compared to those who did not. CONCLUSION In this multicentre, propensity-score matched study, the use of pre-hospital heparin by paramedics was safe and is associated with fewer occluded IRAs in patients presenting with STEMI.
Collapse
Affiliation(s)
- Jason E Bloom
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Emily Andrew
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Himawan Fernando
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - William Y Shi
- Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Pieter Vriesendorp
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Shane Nanayakarra
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Luke P Dawson
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - Jamie Layland
- Department of Cardiology, Peninsula Health, 2 Hastings Road, Frankston, VIC 3199, Australia
| | - Jeremy William
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia
| | - Matthew Brooks
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia
| | - Adam Hutchinson
- Department of Cardiology, Geelong University Hospital, Bellerine Street, Geelong, VIC 3220, Australia
| | - David McGaw
- Department of Cardiology, Monash Health, 246 Clayton Road, Clayton, VIC 3168, Australia
| | - William Van Gaal
- Department of Cardiology, Northern Health, 185 Cooper Street, Epping, VIC 3076, Australia
| | - William Willson
- Department of Cardiology, Eastern Health, 5 Arnold Street, Box Hill, VIC 3128, Australia
| | - Anthony White
- Curtain University, Kent Street, Bentley, WA 6102, Australia
| | - Roshan Prakash
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Christopher Reid
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Curtain University, Kent Street, Bentley, WA 6102, Australia
| | - Jeffrey Lefkovits
- Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,Melbourne Medical School, Ground Floor, Medical Building, Grattan Street, University of Melbourne, VIC 3010, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia
| | - Michael Stephenson
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Stephen Bernard
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.,Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia.,Ambulance Victoria, 31 Joseph Street, Blackburn, VIC 3130, Australia.,Department of Cardiology, Western Health, Furlong Road, St Albans, VIC 3021, Australia
| |
Collapse
|
25
|
Lang CN, Zotzmann V, Schmid B, Kaier K, Bode C, Wengenmayer T, Staudacher DL. Utilization of transfusions and coagulation products in cardiogenic shock with and without mechanical circulatory support. J Crit Care 2021; 65:62-64. [PMID: 34090149 DOI: 10.1016/j.jcrc.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/30/2021] [Accepted: 05/25/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Corinna N Lang
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany.
| | - Viviane Zotzmann
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I (Heart Center Freiburg University - Bad Krozingen), Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany
| |
Collapse
|
26
|
Orban M, Kleeberger J, Ouarrak T, Freund A, Feistritzer HJ, Fuernau G, Geisler T, Huber K, Dudek D, Noc M, Montalescot G, Neumer A, Haller P, Clemmensen P, Zeymer U, Desch S, Massberg S, Schneider S, Thiele H, Hausleiter J. Clopidogrel vs. prasugrel vs. ticagrelor in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis. Clin Res Cardiol 2021; 110:1493-1503. [PMID: 33999281 PMCID: PMC8405498 DOI: 10.1007/s00392-021-01866-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/30/2021] [Indexed: 11/25/2022]
Abstract
Aims The aim of this pooled sub-analysis of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated either with clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor. Methods and results For the current analysis the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. 856 patients were eligible for analysis. Of these, 507 patients (59.2%) received clopidogrel, 178 patients (20.8%) prasugrel and 171 patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ significantly between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60–1.09, padj = 0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65–1.15, padj = 0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20 -0.69, padj = 0.002) and not significantly different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43 -1.24, padj = 0.24). Conclusion This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that acute therapy with either clopidogrel, prasugrel or ticagrelor is no independent predictor of 1-year mortality. Treatment with ticagrelor seems independently associated with less in-hospital moderate and severe bleeding events compared to clopidogrel. This finding might be due to selection bias and should be interpreted with caution. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01866-3.
Collapse
Affiliation(s)
- Martin Orban
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany.
- Medizinische Klinik und Poliklinik I, LMU Klinikum München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Germany.
| | - Jan Kleeberger
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Taoufik Ouarrak
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Anne Freund
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | | | - Kurt Huber
- Medical Faculty, 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, and Sigmund Freud University, Vienna, Austria
| | | | - Marko Noc
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Alexander Neumer
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Paul Haller
- Universitäres Herz- Und Gefäßzentrum UKE Hamburg, Klinik Und Poliklinik Für Kardiologie, Hamburg, Germany
| | - Peter Clemmensen
- Universitäres Herz- Und Gefäßzentrum UKE Hamburg, Klinik Und Poliklinik Für Kardiologie, Hamburg, Germany
| | - Uwe Zeymer
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | | | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, Ludwig-Maximilians-University, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| |
Collapse
|
27
|
New challenges in cardiac intensive care units. Clin Res Cardiol 2021; 110:1369-1379. [PMID: 33966127 DOI: 10.1007/s00392-021-01869-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
Critical care cardiology is a steadily and rapidly developing sub-specialization within cardiovascular medicine, since the first emergence of a coronary care unit in the early 1960s. Today, modern cardiac intensive care units (CICU) serve a complex patient population with a high burden of cardiovascular and non-cardiovascular critical illnesses. Treatment of these patients requires a multidisciplinary approach, with a combination of highly specialized knowledge and skills in cardiovascular diseases, as well as emergency, critical-care and internal medicine. The CICU has always posed special challenges to both experienced intensivists as well as fellows-in-training (FIT) and is certainly one of the most demanding training phases. In recent years, these challenges have grown significantly owing to technological innovations, with new and steadily rising numbers of complex interventional procedures and new options for temporary circulatory support for critically ill patients, such as venoarterial extracorporeal membrane oxygenation (VA-ECMO). Herein, we focus on the successful CICU management of these special patient cohorts, which must become an integral part of critical-care training.
Collapse
|
28
|
Nishihira K, Honda S, Takegami M, Kojima S, Asaumi Y, Suzuki M, Kosuge M, Takahashi J, Sakata Y, Takayama M, Sumiyoshi T, Ogawa H, Kimura K, Yasuda S. Impact of bleeding on mortality in patients with acute myocardial infarction complicated by cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:388-396. [PMID: 34037718 DOI: 10.1093/ehjacc/zuab014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/30/2020] [Accepted: 03/05/2021] [Indexed: 11/13/2022]
Abstract
AIMS Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with substantial mortality, although there are limited data available on bleeding in this critical condition. This study sought to investigate the incidence and impact of major in-hospital bleeding on all-cause mortality in patients with AMICS who undergo percutaneous coronary intervention (PCI). METHODS AND RESULTS Between 2015 and 2017, a total of 3411 patients hospitalized within 24 h after symptom onset were prospectively enrolled in the Japan Acute Myocardial Infarction Registry (JAMIR) and followed up for a median of 293 (interquartile range, 22-375) days. AMICS developed in 335 (9.8%) patients (mean age, 71.3 ± 13.6 years). Overall, the rate of major in-hospital bleeding (Bleeding Academic Research Consortium types 3 and 5) and in-hospital mortality was 14.6% and 28.7%, respectively. The majority of major in-hospital bleeding (73.5%) occurred within 48 h after PCI. Compared to patients without major in-hospital bleeding, those with it had higher rates of renal failure, left main coronary artery culprit lesion, and intra-aortic balloon pump or extracorporeal membrane oxygenation support, and had longer door-to-device time. The cumulative incidence of 1-year all-cause mortality was significantly higher in the major bleeding group compared to the non-major bleeding group (63.8% vs. 25.5%; log-rank P < 0.001). After adjusting for confounders, major in-hospital bleeding was independently associated with increased all-cause mortality (hazard ratio, 1.70; 95% confidence interval, 1.08-2.69). CONCLUSIONS These findings of JAMIR indicate that major in-hospital bleeding is associated with all-cause mortality in patients with AMICS who undergo PCI.
Collapse
Affiliation(s)
- Kensaku Nishihira
- Department of Cardiology, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki 880-2102, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe shin-machi, Suita 564-8565, Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiologic Informatics, National Cerebral and Cardiovascular Center, 6-1 Kishibe shin-machi, Suita 564-8565, Japan
| | - Sunao Kojima
- Department of General Internal Medicine 3, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama 700-8505, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe shin-machi, Suita 564-8565, Japan
| | - Makoto Suzuki
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu 183-0003, Japan
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Morimasa Takayama
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu 183-0003, Japan
| | - Tetsuya Sumiyoshi
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu 183-0003, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe shin-machi, Suita 564-8565, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe shin-machi, Suita 564-8565, Japan.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | | |
Collapse
|
29
|
Scherer C, Lüsebrink E, Kupka D, Stocker TJ, Stark K, Kleeberger J, Orban M, Kellnar A, Petzold T, Deseive S, Krieg K, Würbel S, Kika S, Istrefi M, Brunner S, Braun D, Hagl C, Hausleiter J, Massberg S, Sibbing D, Orban M. ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock. Platelets 2021; 33:371-380. [PMID: 33941008 DOI: 10.1080/09537104.2021.1913577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock. The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock and with available on-treatment ADP-induced platelet aggregation measurements. Out of 233 patients, 74 suffered from a severe BARC3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (p < .001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU). An optimal cutoff value of <12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, the use of VA-ECMO (HR 1.972) or coaxial left ventricular pump (HR 2.593), first lactate (HR 1.093 per mmol/l) and thrombocyte count (HR 0.994 per G/l) were independent predictors of BARC≥3 bleedings. In conclusion, lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in cardiogenic shock warrants further investigation.
Collapse
Affiliation(s)
- Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Danny Kupka
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Thomas J Stocker
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Konstantin Stark
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Jan Kleeberger
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Mathias Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Antonia Kellnar
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Tobias Petzold
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Simon Deseive
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Kathrin Krieg
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Sara Würbel
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Sara Kika
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Mario Istrefi
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Brunner
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Braun
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Dirk Sibbing
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
30
|
Damluji AA, Gilchrist IC. Lies, damned lies, and statistics, but bleeding and acute limb ischemia are facts! Catheter Cardiovasc Interv 2021; 97:1139-1140. [PMID: 33974740 DOI: 10.1002/ccd.29726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Abdulla A Damluji
- The Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA.,Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ian C Gilchrist
- Penn State Heart and Vascular Institute, Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
31
|
Ratcovich H, Josiassen J, Helgestad OKL, Linde L, Sadjadieh G, Engstrøm T, Jensen LO, Ravn HB, Schmidt H, Hassager C, Møller JE, Holmvang L. Incidence, Predictors, and Outcome of In-Hospital Bleeding in Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction. Am J Cardiol 2021; 144:13-19. [PMID: 33383003 DOI: 10.1016/j.amjcard.2020.12.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 11/18/2022]
Abstract
Bleeding after acute myocardial infarction (AMI) is associated with an increased morbidity and mortality. The frequency and consequences of bleeding events in patients with AMICS are not well described. The objective was to investigate incidence and outcome of bleeding complications among unselected patients with AMI complicated by cardiogenic shock (AMICS) and referred for immediate revascularization. Bleeding events were assessed by review of medical records in consecutive AMICS patients admitted between 2010 and 2017. Bleedings during admission were classified according to Bleeding Academic Research Consortium classification. Patients who did not survive to admission in the intensive care unit were excluded. Of the 1,716 patients admitted with AMICS, 1,532 patients (89%) survived to ICU admission. At 30 days, mortality was 48%. Severe bleedings classified as BARC 3/5 were seen in 87 non-coronary bypass grafting patients (6.1%). Co-morbidity did not differ among patients; however, patients who had a BARC 3/5 bleeding had significantly higher lactate and lower systolic blood pressure at admission, indicating a more severe state of shock. The use of mechanical assist devices was significantly associated with severe bleeding events. Univariable analysis showed that patients with a BARC 3/5 bleeding had a significantly higher 30-day mortality hazard compared with patients without severe bleedings. The association did not sustain after multivariable adjustment (hazard ratio 0.90, 95% confidence interval 0.64; 1.26, p = 0.52). In conclusion, severe bleeding events according to BARC classification in an all-comer population of patients with AMICS were not associated with higher mortality when adjusting for immediate management, hemodynamic, and metabolic state. This indicates that mortality in these patients is primarily related to other factors.
Collapse
Affiliation(s)
- Hanna Ratcovich
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ole K L Helgestad
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Odense Patient data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Golnaz Sadjadieh
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lisette O Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Hanne B Ravn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Cardiothoracic Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Cardiothoracic Anaesthesia, Odense University Hospital, Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, Odense, Denmark; Odense Patient data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
32
|
Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
Collapse
Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| |
Collapse
|
33
|
Schurtz G, Rousse N, Saura O, Balmette V, Vincent F, Lamblin N, Porouchani S, Verdier B, Puymirat E, Robin E, Van Belle E, Vincentelli A, Aissaoui N, Delhaye C, Delmas C, Cosenza A, Bonello L, Juthier F, Moussa MD, Lemesle G. IMPELLA ® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock. J Clin Med 2021; 10:jcm10040759. [PMID: 33672792 PMCID: PMC7918655 DOI: 10.3390/jcm10040759] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/25/2022] Open
Abstract
Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.
Collapse
Affiliation(s)
- Guillaume Schurtz
- Cardiac Intensive Care Unit, Heart and Lung Institute, CHU Lille, 59000 Lille, France; (G.S.); (O.S.); (V.B.); (N.L.); (B.V.)
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, CHU Lille, Institut Coeur Poumon, Cardiology, 59000 Lille, France; (F.V.); (S.P.); (E.V.B.); (C.D.); (A.C.)
| | - Natacha Rousse
- Department of Cardiac Surgery, Institut Cœur Poumon, CHU Lille, INSERM U1011, Institut Pasteur de Lille, Université de Lille, 59000 Lille, France; (N.R.); (E.R.); (A.V.); (F.J.); (M.D.M.)
| | - Ouriel Saura
- Cardiac Intensive Care Unit, Heart and Lung Institute, CHU Lille, 59000 Lille, France; (G.S.); (O.S.); (V.B.); (N.L.); (B.V.)
| | - Vincent Balmette
- Cardiac Intensive Care Unit, Heart and Lung Institute, CHU Lille, 59000 Lille, France; (G.S.); (O.S.); (V.B.); (N.L.); (B.V.)
| | - Flavien Vincent
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, CHU Lille, Institut Coeur Poumon, Cardiology, 59000 Lille, France; (F.V.); (S.P.); (E.V.B.); (C.D.); (A.C.)
| | - Nicolas Lamblin
- Cardiac Intensive Care Unit, Heart and Lung Institute, CHU Lille, 59000 Lille, France; (G.S.); (O.S.); (V.B.); (N.L.); (B.V.)
- Heart and Lung Institute, University Hospital of Lille, Institut Pasteur of Lille, Inserm U1011 and FACT (French Alliance for Cardiovascular Trials), F-75000 Paris, France
| | - Sina Porouchani
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, CHU Lille, Institut Coeur Poumon, Cardiology, 59000 Lille, France; (F.V.); (S.P.); (E.V.B.); (C.D.); (A.C.)
| | - Basile Verdier
- Cardiac Intensive Care Unit, Heart and Lung Institute, CHU Lille, 59000 Lille, France; (G.S.); (O.S.); (V.B.); (N.L.); (B.V.)
| | - Etienne Puymirat
- Department of Cardiology, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris, 75015 Paris, France;
| | - Emmanuel Robin
- Department of Cardiac Surgery, Institut Cœur Poumon, CHU Lille, INSERM U1011, Institut Pasteur de Lille, Université de Lille, 59000 Lille, France; (N.R.); (E.R.); (A.V.); (F.J.); (M.D.M.)
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, CHU Lille, Institut Coeur Poumon, Cardiology, 59000 Lille, France; (F.V.); (S.P.); (E.V.B.); (C.D.); (A.C.)
| | - André Vincentelli
- Department of Cardiac Surgery, Institut Cœur Poumon, CHU Lille, INSERM U1011, Institut Pasteur de Lille, Université de Lille, 59000 Lille, France; (N.R.); (E.R.); (A.V.); (F.J.); (M.D.M.)
| | - Nadia Aissaoui
- Department of Critical Care Unit, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou (HEGP), Université Paris-Descartes, 75015 Paris, France;
| | - Cédric Delhaye
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, CHU Lille, Institut Coeur Poumon, Cardiology, 59000 Lille, France; (F.V.); (S.P.); (E.V.B.); (C.D.); (A.C.)
| | - Clément Delmas
- INSERM UMR-1048, Intensive Cardiac Care Unit, Rangueil University Hospital, 31400 Toulouse, France;
| | - Alessandro Cosenza
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, CHU Lille, Institut Coeur Poumon, Cardiology, 59000 Lille, France; (F.V.); (S.P.); (E.V.B.); (C.D.); (A.C.)
| | - Laurent Bonello
- Cardiology Department, Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13015 Marseille, France;
- Centre for CardioVascular and Nutrition Research (C2VN), Aix-Marseille Univ, INSERM 1263, INRA 1260, Hopital Nord, 13015 Marseille, France
| | - Francis Juthier
- Department of Cardiac Surgery, Institut Cœur Poumon, CHU Lille, INSERM U1011, Institut Pasteur de Lille, Université de Lille, 59000 Lille, France; (N.R.); (E.R.); (A.V.); (F.J.); (M.D.M.)
| | - Mouhamed Djahoum Moussa
- Department of Cardiac Surgery, Institut Cœur Poumon, CHU Lille, INSERM U1011, Institut Pasteur de Lille, Université de Lille, 59000 Lille, France; (N.R.); (E.R.); (A.V.); (F.J.); (M.D.M.)
| | - Gilles Lemesle
- Cardiac Intensive Care Unit, Heart and Lung Institute, CHU Lille, 59000 Lille, France; (G.S.); (O.S.); (V.B.); (N.L.); (B.V.)
- Heart and Lung Institute, University Hospital of Lille, Institut Pasteur of Lille, Inserm U1011 and FACT (French Alliance for Cardiovascular Trials), F-75000 Paris, France
- Correspondence: ; Tel.: +33-320445330; Fax: +33-320444898
| |
Collapse
|
34
|
Katz A, Lewis TC, Arnouk S, Altshuler D, Papadopoulos J, Toy B, Smith DE, Merchan C. Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support. Ann Pharmacother 2021; 55:1215-1222. [PMID: 33567855 DOI: 10.1177/1060028021994621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients with cardiogenic shock after percutaneous coronary intervention (PCI) may require mechanical circulatory support (MCS). The combination of dual antiplatelet therapy with cangrelor and continuous anticoagulation required for MCS may increase the risk of bleeding. OBJECTIVE The objective of the study is to describe the complications and outcomes of patients who received cangrelor during MCS following PCI. METHODS This is a single-center, retrospective, observational case series of 17 patients who received cangrelor while on MCS from June 2017 to September 2019. RESULTS In a case series of 17 patients, 8 patients (47%) were supported with an Impella device and 4 patients (24%) with venoarterial (VA) extracorporeal membrane oxygenation (ECMO); 5 required (29%) concomitant VA ECMO and Impella support in the setting of cardiogenic shock. All patients received triple antithrombotic therapy with aspirin, heparin, and cangrelor. Cangrelor was commonly initiated at a median dose of 0.75 (range 0.5-4) µg/kg/min. Cangrelor dose adjustments included changes in increments up to 0.25 µg/kg/min with review of P2Y12 levels. A total of 10 patients (59%) experienced a bleeding event, most commonly located at the peripheral cannulation site (40%) and in the gastrointestinal tract (30%). Seven (70%) and 3 (30%) of the bleeding complications were classified as major and minor, respectively. No patient developed in-stent thrombosis during the hospitalization; 14 (82%) patients survived their MCS course. CONCLUSION AND RELEVANCE This case series suggests that cangrelor doses less than 0.75 µg/kg/min may be beneficial. Larger studies should evaluate alternative dosing regimens.
Collapse
|
35
|
Chandrasekar B. Mechanical circulatory support with Impella in percutaneous coronary intervention: current status. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 1:100002. [PMID: 38560363 PMCID: PMC10976289 DOI: 10.1016/j.ahjo.2020.100002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/25/2020] [Accepted: 11/11/2020] [Indexed: 04/04/2024]
Abstract
In patients with, or at risk of, hemodynamic instability during percutaneous coronary intervention, maintaining perfusion of vital organs is crucial. The intra-aortic balloon pump and Impella are the two most commonly used percutaneous mechanical circulatory support devices. Intra-aortic balloon pump has been in widespread use for over three decades. Mechanical circulatory support with Impella is being used increasingly often in patients with acute myocardial infarction complicated by cardiogenic shock, and in those undergoing high-risk percutaneous coronary intervention. Besides improving cardiac output and coronary perfusion, Impella has potential myocardial protective effects. Three key measures that determine the clinical utility of a device are clinical outcome, device-related complications, and cost impact. In this review, the current data on use of Impella in patients with acute myocardial infarction complicated by cardiogenic shock, in left ventricular unloading in acute myocardial infarction, and in those undergoing high-risk percutaneous coronary intervention is analyzed.
Collapse
|
36
|
Schwartz B, Jain P, Salama M, Kapur NK. The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges. Expert Rev Cardiovasc Ther 2020; 19:151-164. [PMID: 33356662 DOI: 10.1080/14779072.2021.1863147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Cardiogenic shock due to acute myocardial infarction and decompensated advanced heart failure remains a source of significant morbidity and mortality. Endovascular mechanical circulatory support devices including intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (Impella and Tandemheart pumps), and veno-arterial extracorporeal oxygenation (VA-ECMO) are utilized for a broadening range of indications.Areas covered: This narrative review explores the specific devices, their distinctive hemodynamic profiles, and practical considerations. Furthermore, reviewed are the trials evaluating device outcomes which have generated significant controversy within the field of heart failure and shock. New applications and future directions are discussed.Expert opinion: Use of endovascular mechanical circulatory support has increased over the last decade, though evidence supporting their use is lacking. Development of large-scale prospective registries and clinical classification systems will facilitate patient enrollment and inform trial design. Furthermore, expansion of indications for these devices is revolutionizing how the field of heart failure and cardiogenic shock thinks about hemodynamic support. The ability to tailor therapy to a patient's specific hemodynamic profile appears to be the future of cardiogenic shock management.
Collapse
Affiliation(s)
- Benjamin Schwartz
- Department of Internal Medicine, Tufts Medical Center, Boston, MA, USATurkey
| | - Pankaj Jain
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
| | - Michael Salama
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
| | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
| |
Collapse
|
37
|
Prognostic Impact of Active Mechanical Circulatory Support in Cardiogenic Shock Complicating Acute Myocardial Infarction, Results from the Culprit-Shock Trial. J Clin Med 2020; 9:jcm9061976. [PMID: 32599815 PMCID: PMC7356113 DOI: 10.3390/jcm9061976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/11/2020] [Accepted: 06/18/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). BACKGROUND Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. METHODS This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. RESULTS Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®; n = 95 extracorporeal membrane oxygenation (ECMO); n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p < 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p < 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7-5.9; p < 0.001). CONCLUSIONS In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.
Collapse
|
38
|
Abstract
Approximately 10% of patients with acute myocardial infarction develop cardiogenic shock. Randomized studies have shown a significant improvement in survival with early revascularization, which now represents the most important cornerstone in the treatment of infarct-related cardiogenic shock. In the vast majority of cases, this is achieved by percutaneous coronary intervention (PCI). In cases of complex coronary anatomy or mechanical complications, the Heart Team should be consulted promptly. The randomized CULPRIT-SHOCK study showed a survival advantage for patients with multivessel coronary artery disease and a percutaneous revascularization strategy who were treated by culprit-lesion-only PCI compared with immediate multivessel PCI. There are currently few data on anticoagulation and antiplatelet therapy in cardiogenic shock as well as on active mechanical circulatory support in this setting.
Collapse
Affiliation(s)
- Anne Freund
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany. .,German Center for Cardiovascular Research (DZHK), Berlin, Deutschland.
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Deutschland
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| |
Collapse
|
39
|
Two Sides of a Coin With Disparate Effects: Mechanical Circulatory Support and Bleeding. JACC Cardiovasc Interv 2020; 13:1194-1197. [PMID: 32438989 DOI: 10.1016/j.jcin.2020.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
|