Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?

Does Timing of Coronary Artery Bypass Grafting after ST-Elevation Myocardial Infarction Impact Early- and Long-Term Outcomes?

BACKGROUND

 The optimal timing of surgical revascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-term outcomes in these patients.

METHODS

 Retrospective single-center analysis of patients with STEMI undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptom onset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and 10-year survival.

RESULTS

 During the study period, 437 consecutive patients underwent surgical revascularization in the setting of STEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality including patients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 (p = 0.31), whereas 10-year survival was 48.5, 57.3, and 54.9% (log-rank: p = 0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing of surgery had no influence on early- and long-term survival.

CONCLUSION

 In patients with STEMI, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularization strategy. Hence, when indicated, an early CABG strategy has no disadvantages in comparison to a delayed strategy.

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

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

Transcatheter Mitral Valve Repair for an Extremely High Surgical Risk Acute Mitral Regurgitation Patient

Transcatheter edge to edge repair (TEER) has been proven to be safe and effective for mitral regurgitation (MR) caused by acute myocardial infarction (AMI). However, for some specific conditions, such as papillary muscle rupture complicating AMI, the feasibility of TEER is not yet fully determined. A 74-year-old woman with coronary disease developed acute MR and heart failure after AMI. Transesophageal echocardiography confirmed severe MR due to papillary muscle rupture. The patient underwent emergency TEER, which successfully reduced MR and improved symptoms. This case highlights the life-saving potential of the Dragonfly TEER system in treating acute MR after MI, particularly in patients with extremely high surgical risk.

Transcatheter Edge-to-Edge Repair for Severe Mitral Regurgitation in Patients With Cardiogenic Shock: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with severe mitral regurgitation and cardiogenic shock demonstrate a poor prognosis. Mitral transcatheter edge-to-edge repair could alter patient management.

METHODS AND RESULTS

We systematically reviewed PubMed/Medline, Scopus, and Cochrane Library until January 2023, including studies assessing transcatheter edge-to-edge repair in patients with severe mitral regurgitation and cardiogenic shock. Studies with <5 patients were excluded. The primary outcome was device success and all-cause death, while secondary outcomes included myocardial infarction, stroke, and heart failure hospitalization rates at 30-day and intermediate-term follow-up. A fixed-effects meta-analysis was used to estimate pooled rates. Risk of bias was assessed with the Newcastle-Ottawa Scale. A total of 24 studies and 5428 patients were included, with a mean age of 71.2±3.3 years and a high mean Society of Thoracic Surgery score (15.2±8.9). Device success was achieved in 86% (95% CI, 85%-87%) and mitral regurgitation ≤2+ in 89% (95% CI: 88%-90%). The 30-day all-cause mortality rate was 14% (95% CI, 13%-15%). Stroke, myocardial infarction, and heart failure hospitalization rates were 2% (95% CI, 1%-2%), 15% (95% CI, 13%-18%), and 9% (95% CI, 8%-10%), respectively. Patients with acute myocardial infarction had similar device success (81% [95% CI, 74%-87%]), a 30-day mortality rate of 20% (95% CI, 16%-25%), and intermediate-term mortality rate of 14% (95% CI, 9%-19%). In non-myocardial infarction populations, the 30-day mortality rate was 13% (95% CI, 13%-14%), and the intermediate-term mortality rate was 35% (95% CI, 34%-36%).

CONCLUSIONS

In patients with mitral regurgitation and cardiogenic shock, transcatheter edge-to-edge repair is associated with favorable 30-day and intermediate-term outcomes. Limitations, including the observational design of included studies and considerable heterogeneity, necessitate further research in this setting.

Transcatheter closure of multiple ventricular septal ruptures after acute myocardial infarction: a case report highlighting the role of 3D transthoracic echocardiography

BACKGROUND

Post-infarct ventricular septal rupture (PI-VSR) is a rare complication of acute myocardial infarction (AMI) but has very serious implications. Managing PI-VSR using transcatheter closure (TCC) presents varying challenges depending on the patient's condition. The aim of this study is to present a highly challenging case of multiple VSRs as a complication of AMI.

CASE PRESENTATION

A 59-year-old male was admitted with symptoms of shortness of breath, dyspnea on exertion, orthopnea, and swelling of the lower extremities. He had typical chest pain related to infarction 2 weeks before his admission. On electrocardiogram (ECG) examination, evidence of an old myocardial infarction in the infero-antero-lateral regions was seen. Echocardiography showed mild mitral and tricuspid regularities. The left ventricular (LV) systolic function was mildly compromised, with a global ejection fraction of 44%. There was also a left-to-right VSR shunt in the apical region of the LV. Multiple defects as outlined by 3D transthoracic echocardiography (TTE)-the largest measuring 17 mm. Given the high risks of open-heart surgery, a percutaneous closure of the VSR was carried out using a 21 mm atrial septal defect (ASD) occluder. The device was satisfactorily placed, and there was an improvement in the clinical condition of the patient. He was discharged after his 8-day stay in the hospital.

CONCLUSION

Our study emphasizes that echocardiography with 3D imaging provides a more detailed view of the size and shape of the rupture and serves as a valuable modality for guiding the percutaneous transcatheter VSR closure procedure.

Revascularization Strategies in Women: Do Women Benefit as Much as Men?

Ischemic heart disease is a leading cause of mortality worldwide. Substantial gaps in knowledge exist in our understanding of gender-related differences in revascularization outcomes. This review aims to highlight the existing evidence of sex-based outcomes in the management of coronary artery disease and cardiogenic shock.

The uses of right heart catheterization in cardio-pulmonary disease: State-of-the-art

The right heart catheterization (RHC) remains an important diagnostic tool for a spectrum of cardiovascular disease processes including pulmonary hypertension (PH), shock, valvular heart disease, and unexplained dyspnea. While it gained widespread utilization after its introduction, the role of the RHC has evolved to provide valuable information for the management of advanced therapies in heart failure (HF) and cardiogenic shock (CS) to name a few. In this review, we provide a comprehensive overview on the indications, utilization, complications, interpretation, and calculations associated with RHC.

Cardiogenic Shock: Focus on Non-Cardiac Biomarkers

PURPOSE OF REVIEW

To examine the evolving multifaceted nature of cardiogenic shock (CS) in the context of non-cardiac biomarkers that may improve CS management and risk stratification.

RECENT FINDINGS

There are increasing data highlighting the role of lactate, glucose, and other markers of inflammation and end-organ dysfunction in CS. These biomarkers provide a more comprehensive understanding of the concurrent hemo-metabolic and cellular disturbances observed in CS and offer insights beyond standard structural and functional cardiac assessments. Non-cardiac biomarkers both refine the diagnostic accuracy and improve the prognostic assessments in CS. Further studies revolving around novel biomarkers are warranted to support more targeted and effective therapeutic and management interventions in these high-risk patients.

The Effect of Percutaneous Coronary Intervention on Patients with Acute Myocardial Infarction and Cardiogenic Shock Supported by Extracorporeal Membrane Oxygenation

Background

Patients suffering from acute myocardial infarction complicated by cardiogenic shock (AMICS), who undergo veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy, typically exhibit high mortality rates. The benefits of percutaneous coronary intervention (PCI) in these patients remains unclear. This study aims to investigate whether PCI can mitigate mortality among patients with AMICS supported by ECMO.

Methods

Data from patients ≥18 years, who underwent VA-ECMO assistance in China between January 1, 2017, and June 30, 2022, were retrieved by searching the Chinese Society of Extracorporeal Life Support (CSECLS) Registry. A total of 1623 patients were included and categorised based on whether they underwent PCI. Using propensity score matching, 320 patient pairs were successfully matched. The primary outcome was in-hospital mortality rate. The secondary outcomes included VA-ECMO duration, Hospital stay, ECMO weaning and ECMO related complications.

Results

In the cohort of 1623 patients, 641 (39.5%) underwent PCI. Upon conducting multivariate logistic regression analysis, it was observed that those who underwent PCI had a lower prevalence of hyperlipidemia (13.1% versus [vs.] 17.8%), chronic respiratory disease (2.5% vs. 4.3%) and lower lactic acid (5.90 vs. 8.40). They also had a more significant history of PCI (24.8% vs. 19.8%) and were more likely to be smokers (42.6% vs. 37.0%). Patients in the PCI group exhibited lower in-hospital mortality before and after matching (40.3% vs. 51.6%; p = 0.005), which persisted in multivariable modeling (adjusted odds ratio [aOR]: 0.69; 95% confidence interval 0.50-0.95; p = 0.024). Patients who received PCI were more successfully weaned from ECMO (88.6% vs. 75.8% before matching). PCI was not a risk factor for ECMO related complications.

Conclusions

Among patients who received ECMO support for AMICS, PCI was associated with a lower rate of in-hospital mortality.

Late mitral leaflet tear after transcatheter edge-to-edge repair for acute ischaemic mitral regurgitation: a case report

Background

Acute mitral regurgitation due to papillary muscle rupture is a severe complication of acute myocardial infarction. Transcatheter edge-to-edge repair is emerging as an effective alternative to surgical treatment, with encouraging outcomes. Leaflet adverse events are rare and are associated with relapse of significant mitral regurgitation.

Case summary

A 54-year-old man arrived at our hospital with a late presentation of ST-elevation myocardial infarction. During primary percutaneous coronary intervention of the circumflex coronary artery, a partial papillary muscle rupture occurred with acute severe mitral regurgitation and cardiogenic shock. Due to the severe haemodynamic instability, the patient underwent an emergent transcatheter edge-to-edge repair with MitraClip device during Impella support with mitral regurgitation resolution and haemodynamic stabilization. At 2-month follow-up, an interclip leaflet tear occurred with relapse of severe mitral regurgitation, requiring a mitral valve replacement surgery.

Discussion

Acute mitral regurgitation due to papillary muscle rupture is a serious complication of acute myocardial infarction. Management is based on haemodynamic stabilization and surgery. The transcatheter edge-to-edge repair is emerging as a therapeutic alternative in high-risk cases. Leaflet adverse events rarely occur during the transcatheter edge-to-edge repair procedure or before patient discharge. Our case is the first to report a late leaflet adverse event, occurring two months after the procedure and, interestingly, after an acute myocardial infarction conditioning an ischaemic mitral regurgitation. This event may be the result of the progressive adverse remodelling of left ventricular inferolateral akinetic wall, with consequent increase of tethering forces on the posterior leaflet, tensioned in the opposite direction by the clip.

Non-acute myocardial infarction-associated cardiogenic shock in Hispanic patients: An analysis from the National Inpatient Sample Database

BACKGROUND

Current knowledge about non-acute myocardial infarction-associated cardiogenic shock (nAMI-CS) by ethnicity is limited. This study compares clinical features and outcomes of nAMI-CS in Hispanic versus non-Hispanic patients in the U.S.

METHODS

Hospitalizations with nAMI-CS from 2018 to 2020 were identified using the National Inpatient Sample (NIS) database. Patients were classified by ethnicity (Hispanic vs. non-Hispanic). Statistical analysis, including Chi-square and t-tests, was conducted using STATA version 18.

RESULTS

Out of 8607 nAMI-CS hospitalizations, 832 (9.6 %) were Hispanic. Hispanic patients were younger (62.3 ± 15.2 vs. 66.2 ± 15.3 years) and had higher incidences of smoking (2.4 % vs. 2.1 %), coronary artery disease (45.4 % vs. 44.1 %), myocardial infarction (2.9 % vs. 1.9 %), heart failure (10.1 % vs. 9.2 %), and diabetes mellitus (18.9 % vs. 18.1 %). They had lower incidences of hypertension (32.9 % vs. 34.3 %), valve disease (1.9 % vs. 2.1 %), and cerebrovascular disease (6.5 % vs. 8.5 %, all p < 0.005). Hispanic patients had slightly higher in-hospital mortality rates (18.6 % vs. 17 %, p < 0.001), with an adjusted odds ratio (aOR) of 1.20 (95 % CI: 1.01-1.50, p = 0.01). Their hospital stays were longer (17.7 ± 1.87 vs. 13.2 ± 0.31 days, p = 0.03) and costlier ($409,280 ± 591,582 vs. $291,298 ± 461,920, p = 0.03).

CONCLUSION

Hispanic nAMI-CS patients are younger, have more co-morbid conditions, longer hospital stays, higher costs, and higher in-hospital mortality rates than non-Hispanic patients. Further research is needed to understand the mechanisms behind these disparities.

Outcome after primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction complicated by cardiogenic shock

BACKGROUND

Primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) may reduce the risk of subsequent cardiovascular events but remains challenging. The study aim was to evaluate the clinical characteristics and long-term outcomes of patients undergoing primary PCI for STEMI with CS.

METHODS

We conducted an observational cohort study of patients with STEMI who underwent primary PCI between April 2004 and December 2017 at Juntendo University Shizuoka Hospital. The primary outcome was cardiovascular death (CVD) during the median 3-year follow-up. We performed a landmark analysis for the incidence of CVD from 0 day to 1 year and from 1 to 10 years.

RESULTS

Among the 1758 STEMI patients in the cohort, 212 (12.1 %) patients with CS showed significantly higher 30-day CVD rate on admission than those without (26.4 % vs 2.9 %). Landmark Kaplan-Meier analysis showed that CVD from day 0 to year 1 was significantly higher in the patients with CS (log-rank p < 0.0001). Multivariate Cox regression analysis showed that CS was significantly associated with higher cardiovascular mortality (adjusted hazard ratio, 11.8; 95%confidence intervals, 7.78-18.1; p < 0.0001), but the mortality rates from 1 to 10 years were comparable (log-rank p = 0.68).

CONCLUSION

The cardiovascular 1-year mortality rate for patients with STEMI was higher for those with CS on admission than without, but the mortality rates of >1 year were comparable. Surviving the early phase is essential for patients with STEMI and CS to improve long-term outcomes.

Long-term outcomes of cardiogenic shock and cardiac arrest complicating ST-elevation myocardial infarction according to timing of occurrence

Aims

Cardiogenic shock (CS) and cardiac arrest (CA) are serious complications in ST-elevation myocardial infarction (STEMI) patients, with lack of long-term data according to their timing of occurrence. This study sought to determine the incidence and relationship between the timing of occurrence and prognostic impact of CS and CA complicating STEMI in the long-term follow-up.

Methods and results

We conducted a retrospective analysis of consecutive STEMI patients treated between 2004 and 2017. Patients were divided into four groups based on the occurrence of neither CA nor CS, CA only, CS only, and both CA and CS (CA-CS-, CA+, CS+, and CA+CS+, respectively). Adjusted Cox regression analysis was used to assess the independent association between the CS and CA categories and mortality. A total of 1603 STEMI patients were followed for a median of 3.6 years. CA and CS occurred in the 12.2% and 15.9% of patients, and both impacted long-term mortality [adjusted hazard ratio (HR) = 2.59, 95% confidence interval (CI): 1.53-4.41, P < 0.001; HR = 3.16, 95% CI: 2.21-4.53, P < 0.001, respectively). CA+CS+ occurred in 7.3%, with the strongest association with higher mortality (adjusted HR = 5.36; 95% CI: 3.80-7.55, P < 0.001). Using flexible parametric models with B-splines, the increased mortality was restricted to the first ∼10 months. In addition, overall mortality rates were higher at all timings (all with P < 0.001), except for CA during initial cardiac catheterization (P < 0.183).

Conclusion

CS and CA complicating patients presenting with STEMI were associated with higher long-term mortality rate, especially in the first 10 months. Both CS+ and CA+ at any timeframe impacted outcomes, except for CA+ during the initial cardiac catheterization, although this will have to be confirmed in larger future studies, given the relatively small number of patients.

Cardiogenic Shock Challenges and Priorities: A Clinician Survey

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

US trends of in-hospital morbidity and mortality for acute myocardial infarctions complicated by cardiogenic shock

BACKGROUND

There is limited real-world data highlighting recent temporal in-hospital morbidity and mortality trends for cases of acute myocardial infarction complicated by cardiogenic shock. The role of mechanical circulatory support within this patient population remains unclear.

METHODS

The US National Inpatient Sample database was sampled from 2011 to 2018 identifying 206,396 hospitalizations with a primary admission diagnosis of ST- or Non-ST elevation myocardial infarction complicated by cardiogenic shock. The primary outcomes included trends of all-cause in-hospital mortality, mechanical circulatory support use, and sex-specific trends for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) over the study period.

RESULTS

The annual number of AMI-CS hospitalizations increased from 22,851 in 2011 to 30,015 in 2018 and in-hospital mortality trends remained similar (42.9 % to 43.7 %, ptrend < 0.001). The proportion of patients receiving any temporary MCS device decreased (46.4 % to 44.4 %). The use of intra-aortic balloon pump (IABP) decreased (44.9 % to 32.9 %) and the use of any other non-IABP MCS device increased (2.5 % to 15.6 %), ptrend<0.001. Sex-specific mortality indicate female in-hospital mortality remained similar (50.3 % to 51 %, ptrend<0.001), but higher than male in-hospital mortality, which increased non-significantly (38.8 % to 40.2 %, ptrend = 0.372).

CONCLUSIONS

From 2011 to 2018, hospitalizations for AMI-CS patients have increased in number. However, there has been no recent appreciable change in AMI-CS mortality despite a changing treatment landscape with decreasing use of IABPs and increasing use of non-IABP MCS devices. Further research is necessary to examine the appropriate use of MCS devices within this population.

ALDH2 polymorphism and myocardial infarction: From alcohol metabolism to redox regulation

Acute myocardial infarction (AMI) remains a leading cause of death worldwide. Increased formation of reactive oxygen species (ROS) during the early reperfusion phase is thought to trigger lipid peroxidation and disrupt redox homeostasis, leading to myocardial injury. Whilst the mitochondrial enzyme aldehyde dehydrogenase 2 (ALDH2) is chiefly recognised for its central role in ethanol metabolism, substantial experimental evidence suggests an additional cardioprotective role for ALDH2 independent of alcohol intake, which mitigates myocardial injury by detoxifying breakdown products of lipid peroxidation including the reactive aldehydes, malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE). Epidemiological evidence suggests that an ALDH2 mutant variant with reduced activity that is highly prevalent in the East Asian population increases AMI risk. Additional studies have uncovered a strong association between coronary heart disease and this ALDH2 mutant variant. It appears this enzyme polymorphism (in particular, in ALDH2*2/2 carriers) has the potential to have wide-ranging effects on thiol reactivity, redox tone and therefore numerous redox-related signaling processes, resilience of the heart to cope with lifestyle-related and environmental stressors, and the ability of the whole body to achieve redox balance. In this review, we summarize the journey of ALDH2 from a mitochondrial reductase linked to alcohol metabolism, via pre-clinical studies aimed at stimulating ALDH2 activity to reduce myocardial injury to clinical evidence for its protective role in the heart.

Cytoprotection as an Innovative Therapeutic Strategy to Cardiogenic Shock: Exploring the Potential of Cytidine-5-Diphosphocholine to Mitigate Target Organ Damage

BACKGROUND

Preservation of organ function and viability is a crucial factor for survival in cardiogenic shock (CS) patients. There is not information enough on cytoprotective substances that may delay organs damage in CS. We hypothesize that cytidine-5-diphosphocholine (CDP-choline) can act as a cytoprotective pharmacological measure that diminishes the target organ damage. So, we aimed to perform a review of works carried out in our institution to evaluate the effect of therapeutic cytoprotection of the CDP-choline.

SUMMARY

CDP-choline is an intermediate metabolite in the synthesis of phosphatidylcholine. It is also a useful drug for the treatment of acute ischaemic stroke, traumatic brain injury, and neurodegenerative diseases and has shown an excellent pharmacological safety profile as well. We review our institution's work and described the cytoprotective effects of CDP-choline in experimental models of heart, liver, and kidney acute damage, where this compound was shown to diminish reperfusion-induced ventricular arrhythmias, oxidative stress, apoptotic cell death, inflammation, lactic acid levels and to preserve mitochondrial function.

KEY MESSAGES

We propose that additional research is needed to evaluate the impact of cytoprotective therapy adjuvant to mitigate target organ damage in patients with CS.

Impact of Age, Gender, and Body Mass Index on Short-Term Outcomes of Patients With Cardiogenic Shock on Mechanical Circulatory Support

This single-center, observational study assessed the impact of age, gender, and body mass index (BMI) in patients with cardiogenic shock (CS) on temporary mechanical circulatory support. All adult patients admitted to the Cleveland Clinic main campus Cardiac Intensive Care Unit (CICU) between December 1, 2015, to December 31, 2019, CICU with CS necessitating mechanical circulatory support (MCS) with intra-aortic balloon pump, Impella, or venous arterial-extra corporeal membrane oxygenation were retrospectively analyzed for this study. Baseline characteristics and 30-day outcomes were collected through physician-directed chart review. The impact of age, gender, and BMI on 30-day mortality was assessed using multivariable logistic regression. Kaplan-Meier survival curves were used to analyze the survival difference in specific subsets. A total of 393 patients with CS on temporary MCS were admitted to our CICU during the study period. The median age of our cohort was 63 years (interquartile range 54 to 70 years), median BMI was 28.50 kg/m2 (interquartile range 24.62 to 29.72) and 70% (n = 276) were men. In total, 22 patients >80 years had received MCS compared with 372 patients <80 years. Patients >80 years on MCS had significantly higher 30-day mortality compared with those <80 years (81.8% vs 49.3%, p = 0.006). Upon stratifying patients by BMI, 161 (41%) patients were found to have BMI ≥30 kg/m2 whereas 232 (59%) patients had BMI <30 kg/m2. Comparison of 30-day mortality revealed that patients with BMI ≥30 did significantly worse than patients with BMI <30 (59.6% vs 45.3%, p = 0.007). There was no difference in 30-day mortality between men and women. On multivariable logistic regression, both age and BMI had a positive linear relation with adjusted 30-day mortality whereas gender did not have a major effect. Advanced age and higher BMI are independently associated with worse outcomes in patients with CS on MCS. Utilizing a strict selection criterion for patients in CS is pertinent to derive the maximum benefit from advanced mechanical support.

Cardiogenic Shock Prior to Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: Outcomes and Predictors of Mortality (ANZACS-QI 73)

BACKGROUND & AIMS

Cardiogenic shock (CS) is a serious complication of acute myocardial infarction (MI) and is associated with significant mortality. We describe a contemporary, real-world cohort of patients with ST-elevation MI (STEMI) and CS, including 30-day mortality and clinically relevant predictors of mortality.

METHODS

All patients presenting with STEMI who were treated with percutaneous coronary intervention (PCI) in New Zealand (2016 to 2020) were identified from the Aotearoa New Zealand All Cardiology Services Quality Improvement (ANZACS-QI) registry and stratified based on their Killip class on arrival to the cardiac catheterisation laboratory. Primary outcome was 30-day all-cause mortality. Multivariable analysis was used to identify predictors of mortality prior to PCI and to develop a mortality scoring system.

RESULTS

In total, 6,649 patients were identified, including 192 (2.9%) Killip IV (CS) patients. Thirty-day mortality was 47.5% in patients with CS, 14.6% in those with heart failure without shock, and 3% in those without heart failure. Independent predictors of 30-day mortality for patients with CS were: estimated glomerular filtration rate <60 mL/min/1.73m2 (relative risk [RR] 1.89, 95% confidence interval [CI] 1.39-2.58), cardiac arrest (RR 1.54, 95% CI 1.15-2.06), diabetes (RR 1.31, 95% CI 1.01-1.70), female sex (RR 1.32, 95% CI 1.01-1.72), femoral arterial access (RR 1.42, 95% CI 1.06-1.90) and left main stem culprit (RR 2.16, 95% CI 1.65-2.84). A multivariable Shock score was developed which predicts 30-day mortality with good global discrimination (area under the curve 0.79, 95% CI 0.73-0.85).

CONCLUSION

In this national cohort, the 30-day mortality for STEMI patients presenting with CS treated with PCI remains high, at nearly 50%. The ANZACS-QI Shock score is a promising tool for mortality risk stratification prior to PCI but requires further validation.

Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock

BACKGROUND

Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no tMCS or either intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella® for AMICS, with a particular focus on long-term outcomes.

METHODS

Using health claim data from AOK-Die Gesundheitskasse (local health care funds), we retrospectively analysed complications and outcomes of all insured patients with AMICS between 1 January 2010 and 31 December 2017.

RESULTS

A total of 39,864 patients were included (IABP 5451; Impella 776; V-A ECMO 833; no tMCS 32,804). In-hospital complications, including renal failure requiring dialysis (50.3% V-A ECMO vs. 30.5% Impella vs. 29.2 IABP vs. 12.1% no tMCS), major bleeding (38.1% vs. 20.9% vs. 18.0% vs. 9.3%) and sepsis (22.5% vs. 15.9% vs. 13.9% vs. 9.3%) were more common in V-A ECMO patients. In a multivariate analysis, the use of both V-A ECMO (HR 1.57, p < 0.001) and Impella (HR 1.25, p < 0.001) were independently associated with long-term mortality, whereas use of IABP was not (HR 0.89, p < 0.001). Kaplan-Meier estimates showed better survival for patients on IABP compared with Impella, V-A ECMO and no-tMCS. Short- and long-term mortality was high across all groups.

CONCLUSIONS

Our data show noticeably more in-hospital complications in patients on tMCS and higher mortality with V-A ECMO and Impella. The use of both devices is an independent risk factor for mortality, whereas the use of IABP is associated with a survival benefit.

Evolving indications for transcatheter mitral edge-to-edge repair

Transcatheter mitral edge-to-edge repair (TEER) is an established procedure for managing mitral regurgitation (MR) in high-risk patients. It is effective in treating both primary and secondary MR, as reported in the surgical and interventional literature. Over time, TEER has gained popularity and achieved procedural success in various anatomies. The less invasive nature of TEER, along with its high safety profile and immediate haemodynamic improvement suggest potential benefits in high-risk populations who are not normally included in major trials. These patients, often deemed unsuitable for surgical intervention, are typically managed conservatively, despite accumulating evidence suggesting the potential of clinical improvement by reducing MR through TEER. Examples include post-myocardial infarction MR, patients with hypertrophic obstructive cardiomyopathy and patients experiencing recurrent MR after surgical intervention. This review discusses the utilisation of TEER beyond recognised indications, examining outcomes and limitations in diverse patient populations. Further studies are warranted to evaluate the benefits of TEER in clinical scenarios beyond the current indications.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Acute Triple Coronary Artery Occlusion Leading to Cardiogenic Shock and Cardiac Arrest Emphasizing the Role of Mechanical Circulatory Support (Escalate before It's Too Late)

We report a case of cardiac arrest in a 38-year-old male with no past medical history who presented as a case of ST-segment elevation myocardial infarction, and coronary angiography showed triple coronary artery thrombosis complicated with cardiogenic shock (CS) that warrants starting on inotropic support and insertion of intra-aortic balloon pump. CS diagnosis with a high likelihood of deterioration was established based on hemodynamics assessment; hence, an early prompt decision for escalation of mechanical circulatory support to Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was made, which helped to prevent the patient's further deterioration and organ damage. The patient had uneventful VA-ECMO decannulation and was transferred to the ward and discharged after 28 days in stable condition on oral medical therapy and was following up regularly in the cardiology clinic. Therefore, early hemodynamics assessment in acute myocardial infarction CS cases will help predict rapid worsening, which may require prompt escalation of mechanical circulatory support and perhaps improve the outcome.

Severe mitral stenosis masquerading as cardiogenic shock successfully managed with extracorporeal membrane oxygenation and percutaneous mitral commissurotomy: a case report

Background

Rheumatic fever is still a major cause of mitral valve (MV) stenosis in the developing world. Few patients with critical rheumatic MV stenosis can present with acute cardiogenic shock (CS) that requires urgent treatment with circulatory support and definitive valvular repair or replacement.

Case summary

A 37-year-old gentleman was admitted with heart failure, CS Society for Cardiovascular Angiography and Interventions D, and atrial fibrillation with a rapid ventricular response. He had no prior medical history. He had multiple organ failures and required intubation, two DC shocks of 200 joules without haemodynamic improvement, continuous renal replacement therapy, and medical and mechanical circulatory support using extracorporeal membrane oxygenation (ECMO). His echocardiography showed severe rheumatic mitral stenosis (mitral valve area 2D of 0.7 cm2, mean diastolic gradient of 17 mmHg, Wilkins score 7). His Society of Thoracic Surgery score and EuroScore were 50.1% and 12.1%, respectively. Thus, a percutaneous transcatheter mitral commissurotomy (PTMC) was decided as the definitive treatment in a multidisciplinary team meeting. Following the procedure, the patient's circulatory support was gradually weaned off, and he was successfully extubated with a marked improvement in his renal functions. The patient achieved a complete recovery without any long-term sequelae.

Discussion

Cardiogenic shock related to severe rheumatic MV stenosis requires multidisciplinary team management with prompt diagnosis, initiation of the most appropriate mechanical support device (e.g. ECMO or tandem heart), and relief of the MV obstruction. Percutaneous transcatheter mitral commissurotomy can be the preferred option in this setting if the valve is pliable.

Advanced Metrics and Early Predictors of Cardiogenic Shock

Cardiogenic shock (CS) can be defined as a range of illnesses that describes a state where cardiac output, which is the blood volume ejected from the left ventricle every minute that leads to tissue perfusion of nutrients, is insufficient in providing adequate oxygenation to the systemic circulation. The incidence of CS on admission has increased in recent years, with the six- and 12-month mortality rates remaining unchanged. The purpose of this literature review is to bring forth several parameters that have been utilized in the past 10 years to predict CS mortality. Further studies to implement these parameters in management algorithms, along with early screenings and advanced treatment options such as mechanical cardiac assist devices, can improve the mortality associated with CS. This literature-based review was conducted by evaluating current research focusing on the clinical presentation of CS and predictors of CS. PubMed served as the primary database for article retrieval due to access. Two searches were conducted: One for clinical presentations and advanced metrics for CS and another for early predictors for CS. Thirteen articles regarding clinical presentation and seven articles regarding early predictors were selected. Three tools/scores and five laboratory tests were identified that allowed clinicians to prognosticate outcomes in patients suffering from CS based on clinical and laboratory presentations. Examining these predictors will allow earlier intervention in the development of CS and potentially help lower the mortality rate of CS. The eventual creation of a scoring system that incorporates multiple metrics discussed in this review can provide the most accurate prognosis of CS, which can lead to more targeted interventions.

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

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

Transcatheter Mitral Edge-to-Edge Repair for Treatment of Acute Mitral Regurgitation

Acute mitral regurgitation (AMR) is a medical emergency which may lead to rapid clinical deterioration and is associated with high morbidity and mortality. The severity of the clinical presentation varies according to several factors, ranging from cardiogenic shock to a milder presentation. The medical management of AMR includes intravenous diuretics, vasodilators, inotropic support, and potentially mechanical support to stabilise patients. Patients persisting with refractory symptoms despite optimal medical therapy are considered for surgical intervention, but high-risk patients deemed to be inoperable frequently experience poor outcomes. This review highlights the variety of clinical presentations of AMR and the pitfalls in diagnosis and management. The emerging role of transcatheter edge-to-edge repair (TEER), particularly in high-risk patients early after myocardial infarction requiring urgent intervention, has demonstrated feasibility and promising efficacy. TEER is well tolerated and improves hemodynamic parameters in AMR. In a recent analysis, the in-hospital and 1-year mortality rates were significantly higher with surgical mitral interventions compared with TEER. The global TEER experience for treating AMR is encouraging, with reports indicating improved clinical outcomes in high-risk patients and its potential as a bridge to recovery. Early recognition of AMR, validated criteria for patient selection, optimal timing of the intervention as well as long-term outcomes and additional prospective data should be addressed in future studies.

The Impact of Sex on Cardiogenic Shock Outcomes Following ST Elevation Myocardial Infarction

BACKGROUND

Cardiogenic shock (CS) remains the leading cause of ST elevation myocardial infarction (STEMI)-related mortality. Contemporary studies have shown no sex-related differences in mortality.

METHODS

STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) were included based on a dedicated prospective STEMI database. We compared sex-specific differences in CS characteristics at baseline, during hospitalization, and in subsequent clinical outcomes. Endpoints included all-cause mortality and major adverse cardiac events (MACE).

RESULTS

Of 3202 consecutive STEMI patients, 210 (6.5%) had CS, of which 63 (30.0%) were women. Women were older than men (73.2 vs. 65.5% y, p < 0.01), and more had hypertension (68.3 vs. 52.8%, p = 0.019) and diabetes (38.7 vs. 24.8%, p = 0.047). Fewer were smokers (13.3 vs. 41.2%, p < 0.01), had previous PCI (9.1 vs. 22.3% p = 0.016), or required IABP (35.3 vs. 51.1% p = 0.027). Women had higher rates of mortality (53.2 vs. 35.3% in-hospital, p = 0.01; 61.3 vs. 41.9% at 1 month, p = 0.01; and 73.8 vs. 52.6% at 3 years, p = 0.05) and MACE (60.6 vs. 41.6% in-hospital, p = 0.032; 66.1 vs. 45.6% at 1 month, p = 0.007; and 62.9 vs. 80.3% at 3 years, p = 0.015). After multivariate adjustment, female sex remained an independent factor for death (HR-2.42 [95% CI 1.014-5.033], p = 0.042) and MACE (HR-1.91 [95% CI 1.217-3.031], p = 0.01).

CONCLUSIONS

CS complicating STEMI is associated with greater short- and long-term mortality and MACE in women. Sex-focused measures to improve diagnosis and treatment are mandatory for CS patients.

Focused Ultrasonography in Cardiac Arrest

Rapid diagnostic tools available to the emergency physician caring for cardiac arrest patients are limited. Focused ultrasound (US), and in particular, focused echocardiography, is a useful tool in the evaluation of patients in cardiac arrest. It can help identify possible causes of cardiac arrest like tamponade and pulmonary embolism, which can guide therapy. US can also yield prognostic information, with lack of cardiac activity being highly specific for failure to achieve return of spontaneous circulation. US may also be used to aid in procedural guidance. Recently, focused transesophageal echocardiography has been used in the emergency department setting.

Role of acute mechanical circulatory support devices in cardiogenic shock

Cardiogenic shock is a state of low cardiac output that is associated with significant morbidity and mortality. A considerable proportion of patients with cardiogenic shock respond poorly to medical management and require acute mechanical circulatory support (AMCS) devices to improve tissue perfusion as well as to support the heart. In the last two decades, many new AMCS devices have been introduced to support the right, left, and both ventricles. All these devices vary in terms of the support they provide to the body and heart, mechanism of functioning, method of insertion, and adverse events. In this review, we compare and contrast the available percutaneous and surgically placed AMCS devices used in cardiogenic shock and discuss the associated clinical and hemodynamic data to make a conscious decision about choosing a device.

Sex-Related Differences in Short-Term Prognosis in Patients with Acute Myocardial Infarction-Related Cardiogenic Shock Receiving Impella Support in Japan: From the J-PVAD Registry

Background and Objectives: Sex-specific outcome in patients with acute myocardial infarction-related cardiogenic shock (AMI-CS) receiving temporary mechanical circulatory support remains controversial. Materials and Methods: Patients with AMI-CS who received Impella support were prospectively enrolled in the Japanese registry for Percutaneous Ventricular Assist Device. Patients enrolled between January 2021 and December 2022 were considered to be eligible. Patients with out-of-hospital cardiac arrest and those without revascularization were excluded. The sex disparity in the 30-day survival after the initiation of Impella support was evaluated. Results: A total of 924 patients (median age 73 years; 21% female) were included. Female patients were older and had a smaller physiques than male patients (p < 0.05 for both). Female sex was significantly associated with a higher 30-day mortality after adjustment for four other potential confounders with a hazard ratio of 1.365 (95% confidence interval 1.026-1.816, p = 0.0324). In the female cohort, patients who received Impella prior to revascularization (N = 138) had a greater survival rate compared to those who received Impella after revascularization (68.1% versus 44.8%, p = 0.0015). Conclusions: Among the patients with AMI-CS who received Impella support and underwent revascularization, female sex was independently associated with a lower 30-day survival. For female patients, early initiation of Impella support prior to revascularization may improve their clinical outcomes.

Outcomes After Left Main Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock (from the German ALKK PCI Registry)

Early revascularization therapy with percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Data from consecutive patients with AMI and CS treated with PCI enrolled into the prospective Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte-PCI registry were centrally collected and analyzed. Patients were divided into 4 groups with PCI for left main (LM), 1-vessel, 2-vessel, and 3-vessel diseases. Patients' characteristics, procedural features, antithrombotic therapies, and in-hospital complications were compared between the 4 groups. Between 2010 and 2015 a total of 2,348 consecutive patients with AMI and CS were treated by PCI in 51 hospitals, 295 for LM (15 for protected, 280 for unprotected) and single-vessel (n = 491), 2-vessel (n = 524), and 3-vessel disease (n = 1,038). Thrombolysis in myocardial infarction 3 patency of the culprit lesion after PCI was 84.3%, 84.0%, 80.8%, and 84.6% in single-vessel, 2-vessel, 3-vessel disease, and LM PCI, respectively, whereas in-hospital mortality was 27.9%, 33.9%, 46.5%, and 55.9%. Bleeding rates were low (2.0%-2.3 %) and not different between groups. In a multivariate analysis a higher age, thrombolysis in myocardial infarction flow <3 after PCI, 3-vessel disease, and LM PCI were independent predictors of mortality. In conclusion, PCI of the LM is performed in about 12.5% of patients with AMI and CS and was associated with a high procedural success rate, whereas mortality is increased with LM PCI.

Interventional management of mechanical complications in acute myocardial infarction

Mechanical complications following a myocardial infarction are uncommon, but with dramatic consequences and high mortality. The left ventricle is the most often affected cardiac chamber and complications can be classified according to the timing in early (from days to first weeks) or late complications (from weeks to years). Despite the decrease in the incidence of these complications thank to primary percutaneous coronary intervention programs -wherever this option is available-, the mortality is still significant and these infrequent complications are an emergent scenario and one of the most important causes of mortality at short term in patients with myocardial infarction. Mechanical circulatory support devices, especially if minimally invasive implantation is used avoiding thoracotomy, have improved the prognosis of these patients by providing stability until definitive treatment can be applied. On the other hand, the growing experience in transcatheter interventions for the treatment of ventricular septal rupture or acute mitral regurgitation has been associated to an improvement in their results, even though prospective clinical evidence is still missing.

Preclinical Studies on Pulsatile Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review

Refractory cardiogenic shock is increasingly being treated with veno-arterial extracorporeal membrane oxygenation (V-A ECMO), without definitive proof of improved clinical outcomes. Recently, pulsatile V-A ECMO has been developed to address some of the shortcomings of contemporary continuous-flow devices. To describe current pulsatile V-A ECMO studies, we conducted a systematic review of all preclinical studies in this area. We adhered to PRISMA and Cochrane guidelines for conducting systematic reviews. The literature search was performed using Science Direct, Web of Science, Scopus, and PubMed databases. All preclinical experimental studies investigating pulsatile V-A ECMO and published before July 26, 2022 were included. We extracted data relating to the 1) ECMO circuits, 2) pulsatile blood flow conditions, 3) key study outcomes, and 4) other relevant experimental conditions. Forty-five manuscripts of pulsatile V-A ECMO were included in this review detailing 26 in vitro , two in silico , and 17 in vivo experiments. Hemodynamic energy production was the most investigated outcome (69%). A total of 53% of studies used a diagonal pump to achieve pulsatile flow. Most literature on pulsatile V-A ECMO focuses on hemodynamic energy production, whereas its potential clinical effects such as favorable heart and brain function, end-organ microcirculation, and decreased inflammation remain inconclusive and limited.

Role of Mechanical Circulatory Support in Acute MI Management

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

Prevalence and Predictors of Cardiogenic Shock in Intermediate-Risk Pulmonary Embolism: Insights From the FLASH Registry

BACKGROUND

Patients with acute pulmonary embolism (PE) and hypotension (high-risk PE) have high mortality. Cardiogenic shock can also occur in nonhypotensive or normotensive patients (intermediate-risk PE) but is less well characterized.

OBJECTIVES

The authors sought to evaluate the prevalence and predictors of normotensive shock in intermediate-risk PE.

METHODS

Intermediate-risk PE patients in the FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical) were included. The prevalence of normotensive shock (systolic blood pressure ≥90 mm Hg but cardiac index ≤2.2 L/min/m²) was assessed. A composite shock score consisting of markers of right ventricular function and ischemia (elevated troponin, elevated B-type natriuretic peptide, moderately/severely reduced right ventricular function), central thrombus burden (saddle PE), potential additional embolization (concomitant deep vein thrombosis), and cardiovascular compensation (tachycardia) was prespecified and assessed for its ability to identify normotensive shock patients.

RESULTS

Over one-third of intermediate-risk PE patients in FLASH (131/384, 34.1%) were in normotensive shock. The normotensive shock prevalence was 0% in patients with a composite shock score of 0 and 58.3% in those with a score of 6 (highest score). A score of 6 was a significant predictor of normotensive shock (odds ratio: 5.84; 95% CI: 2.00-17.04). Patients showed significant on-table improvements in hemodynamics post-thrombectomy, including normalization of the cardiac index in 30.5% of normotensive shock patients. Right ventricular size, function, dyspnea, and quality of life significantly improved at the 30-day follow-up.

CONCLUSIONS

Although hemodynamically stable, over one-third of intermediate-risk FLASH patients were in normotensive shock with a depressed cardiac index. A composite shock score effectively further risk stratified these patients. Mechanical thrombectomy improved hemodynamics and functional outcomes at the 30-day follow-up.

Machine learning prediction of mortality in Acute Myocardial Infarction

BACKGROUND

Acute Myocardial Infarction (AMI) is the leading cause of death in Portugal and globally. The present investigation created a model based on machine learning for predictive analysis of mortality in patients with AMI upon admission, using different variables to analyse their impact on predictive models.

METHODS

Three experiments were built for mortality in AMI in a Portuguese hospital between 2013 and 2015 using various machine learning techniques. The three experiments differed in the number and type of variables used. We used a discharged patients' episodes database, including administrative data, laboratory data, and cardiac and physiologic test results, whose primary diagnosis was AMI.

RESULTS

Results show that for Experiment 1, Stochastic Gradient Descent was more suitable than the other classification models, with a classification accuracy of 80%, a recall of 77%, and a discriminatory capacity with an AUC of 79%. Adding new variables to the models increased AUC in Experiment 2 to 81% for the Support Vector Machine method. In Experiment 3, we obtained an AUC, in Stochastic Gradient Descent, of 88% and a recall of 80%. These results were obtained when applying feature selection and the SMOTE technique to overcome imbalanced data.

CONCLUSIONS

Our results show that the introduction of new variables, namely laboratory data, impacts the performance of the methods, reinforcing the premise that no single approach is adapted to all situations regarding AMI mortality prediction. Instead, they must be selected, considering the context and the information available. Integrating Artificial Intelligence (AI) and machine learning with clinical decision-making can transform care, making clinical practice more efficient, faster, personalised, and effective. AI emerges as an alternative to traditional models since it has the potential to explore large amounts of information automatically and systematically.

Adjusted mortality of extracorporeal membrane oxygenation for acute myocardial infarction patients in cardiogenic shock

Cardiogenic shock (CS) is a common cause of death following acute myocardial infarction (MI). This study aimed to evaluate the adjusted mortality of venoarterial extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon counterpulsation (IABP) for patients with MI-CS. We included 300 MI patients selected from a multinational registry and categorized into VA-ECMO + IABP (N = 39) and no VA-ECMO (medical management ± IABP) (N = 261) groups. Both groups' 30-day and 1-year mortality were compared using the weighted Kaplan-Meier, propensity score, and inverse probability of treatment weighting methods. Adjusted incidences of 30-day (VA-ECMO + IABP vs No VA-ECMO, 77.7% vs 50.7; P = .083) and 1-year mortality (92.3% vs 84.8%; P = .223) along with propensity-adjusted and inverse probability of treatment weighting models in 30-day (hazard ratio [HR], 1.57; 95% confidence interval [CI], 0.92-2.77; P = .346 and HR, 1.44; 95% CI, 0.42-3.17; P = .452, respectively) and 1-year mortality (HR, 1.56; 95% CI, 0.95-2.56; P = .076 and HR, 1.33; 95% CI, 0.57-3.06; P = .51, respectively) did not differ between the groups. However, better survival benefit 30 days post-ECMO could be supposed (31.6% vs 83.4%; P = .022). Therefore, patients with MI-CS treated with IABP with additional VA-ECMO and those not supported with ECMO have comparable overall 30-day and 1-year mortality risks. However, VA-ECMO-supported survivors might have better long-term clinical outcomes.

Ventricular Septal Rupture and Artificial Intelligence (AI)-Assisted Healthcare

This case report highlights the use of point-of-care ultrasound (POCUS) for the diagnosis of ventricular septal rupture (VSR), a severe consequence of acute myocardial infarction (AMI). VSR has a broad spectrum of signs and inconspicuous symptoms, making the diagnosis difficult. POCUS offers non-invasive, real-time cardiac imaging and has an advantage over other methods due to its ability to identify VSR early. Here we present a 63-year-old female with a history of type 2 diabetes, hypothyroidism, hyperlipidemia, and a family history of cardiovascular disease, who came to the ED with chest pain for three days, palpitations, and dyspnea at rest. On examination, the patient was hypotensive, tachycardic, and had crackles with a harsh holosystolic murmur. An EKG and elevated troponin levels suggested acute on chronic anterior-lateral wall ST-elevation myocardial infarction (STEMI). Resuscitation efforts were initiated, followed by a lung ultrasound that revealed good lung sliding and multiple B lines without pleural thickening, indicating pulmonary edema. Echocardiography revealed ischemic heart disease with moderate left ventricle (LV) systolic dysfunction and a 14 mm apical ventricular septal rupture (hypokinetic thinning of the anterior wall, septum, apex, and anterolateral wall with a left ventricular ejection fraction (LVEF) of 39%). The presence of flow on color Doppler across the interventricular septum, showing left-to-right shunting, led to a definitive diagnosis of acute-on-chronic myocardial infarction (MI) with ventricular septal rupture. The case report also emphasizes how modern AI applications like ChatGPT (OpenAI, San Francisco, California, United States), aid in language and research, saving time and redefining the healthcare and research industry. As a result, we are confident that AI-assisted healthcare will be the next global breakthrough.

MitraClip as a therapeutic strategy for post-myocardial infarction mitral regurgitation

Mitral regurgitation is a serious complication of post-myocardial infarction, with increasing mortality. Surgery as the primary treatment carries a high risk. MitraClip is a new therapeutic to treat post-myocardial infarction mitral regurgitation. In this case, a 62-year-old male patient suffered from severe heart failure symptoms after emergency coronary intervention and extracorporeal membrane oxygenation support. Based on cardiac echocardiography, severe mitral regurgitation was monitored in this patient. After MitraClip treatment, the patient's condition was gradually improved and discharged successfully. This case highlights that MitraClip is a safe and effective strategy for post-myocardial infarction mitral regurgitation.

Clinical characteristics and evolution of patients with cardiogenic shock in Argentina in the context of an acute myocardial infarction with ST segment elevation. Data from the nationwide ARGEN-IAM-ST Registry

Cardiogenic Shock is one of the main causes of death in ST segment Elevation Myocardial Infarction. To know the clinical characteristics, in-hospital evolution and mortality of patients with Cardiogenic Shock. Patients enrolled in the ARGEN-IAM-ST Registry were analyzed. Predictors of Cardiogenic Shock and death during hospital stay were established. A total of 6122 patients were admitted between 2015 and 2022. Cardiogenic Shock was present in 10.75% of cases. Patients with CS were older (64.5 vs 60 years), more females (41% vs 36%), with more antecedents of infarction and a higher prevalence of anterior location of infarction and multivessel disease. They were also less revascularized (88.5% vs 91.5%) and had a higher incidence of failed angioplasty (15.7% vs 2.7%). They also evidenced a higher occurrence of mechanical complications (6.8% vs 0.4%), ischemic recurrence (7.4% vs 3.4%) and cardiac arrest on admission (44.8% vs 2.6%). All the differences described showed statistical significance with P < 0.05. Overall mortality was 58% in contrast to 2.77% in patients without Cardiogenic Shock (P < 0.001). Only age, DBT, and early cardiac arrest were independent predictors of shock on admission whereas age, female gender, cardiac arrest on admission and failed angioplasty were independent predictors of death. One out of 10 patients with ST Elevation Myocardial Infarction presented cardiogenic shock. Its clinical characteristics were similar to those described more than 20 years ago. Despite a high use of reperfusion strategy cardiogenic shock continues to have a very high mortality Argentina.

Involvement of Vasopressin in Tissue Hypoperfusion during Cardiogenic Shock Complicating Acute Myocardial Infarction in Rats

Acute heart failure (AHF) due to acute myocardial infarction (AMI) is likely to involve cardiogenic shock (CS), with neuro-hormonal activation. A relationship between AHF, CS and vasopressin response is suspected. This study aimed to investigate the implication of vasopressin on hemodynamic parameters and tissue perfusion at the early phase of CS complicating AMI. Experiments were performed on male Wistar rats submitted or not to left coronary artery ligation (AMI and Sham). Six groups were studied Sham and AMI treated or not with either a vasopressin antagonist SR-49059 (Sham-SR, AMI-SR) or agonist terlipressin (Sham-TLP, AMI-TLP). Animals were sacrificed one day after surgery (D₁) and after hemodynamic parameters determination. Vascular responses to vasopressin were evaluated, ex vivo, on aorta. AHF was defined by a left ventricular ejection fraction below 40%. CS was defined by AHF plus tissue hypoperfusion evidenced by elevated serum lactate level or low mesenteric oxygen saturation (SmO₂) at D₁. Mortality rates were 40% in AMI, 0% in AMI-SR and 33% in AMI-TLP. Immediately after surgery, a sharp decrease in SmO₂ was observed in all groups. At D₁, SmO₂ recovered in Sham and in SR-treated animals while it remained low in AMI and further decreased in TLP-treated groups. The incidence of CS among AHF animals was 72% in AMI or AMI-TLP while it was reduced to 25% in AMI-SR. Plasma copeptin level was increased by AMI. Maximal contractile response to vasopressin was decreased in AMI (32%) as in TLP- and SR- treated groups regardless of ligation. Increased vasopressin secretion occurring in the early phase of AMI may be responsible of mesenteric hypoperfusion resulting in tissue hypoxia. Treatment with a vasopressin antagonist enhanced mesenteric perfusion and improve survival. This could be an interesting therapeutic strategy to prevent progression to cardiogenic shock.

MitraClip to the Rescue in Cardiogenic Shock: Case Series from a Single Center

Cardiogenic shock (CS) in the setting of acute coronary syndrome carries detrimental consequences and high levels of mortality and morbidity if not managed promptly. Acute mitral regurgitation (MR) as a complication of the myocardial infarction might superimpose refractory CS that warrants mitral valve repair. There has been growing use of Transcatheter edge-to-edge mitral valve repair (TEER) as a therapy for CS secondary to acute MR. In this cohort, we describe two cases of CS secondary to acute ischemic MR managed with a Mitraclip.

Defining the optimal revascularization strategy during protected high-risk procedures with Impella

Complete revascularization (CR) in patients with multi-vessel disease improves outcomes. The use of percutaneous left-ventricular assist devices, such as the Impella heart pump, is useful to minimize the risk of haemodynamic compromise in complex higher risk and clinically indicated patients. The recently published data from the PROTECT III trial suggest more CR during Impella-protected percutaneous coronary intervention with more extensive lesion preparation and treatment, resulting in the reduced need for repeat revascularization. To achieve CR and improve survival, procedural guidance by intravascular imaging, extensive lesion preparation, debulking with atherectomy devices, advanced chronic total occlusion revascularization techniques, and post-interventional treatment with modern anti-platelet medication are essential.