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Wang J, Wang S, Song Y, Huang M, Cao W, Liu S, Chen S, Li X, Liu M, He Y. Analysis of 24-hour Death Risk Factors in Circulatory Failure Patients Treated with Venoarterial Extracorporeal Membrane Oxygenation. Braz J Cardiovasc Surg 2023; 38:e20220398. [PMID: 37801399 PMCID: PMC10550103 DOI: 10.21470/1678-9741-2022-0398] [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: 04/01/2022] [Accepted: 12/27/2022] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE To explore the factors affecting short-term prognosis of circulatory failure patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) treatment. METHODS A total of 136 patients undergoing VA-ECMO were enrolled in this study and subsequently divided into the death group (n=35) and the survival group (n=101) based on whether death occurred during hospitalisation. Extracorporeal membrane oxygenation (ECMO) running time, length of intensive care unit stay, length of hospital stay, costs, and ECMO complications were then compared between the two groups. RESULTS The average age of all patients undergoing ECMO was 47.64±16.78 years (53.2±16.20 years in the death group and 45.713±16.62 years in the survival group) (P=0.022). Patients in the survival group exhibited a clear downward trend in lactic acid value following ECMO treatment compared to those in the death group. Total hospitalisation stay was longer in the survival group (35 days) than in the death group (15.5 days) (P<0.001). In the analysis of ECMO complications, the incidence of neurological complications, renal failure, limb complications, and infection were higher in the death group than in the survival group (P<0.05 for all). Specifically, as a risk factor for patient survival and discharge, the occurrence of infection will lead to increased hospitalisation stays and costs (P<0.05 for both). CONCLUSION Complications such as kidney failure and infection are associated with in-hospital death, and ECMO-related complications should be actively prevented to improve the survival rate of VA-ECMO treatment.
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Affiliation(s)
- Jianwei Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
- Department of Critical Care Medicine, Puyang People’s Hospital,
Henan, People’s Republic of China
| | - Shengshu Wang
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
| | - Yang Song
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - MingJun Huang
- Department of Extracorporeal Support Center, The First Affiliated
Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Wenzhe Cao
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shaohua Liu
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Shimin Chen
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Xuehang Li
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- Chinese People’s Liberation Army Medical School, Beijing, People’s
Republic of China
| | - Miao Liu
- Department of Statistics and Epidemiology, Graduate School, Chinese
People’s Liberation Army General Hospital, Beijing, People’s Republic of China
| | - Yao He
- Institute of Geriatrics, Beijing Key Laboratory of Aging and
Geriatrics, National Clinical Research Center for Geriatrics Diseases, Second
Medical Center, Chinese People's Liberation Army General Hospital, Beijing, People’s
Republic of China
- State Key Laboratory of Kidney Diseases, Beijing, People’s Republic
of China
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2
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Niemann B, Stoppe C, Wittenberg M, Rohrbach S, Diyar S, Billion M, Potapov E, Oezkur M, Akhyari P, Schmack B, Schibilsky D, Bernhardt AM, Schmitto JD, Hagl C, Masiello P, Böning A. Rational and Initiative of the Impella in Cardiac Surgery (ImCarS) Register Platform. Thorac Cardiovasc Surg 2022; 70:458-466. [PMID: 35817063 DOI: 10.1055/s-0042-1749686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Cardiac support systems are being used increasingly more due to the growing prevalence of heart failure and cardiogenic shock. Reducing cardiac afterload, intracardiac pressure, and flow support are important factors. Extracorporeal membrane oxygenation (ECMO) and intracardiac microaxial pump systems (Impella) as non-permanent MCS (mechanical circulatory support) are being used increasingly. METHODS We reviewed the recent literature and developed an international European registry for non-permanent MCS. RESULTS Life-threatening conditions that are observed preoperatively often include reduced left ventricular function, systemic hypoperfusion, myocardial infarction, acute and chronic heart failure, myocarditis, and valve vitia. Postoperative complications that are commonly observed include severe systemic inflammatory response, ischemia-reperfusion injury, trauma-related disorders, which ultimately may lead to low cardiac output (CO) syndrome and organ dysfunctions, which necessitates a prolonged ICU stay. Choosing the appropriate device for support is critical. The management strategies and complications differ by system. The "heart-team" approach is inevitably needed.However despite previous efforts to elucidate these topics, it remains largely unclear which patients benefit from certain systems, when is the right time to initiate (MCS), which support system is appropriate, what is the optimal level and type of support, which therapeutic additive and supportive strategies should be considered and ultimately, what are the future prospects and therapeutic developments. CONCLUSION The European cardiac surgical register ImCarS has been established as an IIT with the overall aim to evaluate data received from the daily clinical practice in cardiac surgery. Interested colleagues are cordially invited to join the register. CLINICAL REGISTRATION NUMBER DRKS00024560. POSITIVE ETHICS VOTE AZ 246/20 Faculty of Medicine, Justus-Liebig-University-Gießen.
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Affiliation(s)
- Bernd Niemann
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
| | - Christian Stoppe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Bavaria, Germany.,Abiomed, Abiomed, Danvers, Massachusetts, United States
| | - Michael Wittenberg
- Coordinating Center for Clinical Trials, Philipps-University of Marburg, Marburg, Hessia, Germany
| | - Susanne Rohrbach
- Institute of Physiology, Justus-Liebig-University Giessen, Giessen, Hessen, Germany
| | - Saeed Diyar
- Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael Billion
- Department of Cardiac Surgery, Schüchtermann Hospital Bad Rothenfelde, Bad Rothenfelde, Niedersachsen, Germany
| | - Evgenij Potapov
- Department of Cardiac Surgery, Deutsches Herzzentrum Berlin Ringgold Standard Institution, Berlin, Berlin, Germany
| | - Mehmet Oezkur
- Department of Cardiac and Vascular Surgery, University of Mainz, Mainz, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University of Essen, Essen, Germany
| | - David Schibilsky
- Department of Cardiac Surgery, University of Freiburg, Freiburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Jan D Schmitto
- Department of Cardiac-, Thoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Hagl
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, München, Germany
| | - Paolo Masiello
- Department of Cardiac Surgery, San Giovanni di Dio e R.A. Hospital, Salerno, Salerno, Italy
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
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3
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Claessen B, Henriques JP. The Management of Cardiogenic Shock and Hemodynamic Support Devices and Techniques. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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4
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Delmas C, Pernot M, Le Guyader A, Joret R, Roze S, Lebreton G. Budget Impact Analysis of Impella CP ® Utilization in the Management of Cardiogenic Shock in France: A Health Economic Analysis. Adv Ther 2022; 39:1293-1309. [PMID: 35067868 PMCID: PMC8918169 DOI: 10.1007/s12325-022-02040-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Early detection and treatment of cardiogenic shock (CS) is crucial to avoid irreparable multiorgan damage and mortality. Impella CP® is a novel temporary mechanical circulatory support (MCS) device associated with greater hemodynamic support and significantly fewer device-related complications compared with other MCS devices, e.g., intra-aortic balloon pumps (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study evaluated the budget impact of introducing Impella CP versus IABP and VA-ECMO in patients with CS following an acute myocardial infarction (MI) in France. METHODS A budget impact model was developed to compare the cost of introducing Impella CP with continuing IABP and VA-ECMO treatment from a Mandatory Health Insurance (MHI) perspective in France over a 5-year time horizon, with 700 patients with refractory CS assumed to be eligible for treatment per year. Costs associated with Impella CP and device-related complications for all interventions were captured and clinical input data were based on published sources. Scenario analyses were performed around key parameters. RESULTS Introducing Impella CP was associated with cumulative cost savings of EUR 2.7 million over 5 years, versus continuing current clinical practice with IABP and VA-ECMO. Cost savings were achieved in every year of the analysis and driven by the lower incidence of device-related complications with Impella CP, with estimated 5-year cost savings of EUR 22.4 million due to avoidance of complications. Total cost savings of more than EUR 250,000 were projected in the first year of the analysis, which increased as the market share of Impella CP was increased. Scenario analyses indicated that the findings of the analysis were robust. CONCLUSION Treatment with Impella CP in adult patients aged less than 75 years in a state of refractory CS following an MI was projected to lead to substantial cost savings from an MHI perspective in France, compared with continuing current clinical practice.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | - Mathieu Pernot
- Department of Cardiology and Cardiovascular Surgery, Haut-Lévèque University Hospital, Bordeaux, France
| | - Alexandre Le Guyader
- Department of Thoracic and Cardiovascular Surgery, Dupuytren University Hospital, Limoges, France
| | | | | | - Guillaume Lebreton
- Cardiac Surgery Department, Pitié-Salpétrière Hospital, Sorbonne University, Paris, France
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5
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Complicating Acute Myocardial Infarction. Current Status and Unresolved Targets for Subsequent Research. J Clin Med 2021; 10:jcm10245904. [PMID: 34945202 PMCID: PMC8705405 DOI: 10.3390/jcm10245904] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 11/17/2022] Open
Abstract
Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full epicardial and tissue reperfusion but also with a very good immediate and long-term clinical outcome. However, the Achilles heel of MI treatment is its ensemble of complications, such as cardiogenic shock due to severe systolic and/or diastolic dysfunction or MI mechanical complications, including perforation of the left ventricular free wall, papillary muscle rupture with acute mitral regurgitation and ventricular septal rupture. They are associated with an increased or, sometimes, with an extremely high mortality rate, determining the overall mortality in an MI patient population. In this review we summarize the mechanisms of MI complications, current therapeutic management and alternative directions for overcoming their devastating consequences. Moreover, we have sought to indicate gaps in the evidence on current treatments as the potential targets for further clinical research. From the perspective of mortality trends that are not improving, the forthcoming therapeutic management of complicated MI will require an individualized and novel approach based on their thorough pathobiology.
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6
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Bossi E, Marini C, Gaetti G, Diamanti L, Alessio D, Bertoldi LF, Pappalardo F, Odone A. Efficacy and safety of Impella 5.0 in cardiogenic shock: an updated systematic review. Future Cardiol 2021; 18:253-264. [PMID: 34713720 DOI: 10.2217/fca-2021-0046] [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: 11/21/2022] Open
Abstract
Aim: The impact on safety and efficacy outcomes of Impella 5.0 in cardiogenic shock (CS) has not been systematically assessed. Materials & methods: We conducted a systematic review of the literature (PROSPERO protocol: CRD42020164680) to critically appraise available evidence on Impella 5.0 comparative safety, efficacy and effectiveness. Results: Of 244 retrieved citations, 17 original articles met the a priori defined inclusion criteria. All included studies had a retrospective study design and, overall, reported on, respectively, 52 and 67 different safety and efficacy/effectiveness outcomes. Thirty-day survival rates ranged from 40 to 94%, myocardial recovery from 18 to 93%. Conclusion: Impella 5.0 provides a full cardiac support, it is associated with a lower rate of vascular complications, it represents a valuable bridge-to-decision and allows for resolution of intercurrent clinical conditions. As available data suggest Impella 5.0 good performance in CS of various etiologies, more solid evidence will come from much-needed large-scale all-comer registries and prospective multicenter randomized trials.
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Affiliation(s)
- Eleonora Bossi
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,School of Public Health, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Claudia Marini
- Advanced Heart Failure & Mechanical Circulatory Support Program, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Cardiovascular, ASST Santi Paolo e Carlo, Milan, 20142, Italy
| | - Giovanni Gaetti
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,School of Public Health, Vita-Salute San Raffaele University, Milan, 20132, Italy
| | - Luca Diamanti
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy
| | - Davide Alessio
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy
| | - Letizia Fausta Bertoldi
- Advanced Heart Failure & Mechanical Circulatory Support Program, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Cardiovascular, Humanitas Clinical & Research Center IRCCS, Rozzano, 20089, Italy
| | - Federico Pappalardo
- Advanced Heart Failure & Mechanical Circulatory Support Program, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Cardiothoracic & Vascular Anesthesia & Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, 15121, Alessandria
| | - Anna Odone
- HTA Committee, Health Directorate, IRCCS San Raffaele Hospital, Milan, 20132, Italy.,Department of Public Health, Experimental & Forensic Medicine, University of Pavia, Pavia, 27100, Italy
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7
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McGovern L, Cosgrave J. Axial flow ventricular assist devices in cardiogenic shock complicating acute myocardial infarction. Heart 2021; 107:1856-1861. [PMID: 33811130 DOI: 10.1136/heartjnl-2020-318226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 11/04/2022] Open
Abstract
Cardiogenic shock (CS) remains the leading cause of death in patients hospitalised with acute myocardial infarction with mortality as high as 40%-50% prior to hospital discharge. The failure of inotropic therapy to maintain adequate perfusion and to prevent irreversible end-organ failure has led to attempts to improve outcomes by mechanical circulatory support (MCS) devices. Axial flow ventricular assist devices, namely Impella, are an attractive therapeutic option due to their positive haemodynamic benefits and ease of use. Despite clear beneficial haemodynamic effects, which should significantly impact on the pathophysiology of CS, there are currently no clear data to support their use in the reduction of clinical end points such as cardiac death. This review summarises and critically evaluates the current scientific evidence for the use of axial flow ventricular assist devices and highlights gaps in our understanding. Given such gaps, a consensus multidisciplinary approach, predicated on emphasising timely diagnosis and appropriate use of MCS, is vital to ensure that the right patient is paired with the right device at the right time.
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8
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Chatzis G, Syntila S, Markus B, Ahrens H, Patsalis N, Luesebrink U, Divchev D, Parahuleva M, Al Eryani H, Schieffer B, Karatolios K. Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival. J Clin Med 2021; 10:747. [PMID: 33668590 PMCID: PMC7918629 DOI: 10.3390/jcm10040747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/01/2022] Open
Abstract
Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p < 0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate > 6 mmol/L, vasoactive score > 100 and pH < 7.26 on initiation of biventricular support, as well as Charlson comorbity index > 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels.
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Affiliation(s)
- Georgios Chatzis
- Department of Cardiology, Angiology and Intensive Care, Philipps University Marburg, 35037 Marburg, Germany; (S.S.); (B.M.); (H.A.); (N.P.); (U.L.); (D.D.); (M.P.); (H.A.E.); (B.S.); (K.K.)
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9
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Seliem A, Hall SA. The New Era of Cardiogenic Shock: Progress in Mechanical Circulatory Support. Curr Heart Fail Rep 2020; 17:325-332. [DOI: 10.1007/s11897-020-00490-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
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10
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Chen S, Paone D, Spellman L, Ranganath NK, Carillo JA, Gidea CG, Reyentovich A, Thompson CA, Razzouk L, Kon ZN, Moazami N, Smith DE. Comparison of device‐specific adverse event profiles between Impella platforms. J Card Surg 2020; 35:3310-3316. [DOI: 10.1111/jocs.15038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/25/2020] [Accepted: 09/06/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Stacey Chen
- Department of Cardiothoracic Surgery NYU Langone Health New York New York USA
| | - Darien Paone
- Department of Cardiothoracic Surgery NYU Langone Health New York New York USA
| | - Lilly Spellman
- Department of Biochemistry Barnard College New York New York USA
| | - Neel K. Ranganath
- Department of Cardiothoracic Surgery NYU Langone Health New York New York USA
| | - Julius A. Carillo
- Department of Cardiothoracic Surgery NYU Langone Health New York New York USA
| | - Claudia G. Gidea
- Division of Cardiology, Department of Medicine NYU Langone Health New York New York USA
| | - Alex Reyentovich
- Division of Cardiology, Department of Medicine NYU Langone Health New York New York USA
| | - Craig A. Thompson
- Division of Cardiology, Department of Medicine NYU Langone Health New York New York USA
| | - Louai Razzouk
- Division of Cardiology, Department of Medicine NYU Langone Health New York New York USA
| | - Zachary N. Kon
- Department of Cardiothoracic Surgery NYU Langone Health New York New York USA
| | - Nader Moazami
- Department of Cardiothoracic Surgery NYU Langone Health New York New York USA
| | - Deane E. Smith
- Department of Cardiothoracic Surgery NYU Langone Health New York New York USA
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11
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Kuno T, Takagi H, Ando T, Kodaira M, Numasawa Y, Fox J, Bangalore S. Safety and efficacy of mechanical circulatory support with Impella or intra‐aortic balloon pump for high‐risk percutaneous coronary intervention and/or cardiogenic shock: Insights from a network meta‐analysis of randomized trials. Catheter Cardiovasc Interv 2020; 97:E636-E645. [DOI: 10.1002/ccd.29236] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/28/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Toshiki Kuno
- Department of Medicine Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel New York New York
| | - Hisato Takagi
- Department of Cardiovascular Surgery Shizuoka Medical Center Shizuoka Japan
| | - Tomo Ando
- Division of Cardiology Center for Interventional Vascular Therapy, NewYork‐Presbyterian Hospital/Columbia University Medical Center New York New York
| | - Masaki Kodaira
- Department of Cardiology Japanese Red Cross Ashikaga Hospital Ashikaga Japan
| | - Yohei Numasawa
- Department of Cardiology Japanese Red Cross Ashikaga Hospital Ashikaga Japan
| | - John Fox
- Department of Cardiology Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel New York New York
| | - Sripal Bangalore
- Division of Cardiology University School of Medicine New York New York
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12
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Vargas KG, Jäger B, Kaufmann CC, Biagioli A, Watremez S, Gatto F, Özbek C, Razouk A, Geppert A, Huber K. Impella in cardiogenic shock following acute myocardial infarction: a systematic review and meta-analysis. Wien Klin Wochenschr 2020; 132:716-725. [DOI: 10.1007/s00508-020-01712-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 06/27/2020] [Indexed: 11/24/2022]
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13
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Short-Term Efficacy and Safety of Different Mechanical Hemodynamic Support Devices for Cardiogenic Shock or High-Risk Pci: a Network Meta-Analysis of Thirty-Seven Trials. Shock 2020; 55:5-13. [PMID: 33337786 DOI: 10.1097/shk.0000000000001611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND With more advanced mechanical hemodynamic support for patients with cardiogenic shock (CS) or high-risk percutaneous coronary intervention (HS-PCI), the morality rate is now significantly lower than before. While previous studies showed that intra-aortic balloon pumping (IABP) did not reduce the risk of mortality in patients with CS compared to conservative treatment, the efficacy in other mechanical circulatory support (MCS) trials was inconsistent. OBJECTIVE We conducted this network meta-analysis to assess the short-term efficacy and safety of different intervention measures for patients with CS or who underwent HS-PCI. METHODS Four online databases were searched. From the initial 1,550 articles, we screened 38 studies (an extra 14 studies from references) into this analysis, including a total of 11,270 patients from five interventions (pharmacotherapy, IABP, pMCS, ECMO alone, and ECMO+IABP). RESULT The short-term efficacy was determined by 30-day or in-hospital mortality. ECMO+IABP significantly reduced mortality compared with pMCS and ECMO alone (OR = 1.85, 95% CrI [1.03-3.26]; OR = 1.89, 95% CrI [1.19-3.01], respectively). ECMO+IABP did not show reduced mortality when compared with pharmacotherapy and IABP (OR = 1.73, 95% CrI [0.97-3.82]; OR = 1.67, 95% CrI [0.98-2.89], respectively). The rank probability, however, supported that ECMO+IABP might be a more suitable intervention in improving mortality for patients with CS or who underwent HS-PCI. Regarding bleeding, compared with other invasive intervention measures, IABP showed a trend of reduced bleeding (with pMCS OR = 3.86, 95% CrI [1.53-10.66]; with ECMO alone OR = 3.74, 95% CrI [1.13-13.78]; with ECMO+IABP OR = 4.80, 95% CrI [1.61-18.53]). No difference was found in stroke, myocardial infarction, limb ischemia, and hemolysis among the invasive therapies evaluated. CONCLUSION Following this analysis, ECMO+IABP might be a more suitable intervention measure in improving short-term mortality for patients with CS and who underwent HS-PCI. However, the result was limited by the lack of sufficient direct comparisons and evidence from randomized controlled trials. Moreover, bleeding and other device-related complications should be considered in clinical applications.
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14
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Wood E, Hayes C, Hart A. Anticoagulation Management for Impella Percutaneous Ventricular Assist Devices: An Analysis of a Single-Center Experience. Ann Pharmacother 2020; 54:1073-1082. [PMID: 32410456 DOI: 10.1177/1060028020922542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Impella devices offer temporary mechanical circulatory support for cardiogenic shock. The manufacturer recommends systemic anticoagulation with a target activated clotting time of 160 to 180 s but provides no guidance on how to manage both the heparinized purge solution and the additional intravenous heparin needed to reach this therapeutic range. Previous publications demonstrated a lack of standardization in heparin management for Impella devices. OBJECTIVE The purpose of this study was to compare the effectiveness and safety of 2 different heparin protocols for long-term Impella support. METHODS This single-center, retrospective study included adult patients on Impella support for greater than 24 hours. The primary end point was time to therapeutic range measured in hours, from time of implantation to the first of 2 consecutive measurements within the therapeutic range. Secondary end points included percentage of time in therapeutic range, rates of major bleeding, pump thrombosis, hemolysis, and nursing satisfaction. RESULTS There were 19 patients identified, with 7 using the original protocol and 12 using the revised protocol. Time to therapeutic range was similar between protocols (15.5 vs 12 hours, P = NS). Another 14 patients were managed with patient-specific protocols as a result of bleeding or physician preference. In total, 42% of all patients in this study experienced major bleeding. There were no confirmed thrombosis events. This study was limited by a small sample size. CONCLUSION AND RELEVANCE Despite using different heparin protocols, outcomes and bleeding events were similar between groups. Future studies are needed to determine the optimal degree of anticoagulation necessary to reduce bleeding risk.
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Affiliation(s)
- Ethan Wood
- Saint Luke's Hospital of Kansas City, Kansas City, MO, USA
| | - Charles Hayes
- Saint Luke's Hospital of Kansas City, Kansas City, MO, USA
| | - Anthony Hart
- Saint Luke's Hospital of Kansas City, Kansas City, MO, USA
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Bonello L, Delmas C, Gaubert M, Schurtz G, Ouattara A, Roubille F. Trials of mechanical circulatory support with percutaneous axial flow pumps in cardiogenic shock complicating acute myocardial infarction: Mission impossible? Arch Cardiovasc Dis 2020; 113:448-460. [PMID: 32291187 DOI: 10.1016/j.acvd.2020.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/06/2019] [Accepted: 02/11/2020] [Indexed: 01/05/2023]
Abstract
Cardiogenic shock is a complex clinical entity associated with very high mortality and intensive resource utilization. Despite the widespread use of timely reperfusion and appropriate pharmacotherapy, the survival rate remains at around 50%. Recently, percutaneous axial flow pumps have been integrated into the therapeutic spectrum of cardiogenic shock management. However, most of the literature supporting their use stems from observational studies. To date, attempts to perform randomized controlled trials with percutaneous axial flow pumps have failed. This underlines the challenge of performing a well-conducted randomized controlled trial that provides the highest level of evidence. Such a trial is warranted, because percutaneous axial flow pumps are costly, and are associated with serious complications. The major pitfalls of previous studies were lack of standardized cardiogenic shock definitions according to clinical severity, inappropriate patient and device selection, lack of standardized trial endpoints and high rates of crossovers; these issues must be carefully considered and evaluated. In light of recent trial failures, we aim to summarize the challenges associated with performing randomized controlled trials of percutaneous axial flow pumps in patients experiencing acute myocardial infarction complicated by cardiogenic shock, and to suggest potential means of overcoming them.
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Affiliation(s)
- Laurent Bonello
- Aix-Marseille University, Intensive Care Unit, Department of Cardiology, hôpital Nord, AP-HM, chemin des Bourrely, 13015 Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13015 Marseille, France; Inserm 1263, INRA 1260, Centre for CardioVascular and Nutrition Research (C2VN), 13385 Marseille, France.
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, 31400 Toulouse, France; Cardiovascular Diseases (I2MC), Institute of Metabolic and UMR-1048, Institut national de la santé et de la recherche médicale (Inserm), 31432 Toulouse, France
| | - Mélanie Gaubert
- Aix-Marseille University, Intensive Care Unit, Department of Cardiology, hôpital Nord, AP-HM, chemin des Bourrely, 13015 Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13015 Marseille, France; Inserm 1263, INRA 1260, Centre for CardioVascular and Nutrition Research (C2VN), 13385 Marseille, France
| | - Guillaume Schurtz
- Intensive Cardiac Care Unit, université de Lille, Institut Coeur-Poumon Inserm, Institut Pasteur, U1011, 59000 Lille, France
| | - Alexandre Ouattara
- Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, CHU de Bordeaux, 33000 Bordeaux, France; Inserm, UMR 1034, Biology of Cardiovascular Diseases, University of Bordeaux, 33600 Pessac, France
| | - François Roubille
- PhyMedExp, CNRS, Cardiology Department, université de Montpellier, Inserm, CHU de Montpellier, 34295 Montpellier, France
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Bochaton T, Huot L, Elbaz M, Delmas C, Aissaoui N, Farhat F, Mewton N, Bonnefoy E. Mechanical circulatory support with the Impella® LP5.0 pump and an intra-aortic balloon pump for cardiogenic shock in acute myocardial infarction: The IMPELLA-STIC randomized study. Arch Cardiovasc Dis 2020; 113:237-243. [DOI: 10.1016/j.acvd.2019.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 10/04/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
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Jiritano F, Lo Coco V, Matteucci M, Fina D, Willers A, Lorusso R. Temporary Mechanical Circulatory Support in Acute Heart Failure. Card Fail Rev 2020; 6:e01. [PMID: 32257388 PMCID: PMC7111303 DOI: 10.15420/cfr.2019.02] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/27/2019] [Indexed: 01/06/2023] Open
Abstract
Cardiogenic shock (CS) is a challenging syndrome, associated with significant morbidity and mortality. Although pharmacological therapies are successful and can successfully control this acute cardiac illness, some patients remain refractory to drugs. Therefore, a more aggressive treatment strategy is needed. Temporary mechanical circulatory support (TCS) can be used to stabilise patients with decompensated heart failure. In the last two decades, the increased use of TCS has led to several kinds of devices becoming available. However, indications for TCS and device selection are part of a complex process. It is necessary to evaluate the severity of CS, any early and prompt haemodynamic resuscitation, prior TCS, specific patient risk factors, technical limitations and adequacy of resources and training, as well as an assessment of whether care would be futile. This article examines options for commonly used TCS devices, including intra-aortic balloon pumps, a pulsatile percutaneous ventricular assist device (the iVAC), veno-arterial extra-corporeal membrane oxygenation and Impella (Abiomed) and TandemHeart (LivaNova) percutaneous ventricular assist device.
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Affiliation(s)
- Federica Jiritano
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute MaastrichtMaastricht, the Netherlands
- Cardiac Surgery Unit, University Magna Graecia of CatanzaroCatanzaro, Italy
| | - Valeria Lo Coco
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute MaastrichtMaastricht, the Netherlands
| | - Matteo Matteucci
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute MaastrichtMaastricht, the Netherlands
- Department of Cardiac Surgery, Circolo Hospital, University of InsubriaVarese, Italy
| | - Dario Fina
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute MaastrichtMaastricht, the Netherlands
- University of Milan, IRCCS Policlinico San DonatoMilan, Italy
| | - Anne Willers
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute MaastrichtMaastricht, the Netherlands
| | - Roberto Lorusso
- Cardiothoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute MaastrichtMaastricht, the Netherlands
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Circulatory Support with Extracorporeal Membrane Oxygenation and/or Impella for Cardiogenic Shock During Myocardial Infarction. ASAIO J 2019; 64:708-714. [PMID: 29240628 DOI: 10.1097/mat.0000000000000704] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Temporary mechanical circulatory support (TCS) is recommended for patients with profound cardiogenic shock (CS). Extracorporeal membrane oxygenation (ECMO) and Impella are possible TCS devices, but the device choice and the implantation timing are not definitely established, specifically during acute myocardial infarction. We have analyzed the respective use of ECMO or Impella (2.5, CP, or 5.0) for CS following acute myocardial infarction, from a cohort of patients who underwent TCS within 72 hours after admission for emergency percutaneous coronary intervention (PCI) from January 2009 to April 2015. Among 88 TCS-treated patients, 42 had early TCS: 23 ECMO and 19 Impella. Cardiac management, including PCI, was similar between the two groups, but ECMO patients were sicker than Impella patients (higher blood lactate level at ICU admission, higher vasoactive-inotroic and ENCOURAGE scores before TCS implantation, p ≤ 0.02). Three patients (7%) have had TCS implantation before admission, but TCS was implanted mostly in cathlab (43%, 1 during PCI, 13 just after PCI) or soon after ICU admission (50%, n = 21). Modification of the initial TCS choice was required in 10 cases (24%) for assistance upgrading in case of Impella (n = 4) or for left ventricle unloading in case of ECMO (n = 6). Extracorporeal membrane oxygenation is the technique of choice in case of profound CS, whereas Impella devices seem more appropriate for less severe hemodynamic compromise. Interestingly, the combination of both techniques may help to overcome the limits inherent to each device.
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Abstract
PURPOSE OF REVIEW Temporary circulatory support (TCS) with short-term mechanical circulatory support (MCS) devices is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of current devices, their indications and management, and discusses results of recent case series and trials. RECENT FINDINGS Percutaneous active MCS devices (Impella, TandemHeart…) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) are utilized as a bridge to 'decision' that includes weaning after cardiac function recovery, transplantation, long-term MCS and withdrawal in case of futility. VA-ECMO is considered the first-line TCS since it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella or intra-aortic balloon pump support with ECMO might decrease left ventricular pressure and improve outcomes. Sepsis-associated cardiomyopathy, massive pulmonary embolism, arrhythmic storm and Takotsubo-like cardiomyopathy are among emerging indications for TCS. SUMMARY TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the respective place of different MCS devices in cardiogenic shock treatment strategies.
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20
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Laliberte B, Reed BN. Use of an argatroban-based purge solution in a percutaneous ventricular assist device. Am J Health Syst Pharm 2019; 74:e163-e169. [PMID: 28438820 DOI: 10.2146/ajhp160212] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The use of an argatroban-based percutaneous ventricular assist device (pVAD) purge solution in a patient with suspected heparin-induced thrombocytopenia (HIT) is described. SUMMARY A 70-year-old woman in cardiogenic shock was admitted to a coronary care unit after being discovered unresponsive at home. A transthoracic echocardiogram revealed a low ejection fraction and findings consistent with takotsubo cardiomyopathy. Administration of multiple inotropes and vasopressors was initially required for hemodynamic support. The patient was implanted with an Impella pVAD (Abiomed, Inc., Danvers, MA) using a heparin-based purge solution; an i.v. heparin infusion was initiated for supplemental systemic anticoagulation. Over the next 24 hours, the patient's platelet count decreased from 168,000 to 37,000 cells/μL. Given a differential diagnosis that included HIT, the patient was transitioned to an argatroban-based purge solution. Due to prolonged activated partial thromboplastin times, a systemic argatroban infusion was not initiated, and the patient remained fully anticoagulated throughout pVAD support with only the argatroban-based purge solution. An HIT antibody test was negative. On hospitalization day 9 (day 6 of pVAD support with argatroban use), the patient became hemodynamically stable and was weaned off pVAD support. Three days later, the platelet count had recovered to 117,000 cells/μL (from a nadir of 21,000 cells/μL). During pVAD support, the patient developed hemolytic anemia with minimal bleeding complications. CONCLUSION Argatroban was used as a purge solution anticoagulant in a patient with an Impella pVAD and found to be a safe and effective alternative to heparin.
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Affiliation(s)
| | - Brent N Reed
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD.
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21
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Abstract
Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion primarily due to cardiac dysfunction. This condition is the most common cause of death in patients affected by acute myocardial infarction (AMI). Despite early revascularization, prompt optimal medical therapy, and up-to-date mechanical circulatory supports, mortality of patients with CS remains high.The objective of this review is to summarize epidemiology, pathophysiology, and treatment options of CS in light of the new European Society of Cardiology (ESC) recommendations. The latest European guidelines on myocardial revascularization have reviewed the previous guidelines with respect to early multivessel revascularization and routine use of intra-aortic balloon pump (IABP) in patients with AMI-related CS.Most of the current evidences come partly from randomized trials, but mostly from observational registries because of the difficulty to test different treatments in this life-threatening clinical setting.Some of the latest studies highlight the potential crucial benefit of newly introduced mechanical circulatory support devices, although evidences are not sufficient to definitely assess the benefit/risk ratio of the different systems.Many questions remain unanswered in this field, and further trials are advocated to better elucidate the best medical, reperfusion, and circulatory support approaches aimed to improve the poor prognosis of patients with CS after AMI.
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Quessard A, Cadier G, Imbault J, Rey J, Pernot M, Ouattara A. Assistance ventriculaire gauche par Impella® : indications, gestion et complications. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’assistance monoventriculaire Impella® est une assistance microaxiale non pulsatile dépourvue de fonction d’oxygénation et/ou de décarboxylation. Sur le principe de la vis sans fin d’Archimède, elle aspire le sang dans le ventricule gauche pour le réinjecter dans la racine de l’aorte en regard des ostia coronaires. Selon le modèle utilisé, le débit d’assistance antérograde ainsi généré varie de 2,5 à 5 l/min. De par son mode de fonctionnement, l’assistance Impella® permet une décharge ventriculaire efficace. Ses indications sont l’angioplastie coronaire à haut risque et le choc cardiogénique réfractaire aux agents cardiovasoactifs. Chez le patient assisté par une extracorporeal life support (ECLS), la pompe Impella® permet de limiter le risque de surcharge ventriculaire. Chez le patient exclusivement assisté par Impella® soit d’emblée ou après une association avec l’ECLS, la voie d’abord axillaire permet sa réhabilitation active y compris la déambulation et l’activité physique. Elle se révèle alors une mise à l’épreuve cliniquement pertinente du ventricule droit en vue d’une assistance de longue durée de type left ventricular assist device.
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Percutaneous left ventricular assist device
vs
. intra‐aortic balloon pump in patients with severe left ventricular dysfunction undergoing cardiovascular intervention: A meta‐analysis. Chronic Dis Transl Med 2018; 4:260-267. [PMID: 30603744 PMCID: PMC6308918 DOI: 10.1016/j.cdtm.2017.11.002] [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: 05/22/2017] [Indexed: 11/24/2022] Open
Abstract
Objective Although controversial, the intra-aortic balloon pump (IABP) and percutaneous left ventricular assist device (PLVAD) are widely used for initial hemodynamic stabilization. We performed a meta-analysis to compare the clinical outcomes of these two devices in patients with severe left ventricular (LV) dysfunction undergoing percutaneous coronary intervention (PCI) or ventricular tachycardia (VT) ablation. Methods MEDLINE, EMBASE, the Cochrane Registry of Controlled Trials, and reference lists of relevant articles were searched. We included randomized controlled trials (RCTs) and prospective observational studies. Meta-analysis was conducted using a random effects model. Results The quantitative analysis included 4 RCTs and 2 observational studies. A total of 348 patients received PLVAD and 340 received IABP. Meta-analysis revealed that early mortality rates (in-hospital or 30-day) did not differ between the PLVAD and IABP groups (relative risk (RR) = 1.03, 95% confidence interval (CI) = 0.70–1.51, P = 0.89). Significant differences were observed between the two groups in the composite, in-hospital, non-major adverse cardiac and cerebrovascular events (MACCE) rate (RR = 1.30, 95% CI = 1.01–1.68, P = 0.04). Conclusions Compared with IABP, PLVAD with active circulatory support did not improve early survival in those with severe left ventricular dysfunction undergoing either PCI or VT ablation, but increased the in-hospital non-MACCE rate.
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Higami H, Toyofuku M, Morimoto T, Ohya M, Fuku Y, Yamaji K, Muranishi H, Yamaji Y, Nishida K, Furukawa D, Tada T, Ko E, Ando K, Sakamoto H, Tamura T, Kawai K, Kadota K, Kimura T. Acute Coronary Syndrome With Unprotected Left Main Coronary Artery Culprit - An Observation From the AOI-LMCA Registry. Circ J 2018; 83:198-208. [PMID: 30416191 DOI: 10.1253/circj.cj-18-0896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Data on the clinical outcomes of percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) in patients with acute coronary syndrome (ACS) are limited. Therefore, this study aimed to assess the clinical outcome of patients with ACS who underwent PCI for LMCA culprit lesion.Methods and Results:Of 1,809 patients enrolled in the Assessing Optimal Percutaneous Coronary Intervention for the LMCA (AOI-LMCA) registry (a retrospective 6-center registry of consecutive patients undergoing LMCA stenting in Japan), the current study population consisited of 1,500 patients with unprotected LMCA stenting for LMCA ACS (ACS with shock: 115 patients, ACS without shock: 281 patients) and stable CAD (1,104 patients). The cumulative 180-day incidence of death was markedly higher in the ACS with shock group than in the other groups (49.5%, 8.6%, and 3.3%, respectively; P<0.0001), but mortality beyond 180-day was not significantly different among the 3 groups (30.2%, 20.4%, and 19.5%, respectively; P=0.65). In the ACS with shock group, the initial TIMI flow grade did not affect 5-year mortality (57.1% and 62.2%, P=0.99), but in the ACS without shock group, 5-year mortality was significantly higher in patients with initial TIMI flow grade ≤1 than in patients with TIMI flow grade ≥2 (44.4% and 23.7%, respectively; P=0.008). CONCLUSIONS In patients with LMCA ACS, survival correlates with baseline hemodynamic and coronary flow status.
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Affiliation(s)
- Hirooki Higami
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | | | | | | | | | | | | | | | | | | | - Euihong Ko
- Japanese Red Cross Society Wakayama Medical Center
| | | | | | | | | | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Ouweneel DM, de Brabander J, Karami M, Sjauw KD, Engström AE, Vis MM, Wykrzykowska JJ, Beijk MA, Koch KT, Baan J, de Winter RJ, Piek JJ, Lagrand WK, Cherpanath TG, Driessen AH, Cocchieri R, de Mol BA, Tijssen JG, Henriques JP. Real-life use of left ventricular circulatory support with Impella in cardiogenic shock after acute myocardial infarction: 12 years AMC experience. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:338-349. [PMID: 30403366 PMCID: PMC6616211 DOI: 10.1177/2048872618805486] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS Mortality in cardiogenic shock patients remains high. Short-term mechanical circulatory support with Impella can be used to support the circulation in these patients, but data from randomised controlled studies and 'real-world' data are sparse. The aim is to describe real-life data on outcomes and complications of our 12 years of clinical experience with Impella in patients with cardiogenic shock after acute myocardial infarction and to identify predictors of 6-month mortality. METHODS We describe a single-centre registry from October 2004 to December 2016 including all patients treated with Impella for cardiogenic shock after acute myocardial infarction. We report outcomes and complications and identify predictors of 6-month mortality. RESULTS Our overall clinical experience consists of 250 patients treated with Impella 2.5, Impella CP or Impella 5.0. A total of 172 patients received Impella therapy for cardiogenic shock, of which 112 patients had cardiogenic shock after acute myocardial infarction. The mean age was 60.1±10.6 years, mean arterial pressure was 67 (56-77) mmHg, lactate was 6.2 (3.6-9.7) mmol/L, 87.5% were mechanically ventilated and 59.6% had a cardiac arrest before Impella placement. Overall 30-day mortality was 56.2% and 6-month mortality was 60.7%. Complications consisted of device-related vascular complications (17.0%), non-device-related bleeding (12.5%), haemolysis (7.1%) and stroke (3.6%). In a multivariate analysis, pH before Impella placement is a predictor of 6-month mortality. CONCLUSIONS Our registry shows that Impella treatment in cardiogenic shock after acute myocardial infarction is feasible, although mortality rates remain high and complications occur.
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Affiliation(s)
- Dagmar M Ouweneel
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | | | - Mina Karami
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | - Krischan D Sjauw
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | | | - M Marije Vis
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | | | - Marcel A Beijk
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | - Karel T Koch
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | - Jan Baan
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | | | - Jan J Piek
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | - Wim K Lagrand
- 2 Department of Intensive Care Medicine, Amsterdam UMC, The Netherlands
| | | | | | - Riccardo Cocchieri
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | - Bas Ajm de Mol
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | - Jan Gp Tijssen
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
| | - José Ps Henriques
- 1 Heart Center; department of Cardiology, Amsterdam UMC, The Netherlands
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Boll G, Fischer A, Kapur NK, Salehi P. Right Axillary Artery Conduit Is a Safe and Reliable Access for Implantation of Impella 5.0 Microaxial Pump. Ann Vasc Surg 2018; 54:54-59. [PMID: 30339902 DOI: 10.1016/j.avsg.2018.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 10/01/2018] [Accepted: 10/09/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Impella 5.0 is a powerful mechanical circulatory support device placed into the left ventricle of patients in cardiogenic shock not responding to pharmacologic support alone. This therapy can support patient hemodynamics from weeks to several months, and patients can potentially ambulate with the device implanted while awaiting destination therapy. METHODS From July 2012 to September 2017, 22 Impella 5.0 devices (Abiomed Inc., Danvers, MA) were implanted via right axillary artery at our center. All devices were implanted under fluoroscopic and transesophageal echocardiographic guidance. RESULTS Eighty-one percent of patients were male, and average age was 61 years (range 27-73). A 10- or 12-mm graft was used in 96% of the cases, most commonly Hemashield (Maquet, Rastatt, Germany; 46%) or Dacron (DuPont, Wilmington, DE; 23%). The graft was tunneled laterally in a subcutaneous plane in 91% of the cases. All attempts at right axillary artery conduit creation and device implantation were successful. The angle of end-to-side anastomosis was 45-60°. The average duration of therapy was 8.8 days (range 1-19). There were no brachial plexus injuries, patients with upper extremity ischemia, or bleeding requiring intervention in the postoperative period. One patient was coagulopathic and developed a hemorrhagic stroke. Concurrent use of mechanical circulatory support for the right heart was present in 27% of the cases. Twenty-seven percent of patients bridged successfully to ventricular assist devices, 18% recovered to have the device explanted, and 55% of patients died within 30 days of device implantation. CONCLUSIONS Right axillary artery conduit is a safe and reliable access for implantation of Impella 5.0. This technique appears to be associated with low complication rates when implanted with a standardized technique.
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Affiliation(s)
- Griffin Boll
- Department of Surgery, Tufts Medical Center, Boston, MA
| | - Ariel Fischer
- Department of Surgery, Tufts Medical Center, Boston, MA
| | - Navin K Kapur
- Department of Cardiology, Tufts Medical Center, Boston, MA
| | - Payam Salehi
- Department of Surgery, Tufts Medical Center, Boston, MA.
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Rios SA, Bravo CA, Weinreich M, Olmedo W, Villablanca P, Villela MA, Ramakrishna H, Hirji S, Robles OA, Mahato P, Gluud C, Bhatt DL, Jorde UP. Meta-Analysis and Trial Sequential Analysis Comparing Percutaneous Ventricular Assist Devices Versus Intra-Aortic Balloon Pump During High-Risk Percutaneous Coronary Intervention or Cardiogenic Shock. Am J Cardiol 2018; 122:1330-1338. [PMID: 30146099 DOI: 10.1016/j.amjcard.2018.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 01/21/2023]
Abstract
The intra-aortic balloon pump (IABP) and percutaneous ventricular assist devices (pVAD) are commonly used in different clinical scenarios. The goal of this study was to carry out a meta-analysis and Trial Sequential Analysis (TSA) comparing the IABP versus pVAD (TandemHeart and the Impella) during high-risk percutaneous coronary intervention (PCI) or cardiogenic shock (CS). Using PubMed, Cochrane Central Register of Controlled Trials, and EMBASE we searched for randomized clinical trials (RCTs) and nonrandomized studies that compared pVAD versus IABP in patients who underwent high-risk PCI or with CS. We included 5 RCTs and 1 nonrandomized study comparing pVAD versus IABP. Based on the RCTs, we demonstrated no difference in short-term (6 months) (risk ratio [RR] 1.09, 95% confidence interval [CI] 0.79 to 1.52; p = 0.59) or long-term (12 months) (RR 1.00, 95% CI 0.57 to 1.76; p = 1.00) all-cause mortality. The use of pVAD seemed associated with more adverse events (acute kidney injury, limb ischemia, infection, major bleeding, and vascular injury) compared with IABP (RR 1.65, 95% CI 1.14 to 2.39; p = 0.008) but this was not supported by TSA (random-effects RR 1.66, 95% CI 0.89 to 3.09; p = 0.11; TSA-adjusted CI 0.13 to 21.3). In conclusion there were no differences in short or long-term mortality when using IABP versus pVAD for high-risk PCI or CS. IABP showed superiority over pVAD in terms of risk of harm. However, further RCTs are needed to establish more conclusively the role of these modalities of mechanical circulatory support during high-risk PCI or CS.
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Kalmanovich E, Audurier Y, Akodad M, Mourad M, Battistella P, Agullo A, Gaudard P, Colson P, Rouviere P, Albat B, Ricci JE, Roubille F. Management of advanced heart failure: a review. Expert Rev Cardiovasc Ther 2018; 16:775-794. [PMID: 30282492 DOI: 10.1080/14779072.2018.1530112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.
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Affiliation(s)
- Eran Kalmanovich
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Yohan Audurier
- b Pharmacy Department , University Hospital of Montpellier , Montpellier , France
| | - Mariama Akodad
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Marc Mourad
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Pascal Battistella
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Audrey Agullo
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Philippe Gaudard
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Pascal Colson
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Philippe Rouviere
- e Department of Cardiovascular Surgery , University Hospital of Montpellier, University of Montpellier , Montpellier , France
| | - Bernard Albat
- e Department of Cardiovascular Surgery , University Hospital of Montpellier, University of Montpellier , Montpellier , France
| | - Jean-Etienne Ricci
- f Department of Cardiology , Nîmes University Hospital, University of Montpellier , Nîmes , France
| | - François Roubille
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
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Crespo-Leiro MG, Metra M, Lund LH, Milicic D, Costanzo MR, Filippatos G, Gustafsson F, Tsui S, Barge-Caballero E, De Jonge N, Frigerio M, Hamdan R, Hasin T, Hülsmann M, Nalbantgil S, Potena L, Bauersachs J, Gkouziouta A, Ruhparwar A, Ristic AD, Straburzynska-Migaj E, McDonagh T, Seferovic P, Ruschitzka F. Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018; 20:1505-1535. [DOI: 10.1002/ejhf.1236] [Citation(s) in RCA: 373] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Maria G. Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC); Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC; La Coruña Spain
| | - Marco Metra
- Cardiology; University of Brescia; Brescia Italy
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology; Karolinska Institute; Stockholm Sweden
| | - Davor Milicic
- Department for Cardiovascular Diseases; University Hospital Center Zagreb, University of Zagreb; Zagreb Croatia
| | | | | | - Finn Gustafsson
- Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | - Steven Tsui
- Transplant Unit; Royal Papworth Hospital; Cambridge UK
| | - Eduardo Barge-Caballero
- Complexo Hospitalario Universitario A Coruña (CHUAC); Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC; La Coruña Spain
| | - Nicolaas De Jonge
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Maria Frigerio
- Transplant Center and De Gasperis Cardio Center; Niguarda Hospital; Milan Italy
| | - Righab Hamdan
- Department of Cardiology; Beirut Cardiac Institute; Beirut Lebanon
| | - Tal Hasin
- Jesselson Integrated Heart Center; Shaare Zedek Medical Center; Jerusalem Israel
| | - Martin Hülsmann
- Department of Internal Medicine II; Medical University of Vienna; Vienna Austria
| | | | - Luciano Potena
- Heart and Lung Transplant Program; Bologna University Hospital; Bologna Italy
| | - Johann Bauersachs
- Department of Cardiology and Angiology; Medical School Hannover; Hannover Germany
| | - Aggeliki Gkouziouta
- Heart Failure and Transplant Unit; Onassis Cardiac Surgery Centre; Athens Greece
| | - Arjang Ruhparwar
- Department of Cardiac Surgery; University of Heidelberg; Heidelberg Germany
| | - Arsen D. Ristic
- Department of Cardiology of the Clinical Center of Serbia; Belgrade University School of Medicine; Belgrade Serbia
| | | | | | - Petar Seferovic
- Department of Internal Medicine; Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center; Belgrade Serbia
| | - Frank Ruschitzka
- University Heart Center; University Hospital Zurich; Zurich Switzerland
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Glazier JJ, Kaki A. In Reference to Trends, Etiologies, and Predictors of 90-Day Readmission After Percutaneous Ventricular Assist Device Implantation: A National Population-Based Cohort Study. Clin Cardiol 2018; 41:886-887. [PMID: 29869391 DOI: 10.1002/clc.22989] [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: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- James J Glazier
- Department of Cardiology, Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
| | - Amir Kaki
- Department of Cardiology, Wayne State University/Detroit Medical Center, Heart Hospital, Detroit, Michigan
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Delmas C, Elbaz M, Bonello L, Biendel C, Bouisset F, Lairez O, Silva S, Marcheix B, Galinier M. Place de l’assistance circulatoire dans le choc cardiogénique en France en 2018 : revue de la littérature et perspectives. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Le choc cardiogénique reste de nos jours une entité mal définie, assez fréquente en pratique clinique (60 000–70 000 cas/an en Europe), dont le pronostic est sombre, avec une mortalité souvent supérieure à 40 % à 30 jours. À travers cette revue de la littérature, nous essaierons de définir cette entité et ses étiologies, avant de parler de son incidence et de son pronostic. L’approche physiopathologique du choc cardiogénique nous permettra par la suite d’approcher sa prise en charge thérapeutique classique (gestion de la volémie, amines inotropes et vasoconstrictives, ventilation) et les limites de cette dernière. Ainsi, nous aborderons les assistances circulatoires et cardiocirculatoires disponibles en France, afin de les envisager au sein d’une stratégie globale de prise en charge du patient en choc cardiogénique. Nous discuterons plus spécifiquement leurs indications ainsi que l’importance du moment d’implantation afin d’optimiser leur efficacité. Enfin, nous évoquerons les assistances actuellement en développement, mais également les nouvelles stratégies thérapeutiques qui pourraient arriver dans les prochaines années.
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Primary Percutaneous Coronary Intervention. Coron Artery Dis 2018. [DOI: 10.1016/b978-0-12-811908-2.00021-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Truesdell AG, Tehrani B, Singh R, Desai S, Saulino P, Barnett S, Lavanier S, Murphy C. 'Combat' Approach to Cardiogenic Shock. Interv Cardiol 2018; 13:81-86. [PMID: 29928313 DOI: 10.15420/icr.2017:35:3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The incidence of cardiogenic shock is rising, patient complexity is increasing and patient survival has plateaued. Mirroring organisational innovations of elite military units, our multidisciplinary medical specialists at the INOVA Heart and Vascular Institute aim to combine the adaptability, agility and cohesion of small teams across our large healthcare system. We advocate for widespread adoption of our 'combat' methodology focused on: increased disease awareness, early multidisciplinary shock team activation, group decision-making, rapid initiation of mechanical circulatory support (as appropriate), haemodynamic-guided management, strict protocol adherence, complete data capture and regular after action reviews, with a goal of ending preventable death from cardiogenic shock.
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Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, Falls Church VA, USA.,INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Behnam Tehrani
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Ramesh Singh
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Shashank Desai
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | | | - Scott Barnett
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | | | - Charles Murphy
- INOVA Heart and Vascular Institute, Falls Church VA, USA
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Abstract
OBJECTIVES To review temporary percutaneous mechanical circulatory support devices for the treatment of cardiogenic shock, including current evidence, contraindications, complications, and future directions. DATA SOURCES A MEDLINE search was conducted with MeSH terms: cardiogenic shock, percutaneous mechanical circulatory support, extracorporeal membrane oxygenation, Impella, and TandemHeart. STUDY SELECTION Selected publications included randomized controlled trial data and observational studies describing experience with percutaneous mechanical circulatory support in cardiogenic shock. DATA EXTRACTION Studies were chosen based on strength of association with and relevance to cardiogenic shock. DATA SYNTHESIS Until recently, there were few options if cardiogenic shock was refractory to vasopressors or intra-aortic balloon pump counterpulsation. Now, several percutaneous mechanical circulatory support devices, including Impella (Abiomed, Danvers, MA), TandemHeart (CardiacAssist, Pittsburgh, PA), and extracorporeal membrane oxygenation, are more accessible. Compared with intra-aortic balloon pump, Impella provides greater hemodynamic support but no reduction in mortality. Similarly, TandemHeart improves hemodynamic variables but not survival. Comparative studies have been underpowered for mortality because of small sample size. Veno-arterial extracorporeal membrane oxygenation offers the advantage of biventricular circulatory support and oxygenation, but there are significant vascular complications. Comparative studies with extracorporeal membrane oxygenation have not been completed. Despite lack of randomized controlled data, there has been a substantial increase in use of percutaneous mechanical circulatory support. Several ongoing prospective studies with larger sample sizes may provide answers, and newer devices may become smaller, easier to insert, and more effective. CONCLUSIONS Mortality from cardiogenic shock remains unacceptably high despite early coronary revascularization or other therapies. Although evidence is lacking and complications rates are high, improvements and experience with percutaneous mechanical circulatory support may offer the prospect of better outcomes.
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de Waha S, Desch S, Fuernau G, Pöss J, Ledwoch J, Jobs A, Eitel I, Thiele H. Interventional therapies in acute myocardial infarction complicated by cardiogenic shock. Herz 2017; 42:11-17. [PMID: 27909767 DOI: 10.1007/s00059-016-4511-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiogenic shock remains the most common cause of death in patients with acute myocardial infarction. Early revascularization of the infarct-related artery has been shown to reduce mortality and is the therapeutic cornerstone. The optimal revascularization strategy of additional non-culprit lesions remains yet to be determined. Further, uncertainties exist with respect to access site choice, antiplatelet regimen as well as mechanical support devices. This review outlines current evidence on the interventional management of cardiogenic shock complicating acute myocardial infarction.
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Affiliation(s)
- S de Waha
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany. .,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany.
| | - S Desch
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - G Fuernau
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - J Pöss
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - J Ledwoch
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - A Jobs
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - I Eitel
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - H Thiele
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
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Ait Ichou J, Larivée N, Eisenberg MJ, Suissa K, Filion KB. The effectiveness and safety of the Impella ventricular assist device for high-risk percutaneous coronary interventions: A systematic review. Catheter Cardiovasc Interv 2017; 91:1250-1260. [PMID: 28941078 DOI: 10.1002/ccd.27316] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 07/31/2017] [Accepted: 08/07/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Small randomized controlled trials (RCTs) and observational studies have examined the effectiveness and safety of the Impella device, a percutaneous left ventricular assist device, in the setting of high-risk percutaneous coronary intervention (PCI). However, data are sparse and results are conflicting. Our objective was to evaluate the effectiveness and safety of the Impella device in high-risk patients undergoing PCI via a systematic review of the literature. METHODS We searched Medline, EMBASE, and the Cochrane Library for RCTs and observational studies that evaluated the Impella device in high-risk patients undergoing PCI. Inclusion was restricted to studies in which ≥10 patients received the Impella device; both uncontrolled and controlled (versus intra-aortic-balloon pump [IABP]) studies were included. RESULTS A total of 20 studies (4 RCTs, 2 controlled observational studies, and 14 uncontrolled observational studies; 1,287 patients) were included, with follow-up ranging from 1 to 42 months. The use of Impella resulted in improved procedural and hemodynamic characteristics in controlled and uncontrolled studies. In controlled studies, the 30-day rates of all-cause mortality and MACE were similar across groups. In most uncontrolled studies, the 30-day rates of all-cause mortality were generally low (range: 3.7%-10%), though rates of MACE were slightly higher (range: 5%-20%). CONCLUSION The Impella device was found to improve procedural and hemodynamic parameters, but only limited randomized data are available regarding clinical outcomes associated with its use. Large, multicenter RCTs are needed to definitively establish the effectiveness of the Impella device among high-risk PCI patients.
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Affiliation(s)
- Jamal Ait Ichou
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Natasha Larivée
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Mark J Eisenberg
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Division of Cardiology, Jewish General Hospital/McGill University, Montreal, Quebec, Canada
| | - Karine Suissa
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Kristian B Filion
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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Hemodynamic Benefits of Counterpulsation, Implantable, Percutaneous, and Intraaortic Rotary Blood Pumps: An In-Silico and In Vitro Study. Cardiovasc Eng Technol 2017; 8:439-452. [PMID: 28707188 DOI: 10.1007/s13239-017-0314-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 06/17/2017] [Indexed: 10/19/2022]
Abstract
Mechanical circulatory support (MCS) devices have become a standard therapy for heart failure (HF) patients. MCS device designs may differ by level of support, inflow and/or outflow cannulation sites, and mechanism(s) of cardiac unloading and blood flow delivery. Investigation and direct comparison of hemodynamic parameters that help characterize performance of MCS devices has been limited. We quantified cardiac and vascular hemodynamic responses for different types of MCS devices. Continuous flow (CF) left ventricular (LV) assist devices (LVAD) with LV or left atrial (LA) inlet, counterpulsation devices, percutaneous CF LVAD, and intra-aortic rotary blood pumps (IARBP) were quantified using established computer simulation and mock flow loop models. Hemodynamic data were analyzed on a beat-to-beat basis at baseline HF and over a range of MCS support. Results demonstrated that all LVAD greatly diminished vascular pulsatility (P) and LV external work (LVEW). LVAD with LA inflow provided a greater reduction in LVEW compared to LVAD with LV inflow, but at the potential risk for blood stasis/thrombosis in the LV at high support. Counterpulsation provided greater coronary flow (CoF) augmentation, but had a lower reduction in LVEW compared to partial percutaneous LVAD support. IARBP diminished LVEW, but at the expense of diminished CoF due to coronary steal. The hemodynamic benefits for each type of mechanical circulatory support system are unique and clinical decisions on device selection to maximize end organ perfusion and minimize invasiveness needs to be considered for an individual patients' presentation.
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den Uil CA, Akin S, Jewbali LS, dos Reis Miranda D, Brugts JJ, Constantinescu AA, Kappetein AP, Caliskan K. Short-term mechanical circulatory support as a bridge to durable left ventricular assist device implantation in refractory cardiogenic shock: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2017; 52:14-25. [DOI: 10.1093/ejcts/ezx088] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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[Cardiac support and replacement systems]. Med Klin Intensivmed Notfmed 2017; 112:417-425. [PMID: 28466294 DOI: 10.1007/s00063-017-0295-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 03/24/2017] [Indexed: 10/19/2022]
Abstract
In recent years, the widespread use of partial mechanical cardiac support and even temporary complete replacement of cardiac function has been established in many intensive care units in the treatment of refractory cardiogenic shock. There is a difference between partial left-ventricular assist devices (LVAD) and the possibility of complete heart (and lung) replacement by extra corporeal life support (ECLS). Despite the use of mechanical support devices, the mortality of cardiogenic shock remains high. The consideration of using percutaneous LVAD and ECLS in cardiogenic shock should be considered in refractory cardiogenic shock patients in addition to support by catecholamines and after early revascularization in acute coronary syndromes. However, there are no large randomized studies evaluating mechanical support systems with respect to outcome in cardiogenic shock patients. German and international guidelines do not recommend the routine use of mechanical support as a first-line treatment in cardiogenic shock patients and emphasize that their application should be restricted to patients with therapy refractory shock. In other cases of noninfarct-related cardiogenic shock (e. g., poisoning, myocarditis), ECLS use should be considered as bridging therapy. ECLS may also be considered in cardiopulmonary resuscitation which is termed E‑CPR. According to registry data, E‑CPR may reduce mortality in selected patients. A possible application of ECLS is severe accidental hypothermia with cardiac arrest despite limited data. In these rare cases, early ECLS should be considered for rewarming and stabilization.
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41
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The ICM research agenda on extracorporeal life support. Intensive Care Med 2017; 43:1306-1318. [PMID: 28470346 DOI: 10.1007/s00134-017-4803-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/12/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE This study aimed to concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to extracorporeal membrane oxygenation (ECMO). METHODS Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. RESULTS The use of venovenous ECMO (VV-ECMO) is increasing in the most severe forms of acute lung injury. In patients with cardiogenic shock, short-term veno-arterial ECMO (VA-ECMO) provides both pulmonary and circulatory support. Technological improvements and recently published studies suggest that ECMO is able to improve patients' outcomes. There are, however, many uncertainties regarding the real benefits of this technique both in hemodynamic and respiratory failure, the territorial organization to deliver ECMO, the indications and the use of concomitant treatments. CONCLUSIONS Although there have been considerable advances regarding the use of ECMO in critically ill patients, the risk/benefit ratio remains underinvestigated. ECMO indications, organization of ECMO delivery, and use of adjuvant therapeutics need also to be explored. Ongoing and future studies may be able to resolve these issues.
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Abstract
Mechanical circulatory assistance has become a frequent therapeutic option for patients with advanced heart failure. For patients with acute cardiogenic shock and impaired organ function, short-term assistance with venoarterial extracorporeal membrane oxygenation is the leading therapeutic option. It enables a "bridge to decision-making" i.e. withdrawal of the device after myocardial recovery or after recognition of therapeutic futility, or as a bridge-to-transplantation or to long-term mechanical support. For Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 2-6 patients, implantation of a long-term ventricular assist-device (VAD) should be considered before progression to multiple organ failure if heart transplantation is not a first-line option. Most patients receive a miniaturized axial or centrifugal fully implantable left VAD as a bridge-to-transplantation or as "destination therapy" in this setting.
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Affiliation(s)
- Alain Combes
- Medical-Surgical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, F-75013 Paris, France; Sorbonne University, UPMC Univ Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013 Paris, France.
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Ouweneel DM, Eriksen E, Sjauw KD, van Dongen IM, Hirsch A, Packer EJ, Vis MM, Wykrzykowska JJ, Koch KT, Baan J, de Winter RJ, Piek JJ, Lagrand WK, de Mol BA, Tijssen JG, Henriques JP. Percutaneous Mechanical Circulatory Support Versus Intra-Aortic Balloon Pump in Cardiogenic Shock After Acute Myocardial Infarction. J Am Coll Cardiol 2017; 69:278-287. [DOI: 10.1016/j.jacc.2016.10.022] [Citation(s) in RCA: 473] [Impact Index Per Article: 67.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 10/18/2016] [Indexed: 01/16/2023]
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44
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Claessen BE, Ouweneel D, Henriques JP. The Management of Cardiogenic Shock and Hemodynamic Support Devices and Techniques. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Bimmer E.P.M. Claessen
- Department of Cardiology; Academic Medical Center-University of Amsterdam; Amsterdam the Netherlands
| | - Dagmar Ouweneel
- Department of Cardiology; Academic Medical Center-University of Amsterdam; Amsterdam the Netherlands
| | - José P.S. Henriques
- Department of Cardiology; Academic Medical Center-University of Amsterdam; Amsterdam the Netherlands
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Karatolios K, Chatzis G, Markus B, Luesebrink U, Richter A, Schieffer B. Biventricular unloading in patients with refractory cardiogenic shock. Int J Cardiol 2016; 222:247-252. [DOI: 10.1016/j.ijcard.2016.07.227] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
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46
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Kalavrouziotis D, Rodés-Cabau J, Mohammadi S. Moving Beyond SHOCK: New Paradigms in the Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock. Can J Cardiol 2016; 33:36-43. [PMID: 28024554 DOI: 10.1016/j.cjca.2016.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 10/04/2016] [Accepted: 10/13/2016] [Indexed: 12/17/2022] Open
Abstract
The current management of patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with a high rate of mortality, despite widespread regional implementation of rapid transfer to percutaneous coronary intervention-capable centres for prompt infarct-related artery reperfusion. The limited clinical effectiveness of early revascularization in patients with AMI-CS might be secondary to the extent of coronary artery disease in these patients and the risk of incomplete revascularization, as well as the lower probability of achieving successful reperfusion compared with acute myocardial infarction without hemodynamic instability. Also, the severity of end-organ injury is a critical determinant of outcome. We review adjunctive therapies to early revascularization in AMI-CS, specifically with a focus on the role of short-term mechanical circulatory support. In selected patients with AMI-CS, there might be a benefit associated with early institution of mechanical circulatory support before revascularization.
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Affiliation(s)
- Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Québec City, Québec, Canada.
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Québec City, Québec, Canada
| | - Siamak Mohammadi
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Québec City, Québec, Canada
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47
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Mastroianni C, Bouabdallaoui N, Leprince P, Lebreton G. Short-term mechanical circulatory support with the Impella 5.0 device for cardiogenic shock at La Pitié-Salpêtrière. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:87-92. [DOI: 10.1177/2048872616633877] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Ciro Mastroianni
- Department of Thoracic and Cardiovascular Surgery, Pierre et Marie Curie University, Paris VI, Assistance Publique des Hôpitaux de Paris, La Pitié-Salpêtrière Hospital, France
| | - Nadia Bouabdallaoui
- Department of Thoracic and Cardiovascular Surgery, Pierre et Marie Curie University, Paris VI, Assistance Publique des Hôpitaux de Paris, La Pitié-Salpêtrière Hospital, France
| | - Pascal Leprince
- Department of Thoracic and Cardiovascular Surgery, Pierre et Marie Curie University, Paris VI, Assistance Publique des Hôpitaux de Paris, La Pitié-Salpêtrière Hospital, France
| | - Guillaume Lebreton
- Department of Thoracic and Cardiovascular Surgery, Pierre et Marie Curie University, Paris VI, Assistance Publique des Hôpitaux de Paris, La Pitié-Salpêtrière Hospital, France
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48
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Retrospective analysis of circulatory support with the Impella CP® device in patients with therapy refractory cardiogenic shock. Int J Cardiol 2016; 219:200-3. [DOI: 10.1016/j.ijcard.2016.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 06/12/2016] [Indexed: 11/24/2022]
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49
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Dind A, Allahwala U, Asrress KN, Jolly SS, Bhindi R. Contemporary Management of ST-Elevation Myocardial Infarction. Heart Lung Circ 2016; 26:114-121. [PMID: 27617370 DOI: 10.1016/j.hlc.2016.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/11/2016] [Accepted: 07/22/2016] [Indexed: 02/07/2023]
Abstract
Recent advances have caused a major shift in the way ST-elevation myocardial infarctions are managed. This review explores the pharmacological and interventional techniques that have evidence for improving outcomes and the landmark trials that have sparked change. The new P2Y12 inhibitors, ticagrelor and prasugrel, have been shown to be superior to clopidogrel in STEMI patients undergoing primary percutaneous coronary intervention. Concurrently, many technical aspects of percutaneous coronary intervention have been further clarified by trial data, with bare-metal stents, routine thrombus aspiration and femoral access showing evidence of inferiority. Ongoing trials will provide more information on the role of non-culprit lesion PCI, bioresorbable vascular scaffolds, mechanical devices in persistent ischaemia and early automatic implantable cardioverter-defibrillators for inducible ventricular tachycardia.
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Affiliation(s)
- Ashleigh Dind
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Usaid Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Kaleab N Asrress
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sanjit S Jolly
- Department of Medicine, Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, NSW, Australia.
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50
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Briceno N, Kapur NK, Perera D. Percutaneous mechanical circulatory support: current concepts and future directions. Heart 2016; 102:1494-507. [DOI: 10.1136/heartjnl-2015-308562] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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