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Movahed MR, Talle A, Hashemzadeh M. Intra-aortic balloon pump is associated with the lowest whereas Impella with the highest inpatient mortality and complications regardless of severity or hospital types. Cardiovasc Interv Ther 2024; 39:252-261. [PMID: 38555535 DOI: 10.1007/s12928-024-00993-8] [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: 01/27/2024] [Accepted: 03/04/2024] [Indexed: 04/02/2024]
Abstract
Impella and intra-aortic balloon pumps (IABP) are commonly utilized in patients with cardiogenic shock. However, the effect on mortality remains controversial. The goal of this study was to evaluate the effect of Impella and IABP on mortality in patients with cardiogenic shock the large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of IABP or Impella on outcome. ICD-10 codes for Impella, IABP, and cardiogenic shock for available years 2016-2020 were utilized. A total of 844,020 patients had a diagnosis of cardiogenic shock. A total of 101,870 patients were treated with IABP and 39645 with an Impella. Total inpatient mortality without any device was 34.2% vs only 25.1% with IABP use (OR = 0.65, CI 0.62-0.67) but was highest at 40.7% with Impella utilization (OR = 1.32, CI 1.26-1.39). After adjusting for 47 variables, Impella utilization remained associated with the highest mortality (OR: 1.33, CI 1.25-1.41, p < 0.001), whereas IABP remained associated with the lowest mortality (OR: 0.69, CI 0.66-0.72, p < 0.001). Separating rural vs teaching hospitals revealed similar findings. In patients with cardiogenic shock, the use of Impella was associated with the highest whereas IABP was associated with the lowest in-hospital mortality regardless of comorbid condition.
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Affiliation(s)
- Mohammad Reza Movahed
- University of Arizona Sarver Heart Center, 1501 North Campbell Avenue, Tucson, Arizona, USA.
- University of Arizona, College of Medicine, Phoenix, Arizona, USA.
| | - Armin Talle
- University of Arizona, College of Medicine, Phoenix, Arizona, USA
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Vandenbriele C, M'Pembele R, Dannenberg L, Metzen D, Zako S, Helten C, Mourikis P, Ignatov D, Huhn R, Balthazar T, Adriaenssens T, Vanassche T, Meyns B, Panoulas V, Monteagudo-Vela M, Arachchillage D, Janssens S, Scherer C, Orban M, Petzold T, Horn P, Jung C, Zeus T, Price S, Westenfeld R, Kelm M, Polzin A. Heparin dosing in patients with Impella-supported cardiogenic shock. Int J Cardiol 2024; 399:131690. [PMID: 38160912 DOI: 10.1016/j.ijcard.2023.131690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Impella™ is increasingly used in cardiogenic shock. However, thromboembolic and bleeding events are frequent during percutaneous mechanical circulatory support (pMCS). OBJECTIVE Therefore, we aimed to explore the optimal anticoagulation regime for pMCS to prevent thromboembolism and bleedings. METHODS This hypothesis-generating multi-center cohort study investigated 170 patients with left-Impella™ support. We (A) compared bleeding/thrombotic events in two centers with therapeutic range (TR-aPTT) activated partial thromboplastin time (60-80s) and (B) compared events of these centers with one center with intermediate range aPTT (40-60s). RESULTS After matching, there were no differences in patients' characteristics. In centers aiming at TR-aPTT, major bleeding was numerically lower with aPTT <60s within 48 h of left-Impella™ support, versus patients that achieved the aimed aPTT of ≥60s [aPTT ≥60s: 22 (37.3%) vs. aPTT<60s 14 (23.7%); Hazard ratio [HR], 0.62 (95%) CI, 0.28-1.38; p = 0.234]. Major cardiovascular and cerebrovascular adverse events (MACCE) did not differ between groups. In comparison of centers, TR-aPTT strategy showed higher major bleeding rates [TR: 8 (47.1%) vs. intermediate range: 1 (5.9%); HR, 0.06 (95%) CI, 0.01-0.45; p = 0.006]. MACCE were lower in the intermediate range aPTT group as well [TR 12 (70.6%) vs. intermediate range 5 (29.4%) HR, 0.32 (95%) CI, 0.11-0.92; p = 0.034]. CONCLUSION This pilot analysis showed that lowering UFH-targets in left-Impella™ supported CS patients seems to be a safe and promising strategy for reducing major bleedings without increasing MACCE. This needs to be validated in larger, randomized clinical trials.
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Affiliation(s)
| | - René M'Pembele
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Germany
| | - Lisa Dannenberg
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Daniel Metzen
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Saif Zako
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Carolin Helten
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Philipp Mourikis
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Denis Ignatov
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Ragnar Huhn
- Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, Germany
| | - Tim Balthazar
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of cardiac surgery, University Hospitals Leuven, Belgium
| | - Vasileios Panoulas
- Department of Adult Intensive Care, Royal Brompton and Harefield Hospitals, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Maria Monteagudo-Vela
- Department of Adult Intensive Care, Royal Brompton and Harefield Hospitals, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Deepa Arachchillage
- Centre for haematology, Department of Immunology and Inflammation, Imperial College London, London, UK; Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Stefan Janssens
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Clemens Scherer
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Martin Orban
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Patrick Horn
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Christian Jung
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Tobias Zeus
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Susanna Price
- Department of Adult Intensive Care, Royal Brompton and Harefield Hospitals, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Ralf Westenfeld
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Malte Kelm
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | - Amin Polzin
- Cardiovascular Research Institute Düsseldorf (CARID), Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
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Hazan Shenberger S, Avrahami I. The Effect of Mechanical Circulatory Support on Blood Flow in the Ascending Aorta: A Combined Experimental and Computational Study. Bioengineering (Basel) 2024; 11:238. [PMID: 38534512 DOI: 10.3390/bioengineering11030238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/11/2024] [Accepted: 02/22/2024] [Indexed: 03/28/2024] Open
Abstract
Percutaneous mechanical circulatory support (MCS) devices are designed for short-term treatment in cases of acute decompensated heart failure as a bridge to transplant or recovery. Some of the known complications of MCS treatments are related to their hemodynamics in the aorta. The current study investigates the effect of MCS on the aortic flow. The study uses combined experimental and numerical methods to delineate complex flow structures. Particle image velocimetry (PIV) is used to capture the vortical and turbulent flow characteristics in a glass model of the human aorta. Computational fluid dynamics (CFD) analyses are used to complete the 3D flow in the aorta. Three specific MCS configurations are examined: a suction pump with a counterclockwise (CCW) rotating impeller, a suction pump with a clockwise (CW) rotating impeller, and a discharge pump with a straight jet. These models were examined under varying flow rates (1-2.5 L/min). The results show that the pump configuration strongly influences the flow in the thoracic aorta. The rotating impeller of the suction pump induces a dominant swirling flow in the aorta. The swirling flow distributes the incoming jet and reduces the turbulent intensity near the aortic valve and in the aorta. In addition, at high flow rates, the local vortices formed near the pump are washed downstream toward the aortic arch. Specifically, an MCS device with a CCW rotating impeller induces a non-physiological CCW helical flow in the descending aorta (which is opposite to the natural helical flow), while CW swirl combines better with the natural helical flow.
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Affiliation(s)
- Sapir Hazan Shenberger
- Department of Mechanical Engineering and Mechatronics, Ariel University, Ariel 40700, Israel
| | - Idit Avrahami
- Department of Mechanical Engineering and Mechatronics, Ariel University, Ariel 40700, Israel
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Low CJW, Ling RR, Lau MPXL, Liu NSH, Tan M, Tan CS, Lim SL, Rochwerg B, Combes A, Brodie D, Shekar K, Price S, MacLaren G, Ramanathan K. Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies. Intensive Care Med 2024; 50:209-221. [PMID: 38206381 DOI: 10.1007/s00134-023-07278-3] [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: 09/01/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit. METHODS We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model. RESULTS We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66). CONCLUSION In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.
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Affiliation(s)
- Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Michele Petrova Xin Ling Lau
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Nigel Sheng Hui Liu
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Melissa Tan
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Shir Lynn Lim
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
- Duke-NUS Medical School, Pre-Hospital and Emergency Research Center, Singapore, Singapore
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Alain Combes
- Service de Médecine Intensive-RéanimationInstitut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Paris, France
- UMRS 116, Institute of Cardio Metabolism and Nutrition, Sorbonne Universite INSERM, Paris, France
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Queensland University of Technology, Gold Coast, QLD, Australia
- University of Queensland, Gold Coast, QLD, Australia
- Bond University, Gold Coast, QLD, Australia
| | - Susanna Price
- Royal Brompton and Harefield Hospitals, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
- Cardiothoracic Intensive Care Unit, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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5
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Chen C, Zhang M, Hao P, He F, Zhang X. An in silico analysis of unsteady flow structures in a microaxial blood pump under a pulsating rotation speed. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 243:107919. [PMID: 37972458 DOI: 10.1016/j.cmpb.2023.107919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVE Ventricular assist devices (VADs) are generally designed to perform continuous flow. However, it has been proven that continuous flow, which is not a physiological hemodynamic state, may cause severe complications such as gastrointestinal bleeding, pulmonary hypertension, and ventricular suction. For these reasons, many pulsating blood pump control strategies have been proposed and have the potential for application in percutaneous ventricular assist devices (pVADs) or microaxial blood pumps. A few cases report extra hemolysis when introducing pulsating speed, while none involve blood pumps. This research's primary purpose is to evaluate the potential hemolysis of pVAD under pulsating flow conditions. METHODS First, the pulsating flow state is deduced using a heart failure model and varying speed. The heart model is established according to the pathology state collected from a clinical check. The rotation speed and boundary physical state are set to fit the heart failure model. The computational fluid dynamics (CFD) method with the hemolysis prediction model is performed. Furthermore, we used proper orthogonal decomposition (POD) analysis to reconstruct the flow field and obtain more details about shearing and transporting effects. RESULTS (1) As a variable rotational speed was introduced, no significant gain in hemolysis accumulation appeared in pVAD. This is quite different from long-term implantable VADs. (2) Pulsation affects hemolysis mainly through pressure (or normal stress). Variable rotational speed affects hemolysis mainly through flow instability. (3) Variable rotational speed will increase the instability and influence hemolysis by transporting and shearing effects, while the transporting effect is more significant. CONCLUSIONS The unsteady flow state will affect the spatial distribution of hemolysis, which should be taken into account during control strategy and impeller shape design.
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Affiliation(s)
- Chenghan Chen
- Applied Mechanics Laboratory, Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing, PR China; Department of Cardiovascular Surgery, First Hospital of Tsinghua University, Beijing, PR China
| | - Mingkui Zhang
- Department of Cardiovascular Surgery, First Hospital of Tsinghua University, Beijing, PR China
| | - Pengfei Hao
- Applied Mechanics Laboratory, Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing, PR China
| | - Feng He
- Applied Mechanics Laboratory, Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing, PR China
| | - Xiwen Zhang
- Applied Mechanics Laboratory, Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing, PR China.
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Frain K, Rees P. Intra-aortic balloon pump versus percutaneous Impella © in emergency revascularisation for myocardial infarction and cardiogenic shock: systematic review. Perfusion 2024; 39:45-59. [PMID: 34479465 DOI: 10.1177/02676591211037026] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Mortality rates in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) remain persistently high despite advances over the past decade in percutaneous mechanical circulatory support. This systematic review aims to analyse the existing literature to compare mortality outcomes in patients mechanically supported by intra-aortic balloon pump or percutaneous Impella 2.5/CP© for AMI-CS undergoing emergency revascularisation. METHODS The following MeSH terms were applied to the databases Ovid Medline, Ovid Embase, Cochrane and Web of Science: 'Intra-aortic balloon pump', 'Impella', 'Cardiogenic shock', 'Myocardial Infarction' and 'Mortality'. This yielded 2643 studies. Using predefined inclusion and exclusion criteria, the studies were initially screened by title and abstract before full text analysis. RESULTS Fourteen studies met eligibility criteria: two randomised controlled trials (RCTs) and 12 observational studies. Data from a total of 21,006 patients were included across the studies. Notably, one study claimed reduced mortality with IABP versus control, and one study concluded that Impella© improved survival rates over the IABP. The average 30-day all-cause mortality in patients supported by IABP was 38.1%, 54.3% in Impella© groups and 39.4% in control groups. CONCLUSION AMI-CS presents an important cohort of patients in whom conducting RCTs is difficult. As a result, the literature is limited. Analysis of the available literature suggests that there is insufficient evidence to support superior survival in those supported by IABP or Impella© when compared to control despite suggestions that the Impella© offers superior haemodynamic support. Limitations of the studies have been discussed to outline suggestions for future research.
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Affiliation(s)
- Kristina Frain
- Faculty of Medicine, University of St Andrews, St Andrews, UK
| | - Paul Rees
- Academic Department of Military Medicine, Barts Heart Centre, London, UK
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Bhuiyan R, Bimal T, Fishbein J, Gandotra P, Selim S, Ong L, Gruberg L. Percutaneous coronary intervention with Impella support with and without intra-aortic balloon in cardiogenic shock patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 55:68-73. [PMID: 37076412 DOI: 10.1016/j.carrev.2023.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To assess the clinical characteristics and in-hospital bleeding complications and major adverse cardiac and cerebrovascular events (MACCE) associated with the use of Impella alone or the combination of an intra-aortic balloon pump (IABP) with Impella in cardiogenic shock (CS) patients undergoing percutaneous coronary intervention (PCI). METHODS All CS patients who underwent PCI and were treated with an Impella mechanical circulatory support (MCS) device were identified. Patients were divided into two groups: having MCS support with Impella alone or with both, IABP and Impella simultaneously (dual MCS group). Bleeding complications were classified by a modified Bleeding Academic Research Consortium (BARC) classification. Major bleeding was defined as BARC≥3 bleeding. MACCE was the composite of in-hospital death, myocardial infarction, cerebrovascular events and major bleeding complications. RESULTS Between 2010 and 2018 a total of 101 patients were treated at six tertiary care New York hospitals with either Impella (n = 61) or dual MCS with Impella and IABP (n = 40). Clinical characteristics were similar for both groups. Dual MCS patients presented more often with a STEMI (77.5 % vs. 45.9 %, p = 0.002) and had left main coronary artery intervention (20.3 % vs. 8.6 %, p = 0.03). Major bleeding complications (69.4 % vs. 74.1 %, p = 0.62) and MACCE rates (80.6 % vs. 79.3 %, p = 0.88) were very high but similar in both groups, however access site bleeding complications were lower in patients treated with dual MCS. In-hospital mortality was 29.5 % for the Impella group and 25.0 % for the dual MCS group (p = 062). Access site bleeding complications were lower in in patients treated with dual MCS (5.0 % vs. 24.6 %, p = 0.01). CONCLUSION In CS patients undergoing PCI with either the Impella device alone or with Impella and IABP, major bleeding complications and MACCE rates were high but not significantly different between the two groups. In hospital mortality was relatively low in both MCS groups despite the high-risk characteristics of these patients. Future studies should assess the risks and benefits of the simultaneous use of these two MCS in CS patients undergoing PCI.
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Affiliation(s)
- Refayat Bhuiyan
- Mather Hospital, Port Jefferson, NY, United States of America
| | - Tia Bimal
- Mather Hospital, Port Jefferson, NY, United States of America
| | - Joanna Fishbein
- Office of Academic Affairs, Northwell Health, Manhasset, NY, United States of America
| | - Puneet Gandotra
- Division of Cardiology, South Shore University Hospital, Bay Shore, NY, United States of America
| | - Samy Selim
- Division of Cardiology, South Shore University Hospital, Bay Shore, NY, United States of America
| | - Lawrence Ong
- Division of Cardiology, South Shore University Hospital, Bay Shore, NY, United States of America
| | - Luis Gruberg
- Mather Hospital, Port Jefferson, NY, United States of America.
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8
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Hamdan R, Kadri Z, Abdallah H, Hamadeh A, Alsaedi E, Al Baba B, Shoka WA, Yassine N, Al Aila F, Gafar S, Mansour A, Lozon H, Daka LA, Soukieh F, Hamadi O, Jayyousi WA, Chah I, Balchi M, Abdallah Y, Nooryani AA. [Place du ballon de contre pulsion intra aortique dans l'infarctus aigu du myocarde compliqué par état de choc cardiogénique]. Ann Cardiol Angeiol (Paris) 2023; 72:101635. [PMID: 37639738 DOI: 10.1016/j.ancard.2023.101635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND AND METHODS Cardiogenic shock remains one of the leading causes of death in patients with myocardial infarction. The Intra-aortic balloon pump (IABP) has been widely used as a treatment for acute myocardial infarction (AMI), despite recommendations against its routine use. In this paper, our aim is to analyze and share our own experience with IABP in the setting of AMI. We retrospectively reviewed the files of patients admitted with AMI and cardiogenic shock and for whom IABP was inserted between June 2016 and December 2022. RESULTS 300 patients with AMI and cardiogenic shock were admitted and benefited from IABP insertion and primary coronary revascularization. The overall mortality rate was 62.3%, the site related complication rate was 0.6%, and the overall complications rate (including site related and major bleeding) was 10.6%. There was a significantly higher mortality in the group of patients where the Left Anterior Descending artery (LAD) was the culprit lesion, in the group of patients who required dialysis, the group who had creatinine levels greater than 200 um/L compared to the group who had creatinine lower than 200 um/L, and in patients older than 70 years. Interestingly, no difference in mortality was observed between men and women, single versus multiple vessel disease, and between STEMI and non-STEMI patients. CONCLUSION Mortality of AMI complicated by cardiogenic shock and treated by IABP remains high. However, IABP usage is associated with a low complication rate. Better selection criteria for IABP usage versus other more powerful mechanical circulatory support devices in such patients might improve the outcome for the patient.
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Affiliation(s)
- Righab Hamdan
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates.
| | - Zena Kadri
- Cardiology Department, Hotel Dieu de France, Beirut, Lebanon
| | | | - Ahmad Hamadeh
- University of Sharjah, Sharjah, United Arab Emirates
| | - Ehab Alsaedi
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Bassam Al Baba
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Wael Abo Shoka
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Noha Yassine
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Farah Al Aila
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Salma Gafar
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Anoop Mansour
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Hadeel Lozon
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Loai Abo Daka
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | - Farah Soukieh
- University of Sharjah, Sharjah, United Arab Emirates
| | - Omar Hamadi
- University of Sharjah, Sharjah, United Arab Emirates
| | | | - Islam Chah
- Cardiology department, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
| | | | | | - Arif Al Nooryani
- Head of Cardiology Department, CEO, Al Qassimi Hospital, Emirates Health Services, Sharjah, United Arab Emirates
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9
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Abdul-Rahman T, Lizano-Jubert I, Garg N, Tejerina-Marion E, Awais Bukhari SM, Luisa Ek A, Wireko AA, Mares AC, Sikora V, Gupta R. The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery. Healthcare (Basel) 2023; 11:healthcare11081094. [PMID: 37107928 PMCID: PMC10137626 DOI: 10.3390/healthcare11081094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/28/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
In the United States, about one million people are seen to visit the operating theater for cardiac surgery annually. However, nearly half of these visits result in complications such as renal, neurological, and cardiac injury of varying degrees. Historically, many mechanisms and approaches have been explored in attempts to reduce injuries associated with cardiac surgery and percutaneous procedures. Devices such as cardioplegia, mechanical circulatory support, and other methods have shown promising results in managing and preventing life-threatening cardiac-surgery-related outcomes such as heart failure and cardiogenic shock. Comparably, cardioprotective devices such as TandemHeart, Impella family devices, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) have also been proven to show significant cardioprotection through mechanical support. However, their use as interventional agents in the prevention of hemodynamic changes due to cardiac surgery or percutaneous interventions has been correlated with adverse effects. This can lead to a rebound increased risk of mortality in high-risk patients who undergo cardiac surgery. Further research is necessary to delineate and stratify patients into appropriate cardioprotective device groups. Furthermore, the use of one device over another in terms of efficacy remains controversial and further research is necessary to assess device potential in different settings. Clinical research is also needed regarding novel strategies and targets, such as transcutaneous vagus stimulation and supersaturated oxygen therapy, aimed at reducing mortality among high-risk cardiac surgery patients. This review explores the recent advances regarding the use of cardioprotective devices in patients undergoing percutaneous procedures and cardiac surgery.
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Affiliation(s)
- Toufik Abdul-Rahman
- Medical Institute, Sumy State University, 40007 Sumy, Ukraine
- Department of Cardiology, Otto Von Guericke University of Magdeburg, 39120 Magdeburg, Germany
| | - Ileana Lizano-Jubert
- Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac Campus Norte, Huixquilucan 52786, Mexico
| | - Neil Garg
- Rowan-Virtua School of Osteopathic Medicine, One Medical Center Drive Stratford, Stratford, NJ 08084, USA
| | - Emilio Tejerina-Marion
- Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac Campus Norte, Huixquilucan 52786, Mexico
| | | | - Ana Luisa Ek
- Centro de Investigación en Ciencias de la Salud (CICSA), FCS, Universidad Anáhuac Campus Norte, Huixquilucan 52786, Mexico
| | - Andrew Awuah Wireko
- Medical Institute, Sumy State University, 40007 Sumy, Ukraine
- Department of Cardiology, Otto Von Guericke University of Magdeburg, 39120 Magdeburg, Germany
| | - Adriana C Mares
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX 79905, USA
| | - Vladyslav Sikora
- Medical Institute, Sumy State University, 40007 Sumy, Ukraine
- Department of Clinical and Experimental Medicine, University of Foggia, Via Napoli, 20, 71122 Foggia, Italy
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA 18103, USA
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10
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Ardito V, Sarucanian L, Rognoni C, Pieri M, Scandroglio AM, Tarricone R. Impella Versus VA-ECMO for Patients with Cardiogenic Shock: Comprehensive Systematic Literature Review and Meta-Analyses. J Cardiovasc Dev Dis 2023; 10:jcdd10040158. [PMID: 37103037 PMCID: PMC10142129 DOI: 10.3390/jcdd10040158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
Impella and VA-ECMO are two possible therapeutic courses for the treatment of patients with cardiogenic shock (CS). The study aims to perform a systematic literature review and meta-analyses of a comprehensive set of clinical and socio-economic outcomes observed when using Impella or VA-ECMO with patients under CS. A systematic literature review was performed in Medline, and Web of Science databases on 21 February 2022. Nonoverlapping studies with adult patients supported for CS with Impella or VA-ECMO were searched. Study designs including RCTs, observational studies, and economic evaluations were considered. Data on patient characteristics, type of support, and outcomes were extracted. Additionally, meta-analyses were performed on the most relevant and recurring outcomes, and results shown using forest plots. A total of 102 studies were included, 57% on Impella, 43% on VA-ECMO. The most common outcomes investigated were mortality/survival, duration of support, and bleeding. Ischemic stroke was lower in patients treated with Impella compared to the VA-ECMO population, with statistically significant difference. Socio-economic outcomes including quality of life or resource use were not reported in any study. The study highlighted areas where further data collection is needed to clarify the value of complex, new technologies in the treatment of CS that will enable comparative assessments focusing both on the health impact on patient outcomes and on the financial burden for government budgets. Future studies need to fill the gap to comply with recent regulatory updates at the European and national levels.
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Affiliation(s)
- Vittoria Ardito
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Lilit Sarucanian
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, 20136 Milan, Italy
- Department of Social and Political Science, Bocconi University, 20136 Milan, Italy
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11
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Shimizu M, Hiraiwa H, Tanaka S, Tsuchikawa Y, Ito R, Kazama S, Kimura Y, Araki T, Mizutani T, Oishi H, Kuwayama T, Kondo T, Morimoto R, Okumura T, Ito H, Yoshizumi T, Mutsuga M, Usui A, Murohara T. Cardiac Rehabilitation in Severe Heart Failure Patients with Impella 5.0 Support via the Subclavian Artery Approach Prior to Left Ventricular Assist Device Implantation. J Pers Med 2023; 13:jpm13040630. [PMID: 37109016 PMCID: PMC10143331 DOI: 10.3390/jpm13040630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Impella 5.0 circulatory support via subclavian artery (SA) access may be a safe approach for patients undergoing cardiac rehabilitation (CR). In this case series, we retrospectively analyzed the demographic characteristics, physical function, and CR data of six patients who underwent Impella 5.0 implantation via the SA prior to left ventricular assist device (LVAD) implantation between October 2013 and June 2021. The median age was 48 years, and one patient was female. Grip strength was maintained or increased in all patients before LVAD implantation (pre-LVAD) compared to after Impella 5.0 implantation. The pre-LVAD knee extension isometric strength (KEIS) was less than 0.46 kgf/kg in two patients and more than 0.46 kgf/kg in three patients (unavailable KEIS data, n = 1). With Impella 5.0 implantation, two patients could ambulate, one could stand, two could sit on the edge of the bed, and one remained in bed. One patient lost consciousness during CR due to decreased Impella flow. There were no other serious adverse events. Impella 5.0 implantation via the SA allows mobilization, including ambulation, prior to LVAD implantation, and CR can be performed relatively safely.
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Affiliation(s)
- Miho Shimizu
- Department of Rehabilitation, Nagoya University Hospital, Nagoya 466-8560, Japan
- Department of Rehabilitation, Mie University Hospital, Tsu 514-8507, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Shinya Tanaka
- Department of Rehabilitation, Nagoya University Hospital, Nagoya 466-8560, Japan
| | - Yohei Tsuchikawa
- Department of Rehabilitation, Nagoya University Hospital, Nagoya 466-8560, Japan
| | - Ryota Ito
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yuki Kimura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Takashi Mizutani
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hideki Ito
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Tomo Yoshizumi
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
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12
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Salter BS, Gross CR, Weiner MM, Dukkipati SR, Serrao GW, Moss N, Anyanwu AC, Burkhoff D, Lala A. Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Nat Rev Cardiol 2023; 20:263-277. [PMID: 36357709 PMCID: PMC9649020 DOI: 10.1038/s41569-022-00796-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/12/2022]
Abstract
Originally intended for life-saving salvage therapy, the use of temporary mechanical circulatory support (MCS) devices has become increasingly widespread in a variety of clinical settings in the contemporary era. Their use as a short-term, prophylactic support vehicle has expanded to include procedures in the catheterization laboratory, electrophysiology suite, operating room and intensive care unit. Accordingly, MCS device design and technology continue to develop at a rapid pace. In this Review, we describe the functionality, indications, management and complications associated with temporary MCS, together with scenario-specific utilization, goal-directed development and bioengineering of future devices. We address various considerations for the use of temporary MCS devices in both prophylactic and rescue scenarios, with input from stakeholders from various cardiovascular specialties, including interventional and heart failure cardiology, electrophysiology, cardiothoracic anaesthesiology, critical care and cardiac surgery.
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Affiliation(s)
- Benjamin S Salter
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Caroline R Gross
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Menachem M Weiner
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory W Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Anelechi C Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
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13
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Bochenek T, Sowula P, Rodak M, Rybicka-Musialik A, Gruchlik B, Mizia-Stec K. Retrospective Analysis of Intra-Aortic Balloon Pump Use in Cardiology Ward Patients Undergoing Coronary Angiography between 2012 and 2020. J Clin Med 2023; 12:1567. [PMID: 36836102 PMCID: PMC9962021 DOI: 10.3390/jcm12041567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/19/2023] [Accepted: 02/15/2023] [Indexed: 02/18/2023] Open
Abstract
We aimed to evaluate the rate and risk factors of in-hospital mortality in patients undergoing coronary angiography/angioplasty with IABP use as support. We included 214 patients (mean age: 67.5 ± 7.5 years, M/F: 143/71) with an IABP used as the periprocedural support between 2012 and 2020. The main indications for an IABP were cardiogenic shock (143 pts; 66.8%: 55 survivors (51.9%)/88 non-survivors (81.5%); p < 0.001) and infarction with an initial significant impairment of ventricular function (34 pts; 15.9%: 21 (19.8%)/13 (12%); p = 0.12). In-hospital death was the endpoint of this study. In-hospital death occurred in 108 (50.5%, M/F: 69.4%/30.6%) patients. The mean hospitalization time was 7 days (2-13); deaths occurred more frequently on the first day after the procedure (1 (1-3 days) vs. 3 (1-8), p < 0.001); and the mean hospitalization time was 2 days (1-6) for non-survivors vs. 11 days (7-17) for survivors (p < 0.001). Regarding the patients who did not survive, they were older (69 vs. 66.5, p = 0.043), their LVEF was lower (0-15%: 15 (13.9%) vs. 12 (11.3%); 16-40%: 73 (67.6%) vs. 65 (61.3%); >40%: 14 (13%) vs. 29 (27.4%); p = 0.007), and hyperlipidemia was less common (30 (27.8%) vs. 55 (51.9%) pts, p = 0.001) than in those who survived. The IABP is still a method for cardiac support; however, mortality limits its use.
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Affiliation(s)
- Tomasz Bochenek
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40055 Katowice, Poland
- Upper-Silesian Medical Center, 40635 Katowice, Poland
| | - Patrycja Sowula
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40055 Katowice, Poland
| | - Małgorzata Rodak
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40055 Katowice, Poland
| | | | | | - Katarzyna Mizia-Stec
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40055 Katowice, Poland
- Upper-Silesian Medical Center, 40635 Katowice, Poland
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14
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Gilani A, Maknojia A, Mufty M, Patel S, Grines CL, Ghatak A. Mechanical circulatory device utilization in cardiac arrest: Racial and gender disparities and impact on mortality. Int J Cardiol 2023; 371:460-464. [PMID: 36087630 DOI: 10.1016/j.ijcard.2022.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/16/2022] [Accepted: 09/03/2022] [Indexed: 01/08/2023]
Abstract
The objectives of this retrospective study include identifying the utilization trend of mechanical circulatory devices (MCD) such as Intra-Aortic Balloon Pump (IABP), Impella and Extracorporeal Membrane Oxygenation (ECMO) in admissions with cardiac arrest, determining whether racial or gender disparities exist in their usage, and discerning if their use is associated with a reduction in mortality. By leveraging the National Inpatient Sample, we identified 229,180 weighted adult cardiac arrest admissions between October 1, 2015 and December 31, 2018. MCD were used in 6005 admissions (2.6%). IABP had the highest utilization, representing 77.8% of all MCDs, followed by Impella at 24.8%. The utilization of IABP decreased from 90.6% to 71.6%, while the use of Impella increased from 13.5% to 29.8% in this study period; both trends were statistically significant. MCD use was found to be lower in women compared to men (1.4% vs 3.6, P < 0.001) and in the Black population compared to White (1.5% vs 2.8%, P < 0.001). There was no difference in MCD utilization between Hispanic and the White cohorts. In-hospital mortality was lower in admissions associated with MCD (31.4% vs 45.9%, P < 0.001). ECMO was associated with the lowest mortality rate at 14.3%, followed by IABP at 28.1%. The use of Impella and combination therapy were not associated with a significant decrease in mortality. In conclusion, MCD use may decrease mortality in cardiac arrest, however their utilization appears to be lower in African Americans and in women.
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Affiliation(s)
- Aamir Gilani
- Internal Medicine Chief Resident; Northside Hospital Gwinnett, 1000 Medical Center Blvd, Lawrenceville, GA 30046, USA.
| | - Arish Maknojia
- Internal Medicine Resident; Northside Hospital Gwinnett, 1000 Medical Center Blvd, Lawrenceville, GA 30046, USA
| | - Muhammad Mufty
- Internal Medicine Resident; Northside Hospital Gwinnett, 1000 Medical Center Blvd, Lawrenceville, GA 30046, USA
| | - Shaan Patel
- Internal Medicine Resident; Northside Hospital Gwinnett, 1000 Medical Center Blvd, Lawrenceville, GA 30046, USA
| | - Cindy L Grines
- Northside Hospital Cardiovascular Institute, 575 Professional Dr #400, Lawrenceville, GA 30046, USA. Past president of the Society for Cardiovascular Angiography and Interventions
| | - Abhijit Ghatak
- Cardiovascular Clinic of North Georgia, 1475 Jesse Jewell Pkwy NE #300, Gainesville, GA 30501, USA
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15
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Ibrahim K, Tongers J, Mangner N, Werner N, Tycinska A, Leick J, Oreglia J, Schröder J. Handling high-risk patients in the catheterization laboratory. Eur Heart J Suppl 2022; 24:J30-J36. [PMCID: PMC9730785 DOI: 10.1093/eurheartjsupp/suac063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Protected percutaneous coronary intervention is considered a life-saving procedure for high-risk patients. Therefore it is important that the interventional cardiology team is prepared, the procedure is planned, and potential complications, as well as bail out strategies are considered. Throughout the procedure, it is critical to monitor the patient to identify any early signs of deterioration or changes in patient well-being to avoid any potential complications.
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Affiliation(s)
- Karim Ibrahim
- Department of Cardiology, Technische Universität Dresden, (Campus Chemnitz) , Klinikum Chemnitz, Flemmingstrasse 2, 09116 Chemnitz , Germany
| | - Jörn Tongers
- Department of Cardiology and Intensive Care Medicine, Mid-German Heart Center, University Hospital, Martin-Luther-University Halle-Wittenberg , 06120 Halle , Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universitaet Dresden , Dresden , Germany
| | - Nikos Werner
- Department of Cardiology, Heart Centre Trier, Barmherzige Brüder Hospital , 54292 Trier , Germany
| | - Agnieszka Tycinska
- Department of Cardiology, Medical University of Bialystok , 15-276 Bialystok , Poland
| | - Jürgen Leick
- Department of Cardiology, Heart Centre Trier, Barmherzige Brüder Hospital , 54292 Trier , Germany
| | - Jacopo Oreglia
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda , 20162 Milano , Italy
| | - Jörg Schröder
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen , 52074 Aachen , Germany
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Sinning JM, Ibrahim K, Schröder J, Sef D, Burzotta F. Optimal bail-out and complication management strategies in protected high-risk percutaneous coronary intervention with the Impella. Eur Heart J Suppl 2022; 24:J37-J42. [PMID: 36518892 PMCID: PMC9730790 DOI: 10.1093/eurheartjsupp/suac064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Despite the routine use of percutaneous mechanical circulatory support (pMCS) with the Impella heart pump, vascular and bleeding complications may occur during removal with or without pre-closure. To safely close the large-bore access (LBA), post-hoc selection of the appropriate treatment of vascular complications is critical to patient recovery and survival. Femoral artery access is typically utilized for LBA, and percutaneous axillary artery access is a common alternative, especially in the instance of severe peripheral artery disease. Optimization of patient outcomes and efficiency of pMCS can be achieved with adequate arterial access using state-of-the-art techniques. Impella removal techniques with or without pre-closure will be addressed as well as the management of large-bore femoral access complications. In addition, treatment strategies to manage patient deterioration during a protected high-risk percutaneous coronary intervention will be provided.
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Affiliation(s)
- Jan-Malte Sinning
- Department of Cardiology, St Vinzenz Hospital Cologne, Cologne, Germany
| | - Karim Ibrahim
- Department of Cardiology, Technische Universität Dresden (Campus Chemnitz), Klinikum Chemnitz, Chemnitz, Germany
| | - Jörg Schröder
- Department of Cardiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Davorin Sef
- Department of Cardiac Surgery and Transplant Unit, Royal Brompton & Harefield NHS Foundation Trust Harefield Hospital, Harefield, UK
| | - Francesco Burzotta
- UOC Interventistica Cardiologica e Diagnostica Invasiva, Fondazione Policlinico Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
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17
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Intra-aortic Balloon Pump Versus Impella in Managing Cardiogenic Shock After Myocardial Infarction: Literature Review. Dimens Crit Care Nurs 2022; 41:321-329. [PMID: 36179310 DOI: 10.1097/dcc.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite early revascularization and supportive medical therapies, acute myocardial infarction with cardiogenic shock (AMICS) remains the leading cause of death in patient's with myocardial infarction. Intra-aortic balloon pump (IABP) has been the device of choice for these patients but has failed to show mortality benefit over medical therapy alone. The Impella (AbioMed, Danvers, Massachusetts) is a more recently developed alternative in bridging patients to recovery. AIM The aim of this study was to evaluate available evidence comparing mortality with the use of Impella (2.0 or CP) versus IABP in patients with AMICS. METHODS PubMed, CINAHL, EMBASE, and Scopus were searched to find articles comparing the outcomes of IABP versus Impella in AMICS patients. A total of 7 articles met the inclusion criteria. RESULTS Thirty-day mortality was the primary outcome observed. Secondary outcomes included myocardial recovery and complications from device implantation. All studies support that there is no statistically significant reduction in mortality when utilizing the Impella over the IABP. DISCUSSION Further research in an adequately powered randomized clinical trial is needed to shed light on the clinical characteristics of patients after AMICS who would benefit from 1 type of mechanical circulatory support over another. The therapy chosen is determined by provider discretion and skill set, as well as device availability. It is important for all care team members, including the critical care nurse, to understand the implications and complications associated with each therapy, so care can be catered to the individual patient's needs.
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18
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Tan SR, Low CJW, Ng WL, Ling RR, Tan CS, Lim SL, Cherian R, Lin W, Shekar K, Mitra S, MacLaren G, Ramanathan K. Microaxial Left Ventricular Assist Device in Cardiogenic Shock: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12101629. [PMID: 36295065 PMCID: PMC9605512 DOI: 10.3390/life12101629] [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: 09/30/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Microaxial left ventricular assist devices (LVAD) are increasingly used to support patients with cardiogenic shock; however, outcome results are limited to single-center studies, registry data and select reviews. We conducted a systematic review and meta-analysis, searching three databases for relevant studies reporting on microaxial LVAD use in adults with cardiogenic shock. We conducted a random-effects meta-analysis (DerSimonian and Laird) based on short-term mortality (primary outcome), long-term mortality and device complications (secondary outcomes). We assessed the risk of bias and certainty of evidence using the Joanna Briggs Institute and the GRADE approaches, respectively. A total of 63 observational studies (3896 patients), 6 propensity-score matched (PSM) studies and 2 randomized controlled trials (RCTs) were included (384 patients). The pooled short-term mortality from observational studies was 46.5% (95%-CI: 42.7–50.3%); this was 48.9% (95%-CI: 43.8–54.1%) amongst PSM studies and RCTs. The pooled mortality at 90 days, 6 months and 1 year was 41.8%, 51.1% and 54.3%, respectively. Hemolysis and access-site bleeding were the most common complications, each with a pooled incidence of around 20%. The reported mortality rate of microaxial LVADs was not significantly lower than extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumps (IABP). Current evidence does not suggest any mortality benefit when compared to ECMO or IABP.
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Affiliation(s)
- Shien Ru Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Wei Lin Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119228, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Robin Cherian
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Weiqin Lin
- Department of Cardiology, National University Heart Centre, Singapore 119228, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD 4032, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD 4000, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
| | - Saikat Mitra
- Intensive Care Unit, Dandenong and Casey Hospital, Monash Health, Melbourne, VIC 3175, Australia
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Health System, Singapore 119228, Singapore
- Correspondence:
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19
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Chahdi HO, Berbach L, Boivin-Proulx LA, Hillani A, Noiseux N, Matteau A, Mansour S, Gobeil F, Nauche B, Jolicoeur EM, Potter BJ. Percutaneous Mechanical Circulatory Support in Post-Myocardial Infarction Cardiogenic Shock: A Systematic Review and Meta-Analysis. Can J Cardiol 2022; 38:1525-1538. [DOI: 10.1016/j.cjca.2022.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/15/2022] [Accepted: 05/16/2022] [Indexed: 02/01/2023] Open
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20
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Timing of impella placement in PCI for acute myocardial infarction complicated by cardiogenic shock: An updated meta-analysis. Int J Cardiol 2022; 362:47-54. [DOI: 10.1016/j.ijcard.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/07/2022] [Accepted: 05/04/2022] [Indexed: 02/06/2023]
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21
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Lüsebrink E, Kellnar A, Krieg K, Binzenhöfer L, Scherer C, Zimmer S, Schrage B, Fichtner S, Petzold T, Braun D, Peterss S, Brunner S, Hagl C, Westermann D, Hausleiter J, Massberg S, Thiele H, Schäfer A, Orban M. Percutaneous Transvalvular Microaxial Flow Pump Support in Cardiology. Circulation 2022; 145:1254-1284. [PMID: 35436135 DOI: 10.1161/circulationaha.121.058229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Impella device (Impella, Abiomed, Danvers, MA) is a percutaneous transvalvular microaxial flow pump that is currently used for (1) cardiogenic shock, (2) left ventricular unloading (combination of venoarterial extracorporeal membrane oxygenation and Impella concept), (3) high-risk percutaneous coronary interventions, (4) ablation of ventricular tachycardia, and (5) treatment of right ventricular failure. Impella-assisted forward blood flow increased mean arterial pressure and cardiac output, peripheral tissue perfusion, and coronary blood flow in observational studies and some randomized trials. However, because of the need for large-bore femoral access (14 F for the commonly used Impella CP device) and anticoagulation, the incidences of bleeding and ischemic complications are as much as 44% and 18%, respectively. Hemolysis is reported in as many as 32% of patients and stroke in as many as 13%. Despite the rapidly growing use of the Impella device, there are still insufficient data on its effect on outcome and complications on the basis of large, adequately powered randomized controlled trials. The only 2 small and also underpowered randomized controlled trials in cardiogenic shock comparing Impella versus intra-aortic balloon pump did not show improved mortality. Several larger randomized controlled trials are currently recruiting patients or are in preparation in cardiogenic shock (DanGer Shock [Danish-German Cardiogenic Shock Trial; NCT01633502]), left ventricular unloading (DTU-STEMI [Door-To-Unload in ST-Segment-Elevation Myocardial Infarction; NCT03947619], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO], and REVERSE [A Prospective Randomised Trial of Early LV Venting Using Impella CP for Recovery in Patients With Cardiogenic Shock Managed With VA ECMO; NCT03431467]) and high-risk percutaneous coronary intervention (PROTECT IV [Impella-Supported PCI in High-Risk Patients With Complex Coronary Artery Disease and Reduced Left Ventricular Function; NCT04763200]).
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Affiliation(s)
- Enzo Lüsebrink
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Antonia Kellnar
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Kathrin Krieg
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Leonhard Binzenhöfer
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Clemens Scherer
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Germany (S.Z.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, and German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck (B.S.)
| | - Stephanie Fichtner
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Tobias Petzold
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Daniel Braun
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Sven Peterss
- Herzchirurgische Klinik und Poliklinik (S.P., C.H.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Stefan Brunner
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik (S.P., C.H.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany (D.W.)
| | - Jörg Hausleiter
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Steffen Massberg
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Germany (H.T.)
| | - Andreas Schäfer
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Germany (A.S.)
| | - Martin Orban
- Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I (E.L., A.K., K.K., L.B., C.S., S.F., T.P., D.B., S.B., J.H., S.M., M.O.), Klinikum der Universität München, and German Center for Cardiovascular Research, partner site Munich Heart Alliance
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22
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Mechanical Left Ventricular Unloading in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation. J Am Coll Cardiol 2022; 79:1239-1250. [DOI: 10.1016/j.jacc.2022.01.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/06/2022] [Accepted: 01/18/2022] [Indexed: 12/21/2022]
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23
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Mughal LH, Sastry S. Advances in the treatment of ST Elevation Myocardial Infarction in the UK. JRSM Cardiovasc Dis 2022; 11:20480040221075519. [PMID: 35186283 PMCID: PMC8855403 DOI: 10.1177/20480040221075519] [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: 02/26/2021] [Revised: 12/13/2021] [Accepted: 01/04/2022] [Indexed: 11/17/2022] Open
Abstract
The treatment of acute coronary occlusion with Primary PCI has been a major factor in improving outcomes of patients suffering STEMI in the last 15 years, and is the standard treatment for patients suffering STEMI in the UK. Treatment is beneficial for patients presenting within 12 hours of the onset of symptoms, with the goal being opening of the occluded artery within 150 min of the call for help. Opening of the occluded artery is typically completed with a drug-eluting stent followed by administration of antiplatelet medications for 12 months. Procedures are performed using the radial artery which is associated with improved outcomes compared to vascular access via the femoral artery. Evidence is growing to support full revascularisation including the treatment of severe narrowing in other blood vessels as well as the culprit vessel.
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Affiliation(s)
- Lal Hussain Mughal
- Senior Clinical Fellow in Interventional Cardiology, Wythenshawe Hospital, Manchester University Foundation Trust, UK
| | - Sanjay Sastry
- Consultant Interventional Cardiologist, Wythenshawe Hospital, Manchester University Foundation Trust, UK
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24
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Ott S, Leser L, Lanmüller P, Just IA, Leistner DM, Potapov E, O’Brien B, Klages J. Cardiogenic Shock Management and Research: Past, Present, and Future Outlook. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Although great strides have been made in the pathophysiological understanding, diagnosis and management of cardiogenic shock (CS), morbidity and mortality in patients presenting with the condition remain high. Acute MI is the commonest cause of CS; consequently, most existing literature concerns MI-associated CS. However, there are many more phenotypes of patients with acute heart failure. Medical treatment and mechanical circulatory support are well-established therapeutic options, but evidence for many current treatment regimens is limited. The issue is further complicated by the fact that implementing adequately powered, randomized controlled trials are challenging for many reasons. In this review, the authors discuss the history, landmark trials, current topics of medical therapy and mechanical circulatory support regimens, and future perspectives of CS management.
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Affiliation(s)
- Sascha Ott
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Laura Leser
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | - Pia Lanmüller
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Isabell A Just
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - David Manuel Leistner
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Evgenij Potapov
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Benjamin O’Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; William Harvey Research Institute, London, UK
| | - Jan Klages
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
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25
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Ikeda Y, Ishii S, Maemura K, Oki T, Yazaki M, Fujita T, Iida Y, Kinoshita D, Sato N, Ako J. Hemodynamic assessment and risk classification for successful weaning of Impella in patients with cardiogenic shock. Artif Organs 2022; 46:1358-1368. [PMID: 35132664 DOI: 10.1111/aor.14197] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical predictors for successful weaning of patients from Impella heart pump have not been clarified. We aimed to elucidate the relationship between pulmonary artery catheter (PAC) parameters at the time of Impella weaning and subsequent outcomes. METHODS We enrolled consecutive patients who had received Impella for cardiogenic shock. PAC data were collected immediately before Impella weaning. Patients were classified as non-survivors if they died or required any mechanical circulatory support reintroduction within 30 days of weaning. RESULTS Of 81 patients enrolled, 61 underwent Impella weaning. Of these, 16 were non-survivors. Predictive indicators of non-survival were high pulmonary artery wedge pressure (PAWP; hazard ratio [HR] per 5 mmHg 1.97, 95% CI 1.35-2.80; p < 0.001), high mean pulmonary artery pressure (MPAP; HR per 5 mmHg 1.90, 1.38-2.58; p < 0.001), and low cardiac power output (CPO; HR per 0.1 Watts 0.71, 0.52-0.92; p = 0.006). Cutoff values of PAWP 20 mmHg, MPAP 22 mmHg, and CPO 0.59 Watts showed strong associations with 30-day non-survival risk (low risk 8% in patients with low PAWP and high CPO or 4% in patients with low MPAP and high CPO; high risk 100% in patients with high PAWP and low CPO or 82% in patients with high MPAP and low CPO). CONCLUSIONS PAWP or MPAP higher than the cutoff with CPO below the cutoff at Impella weaning were associated with worse outcomes. We proposed a risk classification model for successful Impella weaning using PAC.
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Affiliation(s)
- Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shunsuke Ishii
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Kenji Maemura
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takumi Oki
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Mayu Yazaki
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Teppei Fujita
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yuichiro Iida
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Daisuke Kinoshita
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Nobuhiro Sato
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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26
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Simko LC. Cardiogenic Shock and the Use of Percutaneous Mechanical Assist Devices. Crit Care Nurse 2022; 42:56-67. [PMID: 35100629 DOI: 10.4037/ccn2022140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Percutaneous mechanical assist devices are used in patients with cardiogenic shock. The purpose of this article is to familiarize critical care nurses with the various types of percutaneous mechanical assist devices, including the intra-aortic balloon pump, the Impella device, extracorporeal membrane oxygenation, and the TandemHeart device. Each type of device requires specific nursing care. In a patient with cardiogenic shock, the monitoring, care, and interventions provided by an experienced critical care nurse can make the difference between survival and death.
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Affiliation(s)
- Lynn Coletta Simko
- Lynn Coletta Simko is a retired associate professor, North Versailles, Pennsylvania
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27
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Affas ZR, Touza GG, Affas S. A Meta-Analysis Comparing Venoarterial (VA) Extracorporeal Membrane Oxygenation (ECMO) to Impella for Acute Right Ventricle Failure. Cureus 2021; 13:e19622. [PMID: 34956754 PMCID: PMC8674946 DOI: 10.7759/cureus.19622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2021] [Indexed: 11/05/2022] Open
Abstract
The right ventricular complication happens when the right ventricle (RV) fails to move sufficient blood through the pulmonary circle to enable enough left ventricular pumping. A significant pulmonary embolism/right-sided myocardial infarction may cause this to develop suddenly in a previously healthy heart, but many of the patients treated in the critical care unit have gradual, compensated RV failure as a result of chronic heart and lung disease. RV failure management aims to decrease afterload and improve right-side filling pressures. Vasoactive medications have a lower effect on lowering vascular obstruction in the pulmonary circulation than in the systemic circle because the vascular tone is lower in the pulmonary circulation. Any factors that induce an elevation in pulmonary vascular tone must be addressed, and selective pulmonary vasodilators must be administered in a prescription that does not result in systemic hypotension or compromise oxygenation. The system-based systolic arterial pressure should be kept near the RV systolic pressure to ensure RV perfusion. When these efforts prove futile, judicious application of inotropic medications for better RV contractility may help ensure cardiac output. After obtaining the finest medical treatment, certain individuals may need the implantation of a mechanical circulatory support device. This meta-analysis is intended to compare the Impella and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) mechanical supports for patients with acute right ventricular failure. This comparison should demonstrate the best mechanical support between the two through thorough analysis. The analysis was begun by data collection from relevant sites; PUBMED and EMBASE were searched in collaboration with Google Scholar. Keywords were searched: Impella for acute right ventricle failure and VA ECMO for acute right ventricle failure. The results that were close to the search titles had their respective articles downloaded for further scrutiny. The search finally brought 1001 related articles that were exposed to further analysis to find more refined and closer articles within the needs of this meta-analysis. After extensive scrutiny, 23 articles were found to be the best for these analyses. The data showed that VA ECMO had better results than Impella for acute RV failure. However, the data were not statistically significant, as either the numbers of the studies were not enough or the null hypothesis was true and there was no true difference between them. More studies will be needed to confirm this.
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Affiliation(s)
- Ziad R Affas
- Internal Medicine, Henry Ford Macomb Hospital, Clinton Township, USA
| | - Ghaid G Touza
- Internal Medicine, Hawler Medical University, Erbil, IRQ
| | - Saif Affas
- Internal Medicine, Ascension Providence Hospital, Detroit, USA
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28
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Thakkar S, Patel HP, Kumar A, Tan BEX, Arora S, Patel S, Doshi R, Depta JP, Kalra A, Dani SS, Deshmukh A, Badheka A, Widmer RJ, Mamas MA, Rihal CS, Girotra S, Panaich SS. Outcomes of Impella compared with intra-aortic balloon pump in ST-elevation myocardial infarction complicated by cardiogenic shock. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 12:100067. [PMID: 38559603 PMCID: PMC10978134 DOI: 10.1016/j.ahjo.2021.100067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 04/04/2024]
Abstract
Background Despite limited randomized trial data demonstrating clinical efficacy, the utilization of Impella in ST-elevation myocardial infarction (STEMI) patients complicated with cardiogenic shock (CS) has increased over time. Methods We identified 75,769 hospitalizations with STEMI complicated by CS between October 2015 and December 2018 using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. From this cohort, hospitalizations were stratified according to IABP or Impella placement. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were divided into efficacy, safety, and device-related complications. Propensity-score matching was used to account for differences in the baseline characteristics between the groups. Logistic regression was performed to get the odds ratio and confidence intervals. Results Among 75,769 admissions with STEMI and CS, hospitalizations with <18 years old, both IABP and Impella placement, and who underwent ECMO and/or LVAD implantation were excluded. After the exclusion, out of 72,791 admissions, 25,260 (34.70%) hospitalizations received IABP, and 7825 (10.75%) received Impella support. After propensity score-matched analysis, 7345 hospitalizations were included in each group. All-cause in-hospital mortality was higher in the hospitalizations requiring Impella support as compared to IABP (42.10% vs. 31.54%, adjusted OR 1.71; 95% confidence interval (CI) 1.60-1.84, P < 0.0001). Impella was associated with a higher risk of in-hospital complications and hospitalization cost compared with IABP. Conclusion Impella compared with IABP in STEMI patients with CS was associated with higher in-hospital mortality and other adverse clinical and procedural outcomes.
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Affiliation(s)
| | - Harsh P. Patel
- Department of Internal Medicine, Louis A Weiss Memorial Hospital, Chicago, IL, USA
| | - Ashish Kumar
- Section of Cardiovascular Research, Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Bryan E-Xin Tan
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Shilpkumar Arora
- Department of Cardiology, Case Western University, Cleveland, OH, USA
| | - Smit Patel
- Department of Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY, USA
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, NV, USA
| | - Jeremiah P. Depta
- Sands Constellation Heart Institute, Rochester Regional Health, Rochester, NY, USA
| | - Ankur Kalra
- Section of Cardiovascular Research, Heart, Vascular and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sourbha S. Dani
- Department of Cardiology, Lahey Hospital & Medical Center, MA, USA
| | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Apurva Badheka
- Heart and Vascular Center, The Everett Clinic, Everett, WA, USA
| | - Robert J. Widmer
- Department of Cardiovascular Medicine, Baylor Scott & White Health, Temple, TX, USA
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Institute of Applied Clinical Science, Keele University, Stoke-on-Trent, UK
- Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | | | - Saket Girotra
- Department of Cardiology, University of Iowa Carver College of Medicine, IA, USA
| | - Sidakpal S. Panaich
- Department of Cardiology, University of Iowa Carver College of Medicine, IA, USA
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29
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Panoulas V, Monteagudo-Vela M. Predictors of Short-term Survival in Cardiogenic Shock Patients Requiring Left Ventricular Support Using the Impella CP or 5.0. CJC Open 2021; 3:1002-1009. [PMID: 34505039 PMCID: PMC8413249 DOI: 10.1016/j.cjco.2021.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background Percutaneous ventricular assist devices (pVADs) have been used to support patients who are in cardiogenic shock (CS). There is limited data on 30-day mortality predictors in patients supported by an Impella pVAD. Methods All CS patients requiring left-sided Impella implantation in Harefield Hospital (Greater London, United Kingdom) between 2017 and 2020 were included in the current study. Logistic regression analysis was used to identify predictors of 30-day mortality. Results A total of 92 patients were included. The mean age was 53.8 ± 14.9 years, and 78.3% were male. CS etiology was predominantly acute coronary syndromes (44.6%), followed by decompensated dilated cardiomyopathy (28.3%). Survival at 30 days was 63% (58 of 92). Deceased patients had a lower left ventricular ejection fraction (LVEF) (15.1 ± 9.6 vs 21.8 ± 14.2, P < 0.001), higher serum lactate levels (2.8[1.6 to 5.4] vs 1.45 [1.08 to 3.53], P = 0.012), a higher percentage of prolonged invasive ventilation (> 24 hours) (64.7% vs 13.8%, P < 0.001), and worse renal and liver function. Serum lactate, baseline LVEF, and prolonged ventilation (> 24 hours) were independent predictors of 30-day survival with an area under the curve of 0.85 (95% confidence interval 0.769 to 0.930), P < 0.001. Conclusions In the current retrospective registry of patients requiring Impella pVAD implantation, independent 30-day mortality predictors included serum lactate, baseline LVEF, and prolonged invasive ventilation (> 24 hours). These parameters could highlight patients who would benefit from earlier mechanical circulatory support escalation or neurologic assessment to inform withdrawal decisions.
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Affiliation(s)
- Vasileios Panoulas
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield Hospitals, part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Corresponding author: Dr Vasileios F. Panoulas, Harefield Hospital, Harefield, Middlesex, UB9 6JH, United Kingdom. Tel.: 44(0)1895 823737 x5200; fax: +44(0)1895 828892.
| | - María Monteagudo-Vela
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield Hospitals, part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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30
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The Effects of Percutaneous Left Ventricular Assist Device Placement on Native Valve Competency. ASAIO J 2021; 68:541-546. [PMID: 34419983 DOI: 10.1097/mat.0000000000001529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Impella left ventricular assist devices (LVADs) (Abiomed, Danvers, MA) are implanted in the left ventricle across the aortic valve. Several cases of secondary aortic insufficiency (AI) or mitral regurgitation (MR) after Impella LVAD use have been reported. Secondary valvulopathies can worsen cardiac function. This single center retrospective study sought to characterize the incidence of secondary AI and MR development after Impella LVAD support. One hundred fifty-two patients who underwent Impella LVAD support between April 2014 and August 2019 were included. Patient demographics, implant indications, duration of support, pre- and post-Impella LVAD echocardiograms, and incidence of increased AI/MR were analyzed. Impella 5.0 and Impella CP were subanalyzed. Following exclusion criteria, AI and MR were analyzed in 93 and 78 patients, respectively. An increase in AI and MR was seen in 17.2% and 12.8% of patients with an event per support days of 0.03 and 0.02, respectively. Clinically significant increases in AI and MR were seen in 3.2% (n = 3), 6.4% (n = 5), respectively. The incidences of increased AI (p = 0.33) and MR (p = 0.45) were similar between Impella 5.0 and Impella CP patients. Worsening AI and MR clinically occur at a low incidence with Impella LVAD use. However, careful follow-up is still warranted.
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Singh H, Mehta RH, O'Neill W, Kapur NK, Lalonde T, Ohman M, Ghiu I, Chen-Hsing Y, Dutcheshen K, Schreiber T, Rosman H, Kaki A. Clinical features and outcomes in patients with cardiogenic shock complicating acute myocardial infarction: early vs recent experience with impella. Am Heart J 2021; 238:66-74. [PMID: 33848505 DOI: 10.1016/j.ahj.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To compare clinical features and outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) treated in the early experience with Impella percutaneous ventricular assist device and patients treated recently. BACKGROUND Since pre-market approval (PMA) of Impella device as treatment for AMICS, use of the device has grown considerably. METHODS We retrospectively analyzed 649 AMICS patients treated with perioperative Impella, with 291 patients treated from 2008 to 2014 comprising the early experience cohort and 358 patients treated from 2017 to 2019 comprising the recent experience cohort. The primary end point was risk adjusted in-hospital mortality. RESULTS Mean age and gender distribution of patients was similar in the two cohorts. The recent cohort had more invasive hemodynamic monitoring (64% vs 46%; P < .001) and less use of an intra-aortic balloon pump prior to Impella (15% vs 41%; P < .001). Recently treated patients were significantly more likely to receive Impella support prior to PCI (58% vs 44%; P = .005). In-hospital mortality was lower in the recent cohort (48% vs 56%; P = .043). This difference was however no longer significant after risk adjustment (adjusted OR 0.89, 95% CI 0.59-1.34, P = .59). Rates of acute kidney injury, major bleeding, and vascular complications requiring surgery were also significantly lower in the recent cohort. CONCLUSIONS Use of Impella for AMICS during recent years is associated with lower unadjusted in-hospital mortality, which may reflect better patient selection, earlier device implantation, and improved management algorithms. In-depth understanding of these factors may inform the development of future treatment protocols.
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Morici N, Tavazzi G. Mechanical circulatory support in CS: device or patient? Open Heart 2021; 8:openhrt-2021-001733. [PMID: 34301817 PMCID: PMC8728356 DOI: 10.1136/openhrt-2021-001733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Nuccia Morici
- SS UTIC/ SC Cardiologia 1-Emodinamica, ASST Grande Ospedale Metropolitano Niguarda, Milano, Lombardia, Italy.,Fondazione IRCCS Policlinico S. Matteo, Department of Anesthesia and Intensive Care Unit, Pavia, Italy
| | - Guido Tavazzi
- Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
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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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35
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Ratcovich H, Josiassen J, Helgestad OKL, Linde L, Sadjadieh G, Engstrøm T, Jensen LO, Ravn HB, Schmidt H, Hassager C, Møller JE, Holmvang L. Incidence, Predictors, and Outcome of In-Hospital Bleeding in Patients With Cardiogenic Shock Complicating Acute Myocardial Infarction. Am J Cardiol 2021; 144:13-19. [PMID: 33383003 DOI: 10.1016/j.amjcard.2020.12.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 11/18/2022]
Abstract
Bleeding after acute myocardial infarction (AMI) is associated with an increased morbidity and mortality. The frequency and consequences of bleeding events in patients with AMICS are not well described. The objective was to investigate incidence and outcome of bleeding complications among unselected patients with AMI complicated by cardiogenic shock (AMICS) and referred for immediate revascularization. Bleeding events were assessed by review of medical records in consecutive AMICS patients admitted between 2010 and 2017. Bleedings during admission were classified according to Bleeding Academic Research Consortium classification. Patients who did not survive to admission in the intensive care unit were excluded. Of the 1,716 patients admitted with AMICS, 1,532 patients (89%) survived to ICU admission. At 30 days, mortality was 48%. Severe bleedings classified as BARC 3/5 were seen in 87 non-coronary bypass grafting patients (6.1%). Co-morbidity did not differ among patients; however, patients who had a BARC 3/5 bleeding had significantly higher lactate and lower systolic blood pressure at admission, indicating a more severe state of shock. The use of mechanical assist devices was significantly associated with severe bleeding events. Univariable analysis showed that patients with a BARC 3/5 bleeding had a significantly higher 30-day mortality hazard compared with patients without severe bleedings. The association did not sustain after multivariable adjustment (hazard ratio 0.90, 95% confidence interval 0.64; 1.26, p = 0.52). In conclusion, severe bleeding events according to BARC classification in an all-comer population of patients with AMICS were not associated with higher mortality when adjusting for immediate management, hemodynamic, and metabolic state. This indicates that mortality in these patients is primarily related to other factors.
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Affiliation(s)
- Hanna Ratcovich
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ole K L Helgestad
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Odense Patient data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Golnaz Sadjadieh
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lisette O Jensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Hanne B Ravn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Cardiothoracic Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Cardiothoracic Anaesthesia, Odense University Hospital, Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, Odense, Denmark; Odense Patient data Explorative Network, University of Southern Denmark, Odense, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Briani M, Torracca L, Crescenzi G, Barbone A. Impella 5.0 support before, during, and after surgical ventriculoplasty following acute myocardial infarction in the COVID-19 era: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab037. [PMID: 34104861 PMCID: PMC8108613 DOI: 10.1093/ehjcr/ytab037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/03/2020] [Accepted: 01/17/2021] [Indexed: 11/14/2022]
Abstract
Background Left ventricular (LV) aneurysms complicate anterior myocardial infarctions (MIs) in 8–15% of cases. In case of associated LV dysfunction, rapidly evolving heart failure may follow, and urgent surgery becomes life-saving. Case summary Following an acute anterior MI treated by percutaneous coronary intervention, which resulted in apical hypokinesis, depressed LV function, and moderate mitral regurgitation, a 70-year-old male patient kept in contact with our cardiology department through phone calls. Over 6 weeks, the patient's conditions worsened. For fear of contracting COVID-19, he refused to attend to the Emergency Room. Conditions did not improve despite medical therapy adjustments, and he was admitted to hospital following a syncope. Computed tomography scan revealed pneumonia, and he was placed in a ‘grey’ ward while waiting for nose-swab results for COVID-19. A rapid escalation of treatment was necessary as conditions did not improve with low-dose inotropes, and he required invasive ventilation. An Impella 5.0 was implanted as support prior to surgery, was maintained during the procedure and as a means of weaning off extracorporeal circulation. Surgery was successful and Impella 5.0 was removed on postoperative Day 5. Discussion To date, Impella use in cardiothoracic surgery has been described in case of ventricular septal rupture or as a bridge to permanent LV assist device. In our case, Impella 5.0 was implanted, used as a bridge to surgery, and as postoperative support in a patient with evolving cardiogenic shock due to LV aneurysm and depressed LV ejection fraction following acute MI, in the difficult setting of the COVID-19 pandemic.
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Affiliation(s)
- Martina Briani
- Department of Clinical and Interventional Cardiology, Humanitas Clinical and Research Centre, IRCCS, Via Alessandro Manzoni, 56, Rozzano, 20089 Milan, Italy
- Corresponding author. Tel: 0039 2 8224 7084,
| | - Lucia Torracca
- Department of Cardiothoracic Surgery, Humanitas Clinical and Research Centre, IRCCS, Via Alessandro Manzoni, 56, Rozzano, 20089 Milan, Italy
| | - Giuseppe Crescenzi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Hospital, IRCCS, Via Alessandro Manzoni, 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Barbone
- Department of Cardiothoracic Surgery, Humanitas Clinical and Research Centre, IRCCS, Via Alessandro Manzoni, 56, Rozzano, 20089 Milan, Italy
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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:jcm10040747. [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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38
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Wernly B, Karami M, Engström AE, Windecker S, Hunziker L, Lüscher TF, Henriques JP, Ferrari MW, Binnebößel S, Masyuk M, Niederseer D, Abel P, Fuernau G, Franz M, Kelm M, Busch MC, Felix SB, Thiele H, Lauten A, Jung C. Impella versus extracorporal life support in cardiogenic shock: a propensity score adjusted analysis. ESC Heart Fail 2021; 8:953-961. [PMID: 33560591 PMCID: PMC8006691 DOI: 10.1002/ehf2.13200] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 11/20/2020] [Accepted: 01/02/2021] [Indexed: 12/17/2022] Open
Abstract
Aims The mortality in cardiogenic shock (CS) is high. The role of specific mechanical circulatory support (MCS) systems is unclear. We aimed to compare patients receiving Impella versus ECLS (extracorporal life support) with regard to baseline characteristics, feasibility, and outcomes in CS. Methods and results This is a retrospective cohort study including CS patients over 18 years with a complete follow‐up of the primary endpoint and available baseline lactate level, receiving haemodynamic support either by Impella 2.5 or ECLS from two European registries. The decision for device implementation was made at the discretion of the treating physician. The primary endpoint of this study was all‐cause mortality at 30 days. A propensity score for the use of Impella was calculated, and multivariable logistic regression was used to obtain adjusted odds ratios (aOR). In total, 149 patients were included, receiving either Impella (n = 73) or ECLS (n = 76) for CS. The feasibility of device implantation was high (87%) and similar (aOR: 3.14; 95% CI: 0.18–56.50; P = 0.41) with both systems. The rates of vascular injuries (aOR: 0.95; 95% CI: 0.10–3.50; P = 0.56) and bleedings requiring transfusions (aOR: 0.44; 95% CI: 0.09–2.10; P = 0.29) were similar in ECLS patients and Impella patients. The use of Impella or ECLS was not associated with increased odds of mortality (aOR: 4.19; 95% CI: 0.53–33.25; P = 0.17), after correction for propensity score and baseline lactate level. Baseline lactate level was independently associated with increased odds of 30 day mortality (per mmol/L increase; OR: 1.29; 95% CI: 1.14–1.45; P < 0.001). Conclusions In CS patients, the adjusted mortality rates of both ECLS and Impella were high and similar. The baseline lactate level was a potent predictor of mortality and could play a role in patient selection for therapy in future studies. In patients with profound CS, the type of device is likely to be less important compared with other parameters including non‐cardiac and neurological factors.
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Affiliation(s)
- Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University, Salzburg, Austria.,Division of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Mina Karami
- Department of Cardiology, Heart Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Annemarie E Engström
- Department of Cardiology, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Lukas Hunziker
- Department of Cardiology, University of Bern, Bern, Switzerland
| | - Thomas F Lüscher
- Imperial College, Research, Education & Development, Royal Brompton and Harefield Hospitals London, London, UK
| | - Jose P Henriques
- Department of Cardiology, Heart Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Markus W Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Stephan Binnebößel
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Maryna Masyuk
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - David Niederseer
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Peter Abel
- Division of Cardiology, Pneumology and Critical Care Medicine, Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Georg Fuernau
- Department of Cardiology, Angiology, Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Luebeck, Germany
| | - Marcus Franz
- Department of Cardiology, Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Malte Kelm
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mathias C Busch
- Division of Cardiology, Pneumology and Critical Care Medicine, Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Stephan B Felix
- Division of Cardiology, Pneumology and Critical Care Medicine, Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Alexander Lauten
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Christian Jung
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
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Benedetto M, Nardozi L, Baca GL, Loforte A, Baiocchi M. Heart failure: role and point of view of cardiac intensivist. Cardiovasc Diagn Ther 2021; 11:301-308. [PMID: 33708501 DOI: 10.21037/cdt-20-339] [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: 11/06/2022]
Abstract
Heart failure is an acute or chronic syndrome where the heart is unable to provide adequate amount of oxygen to body tissues. The treatment of heart failure aims to give an immediate answer in terms of regression of volume overload and restoration of hemodynamic stability and then to ensure management of clinical exacerbation, reduction in hospital stay, and increasing of survival. The pharmacological treatment of heart failure includes drugs with different strength of evidence. When the patient is no more responsive to medical therapy a non-pharmacological approach may be required. The first step is cardiac resynchronization therapy and implantable cardiac defibrillator. Then hospitalization and inotropic support may be needed. When cardiac disease reaches the end stage, the severe decrease in multi organ perfusion requires a quick therapeutic response. This is a time dependent scenario, when mechanical circulatory support (MCS) plays a crucial role. MCS may be used as temporary hemodynamic support on situations where myocardial recovery is likely, such as after revascularization and in cases of fulminant acute myocarditis. Conversion to ventricular assist devices or transplantation should be considered if longer duration of MCS is required. Advances in the treatment of cardiogenic shock patients in terms of pharmacological therapies, short term and long term MCS could provide opportunities to improve survival, but they also increase the complexity of clinical care. For this reason a multidisciplinary shock team approach is paramount for early symptom detection, to guide initial haemodynamic therapy and for the right choice of MCS device at the right time.
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Affiliation(s)
- Maria Benedetto
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Sant' Orsola Malpighi University Hospital, Bologna, Italy
| | - Ludovica Nardozi
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Sant' Orsola Malpighi University Hospital, Bologna, Italy
| | | | - Antonio Loforte
- Cardiothoracic Department, Sant' Orsola Malpighi University Hospital, Bologna, Italy
| | - Massimo Baiocchi
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Sant' Orsola Malpighi University Hospital, Bologna, Italy
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40
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Moustafa A, Khan MS, Saad M, Siddiqui S, Eltahawy E. Impella support versus intra-aortic balloon pump in acute myocardial infarction complicated by cardiogenic shock: A meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 34:25-31. [PMID: 33549497 DOI: 10.1016/j.carrev.2021.01.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with high mortality rates. Data has shown that intra-aortic balloon pump (IABP) support does not provide a survival benefit over optimal medical therapy in AMICS. Despite lack of supportive evidence, IABP is still commonly used in these clinical situations. The Impella percutaneous ventricular assist device (PVAD) (Abiomed, Denver, MA) rapidly deploys superior mechanical circulatory support (MCS) in patients with AMICS. However, the safety and efficacy of Impella in AMICS is a matter of ongoing investigation, and its role in AMICS management is not yet fully established. METHODS The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to March 2020. Relevant randomized trials and observational studies comparing Impella versus IABP in AMICS were identified and a meta-analysis was performed using the random effect model. The efficacy endpoint of interest was short-term mortality (defined as in-hospital or 30-day mortality). The safety endpoints of interest were major bleeding, limb complications, stroke and hemolysis. RESULTS A total of 2 randomized trials and 5 observational studies with 3921 patients were included. No difference in short-term mortality between the two groups [RR 1.08, 95% CI 0.87-1.33, P = 0.49] was found. For safety endpoints, Impella was associated with significantly higher incidence of major bleeding [RR: 2.03, 95% CI 1.56-2.64, P < 0.0001], limb complications [RR: 3.67, 95% CI 1.56-8.65, P = 0.003] as well as hemolysis [RR: 9.46, 95% CI 1.75-51.22, P = 0.009] compared with IABP. No significant difference was observed for the incidence of stroke [RR: 1.07 95% CI 0.34-3.31 P = 0.91]. CONCLUSION Impella support in AMICS patients was associated with a significantly increased risk of bleeding, limb complications and hemolysis without an improved short-term survival advantage compared with IABP.
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Affiliation(s)
- Abdelmoniem Moustafa
- Department of Medicine, Division of Hospital Medicine, Miriam Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States of America.
| | - Mohammad Saud Khan
- Department of Medicine, Division of Hospital Medicine, Miriam Hospital and Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Marwan Saad
- Department of Medicine, Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Shaffin Siddiqui
- Medical School of Princeton University, NJ, United States of America
| | - Ehab Eltahawy
- Division of Cardiovascular Medicine, University of Toledo, Toledo, OH, United States of America
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Comparison of Mortality Risk Models in Patients with Postcardiac Arrest Cardiogenic Shock and Percutaneous Mechanical Circulatory Support. J Interv Cardiol 2021; 2021:8843935. [PMID: 33536855 PMCID: PMC7834787 DOI: 10.1155/2021/8843935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/20/2020] [Accepted: 12/30/2020] [Indexed: 11/17/2022] Open
Abstract
Background Although scoring systems are widely used to predict outcomes in postcardiac arrest cardiogenic shock (CS) after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI), data concerning the accuracy of these scores to predict mortality of patients treated with Impella in this setting are lacking. Thus, we aimed to evaluate as well as to compare the prognostic accuracy of acute physiology and chronic health II (APACHE II), simplified acute physiology score II (SAPS II), sepsis-related organ failure assessment (SOFA), the intra-aortic balloon pump (IABP), CardShock, the prediction of cardiogenic shock outcome for AMI patients salvaged by VA-ECMO (ENCOURAGE), and the survival after venoarterial extracorporeal membrane oxygenation (SAVE) score in patients with OHCA refractory CS due to an AMI treated with Impella 2.5 or CP. Methods Retrospective study of 65 consecutive Impella 2.5 and 32 CP patients treated in our cardiac arrest center from September 2015 until June 2020. Results Overall survival to discharge was 44.3%. The expected mortality according to scores was SOFA 70%, SAPS II 90%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 50%, and SAVE score 70% in the 2.5 group; SOFA 70%, SAPS II 85%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 75%, and SAVE score 70% in the CP group. The ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under the curve (AUC) of 0.79, followed by the CardShock, APACHE II, IABP, and SAPS score. These derived an AUC between 0.71 and 0.78. The SOFA and the SAVE scores failed to predict the outcome in this particular setting of refractory CS after OHCA due to an AMI. Conclusion The available intensive care and newly developed CS scores offered only a moderate prognostic accuracy for outcomes in OHCA patients with refractory CS due to an AMI treated with Impella. A new score is needed in order to guide the therapy in these patients.
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42
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Sef D, Kabir T, Lees NJ, Stock U. Valvular complications following the Impella device implantation. J Card Surg 2021; 36:1062-1066. [PMID: 33410194 DOI: 10.1111/jocs.15303] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/21/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite clear clinical benefits, there is limited evidence regarding possible complications of the novel mechanical support device Impella. Aortic and mitral valve regurgitation or injury are rare but potential complications following implantation of the Impella device. METHODS To evaluate valvular complications after the Impella device implantation, we have performed a comprehensive search of literature on multiple sites on this topic. RESULTS AND CONCLUSION Ten case reports and one observational retrospective study were identified, with a total number of 19 patients identified. This article aims to draw attention to potential periprocedural complications relating to the Impella, in particular iatrogenic aortic and mitral valve injuries. Moreover, we have summarized our recommendations emphasizing the need for careful management and meticulous follow-up of these patients to avoid such potentially devastating complications.
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Affiliation(s)
- Davorin Sef
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Tito Kabir
- Department of Cardiology, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Nicholas James Lees
- Department of Anaesthesia and Critical Care, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
| | - Ulrich Stock
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, London, UK
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Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther 2020; 5:287. [PMID: 33303763 PMCID: PMC7730152 DOI: 10.1038/s41392-020-00360-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - John M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta, Edmonton, Alberta, T6G 2E1, Canada.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Sanaiha Y, Ziaeian B, Antonios JW, Kavianpour B, Anousheh R, Benharash P. Intraaortic Balloon Pump vs Peripheral Ventricular Assist Device Use in the United States. Ann Thorac Surg 2020; 110:1997-2005. [PMID: 32454014 PMCID: PMC7687352 DOI: 10.1016/j.athoracsur.2020.03.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/26/2020] [Accepted: 03/31/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective of this study was to characterize practical use trends and outcomes for intraaortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) use in cardiogenic shock at a national level. METHODS An analysis of all adult patients admitted nonelectively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample. Trends of inpatient IABP and pVAD use were analyzed using survey-weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights were used to perform risk-adjusted analyses of pVAD mortality, a composite of adverse events (AE), and resource use, with IABP as reference. RESULTS Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051 received a device: IABP, 127,792 (16.5%); or pVAD, 15,259 (2.0%). IABP use decreased (23.8% to 12.7%; P for trend <.001), whereas pVAD implantation increased significantly during the study period (0.2% to 4.5%; P for trend <.001). Inverse probability of treatment weights demonstrated significantly higher odds of mortality with pVAD (odds ratio, 1.9; 95% confidence interval, 1.7 to 2.2), but not AE (odds ratio, 1.1; 95% confidence interval, 0.96 to 1.27), compared with IABP. After risk adjustment, pVAD use was associated with an additional $15,202 (P < .001) in cost for survivors and $29,643 for nonsurvivors (P < .001). CONCLUSIONS Over the study period, the rate of pVAD use for cardiogenic shock significantly increased. Compared with IABP, pVAD use was associated with increased mortality, higher costs, and several AEs. Multi-institutional clinical trials with rigorous inclusion criteria are warranted to evaluate the clinical utility of pVADs in the modern era.
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Affiliation(s)
- Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Division of Cardiology, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California
| | - James W Antonios
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Behdad Kavianpour
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Ramtin Anousheh
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California.
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Scolari FL, Schneider D, Fogazzi DV, Gus M, Rover MM, Bonatto MG, de Araújo GN, Zimerman A, Sganzerla D, Goldraich LA, Teixeira C, Friedman G, Polanczyk CA, Rohde LE, Rosa RG, Wainstein RV. Association between serum lactate levels and mortality in patients with cardiogenic shock receiving mechanical circulatory support: a multicenter retrospective cohort study. BMC Cardiovasc Disord 2020; 20:496. [PMID: 33234107 PMCID: PMC7687839 DOI: 10.1186/s12872-020-01785-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/12/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To evaluate the prognostic value of peak serum lactate and lactate clearance at several time points in cardiogenic shock treated with temporary mechanical circulatory support (MCS) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella CP®. METHODS Serum lactate and clearance were measured before MCS and at 1 h, 6 h, 12 h, and 24 h post-MCS in 43 patients at four tertiary-care centers in Southern Brazil. Prognostic value was assessed by univariable and multivariable analysis and receiver operating characteristic (ROC) curves for 30-day mortality. RESULTS VA-ECMO was the most common MCS modality (58%). Serum lactate levels at all time points and lactate clearance after 6 h were associated with mortality on unadjusted and adjusted analyses. Lactate levels were higher in non-survivors at 6 h, 12 h, and 24 h after MCS. Serum lactate > 1.55 mmol/L at 24 h was the best single prognostic marker of 30-day mortality [area under the ROC curve = 0.81 (0.67-0.94); positive predictive value = 86%). Failure to improve serum lactate after 24 h was associated with 100% mortality. CONCLUSIONS Serum lactate was an important prognostic biomarker in cardiogenic shock treated with temporary MCS. Serum lactate and lactate clearance at 24 h were the strongest independent predictors of short-term survival.
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Affiliation(s)
- Fernando Luís Scolari
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos 630, 10º andar, Porto Alegre, RS 90035-001 Brazil
- Division of Cardiology, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos 630, Porto Alegre, RS 90035-001 Brazil
| | - Daniel Schneider
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos 630, 10º andar, Porto Alegre, RS 90035-001 Brazil
| | - Débora Vacaro Fogazzi
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos 630, 10º andar, Porto Alegre, RS 90035-001 Brazil
| | - Miguel Gus
- Division of Cardiology, HMV, Rua Tiradentes, 333, Porto Alegre, RS 90560-030 Brazil
| | - Marciane Maria Rover
- Division of Cardiology, HMV, Rua Tiradentes, 333, Porto Alegre, RS 90560-030 Brazil
- Heart Failure and Transplant Division, Instituto de Cardiologia – Fundação Universitária de Cardiologia, Av. Princesa Isabel, 395, Porto Alegre, RS 90040-371 Brazil
| | - Marcely Gimenes Bonatto
- Cardiology Department, Transplant Division, Irmandade Hospital da Santa Casa de Misericórdia de Curitiba, Praça Rui Barbosa, 694, Curitiba, PR 80010-030 Brazil
| | - Gustavo Neves de Araújo
- Division of Cardiology, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos 630, Porto Alegre, RS 90035-001 Brazil
- Postgraduate Program in Health Sciences: Cardiology and Cardiovascular Sciences,, UFGRS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-007 Brazil
| | - André Zimerman
- Postgraduate Program in Health Sciences: Cardiology and Cardiovascular Sciences,, UFGRS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-007 Brazil
| | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos 630, 10º andar, Porto Alegre, RS 90035-001 Brazil
| | - Lívia Adams Goldraich
- Division of Cardiology, London Health Sciences Center and Western University, London, Canada
- Heart Transplant and Mechanical Circulatory Support Program, Division of Cardiology, HCPA, Rua Ramiro Barcelos, 2350, Porto Alegre, RS 90035-007 Brazil
| | - Cassiano Teixeira
- Division of Critical Care Medicine, HMV, R. Tiradentes, 333, Porto Alegre, 90560-030 Brazil
| | - Gilberto Friedman
- Division of Critical Care Medicine, HCPA, Rua Ramiro Barcelos 630, Porto Alegre, 90035-001 Brazil
- Universidade Federal do Rio Grande do Sul, R. Tiradentes, 333, Porto Alegre, 90560-030 Brazil
| | - Carisi Anne Polanczyk
- Division of Cardiology, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos 630, Porto Alegre, RS 90035-001 Brazil
- Division of Cardiology, HMV, Rua Tiradentes, 333, Porto Alegre, RS 90560-030 Brazil
- Universidade Federal do Rio Grande do Sul, R. Tiradentes, 333, Porto Alegre, 90560-030 Brazil
| | - Luis Eduardo Rohde
- Division of Cardiology, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos 630, Porto Alegre, RS 90035-001 Brazil
- Division of Cardiology, HMV, Rua Tiradentes, 333, Porto Alegre, RS 90560-030 Brazil
- Universidade Federal do Rio Grande do Sul, R. Tiradentes, 333, Porto Alegre, 90560-030 Brazil
| | - Regis Goulart Rosa
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos 630, 10º andar, Porto Alegre, RS 90035-001 Brazil
| | - Rodrigo Vugman Wainstein
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos 630, 10º andar, Porto Alegre, RS 90035-001 Brazil
- Division of Cardiology, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos 630, Porto Alegre, RS 90035-001 Brazil
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Contemporary National Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Patients with Prior Chronic Kidney Disease and End-Stage Renal Disease. J Clin Med 2020; 9:jcm9113702. [PMID: 33218121 PMCID: PMC7698908 DOI: 10.3390/jcm9113702] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background: There are limited data on acute myocardial infarction with cardiogenic shock (AMI-CS) stratified by chronic kidney disease (CKD) stages. Objective: To assess clinical outcomes in AMI-CS stratified by CKD stages. Methods: A retrospective cohort of AMI-CS during 2005–2016 from the National Inpatient Sample was categorized as no CKD, CKD stage-III (CKD-III), CKD stage-IV (CKD-IV) and end-stage renal disease (ESRD). CKD-I/II were excluded. Outcomes included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS). We also evaluated acute kidney injury (AKI) and acute hemodialysis in non-ESRD admissions. Results: Of 372,412 AMI-CS admissions, CKD-III, CKD-IV and ESRD comprised 20,380 (5.5%), 7367 (2.0%) and 18,109 (4.9%), respectively. Admissions with CKD were, on average, older, of the White race, bearing Medicare insurance, of a lower socioeconomic stratum, with higher comorbidities, and higher rates of acute organ failure. Compared to the cohort without CKD, CKD-III, CKD-IV and ESRD had lower use of coronary angiography (72.7%, 67.1%, 56.9%, 61.1%), PCI (53.7%, 43.8%, 38.4%, 37.6%) and MCS (47.9%, 38.3%, 33.3%, 34.2%), respectively (all p < 0.001). AKI and acute hemodialysis use increased with increase in CKD stage (no CKD–38.5%, 2.6%; CKD-III–79.1%, 6.5%; CKD-IV–84.3%, 12.3%; p < 0.001). ESRD (adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.21–1.31]; p < 0.001), but not CKD-III (OR 0.72 [95% CI 0.69–0.75); p < 0.001) or CKD-IV (OR 0.82 [95 CI 0.77–0.87] was predictive of in-hospital mortality. Conclusions: CKD/ESRD is associated with lower use of evidence-based therapies. ESRD was an independent predictor of higher in-hospital mortality in AMI-CS.
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Nersesian G, Tschöpe C, Spillmann F, Gromann T, Roehrich L, Mueller M, Mulzer J, Starck C, Falk V, Schoenrath F, Potapov E. Prediction of survival of patients in cardiogenic shock treated by surgically implanted Impella 5+ short-term left ventricular assist device. Interact Cardiovasc Thorac Surg 2020; 31:475-482. [DOI: 10.1093/icvts/ivaa150] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/28/2020] [Accepted: 07/01/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Short-term mechanical circulatory support is a life-saving treatment for acute cardiogenic shock (CS). This multicentre study investigates the preoperative predictors of 30-day mortality in CS patients treated with Impella 5.0 and 5.5 short-term left ventricular assist devices.
METHODS
Data of patients in CS (n = 70) treated with the Impella 5 (n = 63) and 5.5 (n = 7) in 2 centres in Berlin between October 2016 and October 2019 were collected retrospectively.
RESULTS
CS was caused by acute myocardial infarction (n = 16), decompensated chronic heart failure (n = 41), postcardiotomy syndrome (n = 5) and acute myocarditis (n = 8). Before implantation 12 (17%) patients underwent cardiopulmonary resuscitation and 32 (46%) patients were ventilated. INTERMACS level 1, 2 and 3 was established in 35 (50%), 29 (41%) and 6 (9%) of patients, respectively. The mean preoperative lactate level was 4.05 mmol/l. The median support time was 7 days (IR= 4–15). In 18 cases, the pump was removed for myocardial recovery, in 22 cases, durable left ventricular assist devices were implanted, and 30 patients died on support. The overall 30-day survival was 51%. Statistical analysis showed that an increase in lactate per mmol/l [odds ratio (OR) 1.217; P = 0.015] and cardiopulmonary resuscitation before implantation (OR 16.74; P = 0.009) are predictors of 30-day survival. Based on these data, an algorithm for optimal short-term mechanical circulatory support selection is proposed.
CONCLUSIONS
Impella treatment is feasible in severe CS. Severe organ dysfunction, as well as the level and duration of shock predict early mortality. An algorithm based on these parameters may help identify patients who would benefit from Impella 5+ support.
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Affiliation(s)
- Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Carsten Tschöpe
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapy (BCRT), Charité, University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Frank Spillmann
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tom Gromann
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Luise Roehrich
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- German Heart Foundation, Frankfurt am Main, Germany
| | - Marcus Mueller
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Johanna Mulzer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
- Institute of Health (BIH), Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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Kajy M, Laktineh A, Blank N, Tayal R, Tanveer S, Mohamad T, Elder M, Schreiber T, Kaki A. Deploying Mechanical Circulatory Support Via the Axillary Artery in Cardiogenic Shock and High-Risk Percutaneous Coronary Intervention. Am J Cardiol 2020; 128:127-133. [PMID: 32650906 DOI: 10.1016/j.amjcard.2020.04.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 11/18/2022]
Abstract
We sought to study the feasibility of axillary artery as alternative access for mechanical circulatory support (MCS) in cardiogenic shock and high-risk percutaneous coronary intervention (HR-PCI) patients with severe occlusive peripheral artery disease (PAD). In patients with severe PAD, the iliofemoral artery may be so diseased preventing deployment of MCS, precluding the use of lifesaving therapy. In such circumstances, the axillary artery may be a viable access site. Records of all patients presenting with cardiogenic shock or HR-PCI requiring MCS through axillary artery access at our institution from January 2016 to September 2018 were examined. Demographics, clinical, procedural, and outcomes data were collected on all patients. A total of 48 patients presented with cardiogenic shock (60%) or HR-PCI (40%) requiring MCS via axillary artery due to prohibitive PAD (mean age 66 ± 11 years). Admission diagnoses were non-ST segment elevation myocardial infarction (38%), unstable angina (23%), ST segment elevation myocardial infarction (19%), and cardiac arrest (21%). Time from axillary access to activation of Impella was 11.9 ± 4 minutes. Four patients required concomitant Impella RP for right ventricular support due to biventricular cardiogenic shock. Twenty-two patients died before Impella was explanted due to multiorgan failure, stroke, and infection. None of the patients who died had vascular complications related to axillary access. Axillary artery appears to be a viable alternative access for large bore devices in patients with prohibitive PAD. As experience of the field with this approach grows, it may be the default access for deployment of large bore sheaths in the future.
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Affiliation(s)
- Marvin Kajy
- Wayne State University School of Medicine, Detroit Medical Center, Detroit, Michigan.
| | - Amir Laktineh
- Wayne State University School of Medicine, Detroit Medical Center, Detroit, Michigan
| | - Nimrod Blank
- Wayne State University School of Medicine, Detroit Medical Center, Detroit, Michigan
| | - Raj Tayal
- RWJ-Barnabas Health Structural Heart Leadership Group, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Syed Tanveer
- Emory University School of Medicine, Emory University Hospital, Atlanta, Georgia
| | - Tamam Mohamad
- Wayne State University School of Medicine, Detroit Medical Center, Detroit, Michigan
| | - Mahir Elder
- Heart & Vascular Institute, Dearborn, Michigan
| | | | - Amir Kaki
- Ascension St. John Hospital, Detroit, Michigan
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Kapur NK, Whitehead EH, Thayer KL, Pahuja M. The science of safety: complications associated with the use of mechanical circulatory support in cardiogenic shock and best practices to maximize safety. F1000Res 2020; 9. [PMID: 32765837 PMCID: PMC7391013 DOI: 10.12688/f1000research.25518.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 12/16/2022] Open
Abstract
Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use. Multiple devices exist across a spectrum from modest to complete support, and each is associated with unique risks. In this review, we summarize existing data on complications associated with the three most widely used acute MCS platforms: the intra-aortic balloon pump (IABP), Impella systems, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We review evidence from available randomized trials and highlight challenges comparing complication rates from case series and comparative observational studies where a lack of granular data precludes appropriate matching of patients by CS severity. We further offer a series of best practices to help shock practitioners minimize the risk of MCS-associated complications and ensure the best possible outcomes for patients.
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Affiliation(s)
- Navin K Kapur
- The Cardiovascular Center for Research and Innovation, Tufts Medical Center, Boston, MA, USA
| | - Evan H Whitehead
- The Cardiovascular Center for Research and Innovation, Tufts Medical Center, Boston, MA, USA
| | - Katherine L Thayer
- The Cardiovascular Center for Research and Innovation, Tufts Medical Center, Boston, MA, USA
| | - Mohit Pahuja
- Division of Cardiology, Detroit Medical Center/Wayne State University School of Medicine, Detroit, MI, USA
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Prognostic Impact of Active Mechanical Circulatory Support in Cardiogenic Shock Complicating Acute Myocardial Infarction, Results from the Culprit-Shock Trial. J Clin Med 2020; 9:jcm9061976. [PMID: 32599815 PMCID: PMC7356113 DOI: 10.3390/jcm9061976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/11/2020] [Accepted: 06/18/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). BACKGROUND Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. METHODS This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. RESULTS Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®; n = 95 extracorporeal membrane oxygenation (ECMO); n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p < 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p < 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7-5.9; p < 0.001). CONCLUSIONS In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.
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