ECLS-SHOCK and DanGer Shock: Implications for Optimal Temporary Mechanical Circulatory Support Use for Cardiogenic Shock Due to Acute Myocardial Infarction

Despite concerted efforts to rapidly identify patients with cardiogenic shock complicating acute myocardial infarction (AMI-CS) and provide timely revascularization, early mortality remains stubbornly high. Although artificially augmenting systemic flow by using temporary mechanical circulatory support (tMCS) devices would be expected to reduce the rate of progression to multiorgan dysfunction and thereby enhance survival, reliable evidence for benefit has remained elusive with lingering questions regarding the appropriate selection of both patients and devices, as well as the timing of device implantation relative to other critical interventions. Further complicating matters are the resource-intensive multidisciplinary systems of care that must be brought to bear in this complex patient population. Until recently, studies of tMCS were extremely heterogeneous in design, populations treated, and timing of device implantation with regard to shock onset and revascularization. Attempts at summarizing the available data had resulted in a lack of clear benefit for any type of tMCS modality. On this background, 2 landmark trials of tMCS in the setting of AMI-CS---ECLS-SHOCK and DanGer Shock---have recently been published with divergent results that deserve detailed consideration. Thus, we provide a detailed narrative review of the current state of knowledge regarding tMCS for AMI-CS. The most common types of tMCS and related evidence are presented, as well as evidence for organizational considerations, such as the shock team. We also provide some insight into how this new evidence may be incorporated into practice and influence future research.

Cardiogenic shock mortality according to Aetiology in a Mediterranean cohort: Results from the Shock-CAT study

AIMS

Mortality in cardiogenic shock (CS) remains elevated, with the potential for CS causes to impact prognosis and risk stratification. The aim was to investigate in-hospital prognosis and mortality in CS patients according to aetiology. We also assessed the prognostic accuracy of CardShock and IABP-SHOCK II scores.

METHODS

Shock-CAT study was a multicentre, prospective, observational study conducted from December 2018 to November 2019 in eight university hospitals in Catalonia, including non-selected consecutive CS patients. Data on clinical presentation, management, including mechanical circulatory support (MCS) were analysed comparing acute myocardial infarction (AMI) related CS and non-AMI-CS. The accuracy of CardShock and IABP-SHOCK II scores to assess 90 day mortality risk were also compared.

RESULTS

A total of 382 CS patients were included, age 65.3 (SD 13.9) years, 75.1% men. Patients were classified as AMI-CS (n = 232, 60.7%) and non-AMI-CS (n = 150, 39.3%). In the AMI-CS group, 77.6% were STEMI. Main aetiologies for non-AMI-CS were heart failure (36.2%), arrhythmias (22.1%) and valve disease (8.0%). AMI-CS patients required more MCS than non-AMI-CS (43.1% vs. 16.7%, P < 0.001). In-hospital mortality was higher in AMI-CS (37.1 vs. 26.7%, P = 0.035), with a two-fold increased risk after multivariate adjustment (odds ratio 2.24, P = 0.019). The IABP-SHOCK II had superior discrimination for predicting 90 day mortality when compared with CardShock in AMI-CS patients [area under the curve (AUC) 0.74 vs. 0.66, P = 0.047] although both scores performed similarly in non-AMI-CS (AUC 0.64 vs. 0.62, P = 0.693).

CONCLUSIONS

In our cohort, AMI-CS mortality was increased by two-fold when compared with non-AMI-CS. IABP-SHOCK II score provides better 90 day mortality risk prediction than CardShock score in AMI-CS, but both scores performed similar in non-AMI-CS patients.

Expert Opinion: ECLS-SHOCK Trial

ECLS-SHOCK is the largest randomized control trial on Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in Acute Myocardial Infarction-related Cardiogenic Shock (AMI-CS). Unfortunately, ECLS-SHOCK failed to demonstrate a reduction of mortality in AMI-CS with VA-ECMO. Interpretation of these findings must account for frequent crossover to VA-ECMO or other temporary mechanical circulatory support (tMCS) devices in the control group, as well as the exceptionally high severity of illness among participants. We detail here point by point what could explain the outcomes and the unanswered questions. In the light of these results, a liberal use of VA-ECMO might be avoided. Further trials are needed to refine patient selection criteria and determine the optimal timing ("sweet-spot") for VA-ECMO implementation. Current practice and future guidelines will have to take in count ECLS-SHOCK results.

A Systematic Review and Meta-Analysis of the Efficacy and Safety of Combined Mechanical Circulatory Support in Acute Myocardial Infarction Related Cardiogenic Shock

BACKGROUND

Acute myocardial infarction-related cardiogenic shock (AMICS) is a severe complication associated with exceedingly high mortality rates. While mechanical circulatory support (MCS) has emerged as a potential intervention, the evidence base for independent MCS use remains weak. In contrast, systematic reviews of observational studies have revealed significant mortality reduction when a combination of MCS was used: VA-ECMO in conjunction with a left ventricular (LV) unloading device (Impella or IABP). The ongoing dilemma concerning the selection between two LV unloading devices (VA-ECMO + Impella vs. VA-ECMO + IABP) warrants further investigation and clarification.

AIM

This is the first systematic review and meta-analysis assessing the short-term efficacy and safety of VA-ECMO + Impella versus VA-ECMO + IABP in treatment of AMICS.

METHODS

A systematic search was performed on the EMBASE, MEDLINE, and Cochrane databases. Studies reporting the short-term (30-day/inpatient) mortality and complications of adult patients with AMICS treated with VA-ECMO + Impella and VA-ECMO + IABP were included. Subgroup analysis was performed including studies with ACS predominant CS (CS etiology 100% by AMI).

RESULTS

Four observational studies with 14,247 patients were included. There was no significant difference in mortality between VA-ECMO + Impella and VA-ECMO + IABP (56.5% vs. 66.5%; OR, 0.90; 95% CI, 0.79-1.02; p = 0.09). However, VA-ECMO + Impella was associated with significantly lower mortality in patients with ACS predominant CS (53.2% vs. 67.7%; OR, 0.72; 95% CI, 0.62-0.85; p < 0.0001). VA-ECMO + Impella was concomitantly associated with a significantly higher risk of complications.

CONCLUSIONS

When comparing LV unloading devices in patients with AMICS requiring a combination of MCS, VA-ECMO + Impella was superior in mortality reduction only in the cohort where 100% of CS was caused by AMI.

Biventricular dysfunction predicts mortality in ST elevation myocardial infarction patients with cardiogenic shock

BACKGROUND

The incidence of mortality in patients with cardiogenic shock due to ST elevation myocardial infarction (STEMI) remains high even with prompt reperfusion therapy. Ventricular systolic dysfunction is the primary condition causing cardiogenic shock in STEMI. Studies have been widely conducted on the left ventricle (LV) and right ventricle (RV) systolic dysfunction related to mortality events. However, the parameters of biventricular systolic dysfunction predicting mortality as a stronger predictor of mortality are still unclear. Accordingly, we evaluated the predictor mortality value of biventricular systolic dysfunction in STEMI patients with cardiogenic shocks. Based on The Society for Cardiovascular Angiography and Intervention classification, we analyzed data from November 2021 to September 2023 at Dr. Sardjito General Hospital in Yogyakarta, Indonesia, using the Sardjito Cardiovascular Intensive Care (SCIENCE) registry with a retrospective cohort design. Multivariate logistic regression analysis was used to assess predictors of in-hospital mortality.

RESULTS

There were 1,059 subjects with a mean ± SD age of 59 ± 11 years, dominated by men (80.5%) who met the inclusion and exclusion criteria. Based on multivariate analysis, biventricular dysfunction (BVD) is a factor that significantly increases the risk of in-hospital mortality (Odds ratio [OR], 1.771: 95% confidence interval [CI] 1.113-2.819; p = 0.016). Other significant factors affecting mortality were renal failure (OR, 5.122; 95% CI 3.233-8.116; p < 0.001), percutaneous coronary intervention (PCI) (OR, 0.493; 95% CI 0.248-0.981; p = 0.044), and inotropic/vasopressor (OR, 6.876; 95% CI 4.583-10.315; p < 0.001).

CONCLUSIONS

Biventricular dysfunction significantly increases the risk of in-hospital mortality in STEMI patients with cardiogenic shock. Renal failure, PCI, and the requirement for inotropic or vasopressor drugs are also factors that influence in-hospital mortality.

Influence of Right and Left Bundle Branch Block in Patients With Cardiogenic Shock and Cardiac Arrest

OBJECTIVES

The study investigates the prognostic impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) in patients with cardiogenic shock (CS) compared with no bundle branch block (BBB). In patients with heart failure, existence of RBBB and LBBB has influence on prognosis.

DESIGN

Prospective registry-study.

SETTING

ICU of a tertiary academic hospital in Germany.

PATIENTS

Adult patients with CS.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Consecutive patients with CS were included. The prognostic impact of RBBB and LBBB on 30-day all-cause mortality was tested within the entire cohort and in the subgroup of CS patients with cardiac arrest at admission. The final study cohort comprised 248 patients. Patients with RBBB showed the highest 30-day all-cause mortality followed by LBBB and no BBB (72.5% vs. 52.9% vs. 50.0%; log-rank p = 0.015). These findings were consistent even after solely including CS patients with cardiac arrest (90.0% vs. 73.3% vs. 62.2%; log-rank p = 0.008). After adjustment for lactate, norepinephrine, troponin I, Acute Physiology Score, Society of Cardiovascular Angiography & Interventions shock stage, and heart rate in a multivariable Cox regression analysis, RBBB still revealed a negative impact on 30-day all-cause mortality (hazard ratio [HR], 1.807; 95% CI, 1.107-2.947; p = 0.018), whereas LBBB was not associated with 30-day all-cause mortality. In this multivariable Cox regression model lactate (HR, 1.065; 95% CI, 1.018-1.115; p = 0.006), troponin I (HR, 1.003; 95% CI, 1.001-1.005; p = 0.001), and Acute Physiology Score (HR, 1.033; 95% CI, 1.001-1.066; p = 0.041) were as well associated with 30-day all-cause mortality. Finally, no association of RBBB was found with the incidence of liver or severe renal failure.

CONCLUSIONS

Besides the Acute Physiology Score, lactate, and troponin levels, RBBB was associated with an increased 30-day all-cause mortality in consecutive CS patients with and without cardiac arrest, whereas LBBB showed no prognostic impact.

Clinical outcomes among patients with mitral valve regurgitation undergoing Impella-supported high-risk PCI

BACKGROUND

Mitral valve regurgitation (MR) is associated with worse outcomes in patients undergoing percutaneous coronary intervention (PCI). We sought to evaluate outcomes of Impella-supported high-risk PCI (HRPCI) patients according to MR severity.

METHODS

Patients from the PROTECT III study undergoing Impella-supported HRPCI were stratified into 4 groups according to MR severity: No or trace MR, mild MR, moderate MR, and severe MR. Immediate PCI-related complications, major adverse cardiovascular and cerebrovascular events (MACCE: all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 90 days and death at 1-year were assessed.

RESULTS

From March 2017 to March 2020, 631 patients who underwent Impella-supported HRPCI in the PROTECT III study had evaluable MR severity at baseline. Patients with severe MR had lower body mass indices, lower left ventricular ejection fractions (LVEFs), and were more frequently diagnosed with heart failure. The incidence of immediate PCI-related complications was similar between groups. Unadjusted 90-day MACCE and 1-year mortality rates were numerically higher in patients with severe MR compared to the other study groups yet without reaching statistical significance. In multivariable analyses, there was no significant association between the presence of severe MR for 90-day MACCE or 1-year mortality compared with other degrees of MR (adj. HR = 1.71, 95% CI [0.73, 3.98], p = 0.21; adj. HR = 1.79, 95% CI [0.86, 3.74], p = 0.12, respectively).

CONCLUSIONS

Impella-supported HRPCI patients with moderate or severe MR exhibited a higher prevalence of heart failure, lower LVEF, and longer hospital stays. Patients with severe MR showed numerically higher unadjusted rates of 90-day MACCE and 1-year mortality compared to other groups, however these differences did not reach statistical significance even after adjustment for potential confounders.

CLINICAL TRIAL INFORMATION

Trial Name: The Global cVAD Study (cVAD) ClinicalTrial.govIdentifier:NCT04136392 URL: https://clinicaltrials.gov/ct2/show/NCT04136392?term=cvad&draw=2&rank=2.

Sex-specific outcomes in acute myocardial infarction-associated cardiogenic shock treated with and without V-A ECMO: a retrospective German nationwide analysis from 2014 to 2018

Acute myocardial infarction-associated cardiogenic shock (AMICS) remains a condition with high mortality. Some patients require mechanical circulatory support (MCS) as their condition deteriorates. Sex-specific differences in risk factors and outcomes of cardiovascular disease have previously been described but are inconclusive regarding the use of MCS in AMICS. We aimed to investigate these with a focus on long-term outcomes. Health claim data from AOK - Die Gesundheitskasse (local health care funds) for patients hospitalized with AMICS between January 1, 2014, and December 31, 2015, was descriptively analyzed. Then, a Cox proportional hazards model was used to adjust for confounders. We analyzed 10,023 patients, of which 477 (4.8%) were treated with veno-arterial extra-corporeal membrane oxygenation (V-A ECMO). In-hospital mortality was high, but similar between treatments (V-A ECMO 59.1%, no V-A ECMO 56.6%). Women had a higher median age (78.9 years, IQR 13.8 vs. 71.8 years, IQR 17.9; p < 0.001), a different cardiovascular risk profile and in the conservatively treated patients underwent revascularization less often (69.2% vs. 77.1%; p < 0.001) than men did. In a multivariate analysis, female sex was not associated with lower survival (HR 1.03, CI 0.98-1.09; p = 0.233). V-A ECMO, however, was associated with lower survival in both sexes. We observed a low overall survival in follow-up after three years (no V-A ECMO: men 28.9% vs. women 21.7%, V-A ECMO: men 18.2% vs. women 17.0%). In conclusion, women with AMICS presented with a different risk profile, especially a higher age, and underwent guideline-recommended therapies such as revascularization less often than men. Female sex, however, was not associated with lower survival in a multivariate analysis. In-hospital mortality was high, regardless of treatment, and V-A ECMO was associated with lower survival in follow-up.

The microcirculation in cardiogenic shock

Cardiogenic shock is a life-threatening condition characterized by inadequate cardiac output, leading to end-organ hypoperfusion and associated mortality rates ranging between 40 and 50%. The critical role of microcirculatory impairments in the progression of organ failure during shock has been highlighted in several studies. Traditional therapies have often focused on stabilizing macrocirculation, neglecting microcirculatory dysfunction, which can result in persistent tissue hypoxia and poor outcomes. This review highlights the importance of assessing microcirculation in cardiogenic shock, including parameters such as skin perfusion, sublingual microcirculation, and lactate dynamics. Integrating microcirculatory assessments into clinical practice remains challenging due to the complexity of the methods and limited therapeutic options targeting microvascular perfusion. While advances in microcirculation-guided therapies hold promise for improving outcomes in cardiogenic shock, further research is needed to establish effective protocols.

Mechanical circulatory support in cardiogenic shock patients

Cardiogenic shock (CS) is a highly complex clinical condition that requires a management strategy focused on early resolution of the underlying cause and the provision of circulatory support. In cases of refractory CS, mechanical circulatory support (MCS) is employed to replace the failed cardiocirculatory system, thereby preventing the development of multiorgan failure. There are various types of MCS, and patients with CS typically require devices that are either short-term (< 15 days) or intermediate-term (15-30 days). When choosing the device the underlying cause of CS, as well as the presence or absence of concomitant conditions such as failed ventricle, respiratory failure, and the intended purpose of the support should be taken into consideration. Patients with MCS require the comprehensive care indicated in complex critically ill patients with multiorgan dysfunction, with an emphasis on device monitoring and control. Different complications may arise during support management, and its withdrawal must be protocolized.

Cardiogenic Shock: Focus on Non-Cardiac Biomarkers

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Management of cardiogenic shock: state-of-the-art

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

Impact of awake extracorporeal membrane oxygenation on patients mortality with cardiogenic shock: a systematic review and trial sequential meta-analysis based on observational studies

OBJECTIVES

The use of awake extracorporeal membrane oxygenation (ECMO, without intubation or sedation under ECMO support in patients with cardiogenic shock is growing rapidly because emerging clinical investigations indicates it may reduce morbidity associated with sedation and intubation. We systematically reviewed the efficacy of awake ECMO and provided evidence for clinical practitioners and researchers.

DESIGN

Systematic review and trial sequential meta-analysis based on observational studies.

DATA SOURCES

Data was retrieved from seven databases (PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database and Cochrane Library) up to 1 March 2024.

ELIGIBILITY CRITERIA

We included observational studies that compared the differences in clinical outcomes between awake ECMO and non-awake ECMO in patients with cardiogenic shock.

DATA EXTRACTION AND SYNTHESIS

Two reviewers rigorously conducted literature retrieval, screening and data extraction. The RevMan software was used for data synthesis.

RESULTS

Five retrospective observational studies involving 1044 patients with cardiogenic shock were included. Compared with non-awake ECMO, awake ECMO was associated with a lower mortality rate of patients with cardiogenic shock (OR=0.28; 95% CI, (0.15, 0.49); p<0.0001; I2=50%). Trial sequential analysis indicated that the sample mortality outcome reached the required information size. No significant differences were observed between the two groups on secondary outcomes such as the occurrence of ventilator-associated pneumonia, weaning from ECMO, tracheostomy, haemorrhage, thrombosis, limb ischaemia and nosocomial infection.

CONCLUSIONS

Implementing awake ECMO may result in better clinical outcomes in patients with cardiogenic shock. Because of the limited sample sizes and potential bias of the current studies, more rigorously designed large-scale trials are urgently needed to verify the above findings.

PROSPERO REGISTRATION NUMBER

CRD42023407607.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 2: Complications, postrevascularization care, and quality improvement

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the later phases of inpatient care are reviewed.

SUMMARY

Published descriptions and validation of clinical pharmacist roles specific to the acute management of STEMI are limited. This high-risk period from presentation through revascularization, stabilization, and hospital discharge involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. A companion article reviewed STEMI pharmacotherapy from emergency department presentation through revascularization. Herein we complete the pharmacotherapy review for the STEMI patient across the inpatient phases of care, including the management of peri-infarction complications with vasoactive and antiarrhythmic agents, considerations for postrevascularization antithrombotics, and assessments of supportive therapies and secondary prevention. Key guideline recommendations and literature developments are summarized from the clinical pharmacist's perspective alongside suggested pharmacist roles and responsibilities. Considerations for successful hospital discharge after STEMI and pharmacist involvement in associated institutional quality improvement efforts are also provided. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population and call for further research delineating pharmacists' impact on patient and institutional STEMI outcomes.

Ventilation strategies in cardiogenic shock: insights from the FRENSHOCK observational registry

BACKGROUND

Despite scarce data, invasive mechanical ventilation (MV) is widely suggested as first-line ventilatory support in cardiogenic shock (CS) patients. We assessed the real-life use of different ventilation strategies in CS and their influence on short and mid-term prognosis.

METHODS

FRENSHOCK was a prospective registry including 772 CS patients from 49 centers in France. Patients were categorized into three groups according to the ventilatory supports during hospitalization: no mechanical ventilation group (NV), non-invasive ventilation alone group (NIV), and invasive mechanical ventilation group (MV). We compared clinical characteristics, management, and occurrence of death and major adverse event (MAE) (death, heart transplantation or ventricular assist device) at 30 days and 1 year between the three groups.

RESULTS

Seven hundred sixty-eight patients were included in this analysis. Mean age was 66 years and 71% were men. Among them, 359 did not receive any ventilatory support (46.7%), 118 only NIV (15.4%), and 291 MV (37.9%). MV patients presented more severe CS with more skin mottling, higher lactate levels, and higher use of vasoactive drugs and mechanical circulatory support. MV was associated with higher mortality and MAE at 30 days (HR 1.41 [1.05-1.90] and 1.52 [1.16-1.99] vs NV). No difference in mortality (HR 0.79 [0.49-1.26]) or MAE (HR 0.83 [0.54-1.27]) was found between NIV patients and NV patients. Similar results were found at 1-year follow-up.

CONCLUSIONS

Our study suggests that using NIV is safe in selected patients with less profound CS and no other MV indication. NCT02703038.

Hemodynamic monitoring and echocardiographic evaluation in cardiogenic shock

Cardiogenic shock (CS) is characterized by the presence of a state of tissue hypoperfusion secondary to ventricular dysfunction. Hemodynamic monitoring allows us to obtain information about cardiovascular pathophysiology that will help us make the diagnosis and guide therapy in CS situations. The most used monitoring system in CS is the pulmonary artery catheter since it provides key hemodynamic variables in CS, such as cardiac output, pulmonary artery pressure, and pulmonary artery occlusion pressure. On the other hand, echocardiography makes it possible to obtain, at the bedside, anatomical and hemodynamic data that complement the information obtained through continuous monitoring devices. CS monitoring can be considered multimodal and integrative by including hemodynamic, metabolic, and echocardiographic parameters that allow describing the characteristics of CS and guiding therapeutic interventions during hemodynamic resuscitation.

Propensity score-based comparison of high-risk coronary artery bypass grafting vs. left ventricular assist device implantation in patients with coronary artery disease and advanced heart failure

Objectives

Revascularization in patients with severely reduced left ventricular function and coronary artery disease (CAD) is associated with a high perioperative risk. In this setting, implantation of a durable left ventricular assist device (LVAD) might be an alternative.

Methods

We retrospectively compared the outcomes of adult patients with CAD and a left ventricular ejection fraction (LVEF) ≤ 25% who underwent coronary artery bypass grafting (CABG) vs. LVAD implantation. Propensity score (PS) matching was performed for statistical analysis, resulting in 168 pairs.

Results

In the PS-matched cohorts, the mean age was 62 years; one third had a history of myocardial infarction, 11% were resuscitated, half of the patients were on inotropic support, and 20% received preoperative mechanical circulatory support. LVAD patients required significantly longer ventilation (58 h [21, 256] vs. 16 h [9, 73], p < 0.001) and had a longer ICU stay (11d [7, 24] vs. 4d [2, 10], p ≤ 0.001) compared to CABG patients The incidence of postoperative renal replacement therapy (2 [1.2%] vs.15 [8.9%], p = 0.002) and temporary mechanical circulatory support was lower in the LVAD group (1 [0.6%] vs. 51 [30.4%], p ≤ 0.001). The in-hospital stroke rate was similar (LVAD 7 [5.4%] vs. CABG 8 [6.2%], p = 0.9). In-hospital survival, 1-year survival, and 3-year survival were 90.5% vs. 85.5% (p = 0.18), 77.4% vs. 68.9% (p = 0.10) and 69.6% vs. 45.9% (p < 0.001), for CABG and LVAD patients respectively.

Conclusion

Patients with CAD and advanced HF demonstrate better mid-term survival if they undergo CABG rather than LVAD implantation.

Blood Urea Nitrogen to Left Ventricular Ejection Ratio as a Predictor of Short-Term Outcome in Acute Myocardial Infarction Complicated by Cardiogenic Shock

INTRODUCTION

Cardiogenic shock (CS) is the most critical complication after acute myocardial infarction (AMI) with mortality above 50%. Both blood urea nitrogen and left ventricular ejection fraction were important prognostic indicators. We aimed to evaluate the prognostic value of admission blood urea nitrogen to left ventricular ejection fraction ratio (BUNLVEFr) in patients with AMI complicated by CS (AMI-CS).

METHODS

268 consecutive patients with AMI-CS were divided into two groups according to the admission BUNLVEFr cut-off value determined by Youden index. The primary endpoint was 30-day all-cause mortality and the secondary endpoint was the composite events of major adverse cardiovascular events (MACEs). Cox proportional hazard models were performed to analyze the association of BUNLVEFr with the outcome.

RESULTS

The optimal cut-off value of BUNLVEFr is 16.63. The 30-day all-cause mortality and MACEs in patients with BUNLVEFr≥16.63 was significantly higher than in patients with BUNLVEFr<16.63 (30-day all-cause mortality: 66.2% vs. 17.1%, p < 0.001; 30-day MACEs: 80.0% vs. 48.0%, p < 0.001). After multivariable adjustment, BUNLVEFr≥16.63 remained an independent predictor for higher risk of 30-day all-cause mortality (HR = 3.553, 95% CI: 2.125-5.941, p < 0.001) and MACEs (HR = 2.026, 95% CI: 1.456-2.820, p < 0.001). Subgroup analyses found that the effect of BUNLVEFr was consistent in different subgroups (all p-interaction>0.05).

CONCLUSION

The admission BUNLVEFr provided important prognostic information for AMI-CS patients.

Management of Myocardial Infarction and the Role of Cardiothoracic Surgery

Myocardial infarction (MI) is a leading cause of mortality globally and is predominantly attributed to coronary artery disease (CAD). MI is categorized as ST-elevation MI (STEMI) or non-ST-elevation MI (NSTEMI), each with distinct etiologies and treatment pathways. The goal in treatment for both is restoring blood flow back to the myocardium. STEMI, characterized by complete occlusion of a coronary artery, is managed urgently with reperfusion therapy, typically percutaneous coronary intervention (PCI). In contrast, NSTEMI involves a partial occlusion of a coronary artery and is treated with medical management, PCI, or coronary artery bypass grafting (CABG) depending on risk scores and clinical judgment. The Heart Team approach can assist in deciding which reperfusion technique would provide the greatest benefit to the patient and is especially useful in complicated cases. Despite advances in treatment, complications such as cardiogenic shock (CS) and ischemic heart failure (HF) remain significant. While percutaneous coronary intervention (PCI) is considered the primary treatment for MI, it is important to recognize the significance of cardiac surgery in treatment, especially when there is complex disease or MI-related complications. This comprehensive review analyzes the role of cardiac surgery in MI management, recognizing when it is useful, or not.

What is cardiogenic shock? New clinical criteria urgently needed

PURPOSE OF REVIEW

Cardiogenic shock is a clinical syndrome with different causes and a complex pathophysiology. Recent evidence from clinical trials evokes the urgent need for redefining clinical diagnostic criteria to be compliant with the definition of cardiogenic shock and current diagnostic methods.

RECENT FINDINGS

Conflicting results from randomized clinical trials investigating mechanical circulatory support in patients with cardiogenic shock have elicited several extremely important questions. At minimum, it is questionable whether survivors of cardiac arrest should be included in trials focused on cardiogenic shock. Moreover, considering the wide availability of ultrasound and hemodynamic monitors capable of arterial pressure analysis, the current clinical diagnostic criteria based on the presence of hypotension and hypoperfusion have become insufficient. As such, new clinical criteria for the diagnosis of cardiogenic shock should include evidence of low cardiac output and appropriate ventricular filling pressure.

SUMMARY

Clinical diagnostic criteria for cardiogenic shock should be revised to better define cardiac pump failure as a primary cause of hemodynamic compromise.

ICU management of cardiogenic shock before mechanical support

PURPOSE OF REVIEW

Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS).

RECENT FINDINGS

Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock.

SUMMARY

Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.

Efficacy and safety of extracorporeal membrane oxygenation for cardiogenic shock complicating myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been presented as a potential therapeutic option for patients with cardiogenic shock complicating myocardial infarction (CS-MI). We aimed to investigate the efficacy and safety of ECMO in CS-MI.

METHODS

A systematic review and meta-analysis synthesizing evidence from randomized controlled trials obtained from PubMed, Embase, Cochrane, Scopus, and Web of Science until September 2023. We used the random-effects model to report dichotomous outcomes using risk ratio and continuous outcomes using mean difference with a 95% confidence interval. Finally, we implemented a trial sequential analysis to evaluate the reliability of our results.

RESULTS

We included four trials with 611 patients. No significant difference was observed between ECMO and standard care groups in 30-day mortality with pooled RR of 0.96 (95% CI: 0.81-1.13, p = 0.60), acute kidney injury (RR: 0.65, 95% CI: 0.41-1.03, p = 0.07), stroke (RR: 1.16, 95% CI: 0.38-3.57, p = 0.80), sepsis (RR: 1.06, 95% CI: 0.77-1.47, p = 0.71), pneumonia (RR: 0.99, 95% CI: 0.58-1.68, p = 0.96), and 30-day reinfarction (RR: 0.95, 95% CI: 0.25-3.60, p = 0.94). However, the ECMO group had higher bleeding events (RR: 2.07, 95% CI: 1.44-2.97, p < 0.0001).

CONCLUSION

ECMO did not improve clinical outcomes compared to the standard of care in patients with CS-MI but increased the bleeding risk.

The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock: a narrative review

Aims

Cardiogenic shock (CS) develops in up to 10% of patients with acute myocardial infarction (AMI) and carries a 50% risk of mortality. Despite the paucity of evidence regarding its benefits, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in clinical practice in patients with AMI in CS (AMI-CS). This review aims to provide an in-depth description of the four available randomized controlled trials to date designed to evaluate the benefit of VA-ECMO in patients with AMI-CS.

Methods and results

The literature search was conducted on PubMed, Google Scholar, and clinicaltrials.gov to identify the four relevant randomized control trials from years of inception to October 2023. Despite differences in patient selection, nuances in trial conduction, and variability in trial endpoints, all four trials (ECLS-SHOCK I, ECMO-CS, EUROSHOCK, and ECLS-SHOCK) failed to demonstrate a mortality benefit with the use of VA-ECMO in AMI-CS, with high rates of device-related complications. However, the outcome of these trials is nuanced by the limitations of each study that include small sample sizes, challenging patient selection, and high cross-over rates to the intervention group, and lack of use of left ventricular unloading strategies.

Conclusion

The presented literature of VA-ECMO in CS does not support its routine use in clinical practice. We have yet to identify which subset of patients would benefit most from this intervention. This review emphasizes the need for designing adequately powered trials to properly assess the role of VA-ECMO in AMI-CS, in order to build evidence for best practices.

Influence of tricuspid regurgitation on the prognosis of patients with cardiogenic shock

OBJECTIVE

Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations. However, data regarding the prognostic impact in patients with cardiogenic shock (CS) is limited. The study investigates the prognostic impact of pre-existing TR in patients with CS.

METHODS

Consecutive patients with CS from 2019 to 2021 were included in a monocentric registry. Every patient's medical history, including echocardiographic data, was recorded. The influence of pre-existing TR on prognosis was investigated. Furthermore, Kaplan-Meier analyses based on TR severity were conducted. Statistical analyses comprised univariable t-test, Spearman's correlation, Kaplan-Meier analyses, as well as multivariable Cox proportional regression models. Analyses were stratified by the underlying cause of CS such as acute myocardial infarction (AMI), or the need for mechanical ventilation.

RESULTS

105 patients with CS and pre-existing TR were included. In Kaplan Meier analyses, it could be demonstrated that patients with severe TR (TR III°) had the highest 30-day all-cause mortality compared to mild (TR I°) and moderate TR (TR II°) (44% vs. 52% vs. 77%; log rank p = .054). In the subgroup analyses of CS-patients without AMI, TR II°/TR III° showed a higher all-cause mortality after 30 days compared to TR I° (39% vs. 64%; log rank p = .027). In multivariable Cox regression TR II°/TR III° was associated with 30-day all-cause mortality in CS-patients without AMI (HR = 2.193; 95% CI 1.007-4.774; p = .048). No significant difference could be found in the AMI group. Furthermore, TR II°/III° was linked to an increased 30-day all-cause mortality in non-ventilated CS-patients (6% vs. 50%, log rank p = .015), which, however, could not be confirmed in multivariable Cox regression.

CONCLUSION

The occurrence of pre-existing TR II°/III° was independently related with 30-day all-cause mortality in CS-patients without AMI. However, no prognostic influence was observed in CS-patients with AMI.

Cardiogenic Shock: An Overview

Cardiogenic shock (CS) is a complex and dreadful condition for which effective treatments remain unclear. The concerningly high mortality rate of CS emphasizes a need for developing effective therapies to reduce its mortality and reverse its detrimental course. This article aims to provide an updated and evidence-based review of the pathophysiology of CS and the related pharmacotherapeutics with a special focus on vasoactive and inotropic agents.

[Open questions with respect to extracorporeal circulatory support 2024]

The use of extracorporeal circulatory support, both for cardiogenic shock and during resuscitation, still presents many unanswered questions. The inclusion and exclusion criteria for such a resource-intensive treatment must be clearly defined, considering that these criteria are directly associated with the type and location of treatment. For example, it is worth questioning the viability of an extracorporeal resuscitation program in areas where it is impossible to achieve low-flow times under 60 min due to local limitations. Additionally, the best approach for further treatment, including whether it is necessary to regularly relieve the left ventricle, must be explored. To find answers to some of these questions, large-scale, multicenter, randomized studies and registers must be performed. Until then this treatment must be carefully considered before use.

Extracorporeal Life Support in Myocardial Infarction: New Highlights

Background and Objectives: Cardiogenic shock (CS) is a potentially severe complication following acute myocardial infarction (AMI). The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in these patients has risen significantly over the past two decades, especially when conventional treatments fail. Our aim is to provide an overview of the role of VA-ECMO in CS complicating AMI, with the most recent literature highlights. Materials and Methods: We have reviewed the current VA-ECMO practices with a particular focus on CS complicating AMI. The largest studies reporting the most significant results, i.e., overall clinical outcomes and management of the weaning process, were identified in the PubMed database from 2019 to 2024. Results: The literature about the use of VA-ECMO in CS complicating AMI primarily has consisted of observational studies until 2019, generating the need for randomized controlled trials. The EURO-SHOCK trial showed a lower 30-day all-cause mortality rate in patients receiving VA-ECMO compared to those receiving standard therapy. The ECMO-CS trial compared immediate VA-ECMO implementation with early conservative therapy, with a similar mortality rate between the two groups. The ECLS-SHOCK trial, the largest randomized controlled trial in this field, found no significant difference in mortality at 30 days between the ECMO group and the control group. Recent studies suggest the potential benefits of combining left ventricular unloading devices with VA-ECMO, but they also highlight the increased complication rate, such as bleeding and vascular issues. The routine use of VA-ECMO in AMI complicated by CS cannot be universally supported due to limited evidence and associated risks. Ongoing trials like the Danger Shock, Anchor, and Recover IV trials aim to provide further insights into the management of AMI complicated by CS. Conclusions: Standardizing the timing and indications for initiating mechanical circulatory support (MCS) is crucial and should guide future trials. Multidisciplinary approaches tailored to individual patient needs are essential to minimize complications from unnecessary MCS device initiation.

Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial

AIMS

We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry.

METHODS AND RESULTS

In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year.

CONCLUSION

In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.

Predicting the mortality of patients with cardiogenic shock after coronary artery bypass grafting

INTRODUCTION

Cardiogenic shock (CS) is a critical condition and the leading cause of mortality after coronary artery bypass grafting (CABG). To define the risk factors for CS in patients who undergo CABG and create a risk-predictive model is crucial.

METHODS

In this observational study, we retrospectively evaluated consecutive patients who underwent CABG between January 2018 and October 2022 at Beijing Anzhen Hospital. A total of 496 patients were enrolled and categorized into the training (396 cases) and internal test (100 cases) sets. The variables significantly associated with mortality (p < 0.05) were analyzed using logistic regression analyses.

RESULTS

The E/A ratio at admission, postoperative brain natriuretic peptide, postoperative arterial lactate, two or more arrhythmias at the same time after CABG, and carotid artery stenosis at admission were identified as independent prognostic factors for in-hospital mortality after multivariate logistic regression analysis. The CS after CABG score (ACCS) was established and three classes of ACCS, named classes I (ACCS, <20), II (ACCS, 20-30), and III (ACCS, >30), made up the risk model. The ACCS showed better discrimination with an AUROC of 0.937 (95% confidence interval, 0.982-0.892) and calibration with the Hosmer-Lemeshow test (X2 = 5.854 with 8 df; p = 0.664). In addition, tenfold cross-validation demonstrated that the mean misdiagnosis rate was 5.56% and the lowest misdiagnosis rate was 6.38%.

CONCLUSION

The ACCS score represents a risk-predictive model for in-hospital mortality of patients with CS after CABG in acute care settings. Patients identified as class III may have a worse prognosis.

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

BACKGROUND & AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prognosis of cardiogenic shock with and without acute myocardial infarction: results from a prospective, monocentric registry

OBJECTIVE

The study investigates the prognostic impact of cardiogenic shock (CS) stratified by the presence or absence of acute myocardial infarction (AMI).

BACKGROUND

Intensive care unit (ICU) related mortality in CS patients remains unacceptably high despite improvement concerning the treatment of CS patients.

METHODS

Consecutive patients with CS from 2019 to 2021 were included monocentrically. The prognostic impact of CS related to AMI was compared to patients without AMI-related CS. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier analyses, multivariable Cox proportional regression analyses and propensity score matching.

RESULTS

273 CS patients were included (AMI-related CS: 49%; non-AMI-related CS: 51%). The risk of 30-day all-cause mortality was increased in patients with AMI-related CS (64% vs. 47%; HR = 1.653; 95% CI 1.199-2.281; p = 0.002), which was still observed after multivariable adjustment (HR = 1.696; 95% CI 1.153-2.494; p = 0.007). Even after propensity score matching (i.e., 87 matched pairs), AMI was still an independent predictor of 30-day mortality (HR = 1.524; 95% CI 1.020-2.276; p = 0.040). In contrast, non-ST-segment AMI (NSTEMI) and STEMI were associated with comparable prognosis (log-rank p = 0.528).

CONCLUSION

AMI-related CS was associated with increased 30-day all-cause mortality compared to patients with CS not related to AMI. In contrast, the prognosis of STEMI- and NSTEMI-CS patients was comparable.

Discussion of hemodynamic optimization strategies and the canonical understanding of hemodynamics during biventricular mechanical support in cardiogenic shock: does the flow balance make the difference?

BACKGROUND

Mechanical circulatory support (MCS) devices may stabilize patients with severe cardiogenic shock (CS) following myocardial infarction (MI). However, the canonical understanding of hemodynamics related to the determination of the native cardiac output (CO) does not explain or support the understanding of combined left and right MCS. To ensure the most optimal therapy control, the current principles of hemodynamic measurements during biventricular support should be re-evaluated.

METHODS

Here we report a protocol of hemodynamic optimization strategy during biventricular MCS (VA-ECMO and left ventricular Impella) in a case series of 10 consecutive patients with severe cardiogenic shock complicating myocardial infarction. During the protocol, the flow rates of both devices were switched in opposing directions (+ / - 0.7 l/min) for specified times. To address the limitations of existing hemodynamic measurement strategies during biventricular support, different measurement techniques (thermodilution, Fick principle, mixed venous oxygen saturation) were performed by pulmonary artery catheterization. Additionally, Doppler ultrasound was performed to determine the renal resistive index (RRI) as an indicator of renal perfusion.

RESULTS

The comparison between condition 1 (ECMO flow > Impella flow) and condition 2 (Impella flow > VA-ECMO flow) revealed significant changes in hemodynamics. In detail, compared to condition 1, condition 2 results in a significant increase in cardiac output (3.86 ± 1.11 vs. 5.44 ± 1.13 l/min, p = 0.005) and cardiac index (2.04 ± 0.64 vs. 2.85 ± 0.69, p = 0.013), and mixed venous oxygen saturation (56.44 ± 6.97% vs. 62.02 ± 5.64% p = 0.049), whereas systemic vascular resistance decreased from 1618 ± 337 to 1086 ± 306 s*cm-5 (p = 0.002). Similarly, RRI decreased in condition 2 (0.662 ± 0.05 vs. 0.578 ± 0.06, p = 0.003).

CONCLUSIONS

To monitor and optimize MCS in CS, PA catheterization for hemodynamic measurement is applicable. Higher Impella flow is superior to higher VA-ECMO flow resulting in a more profound increase in CO with subsequent improvement of organ perfusion.

Outcomes of patients with myocardial infarction and cardiogenic shock treated with culprit vessel-only versus multivessel primary PCI

INTRODUCTION AND OBJECTIVES

Multivessel primary percutaneous coronary intervention (pPCI) is still often used in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and multivessel coronary disease (MVD) treated with culprit vessel-only pPCI or multivessel-pPCI during the initial procedure.

MATERIAL AND METHODS

From 2016 to 2020, 23,703 primary PCI patients with STEMI were included in a national all-comers registry of cardiovascular interventions. Of them, 1,213 (5.1%) patients had CS and MVD at admission to the hospital. Initially, 921 (75.9%) patients were treated with culprit vessel (CV)-pPCI and 292 (24.1%) with multivessel (MV)-pPCI.

RESULTS

Patients with 3-vessel disease and left main disease had a higher probability of being treated with MV-pPCI than patients with 2-vessel disease and patients without left main disease (28.5% vs. 18.6%; p < 0.001 and 37.7% vs. 20.6%; p < 0.001). Intra-aortic balloon pump, extracorporeal membrane oxygenation (ECMO), and other mechanical circulatory support systems were more often used in patients with MV-pPCI. Thirty (30)-day and 1-year all-cause mortality rates were similar in the CV-pPCI and MV-pPCI groups (odds ratio, 1.01; 95% confidence interval [CI] 0.77 to 1.32; p = 0.937 and 1.1; 95% CI 0.84 to 1.44; p = 0.477). The presence of 3-vessel disease and the use of ECMO were the strongest adjusted predictors of 30-day and 1-year mortality.

CONCLUSIONS

Our data from an extensive all-comers registry suggests that selective use of MV-pPCI does not increase the all-cause mortality rate in patients with CS-STEMI and MVD compared to CV-pPCI.

Comparative efficacy of Chinese herbal injections in patients with cardiogenic shock (CS): a systematic review and Bayesian network meta-analysis of randomized controlled trials

Background: Cardiogenic shock (CS) is the primary cause of death in patients suffering acute myocardial infarction. As an emerging and efficacious therapeutic approach, Chinese herbal injections (CHIs) are gaining significant popularity in China. However, the optimal CHIs for treating CS remain uncertain. Method: We searched eight databases from inception to 30 September 2023. Subsequently, we conducted the Bayesian network meta-analysis (NMA). Interventions were ranked based on the surface under the cumulative ranking curve (SUCRA) probability values. To compare the effects of CHIs on two distinct outcomes, a clustering analysis was performed. Furthermore, the quality of the studies was assessed. Results: For the study, we included 43 RCTs, encompassing 2,707 participants. The study evaluated six herbal injections, namely, Shenfu injection (SF), Shengmai injection (SM), Shenmai injection (Sm), Danshen injection (DS), Huangqi injection (HQ), and Xinmailong injection (XML). The analysis findings suggested that Sm (MD = -1.05, 95% CI: -2.10, -0.09) and SF (MD = -0.81, 95% CI: -1.40, -0.25) showed better efficacy compared to Western medicine (WM) alone in reducing in-hospital mortality. The SUCRA values revealed that Sm + WM ranked first in terms of in-hospital mortality, cardiac index (CI), and hourly urine output but second in improving left ventricular ejection fraction (LVEF) and mean arterial pressure (MAP). SF + WM, however, had the greatest impact on raising the clinical effective rate. In MAP, SM + WM came out on top. Moreover, in terms of safety, only 14 studies (31.8%), including five types of CHIs: SF, Sm, SM, HQ, and XML, observed adverse drug reactions. Conclusion: To summarize, this analysis discovered that, in terms of patients suffering from CS, CHIs + WM yielded significantly greater advantages than WM alone. Based on in-hospital mortality and the remaining outcomes, Sm performed excellently among all the involved CHIs. Systematic Review Registration: https:// www.Crd.york.ac.uk/prospero/, identifier: CRD42022347053.

Association of body mass index with 30-day all-cause mortality in cardiogenic shock

BACKGROUND AND AIMS

This study investigates the prognostic impact of body mass index (BMI) on the risk of 30-day all-cause mortality in patients with cardiogenic shock (CS). Due to ongoing epidemiological developments, the characteristics of patients with cardiovascular disease are consistently changing. Especially increasing rates of obesity and associated comorbidities have been observed. However, data regarding the prognostic value of BMI in patients with CS remains inconclusive.

METHODS AND RESULTS

Consecutive patients with CS were included from 2019 to 2021. The prognostic value of BMI (i.e., BMI 18.5-<25; 25-30 and >30 kg/m2) was analyzed using Kaplan-Meier and multivariable Cox proportional regression analyses regarding the primary endpoint of 30-day all-cause mortality. Additional risk stratification was performed based on the presence or absence of CS related to acute myocardial infarction (AMI). 256 patients with a median BMI of 26.4 kg/m2 were included. The overall risk of 30-day all-cause mortality was 53.5%. Within the entire study cohort, BMI was not associated with the risk of 30-day all-cause mortality (log rank p ≥ 0.107). In contrast, BMI >30 kg/m2 was associated with higher risk of 30-day all-cause mortality when compared to BMI <25 kg/m2 in patients with AMI-CS (78% vs 47%; log rank p = 0.017), which was confirmed after multivariable adjustment (HR = 2.466; 95% CI 1.126-5.399; p = 0.024). However, BMI was not associated with mortality in patients with non-AMI-CS.

CONCLUSION

BMI >30 kg/m2 was associated with increased risk of 30-day all-cause mortality in patients with AMI-CS, but not in non-AMI-CS.

Contemporary Evidence and Practice on Right Heart Catheterization in Patients with Acute or Chronic Heart Failure

Heart failure (HF) has a global prevalence of 1-2%, and the incidence around the world is growing. The prevalence increases with age, from around 1% for those aged <55 years to >10% for those aged 70 years or over. Based on studies in hospitalized patients, about 50% of patients have heart failure with reduced ejection fraction (HFrEF), and 50% have heart failure with preserved ejection fraction (HFpEF). HF is associated with high morbidity and mortality, and HF-related hospitalizations are common, costly, and impact both quality of life and prognosis. More than 5-10% of patients deteriorate into advanced HF (AdHF) with worse outcomes, up to cardiogenic shock (CS) condition. Right heart catheterization (RHC) is essential to assess hemodynamics in the diagnosis and care of patients with HF. The aim of this article is to review the evidence on RHC in various clinical scenarios of patients with HF.

Effect of Admission and Onset Time on the Prognosis of Patients With Cardiogenic Shock

BACKGROUND

The spectrum of patients with cardiogenic shock (CS) has changed significantly over time. CS has become especially more common in the absence of acute myocardial infarction (AMI), while this subset of patients was typically excluded from recent studies. Furthermore the prognostic impact of onset time and onset place due to CS has rarely been investigated.

RESEARCH QUESTION

Do the place of CS onset (out-of-hospital, ie, primary CS vs in-hospital, ie, secondary CS) and the onset time of out-of-hospital CS (ie, on-hours vs off-hours admission) affect the risk of all-cause mortality at 30 days?

STUDY DESIGN AND METHODS

This prospective monocentric registry included consecutive patients with CS of any cause from 2019 until 2021. First, the prognostic impact of the place of CS onset (out-of-hospital, ie, primary CS vs during hospitalization, ie, secondary CS) was investigated. Thereafter, the prognostic impact of the onset time of out-of-hospital CS was investigated. Furthermore, the prognostic impact of causative AMI vs non-AMI was investigated. Statistical analyses included Kaplan-Meier analyses, and univariable and multivariable Cox regression analyses.

RESULTS

Two hundred seventy-three patients with CS were included prospectively (64% with primary out-of-hospital CS). The place of CS onset was not associated with increased risk of all-cause mortality within the entire study cohort (secondary in-hospital CS: hazard ratio [HR], 1.532; 95% CI, 0.990-2.371; P = .06). However, increased risk of 30-day all-cause mortality was seen in patients with AMI related secondary in-hospital CS (HR, 2.087; 95% CI, 1.126-3.868; P = .02). Furthermore, primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality compared to primary CS admitted during on-hours (HR, 0.497; 95% CI, 0.302-0.817; P = .01), irrespective of the presence or absence of AMI.

INTERPRETATION

Primary and secondary CS were associated with comparable, whereas primary out-of-hospital CS admitted during off-hours was associated with lower risk of all-cause mortality at 30 days.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT05575856; URL: www.

CLINICALTRIALS

gov.

The impact of extracorporeal membrane oxygenation on mortality in patients with cardiogenic shock post-acute myocardial infarction: a systematic review and meta-analysis

Aims

Cardiogenic shock remains the leading cause of death in patients hospitalized with acute myocardial infarction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in the treatment of infarct-related cardiogenic shock. However, there is limited evidence regarding its beneficial impact on mortality. The aim of this study was to systematically review studies reporting the impact of VA-ECMO on mortality in patients with acute myocardial infarction complicated by cardiogenic shock.

Methods and results

A comprehensive search of medical databases (Cochrane Register and PubMed) was conducted. Studies that reported mortality outcomes in patients treated with VA-ECMO for infarct-related cardiogenic shock were included. The database search yielded 1194 results, of which 11 studies were included in the systematic review. Four of these studies, with a total of 586 patients, were randomized controlled trials and were included in the meta-analysis. This demonstrated that there was no significant difference in 30-day all-cause mortality with the use of VA-ECMO compared with standard medical therapy [odds ratio (OR) 0.91; 95% confidence interval (CI) 0.65-1.27]. Meta-analysis of two studies showed that VA-ECMO was associated with a significant reduction in 12-month all-cause mortality (OR 0.31; 95% CI 0.11-0.86). Qualitative synthesis of the observational studies showed that age, serum creatinine, serum lactate, and successful revascularization are independent predictors of mortality.

Conclusion

Veno-arterial extracorporeal membrane oxygenation does not improve 30-day all-cause mortality in patients with cardiogenic shock following acute myocardial infarction; however, there may be significant reduction in all-cause mortality at 12 months. Further studies are needed to delineate the potential benefit of VA-ECMO in long-term outcomes.

Registration

The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42023461740).

Platelet Count During Course of Cardiogenic Shock

The study investigates the prognostic value of the platelet count in patients with cardiogenic shock (CS). Limited data regarding the prognostic value of platelets in patients suffering from CS is available. Consecutive patients with CS from 2019 to 2021 were included at one institution. Firstly, the prognostic value of the baseline platelet count was tested for 30-day all-cause mortality. Thereafter, the prognostic impact of platelet decline during course of intensive care unit (ICU) hospitalization was assessed. A total of 249 CS patients were included with a median platelet count of 224 × 10 6 /ml. No association of the baseline platelet count with the risk of 30-day all-cause mortality was found (log-rank p = 0.563; hazard ratio [HR] = 0.879; 95% confidence interval [CI] 0.557-1.387; p = 0.579). In contrast, a decrease of platelet count by ≥ 25% from day 1 to day 3 was associated with an increased risk of 30-day all-cause mortality (55% vs. 39%; log-rank p = 0.045; HR = 1.585; 95% CI 0.996-2.521; p = 0.052), which was still evident after multivariable adjustment (HR = 1.951; 95% CI 1.116-3.412; p = 0.019). Platelet decrease during the course of ICU hospitalization but not the baseline platelet count was associated with an increased risk of 30-day all-cause mortality in CS patients.

Cardiogenic Shock: Pathogenesis, Classification, and Management

Cardiogenic shock (CS) is a life-threatening circulatory failure syndrome which can progress rapidly to irreversible multiorgan failure through self-perpetuating pathophysiological processes. Recent developments in CS classification have highlighted its etiologic, mechanistic, and hemodynamic heterogeneity. Optimal CS management depends on early recognition, rapid reversal of the underlying cause, and prompt initiation of hemodynamic support.

Glimpse into the future

Randomized studies attempting to prove benefit of mechanical circulatory support in cardiogenic shock have failed to reduce the risk of death. Further, both registry and randomized data suggest increased rates of serious complications associated with these devices. This last review in the supplement discusses current evidence and provides a perspective on how the scientific community could advance cardiogenic shock research focused on mechanical circulatory support.

Network meta-analysis of temporary mechanical circulatory support in acute myocardial infarction cardiogenic shock

We performed a network meta-analysis of 11 published randomized clinical trials examining the use of temporary mechanical circulatory support (MCS) devices in adults with acute myocardial infarction cardiogenic shock, including 1,053 total patients with an observed in-hospital or 30-day mortality of 40.4%. None of the temporary MCS devices was associated with lower in-hospital or 30-day mortality compared with initial medical therapy or any other MCS device, either individually or in combination. These data do not support the routine use of temporary MCS devices for the purpose of reducing short-term mortality in unselected patients with acute myocardial infarction cardiogenic shock.

Risk factors for immediate and delayed cardiogenic shock in patients with ventricular septal rupture after myocardial infarction

BACKGROUND

Ventricular septal rupture (VSR) is a serious complication occurring after myocardial infarction (MI). Cardiogenic shock (CS) is a common complication of VSR and an important factor affecting its prognosis. CS can occur in either an immediate or delayed manner after VSR; however, studies on the risk factors associated with immediate or delayed CS are scarce.

METHODS

We retrospectively studied patients diagnosed with VSR after MI and admitted to the West China Hospital between September 2009 and August 2023. Demographic data, medical history, physical examination results, electrocardiograms, and echocardiographic and hematological data were extracted from electronic medical records or archived records. CS was defined as hypotension (<90 mmHg) and/or the requirement for catecholamines, pulmonary congestion, and signs of end-organ failure. The CS onset time was defined as the time at which catecholamines were initiated.

RESULTS

A total of 88 patients with VSR after MI, including 49 males (55.7%), were enrolled. The average age was 70.2 years. Of these patients, 32 (36.4%) who already had CS at the time of VSR discovery were defined as immediate CS, and 28 (31.8%) who developed CS within 2 weeks after VSR discovery were defined as delayed CS. A smaller left ventricular end-diastolic diameter (LVEDD) and VSR discovered after admission were independent risk factors for immediate CS. Elevated heart rate and higher levels of creatine kinase-MB isoenzyme on admission were independent risk factors for delayed CS in patients without immediate CS after VSR.

CONCLUSIONS

The occurrence of CS in patients with VSR after MI has an evident time course. Thus, an early identification of patients at risk of immediate or delayed CS and optimization of treatment procedures may help improve the prognosis.

Noninvasive Hemodynamic Characterization of Shock and Preshock Using Echocardiography in Cardiac Intensive Care Unit Patients

BACKGROUND

Shock and preshock are defined on the basis of the presence of hypotension, hypoperfusion, or both. We sought to determine the hemodynamic underpinnings of shock and preshock noninvasively using transthoracic echocardiography (TTE).

METHODS AND RESULTS

We included Mayo Clinic cardiac intensive care unit patients from 2007 to 2015 with TTE within 1 day of admission. Hypotension and hypoperfusion at the time of cardiac intensive care unit admission were used to define 4 groups. TTE findings were evaluated across these groups, and in-hospital mortality was evaluated according to TTE findings in each group. We included 5375 patients with a median age of 69.2 years (36.8% women). The median left ventricular ejection fraction was 50%. Groups based on hypotension and hypoperfusion were assigned as follows: no hypotension or hypoperfusion, 59.7%; isolated hypotension, 15.3%; isolated hypoperfusion, 16.4%; and both hypotension and hypoperfusion, 8.7%. Most TTE variables of interest varied across these groups, with worse biventricular function, lower forward flow, and higher filling pressures as the degree of hemodynamic compromise increased. In-hospital mortality occurred in 8.2%, and inpatient deaths had more TTE parameter abnormalities. In-hospital mortality increased with the degree of hemodynamic compromise, and a marked gradient in in-hospital mortality was observed when the clinical classification of shock and preshock was combined with TTE findings reflecting worse biventricular function, lower forward flow, or higher filling pressures.

CONCLUSIONS

Substantial differences in cardiac function are observed between cardiac intensive care unit patients with preshock and shock using TTE, and the combination of the clinical and TTE hemodynamic assessment provides robust mortality risk stratification.

Outcome of Patients With Cardiogenic Shock and Previous Right Ventricular Impairment Represented by Decreased Tricuspid Annular Plane Systolic Excursion and Tricuspid Annular Plane Systolic Excursion to Pulmonary Artery Systolic Pressure Ratio

This study investigates the prognostic impact of known decreased ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) and TAPSE in patients with cardiogenic shock (CS). In patients with pulmonary artery hypertension and in critically ill patients, decreased TAPSE and TAPSE/PASP ratio are known to be negative predictors. However, studies regarding the prognostic impact in patients with CS are limited. Consecutive patients with CS from June 2019 to May 2021 treated at a single center were included. Medical history including echocardiographic parameters such as TAPSE and PASP was documented for each patient. The primary endpoint was all-cause mortality at 30 days. Statistical analyses included univariable t test, Spearman's correlation, C-statistics, Kaplan-Meier analyses, and Cox proportional regression analyses. A total of 90 patients with CS and measurement of TAPSE and TAPSE/PASP ratio were included. TAPSE and TAPSE/PASP ratio measured several months before intensive care unit admission were both able to predict 30-day survival in CS patients, and were both lower in 30-day nonsurvivors. TAPSE/PASP ratio <0.4 mm/mmHg (log-rank p = 0.006) and TAPSE <18 mm (log-rank p = 0.004) were associated with increased risk of 30-day all-cause mortality. After multivariable adjustment, TAPSE/PASP ratio <0.4 mm/mmHg was not able to predict 30-day all-cause mortality, whereas TAPSE <18 mm was still significantly associated with the primary endpoint (hazard ratio 2.336, confidence interval 1.067 to 5.115, p = 0.034). In consecutive patients presenting with CS, compared to TAPSE alone, previously determined TAPSE/PASP ratio did not improve risk prediction for 30-day all-cause mortality.

Outcomes of ECLS-SHOCK Eligibility Criteria Applied to a Real-World Cohort

BACKGROUND

Cardiogenic shock (CS) exhibits high (~50%) in-hospital mortality. The recently published Extracorporeal life Support in Cardiogenic Shock (ECLS-SHOCK) trial demonstrated the neutral effects of the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) on all-cause death, as well as on all secondary outcomes in subjects presenting with myocardial-infarction (MI)-related CS. Here, we compared ECLS-SHOCK eligibility criteria with a real-world cohort of CS patients.

METHODS AND RESULTS

ECLS-SHOCK eligibility criteria were applied to a prospective single-center CS registry (the PREPARE CS registry) consisting of 557 patients who were consecutively admitted to the catheterization laboratory (cath lab) of the Medical University of Graz, Austria, due to CS (SCAI C-E). Overall use of mechanical circulatory support (MCS) in this cohort was 19%. Sixty-nine percent of the entire cohort had MI-related CS, 38% of whom would have met ECLS-SHOCK eligibility criteria, thus representing only 27% of the PREPARE CS registry. Exclusion from the ECLS-SHOCK trial was based on patients with initial lactate values below 3 mmol/L (n = 168; 43.6%), aged over 80 years (n = 65; 16.9%), and with a duration of cardiopulmonary resuscitation (CPR) exceeding 45 min (n = 22; 5.7%). The 30-day mortality of patients of the PREPARE CS registry who met the ECLS-SHOCK eligibility criteria was 57.0%, compared to 48.4% of patients in the ECLS-SHOCK trial. The patients' baseline characteristics, however, differed considerably with respect to type of infarction, age, and gender.

CONCLUSIONS

In a real-world cohort of patients with MI-related CS, only 38% of patients met the eligibility criteria of the ECLS-SHOCK trial. Thus, the impact of the use of VA-ECMO on outcome parameters in MI-related CS, as observed in the ECLS-SHOCK trial, may differ in a more heterogeneous real-world CS population of the PREPARE CS registry.

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

Background

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

Case summary

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

Discussion

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