Left ventricular unloading to facilitate ventricular remodelling in heart failure: A narrative review of mechanical circulatory support

Heart failure represents a dynamic clinical challenge with the continuous rise of a multi-morbid and ageing population. Yet, the evolving nature of mechanical circulatory support offers a variety of means to manage candidates who might benefit from such interventions. This narrative review focuses on the role of the main mechanical circulatory support devices, such as ventricular assist device, extracorporeal membrane oxygenation, Impella and TandemHeart, in the physiological process of ventricular unloading and remodelling in heart failure, highlighting their characteristics, mechanism and clinical outcomes. The outcome measures described include physiological changes (i.e., stroke volume or preload and afterload), intracardiac pressure (i.e., end-diastolic pressure) and extracardiac pressure (i.e., pulmonary capillary wedge pressure). Overall, all the above mechanical circulatory support strategies can facilitate the unloading of the ventricular failure through different mechanisms, which subsequently affects the ventricular remodelling process. These physiological changes start immediately after ventricular assist device implantation. The devices are indicated in different but overlapping populations and operate in distinctive ways; yet, they have evidenced performance to a favourable standard to improve cardiac function in heart failure, although this proved variable for different devices, and further high-quality trials are vital to assess their clinical outcomes further. Both Impella and TandemHeart are indicated mainly in cardiogenic shock and high-risk percutaneous coronary intervention patients; at the time the literature was evaluated, both devices were found to yield a significant improvement in haemodynamics but not in survival. Nevertheless, the choice of device strategy should be based on individual patient factors, including indication, to optimize clinical outcomes.

Association of Prophylactic Distal Perfusion Cannulation With Mortality in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation

Prophylactic distal perfusion cannulation (PDPC) is protectively associated with limb ischemia in patients with cardiogenic shock (CS) receiving femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, evidence supporting its benefits beyond limb ischemia reduction is scarce. We aimed to investigate whether PDPC, compared with no-PDPC, is associated with a lower risk of mortality in patients receiving VA-ECMO. From a multicenter registry, we identified 479 patients who underwent VA-ECMO support for refractory CS. The association of PDPC with 30-day mortality was assessed using multiple methods, including instrumental variable analysis, overlap weighting, and propensity score matching. Of the 479 patients, 154 (32.2%) received PDPC. The 30-day mortality rate was 33.1% in the PDPC group and 53.2% in the no-PDPC group. The instrumental variable analysis showed a protective association of PDPC with 30-day mortality (absolute risk difference -16.7%, 95% confidence interval -31.3% to -2.1%; relative risk 0.68, 95% confidence interval 0.40 to 0.96). The findings were consistent in the overlap-weighted analysis (hazard ratio 0.68, 95% confidence interval 0.48 to 0.98) and in the propensity score-matched analysis (hazard ratio 0.67, 95% confidence interval 0.45 to 1.00). There were no significant differences in safety outcomes, including stroke, ECMO site bleeding, gastrointestinal bleeding, and sepsis, between PDPC and no-PDPC. In conclusion, PDPC was associated with a lower risk of mortality at 30 days in patients with CS receiving VA-ECMO. The efficacy and safety of PDPC merit evaluation in future randomized studies. Clinical trial registration: ClinicalTrials.gov; NCT02985008.

Using Machine Learning for Early Prediction of Cardiogenic Shock in Patients With Acute Heart Failure

Background

Despite technological and treatment advancements over the past 2 ​decades, cardiogenic shock (CS) mortality has remained between 40% and 60%. Our objective was to develop an algorithm that can continuously monitor heart failure patients and partition them into cohorts of high and low risk for CS.

Methods

We retrospectively studied 24,461 patients hospitalized with acute decompensated heart failure, 265 of whom developed CS, in the Johns Hopkins Health System. Our cohort identification approach is based on logistic regression and makes use of vital signs, lab values, and medication administrations recorded during the normal course of care.

Results

Our algorithm identified patients at high risk of CS. Patients in the high-risk cohort had 10.2 times (95% confidence interval, 6.1-17.2) higher prevalence of CS than those in the low-risk cohort. Patients who experienced CS while in the high-risk cohort were first deemed high risk a median of 1.7 ​days (interquartile range, 0.8-4.6) before CS diagnosis was made by their clinical team. To evaluate actionability, we randomly selected 50 patients designated as high risk who did develop CS and 50 who did not. On review of true positive cases, from the time of model identification as high risk to the eventual diagnosis of CS, 12% of patients had possible inappropriate therapy, and for 50% of patients, more tailored therapy options existed. On review of the false positive cases, 44% of cases were considered at high risk of CS or end-stage cardiomyopathy by their clinical teams or went onto develop other types of shock.

Conclusions

This risk model was able to predict patients at higher risk of CS in a time frame that allowed a change in clinical care. The actionability evaluation demonstrates a possible opportunity to intervene as part of a CS algorithm for escalation of care.

The quality of afterlife: surviving extracorporeal life support after therapy-refractory circulatory failure-a comprehensive follow-up analysis

Aims

Extracorporeal life support (ECLS) represents a popular treatment option for therapy‐refractory circulatory failure and substantially increases survival. However, comprehensive follow‐up (FU) data beyond short‐term survival are mostly lacking. Here, we analyse functional recovery and quality of life of longer‐term survivors.

Methods and results

Between 2011 and 2016, a total of n = 246 consecutive patients were treated with ECLS for therapy‐refractory circulatory failure in our centre. Out of those, 99 patients (40.2%) survived the first 30 days and were retrospectively analysed. Fifty‐eight patients (23.6%) were still alive after a mean FU of 32.4 ± 16.8 months. All surviving patients were invited to a prospective, comprehensive clinical FU assessment, which was completed by 39 patients (67.2% of survivors). Despite high incidence of early functional impairments, FU assessment revealed a high degree of organ and functional recovery with more than 70% of patients presenting with New York Heart Association class ≤ II, 100% free of haemodialysis, 100% free of moderate or severe neurological disability, 71.8% free of moderate or severe depression, and 84.4% of patients reporting to be caring for themselves without need for assistance.

Conclusions

Patients surviving the first 30 days of ECLS therapy for circulatory failure without severe adverse events have a quite favourable outcome in terms of subsequent survival as well as functional recovery, showing the potential of ECLS therapy for patients to recover. Patients can recover even after long periods of mechanically support and regain physical and mental health to participate in their former daily life and work.

Cardiogenic shock and machine learning: A systematic review on prediction through clinical decision support softwares

BACKGROUND AND AIM

Cardiogenic shock (CS) withholds a significantly high mortality rate between 40% and 60% despite advances in diagnosis and medical/surgical intervention. To date, machine learning (ML) is being implemented to integrate numerous data to optimize early diagnostic predictions and suggest clinical courses. This systematic review summarizes the area under the curve (AUC) receiver operating characteristics (ROCs) accuracy for the early prediction of CS.

METHODS

A systematic review was conducted within databases of PubMed, ScienceDirect, Clinical Key/MEDLINE, Embase, GoogleScholar, and Cochrane. Cohort studies that assessed the accuracy of early detection of CS using ML software were included. Data extraction was focused on AUC-ROC values directed towards the early detection of CS.

RESULTS

A total of 943 studies were included for systematic review. From the reviewed studies, 2.2% (N = 21) evaluated patient outcomes, of which 14.3% (N = 3) were assessed. The collective patient cohort (N = 698) consisted of 314 (45.0%) females, with an average age and body mass index of 64.1 years and 28.1 kg/m² , respectively. Collectively, 159 (22.8%) mortalities were reported following early CS detection. Altogether, the AUC-ROC value was 0.82 (α = .05), deeming it of superb sensitivity and specificity.

CONCLUSIONS

From the present comprehensively gathered data, this study accounts the use of ML software for the early detection of CS in a clinical setting as a valid tool to predict patients at risk of CS. The complexity of ML and its parallel lack of clinical evidence implies that further prospective randomized control trials are needed to draw definitive conclusions before standardizing the use of these technologies.

BRIEF SUMMARY

The catastrophic risk of developing CS continues to be a concern in the management of critical cardiac care. The use of ML predictive models have the potential to provide the accurate and necessary feedback for the early detection and proper management of CS. This systematic review summarizes the AUC-ROCs accuracy for the early prediction of CS.

Extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock - Design and rationale of the ECLS-SHOCK trial

BACKGROUND

In acute myocardial infarction complicated by cardiogenic shock the use of mechanical circulatory support devices remains controversial and data from randomized clinical trials are very limited. Extracorporeal life support (ECLS) - venoarterial extracorporeal membrane oxygenation - provides the strongest hemodynamic support in addition to oxygenation. However, despite increasing use it has not yet been properly investigated in randomized trials. Therefore, a prospective randomized adequately powered clinical trial is warranted.

STUDY DESIGN

The ECLS-SHOCK trial is a 420-patient controlled, international, multicenter, randomized, open-label trial. It is designed to compare whether treatment with ECLS in addition to early revascularization with percutaneous coronary intervention or alternatively coronary artery bypass grafting and optimal medical treatment is beneficial in comparison to no-ECLS in patients with severe infarct-related cardiogenic shock. Patients will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoint of ECLS-SHOCK is 30-day mortality. Secondary outcome measures such as hemodynamic, laboratory, and clinical parameters will serve as surrogate endpoints for prognosis. Furthermore, a longer follow-up at 6 and 12 months will be performed including quality of life assessment. Safety endpoints include peripheral ischemic vascular complications, bleeding and stroke.

CONCLUSIONS

The ECLS-SHOCK trial will address essential questions of efficacy and safety of ECLS in addition to early revascularization in acute myocardial infarction complicated by cardiogenic shock.

Blood lactate predicts survival after percutaneous implantation of extracorporeal life support for refractory cardiac arrest or cardiogenic shock complicating acute coronary syndrome: insights from the CareGem registry

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients' condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01-18.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival.

Veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock: rationale and design of the randomised, multicentre, open-label EURO SHOCK trial

AIMS

Cardiogenic shock (CGS) occurs in 6-10% of patients with acute coronary syndromes (ACS). Mortality has fallen over time from 80% to approximately 50% consequent on acute revascularisation but has plateaued since the 1990s. Once established, patients with CGS develop adverse compensatory mechanisms that contribute to the downward spiral towards death, which becomes difficult to reverse. We aimed to test in a robust, prospective, randomised controlled trial whether early support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides clinical benefit by improving mortality and morbidity.

METHODS AND RESULTS

The EURO SHOCK trial will test the benefit or otherwise of mechanical cardiac support using VA-ECMO, initiated early after acute percutaneous coronary intervention (PCI) for CGS. The trial sets out to randomise 428 patients with CGS complicating ACS, following primary PCI (P-PCI), to either very early ECMO plus standard pharmacotherapy, or standard pharmacotherapy alone. It will be conducted in 39 European centres. The primary endpoint is 30-day all-cause mortality with key secondary endpoints: 1) 12-month all-cause mortality or admission for heart failure, 2) 12-month all-cause mortality, 3) 12-month admission for heart failure. Cost-effectiveness analysis (including quality of life measures) will be embedded. Mechanistic and hypothesis-generating substudies will be undertaken.

CONCLUSIONS

The EURO SHOCK trial will determine whether early initiation of VA-ECMO in patients presenting with ACS-CGS persisting after PCI improves mortality and morbidity.

[Heart failure networks and centers : What does everyday life look like?]

The German Cardiac Society (DGK) and the German Society for Thoracic and Cardiovascular Surgery (DGTHG) jointly advocated the initiation and certification of heart failure (HF) networks in a position statement in 2016. In these networks, supraregional HF centers cooperate with specialized regional HF clinics and registered cardiologists to improve intersectoral treatment of patients with HF. So far predominantly supraregional HF centers have achieved certification but more recently regional clinics as well as registered cardiologists have applied for certification, now enabling the comprehensive establishment of HF networks. In this article the background, the current situation and the future perspectives of HF networks are assessed and approaches for better networking are discussed.

Real-world clinical experience with the percutaneous extracorporeal life support system: Results from the German Lifebridge® Registry

BACKGROUND

The concept of percutaneous extracorporeal life support (ECLS) is based on immediate cardiovascular stabilization allowing for sufficient end-organ perfusion, thus improving the outcome in patients with circulatory arrest. Lifebridge^® (Zoll Medical GmbH, Germany) is a portable ECLS device designed for rapid application due to its automated set-up.

METHODS

A total of 60 tertiary cardiovascular centers were interrogated with regard to application and short-term results after use of Lifebridge ECLS system. Detailed data were collected by standardized case report forms in all centers consented to participate in the study. Demographic and clinical baseline characteristics of the patient population, procedural and follow-up data were recorded and analyzed.

RESULTS

In total, 444 patients were analyzed regarding mortality. The detailed study cohort consisted of 112 patients. A total of 80% of the study subjects represented patients post cardiopulmonary resuscitation, 43% were in cardiogenic shock and 50% suffered from acute myocardial infarction. The survival rates were 36% immediately after device implementation and 16% after 30 days. Multivariable analysis revealed that only serum lactate concentration at admission could be proven as independent predictor of patients' outcome. Patients with lactate concentrations above 10 mmol/L exhibited > 95% mortality (p < 0.05 versus below 10 mmol/L).

CONCLUSION

The present study provides real-world clinical data of patients treated with a transportable automated ECLS system. In conclusion, Lifebridge is a safely applicable cardiorespiratory stabilization tool associated with acceptable complication rates. Nevertheless, mortality rates were high in these critically ill patients, especially in those showing high lactate concentrations at admission.

Long-term survival and major outcomes in post-cardiotomy extracorporeal membrane oxygenation for adult patients in cardiogenic shock

Extracorporeal membrane oxygenation (ECMO) in the veno-arterial (VA) configuration is an established method for the treatment of refractory cardiogenic shock. Such a condition characterizes the postoperative course of approximatively 1% of cardiac surgery patients. Although some studies have reported ECMO-related short-term results, little is known about the long-term outcomes of VA-ECMO therapy in the post-cardiotomy setting. Therefore, an extensive literature search was conducted regarding articles published after 1990 reporting postoperative ECMO use. PubMed, EMBASE and Web of Science were searched for sources. In-hospital mortality was high in post-cardiotomy VA-ECMO patients, ranging from 24.8% to 52%. Long-term results were poorly reported. However, based on the limited information available, hospital survivors showed a favorable outcome, with improvement in overall clinical condition, quality of life and limited hospital readmission for cardiac-related events. To conclude, in-hospital outcome in post-cardiotomy ECMO is often unfavorable, post-discharge results show satisfactory condition, with stable improvement of overall patient clinical status and low rate of hospital readmission and cardiac-related adverse events. Data reporting is, however, scarce and hence new and detailed studies are still warranted to investigate such aspects.

Mechanical circulatory support in patients with cardiogenic shock in intensive care units: A position paper of the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology, endorsed by the "Groupe Athérome et Cardiologie Interventionnelle" of the French Society of Cardiology

Cardiogenic shock (CS) is a major challenge in contemporary cardiology. Despite a better understanding of the pathophysiology of CS, its management has only improved slightly. The prevalence of CS has remained stable over the past decade, but its outcome has seen few improvements, with the 1-month mortality rate still in the range of 40-60%. Inotropes and vasopressors are the first-line therapies for CS, but they are associated with significant hazards, and have well-known deleterious effects. Furthermore, a significant number of patients develop refractory CS with haemodynamic instability, causing critical organ hypoperfusion and/or pulmonary congestion, despite increasing doses of catecholamines. A major change has resulted from the recent advent and availability of potent mechanical circulatory support (MCS) devices. These devices, which ensure sustained blood flow, provide a great and long-awaited opportunity to improve the prognosis of CS. Several efficient MCS devices are now available, including left ventricle-to-aorta circulatory support devices and full pulmonary and circulatory support with venoarterial extracorporeal membrane oxygenation. However, evidence to support their indications, the timing of implantation and the selection of patients and devices is scarce. Because these devices are gaining momentum and are becoming readily available, the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology aims to propose practical algorithms for the use of these devices, to help intensive care unit and cardiac care unit physicians in this complex area, where evidence is limited.

Place de l’assistance circulatoire dans le choc cardiogénique en France en 2018 : revue de la littérature et perspectives

Le choc cardiogénique reste de nos jours une entité mal définie, assez fréquente en pratique clinique (60 000–70 000 cas/an en Europe), dont le pronostic est sombre, avec une mortalité souvent supérieure à 40 % à 30 jours. À travers cette revue de la littérature, nous essaierons de définir cette entité et ses étiologies, avant de parler de son incidence et de son pronostic. L’approche physiopathologique du choc cardiogénique nous permettra par la suite d’approcher sa prise en charge thérapeutique classique (gestion de la volémie, amines inotropes et vasoconstrictives, ventilation) et les limites de cette dernière. Ainsi, nous aborderons les assistances circulatoires et cardiocirculatoires disponibles en France, afin de les envisager au sein d’une stratégie globale de prise en charge du patient en choc cardiogénique. Nous discuterons plus spécifiquement leurs indications ainsi que l’importance du moment d’implantation afin d’optimiser leur efficacité. Enfin, nous évoquerons les assistances actuellement en développement, mais également les nouvelles stratégies thérapeutiques qui pourraient arriver dans les prochaines années.

Reduction of Serious Adverse Events Demanding Study Exclusion in Model Development: Extracorporeal Life Support Resuscitation of Ventricular Fibrillation Cardiac Arrest in Rats

Extracorporeal life support is a promising concept for selected patients in refractory cardiogenic shock and for advanced life support of persistent ventricular fibrillation cardiac arrest. Animal models of ventricular fibrillation cardiac arrest could help to investigate new treatment strategies for successful resuscitation. Associated procedural pitfalls in establishing a rat model of extracorporeal life support resuscitation need to be replaced, refined, reduced, and reported.Anesthetized male Sprague-Dawley rats (350-600 g) (n = 126) underwent cardiac arrest induced with a pacing catheter placed into the right ventricle via a jugular cannula. Rats were resuscitated with extracorporeal life support, mechanical ventilation, defibrillation, and medication. Catheter and cannula explantation was performed if restoration of spontaneous circulation was achieved. All observed serious adverse events (SAEs) occurring in each of the experimental phases were analyzed.Restoration of spontaneous circulation could be achieved in 68 of 126 rats (54%); SAEs were observed in 76 (60%) experiments. Experimental procedures related SAEs were 62 (82%) and avoidable human errors were 14 (18%). The most common serious adverse events were caused by insertion or explantation of the venous bypass cannula and resulted in lethal bleeding, cannula dislocation, or air embolism.Establishing an extracorporeal life support model in rats has confronted us with technical challenges. Even advancements in small animal critical care management over the years delivered by an experienced team and technical modifications were not able to totally avoid such serious adverse events. Replacement, refinement, and reduction reports of serious adverse events demanding study exclusions to avoid animal resources are missing and are presented hereby.

'Combat' Approach to Cardiogenic Shock

The incidence of cardiogenic shock is rising, patient complexity is increasing and patient survival has plateaued. Mirroring organisational innovations of elite military units, our multidisciplinary medical specialists at the INOVA Heart and Vascular Institute aim to combine the adaptability, agility and cohesion of small teams across our large healthcare system. We advocate for widespread adoption of our 'combat' methodology focused on: increased disease awareness, early multidisciplinary shock team activation, group decision-making, rapid initiation of mechanical circulatory support (as appropriate), haemodynamic-guided management, strict protocol adherence, complete data capture and regular after action reviews, with a goal of ending preventable death from cardiogenic shock.

Interventional therapies in acute myocardial infarction complicated by cardiogenic shock

Cardiogenic shock remains the most common cause of death in patients with acute myocardial infarction. Early revascularization of the infarct-related artery has been shown to reduce mortality and is the therapeutic cornerstone. The optimal revascularization strategy of additional non-culprit lesions remains yet to be determined. Further, uncertainties exist with respect to access site choice, antiplatelet regimen as well as mechanical support devices. This review outlines current evidence on the interventional management of cardiogenic shock complicating acute myocardial infarction.

[Cardiogenic shock : Current evidence]

This CME article addresses the pathophysiology, incidence, current survival outcome and treatment options for patients with cardiogenic shock as a complication of acute myocardial infarction. The shock spiral of left heart failure due to cardiac infarction, subsequent vasoconstriction and paradoxical vasodilation due to the systemic inflammation response syndrome (SIRS) is a vicious circle which must be interrupted. Treatment focuses on the evidence from randomized clinical trials and the current guideline recommendations. With respect to interventional and surgical treatment the question of culprit lesion vs. complete revascularization is still unsolved. For medicinal treatment acetylsalicylic acid (ASA) and heparin are more often supplemented with prasugrel and ticagrelor. In the case of inotropes, dobutamine remains the first-line treatment option and for vasopressors norepinephrine. The calcium sensitizer levosimendan has not provided the hoped for superiority over conventional treatment in randomized trials. The use of intra-aortic balloon pumps (IABP) is no longer recommended as circulatory support in acute heart failure (reduced to class III). The use of percutaneous implantable mechanical circulatory support devices has not shown a survival benefit in the few randomized trials carried out so far even when compared with IABP, due to increased bleeding complications.

Percutaneous ventricular assist devices and extracorporeal life support: current applications

Percutaneous mechanical circulatory support devices, such as intra-aortic balloon pump (IABP), active left ventricular assist devices (LVAD) or extracorporeal life support (ECLS), are treatment options for selected patients in cardiogenic shock, undergoing cardiopulmonary resuscitation, or high-risk percutaneous coronary intervention and coronary artery bypass grafting. Potential benefits include the maintenance of organ function and the reduction of intracardiac pressures, volumes, and oxygen consumption. On the other hand, they are invasive, resource intensive, and can be associated with serious complications. Thus, their potential benefits must be weighed against the inherent risks. Despite the lack of sufficient scientific evidence, the use of mechanical circulatory support devices has risen considerably in recent years. This educational article covers practical issues of IABP, LVAD, and ECLS with respect to patient and device selection, implantation technique, potential complications, and future perspectives.

Outcome of elderly undergoing extracorporeal life support in refractory cardiogenic shock

BACKGROUND

The current study presents data from a real-world cohort of patients with refractory cardiogenic shock (CS) undergoing extracorporeal life support (ECLS) focusing on the comparison of elderly versus younger patients.

METHODS AND RESULTS

One hundred consecutive patients with refractory CS underwent percutaneous ECLS implantation performed by interventional cardiologists. Follow-up was performed at hospital discharge as well as at a median of 18 months [interquartile range 15-36]. Patients were grouped according to median age (≤60 versus >60 years). ECLS could be weaned in more than half of the cohort (n = 56, 56%) with no differences between the age groups (p = 1.00). Despite similar rates of initial haemodynamic stabilisation, in-hospital mortality was higher in patients >60 years (82% versus 58%, p = 0.02). At mid-term follow-up, only three patients were alive in the group of patients >60 years. This resulted in a mortality rate of 94% in the elderly in comparison with 68% in patients aged ≤60 years (p = 0.001).

CONCLUSIONS

Despite a high rate of initial successful ECLS weaning, mid-term prognosis of patients with CS undergoing ECLS above the age of 60 years is poor with superior results in patients aged ≤60 years.

The peak of blood lactate during the first 24h predicts mortality in acute coronary syndrome patients under extracorporeal membrane oxygenation

BACKGROUND

Parameters allowing for outcome discrimination of extracorporeal membrane oxygenation (ECMO) therapy in acute coronary syndromes (ACS) complicated by refractory cardiogenic shock (CS) and/or cardio-respiratory arrest (CA) remain elusive. We aimed at evaluating the potential prognostic roles of blood and procedural parameters associated with 30-day mortality following ECMO.

METHODS AND RESULTS

A group of 29 patients with ACS complicated by CS and/or CA, who underwent ECMO at a single center, was retrospectively analyzed. Eighteen patients (62%) died at 30-day follow up. "Survivors" and "non-survivors" had similar demographics, clinical and biochemical characteristics at admission, except for blood lactate peak in the first 24h that was increased in non-survivors. Procedural characteristics of percutaneous coronary intervention (PCI) and ECMO were comparable in either group. The peak of blood lactate concentration predicted 30-day mortality independently of age, sex and ECMO duration. The cutoff value, determined by receiver operating characteristic (ROC) curve analysis, was found at 11mmol/l.

CONCLUSIONS

The peak of serum lactate under ECMO in the first 24h predicted 30-day mortality in patients with ACS complicated with CS and CA.