Gender differences with the use of percutaneous left ventricular assist device in cardiogenic shock patients – results from the Dresden Impella Registry

Background

Cardiogenic shock (CS) is a state of end-organ hypoperfusion due to cardiac output failure and is characterized by high mortality. Percutaneous left ventricular assist devices (pLVAD), like the Impella® system, support the left ventricular function and provide a sufficient oxygen supply to all tissues, which might improve outcome. In the current study, we investigated gender-specific differences in a large, propensity score matched cohort of patients receiving an Impella CP® in CS. Beside all-cause mortality, we focused on requirement of hemodialysis and surrogate parameters like development of systemic inflammatory response syndrome (SIRS), or sepsis, which is known to be associated with enhanced morbidity and mortality.

Methods

The Dresden Impella Registry is an ongoing registry including more than 650 patients since 2014. Among, a total of 95 female and 237 male patients received an Impella CP® in CS. Two groups of similar sample size (n=60) resulted after propensity score matching. A logistic regression model was used for adjustment of the baseline characteristics (nearest neighbor matching). Kaplan-Meier curves at 30, 180 and 365 days as well as clinical, laboratory and hemodynamic parameters were compared between male and female patients.

Results

The propensity score matched cohorts showed a well balancing without significant differences between baseline characteristics. At time of admission, female patients were 68.9±1.8 years old, male patients 67.2±1.5 years. A cardiopulmonary resuscitation (CPR) before pLVAD was performed in 53.3% in both groups. The comparison of mean arterial pressure, norepinephrine and dobutamine dosage showed no differences initially and in course. The left ventricular ejection fraction did not differ between both cohorts (♀ 28.6±2.3% vs. ♂ 26.7±1.7%, p=0.885). The duration of left ventricular unloading was 44.1±6.5 h among female patients and 56.0±7.3 h among male patients (p=0.119).

The all-cause mortality showed no difference at 30, 180, and 365 d (30 d: ♀ 61.7±6.3% vs. ♂ 56.7±6.4%, p=0.349; 180 d: ♀ 73.3±5.7% vs. ♂ 68.3±6.0%, p=0.312; 365 d: ♀ 76.7±5.5% vs. ♂ 70.0±5.9%, p=0.312).

However, hemodialysis was less frequently required in female patients (♀ 28.3% vs. ♂ 45.8%, p=0.049). The duration of hemodialysis did not differ between the groups (♀ 123.9±57.8 h vs. ♂ 108.1±56.3 h, p=0.744). Furthermore, occurrence of SIRS and sepsis were less frequently observed in female patients (SIRS ♀ 45.0% vs. ♂ 75.0%, p=0.042; sepsis ♀ 43.3% vs. ♂ 62.7%, p=0.034).

Conclusion

All-cause mortality showed no gender-specific differences in a well-balanced propensity score matched analysis of CS patients receiving LV-unloading with a pLVAD. However, females had a decreased requirement of hemodialysis and a less frequent occurrence of SIRS and sepsis. Further studies are needed to investigate whether these differences might improve outcome in larger cohorts.

Funding Acknowledgement

Type of funding sources: None.

P6357Left ventricular unloading leads to heart rhythm stabilization in cardiogenic shock - Results from the Dresden Impella Registry

Background

Cardiogenic shock (CS) is often associated with severe heart rhythm disturbances (SHRD). Percutaneous left ventricular assist devices (pLVAD) can actively unload the left ventricle (LV) using a micro-axial pump and resulting in a decreased end-diastolic pressure and wall tension. These parameters are suspected to induce and maintain rhythmological instability.

Purpose

In the current study, we firstly describe the termination of SHRD immediately (less than 5 minutes) after LV-unloading in CS patients with previous unsuccessful antiarrhythmic treatment.

Methods

The Dresden Impella Registry is an ongoing single center registry. Since 2014, a total of 97 patients were included. Each of whom had received a micro-axial heart pump in refractory CS supplying a circulatory support of 3.5 l/min. We investigated the subgroup of patients which initially exhibited SHRD like ventricular tachycardia or ventricular fibrillation, and showed an immediately stabilization of heart rhythm directly after insertion of pLVAD (HRS). This subgroup was compared with the other patients of the registry (NHRS). Therefore, clinical laboratory and hemodynamic parameters were measured and analyzed.

Results

In 19 patients of the registry a HRS was observed. Among these patients, a CPR before pLVAD was performed in 89.5% with a mean duration of 30.7min, whereby 52.6% sustained an in-hospital cardiac arrest and 36.9% an out-of-hospital cardiac arrest respectively. In the NHRS subgroup (n=78), a CPR was performed less frequently (39.7%; p<0.001) with shorter mean duration (19.5min; p=0.016) and a lower out-of-hospital ratio (12.8%; p=0.014). The comparison of hemodynamic parameters between the HRS and NHRS cohort showed no difference in mean arterial pressure, heart rate, left ventricular ejection fraction (LVEF), and serum lactate.

The mortality showed no differences between the HRS and NHRS cohort at 30 days (68.4% vs. 58.1%; p=0.413) and 90 days (78.9% vs. 66.7%; p=0.306), despite a more frequent and longer CPR with a higher ratio of out-of-hospital cardiac arrests among the HRS patients. There was also no difference in mortality between patients, who received an in-hospital CPR. However, HRS patients with in-hospital CPR showed a significantly lower serum lactate and NA dosage compared to the NHRS cohort (Figure A & B). Furthermore, NA recovery, defined as 50% decrease as compared to the initial NA dosage, occurred more frequently in the HRS group (HRS 42.9% vs. NHRS 7.1%; p=0.049). The LVEF nearly double in the HRS subgroup after LV-unloading, whereas it did not change in the NHRS subgroup (relative LVEF increase: HRS 95% vs. NHRS 15%).

Figure A & B

Conclusion

The termination of SHRD due to LV-unloading occurred in around 20% of CS patients in Dresden Impella Registry and was associated with a lower serum lactate and NA dosage as well as an improved LVEF among patients with in-hospital CPR.

Acknowledgement/Funding

None