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Vallabhajosyula S, Dunlay SM, Barsness GW, Rihal CS, Holmes DR, Prasad A. Hospital-Level Disparities in the Outcomes of Acute Myocardial Infarction With Cardiogenic Shock. Am J Cardiol 2019; 124:491-498. [DOI: 10.1016/j.amjcard.2019.05.038] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 11/15/2022]
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102
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Yandrapalli S, Sanaani A, Harikrishnan P, Aronow WS, Frishman WH, Lanier GM, Ahmed A, Fonarow GC. Cardiogenic shock during heart failure hospitalizations: Age-, sex-, and race-stratified trends in incidence and outcomes. Am Heart J 2019; 213:18-29. [PMID: 31078113 DOI: 10.1016/j.ahj.2019.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 03/27/2019] [Indexed: 02/03/2023]
Abstract
The objectives were to study the overall and age-, sex-, and race-stratified incidence of cardiogenic shock (CS) during heart failure hospitalizations (HFHs) not complicated by acute coronary syndromes (ACS), utilization of short-term mechanical circulatory support (MCS) and in-hospital mortality with non-ACS-related CS, and respective temporal trends. Data are lacking regarding the epidemiology of non-ACS-related CS during HFHs. METHODS Retrospective observational analysis of the National Inpatient Sample 2005-2014 to identify all HFHs in adult patients without concomitant ACS. RESULTS Of 8,333,752 HFHs, incidence rate of non-ACS-related CS was 8.7 per thousand HFHs (N = 72,668), a 4-fold increase from 4.1 to 15.6 per thousand HFHs between 2005 and 2014 (Ptrend < .001). Among those with non-ACS-related CS, utilization rates of intra-aortic balloon pump, extracorporeal membrane oxygenation, and temporary ventricular assist devices were 12.8%, 1.4%, and 2.5%, respectively. Respective 2005 to 2014 trends were 14.2% to 10.7%, 0.6% to 1.8%, and 0.8% to 2.7% (Ptrend for all, <.001). In-hospital mortality rate was 27.1%, with a substantial decrease from 42.4% in 2005 to 23.3% in 2014 (Ptrend < .001). These temporal trends were largely consistent across age, sex, and race subgroups. CONCLUSION During HFHs in the United States, non-ACS-related CS occurred infrequently but was associated with substantial mortality. Non-ACS-related CS incidence and certain MCS utilization rates increased, and in-hospital mortality rate decreased between 2005 and 2014. These trends were generally homogenous across the age, sex, and race groups. The observed trends in incidence and mortality may be a reflection of increased identification of CS during HFHs, although further study is needed to assess whether temporal changes in care may have influenced outcomes.
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Affiliation(s)
- Srikanth Yandrapalli
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Abdallah Sanaani
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Prakash Harikrishnan
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Ali Ahmed
- Veterans Affairs Medical Center, George Washington University, and Georgetown University, Washington, DC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, University of California, Los Angeles, CA.
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103
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Chioncel O, Collins SP, Ambrosy AP, Pang PS, Radu RI, Ahmed A, Antohi EL, Masip J, Butler J, Iliescu VA. Therapeutic Advances in the Management of Cardiogenic Shock. Am J Ther 2019; 26:e234-e247. [PMID: 30839372 PMCID: PMC6404765 DOI: 10.1097/mjt.0000000000000920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiogenic shock (CS) is a life-threatening state of tissue hypoperfusion, associated with a very high risk of mortality, despite intensive monitoring and modern treatment modalities. The present review aimed at describing the therapeutic advances in the management of CS. AREAS OF UNCERTAINTY Many uncertainties about CS management remain in clinical practice, and these relate to the intensity of invasive monitoring, the type and timing of vasoactive therapies, the risk-benefit ratio of mechanical circulatory support (MCS) therapy, and optimal ventilation mode. Furthermore, most of the data are obtained from CS in the setting of acute myocardial infarction (AMI), although for non-AMI-CS patients, there are very few evidences for etiological or MCS therapies. DATA SOURCES The prospective multicentric acute heart failure registries that specifically presented characteristics of patients with CS, distinct to other phenotypes, were included in the present review. Relevant clinical trials investigating therapeutic strategies in post-AMI-CS patients were added as source information. Several trials investigating vasoactive medications and meta-analysis providing information about benefits and risks of MCS devices were reviewed in this study. THERAPEUTIC ADVANCES Early revascularization remains the most important intervention for CS in settings of AMI, and in patients with multivessel disease, recent trial data recommend revascularization on a "culprit-lesion-only" strategy. Although diverse types of MCS devices improve hemodynamics and organ perfusion in patients with CS, results from almost all randomized trials incorporating clinical end points were inconclusive. However, development of new algorithms for utilization of MCS devices and progresses in technology showed benefit in selected patients. A major advance in the management of CS is development of concept of regional CS centers based on the level of facilities and expertise. The modern systems of care with CS centers used as hubs integrated with emergency medical systems and other referee hospitals have the potential to improve patient outcomes. CONCLUSIONS Additional research is needed to establish new triage algorithms and to clarify intensity and timing of pharmacological and mechanical therapies.
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Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine and Indianapolis EMS, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Razvan I Radu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Ali Ahmed
- Veteran Affairs Medical Center and George Washington University, Washington DC, USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
| | - Josep Masip
- Cardiology Department, Hospital Sanitas CIMA, Barcelona, Spain; Department of Intensive Care, Consorci Sanitari Integral, Barcelona, Spain
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MI, USA
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute for Cardiovascular Diseases-“Prof. C.C.Iliescu”, Bucharest, Romania
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104
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O'Neill BP, Cohen MG, Basir MB, Schreiber T, Kapur NK, Dixon S, Khandelwal AK, Grines C, Ohman EM, O'Neill WW. Outcomes Among Patients Transferred for Revascularization With Impella for Acute Myocardial Infarction With Cardiogenic Shock from the cVAD Registry. Am J Cardiol 2019; 123:1214-1219. [PMID: 30777319 DOI: 10.1016/j.amjcard.2019.01.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/05/2019] [Accepted: 01/09/2019] [Indexed: 11/28/2022]
Abstract
The outcomes for patients transferred with cardiogenic shock and later treated with revascularization and Impella support have not previously been studied. To evaluate these outcomes, patients in cardiogenic shock were recruited from the catheter-based ventricular assist device registry, a prospective registry enrolling patients who underwent percutaneous coronary intervention with hemodynamic support using Impella 2.5 or CP. Analysis was performed on subgroups of patients who were characterized as those directly admitted to a tertiary care hospital (direct), or those transferred from an outside hospital (transfer). Patients who were transferred with acute myocardial infarction with cardiogenic shock (AMICS) more often presented in shock were in shock longer than 24 hours, and were more likely to be on intra-aortic balloon pump but were less likely to sustain cardiac arrest. The number of pressors, EF, diseased, and treated vessels were similar between the 2 groups. Despite baseline differences, the mortality was similar in the transfer versus direct patients (47.0% vs 53.5% p = 0.19). In a multivariate model, the factors independently associated with 30-day mortality in AMICS treated with revascularization and Impella support were cardiopulmonary resuscitation (CPR) (p <0.01), age (p <0.01), and ST-segment elevation myocardial infarction (STEMI) (p = 0.02). Whether the patient was transferred or directly admittedly with AMICS was not an independent predictor of death. In conclusion, these findings suggest that considerations should be given to transfer patients with AMICS to allow them to be treated in a contemporary manner.
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Affiliation(s)
- Brian P O'Neill
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania. Brian.O'
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Mir Babar Basir
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Simon Dixon
- Department of Cardiology, Beaumont Hospital, Royal Oak, Michigan
| | | | - Cindy Grines
- Northwell Health, North Shore University Hospital, Manhasset, New York
| | - Erik Magnus Ohman
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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105
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Standardized Team-Based Care for Cardiogenic Shock. J Am Coll Cardiol 2019; 73:1659-1669. [DOI: 10.1016/j.jacc.2018.12.084] [Citation(s) in RCA: 214] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 11/23/2022]
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106
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Levy B, Kimmoun A. Choc cardiogénique : plaidoyer pour la création de centres experts régionaux. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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107
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis. Clin Nutr 2019; 39:460-467. [PMID: 30808573 DOI: 10.1016/j.clnu.2019.02.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/18/2019] [Accepted: 02/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Despite extensive research on early enteral nutrition (EEN), it remains unclear whether EEN is effective for patients with shock requiring vasopressors. This study aimed to compare outcomes between EEN and late enteral nutrition (LEN) in ventilated patients with shock requiring low-, medium-, or high-dose noradrenaline. METHODS Using a national inpatient database in Japan, we identified ventilated patients admitted to intensive care units who had shock requiring catecholamines (noradrenaline or dobutamine) from July 2010 to March 2016. We defined patients who started enteral nutrition within 2 days after starting mechanical ventilation as EEN group and the others as LEN group. Propensity score matching was performed between patients undergoing EEN and LEN in each of the low- (<0.1 μg/kg/min), medium- (0.1-0.3 μg/kg/min), and high-dose (≥0.3 μg/kg/min) noradrenaline groups. RESULTS We identified 52,563 eligible patients during the 69-month study period, including 38,488, 11,042, and 3033 patients in the low-, medium-, and high-dose noradrenaline groups, respectively. One-to-two propensity score matching created 5,969, 2,162, and 477 one-to-two matched pairs in the low-, medium-, and high-dose noradrenaline groups, respectively. The 28-day mortality rate was significantly lower in the EEN than LEN group in the low-dose noradrenaline group (risk difference, -2.9%; 95% confidence interval [CI], -4.5% to -1.3%) and in the medium-dose noradrenaline group (risk difference, -6.8%; 95% CI, -9.6% to -4.0%). In the high-dose noradrenaline group, 28-day mortality did not differ significantly between the EEN and LEN groups (absolute risk difference, -1.4%; 95% CI, -7.4%-4.7%). CONCLUSIONS Although the size of the subgroup requiring high-dose noradrenaline may have been too small to demonstrate a significant difference, the results suggest that EEN was associated with a reduction in mortality in ventilated adults treated with low- or medium-dose noradrenaline but not in those requiring high-dose noradrenaline.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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108
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A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2018-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the highest mortality rates recorded in critical care. Mortality rate in this setting is reported around 45-50% even in the most experienced and well-equipped medical centers. The continuous development of ST-segment elevation acute myocardial infarction (STEMI) networks has led not only to a dramatic decrease in STEMI-related mortality, but also to an increase in the frequency of severely complicated cases who survive to be transferred to tertiary centers for life-saving treatments. The reduced effectiveness of vasoactive drugs on a severely altered hemodynamic status led to the development of new devices dedicated to advanced cardiac support. What’s more, efforts are being made to reduce time from first medical contact to initiation of mechanical support in this particular clinical context. This review aims to summarize the most recent advances in mechanical support devices, in the setting of CS-complicated AMI. At the same time, the review presents several modern concepts in the organization of complex CS centers. These specialized hubs could improve survival in this critical condition.
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109
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Kochar A, Al-Khalidi HR, Hansen SM, Shavadia JS, Roettig ML, Fordyce CB, Doerfler S, Gersh BJ, Henry TD, Berger PB, Jollis JG, Granger CB. Delays in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients Presenting With Cardiogenic Shock. JACC Cardiovasc Interv 2018; 11:1824-1833. [DOI: 10.1016/j.jcin.2018.06.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/14/2018] [Accepted: 06/19/2018] [Indexed: 12/27/2022]
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110
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Fiedler AG, Dalia A, Axtell AL, Ortoleva J, Thomas SM, Roy N, Villavicencio MA, D'Alessandro DA, Cudemus G. Impella Placement Guided by Echocardiography Can Be Used as a Strategy to Unload the Left Ventricle During Peripheral Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2018; 32:2585-2591. [PMID: 30007550 DOI: 10.1053/j.jvca.2018.05.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE At the authors' institution, before 2015, patients cannulated for peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) did not undergo left ventricular (LV) decompression with the use of an LV vent. After 2015, the authors' institution began using the Impella device to vent the left ventricle in patients on VA-ECMO. The authors hypothesized that survival outcomes would improve in patients on VA-ECMO with the use of an Impella for LV venting. DESIGN Retrospective, chart based review study. SETTING Single center, university-based hospital. PARTICIPANTS All adult patients at the authors' institution who required VA-ECMO between January 2015 and May 2017. INTERVENTION An Impella (Abiomed, Danvers, MA) device was placed percutaneously in patients cannulated for VA-ECMO as a mechanism to provide LV venting and decompression, therefore unloading the heart. MEASUREMENTS AND MAIN RESULTS Manual chart review was conducted, and a survival analysis was performed. It was observed that patients on VA-ECMO in whom an Impella was implanted had improved survival and an improvement in LV function as demonstrated by echocardiography compared with patients maintained on VA-ECMO alone. CONCLUSIONS Patients on VA-ECMO plus Impella implantation demonstrated improved survival compared with patients treated with VA-ECMO alone. Key echocardiographic characteristics such as improved LV function after Impella placement and LV cavity size reduction during therapy may help predict those patients who may benefit most from this cannulation strategy.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Adam Dalia
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jamel Ortoleva
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sunu M Thomas
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nathalie Roy
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - David A D'Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gaston Cudemus
- Division of Cardiac Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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111
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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. Arch Cardiovasc Dis 2018; 111:601-612. [PMID: 29903693 DOI: 10.1016/j.acvd.2018.03.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/11/2018] [Accepted: 03/12/2018] [Indexed: 12/17/2022]
Abstract
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.
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112
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Čerlinskaitė K, Javanainen T, Cinotti R, Mebazaa A. Acute Heart Failure Management. Korean Circ J 2018; 48:463-480. [PMID: 29856141 PMCID: PMC5986746 DOI: 10.4070/kcj.2018.0125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/02/2018] [Indexed: 01/06/2023] Open
Abstract
Acute heart failure (AHF) is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. However, there are few evidence-based treatment methods. Interestingly, despite relatively similar ways of management of AHF throughout the globe, mid-term outcome in East Asia, including South Korea is more favorable than in Europe. Yet, most of the treatment methods are symptomatic. The cornerstone of AHF management is identifying precipitating factors and specific phenotype. Multidisciplinary approach is important in AHF, which can be caused or aggravated by both cardiac and non-cardiac causes. The main pathophysiological mechanism in AHF is congestion, both systemic and inside the organs (lung, kidney, or liver). Cardiac output is often preserved in AHF except in a few cases of advanced heart failure. This paper provides guidance on AHF management in a time-based approach. Treatment strategies, criteria for triage, admission to hospital and discharge are described.
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Affiliation(s)
- Kamilė Čerlinskaitė
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tuija Javanainen
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Department of Cardiology, University of Helsinki, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Raphaël Cinotti
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Department of Anesthesia and Critical Care, University Hospital of Nantes, Nantes Cedex, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- University Paris Diderot, Paris, France.
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113
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Truesdell AG, Tehrani B, Singh R, Desai S, Saulino P, Barnett S, Lavanier S, Murphy C. 'Combat' Approach to Cardiogenic Shock. Interv Cardiol 2018; 13:81-86. [PMID: 29928313 DOI: 10.15420/icr.2017:35:3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The incidence of cardiogenic shock is rising, patient complexity is increasing and patient survival has plateaued. Mirroring organisational innovations of elite military units, our multidisciplinary medical specialists at the INOVA Heart and Vascular Institute aim to combine the adaptability, agility and cohesion of small teams across our large healthcare system. We advocate for widespread adoption of our 'combat' methodology focused on: increased disease awareness, early multidisciplinary shock team activation, group decision-making, rapid initiation of mechanical circulatory support (as appropriate), haemodynamic-guided management, strict protocol adherence, complete data capture and regular after action reviews, with a goal of ending preventable death from cardiogenic shock.
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Affiliation(s)
- Alexander G Truesdell
- Virginia Heart, Falls Church VA, USA.,INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Behnam Tehrani
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Ramesh Singh
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | - Shashank Desai
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | | | - Scott Barnett
- INOVA Heart and Vascular Institute, Falls Church VA, USA
| | | | - Charles Murphy
- INOVA Heart and Vascular Institute, Falls Church VA, USA
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114
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O'Neill D, Nicholas O, Gale CP, Ludman P, de Belder MA, Timmis A, Fox KAA, Simpson IA, Redwood S, Ray SG. Total Center Percutaneous Coronary Intervention Volume and 30-Day Mortality: A Contemporary National Cohort Study of 427 467 Elective, Urgent, and Emergency Cases. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003186. [PMID: 28320707 DOI: 10.1161/circoutcomes.116.003186] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 02/20/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry. METHODS AND RESULTS A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment-elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment-elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers. CONCLUSIONS After adjustment for differences in case mix and clinical presentation, this study supports the conclusion of no trend for increased mortality in lower volume centers for PCI in the UK healthcare system. CLINICAL TRIAL REGISTRATION https://www.clinicaltrials.gov. Unique identifier: NCT02184949.
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Affiliation(s)
- Darragh O'Neill
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.).
| | - Owen Nicholas
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Chris P Gale
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Peter Ludman
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Mark A de Belder
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Adam Timmis
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Keith A A Fox
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Iain A Simpson
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Simon Redwood
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
| | - Simon G Ray
- From the Research Department of Epidemiology and Public Health, University College London, United Kingdom (D.O., O.N.); Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom (C.P.G.); Department of Cardiology, York Teaching Hospital, United Kingdom (C.P.G.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); The James Cook University Hospital, Middlesbrough, United Kingdom (M.A.d.B.); NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, United Kingdom (A.T.); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.); Wessex Cardiac Unit, University Hospital Southampton, United Kingdom (I.A.S.); King's College London/St Thomas' Hospital, United Kingdom (S.R.); University Hospitals of South Manchester, United Kingdom (S.G.R.)
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115
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Characteristics of hospitalizations for cardiogenic shock after acute myocardial infarction in the United States. Int J Cardiol 2017; 244:213-219. [DOI: 10.1016/j.ijcard.2017.06.088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/08/2017] [Accepted: 06/22/2017] [Indexed: 11/17/2022]
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116
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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 976] [Impact Index Per Article: 139.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
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[Management of cardiogenic shock: Results from a survey in France and Belgium]. Ann Cardiol Angeiol (Paris) 2016; 66:59-65. [PMID: 27836099 DOI: 10.1016/j.ancard.2016.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 10/06/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Physician survey on cardiogenic shock management; recommendations for the management of patients with cardiogenic shock are based mostly on experts' opinion. METHODS Overall 1585 emails were sent to "senior" intensive care physicians from France and Belgium from September 2014 to march 2015. Response rate was 10% (157 respondents). Agreement was assessed based on RAND/UCLA methodology. RESULTS Continuous monitoring of cardiac output, vascular filling, noninvasive ventilation were deemed appropriate. The use of systematic diuretics and dopamine seemed inappropriate. There was a strong agreement to use dobutamine as inotropic drug in first intention. The use of noradrenaline and adrenaline was considered appropriate. There was a strong agreement to use mechanical circulatory support, in particular extracorporeal life support, in refractory cardiogenic shock. Only 25% of responders felt that there are criteria of refractory cardiogenic shock. Concerning the objectives of systolic, diastolic and mean blood pressure, 95% of the responses were in the range between 70 to 100, 30 to 50, and 55 to 65mmHg, respectively. The target of SvO2 was between 55% and 75%, and cardiac index between 1.5 and 3L/min/m2 for 95% of responders. There was a strong agreement to maintain hemoglobin between 7 and 9.9g/dL. CONCLUSION Based on our physician survey, we found an agreement in vascular filling and early enteral nutrition. Dobutamine and noradrenaline should be the preferred drugs, but not dopamine. Mechanical circulatory support (preferably with extracorporeal support) should be restricted to refractory cardiogenic shock. Those responses differed slightly from experts' opinion, available in terms of recommendations.
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Dini CS, Lazzeri C, Chiostri M, Gensini GF, Valente S. A local network for extracorporeal membrane oxygenation in refractory cardiogenic shock. ACTA ACUST UNITED AC 2016; 17:49-54. [DOI: 10.3109/17482941.2016.1174272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Carlotta Sorini Dini
- Intensive Cardiac Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Chiara Lazzeri
- Intensive Cardiac Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Marco Chiostri
- Intensive Cardiac Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Gian Franco Gensini
- Intensive Cardiac Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Serafina Valente
- Intensive Cardiac Care Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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Islam MS, Panduranga P, Al-Mukhaini M, Al-Riyami A, El-Deeb M, Rahman SA, Al-Riyami MB. In-Hospital Outcome of Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction: Results from Royal Hospital Percutaneous Coronary Intervention Registry, Oman. Oman Med J 2016; 31:46-51. [PMID: 26814946 DOI: 10.5001/omj.2016.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Cardiogenic shock (CS) is still the leading cause of in-hospital mortality in patients presenting with acute myocardial infarction (AMI). The aim of this study was to determine the in-hospital mortality and clinical outcome in AMI patients presenting with CS in a tertiary hospital in Oman. METHODS This retrospective observational study included patients admitted to the cardiology department between January 2013 and December 2014. A purposive sampling technique was used, and 63 AMI patients with CS admitted to (36.5%) or transferred from a regional hospital (63.5%) were selected for the study. RESULTS Of 63 patients, 73% (n = 46) were Omani and 27% (n = 17) were expatriates: 79% were male and 21% were female. The mean age of patients was 60±12 years. The highest incidence of CS (30%) was observed in the 51-60 year age group. Diabetes mellitus (43%) and hypertension (40%) were the predominant risk factors. Ninety-two percent of patients had ST-elevation MI, 58.7% patients were thrombolysed, and 8% had non-ST-elevation MI. Three-quarters (75%) of CS patients had severe left ventricular systolic dysfunction (defined as ejection fraction <30%). Coronary angiogram showed single vessel disease in 17%, double vessel disease in 40%, and triple vessel disease in 32% and left main disease in 11%. The majority of the patients (93.6%) underwent percutaneous coronary intervention (PCI), among them 23 (36.5%) underwent primary PCI. In-hospital mortality was 52.4% in this study. CONCLUSIONS CS in AMI patients presenting to a tertiary hospital in Oman have high in-hospital mortality despite the majority undergoing PCI. Even though the in-hospital mortality is comparable to other studies and registries, there is an urgent need to determine the causes and find any remedies to provide better care for such patients, specifically concentrating on the early transfer of patients from regional hospitals for early PCI.
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Santarpino G, Ruggieri VG, Mariscalco G, Bounader K, Beghi C, Fischlein T, Onorati F, Faggian G, Gatti G, Pappalardo A, De Feo M, Bancone C, Perrotti A, Chocron S, Dalen M, Svenarud P, Rubino AS, Mignosa C, Gherli R, Musumeci F, Dell'Aquila AM, Kinnunen EM, Biancari F. Outcome in Patients Having Salvage Coronary Artery Bypass Grafting. Am J Cardiol 2015; 116:1193-8. [PMID: 26303635 DOI: 10.1016/j.amjcard.2015.07.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/12/2015] [Accepted: 07/12/2015] [Indexed: 10/23/2022]
Abstract
Salvage coronary artery bypass grafting (CABG) is often performed for cardiogenic shock on compassionate basis without clinical data justifying this aggressive approach. The aim of this study was to analyze early and intermediate outcomes after salvage CABG. We retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 European cardiac surgery centers. Salvage CABG was defined according to the EuroSCORE criteria, that is, a procedure performed in patients requiring cardiopulmonary resuscitation (external cardiac massage) en route to the operating theater or before induction of anesthesia. A percutaneous coronary intervention procedure preceded salvage CABG in 55 patients (64.7%). Thirty patients (35.3%) died during the inhospital stay. The mean EuroSCORE II was 32.0% and the observed-to-expected ratio was 1.08. Salvage CABG was associated with high rates of postoperative stroke (9.4%), resternotomy for bleeding (23.5%), resternotomy for hemodynamic instability (15.3%), dialysis (18.8%), severe gastrointestinal complications (12.9%), and deep sternal wound infection (10.6%). Survival at 1, 3, and 5 years was 58.6%, 49.8%, and 40.9%, respectively. Twenty patients (23.5%) were postoperatively treated with extracorporeal membrane oxygenation (ECMO). The rates of adverse events after ECMO were particularly high (stroke 40%, resternotomy for bleeding 60%, dialysis 35%, gastrointestinal complications 30%, and deep sternal wound infection 30%). Of patients treated with ECMO, 8 (40%) survived to discharge, and 1-year survival was 29.2%. Salvage CABG is associated with high risk of immediate mortality and severe adverse events. However, the observed immediate and intermediate outcome justify coronary surgery in these critically ill patients. A number of these patients are currently treated by ECMO, and its results are encouraging.
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