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Joner M, Sager H. Mechanical circulatory support-assisted percutaneous coronary intervention: have we reached the point of no return? EUROINTERVENTION 2021; 16:e1211-e1212. [PMID: 33551376 PMCID: PMC9707467 DOI: 10.4244/eijv16i15a218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Michael Joner
- German Heart Centre Munich, Technical University of Munich, Lazarettstraße 36, 80636 Munich, Germany
| | - Hendrik Sager
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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302
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Banning A, Adriaenssens T, Berry C, Bogaerts K, Erglis A, Distelmaier K, Guagliumi G, Haine S, Kastrati A, Massberg S, Orban M, Myrmel T, Vuylsteke A, Alfonso F, Van de Werf F, Verheugt F, Flather M, Sabaté M, Vrints C, Gershlick A. Veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock: rationale and design of the randomised, multicentre, open-label EURO SHOCK trial. EUROINTERVENTION 2021; 16:e1227-e1236. [PMID: 33106225 PMCID: PMC9725005 DOI: 10.4244/eij-d-20-01076] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Amerjeet Banning
- Department of Cardiology, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, United Kingdom
| | - Tom Adriaenssens
- University Hospitals Leuven, and Katholieke Universiteit Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Colin Berry
- University of Glasgow, Institute of Cardiovascular and Medical Sciences and Robertson Centre for Biostatistics, Glasgow, United Kingdom
| | - Kris Bogaerts
- Katholieke Universiteit Leuven, Department of Public Health and Primary Care, I-BioStat, and Universiteit Hasselt, I-BioStat, Leuven, Belgium
| | - Andrejs Erglis
- Paula Stradina Kliniska Universitates Slimnica AS, Department of Cardiovascular Sciences, Riga, Latvia
| | - Klaus Distelmaier
- Medical University of Vienna, Department of Internal Medicine II, Division of Cardiology, Vienna, Austria
| | - Giulio Guagliumi
- Azienda Ospedaliera Papa Giovanni XXIII, Department of Cardiovascular Sciences, Bergamo, Italy
| | - Steven Haine
- Antwerp University Hospital, Department of Cardiology and University of Antwerp, Department of Cardiovascular Diseases, Antwerp, Belgium
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Department of Cardiology, Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, LMU University Hospital Munich, Munich, Germany
| | - Truls Myrmel
- The Heart and Lung Clinic, University Hospital North Norway, Tromsø, Norway
| | - Alain Vuylsteke
- Royal Papworth Hospital, Department of Anaesthesia and Intensive Care, Cambridge, United Kingdom
| | - Fernando Alfonso
- Cardiac Department, La Princesa University Hospital, IIS-IP, CIBERCV, Madrid, Spain
| | - Frans Van de Werf
- University Hospitals Leuven, and Katholieke Universiteit Leuven, Department of Cardiovascular Sciences, Leuven, Belgium
| | - Freek Verheugt
- Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - Marcus Flather
- University of East Anglia and Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Manel Sabaté
- Consorci Institut D’Investicacions Biomediques August Pi i Sunyer, Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Christiaan Vrints
- Antwerp University Hospital, Department of Cardiology and University of Antwerp, Department of Cardiovascular Diseases, Antwerp, Belgium
| | - Anthony Gershlick
- University of Leicester, University Hospitals of Leicester, Leicester Biomedical Research Centre, Leicester, United Kingdom
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Comparison of Vasopressin versus Norepinephrine in a Pig Model of Refractory Cardiogenic Shock Complicated by Cardiac Arrest and Resuscitated with Veno-arterial ECMO. Shock 2021; 56:473-478. [PMID: 33555846 DOI: 10.1097/shk.0000000000001747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The choice of the best vasopressor after ExtraCorporeal Membrane Oxygenation (ECMO) implantation after cardiac arrest is not well defined. Circulatory flow recovery with ECMO is associated with vasoplegia and vasopressor need. The present study aimed to compare the effects of norepinephrine and vasopressin in the first 6 h after ECMO initiation. METHODS Cardiac arrest was induced in 20 pigs by coronary surgical ligature and veno-arterial-ECMO was started after a 30-min period of cardio-pulmonary resuscitation. Pigs were randomized into two groups, arginine vasopressin (AVP) or norepinephrine (NE), with the drugs titrated to maintain a mean arterial pressure (MAP) at 65 mm Hg. Macrocirculatory and metabolic parameters were assessed by lactate clearance. Microcirculatory parameters were assessed by sublingual microcirculation with Sidestream Dark Field imaging and peripheral Near InfraRed Spectroscopy. Pulmonary edema was evaluated by measuring lung wet/dry weight ratio. RESULTS No difference was found between groups regarding ECMO flow and MAP. Fluid resuscitation volume was higher in the NE group (14,000 [11,250-15,250] mL vs. 3,500 [1,750-4,000] mL in the AVP group, P < 0.05). Lung wet/dry weight ratio was higher in the Norepinephrine group. Lactate clearance between H0 and H6 was higher in the AVP group (47.84 [13.42-82.73]% vs. the NE group 25.66 [-7.31 to 35.34)% vs. P < 0.05). No significant difference was observed for sublingual microcirculation values. Baseline tissue oxygen saturation was comparable and higher at both H3 and H6 in the Vasopressin group comparatively to the Norepinephrine group (P < 0.05). Renal and liver function evolution also remained similar in the two groups throughout the study. CONCLUSIONS AVP administration in refractory cardiac arrest resuscitated by veno-arterial-ECMO is associated with a faster lactate clearance, less fluid resuscitation, and less pulmonary edema when compared with NE for similar global and regional hemodynamic effects.
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304
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Saia F, Loforte A, Pacini D. Innovative transcatheter procedures for the treatment of heart failure. Cardiovasc Diagn Ther 2021; 11:292-300. [PMID: 33708500 DOI: 10.21037/cdt-20-335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The prevalence of heart failure (HF) continues to rise over time, with aging of the population and increased survival of incident cases. Major improvements occurred in drug therapy but morbidity and mortality of HF patients remain high. Some non-pharmacologic approaches to HF are already part of standard treatment for HF, including implantable cardioverter-defibrillators, cardiac resynchronization therapy (CRT) and left ventricular assist devices (LVADs). A number of transcatheter treatments and devices have been developed to improve management of valvular heart diseases (VHD), and some of them are being used or tested in specific HF conditions. For example, transcatheter aortic valve implantation (TAVI) to unload the left ventricle in patients with moderate aortic stenosis (AS) and HF or TAVI for severe aortic regurgitation (AR) in patients with LVADs. Similarly, percutaneous mitral valve repair can be used to improve prognosis and quality of life in patients with functional mitral valve regurgitation, and has been proposed as a bridge-to-LVAD or to heart transplant in selected patients. Other devices have been specifically developed for the treatment of chronic HF. In this review we describe the main devices used in the treatment of HF associated with aortic and mitral valve disease, as well as novel transcatheter interventions for chronic HF with different pathophysiologic targets.
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Affiliation(s)
- Francesco Saia
- Cardiology Unit, Cardio-Thoracic-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Antonino Loforte
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
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305
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Szabó GT, Ágoston A, Csató G, Rácz I, Bárány T, Uzonyi G, Szokol M, Sármán B, Jebelovszki É, Édes IF, Czuriga D, Kolozsvári R, Csanádi Z, Édes I, Kőszegi Z. Predictors of Hospital Mortality in Patients with Acute Coronary Syndrome Complicated by Cardiogenic Shock. SENSORS (BASEL, SWITZERLAND) 2021; 21:969. [PMID: 33535491 PMCID: PMC7867036 DOI: 10.3390/s21030969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/21/2021] [Accepted: 01/26/2021] [Indexed: 11/17/2022]
Abstract
As demonstrated by earlier studies, pre-hospital triage with trans-telephonic electrocardiogram (TTECG) and direct referral for catheter therapy shows great value in the management of out-of-hospital chest pain emergencies. It does not only improve in-hospital mortality in ST-segment elevation myocardial infarction, but it has also been identified as an independent predictor of higher in-hospital survival rate. Since TTECG-facilitated triage shortens both transport time and percutaneous coronary intervention (PCI)-related procedural time intervals, it was hypothesized that even high-risk patients with acute coronary syndrome (ACS) and cardiogenic shock (CS) might also benefit from TTECG-based triage. Here, we decided to examine our database for new triage- and left ventricular (LV) function-related parameters that can influence in-hospital mortality in ACS complicated by CS. ACS patients were divided into two groups, namely, (1) hospital death patients (n = 77), and (2) hospital survivors (control, n = 210). Interestingly, TTECG-based consultation and triage of CS and ACS patients were confirmed as significant independent predictors of lower hospital mortality risk (odds ratio (OR) 0.40, confidence interval (CI) 0.21-0.76, p = 0.0049). Regarding LV function and blood chemistry, a good myocardial reperfusion after PCI (high area at risk (AAR) blush score/AAR LV segment number; OR 0.85, CI 0.78-0.98, p = 0.0178) and high glomerular filtration rate (GFR) value at the time of hospital admission (OR 0.97, CI 0.96-0.99, p = 0.0042) were the most crucial independent predictors of a decreased risk of in-hospital mortality in this model. At the same time, a prolonged time interval between symptom onset and hospital admission, successful resuscitation, and higher peak creatine kinase activity were the most important independent predictors for an increased risk of in-hospital mortality. In ACS patients with CS, (1) an early TTECG-based teleconsultation and triage, as well as (2) good myocardial perfusion after PCI and a high GFR value at the time of hospital admission, appear as major independent predictors of a lower in-hospital mortality rate.
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Affiliation(s)
- Gábor Tamás Szabó
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - András Ágoston
- The III: Department of Internal Medicine, Szabolcs–Szatmár–Bereg County Hospitals and University Teaching Hospital, 4400 Nyíregyháza, Hungary;
| | - Gábor Csató
- Hungarian National Ambulance Service, 1024 Budapest, Hungary;
| | - Ildikó Rácz
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - Tamás Bárány
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - Gábor Uzonyi
- Department of Cardiology, Uzsoki Hospital, 1145 Budapest, Hungary; (G.U.); (B.S.)
| | - Miklós Szokol
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - Balázs Sármán
- Department of Cardiology, Uzsoki Hospital, 1145 Budapest, Hungary; (G.U.); (B.S.)
| | - Éva Jebelovszki
- Department of Cardiology, Faculty of Medicine, University of Szeged, 6725 Szeged, Hungary;
| | - István Ferenc Édes
- Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary;
| | - Dániel Czuriga
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - Rudolf Kolozsvári
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - Zoltán Csanádi
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - István Édes
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
| | - Zsolt Kőszegi
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (I.R.); (T.B.); (M.S.); (D.C.); (R.K.); (Z.C.); (I.É.); (Z.K.)
- The III: Department of Internal Medicine, Szabolcs–Szatmár–Bereg County Hospitals and University Teaching Hospital, 4400 Nyíregyháza, Hungary;
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306
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Scheeren TWL, Bakker J, Kaufmann T, Annane D, Asfar P, Boerma EC, Cecconi M, Chew MS, Cholley B, Cronhjort M, De Backer D, Dubin A, Dünser MW, Duranteau J, Gordon AC, Hajjar LA, Hamzaoui O, Hernandez G, Kanoore Edul V, Koster G, Landoni G, Leone M, Levy B, Martin C, Mebazaa A, Monnet X, Morelli A, Payen D, Pearse RM, Pinsky MR, Radermacher P, Reuter DA, Sakr Y, Sander M, Saugel B, Singer M, Squara P, Vieillard-Baron A, Vignon P, Vincent JL, van der Horst ICC, Vistisen ST, Teboul JL. Current use of inotropes in circulatory shock. Ann Intensive Care 2021; 11:21. [PMID: 33512597 PMCID: PMC7846624 DOI: 10.1186/s13613-021-00806-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/09/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock. METHODS From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions. RESULTS A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81-90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement). CONCLUSION Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.
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Affiliation(s)
- Thomas W. L. Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O.Box 30.001, 9700 RB Groningen, The Netherlands
| | - Jan Bakker
- New York University Medical Center, New York, USA
- Columbia University Medical Center, New York, USA
- Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Thomas Kaufmann
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O.Box 30.001, 9700 RB Groningen, The Netherlands
| | - Djillali Annane
- School of Medicine Simone Veil, Raymond Poincaré Hospital (APHP), Department of Intensive Care Medicine, University of Versailles- University Paris Saclay, Garches, France
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation Et de Médecine Hyperbare, Centre Hospitalier Universitaire Angers; and Institut MITOVASC, CNRS UMR 6215, INSERM U1083, Angers University, Angers, France
| | - E. Christiaan Boerma
- Medical Centre Leeuwarden, Department of Intensive Care, Leeuwarden, the Netherlands
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Milan, Italy
| | - Michelle S. Chew
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Bernard Cholley
- Department of Anaesthesiology & Intensive Care Medicine, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
- Université de Paris, Paris, France
| | - Maria Cronhjort
- Section of Anaesthesiology and Intensive Care, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Arnaldo Dubin
- Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata Y Servicio de Terapia Intensiva, Sanatorio Otamendi, Buenos Aires, Argentina
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Assistance Publique Des Hopitaux de Paris, Hôpitaux Universitaires Paris-Saclay, Université Paris-Saclay, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Ludhmila A. Hajjar
- Department of Cardiopneumology, Instituto Do Coracao, Universidade de São Paulo, Hospital SirioLibanes, São Paulo, Brazil
| | - Olfa Hamzaoui
- Assistance Publique-Hôpitaux de Paris, Paris Saclay University Hospitals, Antoine Béclère Hospital, Paris, France
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Marc Leone
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service D’Anesthésie Et de Réanimation CHU Nord, Marseille, France
| | - Bruno Levy
- Service de Réanimation Médicale Brabois Et Pôle Cardio-Médico-Chirurgical. CHRU Brabois, INSERM U1116, Université de Lorraine, Vandoeuvre les NancyNancy, 54500 France
| | - Claude Martin
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service D’Anesthésie Et de Réanimation CHU Nord, Marseille, France
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, APHP Hôpitaux Universitaires Saint Louis LariboisièreUniversité Paris DiderotU942 Inserm, Paris, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Paris-Saclay University Hospitals, Bicêtre hospital, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, FHU SEPSIS, Le Kremlin-Bicêtre, France
| | - Andrea Morelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Science, Sapienza University of Rome, Rome, Italy
| | - Didier Payen
- University Paris 7 Denis Diderot; INSERM 1160 and Hôpital Lariboisière, APHP, Paris, France
| | - Rupert M. Pearse
- William Harvey Research Institute, Queen Mary University of London, London, EC1M 6BQ UK
| | - Michael R. Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Peter Radermacher
- Institut Für Anästhesiologische Pathophysiologie Und Verfahrensentwicklung, Universitätsklinikum Ulm, Ulm, Germany
| | - Daniel A. Reuter
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, UKGM, Justus-Liebig University Giessen, Giessen, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Pierre Squara
- ICU Department, Réanimation CERIC, Clinique Ambroise Paré, Neuilly, France
| | - Antoine Vieillard-Baron
- Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, intensive care unit, Boulogne-Billancourt, France
- INSERM U-1018, CESP, Team 5, University of Versailles Saint-Quentin en Yvelines, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, INSERM CIC-1435, Teaching Hospital of Limoges, Limoges, France
- University of Limoges, Limoges, France
| | - Jean-Louis Vincent
- Université Libre de Bruxelles - Dept of Intensive Care, Erasme Univ Hospital, Brussels, Belgium
| | - Iwan C. C. van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Simon T. Vistisen
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Paris-Saclay University Hospitals, Bicêtre hospital, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, FHU SEPSIS, Le Kremlin-Bicêtre, France
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307
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Jentzer JC, Burstein B, Van Diepen S, Murphy J, Holmes DR, Bell MR, Barsness GW, Henry TD, Menon V, Rihal CS, Naidu SS, Baran DA. Defining Shock and Preshock for Mortality Risk Stratification in Cardiac Intensive Care Unit Patients. Circ Heart Fail 2021; 14:e007678. [PMID: 33464952 DOI: 10.1161/circheartfailure.120.007678] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies have defined preshock as isolated hypotension or isolated hypoperfusion, whereas shock has been variably defined as hypoperfusion with or without hypotension. We aimed to evaluate the mortality risk associated with hypotension and hypoperfusion at the time of admission in a cardiac intensive care unit population. METHODS We analyzed Mayo Clinic cardiac intensive care unit patients admitted between 2007 and 2015. Hypotension was defined as systolic blood pressure <90 mm Hg or mean arterial pressure <60 mm Hg, and hypoperfusion as admission lactate >2 mmol/L, oliguria, or rising creatinine. Associations between hypotension and hypoperfusion with hospital mortality were estimated using multivariable logistic regression. RESULTS Among 10 004 patients with a median age of 69 years, 43.1% had acute coronary syndrome, and 46.1% had heart failure. Isolated hypotension was present in 16.7%, isolated hypoperfusion in 15.3%, and 8.7% had both hypotension and hypoperfusion. Stepwise increases in hospital mortality were observed with hypotension and hypoperfusion compared with neither hypotension nor hypoperfusion (3.3%; all P<0.001): isolated hypotension, 9.3% (adjusted odds ratio, 1.7 [95% CI, 1.4-2.2]); isolated hypoperfusion, 17.2% (adjusted odds ratio, 2.3 [95% CI, 1.9-3.0]); both hypotension and hypoperfusion, 33.8% (adjusted odds ratio, 2.8 [95% CI, 2.1-3.6]). Adjusted hospital mortality in patients with isolated hypoperfusion was higher than in patients with isolated hypotension (P=0.02) and not significant different from patients with both hypotension and hypoperfusion (P=0.18). CONCLUSIONS Hypotension and hypoperfusion are both associated with increased mortality in cardiac intensive care unit patients. Hospital mortality is higher with isolated hypoperfusion or concomitant hypotension and hypoperfusion (classic shock). We contend that preshock should refer to isolated hypotension without hypoperfusion, while patients with hypoperfusion can be considered to have shock, irrespective of blood pressure.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine (J.C.J., J.M., D.R.H., M.R.B., G.W.B., C.S.R.), Mayo Clinic, Rochester, MN.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine (J.C.J., B.B.), Mayo Clinic, Rochester, MN
| | - Barry Burstein
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine (J.C.J., B.B.), Mayo Clinic, Rochester, MN
| | - Sean Van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton (S.v.D.)
| | - Joseph Murphy
- Department of Cardiovascular Medicine (J.C.J., J.M., D.R.H., M.R.B., G.W.B., C.S.R.), Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine (J.C.J., J.M., D.R.H., M.R.B., G.W.B., C.S.R.), Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine (J.C.J., J.M., D.R.H., M.R.B., G.W.B., C.S.R.), Mayo Clinic, Rochester, MN
| | - Gregory W Barsness
- Department of Cardiovascular Medicine (J.C.J., J.M., D.R.H., M.R.B., G.W.B., C.S.R.), Mayo Clinic, Rochester, MN
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, OH (T.D.H.)
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic, OH (V.M.)
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine (J.C.J., J.M., D.R.H., M.R.B., G.W.B., C.S.R.), Mayo Clinic, Rochester, MN
| | - Srihari S Naidu
- Westchester Medical Center and New York Medical College, Valhalla (S.S.N.)
| | - David A Baran
- Sentara Heart Hospital, Advanced Heart Failure Center and Eastern Virginia Medical School, Norfolk, Virginia (D.A.B.)
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308
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Scheen M, Giraud R, Bendjelid K. Stress hyperglycemia, cardiac glucotoxicity, and critically ill patient outcomes current clinical and pathophysiological evidence. Physiol Rep 2021; 9:e14713. [PMID: 33463901 PMCID: PMC7814494 DOI: 10.14814/phy2.14713] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/09/2020] [Accepted: 12/12/2020] [Indexed: 01/07/2023] Open
Abstract
Stress hyperglycemia is a transient increase in blood glucose during acute physiological stress in the absence of glucose homeostasis dysfunction. Its's presence has been described in critically ill patients who are subject to many physiological insults. In this regard, hyperglycemia and impaired glucose tolerance are also frequent in patients who are admitted to the intensive care unit for heart failure and cardiogenic shock. The hyperglycemia observed at the beginning of these cardiac disorders appears to be related to a variety of stress mechanisms. The release of major stress and steroid hormones, catecholamine overload, and glucagon all participate in generating a state of insulin resistance with increased hepatic glucose output and glycogen breakdown. In fact, the observed pathophysiological response, which appears to regulate a stress situation, is harmful because it induces mitochondrial impairment, oxidative stress-related injury to cells, endothelial damage, and dysfunction of several cellular channels. Paradigms are now being challenged by growing evidence of a phenomenon called glucotoxicity, providing an explanation for the benefits of lowering glucose levels with insulin therapy in these patients. In the present review, the authors present the data published on cardiac glucotoxicity and discuss the benefits of lowering plasma glucose to improve heart function and to positively affect the course of critical illness.
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Affiliation(s)
- Marc Scheen
- Intensive Care Division, University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Faculty of Medicine, Geneva, Switzerland
| | - Raphael Giraud
- Intensive Care Division, University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Faculty of Medicine, Geneva, Switzerland
| | - Karim Bendjelid
- Intensive Care Division, University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Faculty of Medicine, Geneva, Switzerland
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309
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Comparison of Mortality Risk Models in Patients with Postcardiac Arrest Cardiogenic Shock and Percutaneous Mechanical Circulatory Support. J Interv Cardiol 2021; 2021:8843935. [PMID: 33536855 PMCID: PMC7834787 DOI: 10.1155/2021/8843935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/20/2020] [Accepted: 12/30/2020] [Indexed: 11/17/2022] Open
Abstract
Background Although scoring systems are widely used to predict outcomes in postcardiac arrest cardiogenic shock (CS) after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI), data concerning the accuracy of these scores to predict mortality of patients treated with Impella in this setting are lacking. Thus, we aimed to evaluate as well as to compare the prognostic accuracy of acute physiology and chronic health II (APACHE II), simplified acute physiology score II (SAPS II), sepsis-related organ failure assessment (SOFA), the intra-aortic balloon pump (IABP), CardShock, the prediction of cardiogenic shock outcome for AMI patients salvaged by VA-ECMO (ENCOURAGE), and the survival after venoarterial extracorporeal membrane oxygenation (SAVE) score in patients with OHCA refractory CS due to an AMI treated with Impella 2.5 or CP. Methods Retrospective study of 65 consecutive Impella 2.5 and 32 CP patients treated in our cardiac arrest center from September 2015 until June 2020. Results Overall survival to discharge was 44.3%. The expected mortality according to scores was SOFA 70%, SAPS II 90%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 50%, and SAVE score 70% in the 2.5 group; SOFA 70%, SAPS II 85%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 75%, and SAVE score 70% in the CP group. The ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under the curve (AUC) of 0.79, followed by the CardShock, APACHE II, IABP, and SAPS score. These derived an AUC between 0.71 and 0.78. The SOFA and the SAVE scores failed to predict the outcome in this particular setting of refractory CS after OHCA due to an AMI. Conclusion The available intensive care and newly developed CS scores offered only a moderate prognostic accuracy for outcomes in OHCA patients with refractory CS due to an AMI treated with Impella. A new score is needed in order to guide the therapy in these patients.
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310
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Miller PE, Chouairi F, Thomas A, Kunitomo Y, Aslam F, Canavan ME, Murphy C, Daggula K, Metkus T, Vallabhajosyula S, Carnicelli A, Katz JN, Desai NR, Ahmad T, Velazquez EJ, Brennan J. Transition From an Open to Closed Staffing Model in the Cardiac Intensive Care Unit Improves Clinical Outcomes. J Am Heart Assoc 2021; 10:e018182. [PMID: 33412899 PMCID: PMC7955420 DOI: 10.1161/jaha.120.018182] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Several studies have shown improved outcomes in closed compared with open medical and surgical intensive care units. However, very little is known about the ideal organizational structure in the modern cardiac intensive care unit (CICU). Methods and Results We retrospectively reviewed consecutive unique admissions (n=3996) to our tertiary care CICU from September 2013 to October 2017. The aim of our study was to assess for differences in clinical outcomes between an open compared with a closed CICU. We used multivariable logistic regression adjusting for demographics, comorbidities, and severity of illness. The primary outcome was in-hospital mortality. We identified 2226 patients in the open unit and 1770 in the closed CICU. The unadjusted in-hospital mortality in the open compared with closed unit was 9.6% and 8.9%, respectively (P=0.42). After multivariable adjustment, admission to the closed unit was associated with a lower in-hospital mortality (odds ratio [OR], 0.69; 95% CI: 0.53-0.90, P=0.007) and CICU mortality (OR, 0.70; 95% CI, 0.52-0.94, P=0.02). In subgroup analysis, admissions for cardiac arrest (OR, 0.42; 95% CI, 0.20-0.88, P=0.02) and respiratory insufficiency (OR, 0.43; 95% CI, 0.22-0.82, P=0.01) were also associated with a lower in-hospital mortality in the closed unit. We did not find a difference in CICU length of stay or total hospital charges (P>0.05). Conclusions We found an association between lower in-hospital and CICU mortality after the transition to a closed CICU. These results may help guide the ongoing redesign in other tertiary care CICUs.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT.,Yale National Clinicians Scholar Program New Haven CT
| | - Fouad Chouairi
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Alexander Thomas
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Yukiko Kunitomo
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Faisal Aslam
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Maureen E Canavan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center Yale School of Medicine New Haven CT
| | | | - Krishna Daggula
- Joint Data Analytics Team Yale New Haven Hospital New Haven CT
| | - Thomas Metkus
- Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | | | | | - Jason N Katz
- Section of Cardiovascular Medicine Duke University Durham NC
| | - Nihar R Desai
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research & Evaluation (CORE) Yale School of Medicine New Haven CT
| | - Tariq Ahmad
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research & Evaluation (CORE) Yale School of Medicine New Haven CT
| | - Eric J Velazquez
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Joseph Brennan
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
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311
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Czerwińska-Jelonkiewicz K, Montero S, Bañeras J, Wood A, Zeid A, De Rosa S, Guerra F, Tica O, Serrano F, Bohm A, Ahrens I, Gierlotka M, Masip J, Bonnefoy E, Lettino M, Kirchhof P, Sionis A. Current status and needs for changes in critical care training: the voice of the young cardiologists. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:94-101. [PMID: 33580774 DOI: 10.1093/ehjacc/zuaa027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/03/2020] [Accepted: 09/22/2020] [Indexed: 01/22/2023]
Abstract
AIMS The implementation of the 2013 European Society of Cardiology (ESC) Core Curriculum guidelines for acute cardiovascular care (acc) training among European countries is unknown. We aimed to evaluate the current status of acc training among cardiology trainees and young cardiologists (<40 years) from ESC countries. METHODS AND RESULTS The survey (March-July 2019) asked about details of cardiology training, self-confidence in acc technical and non-technical skills, access to training opportunities, and needs for further training in the field. Overall 614 young doctors, 31 (26-43) years old, 55% males were surveyed. Place and duration of acc training differed between countries and between centres in the same country. Although the majority of the respondents (91%) had completed their acc training, the average self-confidence to perform invasive procedures and to manage acc clinical scenarios was low-44% (27.3-70.4). The opportunities for simulation-based learning were scarce-18% (5.8-51.3), as it was previous leadership training (32%) and knowledge about key teamwork principles was poor (48%). The need for further acc training was high-81% (61.9-94.3). Male gender, higher level of training centres, professional qualifications of respondents, longer duration of acc/intensive care training, debriefings, and previous leadership training as well as knowledge about teamwork were related to higher self-confidence in all investigated aspects. CONCLUSIONS The current cardiology training program is burdened by deficits in acc technical/non-technical skills, substantial variability in programs across ESC countries, and a clear gender-related disparity in outcomes. The forthcoming ESC Core Curriculum for General Cardiology is expected to address these deficiencies.
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Affiliation(s)
- Katarzyna Czerwińska-Jelonkiewicz
- Andrzej Frycz Modrzewski Krakow University, Gustawa Herlinga-Grudzinskiego 1, 30-705 Krakow, Poland.,Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Hill End Road, UB9 6JH, London, UK
| | - Santiago Montero
- Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia.,Departament de Medicina, Universitat Autònoma de Barcelona, Plaça Cívica 08193 Bellaterra, Barcelona, Spain
| | - J Bañeras
- Acute Cardiovascular Care Unit, Department of Cardiology, Centre de Simulació Clínica Avançada VHISCA, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, 119, 08035 Barcelona, Spain
| | - A Wood
- University Hospital of Leicester, Leicester, LE3 9QP, UK
| | - A Zeid
- El Maamoura Chest Hospital-Cardiology Department, Alexandria, Egypt
| | - S De Rosa
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, 88100 Calabria, Italy
| | - F Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", 60121 Ancona Italy
| | - O Tica
- Faculty of Medicine and Pharmacy, Medical Discipline, University of Oradea, 1st of December Square, no 10, Oradea, Bihor County, Romania
| | - F Serrano
- The European Society of Cardiology, Sophia Antipolis, CS 80179 Biot, France
| | - A Bohm
- Department of Acute Cardiology, National Institute of Cardiovascular Diseases, 833 48 Bratislava 37, Slovakia
| | - I Ahrens
- Cardiology and Medical Intensive Care, Augustinerinnen Hospital, 50678 Cologne, Germany
| | - M Gierlotka
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, pl. Kopernika 11a 45-040 Opole, Poland
| | - J Masip
- Intensive Care Department, Consorci Sanitari Integral University of Barcelona, Barcelona, AVENIDA JOSEP MOLINS, 29 - 41 08906, Spain
| | - E Bonnefoy
- Intensive Cardiac Care Unit, Cardiologic Hospital Louis Pradel, Hospices Civils de Lyon, Université Lyon 1, 69002 Lyon, France
| | - M Lettino
- Cardiovascular Department, San Gerardo Hospital, ASST-Monza, Via Pegolesi 33 20900 Monza, Italy
| | - P Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, B15 2TT Birmingham, UK.,University Heart and Vascular Center, UKE Hamburg, Martinistraße 52 20246, Hamburg, Germany
| | - A Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Carrer de Sant Quintí, 89, 08041, Barcelona, Spain
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312
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van Diepen S, Morrow DA. Potential growth in cardiogenic shock research though an international registry collaboration: the merits and challenges of a Hub-of-Spokes model. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:3-5. [PMID: 33580781 DOI: 10.1093/ehjacc/zuaa038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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313
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Biochemical markers for clinical monitoring of tissue perfusion. Mol Cell Biochem 2021; 476:1313-1326. [PMID: 33387216 PMCID: PMC7921020 DOI: 10.1007/s11010-020-04019-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
The assessment and monitoring of the tissue perfusion is extremely important in critical conditions involving circulatory shock. There is a wide range of established methods for the assessment of cardiac output as a surrogate of oxygen delivery to the peripheral tissues. However, the evaluation of whether particular oxygen delivery is sufficient to ensure cellular metabolic demands is more challenging. In recent years, specific biochemical parameters have been described to indicate the status between tissue oxygen demands and supply. In this review, the authors summarize the application of some of these biochemical markers, including mixed venous oxygen saturation (SvO2), lactate, central venous–arterial carbon dioxide difference (PCO2 gap), and PCO2 gap/central arterial-to-venous oxygen difference (Ca–vO2) for hemodynamic assessment of tissue perfusion. The thorough monitoring of the adequacy of tissue perfusion and oxygen supply in critical conditions is essential for the selection of the most appropriate therapeutic strategy and it is associated with improved clinical outcomes.
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314
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Schwartz B, Jain P, Salama M, Kapur NK. The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges. Expert Rev Cardiovasc Ther 2020; 19:151-164. [PMID: 33356662 DOI: 10.1080/14779072.2021.1863147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Cardiogenic shock due to acute myocardial infarction and decompensated advanced heart failure remains a source of significant morbidity and mortality. Endovascular mechanical circulatory support devices including intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (Impella and Tandemheart pumps), and veno-arterial extracorporeal oxygenation (VA-ECMO) are utilized for a broadening range of indications.Areas covered: This narrative review explores the specific devices, their distinctive hemodynamic profiles, and practical considerations. Furthermore, reviewed are the trials evaluating device outcomes which have generated significant controversy within the field of heart failure and shock. New applications and future directions are discussed.Expert opinion: Use of endovascular mechanical circulatory support has increased over the last decade, though evidence supporting their use is lacking. Development of large-scale prospective registries and clinical classification systems will facilitate patient enrollment and inform trial design. Furthermore, expansion of indications for these devices is revolutionizing how the field of heart failure and cardiogenic shock thinks about hemodynamic support. The ability to tailor therapy to a patient's specific hemodynamic profile appears to be the future of cardiogenic shock management.
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Affiliation(s)
- Benjamin Schwartz
- Department of Internal Medicine, Tufts Medical Center, Boston, MA, USATurkey
| | - Pankaj Jain
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
| | - Michael Salama
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
| | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
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315
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Sawada K, Kawakami S, Murata S, Nishimura K, Tahara Y, Hosoda H, Nakashima T, Kataoka Y, Asaumi Y, Noguchi T, Sugimachi M, Fujita T, Kobayashi J, Yasuda S. Predicting Parameters for Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock. ESC Heart Fail 2020; 8:471-480. [PMID: 33264500 PMCID: PMC7835592 DOI: 10.1002/ehf2.13097] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/24/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022] Open
Abstract
Aims Percutaneous veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is utilized for patients with cardiogenic shock or cardiac arrest. However, the procedure protocol for weaning from VA‐ECMO has not been well established. The present study aimed to determine the usefulness of echocardiographic and pulmonary artery catheter parameters for predicting successful weaning from VA‐ECMO in patients with refractory cardiogenic shock. Methods and results We retrospectively studied 50 patients who were hospitalized and supported by VA‐ECMO for >48 h between January 2013 and March 2017. Patients successfully weaned from VA‐ECMO without reintroduction of VA‐ECMO or left ventricular assist device implantation were defined as 30 day survivors. Echocardiographic and pulmonary artery catheter parameters were evaluated when ECMO flow was limited to a maximum of 1.5–2.0 L/min. Twenty‐four patients were successfully weaned from VA‐ECMO, whereas 26 were not. Fractional shortening, corrected left ventricular ejection time (LVETc, defined as LVET divided by the square root of heart rate), left ventricular outflow tract velocity time integral, and LVETc divided by pulmonary artery wedge pressure (PAWP) were significantly larger in the 30 day survivor groups. Multivariable analysis revealed LVETc∕PAWP as a significant independent predictor of successful weaning (LVETc∕PAWP, odds ratio 0.82, 95% confidence interval 0.71–0.94, P = 0.005). Receiver operating characteristic curve analysis revealed 15.9 as the optimal LVETc∕PAWP for predicting successful weaning (area under the curve 0.82). Conclusions The present findings indicate that LVETc∕PAWP is a potential predictor of successful weaning from VA‐ECMO.
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Affiliation(s)
- Kenichiro Sawada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shoji Kawakami
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Shunsuke Murata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Hayato Hosoda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takahiro Nakashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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316
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Samsky MD, Krucoff MW, Morrow DA, Abraham WT, Aguel F, Althouse AD, Chen E, Cigarroa JE, DeVore AD, Farb A, Gilchrist IC, Henry TD, Hochman JS, Kapur NK, Morrow V, Ohman EM, O'Neill WW, Piña IL, Proudfoot AG, Sapirstein JS, Seltzer JH, Senatore F, Shinnar M, Simonton CA, Tehrani BN, Thiele H, Truesdell AG, Waksman R, Rao SV. Cardiac safety research consortium "shock II" think tank report: Advancing practical approaches to generating evidence for the treatment of cardiogenic shock. Am Heart J 2020; 230:93-97. [PMID: 33011148 DOI: 10.1016/j.ahj.2020.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/29/2022]
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317
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Farhan S, Vogel B, Montalescot G, Barthelemy O, Zeymer U, Desch S, de Waha-Thiele S, Maier LS, Sandri M, Akin I, Fuernau G, Ouarrak T, Hauguel-Moreau M, Schneider S, Thiele H, Huber K. Association of Culprit Lesion Location With Outcomes of Culprit-Lesion-Only vs Immediate Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Cardiol 2020; 5:1329-1337. [PMID: 32845312 DOI: 10.1001/jamacardio.2020.3377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Myocardial infarction with a culprit lesion located in the left main or proximal left anterior descending artery compared with other coronary segments is associated with more myocardium at risk and worse clinical outcomes. Objective To evaluate the association of culprit lesion location with outcomes of culprit-lesion-only percutaneous coronary intervention with optional staged revascularization vs immediate multivessel percutaneous coronary intervention in patients with multivessel disease, myocardial infarction, and cardiogenic shock. Design, Setting, and Participants Post hoc analysis of the Culprit Lesion Only Coronary Intervention vs Multivessel Coronary Intervention in Cardiogenic Shock (CULPRIT-SHOCK), an investigator-initiated randomized, open-label clinical trial. Patients with multivessel disease, acute myocardial infarction, and cardiogenic shock were enrolled at 83 European centers from April 2013 through April 2017. Interventions Patients were randomized to culprit-lesion-only percutaneous coronary intervention with optional staged revascularization or immediate multivessel percutaneous coronary intervention (1:1). For this analysis, patients were stratified by culprit lesion location in the left main or proximal left anterior descending artery group and other-culprit-lesion location group. Main Outcomes and Measures End points included a composite of death or kidney replacement therapy at 30 days and death at 1 year. Results The median age of the study population was 70 (interquartile range, 60-78 years) and 524 of the study participants were men (76.4%). Of the 685 patients, 33.4% constituted the left main or proximal left anterior descending artery group and 66.6% the other-culprit-lesion location group. The left main or proximal left anterior descending artery group had worse outcomes compared with the other-culprit-lesion location group (56.8% vs 47.5%; P = .02 for the composite end point at 30 days and 59.8% vs 50.1%; P = .02 for death at 1 year). In both groups, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a reduced risk of the composite end point at 30 days (49.1% vs 64.3% and 44.1% vs 50.9%; P for interaction = .27). At 1 year, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a significantly reduced risk of death in the left main or proximal left anterior descending artery but not the other-culprit-lesion location group (50.0% vs 69.6%; P = .003 and 49.8% vs 50.4%; P = .89; P for interaction = 0.02). Conclusions and Relevance In patients with multivessel disease with myocardial infarction and cardiogenic shock, a culprit lesion located in the left main or proximal left anterior descending artery vs other coronary segments was associated with worse outcomes. These patients may especially benefit from culprit-lesion-only percutaneous coronary intervention with optional staged revascularization, although further investigation is needed to confirm this finding. Trial Registration ClinicalTrials.gov Identifier: NCT01927549.
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Affiliation(s)
- Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Wilhelminenspital, Department of Cardiology, Vienna, Austria
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Wilhelminenspital, Department of Cardiology, Vienna, Austria
| | - Gilles Montalescot
- ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Sorbonne Université Paris 6, Paris, France
| | - Olivier Barthelemy
- ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Sorbonne Université Paris 6, Paris, France
| | - Uwe Zeymer
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Steffen Desch
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Suzanne de Waha-Thiele
- Department of Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany
| | - Lars S Maier
- Department of Cardiology, Pneumology, and Intensive Care, University Hospital Regensburg, Regensburg, Germany
| | - Marcus Sandri
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Ibrahim Akin
- University Medical Centre Mannheim, First Department of Medicine, Faculty of Medicine, University of Heidelberg, Mannheim, Germany
| | - Georg Fuernau
- Department of Internal Medicine/Cardiology/Angiology/Intensive Care Medicine, University Heart Center Luebeck, Luebeck, Germany
| | | | - Marie Hauguel-Moreau
- ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Sorbonne Université Paris 6, Paris, France
| | | | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Kurt Huber
- Wilhelminenspital, Department of Cardiology, Vienna, Austria.,Medical School, Sigmund Freud University, Vienna, Austria
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Abstract
PURPOSE OF REVIEW To appraise the basic and more advanced methods available for hemodynamic monitoring, and describe the definitions and criteria for the use of hemodynamic variables. RECENT FINDINGS The hemodynamic assessment in critically ill patients suspected of circulatory shock follows a step-by-step algorithm to help determine diagnosis and prognosis. Determination of accurate diagnosis and prognosis in turn is crucial for clinical decision-making. Basic monitoring involving clinical examination in combination with hemodynamic variables obtained with an arterial catheter and a central venous catheter may be sufficient for the majority of patients with circulatory shock. In case of uncertainty of the underlying cause or to guide treatment in severe shock may require additional advanced hemodynamic technologies, and each is utilized for different indications and has specific limitations. Future developments include refining the clinical examination and performing studies that demonstrate better patient outcomes by targeting hemodynamic variables using advanced hemodynamic monitoring. SUMMARY Determination of accurate diagnosis and prognosis for patients suspected of circulatory shock is essential for optimal decision-making. Numerous techniques are available, and each has its specific indications and value.
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van Diepen S. Routine Unloading in Patients Treated With Extracorporeal Membrane Oxygenation for Cardiogenic Shock: Mixed Outcomes Set the Stage for Future Trials. Circulation 2020; 142:2107-2109. [PMID: 33252999 DOI: 10.1161/circulationaha.120.050847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada. Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
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Lang CN, Kaier K, Zotzmann V, Stachon P, Pottgiesser T, von Zur Muehlen C, Zehender M, Duerschmied D, Schmid B, Bode C, Wengenmayer T, Staudacher DL. Cardiogenic shock: incidence, survival and mechanical circulatory support usage 2007-2017-insights from a national registry. Clin Res Cardiol 2020; 110:1421-1430. [PMID: 33258007 PMCID: PMC8405485 DOI: 10.1007/s00392-020-01781-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022]
Abstract
Background A central element in the management of cardiogenic shock (CS) comprises mechanical circulatory support (MCS) systems to maintain cardiac output (CO). This study aims to quantify incidence, outcome and influence of MCS in CS over the last decade. Methods All patients hospitalized with CS in a tertiary university hospital in Germany between 2007 and 2017 were identified utilizing the international coding system ICD-10 with code R57.0. Application of MCS was identified via German procedure classification codes (OPS). Results 383,983 cases of cardiogenic shock were reported from 2007 to 2017. Patients had a mean age of 71 years and 38.5% were female. The incidence of CS rose by 65.6% from 26,828 cases in 2007 (33.1 per 100,000 person-years, hospital survival 39.2%) to 44,425 cases in 2017 (53.7 per 100,000 person-years, survival 41.2%). In 2007, 16.0% of patients with CS received MCS (4.6 per 100,000 person-years, survival 46.6%), dropping to 13.9% in 2017 (6.6 per 100,000 person-years, survival 38.6%). Type of MCS changed over the years, with decreasing use of the intra-aortic balloon pump (IABP), an increase in extracorporeal membrane oxygenation (VA-ECMO) and percutaneous ventricular assist device (pVAD) usage. Significant differences regarding in-hospital survival were observed between the devices (survival: overall: 40.2%; medical treatment = 39.5%; IABP = 49.5%; pVAD = 36.2%; VA-ECMO = 30.5%; p < 0.001). Conclusions The incidence of CS is increasing, but hospital survival remains low. MCS was used in a minority of patients, and the percentage of MCS usage in CS has decreased. The use rates of the competing devices change over time. Graphical Abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01781-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Corinna N Lang
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Faculty of Medicine, Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torben Pottgiesser
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Muehlen
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Vrints CJ. Update on the management of cardiogenic shock complicating acute myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:99-101. [PMID: 32157922 DOI: 10.1177/2048872620914499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Scherer C, Lüsebrink E, Kupka D, Stocker TJ, Stark K, Stremmel C, Orban M, Petzold T, Germayer A, Mauthe K, Kääb S, Mehilli J, Braun D, Theiss H, Brunner S, Hausleiter J, Massberg S, Orban M. Long-Term Clinical Outcome of Cardiogenic Shock Patients Undergoing Impella CP Treatment vs. Standard of Care. J Clin Med 2020; 9:jcm9123803. [PMID: 33255393 PMCID: PMC7760637 DOI: 10.3390/jcm9123803] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/02/2020] [Accepted: 11/21/2020] [Indexed: 12/13/2022] Open
Abstract
The number of patients treated with the mechanical circulatory support device Impella Cardiac Power (CP) for cardiogenic shock is steadily increasing. The aim of this study was to investigate long-term survival and complications related to this modality. Patients undergoing Impella CP treatment for cardiogenic shock were retrospectively enrolled and matched with cardiogenic shock patients not treated with mechanical circulatory support between 2010 and 2020. Data were collected from the cardiogenic shock registry of the university hospital of Munich (DRKS00015860). 70 patients with refractory cardiogenic shock without mechanical circulatory support were matched with 70 patients treated with Impella CP. At presentation, the mean age was 67 ± 15 years with 80% being male in the group without support and 67 ± 14 years (p = 0.97) with 76% being male (p = 0.68) in the group with Impella. There was no significant difference in the rate of cardiac arrest (47% vs. 51%, p = 0.73) and myocardial infarction was the predominant cause of cardiogenic shock in both groups (70% vs. 77%). A total of 41% of patients without cardiocirculatory support and 54% of patients with Impella support died during the first month (p = 0.17). After one year, mortality rates were similar in both groups (55% in conventional vs. 59% in Impella CP group, p = 0.30) as was mortality rate at long-term 5-years follow-up (64% in conventional vs. 73% in Impella CP group, p = 0.33). The rate of clinically significant bleedings during ICU stay was lower in the conventional group than in the Impella support group (15% vs. 43%, p = 0.002). In this small observational and non-randomized analysis no difference in long-term outcome between patients treated with Impella CP vs. guideline directed cardiogenic shock therapy without mechanical circulatory support could be detected. Care must be taken regarding the high rate of bleeding and vascular complications when using Impella CP. Large, adequately powered studies are urgently needed to investigate the efficacy and safety of Impella CP in cardiogenic shock.
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Affiliation(s)
- Clemens Scherer
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Enzo Lüsebrink
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Danny Kupka
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Thomas J. Stocker
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Konstantin Stark
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christopher Stremmel
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Antonia Germayer
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Katharina Mauthe
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Stefan Kääb
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Julinda Mehilli
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Daniel Braun
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Hans Theiss
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Stefan Brunner
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Jörg Hausleiter
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Steffen Massberg
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Martin Orban
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
- Correspondence: or ; Tel.: +49-(0)-4400-75221
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[Cardiogenic shock]. Wien Klin Wochenschr 2020; 132:333-348. [PMID: 32095880 DOI: 10.1007/s00508-020-01612-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Cardiogenic shock (CS) is defined as end-organ hypoperfusion as the consequence of primary myocardial dysfunction. Among the diagnostic criteria are a systolic blood pressure < 90 mmHg, acute renal failure (oligoanuria), ischemic hepatitis, cyanosis and cold, clammy skin. Accepted hemodynamic cutoffs are a cardiac index < 2,2 (l/min)/m2 and a pulmonary capillary wedge pressure > 15 mmHg. It should be acknowledged, that a normal blood pressure does not rule out CS; there is a nonhypotensive variant of CS demonstrating all the signs mentioned above (including elevated lactate levels) while the blood pressure is compensated due to vasoconstriction.The single most frequent cause of CS is pump failure in the setting of an acute myocardial infarction and its mortality rate has been lowered to 40-50%, owing to the widespread availability of primary PCI. Regarding PCI, it has been demonstrated recently that a "culprit-lesion only strategy" should be followed in the setting of CS. Other important causes of CS to take into account are mechanical complications of myocardial infarction (papillary and ventricular septal rupture as well as rupture of the myocardial free wall leading to tamponade), valvular heart disease (mostly decompensated aortic stenosis) as well as myocarditis and end stage cardiomyopathy.The diagnosis of CS is made by patient history, physical examination, ECG, echocardiography and coronary angiography. Echocardiography should always be performed before coronary angiography because, in the case of mechanical complications, it significantly alters the management of the patients. Patients with clinical signs of CS but paradoxically preserved ejection fraction must be thoroughly evaluated for the presence of a papillary muscle rupture, particularly in the setting of a lateral wall infarction.Noradrenaline and dobutamine are the first-line agents for medical stabilization. When such conventional measures fail, extracorporeal support devices such as ECMO or Impella© may be used. Currently, trials are underway to assess wheter these devices confer a survival benefit in this high-risk population.
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Uhlig K, Efremov L, Tongers J, Frantz S, Mikolajczyk R, Sedding D, Schumann J. Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome. Cochrane Database Syst Rev 2020; 11:CD009669. [PMID: 33152122 PMCID: PMC8094388 DOI: 10.1002/14651858.cd009669.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) and low cardiac output syndrome (LCOS) are potentially life-threatening complications of acute myocardial infarction (AMI), heart failure (HF) or cardiac surgery. While there is solid evidence for the treatment of other cardiovascular diseases of acute onset, treatment strategies in haemodynamic instability due to CS and LCOS remains less robustly supported by the given scientific literature. Therefore, we have analysed the current body of evidence for the treatment of CS or LCOS with inotropic and/or vasodilating agents. This is the second update of a Cochrane review originally published in 2014. OBJECTIVES Assessment of efficacy and safety of cardiac care with positive inotropic agents and vasodilator agents in CS or LCOS due to AMI, HF or after cardiac surgery. SEARCH METHODS We conducted a search in CENTRAL, MEDLINE, Embase and CPCI-S Web of Science in October 2019. We also searched four registers of ongoing trials and scanned reference lists and contacted experts in the field to obtain further information. No language restrictions were applied. SELECTION CRITERIA Randomised controlled trials (RCTs) enrolling patients with AMI, HF or cardiac surgery complicated by CS or LCOS. DATA COLLECTION AND ANALYSIS We used standard methodological procedures according to Cochrane standards. MAIN RESULTS We identified 19 eligible studies including 2385 individuals (mean or median age range 56 to 73 years) and three ongoing studies. We categorised studies into 11 comparisons, all against standard cardiac care and additional other drugs or placebo. These comparisons investigated the efficacy of levosimendan versus dobutamine, enoximone or placebo; enoximone versus dobutamine, piroximone or epinephrine-nitroglycerine; epinephrine versus norepinephrine or norepinephrine-dobutamine; dopexamine versus dopamine; milrinone versus dobutamine and dopamine-milrinone versus dopamine-dobutamine. All trials were published in peer-reviewed journals, and analyses were done by the intention-to-treat (ITT) principle. Eighteen of 19 trials were small with only a few included participants. An acknowledgement of funding by the pharmaceutical industry or missing conflict of interest statements occurred in nine of 19 trials. In general, confidence in the results of analysed studies was reduced due to relevant study limitations (risk of bias), imprecision or indirectness. Domains of concern, which showed a high risk in more than 50% of included studies, encompassed performance bias (blinding of participants and personnel) and bias affecting the quality of evidence on adverse events. All comparisons revealed uncertainty on the effect of inotropic/vasodilating drugs on all-cause mortality with a low to very low quality of evidence. In detail, the findings were: levosimendan versus dobutamine (short-term mortality: RR 0.60, 95% CI 0.36 to 1.03; participants = 1701; low-quality evidence; long-term mortality: RR 0.84, 95% CI 0.63 to 1.13; participants = 1591; low-quality evidence); levosimendan versus placebo (short-term mortality: no data available; long-term mortality: RR 0.55, 95% CI 0.16 to 1.90; participants = 55; very low-quality evidence); levosimendan versus enoximone (short-term mortality: RR 0.50, 0.22 to 1.14; participants = 32; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine-dobutamine (short-term mortality: RR 1.25; 95% CI 0.41 to 3.77; participants = 30; very low-quality evidence; long-term mortality: no data available); dopexamine versus dopamine (short-term mortality: no deaths in either intervention arm; participants = 70; very low-quality evidence; long-term mortality: no data available); enoximone versus dobutamine (short-term mortality RR 0.21; 95% CI 0.01 to 4.11; participants = 27; very low-quality evidence; long-term mortality: no data available); epinephrine versus norepinephrine (short-term mortality: RR 1.81, 0.89 to 3.68; participants = 57; very low-quality evidence; long-term mortality: no data available); and dopamine-milrinone versus dopamine-dobutamine (short-term mortality: RR 1.0, 95% CI 0.34 to 2.93; participants = 20; very low-quality evidence; long-term mortality: no data available). No information regarding all-cause mortality were available for the comparisons milrinone versus dobutamine, enoximone versus piroximone and enoximone versus epinephrine-nitroglycerine. AUTHORS' CONCLUSIONS At present, there are no convincing data supporting any specific inotropic or vasodilating therapy to reduce mortality in haemodynamically unstable patients with CS or LCOS. Considering the limited evidence derived from the present data due to a high risk of bias and imprecision, it should be emphasised that there is an unmet need for large-scale, well-designed randomised trials on this topic to close the gap between daily practice in critical care of cardiovascular patients and the available evidence. In light of the uncertainties in the field, partially due to the underlying methodological flaws in existing studies, future RCTs should be carefully designed to potentially overcome given limitations and ultimately define the role of inotropic agents and vasodilator strategies in CS and LCOS.
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Affiliation(s)
- Konstantin Uhlig
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Ljupcho Efremov
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Jörn Tongers
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Stefan Frantz
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics (IMEBI), Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Daniel Sedding
- Cardiology, Angiology and Intensive Care Medicine, University Hospital Halle (Saale), Halle (Saale), Germany
| | - Julia Schumann
- Department of Anaesthesiology and Surgical Intensive Care, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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325
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Lauridsen MD, Rørth R, Lindholm MG, Kjaergaard J, Schmidt M, Møller JE, Hassager C, Torp-Pedersen C, Gislason G, Køber L, Fosbøl EL. Trends in first-time hospitalization, management, and short-term mortality in acute myocardial infarction-related cardiogenic shock from 2005 to 2017: A nationwide cohort study. Am Heart J 2020; 229:127-137. [PMID: 32861678 DOI: 10.1016/j.ahj.2020.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cardiogenic shock remains the leading cause of in-hospital death in acute myocardial infarction (AMI). Because of temporary changes in management of cardiogenic shock with widespread implementation of early revascularization along with increasing attention to the use of mechanical circulatory devices, complete and longitudinal data are important in this subject. The objective of this study was to examine temporal trends of first-time hospitalization, management, and short-term mortality for patients with AMI-related cardiogenic shock (AMICS). METHODS Using nationwide medical registries, we identified patients hospitalized with first-time AMI and cardiogenic shock from January 1, 2005, through December 31, 2017. We calculated annual incidence proportions of AMICS. Thirty-day mortality was estimated with use of Kaplan-Meier estimator comparing AMICS and AMI-only patients. Multivariable Cox regression models were used to assess mortality rate ratios. RESULTS We included 101,834 AMI patients of whom 7,040 (7%) had AMICS. The median age was 72 (interquartile range: 62-80) for AMICS and 69 (interquartile range: 58-79) for AMI-only patients. The gender composition was similar between AMICS and AMI-only patients (male: 64% vs 63%). The annual incidence proportion of AMICS decreased slightly over time (2005: 7.0% vs 2017: 6.1%, P for trend < .0001). In AMICS, use of coronary angiography increased between 2005 and 2017 from 48% to 71%, as did use of left ventricular assist device (1% vs 10%) and norepinephrine (30% to 70%). In contrast, use of intra-aortic balloon pump (14% vs 1%) and dopamine (34% vs 20%) decreased. Thirty-day mortality for AMICS patients was 60% (95% CI: 59-61) and substantially higher than the 8% (95% CI: 7.8-8.2) for AMI-only patients (mortality rate ratio: 11.4, 95% CI: 10.9-11.8). Over time, the mortality decreased after AMICS (2005: 68% to 2017: 57%, P for temporal change in adjusted analysis < .0001). CONCLUSIONS We observed a slight decrease in AMICS hospitalization over time with changing practice patterns. Thirty-day mortality was markedly higher for patients with AMICS compared with AMI only, yet our results suggest improved 30-day survival over time after AMICS.
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Affiliation(s)
- Marie Dam Lauridsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Rasmus Rørth
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matias Greve Lindholm
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Zealand, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Research, Nordsjaellands Hospital, Hillerød and Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Hellerup, Denmark and The Danish Heart Foundation, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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326
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Tehrani BN, Truesdell AG, Psotka MA, Rosner C, Singh R, Sinha SS, Damluji AA, Batchelor WB. A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock. JACC. HEART FAILURE 2020; 8:879-891. [PMID: 33121700 PMCID: PMC8167900 DOI: 10.1016/j.jchf.2020.09.005] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Abstract
Cardiogenic shock is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death. Despite recent advances, clinical outcomes remain poor, with mortality rates exceeding 40%. In the absence of adequately powered randomized controlled trials to guide therapy, best practices for shock management remain nonuniform. Emerging data from North American registries, however, support the use of standardized protocols focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care. In this review, the authors examine the pathophysiology and phenotypes of cardiogenic shock, benefits and limitations of current therapies, and they propose a standardized and team-based treatment algorithm. Lastly, they discuss future research opportunities to address current gaps in clinical knowledge.
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Affiliation(s)
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia; Virginia Heart, Falls Church, Virginia
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia
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327
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Wu X, Reboll MR, Korf-Klingebiel M, Wollert KC. Angiogenesis after acute myocardial infarction. Cardiovasc Res 2020; 117:1257-1273. [PMID: 33063086 DOI: 10.1093/cvr/cvaa287] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/09/2020] [Accepted: 09/30/2020] [Indexed: 12/16/2022] Open
Abstract
Acute myocardial infarction (MI) inflicts massive injury to the coronary microcirculation leading to vascular disintegration and capillary rarefication in the infarct region. Tissue repair after MI involves a robust angiogenic response that commences in the infarct border zone and extends into the necrotic infarct core. Technological advances in several areas have provided novel mechanistic understanding of postinfarction angiogenesis and how it may be targeted to improve heart function after MI. Cell lineage tracing studies indicate that new capillary structures arise by sprouting angiogenesis from pre-existing endothelial cells (ECs) in the infarct border zone with no meaningful contribution from non-EC sources. Single-cell RNA sequencing shows that ECs in infarcted hearts may be grouped into clusters with distinct gene expression signatures, likely reflecting functionally distinct cell populations. EC-specific multicolour lineage tracing reveals that EC subsets clonally expand after MI. Expanding EC clones may arise from tissue-resident ECs with stem cell characteristics that have been identified in multiple organs including the heart. Tissue repair after MI involves interactions among multiple cell types which occur, to a large extent, through secreted proteins and their cognate receptors. While we are only beginning to understand the full complexity of this intercellular communication, macrophage and fibroblast populations have emerged as major drivers of the angiogenic response after MI. Animal data support the view that the endogenous angiogenic response after MI can be boosted to reduce scarring and adverse left ventricular remodelling. The improved mechanistic understanding of infarct angiogenesis therefore creates multiple therapeutic opportunities. During preclinical development, all proangiogenic strategies should be tested in animal models that replicate both cardiovascular risk factor(s) and the pharmacotherapy typically prescribed to patients with acute MI. Considering that the majority of patients nowadays do well after MI, clinical translation will require careful selection of patients in need of proangiogenic therapies.
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Affiliation(s)
- Xuekun Wu
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Marc R Reboll
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Mortimer Korf-Klingebiel
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Kai C Wollert
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
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328
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Simonton C, Thompson C, Wollmuth JR, Morris DL, Dahle TG. The Role of Hemodynamic Support in High-risk Percutaneous Coronary Intervention. US CARDIOLOGY REVIEW 2020. [DOI: 10.15420/usc.2020.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with advanced age, complex coronary anatomy, and multiple comorbidities are often unsuitable for surgical revascularization. In this setting, hemodynamic support devices are used as an adjunct to percutaneous coronary intervention to maintain hemodynamic stability and enable optimal revascularization. This article provides an overview of percutaneous hemodynamic support devices currently used in clinical practice for high-risk percutaneous coronary intervention. These include the intra-aortic balloon pump, centrifugal pumps (TandemHeart, venous arterial extracorporeal membrane oxygenation), and micro-axial Impella pump. The hemodynamic effects, clinical evidence supporting improved outcomes and recovery of heart function, and associated complications with these devices are highlighted, with a special focus on Impella pumps.
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Affiliation(s)
| | | | | | - D Lynn Morris
- East Carolina Heart Institute Brody School of Medicine, Greenville, NC
| | - Thom G Dahle
- Centracare Heart and Vascular Center, St Cloud, MN
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329
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Rossini R, Ferlini M. Arterial Lactate Assessment in Cardiogenic Shock: It Is High Time to Beat the Clock. JACC Cardiovasc Interv 2020; 13:2217-2219. [PMID: 33032709 DOI: 10.1016/j.jcin.2020.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Roberta Rossini
- USC Cardiologia, Ospedale Santa Croce e Carle, Cuneo, Italy.
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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330
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Schrage B, Becher PM, Bernhardt A, Bezerra H, Blankenberg S, Brunner S, Colson P, Cudemus Deseda G, Dabboura S, Eckner D, Eden M, Eitel I, Frank D, Frey N, Funamoto M, Goßling A, Graf T, Hagl C, Kirchhof P, Kupka D, Landmesser U, Lipinski J, Lopes M, Majunke N, Maniuc O, McGrath D, Möbius-Winkler S, Morrow DA, Mourad M, Noel C, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Pazzanese V, Reichenspurner H, Sandri M, Schulze PC, H G Schwinger R, Sinning JM, Aksoy A, Skurk C, Szczanowicz L, Thiele H, Tietz F, Varshney A, Wechsler L, Westermann D. Left Ventricular Unloading Is Associated With Lower Mortality in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation: Results From an International, Multicenter Cohort Study. Circulation 2020; 142:2095-2106. [PMID: 33032450 PMCID: PMC7688081 DOI: 10.1161/circulationaha.120.048792] [Citation(s) in RCA: 265] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. METHODS Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score-matched cohort. RESULTS Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63-0.98]; P=0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site-related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). CONCLUSIONS In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.
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Affiliation(s)
- Benedikt Schrage
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Peter Moritz Becher
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Alexander Bernhardt
- Cardiothoracic Surgery (A.B., H.R.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Hiram Bezerra
- Tampa General Hospital, University of South Florida (H.B.)
| | - Stefan Blankenberg
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Stefan Brunner
- Medizinische Klinik und Poliklinik I (S. Brunner, D.K., M.O.), LMU Klinikum, Munich, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, France (P.C., M.M.)
| | - Gaston Cudemus Deseda
- Division of Anesthesia, Critical Care and Pain Medicine (G.C.D.), Massachusetts General Hospital, Boston
| | - Salim Dabboura
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Germany (D.E., M.P.)
| | - Matthias Eden
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Ingo Eitel
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany (I.E., T.G.)
| | - Derk Frank
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Norbert Frey
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Masaki Funamoto
- Division of Cardiac Surgery (M.F., D.M.), Massachusetts General Hospital, Boston
| | - Alina Goßling
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany (I.E., T.G.)
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik (C.H.), LMU Klinikum, Munich, Germany
| | - Paulus Kirchhof
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Institute of Cardiovascular Sciences, University of Birmingham and University Hospitals Birmingham and Sandwell and West Birmingham National Health ServiceTrusts, United Kingdom (P.K.)
| | - Danny Kupka
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,Medizinische Klinik und Poliklinik I (S. Brunner, D.K., M.O.), LMU Klinikum, Munich, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin, Charité Universitätsmedizin Berlin, Germany (U.L., C.S.).,Franklin/German Centre for Cardiovascular Research (DZHK), partner site Berlin/Institute of Health (BIH), Germany (U.L., C.S.)
| | - Jerry Lipinski
- Department of Internal Medicine, University of California, San Diego (J.L.)
| | - Mathew Lopes
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L., D.A.M., A.V.)
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Octavian Maniuc
- Medizinische Klinik und Poliklinik I (S. Brunner, D.K., M.O.), LMU Klinikum, Munich, Germany.,Department of Internal Medicine I, University Hospital Würzburg, Germany (O.M., P.N.)
| | - Daniel McGrath
- Division of Cardiac Surgery (M.F., D.M.), Massachusetts General Hospital, Boston
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, University Hospital Jena, Germany (S.M.-W., P.C.S.)
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L., D.A.M., A.V.)
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, France (P.C., M.M.)
| | - Curt Noel
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Germany (O.M., P.N.)
| | | | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy (F.P., V.P.).,Department of Anesthesia and Intensive Care, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) ISMETT (Istituto Mediterraneo trapianti e terapie avanzate), UPMC (University of Pittsburgh Medical Center)Italy, Palermo, Italy (F.P.)
| | - Sandeep M Patel
- Department of Interventional Cardiology, St. Rita's Medical Center, Lima, OH (S.M.P.)
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Germany (D.E., M.P.)
| | - Vittorio Pazzanese
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy (F.P., V.P.)
| | - Hermann Reichenspurner
- Cardiothoracic Surgery (A.B., H.R.), University Heart and Vascular Center Hamburg, Germany
| | - Marcus Sandri
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - P Christian Schulze
- Department of Internal Medicine I, University Hospital Jena, Germany (S.M.-W., P.C.S.)
| | | | - Jan-Malte Sinning
- University Heart Center Bonn, Department of Cardiology, Germany (J.-M.S., A.A.)
| | - Adem Aksoy
- University Heart Center Bonn, Department of Cardiology, Germany (J.-M.S., A.A.)
| | - Carsten Skurk
- Department of Cardiology, Campus Benjamin, Charité Universitätsmedizin Berlin, Germany (U.L., C.S.).,Franklin/German Centre for Cardiovascular Research (DZHK), partner site Berlin/Institute of Health (BIH), Germany (U.L., C.S.)
| | - Lukasz Szczanowicz
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Franziska Tietz
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Anubodh Varshney
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L., D.A.M., A.V.)
| | - Lukas Wechsler
- Medizinische Klinik II, Klinikum Weiden, Germany (R.H.G.S., L.W.)
| | - Dirk Westermann
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
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331
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DeJong C, Redberg RF. Multivessel or Culprit Vessel-Only Percutaneous Coronary Intervention for Patients With Acute Myocardial Infarction and Cardiogenic Shock: Real-World Evidence in Support of CULPRIT-SHOCK. JAMA Intern Med 2020; 180:1280-1283. [PMID: 32833000 DOI: 10.1001/jamainternmed.2020.3400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Colette DeJong
- Institute for Healthcare Value, Department of Medicine, University of California, San Francisco
| | - Rita F Redberg
- Department of Medicine, University of California, San Francisco
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332
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Jerónimo A, Ferrández-Escarabajal M, Ferrera C, Noriega FJ, Diz-Díaz J, Fernández-Jiménez R, McInerney A, Fernández-Ortiz A, Viana-Tejedor A. Cardiogenic Shock Clinical Presentation, Management, and In-Hospital Outcomes in Patients Admitted to the Acute Cardiac Care Unit of a Tertiary Hospital: Does Gender Play a Role? J Clin Med 2020; 9:jcm9103117. [PMID: 32992550 PMCID: PMC7601399 DOI: 10.3390/jcm9103117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/16/2020] [Accepted: 09/22/2020] [Indexed: 12/22/2022] Open
Abstract
Cardiogenic shock (CS), as the most severe form of heart failure, is associated with very high mortality rates despite therapeutic advances in the last decades. Gender differences in outcomes have been widely reported regarding several cardiovascular diseases. The aim of our study was to evaluate potential gender disparities in clinical presentation, management, and in-hospital outcomes of all (n = 138) patients admitted to the Acute Cardiac Care Unit of a tertiary hospital from 2013 to 2019. Information on demographic characteristics, past medical history, haemodynamic and clinical status at admission, therapeutic management, and in-hospital outcomes was retrospectively collected. Women represented 31.88% of the cohort, were significantly older than the men and had a lower proportion of smokers, chronic obstructive pulmonary disease, and previous acute myocardial infarction (AMI). Most CSs in both groups were AMI-related. Left ventricular ejection fraction at admission was higher in women, who were less likely to receive vasopressors. No differences were observed regarding mechanical circulatory support use and in-patient outcomes, with age being the only factor associated with in-hospital mortality on multivariate analysis.
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Affiliation(s)
- Adrian Jerónimo
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Marcos Ferrández-Escarabajal
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Carlos Ferrera
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Francisco J. Noriega
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Jesús Diz-Díaz
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Rodrigo Fernández-Jiménez
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
- Centro Nacional de Investigación Cardiovascular (CNIC), 28029 Madrid, Spain
| | - Angela McInerney
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Antonio Fernández-Ortiz
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
| | - Ana Viana-Tejedor
- Acute Cardiac Care Unit, Hospital Clínico San Carlos, 28040 Madrid, Spain; (A.J.); (M.F.-E.); (C.F.); (F.J.N.); (J.D.-D.); (R.F.-J.); (A.M.); (A.F.-O.)
- Correspondence: ; Tel.: +34-91-330-33-000 (ext. 20655)
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Tehrani BN, Basir MB, Kapur NK. Acute myocardial infarction and cardiogenic shock: Should we unload the ventricle before percutaneous coronary intervention? Prog Cardiovasc Dis 2020; 63:607-622. [PMID: 32920027 DOI: 10.1016/j.pcad.2020.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 12/22/2022]
Abstract
Despite early reperfusion and coordinated systems of care, cardiogenic shock (CS) remains the number one cause of morbidity and in-hospital mortality following acute myocardial infarction (AMI). CS is a complex clinical syndrome that begins with hemodynamic instability and can progress to multi-organ failure and profound hemo-metabolic compromise. To improve outcomes, a clear understanding of the treatment objectives in CS and developing time-sensitive management strategies aimed at stabilizing hemodynamics and restoring myocardial perfusion are critical. Left ventricular (LV) load has been identified as an independent predictor of heart failure and mortality following AMI. Decades of preclinical and clinical research have identified several effective LV unloading strategies. Recent initiatives from single and multi-center registries and more recently the Door to Unload (DTU)-STEMI pilot study have provided valuable insight to developing a standardized treatment approach to AMI, based on early invasive hemodynamics and tailored circulatory support to unload the LV. To follow is a review of the pathophysiology and prevalence of shock, limitations of current therapies, and the pre-clinical and translational basis for incorporating LV unloading into contemporary AMI and shock care.
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Affiliation(s)
- Behnam N Tehrani
- Inova Heart and Vascular Institute, Falls Church, VA, United States of America
| | - Mir B Basir
- Henry Ford Medical Center, Detroit, MI, United States of America
| | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, MA, United States of America.
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334
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Kang J, Ahn H, Lee HS, Cho HJ. Still a Long Way to Go in Treating Cardiogenic Shock in Acute Myocardial Infarction. Circ J 2020; 84:1461-1463. [PMID: 32779611 DOI: 10.1253/circj.cj-20-0765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jeehoon Kang
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital
| | - Hyojeong Ahn
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital
| | - Hak Seung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital
| | - Hyun-Jai Cho
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital
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335
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Josiassen J, Helgestad OKL, Udesen NLJ, Banke A, Frederiksen PH, Hyldebrandt JA, Schmidt H, Jensen LO, Hassager C, Ravn HB, Møller JE. Unloading using Impella CP during profound cardiogenic shock caused by left ventricular failure in a large animal model: impact on the right ventricle. Intensive Care Med Exp 2020; 8:41. [PMID: 32785808 PMCID: PMC7423825 DOI: 10.1186/s40635-020-00326-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIM This study aimed to assess right ventricular (RV) function during cardiogenic shock due to acute left ventricular (LV) failure, including during LV unloading with Impella CP and an added moderate dose of norepinephrine. METHODS Cardiogenic shock was induced by injecting microspheres in the left main coronary artery in 18 adult Danish Landrace pigs. Conductance catheters were placed in both ventricles and pressure-volume loops were recorded simultaneously. RESULTS Cardiogenic shock due to LV failure also impaired RV performance, which was partially restored during haemodynamic support with Impella CP, as demonstrated by changes in the ventriculo-arterial coupling (Ea/Ees ratio) (baseline (median [Q1;Q3]) 1.2 [1.1;1.6]), cardiogenic shock (3.0 [2.4;4.5]), Impella CP (2.1 [1.3;2.7]) (pBaseline vs CS < 0.0001, pCS vs Impella = 0.001)). Impella CP support also improved RV stroke work (SW) (cardiogenic shock 333 [263;530] vs Impella CP (830 [717;1121]) (p < 0.001). Moderate norepinephrine infusion concomitant with Impella CP further improved RV SW (Impella CP (818 [751;1065]) vs Impella CP+moderate norepinephrine (1231 [1142;1335]) (p = 0.01)) but at the expense of an increase in LV SW (Impella CP (858 [555;1392]) vs Impella CP+moderate norepinephrine (2101 [1024;2613]) (p = 0.04)). CONCLUSIONS The Impella CP provided efficient LV unloading, improved RV function, and end-organ perfusion. Moderate doses of norepinephrine during Impella support further improved RV function, but at the expense of an increase in SW of the failing LV.
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Affiliation(s)
- Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | | | | | - Ann Banke
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Janus Adler Hyldebrandt
- Department of Anaesthesiology and Intensive Care, Akershus University Hospital, Lørenskog, Norway
| | - Henrik Schmidt
- Department of Cardiothoracic Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Berg Ravn
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiothoracic Anaesthesia, Odense University Hospital, Odense, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Cardiology, Odense University Hospital, Odense, Denmark
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Abstract
Cardiac arrest (CA) results in multiorgan ischemia until return of spontaneous circulation and often is followed by a low-flow shock state. Upon restoration of circulation and organ perfusion, resuscitative teams must act quickly to achieve clinical stability while simultaneously addressing the underlying etiology of the initial event. Optimal cardiovascular care demands focused management of the post-cardiac arrest syndrome and associated shock. Acute coronary syndrome should be considered and managed in a timely manner, because early revascularization improves patient outcomes and may suppress refractory arrhythmias. This review outlines the diagnostic and therapeutic considerations that define optimal cardiovascular care after CA.
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Affiliation(s)
- Barry Burstein
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jacob C Jentzer
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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337
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Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet 2020; 396:199-212. [PMID: 32682486 DOI: 10.1016/s0140-6736(20)31047-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/24/2020] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.
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Affiliation(s)
- Alain Combes
- Sorbonne Université, Institute of Cardiometabolism and Nutrition, Paris, France; Service de Médecine Intensive-Réanimation, Höpitaux Universitaires Pitié Salpêtrière, Assistance Publique-Höpitaux de Paris, Institut de Cardiologie, Paris, France.
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA; Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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338
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Chioncel O, Parissis J, Mebazaa A, Thiele H, Desch S, Bauersachs J, Harjola V, Antohi E, Arrigo M, Gal TB, Celutkiene J, Collins SP, DeBacker D, Iliescu VA, Jankowska E, Jaarsma T, Keramida K, Lainscak M, Lund LH, Lyon AR, Masip J, Metra M, Miro O, Mortara A, Mueller C, Mullens W, Nikolaou M, Piepoli M, Price S, Rosano G, Vieillard‐Baron A, Weinstein JM, Anker SD, Filippatos G, Ruschitzka F, Coats AJ, Seferovic P. Epidemiology, pathophysiology and contemporary management of cardiogenic shock – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1315-1341. [DOI: 10.1002/ejhf.1922] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - John Parissis
- Heart Failure Unit, Department of Cardiology Attikon University Hospital Athens Greece
- National Kapodistrian University of Athens Medical School Athens Greece
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP Paris France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig Leipzig Germany
- Heart Institute Leipzig Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig Leipzig Germany
- Heart Institute Leipzig Germany
| | - Johann Bauersachs
- Department of Cardiology & Angiology, Hannover Medical School Hannover Germany
| | - Veli‐Pekka Harjola
- Emergency Medicine University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Elena‐Laura Antohi
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Mattia Arrigo
- Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Tuvia B. Gal
- Department of Cardiology, Rabin Medical Center Petah Tiqwa Israel
- Sackler Faculty of Medicine, Tel Aviv University Tel Aviv Israel
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Medical Faculty of Vilnius University Vilnius Lithuania
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN USA
| | - Daniel DeBacker
- Department of Intensive Care CHIREC Hospitals, Université Libre de Bruxelles Brussels Belgium
| | - Vlad A. Iliescu
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Ewa Jankowska
- Department of Heart Disease Wroclaw Medical University, University Hospital, Center for Heart Disease Wroclaw Poland
| | - Tiny Jaarsma
- Department of Health, Medicine and Health Sciences Linköping University Linköping Sweden
- Julius Center University Medical Center Utrecht Utrecht The Netherlands
| | - Kalliopi Keramida
- National Kapodistrian University of Athens Medical School Athens Greece
- Department of Cardiology Attikon University Hospital Athens Greece
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota Murska Sobota Slovenia
- Faculty of Medicine, University of Ljubljana Ljubljana Slovenia
| | - Lars H Lund
- Heart and Vascular Theme, Karolinska University Hospital Stockholm Sweden
- Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Alexander R. Lyon
- Imperial College London National Heart & Lung Institute London UK
- Royal Brompton Hospital London UK
| | - Josep Masip
- Consorci Sanitari Integral, University of Barcelona Barcelona Spain
- Hospital Sanitas CIMA Barcelona Spain
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health University of Brescia Brescia Italy
| | - Oscar Miro
- Emergency Department Hospital Clinic, Institut d'Investigació Biomèdica August Pi iSunyer (IDIBAPS) Barcelona Spain
- University of Barcelona Barcelona Spain
| | - Andrea Mortara
- Department of Cardiology Policlinico di Monza Monza Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB) University Hospital Basel Basel Switzerland
| | - Wilfried Mullens
- Department of Cardiology Ziekenhuis Oost Genk Belgium
- Biomedical Research Institute Faculty of Medicine and Life Sciences, Hasselt University Diepenbeek Belgium
| | - Maria Nikolaou
- Heart Failure Unit, Department of Cardiology Attikon University Hospital Athens Greece
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, Emergency Department Guglielmo da Saliceto Hospital, Piacenza, University of Parma; Institute of Life Sciences, Sant'Anna School of Advanced Studies Pisa Italy
| | - Susana Price
- Royal Brompton Hospital & Harefield NHS Foundation Trust London UK
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana Rome Italy
| | - Antoine Vieillard‐Baron
- INSERM U‐1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ Villejuif France
- University Hospital Ambroise Paré, AP‐, HP Boulogne‐Billancourt France
| | - Jean M. Weinstein
- Cardiology Department Soroka University Medical Centre Beer Sheva Israel
| | - Stefan D. Anker
- Department of Cardiology (CVK) Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin Berlin Germany
- Charité Universitätsmedizin Berlin Germany
| | - Gerasimos Filippatos
- University of Athens, Heart Failure Unit, Attikon University Hospital Athens Greece
- School of Medicine, University of Cyprus Nicosia Cyprus
| | - Frank Ruschitzka
- Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Andrew J.S. Coats
- Pharmacology, Centre of Clinical and Experimental Medicine IRCCS San Raffaele Pisana Rome Italy
| | - Petar Seferovic
- Faculty of Medicine University of Belgrade Belgrade, Serbia
- Serbian Academy of Sciences and Arts Belgrade Serbia
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339
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Short-Term Efficacy and Safety of Different Mechanical Hemodynamic Support Devices for Cardiogenic Shock or High-Risk Pci: a Network Meta-Analysis of Thirty-Seven Trials. Shock 2020; 55:5-13. [PMID: 33337786 DOI: 10.1097/shk.0000000000001611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND With more advanced mechanical hemodynamic support for patients with cardiogenic shock (CS) or high-risk percutaneous coronary intervention (HS-PCI), the morality rate is now significantly lower than before. While previous studies showed that intra-aortic balloon pumping (IABP) did not reduce the risk of mortality in patients with CS compared to conservative treatment, the efficacy in other mechanical circulatory support (MCS) trials was inconsistent. OBJECTIVE We conducted this network meta-analysis to assess the short-term efficacy and safety of different intervention measures for patients with CS or who underwent HS-PCI. METHODS Four online databases were searched. From the initial 1,550 articles, we screened 38 studies (an extra 14 studies from references) into this analysis, including a total of 11,270 patients from five interventions (pharmacotherapy, IABP, pMCS, ECMO alone, and ECMO+IABP). RESULT The short-term efficacy was determined by 30-day or in-hospital mortality. ECMO+IABP significantly reduced mortality compared with pMCS and ECMO alone (OR = 1.85, 95% CrI [1.03-3.26]; OR = 1.89, 95% CrI [1.19-3.01], respectively). ECMO+IABP did not show reduced mortality when compared with pharmacotherapy and IABP (OR = 1.73, 95% CrI [0.97-3.82]; OR = 1.67, 95% CrI [0.98-2.89], respectively). The rank probability, however, supported that ECMO+IABP might be a more suitable intervention in improving mortality for patients with CS or who underwent HS-PCI. Regarding bleeding, compared with other invasive intervention measures, IABP showed a trend of reduced bleeding (with pMCS OR = 3.86, 95% CrI [1.53-10.66]; with ECMO alone OR = 3.74, 95% CrI [1.13-13.78]; with ECMO+IABP OR = 4.80, 95% CrI [1.61-18.53]). No difference was found in stroke, myocardial infarction, limb ischemia, and hemolysis among the invasive therapies evaluated. CONCLUSION Following this analysis, ECMO+IABP might be a more suitable intervention measure in improving short-term mortality for patients with CS and who underwent HS-PCI. However, the result was limited by the lack of sufficient direct comparisons and evidence from randomized controlled trials. Moreover, bleeding and other device-related complications should be considered in clinical applications.
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340
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Telukuntla KS, Estep JD. Acute Mechanical Circulatory Support for Cardiogenic Shock. Methodist Debakey Cardiovasc J 2020; 16:27-35. [PMID: 32280415 DOI: 10.14797/mdcj-16-1-27] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cardiogenic shock is associated with significant morbidity and mortality, and clinicians have increasingly used short-term mechanical circulatory support (MCS) over the last 15 years to manage outcomes. In general, the provision of greater hemodynamic support comes with device platforms that are more complex and potentially associated with more adverse events. In this review, we compare and contrast the available percutaneous and surgically placed device types used in cardiogenic shock and discuss the associated clinical and hemodynamic data to support device use.
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341
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Li YH, Lee CH, Huang WC, Wang YC, Su CH, Sung PH, Chien SC, Hwang JJ. 2020 Focused Update of the 2012 Guidelines of the Taiwan Society of Cardiology for the Management of ST-Segment Elevation Myocardial Infarction. ACTA CARDIOLOGICA SINICA 2020; 36:285-307. [PMID: 32675921 PMCID: PMC7355116 DOI: 10.6515/acs.202007_36(4).20200619a] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
Abstract
One of the major missions of the Taiwan Society of Cardiology is to publish practice guidelines that are suitable for local use in Taiwan. The ultimate purpose is to continuously improve cardiovascular health care from the implementation of the recommendations in the guidelines. Despite recent improvement of medical care, patients with ST-segment elevation myocardial infarction (STEMI) still carry a high morbidity and mortality. There have been many changes in the concepts of STEMI diagnosis and treatment in recent years. The 2020 focused update of the 2012 guidelines of the Taiwan Society of Cardiology for the management of STEMI is an amendment of the 2012 guidelines based on the newest published scientific data. The recommendations in this focused update provide the diagnosis and treatment strategy for STEMI that should be generally implemented in Taiwan. Nevertheless, guidelines never completely replace clinical judgment and medical decision still should be determined individually.
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Affiliation(s)
- Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Cheng-Han Lee
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- School of Medicine, National Yang Ming University, Taipei
- Department of Physical Therapy, Fooyin University, Kaohsiung
| | - Yu-Chen Wang
- Division of Cardiology, Department of Internal Medicine, Asia University Hospital
- Department of Biotechnology, Asia University
- Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital
| | - Chun-Hung Su
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung
| | - Pei-Hsun Sung
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine
| | - Shih-Chieh Chien
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
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Prognostic Impact of Active Mechanical Circulatory Support in Cardiogenic Shock Complicating Acute Myocardial Infarction, Results from the Culprit-Shock Trial. J Clin Med 2020; 9:jcm9061976. [PMID: 32599815 PMCID: PMC7356113 DOI: 10.3390/jcm9061976] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 06/11/2020] [Accepted: 06/18/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). BACKGROUND Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. METHODS This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. RESULTS Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®; n = 95 extracorporeal membrane oxygenation (ECMO); n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p < 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p < 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7-5.9; p < 0.001). CONCLUSIONS In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.
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Ni hIci T, Boardman HM, Baig K, Stafford JL, Cernei C, Bodger O, Westaby S. Mechanical assist devices for acute cardiogenic shock. Cochrane Database Syst Rev 2020; 6:CD013002. [PMID: 32496607 PMCID: PMC7271960 DOI: 10.1002/14651858.cd013002.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra-aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer-term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long-term VAD. OBJECTIVES To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra-aortic balloon pump and inotropic support. DATA COLLECTION AND ANALYSIS We performed data collection and analysis according to the published protocol. Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow-up), dialysis-dependent (30 days/end of follow-up), length of hospital stay and length of intensive care unit stay and major adverse events. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta-analysis was performed only to assess the 30-day survival as there were insufficient data to perform any further meta-analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30-day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain. Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting. We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing. AUTHORS' CONCLUSIONS There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.
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Affiliation(s)
| | - Henry Mp Boardman
- Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kamran Baig
- Department of Cardiac Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jody L Stafford
- Perfusion/Cardiothoracic Surgery, University Hospital of Wales, Cardiff, UK
| | - Cristina Cernei
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Owen Bodger
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Stephen Westaby
- Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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344
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Riley RF, Henry TD, Mahmud E, Kirtane AJ, Brilakis ES, Goyal A, Grines CL, Lombardi WL, Maran A, Rab T, Tremmel JA, Truesdell AG, Yeh RW, Zhao DX, Jaffer FA. SCAI
position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease. Catheter Cardiovasc Interv 2020; 96:346-362. [DOI: 10.1002/ccd.28994] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022]
Affiliation(s)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education The Christ Hospital Cincinnati Ohio USA
| | - Ehtisham Mahmud
- Sulpizio Cardiovascular Center University of California San Diego La Jolla California USA
| | - Ajay J. Kirtane
- Center for Interventional Vascular Therapy Columbia University Medical Center New York New York USA
| | | | | | | | | | - Anbukarasi Maran
- Medical University of South Carolina North Charleston South Carolina USA
| | | | | | | | - Robert W. Yeh
- Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - David X. Zhao
- Wake Forest University School of Medicine Winston‐Salem North Carolina USA
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345
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Pahuja M, Ranka S, Chehab O, Mishra T, Akintoye E, Adegbala O, Yassin AS, Ando T, Thayer KL, Shah P, Kimmelstiel CD, Salehi P, Kapur NK. Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock. Catheter Cardiovasc Interv 2020; 97:1129-1138. [PMID: 32473083 DOI: 10.1002/ccd.29003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/22/2020] [Accepted: 05/12/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI). OBJECTIVE We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI. METHODS We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation. RESULTS Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs. CONCLUSIONS Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.
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Affiliation(s)
- Mohit Pahuja
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sagar Ranka
- Division of Cardiology, Department of Internal Medicine, Kansas University Medical Center, Kansas, Kansas, USA
| | - Omar Chehab
- Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Tushar Mishra
- Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Emmanuel Akintoye
- Division of Cardiology, Department of Internal Medicine, University of Iowa Medical Center, Iowa, Iowa, USA
| | - Oluwole Adegbala
- Division of Cardiology, Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Ahmed S Yassin
- Department of Internal Medicine, Detroit Medical Center/Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Tomo Ando
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
| | - Katherine L Thayer
- Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
| | - Palak Shah
- Division of Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
| | - Carey D Kimmelstiel
- Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
| | - Payam Salehi
- Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
| | - Navin K Kapur
- Division of Cardiology, Department of Internal Medicine, Tuft University Medical Center, Boston, Massachusetts, USA
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346
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Reddy PKV, Ng TMH, Oh EE, Moady G, Elkayam U. Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review. J Am Heart Assoc 2020; 9:e016704. [PMID: 32468897 PMCID: PMC7428977 DOI: 10.1161/jaha.120.016704] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Methamphetamine‐associated cardiomyopathy (MACM) is an increasingly recognized disease entity in the context of a rapidly spreading methamphetamine epidemic. MACM may afflict individuals with a wide range of ages and socioeconomic backgrounds. Presentations can vary greatly and may involve several complications unique to the disease. Given the public health significance of this disease, there is a relative dearth of consensus material to guide clinicians in understanding, diagnosing, and managing MACM. This review therefore aims to: (1) describe pathologic mechanisms of methamphetamine as they pertain to the development, progression, and prognosis of MACM, and the potential to recover cardiac function; (2) summarize existing data from epidemiologic studies and case series in an effort to improve recognition and diagnosis of the disease; (3) guide short‐ and long‐term management of MACM with special attention to expected or potential sequelae of the disease; and (4) highlight pivotal unanswered questions in need of urgent investigation from a public health perspective.
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Affiliation(s)
- Pavan K V Reddy
- Division of Cardiovascular Medicine Keck School of Medicine University of Southern California Los Angeles CA
| | - Tien M H Ng
- School of Pharmacy University of Southern California Los Angeles CA
| | - Esther E Oh
- School of Pharmacy University of Southern California Los Angeles CA
| | - Gassan Moady
- Division of Cardiovascular Medicine Keck School of Medicine University of Southern California Los Angeles CA
| | - Uri Elkayam
- Division of Cardiovascular Medicine Keck School of Medicine University of Southern California Los Angeles CA
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347
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Alasnag M, Truesdell AG, Williams H, Martinez SC, Qadri SK, Skendelas JP, Jakobleff WA, Alasnag M. Mechanical Circulatory Support: a Comprehensive Review With a Focus on Women. Curr Atheroscler Rep 2020; 22:11. [DOI: 10.1007/s11883-020-0828-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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348
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Garcia S, Schmidt CW, Garberich R, Henry TD, Bradley SM, Brilakis ES, Burke N, Chavez IJ, Eckman P, Gössl M, Mooney MR, Newell MC, Poulose AK, Sorajja P, Traverse JH, Wang YL, Sharkey SW. Temporal changes in patient characteristics and outcomes in ST-segment elevation myocardial infarction 2003-2018. Catheter Cardiovasc Interv 2020; 97:1109-1117. [PMID: 32294799 DOI: 10.1002/ccd.28901] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/29/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND We sought to describe changes in demographic variables, process of care measures, and outcomes of patients treated in a regional ST-segment elevation myocardial infarction (STEMI) program over the last 15 years. METHODS We describe demographic variables, process of care measures, and outcomes of patients treated in the program in various 5-year time periods: 2003-2007 (n = 1,821), 2008-2012 (n = 1,968), and 2013-2018 (n = 2,223). The primary outcome measures were in-hospital and 30-day mortality. RESULTS Among 6,012 STEMI patients treated from 2003 to 2018 we observed a significant increase in mean age at presentation (62 ± 14 to 64 ± 13 years) and diabetes (14-22%, p < .01). The proportion of patients with cardiogenic shock (CS) and cardiac arrest (CA) pre-PCI increased significantly from 9.5% to 11.1% and 8.5% to 12.7% (p < .05), respectively. The median door-to-balloon (D2B) times decreased from 98 to 93 min and total ischemic time decreased from 202 to 185 min (all p < .05). Despite increased patient complexity, the proportion of nontransfer and transfer patients achieving D2B times consistent with guideline recommendations remained unchanged (for nontransfer patients 79-82%, p = .45 and for transfer patients 65-64%, p = .34). Among all STEMI patients, in-hospital mortality increased during the study period from 4.9 to 6.9% (p = .007) but remained stable (<2%) when CA and CS patients were excluded. CONCLUSIONS Over the last 15 years, short-term STEMI mortality has increased despite improvements in care delivery metrics. Patients with CA and/or CS now represent 10% of STEMI patients and are responsible for 80% of deaths. Therefore, efforts to improve STEMI mortality, and metrics for assessing STEMI programs, should focus on these patients.
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Affiliation(s)
- Santiago Garcia
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Christian W Schmidt
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ross Garberich
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Steven M Bradley
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Nickolas Burke
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ivan J Chavez
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Peter Eckman
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Mario Gössl
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Michael R Mooney
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Marc C Newell
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Anil K Poulose
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Paul Sorajja
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Jay H Traverse
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Yale L Wang
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Scott W Sharkey
- Minneapolis Heart Institute and Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
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349
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Patient Characteristics, Treatment and Outcome in Non-Ischemic vs. Ischemic Cardiogenic Shock. J Clin Med 2020; 9:jcm9040931. [PMID: 32231121 PMCID: PMC7230560 DOI: 10.3390/jcm9040931] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/11/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022] Open
Abstract
Aim: Evidence on non-ischemic cardiogenic shock (CS) is scarce. The aim of this study was to investigate differences in patient characteristics, use of treatments and outcomes in patients with non-ischemic vs. ischemic CS. Methods: Patients with CS admitted between October 2009 and October 2017 were identified and stratified as non-ischemic/ischemic CS based on the absence/presence of acute myocardial infarction. Logistic/Cox regression models were fitted to investigate the association between non-ischemic CS and patient characteristics, use of treatments and 30-day in-hospital mortality. Results: A total of 978 patients were enrolled in this study; median age was 70 (interquartile range 58, 79) years and 70% were male. Of these, 505 patients (52%) had non-ischemic CS. Patients with non-ischemic CS were more likely to be younger and female; were less likely to be active smokers, to have diabetes or decreased renal function, but more likely to have a history of myocardial infarction; and they were more likely to present with unfavorable hemodynamics and with mechanical ventilation. Regarding treatments, patients with non-ischemic CS were more likely to be treated with catecholamines, but less likely to be treated with extracorporeal membrane oxygenation or percutaneous left-ventricular assist devices. After adjustment for multiple relevant confounders, non-ischemic CS was associated with a significant increase in the risk of 30-day in-hospital mortality (hazard ratio 1.14, 95% confidence interval 1.04–1.24, p < 0.01). Conclusion: In this large study, non-ischemic CS accounted for more than 50% of all CS cases. Non-ischemic CS was not only associated with relevant differences in patient characteristics and use of treatments, but also with a worse prognosis. These findings highlight the need for effective treatment strategies for patients with non-ischemic CS.
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350
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Isoflurane Sedation in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation Treatment for Cardiogenic Shock-An Observational Propensity-Matched Study. Crit Care Explor 2020; 2:e0086. [PMID: 32259109 PMCID: PMC7098543 DOI: 10.1097/cce.0000000000000086] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The feasibility and hemodynamic effects of isoflurane sedation in cardiogenic shock in the presence of venoarterial extracorporeal membrane oxygenation treatment are currently unknown. Design Retrospective single-center study. Setting Cardiac ICU of Munich university hospital. Patients/Subjects Cardiogenic shock patients with venoarterial extracorporeal membrane oxygenation treatment under sedation with volatile isoflurane between November 2018 and October 2019 have been enrolled in this study and were matched by propensity score in a 1:1 ratio with IV sedated patients treated between January 2013 and November 2018 from the cardiogenic shock registry of the university hospital of Munich. Measurements and Main Results Isoflurane sedation was used in 32 patients with cardiogenic shock and venoarterial extracorporeal membrane oxygenation treatment. The mean age of conventionally sedated patients was 58.4 ± 13.8 years and 56.3 ± 11.5 years for patients with isoflurane sedation (p = 0.51). Administration of isoflurane was associated with lower IV sedative drug use during venoarterial extracorporeal membrane oxygenation treatment (86% vs 32%; p = 0.01). Mean systolic arterial pressure was similar (94.3 ± 12.6 vs 92.9 ± 10.5 mm Hg; p = 0.65), but mean heart rate was significantly higher in the conventional sedation group, when compared with the isoflurane group (85.2 ± 20.5 vs 74.7 ± 15.0 beats/min; p = 0.02). Catecholamine doses, venoarterial extracorporeal membrane oxygenation blood and gas flow, ventilation time (304 ± 143 vs 398 ± 272 hr; p = 0.16), bleeding complications bleeding academic research consortium 3a or higher (59.3% vs 65.3%; p = 0.76), and 30-day mortality (59.2% vs 63.4%, p = 0.80) were similar in both groups. The overall sedation costs per patient were significantly lower in the conventional group, when compared with the isoflurane group (537 ± 624 vs 1280 ± 837 €; p < 0.001). Conclusions Volatile sedation with isoflurane is feasible-albeit at higher costs-in patients with cardiogenic shock and venoarterial extracorporeal membrane oxygenation treatment and was not associated with higher catecholamine dosage or extracorporeal membrane oxygenation flow rate compared with IV sedation.
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