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

AIMS

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Comparison of Vasopressin versus Norepinephrine in a Pig Model of Refractory Cardiogenic Shock Complicated by Cardiac Arrest and Resuscitated with Veno-arterial ECMO

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.

Innovative transcatheter procedures for the treatment of heart failure

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.

Predictors of Hospital Mortality in Patients with Acute Coronary Syndrome Complicated by Cardiogenic Shock

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.

Current use of inotropes in circulatory shock

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.

Defining Shock and Preshock for Mortality Risk Stratification in Cardiac Intensive Care Unit Patients

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.

Stress hyperglycemia, cardiac glucotoxicity, and critically ill patient outcomes current clinical and pathophysiological evidence

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.

Comparison of Mortality Risk Models in Patients with Postcardiac Arrest Cardiogenic Shock and Percutaneous Mechanical Circulatory Support

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.

Transition From an Open to Closed Staffing Model in the Cardiac Intensive Care Unit Improves Clinical Outcomes

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.

Current status and needs for changes in critical care training: the voice of the young cardiologists

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.

Biochemical markers for clinical monitoring of tissue perfusion

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 (S_vO₂), lactate, central venous–arterial carbon dioxide difference (PCO₂ gap), and PCO₂ gap/central arterial-to-venous oxygen difference (C_a–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.

The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges

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.

Predicting Parameters for Successful Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock

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.

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

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.

This is your toolkit in hemodynamic monitoring

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.

Cardiogenic shock: incidence, survival and mechanical circulatory support usage 2007-2017-insights from a national registry

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.

Long-Term Clinical Outcome of Cardiogenic Shock Patients Undergoing Impella CP Treatment vs. Standard of Care

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.

[Cardiogenic shock]

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.

Inotropic agents and vasodilator strategies for the treatment of cardiogenic shock or low cardiac output syndrome

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.

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

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.

A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock

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.

Angiogenesis after acute myocardial infarction

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.

The Role of Hemodynamic Support in High-risk Percutaneous Coronary Intervention

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.

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

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.

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?

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.

Acute myocardial infarction and cardiogenic shock: Should we unload the ventricle before percutaneous coronary intervention?

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.

Unloading using Impella CP during profound cardiogenic shock caused by left ventricular failure in a large animal model: impact on the right ventricle

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]) (p_{Baseline vs CS} < 0.0001, p_{CS 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.

Comprehensive Cardiac Care After Cardiac Arrest

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.

Temporary circulatory support for cardiogenic shock

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.

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

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.

Acute Mechanical Circulatory Support for Cardiogenic Shock

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.

2020 Focused Update of the 2012 Guidelines of the Taiwan Society of Cardiology for the Management of ST-Segment Elevation Myocardial Infarction

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.

Prognostic Impact of Active Mechanical Circulatory Support in Cardiogenic Shock Complicating Acute Myocardial Infarction, Results from the Culprit-Shock Trial

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.

Mechanical assist devices for acute cardiogenic shock

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.

Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock

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.

Clinical Characteristics and Management of Methamphetamine-Associated Cardiomyopathy: State-of-the-Art Review

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.

Temporal changes in patient characteristics and outcomes in ST-segment elevation myocardial infarction 2003-2018

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.

Patient Characteristics, Treatment and Outcome in Non-Ischemic vs. Ischemic Cardiogenic Shock

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.

Isoflurane Sedation in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation Treatment for Cardiogenic Shock-An Observational Propensity-Matched Study

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.