Association of Use of an Intravascular Microaxial Left Ventricular Assist Device vs Intra-aortic Balloon Pump With In-Hospital Mortality and Major Bleeding Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

In-hospital outcomes of cardiogenic shock patients: A propensity score-matched nationwide comparative analysis between intra-aortic balloon pump and percutaneous ventricular assist devices

BACKGROUND

Percutaneous ventricular assist devices (pVAD) and intra-aortic balloon pumps (IABP) are mechanical circulatory support options for patients with cardiogenic shock (CS). While pVADs provide greater hemodynamic support, their impact on mortality and hospital outcomes compared to IABP remains unclear.

METHODS

We conducted a propensity score-matched analysis of 65,858 CS admissions from the national inpatient sample (2016-2020), evenly divided between IABP and pVAD groups. Admissions, where ECMO or both IABP and pVAD were used during the same admission, were excluded. The primary outcome was in-hospital mortality. Secondary outcomes included complication rate, length of stay, and total hospitalization costs. Sensitivity analyses were performed using inverse probability of treatment weighting (IPTW), and subgroup analyses were conducted based on the different etiologies of CS.

RESULTS

The overall in-hospital mortality rate in the matched cohort was 34.3 %, with significantly higher mortality in the pVAD group compared to the IABP group (40.7 % vs. 28 %, p < 0.001) (OR = 1.77; 95 % CI [1.71, 1.83]). pVAD use was also associated with higher odds of acute kidney injury, ventricular arrhythmia, ischemic stroke, and major bleeding, access site complications like arterial thrombosis and aneurysms. Although the pVAD group had a marginally shorter length of stay, hospitalization costs were higher.

CONCLUSION

In this nationwide cohort, pVAD use was associated with higher in-hospital mortality, increased complication rates, and higher costs compared to IABP. These findings suggest that while pVADs may offer advanced support, they are linked to substantial risks and costs, warranting careful patient selection.

Impella versus Non-Impella for Nonemergent High-Risk Percutaneous Coronary Intervention

The benefit of mechanical circulatory support (MCS) with Impella (Abiomed, Inc, Danvers, MA) for patients undergoing nonemergent, high-risk percutaneous coronary intervention (HR-PCI) is unclear and currently the subject of a large randomized clinical trial (RCT), PROTECT IV. While contemporary registry data from PROTECT III demonstrated improvement of outcomes with Impella when compared with historical data (PROTECT II), there is lack of direct comparison to the HR-PCI cohort that did not receive Impella support. We retrospectively identified patients from our institution meeting PROTECT III inclusion criteria (left ventricular ejection fraction [LVEF] <35% with unprotected left main or last remaining vessel or LVEF <30% undergoing multivessel PCI), and compared this group (NonIMP) to the published outcomes data from the PROTECT III registry (IMP). Baseline differences were balanced using inverse propensity weighting (IPW). The co-primary outcome was major adverse cardiac events (MACE) in-hospital and at 90 days. Secondary outcomes included in-hospital post-PCI complications. We identified 284 high-risk patients who did not receive Impella support; 200 patients had 90-day event ascertainment and were included in IPW analysis, with 504 patients in the IMP group. After calibration, few residual differences remained; patients in the NonIMP group were older (73.4 vs. 69.3, p <0.001) with higher prevalence of coronary artery bypass grafting (65.0% vs. 13.7%, p <0.001). Unprotected left main intervention was performed in 43% of patients in both groups. The primary outcome was not different in-hospital (3.0% vs. 4.8%, p = 0.403), but lower in the NonIMP group at 90 days (7.5% vs. 13.8%, p = 0.033). Peri-procedural vascular complications, bleeding, and transfusion rates were not different between groups. However, acute kidney injury occurred more frequently in the NonIMP group (10.5% vs. 5.4%, p = 0.023). Under identical HR-PCI inclusion criteria for Impella use in PROTECT III, an institutional non-Impella supported HR-PCI cohort demonstrated similar MACE in-hospital but lower MACE at 90 days. There was no signal for peri-procedural harm with Impella use. These results do not support routine usage of Impella for HR-PCI patients. Careful patient selection is critical until a large RCT demonstrates benefits in a broad HR-PCI population.

Microaxial mechanical circulatory support in cardiogenic shock: ready for prime time?

Randomised controlled studies on the use of intra-aortic balloon counterpulsation and veno-arterial extracorporeal life support have failed to offer a survival benefit compared with standard therapy in patients with myocardial infarction-associated cardiogenic shock. Thus, the results of a recent study using microaxial mechanical circulatory support showing a survival benefit in the intention-to-treat analysis will likely immediately enter treatment guidelines. We express the need for some caution regarding an even broader clinical implementation of these devices by pointing out the statistical fragility of existing data and the contrasting results of numerous large observational studies which almost all demonstrate a higher mortality of using microaxial pumps or extracorporeal life support instead of intra-aortic balloon counterpulsation. Additionally, we discuss confounding bias in recent publications on microaxial mechanical circulatory support.

From Escalate to Elevate: A New Paradigm for Comprehensive Cardiogenic Shock Management

Patients with cardiogenic shock (CS) present with critical hemodynamic compromise with low cardiac output (CO) resulting in end-organ dysfunction. Prognosis is closely related to the severity of shock, and treatment of patients with CS is resource intensive. In this review, we consider the current treatment paradigms alongside the evidence that underpins them. The current standard of treatment relies on a feedback mechanism, where small changes in treatment are assessed to see if clinical improvement occurs. This leads to delays that increase time in the shock state. The novel approach described proposes immediate treatment to ameliorate the shock state to "break" the shock spiral as quickly and decisively as possible, suggesting new metrics to measure performance.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

A functional cardiac patch with "gas and ion" dual-effect intervention for reconstructing blood microcirculation in myocardial infarction repair

Postinfarction revascularization is critical for repairing the infarcted myocardium and for stopping disease progression. Considering the limitations of surgical intervention, engineered cardiac patches (ECPs) are more effective in establishing rich blood supply networks. For efficacy, ECPs should promote the formation of more mature blood vessels to improve microcirculatory dysfunction and mitigate hypoxia-induced apoptosis. Developing collateral circulation between infarcted myocardium and ECPs for restoring blood perfusion remains a challenge. Here, an ion-conductive composite ECPs (GMA@OSM) with powerful angiogenesis-promoting ability was constructed. Based on dual-effect intervention of oxygen and strontium, the developed ECPs can promote the formation of high-density circulating microvascular network at the infarcted myocardium. In addition, the GMA@OSM possesses effective reactive oxygen species-scavenging capacity and can facilitate electrophysiological repair of myocardium with ionic conductivity. In vitro and in vivo studies indicate that the multifunctional GMA@OSM ECPs form well-developed collateral circulation with infarcted myocardium to protect cardiomyocytes and improve cardiac function. Overall, this study highlights the potential of a multifunctional platform for developing collateral circulation, which can lead to an effective therapeutic strategy for repairing myocardial infarction.

Different Mechanical Circulatory Support Strategies for Infarct-Related Cardiogenic Shock: A Subanalysis of the ECLS-SHOCK Trial

BACKGROUND

Mechanical circulatory support (MCS) devices are frequently used in patients with acute myocardial infarction complicated by cardiogenic shock. In clinical practice, escalation of MCS device therapy is performed in a significant proportion of patients aiming to improve hemodynamic status.

OBJECTIVES

The aim of this study was to analyze outcomes of different MCS device strategies in the ECLS-SHOCK (Extracorporeal Life Support in Cardiogenic Shock) trial.

METHODS

The present subanalysis from the ECLS-SHOCK trial analyzed outcomes of patients treated with upfront extracorporeal life support (ECLS) only, bailout MCS, and escalated MCS therapy. The primary outcome was 30-day all-cause mortality.

RESULTS

Upfront ECLS only, bailout MCS, and escalated MCS therapy were used in 165 (78.9%), 54 (26.0%), and 27 (12.9%) patients, respectively. Thirty-day all-cause mortality was 44.8% (95% CI: 37.1%-52.8%), 61.1% (95% CI: 46.9%-74.1%), and 55.6% (95% CI: 35.3%-74.5%) in the upfront ECLS, bailout MCS, and escalated MCS group (P = 0.09). Need for renal replacement therapy was higher in the bailout MCS (35.2%; 95% CI: 22.7%-49.4%) than in upfront ECLS (7.3%; 95% CI: 3.8%-12.4%) and escalated MCS (14.8%; 95% CI: 4.2%-33.8%) (P < 0.001). Moderate or severe bleeding complications were similar in the upfront ECLS (25.5%; 95% CI: 19.0%-32.8%), bailout MCS (22.2%; 95% CI: 12.0%-35.6%), and escalated MCS (22.2%; 95% CI: 8.6%-42.3%) group (P = 0.86).

CONCLUSIONS

Bailout and escalated MCS therapy is associated with numerically higher 30-day mortality compared with upfront ECLS use only. Bailout MCS use is also associated with higher need for renal replacement therapy. (Extracorporeal Life Support in Cardiogenic Shock [ECLS-SHOCK]; NCT03637205).

Safety and efficacy of surgical revascularization with percutaneous ventricular assist device for acute myocardial infarction complicated by cardiogenic shock: Japanese national registry study

BACKGROUND

This study aims to assess the safety of coronary artery bypass grafting (CABG) with percutaneous ventricular assist device (PVAD) in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS).

METHODS

A retrospective analysis was conducted on 1198 patients with AMI-CS from the J-PVAD registry, who underwent PVAD support using Impella® (Abiomed Inc., Danvers, MA) and subsequent revascularization between February 2020 and December 2021. Patients were divided into two groups based on the method of coronary revascularization: percutaneous coronary intervention (PCI, n = 1084) and CABG (n = 114). The study assessed short-term all-cause and cardiac-related mortality.

RESULTS AND CONCLUSION

The CABG group exhibited significantly lower short-term all-cause mortality compared with the PCI group (30-day: 26.2% vs. 39.9%, 90-day: 45.5% vs. 58.4%, log-rank p = 0.004). Short-term cardiac-related mortality was similar toward low in the CABG group compared with the PCI group (30-day: 18.7% vs. 25.6%, 90-day: 29.4% vs. 35.5%, log-rank p = 0.084). Multivariable analysis using the Cox proportional hazard model did not identify revascularization strategy as a risk factor for both all-cause mortality (Hazard ratio (HR): 0.743, 95% confidence intervals (CI): 0.457-1.208, p = 0.231) and cardiac-related mortality (HR: 0.762, 95% CI: 0.390-1.490, p = 0.427). These results were not attenuated even in subgroup analyses separately comparing CABG alone and hybrid therapy with PCI after propensity score matching. Thus, CABG can be a treatment option with feasible short-term outcomes in patients with AMI-CS under PVAD support.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Mesenteric Ischemia During Intra-Aortic Balloon Counterpulsation Therapy: Case Series

Intra-aortic balloon pumps (IABPs) are commonly used circulatory support devices. Mesenteric ischemia is a serious and poorly studied complication of IABP use. Here, we examine six cases of mesenteric ischemia associated with IABPs from a single urban academic medical center. We examine patient, device, and radiographic characteristics, and hypothesize several mechanisms behind IABP-associated mesenteric ischemia including anatomic-to-device length mismatch, atheroembolism, and mechanical obstruction. We highlight the high morbidity and mortality of such complication and the need for future studies to examine risk factors that may predispose IABP-treated patients to the development of mesenteric ischemia.

Efficacy of a 16 Fr sheath strategy during Impella support to reduce access site bleeding in patients with cardiogenic shock

Access site bleeding is a complication which may occur during Impella support (Abiomed, Danvers, MA, USA), possibly due to unstable fixation of the device in the groin. Using a large-bore sheath for Impella insertion may reduce this complication. However, the efficacy and safety of this strategy are still unknown. The main aim of this study was to assess whether employing a large-bore sheath during Impella insertion mitigates access site bleeding without increasing limb ischemia. All consecutive patients who received either the Impella 2.5 or CP for cardiogenic shock from September 2019 to February 2023 were included in this study. We compared patients who underwent Impella insertion using the conventional peel-away introducer and the attached sheath (repositioning sheath) and patients in whom the Impella was inserted using a 16 Fr sheath. All patients received antegrade perfusion with a 4Fr sheath to prevent limb ischemia at the Impella site. The primary outcome was access site major bleeding: 36 patients were treated with a 16 Fr sheath and 39 were treated with a conventional sheath. The use of a 16 Fr sheath was associated with a significant reduction in major bleeding (33.0% vs. 64.0%, p = 0.01) in comparison to the conventional sheath. After adjusting for covariates, the risk of major bleeding at the access site in the 16 Fr sheath group was significantly lower than that in the conventional sheath group (adjusted odds ratio, 0.294; 95% confidence interval 0.087-0.991; p = 0.048). The insertion of Impella through a 16 Fr sheath significantly reduced the risk of major bleeding at the access site in comparison to the conventional sheath.

MECHANICAL LEFT VENTRICULAR UNLOADING IN CARDIOGENIC SHOCK TREATED WITH VENOARTERIAL EXTRACORPOREAL MEMBRANE OXYGENATION: A SYSTEMATIC REVIEW AND META-ANALYSIS

ABSTRACT

Objective : To evaluate if mechanical left ventricular unloading could reduce mortality in patients with cardiogenic shock undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). Methods : We searched MEDLINE, Embase, and the Cochrane Library for randomized controlled trials and propensity score-matched studies published until December 20, 2023. The primary outcome was mortality at the longest follow-up. We used a Mantel-Haenszel random effects meta-analysis and reported the pooled results with a risk ratio (RR) and 95% confidence interval (CI). The review protocol was registered on PROSPERO International prospective register of systematic review (CRD42024498665). Results : We identified two randomized controlled trials and 11 propensity score-matched studies, totaling 9,858 patients. Mechanical left ventricular unloading was significantly associated with reduced mortality at the longest follow-up (RR, 0.89; 95% CI, 0.84-0.94; P = 0.0001; moderate certainty of evidence), which was confirmed in studies using intra-aortic balloon pump. Benefits of mechanical unloading were also observed in terms of successful VA-ECMO weaning (RR, 1.15; 95% CI, 1.02-1.29; P = 0.02; low certainty of evidence) and favorable neurological outcome (two studies; RR, 2.45; 95% CI, 1.62-3.69; P < 0.0001; low certainty of evidence), although we observed an increased incidence of major bleeding (RR, 1.27; 95% CI, 1.02-1.59; P = 0.03; low certainty of evidence) and hemolysis (RR, 1.49; 95% CI, 1.10-2.02; P = 0.01; moderate certainty of evidence). Conclusions : Among adult patients with cardiogenic shock treated with VA-ECMO, mechanical left ventricular unloading was associated with reduced mortality, which was confirmed in studies using intra-aortic balloon pump as an unloading device.

Mechanical Circulatory Support in Patients Without Cardiogenic Shock Undergoing Percutaneous Coronary Intervention

BACKGROUND

The use of mechanical circulatory support devices for high-risk percutaneous coronary intervention (PCI) has increased over the past decade despite limited data of benefit. We sought to examine the association between intravascular microaxial left ventricular assist device (LVAD) versus intra-aortic balloon pump use in patients without cardiogenic shock (CS) undergoing PCI.

METHODS AND RESULTS

This retrospective study analyzed claims data from a large, insured population who underwent PCI without CS from April 1, 2016 to July 31, 2022. Using inverse probability treatment weighting, we assessed for the association between device type and clinical outcomes. The primary outcome was all-cause mortality. Secondary outcomes included stroke, bleeding, incident dialysis, repeat revascularization, and total health care costs during the index admission and at 30 days. We identified 2879 patients without CS who underwent PCI with either an intra-aortic balloon pump or microaxial LVAD. The mean±SD age was 68.2±12.5 years, and 27% (n=764) were women. After propensity weighting, intravascular LVAD use was not associated with a significant difference in either in-hospital (odds ratio [OR] 1.30 [95% CI, 0.88-1.91]; P=0.19) or 30-day mortality (OR, 1.19 [95% CI, 0.84-1.69]; P=0.33) compared with intra-aortic balloon pump use. Compared with those receiving an intra-aortic balloon pump, the mean total costs for the index admission ($96 716 versus $71 892; P<0.001) and at 30 days (+$16 671 [95% CI, $6639-$28 103]; P=0.001) were significantly higher in those receiving an intravascular LVAD. There was no significant association between device type and stroke, bleeding, incident dialysis, and repeat revascularization at any time point (all P>0.05).

CONCLUSIONS

In patients without CS undergoing PCI, intravascular LVAD use was associated with higher costs but not associated with lower mortality. Randomized data are needed to improve device selection for patients without CS undergoing PCI.

Myocardial Infarction-Associated Shock: A Comprehensive Analysis of Phenotypes, SCAI Classification, and Outcome Assessment

Background and Objectives: In-hospital mortality associated with myocardial infarction complicated by cardiogenic shock (MI-CS) remains critically high. A particularly challenging form, mixed shock (MS), combines features of cardiogenic shock (CS) with distributive elements such as vasodilation and reduced vascular resistance. MS is associated with elevated mortality rates and presents unique diagnostic and therapeutic challenges. This study aimed to analyze the clinical, historical, instrumental, and laboratory characteristics of the primary phenotypes of MI-CS, stratified according to the Society for Cardiovascular Angiography and Interventions (SCAI) shock severity scale. Materials and Methods: In this single-center, retrospective observational study, we reviewed the medical records of 1289 patients admitted to the emergency cardiology department from 1 January to 12 December 2020. Among them, 117 patients were identified as having MI-CS and were divided into two groups: MS (n = 48) and isolated CS (n = 69). The data were analyzed using the SCAI shock classification. Logistic regression analysis was employed to identify predictors of mortality and improved survival outcomes. Results: Patients with MS were older (80 years [71.0; 83.0] vs. 73 years [64.0; 81.0], p = 0.035). The overall mortality rate was significantly higher in the MS group (68% vs. 53%, RR = 1.438, 95% CI: 1.041-1.986, p = 0.03). Logistic regression identified mechanical ventilation (OR = 8.33, 95% CI: 2.54-22.80, p = 0.012), elevated lactate levels (OR = 1.20, 95% CI: 1.02-1.41, p = 0.026), and cardiopulmonary resuscitation (CPR) (OR = 7.97, 95% CI: 2.51-24.40, p < 0.0001) as independent predictors of mortality. Conversely, the use of an intra-aortic balloon pump (IABP) (OR = 0.22, 95% CI: 0.06-0.80, p = 0.021) and a higher body mass index (BMI) (OR = 0.91, 95% CI: 0.84-0.99, p = 0.038) were associated with reduced mortality risk. Conclusions: MS in the context of MI-CS represents a distinct clinical phenotype with specific hemodynamic features and significantly worsened outcomes. The identification of mortality predictors, such as mechanical ventilation, elevated lactate levels, and CPR, alongside protective factors like IABP use and a higher BMI, underscores the importance of early and tailored therapeutic interventions. These findings highlight the need for further studies to refine treatment protocols and improve outcomes in this high-risk population.

Timing of veno-arterial extracorporeal membrane oxygenation support in patients with cardiogenic shock

AIMS

The optimal timing for implementing mechanical circulatory support (MCS) in cardiogenic shock (CS) remains indeterminate. This study aims to evaluate patient characteristics and outcome associated with the time interval between CS onset and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implementation.

METHODS AND RESULTS

In this study, patients with CS treated with MCS at 15 tertiary care centres in three countries were enrolled. Patients treated with MCS were stratified into early (<2 h), intermediate (2-12 h) and delayed (≥12-24 h) MCS implantation by using the time interval between CS onset and MCS device implementation. Adjusted logistic and Cox regression models were fitted to assess the association between timing of MCS implementation, patient characteristics and 30-day mortality. A total of 330 patients with CS treated with VA-ECMO and/or microaxial flow pump were included in this study; 20.9% received early, 55.8% intermediate, and 23.3% delayed MCS. Although crude 30-day mortality was slightly lower in patients with early MCS (58.1% vs. 64.7% vs. 64.3%), adjusted analyses showed no significant association between timing of MCS implantation and 30-day all-cause mortality (hazard ratio [HR] for early vs. intermediate MCS: 0.93, 95% confidence interval [CI] 0.59-1.46, p = 0.74; HR for early vs. delayed MCS: 1.29, 95% CI 0.78-2.13, p = 0.33). Moreover, the incidence of complications, related and unrelated to MCS, did not differ significantly among groups.

CONCLUSION

In this exploratory study of patients with CS treated with MCS, the timing of device implantation within 24 h after CS onset was not associated with mortality. This supports a restrictive MCS approach, reserving its application for patients experiencing CS deterioration despite conventional therapy.

The effect of standardization of insertion and removal of percutaneous left ventricular assist device

BACKGROUND

The effect of standardizing an insertion and removal protocol for pVAD devices has not been previously described.

OBJECTIVES

We sought to evaluate clinical outcomes in patients who underwent pVAD insertion pre- and post-protocol standardization.

METHODS

All patients who underwent pVAD insertion that remained in place at index procedure completion between January 2017 and September 2023 at a single academic center for both high-risk PCI and cardiogenic shock indications were included in the study. The primary outcome was the incidence of limb ischemia and major bleeding before and after the protocol initiation. Secondary outcomes included in-hospital and 30-day MACCE rate (death, myocardial infarction, stroke, emergent CABG), and how often the operators followed the protocol.

RESULTS

A total of 89 patients had pVAD left in place (29 pre-protocol initiation and 60 post-protocol initiation). There was a significant decrease in incidence of limb ischemia post-protocol initiation compared to pre (17.2 % vs 1.7 %, p = 0.01) but no difference in bleeding incidence (13.8 % vs 20.0 %, p = 0.47). Adherence increased in all components of the protocol except for right heart catheterization.

CONCLUSION

Standardization of an insertion and removal protocol for pVAD devices led to a statistically significant decrease in limb ischemia in a high-risk patient population.

Cardiooncology in the ICU - Cardiac Urgencies in Cancer Care

Cardiovascular disease is an increasing risk of morbidity and mortality in cancer patients, related to an growing number of aging survivors with pre-existing cardiovascular disease and the use of traditional and novel cancer therapies with cardiotoxic effects. While many cardiac complications are chronic processes that develop over time, there are many acute processes that may arise in hospitalized patients. It is important for hospitalists and critical care physicians to be familiar with the recognition and management of these conditions in this unique population. This article reviews the presentation and management of common cardiac urgencies in critically ill cancer patients including acute decompensated heart failure, acute coronary syndromes, arrhythmias, hypertensive crises, pulmonary embolism, pericardial tamponade and myocarditis.

Sex-Related Differences in Outcome of Patients Treated With Microaxial Percutaneous Left Ventricular Assist Device for Cardiogenic Shock

BACKGROUND

The use of microaxial percutaneous left ventricular assist devices (pLVADs) in cardiogenic shock (CS) has increased in recent years, despite limited evidence, and data on sex disparities are particularly scarce. This study aimed to compare short-term outcomes between males and females.

METHODS

Data were retrospectively collected from the Dresden Impella Registry, which is a large, prospective, single-centre registry that consecutively enrolled patients who received microaxial pLVAD. Inclusion criteria were CS due to left ventricular failure with serum lactate >4 mM. Patients with pLVAD other than Impella CP were excluded. The primary endpoint was the composite of all-cause mortality at 30 days or requirement of renal replacement therapy (RRT). Secondary endpoints were the components of the primary endpoint alone. Propensity score matched (PSM) analysis was used to adjust for baseline characteristics.

RESULTS

A total of 319 male (69 years; body mass index, 26.7 kg/m2) and 113 female patients (74 years; 27.9 kg/m2) were included in the study. The primary composite endpoint occurred less frequently in female patients in the unmatched analysis (♂ 75.9% [n=239] vs ♀ 64.4% [n=72]; p=0.040) but not in the PSM analysis (♂ 81.1% [n=73] vs ♀ 68.9% [n=42]; p=0.056). However, females less frequently required RRT in both analyses (♂ 48.2% [n=126] vs ♀ 25.9% [n=25]; p=0.001; PSM: ♂ 49.1% [n=36] vs ♀ 23.3% [n=12]; p=0.007). All-cause mortality did not differ between the cohorts.

CONCLUSIONS

This study showed no differences in all-cause mortality at 30 days between male and female patients receiving microaxial pLVAD in CS. Larger studies are required to confirm whether female sex is associated with reduced requirement of RRT in CS treated with microaxial pLVAD.

Cardiogenic shock severity predicts bleeding events in patients with temporary mechanical circulatory support

BACKGROUND

Data on shock severity and bleeding events in patients with temporary mechanical circulatory support (tMCS) are limited. We investigated the relationship between the Society for Cardiovascular Angiography and Interventions (SCAI) shock stage classification and bleeding events in patients with tMCS.

METHODS

We evaluated the data of 285 consecutive patients with tMCS who were admitted to our institution between June 2019 and May 2022. At the time of tMCS initiation, 81 patients (28.4%) were in SCAI stage A, 38 (13.3%) in stage B, 69 (24.2%) in stage C, 33 (11.6%) in stage D, and 64 (22.5%) in stage E. Multivariable logistic regression modeling was used to assess the association between the SCAI shock stage and in-hospital bleeding events.

RESULTS

In-hospital bleeding occurred in 100 patients (35.1%). The bleeding event rate increased incrementally across the SCAI shock stages (stage A, 11.1%; stage B, 15.8%; stage C, 37.7%; stage D, 54.6%; stage E, 64.1%). In-hospital bleeding was associated with the SCAI shock stage (p < 0.001). Compared with stage A, the adjusted odds ratios for in-hospital bleeding were 1.48 (95% confidence interval [CI] 0.47-4.66), 6.47 (95% CI 2.61-10.66), 11.59 (95% CI 3.77-35.64), and 7.85 (95% CI 2.51-24.55) for stages B, C, D, and E, respectively.

CONCLUSIONS

The SCAI shock stage predicted subsequent bleeding events in patients with tMCS. This simple scheme may be useful for tailored risk-based clinical assessment and management of patients with tMCS.

UHPLC-Q-Orbitrap HRMS and network analysis to explore the mechanisms of QiShenYiQi dripping pill for treating myocardial infarction

This study focused on examining the protection of QiShenYiQi dripping pills (QSYQ) against myocardial infarction (MI) and investigating its potential mechanisms. Ultra high performance liquid chromatography-q exactive-orbitrap high resolution mass spectrometry (UHPLC-Q-Orbitrap HRMS) was employed to analyze potential active compounds of QSYQ. The targets of these compounds were predicted using an integrated in silico method and cross-referenced with relevant databases to identify associated pathways. Experimental validation was then conducted to confirm the accuracy of the systems pharmacology findings. In the end, network analysis combined with UHPLC screened 13 potential active compounds and obtained 99 targets for the intersection of potential active compounds and diseases. The enrichment analysis results indicated that the cyclic guanosine monophosphate-protein kinase G (cGMP-PKG) signaling pathway might be the mechanism of action of QSYQ in the treatment of MI. Experimental verification demonstrated that QSYQ could alleviate oxidative stress, promote vasodilation, and activate proteins related to the mitochondrial ATP-sensitive potassium channel (KATP) and nitric oxide (NO)-cGMP-PKG signaling pathway. This study provides insights into both the pathogenic mechanisms underlying MI and the molecular mechanisms through which QSYQ may confer protection. Given the role of PKG in regulating myocardial stiffness, it emerges as a promising therapeutic target for myocardial remodeling. We propose that the NO-cGMP-PKG and mitochondrial KATP pathways may serve as candidate therapeutic targets for the development of new interventions for MI.

Management of cardiogenic shock: state-of-the-art

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

MI2AMI-CS: A meta-analysis comparing Impella and IABP outcomes in Acute Myocardial Infarction-related Cardiogenic Shock

BACKGROUND

Cardiogenic Shock (CS) complicating acute myocardial infarction (AMI) poses a significant mortality risk, suggesting the opportunity to implement effective mechanical circulatory support strategies. The comparative efficacy of Intra-Aortic Balloon Pump (IABP) and Impella in managing CS-AMI remains a subject of investigation.

OBJECTIVE

This meta-analysis aims to evaluate the comparative effectiveness of Impella and IABP in managing CS-AMI, exploring mortality and adverse events.

METHODS

A systematic search of major databases from inception to November 2023 identified eight studies, comprising 10,628 patients, comparing Impella and IABP in CS-AMI. Retrospective studies (preferably Propensity-matched) and Randomized Clinical Trials (RCTs) were included.

RESULTS

Impella use exhibited significantly higher mortality (57% vs. 46%; OR: 1.44, 95% CI: 1.29-1.60; p < 0.001) and major bleeding (30% vs 15%; OR: 2.93, 95% CI: 1.67-5.13; p < 0.001).

CONCLUSIONS

In unselected CS-AMI patients, Impella usage is associated with significantly higher mortality and major bleeding.

ECMO versus IABP for patients with STEMI complicated by cardiogenic shock undergoing primary PCI: a Chinese National Study and propensity-matched analysis

OBJECTIVE

This study investigated the association between the utilization of extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pump (IABP) and in-hospital mortality among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock undergoing primary percutaneous coronary intervention (PCI).

METHODS

Data encompassing 9635 cases of STEMI complicated by cardiogenic shock and treated with primary PCI using ECMO/IABP support were retrieved from the Chinese Cardiovascular Association database (2019-2021). We conducted an analysis to assess the in-hospital survival disparities among percutaneous mechanical circulatory device recipients and explore the potential advantages of ECMO through multivariable logistic regression analysis within a propensity score-matched (1:2) cohort population.

RESULTS

ECMO was administered to 2028 patients, whereas IABP was used in 7607 patients. Patients supported by ECMO showed a lower in-hospital mortality than those supported by IABP (7.2% versus 15.1%, p < 0.001). Within the propensity-matched (case: control = 1:2) cohort, we noted a 34% reduced risk of in-hospital mortality among patients supported by ECMO compared with those supported by IABP (7.7% versus 11.7%; odds ratio = 0.66; 95% CI, 0.53-0.80; p < 0.001) independent of age, sex, systolic blood pressure, obesity, smoke, hypertension, diabetes, dyslipidemia, family history of coronary artery disease, coronary artery disease, stroke, atrial filiation, peripheral artery disease, chronic kidney disease, vascular lesion sites, 3A-grade hospital, and regional distributions in China.

CONCLUSION

Among patients undergoing primary PCI for STEMI complicated by cardiogenic shock, ECMO was associated with better in-hospital survival than IABP.

Different strategies in left ventricle unloading during venoarterial extracorporeal membrane oxygenation: A network meta-analysis

Background

Left ventricular (LV) overload is a frequent complication during VA-ECMO associated with poor outcomes. Many strategies of LV unloading have been documented but lack of evidence shows which is better. We conducted a network meta-analysis to compare different LV unloading strategies.

Methods

We searched databases for all published studies on LV unloading strategies during VA-ECMO. The pre-defined primary outcome was all-cause mortality.

Results

45 observational studies (34235 patients) were included. The Surface Under the Cumulative Ranking values (SUCRA) demonstrated that compared to no unloading strategy (15.4 %), IABP (73.8 %), pLVAD (60.8 %), atrial septostomy (51.2 %), catheter venting (48.8 %) were all associated with decreased all-cause mortality, in which IABP and pLVAD existed statistical significance. For secondary outcomes, no unloading group had the shortest VA-ECMO duration, ICU and hospital length of stay, and the lower risk of complications compared with unloading strategies. IABP was associated with reducing VA-ECMO duration, ICU and hospital length of stay, and the risk of complications (except for hemolysis as the second best) compared with other unloading strategies.

Conclusions

LV unloading strategies during VA-ECMO were associated with improved survival compared to no unloading, but the tendency to increase the risk of various complications deserves more consideration.

Long-term outcomes of cardiogenic shock and cardiac arrest complicating ST-elevation myocardial infarction according to timing of occurrence

Aims

Cardiogenic shock (CS) and cardiac arrest (CA) are serious complications in ST-elevation myocardial infarction (STEMI) patients, with lack of long-term data according to their timing of occurrence. This study sought to determine the incidence and relationship between the timing of occurrence and prognostic impact of CS and CA complicating STEMI in the long-term follow-up.

Methods and results

We conducted a retrospective analysis of consecutive STEMI patients treated between 2004 and 2017. Patients were divided into four groups based on the occurrence of neither CA nor CS, CA only, CS only, and both CA and CS (CA-CS-, CA+, CS+, and CA+CS+, respectively). Adjusted Cox regression analysis was used to assess the independent association between the CS and CA categories and mortality. A total of 1603 STEMI patients were followed for a median of 3.6 years. CA and CS occurred in the 12.2% and 15.9% of patients, and both impacted long-term mortality [adjusted hazard ratio (HR) = 2.59, 95% confidence interval (CI): 1.53-4.41, P < 0.001; HR = 3.16, 95% CI: 2.21-4.53, P < 0.001, respectively). CA+CS+ occurred in 7.3%, with the strongest association with higher mortality (adjusted HR = 5.36; 95% CI: 3.80-7.55, P < 0.001). Using flexible parametric models with B-splines, the increased mortality was restricted to the first ∼10 months. In addition, overall mortality rates were higher at all timings (all with P < 0.001), except for CA during initial cardiac catheterization (P < 0.183).

Conclusion

CS and CA complicating patients presenting with STEMI were associated with higher long-term mortality rate, especially in the first 10 months. Both CS+ and CA+ at any timeframe impacted outcomes, except for CA+ during the initial cardiac catheterization, although this will have to be confirmed in larger future studies, given the relatively small number of patients.

Role of Mechanical Circulatory Support in Complex High-Risk and Indicated Percutaneous Coronary Intervention: Current Indications, Device Options, and Potential Complications

Improved expertise and technological advancements have enabled the safe and effective performance of complex and high-risk-indicated percutaneous coronary intervention (CHIP) in patients previously considered inoperable or high-risk. Mechanical circulatory support (MCS) devices play a crucial role in stabilizing hemodynamics during percutaneous coronary intervention (PCI) -related ischemia, thereby reducing the risk of major adverse events and achieving a more complete revascularization. However, the use of MCS devices in protected PCI is not without risks, including peri-procedural myocardial infarction (MI), bleeding, and access-related complications. Despite numerous observational studies, there is a significant lack of randomized clinical trials comparing different MCS devices in various CHIP scenarios and evaluating their long-term safety and efficacy profiles. This review aims to summarize the current evidence regarding the benefits of MCS devices during CHIPs, offer a practical guide for selecting appropriate devices based on clinical scenarios, and highlight the unanswered questions that future trials need to address.

Management of Myocardial Infarction: Emerging Paradigms for the Future

Despite significant advancements in managing acute ST-segment elevation myocardial infarctions, the prevalence of heart failure has not decreased. Emerging paradigms with a focus on reducing infarct size show promising evidence in the improvement of the incidence of heart failure after experiencing acute coronary syndromes. Limiting infarct size has been the focus of multiple clinical trials over the past decades and has led to left ventricular (LV) unloading as a potential mechanism. Contemporary use of microaxial flow devices for LV unloading has suggested improvement in mortality in acute myocardial infarction complicated by cardiogenic shock. This review focuses on clinical data demonstrating evidence of infarct size reduction and highlights ongoing clinical trials that provide a new therapeutic approach to the management of acute myocardial infarction.

Impella Versus Non-Impella for Nonemergent High-Risk Percutaneous Coronary Intervention

The benefit of mechanical circulatory support with Impella (Abiomed, Inc., Danvers, Massachusetts) for high-risk percutaneous coronary intervention (HR-PCI) is uncertain. PROTECT III registry data showed improved outcomes with Impella compared with historical data (PROTECT II) but lack a direct comparison with the HR-PCI cohort without Impella support. We retrospectively identified patients meeting the PROTECT III inclusion criteria for HR-PCI and compared this group (non-Impella cohort [NonIMP]) with the outcomes data from the PROTECT III registry (Impella cohort). Baseline differences were balanced using inverse propensity weighting. The coprimary outcome was major adverse cardiac events (MACE) in-hospital and at 90 days. A total of 283 patients at great risk did not receive Impella support; 200 patients had 90-day event ascertainment and were included in the inverse propensity weighting analysis and compared with 504 patients in the Impella cohort group. After calibration, few residual differences remained between groups. The primary outcome was not different in-hospital (3.0% vs 4.8%, p = 0.403) but less in NonIMP at 90 days (7.5% vs 13.8%, p = 0.033). Periprocedural vascular complications, bleeding, and transfusion rate did not differ between groups; however, acute kidney injury occurred more frequently in the NonIMP group (10.5% vs 5.4%, p = 0.023). In conclusion, under identical HR-PCI inclusion criteria for Impella use in PROTECT III, an institutional non-Impella-supported HR-PCI cohort showed similar MACE in-hospital but fewer MACE at 90 days, whereas there was no signal for periprocedural harm with Impella use. These results do not support routine usage of Impella for patients with HR-PCI.

Mechanical Circulatory Support with Impella: Principles, Evidence, and Daily Practice

The Impella (Abiomed, Danvers, MA, USA) microaxial pump is a percutaneous mechanical circulatory support (MCS) that has been shown to increase coronary perfusion, reduce myocardial oxygen demand, and improve peripheral organ perfusion. Therefore, indications for the Impella device include emergency use for cardiogenic shock (CS) and pre-emptive implantation during high-risk percutaneous coronary intervention (HR-PCI). However, despite their exponential use in cardiovascular practice over the past decade, there is limited randomized evidence to support the benefits of this therapy and growing concern regarding complication rates. In this review, we summarize the principles, evidence, and practical considerations of the most widely used Impella CP percutaneous left ventricular support in both CS and HR-PCI settings, moving from the historical background to current issues and future expectations for this device.

Haemodynamic support with percutaneous devices in patients with cardiogenic shock: the current evidence of mechanical circulatory support

INTRODUCTION

Cardiogenic shock (CS) is a complex life-threatening condition that results from primary cardiac dysfunction, leading to persistent hypotension and systemic hypoperfusion. Among the therapeutic options for CS are various percutaneous mechanical circulatory support (MCS) devices that have emerged as an increasingly effective hemodynamic support option. Percutaneous therapies can act as short-term mechanical circulatory assistance and can be split into intra-aortic balloon pump (IABP) and non-IABP percutaneous mechanical devices.

AREAS COVERED

This review will evaluate the MCS value while considering the mortality rate improvements. We also aim to outline the function of pharmacotherapies and percutaneous hemodynamic MCS devices in managing CS patients to avoid the onset of end-organ dysfunction and improve both early and late outcomes.

EXPERT OPINION

Given the complexity, acuity and high mortality associated with CS, and despite the availability and efficacy of pharmacological management, MCS is required to achieve hemodynamic stability and improve survival. Various percutaneous MCS devices are available with varying indications and clinical outcomes. The rates of early mortality and complications were found to be comparable between the four devices, yet, IABP seemed to show the most optimal clinical profile whilst ECMO demonstrated its more long-term efficacy.

Unloading in cardiogenic shock: the rationale and current evidence

PURPOSE OF REVIEW

Discussing the rationale and current evidence for left ventricular unloading in cardiogenic shock.

RECENT FINDINGS

Microaxial flow pumps (MFP) and intra-aortic balloon pumps (IABP) augment cardiac output while simultaneously unloading the left ventricle (e.g. reducing left ventricular pressure), thereby targeting a key mechanism of cardiogenic shock. A recent randomized trial has shown a mortality reduction with MFP in selected patients with cardiogenic shock, strengthening the rationale for this strategy, although the evidence for the IABP is so far neutral. MFP/IABP can also be used concomitantly with veno-arterial extracorporeal membrane oxygenation (va-ECMO) to alleviate the va-ECMO-related increase in left ventricular afterload, to facilitate weaning and ultimately to improve myocardial recovery and prognosis of affected patients. However, the use of MFP/IABP in this indication solely relies on retrospective data, which need to be interpreted with caution, especially as these strategies are associated with more complications. Currently ongoing randomized trials will help to further clarify the role of left ventricular unloading in patients on va-ECMO.

SUMMARY

Left ventricular unloading addresses a key mechanism of cardiogenic shock, with strong evidence to support MFP use in selected patients, but further randomized controlled trials are required to clarify the role of different devices/strategies for the overall shock population.

The predictive value of neutrophil-lymphocyte ratio combined with the Global Registry of Acute Coronary Events score for inhospital adverse cardiovascular events in patients with acute ST-elevation myocardial infarction

Background

The research explores the predictive efficacy of the neutrophil-to-lymphocyte ratio (NLR) in conjunction with the Global Registry of Acute Coronary Events (GRACEs) score for inhospital major adverse cardiovascular events (MACEs) among acute ST-segment elevation myocardial infarction (STEMI) subjects with primary percutaneous coronary intervention (PCI) history.

Materials and Methods

Patients were categorized into MACE (n = 58) and non-MACE cohorts (n = 184) based on MACE occurrence events during hospitalization. The predictive value of the NLR, GRACE score, and their combination for inhospital MACE events in STEMI subjects was assessed by the receiver operating characteristic curve (ROC).

Results

NLR (8.99 [5.06, 12.01] vs. 5.15 [3.13, 7.66]) and GRACE scores (159.62 ± 43.39 vs. 116.96 ± 28.15) within MACE group notably surpassed the non-MACE group (P < 0.05). ROC curve analysis demonstrated that the area under the curve (AUC) for NLR in forecasting inhospital MACE events was 0. 72 (95% confidence interval [CI]: 0.645-0.795), with 0.655 sensitivity and 0.723 specificity, and optimal cutoff value as 7.01. The AUC for the GRACE score was 0.791 (95% CI: 0.717-0.865), with 0.862 sensitivity and 0.598 specificity, and the optimal cutoff value was 121.5. The combined AUC of NLR and GRACE score was 0.814 (95% CI: 0.745-0.884), with 0.707 sensitivity and 0.837 specificity.

Conclusion

Both NLR and GRACE score independently predict inhospital MACE events in STEMI patients post-PCI. Integration of the NLR and GRACE score enhances accuracy in forecasting inhospital MACE event occurrences.

Cardiac ECMO: changing role in times of Impella and ventricular assist devices?

Mortality in infarct-related as well as heart failure-associated cardiogenic shock remains high, reaching 40-50% depending on the etiology and severity of cardiogenic shock. Percutaneous active mechanical circulatory support devices including veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and microaxial left ventricular mechanical circulatory support devices are rapidly evolving in their use. However, evidence of VA-ECMO therapy has only recently emerged and showed no benefit for mortality, with an associated higher complication rate. Evidence for microaxial left ventricular mechanical circulatory support devices such as the Impella pump (Abiomed, Danvers/MA, USA) is limited. The current article aims to give an overview of the basics of VA-ECMO therapy and microaxial left ventricular mechanical circulatory support devices, the current evidence, ongoing trials, patient selection, and potential complications. This article is freely available.

European practices on antithrombotic management during percutaneous mechanical circulatory support in adults: a survey of the Association for Acute CardioVascular Care of the ESC and the European branch of the Extracorporeal Life Support Organization

AIMS

Bleeding and thrombotic complications compromise outcomes in patients undergoing percutaneous mechanical circulatory support (pMCS) with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and/or microaxial flow pumps like Impella™. Antithrombotic practices are an important determinant of the coagulopathic risk, but standardization in the antithrombotic management during pMCS is lacking. This survey outlines European practices in antithrombotic management in adults on pMCS, making an initial effort to standardize practices, inform future trials, and enhance outcomes.

METHODS AND RESULTS

This online cross-sectional survey was distributed through digital newsletters and social media platforms by the Association of Acute Cardiovascular Care and the European branch of the Extracorporeal Life Support Organization. The survey was available from 17 April 2023 to 23 May 2023. The target population were European clinicians involved in care for adults on pMCS. We included 105 responses from 26 European countries. Notably, 72.4% of the respondents adhered to locally established anticoagulation protocols, with unfractionated heparin (UFH) being the predominant anticoagulant (Impella™: 97.0% and V-A ECMO: 96.1%). A minority of the respondents, 10.8 and 14.5%, respectively, utilized the anti-factor-Xa assay in parallel with activated partial thromboplastin time for UFH monitoring during Impella™ and V-A ECMO support. Anticoagulant targets varied across institutions. Following acute coronary syndrome without percutaneous coronary intervention (PCI), 54.0 and 42.7% were administered dual antiplatelet therapy during Impella™ and V-A ECMO support, increasing to 93.7 and 84.0% after PCI.

CONCLUSION

Substantial heterogeneity in antithrombotic practices emerged from participants' responses, potentially contributing to variable device-associated bleeding and thrombotic complications.

Percutaneous Microaxial Ventricular Assist Device Versus Intra-Aortic Balloon Pump for Nonacute Myocardial Infarction Cardiogenic Shock

BACKGROUND

Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited.

METHODS AND RESULTS

We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89).

CONCLUSIONS

Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.

The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review

Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.

Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit

BACKGROUND

Current guidelines recommend the use of mechanical circulatory support (MCS) for patients with cardiogenic shock that is refractory to medical therapy. Bleeding is the most common complication of MCS. Transarterial embolization (TAE) is often performed to treat this complication, because it is a less invasive hemostatic procedure. However, the TAE option needs to be carefully considered during MCS, as the access route may be limited during MCS.

CASE PRESENTATION

A man in his 70 s was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention via venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella. During treatment in the intensive care unit, he suffered damage to a branch of the internal thoracic artery during a cardiac drainage procedure, which was subsequently treated via emergency TAE. An ECMO return cannula and an Impella sheath were inserted into the patient's right and left femoral arteries, respectively. An approach from the left brachial artery was selected, and the left internal thoracic artery was embolized. Subsequently, the patient required re-intervention to treat re-bleeding from another artery. Because it was difficult to target the target artery from the brachial one, owing to interference from the Impella catheter, the ECMO circuit near the return cannula was punctured and a guiding sheath was inserted. The ECMO flow and the patient's blood pressure decreased following placement of this guiding sheath. We were thus able to maintain the patient's blood pressure by increasing the infusion fluids and Impella flow, and embolize the target artery using a gelatin sponge to achieve hemostasis.

CONCLUSION

When TAE is difficult to perform during MCS using an approach from the upper extremities, a lower extremity approach with a sheath inserted into the ECMO circuit may represent a viable alternative.

Intravascular Microaxial Left Ventricular Assist Device Manufacturer Payments to Cardiologists and Use of Devices

This study examines whether payments from a left ventricular assist device manufacturer to cardiologists performing percutaneous coronary intervention were associated with any use of the devices.

Advancing cardiac regeneration through 3D bioprinting: methods, applications, and future directions

Cardiovascular diseases (CVDs) represent a paramount global mortality concern, and their prevalence is on a relentless ascent. Despite the effectiveness of contemporary medical interventions in mitigating CVD-related fatality rates and complications, their efficacy remains curtailed by an array of limitations. These include the suboptimal efficiency of direct cell injection and an inherent disequilibrium between the demand and availability of heart transplantations. Consequently, the imperative to formulate innovative strategies for cardiac regeneration therapy becomes unmistakable. Within this context, 3D bioprinting technology emerges as a vanguard contender, occupying a pivotal niche in the realm of tissue engineering and regenerative medicine. This state-of-the-art methodology holds the potential to fabricate intricate heart tissues endowed with multifaceted structures and functionalities, thereby engendering substantial promise. By harnessing the prowess of 3D bioprinting, it becomes plausible to synthesize functional cardiac architectures seamlessly enmeshed with the host tissue, affording a viable avenue for the restitution of infarcted domains and, by extension, mitigating the onerous yoke of CVDs. In this review, we encapsulate the myriad applications of 3D bioprinting technology in the domain of heart tissue regeneration. Furthermore, we usher in the latest advancements in printing methodologies and bioinks, culminating in an exploration of the extant challenges and the vista of possibilities inherent to a diverse array of approaches.

Sex-related differences in patients presenting with heart failure-related cardiogenic shock

BACKGROUND

Heart failure-related cardiogenic shock (HF-CS) accounts for a significant proportion of all CS cases. Nevertheless, there is a lack of evidence on sex-related differences in HF-CS, especially regarding use of treatment and mortality risk in women vs. men. This study aimed to investigate potential differences in clinical presentation, use of treatments, and mortality between women and men with HF-CS.

METHODS

In this international observational study, patients with HF-CS (without acute myocardial infarction) from 16 tertiary-care centers in five countries were enrolled between 2010 and 2021. Logistic and Cox regression models were used to assess differences in clinical presentation, use of treatments, and 30-day mortality in women vs. men with HF-CS.

RESULTS

N = 1030 patients with HF-CS were analyzed, of whom 290 (28.2%) were women. Compared to men, women were more likely to be older, less likely to have a known history of heart failure or cardiovascular risk factors, and lower rates of highly depressed left ventricular ejection fraction and renal dysfunction. Nevertheless, CS severity as well as use of treatments were comparable, and female sex was not independently associated with 30-day mortality (53.0% vs. 50.8%; adjusted HR 0.94, 95% CI 0.75-1.19).

CONCLUSIONS

In this large HF-CS registry, sex disparities in risk factors and clinical presentation were observed. Despite these differences, the use of treatments was comparable, and both sexes exhibited similarly high mortality rates. Further research is necessary to evaluate if sex-tailored treatment, accounting for the differences in cardiovascular risk factors and clinical presentation, might improve outcomes in HF-CS.

Association between left ventricular ejection fraction, mortality and use of mechanical circulatory support in patients with non-ischaemic cardiogenic shock

BACKGROUND

Currently, use of mechanical circulatory support (MCS) in non-ischaemic cardiogenic shock (CS) is predominantly guided by shock-specific markers, and not by markers of cardiac function. We hypothesise that left ventricular ejection fraction (LVEF) can identify patients with a higher likelihood to benefit from MCS and thus help to optimise their expected benefit.

METHODS

Patients with non-ischaemic CS and available data on LVEF from 16 tertiary-care centres in five countries were analysed. Cox regression models were fitted to evaluate the association between LVEF and mortality, as well as the interaction between LVEF, MCS use and mortality.

RESULTS

N = 807 patients were analysed: mean age 63 [interquartile range (IQR) 51.5-72.0] years, 601 (74.5%) male, lactate 4.9 (IQR 2.6-8.5) mmol/l, LVEF 20 (IQR 15-30) %. Lower LVEF was more frequent amongst patients with more severe CS, and MCS was more likely used in patients with lower LVEF. There was no association between LVEF and 30-day mortality risk in the overall study cohort. However, there was a significant interaction between MCS use and LVEF, indicating a lower 30-day mortality risk with MCS use in patients with LVEF ≤ 20% (hazard ratio 0.72, 95% confidence interval 0.51-1.02 for LVEF ≤ 20% vs. hazard ratio 1.31, 95% confidence interval 0.85-2.01 for LVEF > 20%, interaction-p = 0.017).

CONCLUSION

This retrospective study may indicate a lower mortality risk with MCS use only in patients with severely reduced LVEF. This may propose the inclusion of LVEF as an adjunctive parameter for MCS decision-making in non-ischaemic CS, aiming to optimise the benefit-risk ratio.

Impella - Current issues and future expectations for the percutaneous, microaxial flow left ventricular assist device

The importance of temporary mechanical circulatory support for treating acute heart failure with cardiogenic shock is increasingly recognized, and Impella (Abiomed, Danvers, MA, USA) has received particular attention in this regard. Impella is an axial flow left ventricular assist device (LVAD) built into the tip of a catheter. It is inserted via a peripheral artery and implanted into the left ventricle. Although the morphology of Impella is different from a typical LVAD, it has similar actions and effects as an LVAD in terms of left ventricular drainage and aortic blood delivery. Impella increases mean arterial pressure (MAP) and systemic blood flow, thereby improving peripheral organ perfusion and promoting recovery from multiple organ failure. In addition, left ventricular unloading with increased MAP increases coronary perfusion and decreases myocardial oxygen demand, thereby promoting myocardial recovery. Impella is also useful as a mechanical vent of the left ventricle in patients supported with veno-arterial extracorporeal membrane oxygenation. Indications for Impella include emergency use for cardiogenic shock and non-emergent use during high-risk percutaneous coronary intervention and ventricular tachycardia ablation. Its intended uses for cardiogenic shock include bridge to recovery, durable device, heart transplantation, and heart surgery. Prophylactic use of Impella in high-risk patients undergoing open heart surgery to prevent postcardiotomy cardiogenic shock is also gaining attention. While there have been many case reports and retrospective studies on the benefits of Impella, there is little evidence based on sufficiently large randomized controlled trials (RCTs). Currently, several RCTs are now ongoing, which are critical to determine when, for whom, and how these devices should be used. In this review, we summarize the principles, physiology, indications, and complications of the Impella support and discuss current issues and future expectations for the device.

Management of cardiogenic shock: a narrative review

Cardiogenic shock (CS) is characterized by low cardiac output and sustained tissue hypoperfusion that may result in end-organ dysfunction and death. CS is associated with high short-term mortality, and its management remains challenging despite recent advances in therapeutic options. Timely diagnosis and multidisciplinary team-based management have demonstrated favourable effects on outcomes. We aimed to review evidence-based practices for managing patients with ischemic and non-ischemic CS, detailing the multi-organ supports needed in this critically ill patient population.

The Evolving Field of Acute Coronary Syndrome Management: A Critical Appraisal of the 2023 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndrome

Acute coronary syndromes (ACS), encompassing conditions like ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndromes (NSTE-ACS), represent a significant challenge in cardiovascular care due to their complex pathophysiology and substantial impact on morbidity and mortality. The 2023 European Society of Cardiology (ESC) guidelines for ACS management introduce several updates in key areas such as invasive treatment timing in NSTE-ACS, pre-treatment strategies, approaches to multivessel disease, and the use of imaging modalities including computed tomography (CT) coronary angiography, magnetic resonance imaging (MRI), and intracoronary imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS). They also address a modulation of antiplatelet therapy, taking into consideration different patient risk profiles, and introduce new recommendations for low-dose colchicine. These guidelines provide important evidence-based updates in practice, reflecting an evolution in the understanding and management of ACS, yet some potentially missed opportunities for more personalized care and technology adoption are discussed.