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De Ferrari T, Pistelli L, Franzino M, Molinero AE, De Santis GA, Di Carlo A, Vetta G, Parlavecchio A, Fimiani L, Picci A, Certo G, Parisi F, Venuti G. MI2AMI-CS: A meta-analysis comparing Impella and IABP outcomes in Acute Myocardial Infarction-related Cardiogenic Shock. Int J Cardiol 2024; 414:132411. [PMID: 39094635 DOI: 10.1016/j.ijcard.2024.132411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
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.
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Affiliation(s)
- Tommaso De Ferrari
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy
| | - Lorenzo Pistelli
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy.
| | - Marco Franzino
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy
| | - Agustin Ezequiel Molinero
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy
| | - Giulia Azzurra De Santis
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy
| | - Alessandro Di Carlo
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy
| | - Giampaolo Vetta
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Av. du Laerbeek 101, 1090 Jette, Brussels, Belgium
| | - Antonio Parlavecchio
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy
| | - Luigi Fimiani
- Interventional Cardiology Unit, Department of Cardiovascular Diseases, Papardo Hospital, Messina, Italy
| | - Andrea Picci
- Interventional Cardiology Unit, Department of Cardiovascular Diseases, Papardo Hospital, Messina, Italy
| | - Giuseppe Certo
- Cardiology Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria "Policlinico G. Martino", University of Messina, Messina, Italy
| | - Francesca Parisi
- Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT)-IRCCS, Palermo, Italy
| | - Giuseppe Venuti
- Interventional Cardiology Unit, Department of Cardiovascular Diseases, Papardo Hospital, Messina, Italy
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Zhang H, Wang T, Wang J, Liu G, Yan S, Teng Y, Wang J, Ji B. Different strategies in left ventricle unloading during venoarterial extracorporeal membrane oxygenation: A network meta-analysis. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2024; 54:101506. [PMID: 39296587 PMCID: PMC11408045 DOI: 10.1016/j.ijcha.2024.101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/22/2024] [Accepted: 08/31/2024] [Indexed: 09/21/2024]
Abstract
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.
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Affiliation(s)
- Han Zhang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Tianlong Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Jing Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Gang Liu
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Yuan Teng
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Jian Wang
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
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Jung C, Bruno RR, Jumean M, Price S, Krychtiuk KA, Ramanathan K, Dankiewicz J, French J, Delmas C, Mendoza AA, Thiele H, Soussi S. Management of cardiogenic shock: state-of-the-art. Intensive Care Med 2024:10.1007/s00134-024-07618-x. [PMID: 39254735 DOI: 10.1007/s00134-024-07618-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 08/18/2024] [Indexed: 09/11/2024]
Abstract
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.
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Affiliation(s)
- Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany.
- Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany.
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Medical Faculty, Duesseldorf, Germany
| | | | - Susanna Price
- Division of Heart, Lung and Critical Care, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Konstantin A Krychtiuk
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Lund University, Cardiology, Lund, Sweden
| | - John French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
- School of Medicine, Western Sydney University, Sydney, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, Australia
| | - Clement Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Toulouse University Hospital, Institute of Metabolic and Cardiovascular Diseases (I2MC), UMR-1048, National Institute of Health and Medical Research (INSERM), Toulouse, France
- REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
| | | | - Holger Thiele
- Department of Internal Medicine/Cardiology and Leipzig Heart Science, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network (UHN), Women's College Hospital, University of Toronto, Toronto Western Hospital, Toronto, Canada
- University of Paris Cité, Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Paris, France
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Oyabu K, Hattori H, Kikuchi N, Haruki S, Minami Y, Ichihara Y, Saito S, Nunoda S, Niinami H, Yamaguchi J. Cardiogenic shock severity predicts bleeding events in patients with temporary mechanical circulatory support. Catheter Cardiovasc Interv 2024. [PMID: 39219443 DOI: 10.1002/ccd.31219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 08/25/2024] [Indexed: 09/04/2024]
Abstract
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.
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Affiliation(s)
- Kenjiro Oyabu
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hidetoshi Hattori
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Noriko Kikuchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shintaro Haruki
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuichiro Minami
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuki Ichihara
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Saito
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shinichi Nunoda
- Department of Therapeutic Strategy for Severe Heart Failure, Tokyo Women's Medical University Graduate School of Medicine, Tokyo, Japan
| | - Hiroshi Niinami
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 guideline focused update on indication and operation of PCPS/ECMO/IMPELLA. J Cardiol 2024; 84:208-238. [PMID: 39098794 DOI: 10.1016/j.jjcc.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
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6
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Kanhouche G, Nicolau JC, de Mendonça Furtado RH, Carvalho LS, Dalçoquio TF, Pileggi B, de Sa Marchi MF, Abi-Kair P, Lopes N, Giraldez RR, Baracioli LM, Lima FG, Hajjar LA, Filho RK, de Brito Junior FS, Abizaid A, Ribeiro HB. Long-term outcomes of cardiogenic shock and cardiac arrest complicating ST-elevation myocardial infarction according to timing of occurrence. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae075. [PMID: 39346895 PMCID: PMC11430270 DOI: 10.1093/ehjopen/oeae075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/25/2024] [Accepted: 08/12/2024] [Indexed: 10/01/2024]
Abstract
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.
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Affiliation(s)
- Gabriel Kanhouche
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jose Carlos Nicolau
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Remo Holanda de Mendonça Furtado
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Department of Cardiology, Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Luiz Sérgio Carvalho
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Talia Falcão Dalçoquio
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Brunna Pileggi
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Mauricio Felippi de Sa Marchi
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Pedro Abi-Kair
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Neuza Lopes
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Roberto Rocha Giraldez
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Luciano Moreira Baracioli
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Felipe Gallego Lima
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ludhmila Abrahão Hajjar
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Fábio Sandoli de Brito Junior
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Alexandre Abizaid
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Henrique Barbosa Ribeiro
- Department of Interventional Cardiology, Heart Institute (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Di Muro FM, Bellino M, Esposito L, Attisano T, Meucci F, Mattesini A, Galasso G, Vecchione C, Di Mario C. Role of Mechanical Circulatory Support in Complex High-Risk and Indicated Percutaneous Coronary Intervention: Current Indications, Device Options, and Potential Complications. J Clin Med 2024; 13:4931. [PMID: 39201073 PMCID: PMC11355104 DOI: 10.3390/jcm13164931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 08/13/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
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.
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Affiliation(s)
- Francesca Maria Di Muro
- Department of Experimental and Clinical Medicine, School of Human Health Sciences, Careggi University Hospital, University of Florence, 50134 Florence, Italy
| | - Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
| | - Luca Esposito
- Department of Advanced Biomedical Sciences, University Federico II, 80138 Naples, Italy;
| | - Tiziana Attisano
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
| | - Francesco Meucci
- Division of Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy; (F.M.); (A.M.); (C.D.M.)
| | - Alessio Mattesini
- Division of Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy; (F.M.); (A.M.); (C.D.M.)
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy; (M.B.); (T.A.); (G.G.); (C.V.)
- Vascular Pathophysiology Unit, IRCCS Neuromed, 86077 Pozzilli, Italy
| | - Carlo Di Mario
- Division of Structural Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, 50134 Florence, Italy; (F.M.); (A.M.); (C.D.M.)
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8
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Upadhyaya VD, Wong C, Zakir RM, Aghili N, Faraz H, Kapur NK. Management of Myocardial Infarction: Emerging Paradigms for the Future. Methodist Debakey Cardiovasc J 2024; 20:54-63. [PMID: 39184160 PMCID: PMC11342848 DOI: 10.14797/mdcvj.1393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/25/2024] [Indexed: 08/27/2024] Open
Abstract
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.
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Affiliation(s)
- Vandan D. Upadhyaya
- Hackensack Meridian Health –Jersey Shore University Medical Center, Neptune City, New Jersey, US
| | - Christopher Wong
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, US
| | - Ramzan M. Zakir
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, US
| | - Nima Aghili
- Colorado Heart and Vascular, St. Anthony Hospital, Lakewood, Colorado, US
| | - Haroon Faraz
- Hackensack University Medical Center, Hackensack, New Jersey, US
| | - Navin K. Kapur
- Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts, US
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9
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Reddy P, Merdler I, Zhang C, Cellamare M, Ben-Dor I, Bernardo NL, Hashim HD, Satler LF, Rogers T, Waksman R. Impella Versus Non-Impella for Nonemergent High-Risk Percutaneous Coronary Intervention. Am J Cardiol 2024; 225:4-9. [PMID: 38871158 DOI: 10.1016/j.amjcard.2024.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024]
Abstract
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.
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Affiliation(s)
- Pavan Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Matteo Cellamare
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Hayder D Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia.
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10
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Masiero G, Arturi F, Panza A, Tarantini G. Mechanical Circulatory Support with Impella: Principles, Evidence, and Daily Practice. J Clin Med 2024; 13:4586. [PMID: 39200728 PMCID: PMC11354798 DOI: 10.3390/jcm13164586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/23/2024] [Accepted: 08/03/2024] [Indexed: 09/02/2024] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, 35128 Padua, Italy; (G.M.); (F.A.); (A.P.)
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11
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Kayali F, Agbobu T, Moothathamby T, Jubouri YF, Jubouri M, Abdelhaliem A, Ghattas SNS, Rezk SSS, Bailey DM, Williams IM, Awad WI, Bashir M. Haemodynamic support with percutaneous devices in patients with cardiogenic shock: the current evidence of mechanical circulatory support. Expert Rev Med Devices 2024; 21:755-764. [PMID: 39087797 DOI: 10.1080/17434440.2024.2380330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 07/11/2024] [Indexed: 08/02/2024]
Abstract
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.
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Affiliation(s)
- Fatima Kayali
- University Hospitals Sussex N.H.S. Foundation Trust, Sussex, UK
| | | | - Thurkga Moothathamby
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Amr Abdelhaliem
- Vascular and Endovascular Surgery, Royal Blackburn Hospital, Blackburn, UK
| | | | | | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mohamad Bashir
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
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12
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Besch L, Schrage B. Unloading in cardiogenic shock: the rationale and current evidence. Curr Opin Crit Care 2024; 30:379-384. [PMID: 38841993 DOI: 10.1097/mcc.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
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.
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Affiliation(s)
- Lisa Besch
- Department of Cardiology, University Heart and Vascular Center Hamburg
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
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13
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Van Edom CJ, Swol J, Castelein T, Gramegna M, Huber K, Leonardi S, Mueller T, Pappalardo F, Price S, Schaubroeck H, Schrage B, Tavazzi G, Vercaemst L, Vranckx P, Vandenbriele C. 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. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:458-469. [PMID: 38529950 DOI: 10.1093/ehjacc/zuae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 03/27/2024]
Abstract
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.
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Affiliation(s)
- Charlotte J Van Edom
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Cardiovascular Sciences, University of Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Justyna Swol
- Department of Respiratory Medicine, Paracelsus Medical University, Prof. Ernst-Nathan Str. 1, 90419 Nürnberg, Germany
| | - Thomas Castelein
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Währinger Gürtel 18-20, 1090 Vienna, Austria
- Medical Faculty, Sigmund Freud University, Freudpl. 1+3, 1020 Vienna, Austria
| | - Sergio Leonardi
- Department of Medical Sciences and Infective Disease, University of Pavia, 27100 Pavia, Italy
- Fondazione, IRCCS Policlinico San Matteo, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Spalto Marengo 43, 15121 Alessandria, Italy
| | - Susanna Price
- Department of Critical Care, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Hill End Rd, Harefield, Uxbridge UB9 6JH, United Kingdom
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse St., SW3 6LY London, United Kingdom
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251 Hamburg, Germany
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Intensive Care Unit, Fondazione Policlinico San Matteo IRCCS, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Leen Vercaemst
- Department of Perfusion, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Martelarenplein 42, 3500 Hasselt, Belgium
| | - Christophe Vandenbriele
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
- Department of Critical Care, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Hill End Rd, Harefield, Uxbridge UB9 6JH, United Kingdom
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14
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Watanabe A, Miyamoto Y, Ueyama H, Gotanda H, Tsugawa Y, Kuno T. Percutaneous Microaxial Ventricular Assist Device Versus Intra-Aortic Balloon Pump for Nonacute Myocardial Infarction Cardiogenic Shock. J Am Heart Assoc 2024; 13:e034645. [PMID: 38804220 PMCID: PMC11255633 DOI: 10.1161/jaha.123.034645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/04/2024] [Indexed: 05/29/2024]
Abstract
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.
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Affiliation(s)
- Atsuyuki Watanabe
- Department of MedicineMount Sinai Beth IsraelIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Yoshihisa Miyamoto
- Division of Nephrology and EndocrinologyThe University of TokyoTokyoJapan
| | - Hiroki Ueyama
- Division of CardiologyEmory University School of MedicineAtlantaGA
| | - Hiroshi Gotanda
- Division of General Internal MedicineCedars‐Sinai Medical CenterLos AngelesCA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at The University of California, Los AngelesLos AngelesCA
- Department of Health Policy and ManagementUCLA Fielding School of Public Health, Los AngelesLos AngelesCA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical CenterAlbert Einstein College of MedicineNew YorkNY
- Division of Cardiology, Jacobi Medical CenterAlbert Einstein College of MedicineNew YorkNY
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15
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Alkhunaizi FA, Smith N, Brusca SB, Furfaro D. The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review. CHEST CRITICAL CARE 2024; 2:100071. [PMID: 38993934 PMCID: PMC11238736 DOI: 10.1016/j.chstcc.2024.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
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.
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Affiliation(s)
- Fatimah A Alkhunaizi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nikolhaus Smith
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Samuel B Brusca
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Furfaro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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16
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 Guideline Focused Update on Indication and Operation of PCPS/ECMO/IMPELLA. Circ J 2024; 88:1010-1046. [PMID: 38583962 DOI: 10.1253/circj.cj-23-0698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Yasutaka Hirata
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | | | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | | | - Takeshi Kitai
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center
| | - Takayuki Ohno
- Division of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Kazuhiro Satomi
- Department of Cardiovascular Medicine, Tokyo Medical University Hospital
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Koichi Toda
- Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center
| | - Yasumasa Tsukamoto
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Faculty of Medical Sciences, Kyushu University
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | | | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hirotsugu Kurobe
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
| | - Tetsuya Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Shogo Shimada
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Shinya Unai
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Shunei Kyo
- Tokyo Metropolitan Institute for Geriatrics and Gerontology
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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17
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Tsushima R, Maruhashi T, Kurihara Y, Hashikata T, Asari Y. Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit. CVIR Endovasc 2024; 7:48. [PMID: 38769160 PMCID: PMC11106222 DOI: 10.1186/s42155-024-00460-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/16/2024] [Indexed: 05/22/2024] Open
Abstract
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.
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Affiliation(s)
- Ryota Tsushima
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Takaaki Maruhashi
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan.
| | - Yutaro Kurihara
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Takehiro Hashikata
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
| | - Yasushi Asari
- Department of Emergency and Critical Care Medicine, Kitasato University School of Medicine, 1-15-1KitasatoMinami-Ku, Sagamihara-City, Kanagawa-ken, 252-0375, Japan
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18
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Dhruva SS, Ross JS, Steinman MA, Gan S, Muluk S, Anderson TS. Intravascular Microaxial Left Ventricular Assist Device Manufacturer Payments to Cardiologists and Use of Devices. JAMA 2024; 331:1499-1501. [PMID: 38598231 PMCID: PMC11007652 DOI: 10.1001/jama.2024.4682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Sanket S. Dhruva
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco
| | - Joseph S. Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael A. Steinman
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco
| | - Siqi Gan
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco
| | - Sruthi Muluk
- Department of Obstetrics and Gynecology, University of Connecticut Health, Farmington
| | - Timothy S. Anderson
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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19
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Zheng Z, Tang W, Li Y, Ai Y, Tu Z, Yang J, Fan C. Advancing cardiac regeneration through 3D bioprinting: methods, applications, and future directions. Heart Fail Rev 2024; 29:599-613. [PMID: 37943420 DOI: 10.1007/s10741-023-10367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 11/10/2023]
Abstract
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.
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Affiliation(s)
- Zilong Zheng
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Weijie Tang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Yichen Li
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Yinze Ai
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Zhi Tu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Jinfu Yang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Chengming Fan
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China.
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20
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Rao SV. Mechanical Circulatory Support in Cardiogenic Shock - Persistence and Progress. N Engl J Med 2024; 390:1436-1438. [PMID: 38587251 DOI: 10.1056/nejme2402310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Affiliation(s)
- Sunil V Rao
- From the New York University Grossman School of Medicine and New York University Langone Health System, New York
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21
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Sundermeyer J, Kellner C, Beer BN, Besch L, Dettling A, Bertoldi LF, Blankenberg S, Dauw J, Dindane Z, Eckner D, Eitel I, Graf T, Horn P, Jozwiak-Nozdrzykowska J, Kirchhof P, Kluge S, Linke A, Landmesser U, Luedike P, Lüsebrink E, Majunke N, Mangner N, Maniuc O, Möbius-Winkler S, Nordbeck P, Orban M, Pappalardo F, Pauschinger M, Pazdernik M, Proudfoot A, Kelham M, Rassaf T, Scherer C, Schulze PC, Schwinger RHG, Skurk C, Sramko M, Tavazzi G, Thiele H, Villanova L, Morici N, Winzer EB, Westermann D, Schrage B. Sex-related differences in patients presenting with heart failure-related cardiogenic shock. Clin Res Cardiol 2024; 113:612-625. [PMID: 38353681 PMCID: PMC10954943 DOI: 10.1007/s00392-024-02392-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/31/2024] [Indexed: 03/21/2024]
Abstract
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.
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Affiliation(s)
- Jonas Sundermeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Cardio Center, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Benedikt N Beer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeroen Dauw
- Department of Cardiology, AZ Sint-Lucas, Ghent, Belgium
| | - Zouhir Dindane
- Department for Internal Medicine and Cardiology, Heart Centre Dresden, University Hospital, Dresden, Germany
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nuremberg, Germany
| | - Ingo Eitel
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Düsseldorf, Germany
| | - Joanna Jozwiak-Nozdrzykowska
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Linke
- Department for Internal Medicine and Cardiology, Heart Centre Dresden, University Hospital, Dresden, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, DHZC Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Norman Mangner
- Department for Internal Medicine and Cardiology, Heart Centre Dresden, University Hospital, Dresden, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Federico Pappalardo
- Dept Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nuremberg, Germany
| | | | - Alastair Proudfoot
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London, UK
| | - Matthew Kelham
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London, UK
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, DHZC Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Marek Sramko
- Department of Cardiology, IKEM, Prague, Czech Republic
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Anesthesia and Intensive Care, University of Pavia Italy, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Luca Villanova
- Unità Di Cure Intensive Cardiologiche and De Gasperis Cardio-Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nuccia Morici
- IRCCS Fondazione Don Gnocchi, ONLUS, Santa Maria Nascente, Milan, Italy
| | - Ephraim B Winzer
- Department for Internal Medicine and Cardiology, Heart Centre Dresden, University Hospital, Dresden, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
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22
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Vondran M, Kaminski A, Schemke S, Heringlake M. Shouldn't we first follow the guidelines before implementing alternative mechanical circulatory support modalities? JTCVS OPEN 2024; 18:87-89. [PMID: 38690423 PMCID: PMC11056468 DOI: 10.1016/j.xjon.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Affiliation(s)
- Maximillian Vondran
- Department of Cardiac and Vascular Surgery, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Alexander Kaminski
- Department of Cardiac and Vascular Surgery, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Simon Schemke
- Department of Anesthesiology and Intensive Care Medicine, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart- and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
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23
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Sundermeyer J, Kellner C, Beer BN, Besch L, Dettling A, Bertoldi LF, Blankenberg S, Dauw J, Dindane Z, Eckner D, Eitel I, Graf T, Horn P, Jozwiak-Nozdrzykowska J, Kirchhof P, Kluge S, Linke A, Landmesser U, Luedike P, Lüsebrink E, Majunke N, Mangner N, Maniuc O, Winkler SM, Nordbeck P, Orban M, Pappalardo F, Pauschinger M, Pazdernik M, Proudfoot A, Kelham M, Rassaf T, Scherer C, Schulze PC, Schwinger RHG, Skurk C, Sramko M, Tavazzi G, Thiele H, Villanova L, Morici N, Westenfeld R, Winzer EB, Westermann D, Schrage B. Association between left ventricular ejection fraction, mortality and use of mechanical circulatory support in patients with non-ischaemic cardiogenic shock. Clin Res Cardiol 2024; 113:570-580. [PMID: 37982863 PMCID: PMC10954940 DOI: 10.1007/s00392-023-02332-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/20/2023] [Indexed: 11/21/2023]
Abstract
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.
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Affiliation(s)
- Jonas Sundermeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
| | - Benedikt N Beer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jeroen Dauw
- Department of Cardiology, AZ Sint-Lucas, Ghent, Belgium
| | - Zouhir Dindane
- Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nuremberg, Germany
| | - Ingo Eitel
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Duesseldorf, Germany
| | - Joanna Jozwiak-Nozdrzykowska
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Linke
- Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Norman Mangner
- Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Federico Pappalardo
- Dept Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nuremberg, Germany
| | | | - Alastair Proudfoot
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London, UK
| | - Matthew Kelham
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London, UK
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Carsten Skurk
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Marek Sramko
- Department of Cardiology, IKEM, Prague, Czech Republic
| | - Guido Tavazzi
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Luca Villanova
- Unità Di Cure Intensive Cardiologiche and De Gasperis Cardio-Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nuccia Morici
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Duesseldorf, Germany
| | - Ephraim B Winzer
- Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
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24
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Saito S, Okubo S, Matsuoka T, Hirota S, Yokoyama S, Kanazawa Y, Takei Y, Tezuka M, Tsuchiya G, Konishi T, Shibasaki I, Ogata K, Fukuda H. Impella - Current issues and future expectations for the percutaneous, microaxial flow left ventricular assist device. J Cardiol 2024; 83:228-235. [PMID: 37926367 DOI: 10.1016/j.jjcc.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/04/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
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.
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Affiliation(s)
- Shunsuke Saito
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan.
| | - Shohei Okubo
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Taiki Matsuoka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Shotaro Hirota
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Shohei Yokoyama
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Yuta Kanazawa
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Go Tsuchiya
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Taisuke Konishi
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Koji Ogata
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, Mibu, Japan
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25
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Laghlam D, Benghanem S, Ortuno S, Bouabdallaoui N, Manzo-Silberman S, Hamzaoui O, Aissaoui N. Management of cardiogenic shock: a narrative review. Ann Intensive Care 2024; 14:45. [PMID: 38553663 PMCID: PMC10980676 DOI: 10.1186/s13613-024-01260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/06/2024] [Indexed: 04/02/2024] Open
Abstract
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.
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Affiliation(s)
- Driss Laghlam
- Research & Innovation Department, RIGHAPH, Service de Réanimation polyvalente, CMC Ambroise Paré-Hartmann, 48 Ter boulevard Victor Hugo, 92200, Neuilly-sur-Seine, France.
| | - Sarah Benghanem
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre & Université Paris Cité, Paris, France
- Université Paris Cité, Paris, France
- AfterROSC, Paris, France
| | - Sofia Ortuno
- Service Médecine intensive-réanimation, Hopital Européen Georges Pompidou, Paris, France
- Université Sorbonne, Paris, France
| | - Nadia Bouabdallaoui
- Institut de cardiologie de Montreal, Université de Montreal, Montreal, Canada
| | - Stephane Manzo-Silberman
- Université Sorbonne, Paris, France
- Sorbonne University, Institute of Cardiology- Hôpital Pitié-Salpêtrière (AP-HP), ACTION Study Group, Paris, France
| | - Olfa Hamzaoui
- Service de médecine intensive-réanimation polyvalente, Hôpital Robert Debré, CHU de Reims, Reims, France
- Unité HERVI "Hémostase et Remodelage Vasculaire Post-Ischémie" - EA 3801, Reims, France
| | - Nadia Aissaoui
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre & Université Paris Cité, Paris, France
- Université Paris Cité, Paris, France
- AfterROSC, Paris, France
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Licordari R, Costa F, Garcia-Ruiz V, Mamas MA, Marquis-Gravel G, de la Torre Hernandez JM, Gomez Doblas JJ, Jimenez-Navarro M, Rodriguez-Capitan J, Urbano-Carrillo C, Ortega-Paz L, Piccolo R, Versace AG, Di Bella G, Andò G, Angiolillo DJ, Valgimigli M, Micari A. 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. J Clin Med 2024; 13:1885. [PMID: 38610650 PMCID: PMC11012418 DOI: 10.3390/jcm13071885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
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.
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Affiliation(s)
- Roberto Licordari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
| | | | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Keele ST5 5BG, UK;
| | - Guillaume Marquis-Gravel
- Montréal Heart Institute, Faculty of Medicine, Université de Montréal, Montréal, QC H3T 1J4, Canada;
| | | | - Juan Jose Gomez Doblas
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | - Manuel Jimenez-Navarro
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | - Jorge Rodriguez-Capitan
- Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, Departamento de Medicina UMA, 29010 Malaga, Spain; (J.J.G.D.); (M.J.-N.); (J.R.-C.)
| | | | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA (D.J.A.)
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy;
| | | | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (G.D.B.); (G.A.)
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (G.D.B.); (G.A.)
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA (D.J.A.)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6500 Lugano, Switzerland;
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy; (R.L.); (A.M.)
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27
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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Thiele H. Cardiac ECMO: changing role in times of Impella and ventricular assist devices? Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01121-3. [PMID: 38456998 DOI: 10.1007/s00063-024-01121-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/01/2024] [Indexed: 03/09/2024]
Abstract
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.
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Affiliation(s)
- Holger Thiele
- Leipzig Heart Science, Leipzig, Germany.
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at Leipzig University, Strümpellstr. 39, 04289, Leipzig, Germany.
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29
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Leiva O, Cheng RK, Pauwaa S, Katz JN, Alvarez-Cardona J, Bernard S, Alviar C, Yang EH. Outcomes of Patients With Cancer With Myocardial Infarction-Associated Cardiogenic Shock Managed With Mechanical Circulatory Support. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101208. [PMID: 39131775 PMCID: PMC11307771 DOI: 10.1016/j.jscai.2023.101208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/30/2023] [Accepted: 10/03/2023] [Indexed: 08/13/2024]
Abstract
Background Cardiogenic shock (CS) is the leading cause of death among patients with acute myocardial infarction (AMI) and is managed with temporary mechanical circulatory support (tMCS) in advanced cases. Patients with cancer are at high risk of AMI and CS. However, outcomes of patients with cancer and AMI-CS managed with tMCS have not been rigorously studied. Methods Adult patients with AMI-CS managed with tMCS from 2006 to 2018 with and without cancer were identified using the National Inpatient Sample. Propensity score matching (PSM) was performed for variables associated with cancer. Primary outcome was in-hospital death, and secondary outcomes were major bleeding and thrombotic complications. Results After PSM, 1287 patients with cancer were matched with 12,870 patients without cancer. There was an increasing temporal trend for prevalence of cancer among patients admitted with AMI-CS managed with tMCS (P trend < .001). After PSM, there was no difference in in-hospital death (odds ratio [OR], 1.00; 95% CI, 0.88-1.13) or thrombotic complications (OR, 1.10; 95% CI, 0.91-1.34) between patients with and without cancer. Patients with cancer had a higher risk of major bleeding (OR, 1.29; 95% CI, 1.15-1.46). Conclusions Among patients with AMI-CS managed with tMCS, cancer is becoming increasingly frequent and associated with increased risk of major bleeding, although there was no difference in in-hospital death. Further studies are needed to further characterize outcomes, and inclusion of patients with cancer in trials of tMCS is needed.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Richard K. Cheng
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Sunil Pauwaa
- Division of Cardiology, Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Jason N. Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Jose Alvarez-Cardona
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Samuel Bernard
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Carlos Alviar
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Eric H. Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, California
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30
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Hazan Shenberger S, Avrahami I. The Effect of Mechanical Circulatory Support on Blood Flow in the Ascending Aorta: A Combined Experimental and Computational Study. Bioengineering (Basel) 2024; 11:238. [PMID: 38534512 DOI: 10.3390/bioengineering11030238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/11/2024] [Accepted: 02/22/2024] [Indexed: 03/28/2024] Open
Abstract
Percutaneous mechanical circulatory support (MCS) devices are designed for short-term treatment in cases of acute decompensated heart failure as a bridge to transplant or recovery. Some of the known complications of MCS treatments are related to their hemodynamics in the aorta. The current study investigates the effect of MCS on the aortic flow. The study uses combined experimental and numerical methods to delineate complex flow structures. Particle image velocimetry (PIV) is used to capture the vortical and turbulent flow characteristics in a glass model of the human aorta. Computational fluid dynamics (CFD) analyses are used to complete the 3D flow in the aorta. Three specific MCS configurations are examined: a suction pump with a counterclockwise (CCW) rotating impeller, a suction pump with a clockwise (CW) rotating impeller, and a discharge pump with a straight jet. These models were examined under varying flow rates (1-2.5 L/min). The results show that the pump configuration strongly influences the flow in the thoracic aorta. The rotating impeller of the suction pump induces a dominant swirling flow in the aorta. The swirling flow distributes the incoming jet and reduces the turbulent intensity near the aortic valve and in the aorta. In addition, at high flow rates, the local vortices formed near the pump are washed downstream toward the aortic arch. Specifically, an MCS device with a CCW rotating impeller induces a non-physiological CCW helical flow in the descending aorta (which is opposite to the natural helical flow), while CW swirl combines better with the natural helical flow.
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Affiliation(s)
- Sapir Hazan Shenberger
- Department of Mechanical Engineering and Mechatronics, Ariel University, Ariel 40700, Israel
| | - Idit Avrahami
- Department of Mechanical Engineering and Mechatronics, Ariel University, Ariel 40700, Israel
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31
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Beer BN, Kellner C, Goßling A, Sundermeyer J, Besch L, Dettling A, Kirchhof P, Blankenberg S, Bernhardt AM, Brunner S, Colson P, Eckner D, Frank D, Eitel I, Frey N, Eden M, Graf T, Kupka D, Landmesser U, Majunke N, Maniuc O, Möbius-Winkler S, Morrow DA, Mourad M, Noel C, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Reichenspurner H, Schulze PC, Schwinger RHG, Wechsler A, Skurk C, Thiele H, Varshney AS, Sag CM, Krais J, Westermann D, Schrage B. Complications in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy: distribution and relevance. Results from an international, multicentre cohort study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:203-212. [PMID: 37875127 DOI: 10.1093/ehjacc/zuad129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
AIMS Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2). METHODS AND RESULTS All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor. CONCLUSION Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS.
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Affiliation(s)
- Benedikt N Beer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Sundermeyer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Alexander M Bernhardt
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Brunner
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Derk Frank
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ingo Eitel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Eden
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Graf
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Danny Kupka
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | | | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Curt Noel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | - Martin Orban
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sandeep M Patel
- Department of Interventional Cardiology, St.Rita's Medical Center, Lima, USA
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Hermann Reichenspurner
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Antonia Wechsler
- Department of Internal Medicine II, Klinikum Weiden, Weiden, Germany
| | - Carsten Skurk
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, USA
| | - Can Martin Sag
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jannis Krais
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
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32
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Yang J, Zeng XK, Hu W, Zhu Y. Preserving flow, saving lives: Successful treatment of aortic valve failure in acute myocardial infarction without flow down-regulation using ECMO - a case report and mini review. Perfusion 2024:2676591241231901. [PMID: 38321627 DOI: 10.1177/02676591241231901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Direct percutaneous coronary intervention (PPCI) has significantly reduced cardiac mortality in patients with acute myocardial infarction (AMI), but the mortality rate remains high for those who develop cardiogenic shock (CS), reaching 40% to 50%. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) provides robust hemodynamic support and oxygen delivery for AMI patients with refractory CS, ensuring adequate organ perfusion and oxygen supply. However, there is currently no standardized optimal Mean Arterial Pressure (MAP) range during V-A ECMO support. Achieving the proper MAP is crucial for adequate myocardial perfusion, cardiac function recovery, successful weaning off of V-A ECMO, and improving long-term outcomes. In this case study, we successfully treated a 55-year-old man with AMI and refractory cardiogenic shock using V-A ECMO. By adjusting ECMO blood flow and employing hemodynamic strategies, including vasoactive drugs, we optimized the MAP, leading to improved cardiac function and successful weaning off of V-A ECMO. This presents a potential opportunity for MAP optimization under ECMO support in patients with acute myocardial infarction and cardiogenic shock.
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Affiliation(s)
- Jing Yang
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Kang Zeng
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Hu
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Zhu
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Mullens W, Dauw J, Gustafsson F, Mebazaa A, Steffel J, Witte KK, Delgado V, Linde C, Vernooy K, Anker SD, Chioncel O, Milicic D, Hasenfuß G, Ponikowski P, von Bardeleben RS, Koehler F, Ruschitzka F, Damman K, Schwammenthal E, Testani JM, Zannad F, Böhm M, Cowie MR, Dickstein K, Jaarsma T, Filippatos G, Volterrani M, Thum T, Adamopoulos S, Cohen-Solal A, Moura B, Rakisheva A, Ristic A, Bayes-Genis A, Van Linthout S, Tocchetti CG, Savarese G, Skouri H, Adamo M, Amir O, Yilmaz MB, Simpson M, Tokmakova M, González A, Piepoli M, Seferovic P, Metra M, Coats AJS, Rosano GMC. Integration of implantable device therapy in patients with heart failure. A clinical consensus statement from the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2024; 26:483-501. [PMID: 38269474 DOI: 10.1002/ejhf.3150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/27/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024] Open
Abstract
Implantable devices form an integral part of the management of patients with heart failure (HF) and provide adjunctive therapies in addition to cornerstone drug treatment. Although the number of these devices is growing, only few are supported by robust evidence. Current devices aim to improve haemodynamics, improve reverse remodelling, or provide electrical therapy. A number of these devices have guideline recommendations and some have been shown to improve outcomes such as cardiac resynchronization therapy, implantable cardioverter-defibrillators and long-term mechanical support. For others, more evidence is still needed before large-scale implementation can be strongly advised. Of note, devices and drugs can work synergistically in HF as improved disease control with devices can allow for further optimization of drug therapy. Therefore, some devices might already be considered early in the disease trajectory of HF patients, while others might only be reserved for advanced HF. As such, device therapy should be integrated into HF care programmes. Unfortunately, implementation of devices, including those with the greatest evidence, in clinical care pathways is still suboptimal. This clinical consensus document of the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) describes the physiological rationale behind device-provided therapy and also device-guided management, offers an overview of current implantable device options recommended by the guidelines and proposes a new integrated model of device therapy as a part of HF care.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt, Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Jeroen Dauw
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Finn Gustafsson
- The Heart Center, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Alexandre Mebazaa
- Université de Paris, UMR Inserm - MASCOT; APHP Saint Louis Lariboisière University Hospitals, Department of Anesthesia-Burn-Critical Care, Paris, France
| | - Jan Steffel
- Hirslanden Heart Clinic and University of Zurich, Zurich, Switzerland
| | - Klaus K Witte
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Hospital University Germans Trias i Pujol, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | - Cecilia Linde
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital, Heart Vascular and Neurology Theme, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Davor Milicic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Gerd Hasenfuß
- University Medical Center Göttingen (UMG), Department of Cardiology and Pneumology, German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | | | - Friedrich Koehler
- Medical Department, Division of Cardiology and Angiology, Centre for Cardiovascular Telemedicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Ruschitzka
- Clinic of Cardiology, University Heart Centre, University Hospital, Zurich, Switzerland
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ehud Schwammenthal
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, and Tel Aviv University, Ramat Aviv, Israel
| | - Jeffrey M Testani
- Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Michael Böhm
- Universitatsklinikum des Saarlandes, Klinik fur Innere Medizin III, Saarland University, Kardiologie, Angiologie und Internistische Intensivmedizin, Homburg, Germany
| | - Martin R Cowie
- Royal Brompton Hospital, Guy's & St Thomas' NHS Foundation Trust, and School of Cardiovascular Medicine and Sciences, Faculty of Lifesciences & Medicine, King's College London, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway; and Stavanger University Hospital, Stavanger, Norway
| | - Tiny Jaarsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia; Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | | | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany and Fraunhofer institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Stamatis Adamopoulos
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Centre, Athens, Greece
| | - Alain Cohen-Solal
- Department of Cardiology, University Hospital Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Brenda Moura
- Armed Forces Hospital, Porto, and Faculty of Medicine of Porto, Porto, Portugal
| | - Amina Rakisheva
- Cardiology Department, Scientific Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Badalona, Spain
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité - Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | - Carlo Gabriele Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences (DISMET); Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center for Clinical and Translational Research (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA); Federico II University, Naples, Italy
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Hadi Skouri
- Division of Cardiology, Internal Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Offer Amir
- Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | | | | | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra, and IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Massimo Piepoli
- Clinical Cardiac Unit, Policlinico San Donato, University of Milan, Milan, Italy
| | - Petar Seferovic
- Universi Faculty of Medicine, University of Belgrade, and Serbian Academy of Arts and Sciences, Belgrade, Serbia
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Zhu X, Xie B, Chen Y, Zeng H, Hu J. Machine learning in the prediction of in-hospital mortality in patients with first acute myocardial infarction. Clin Chim Acta 2024; 554:117776. [PMID: 38216028 DOI: 10.1016/j.cca.2024.117776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Persistent efforts are required to further reduce the in-hospital mortality of patients suffering from acute myocardial infarction (AMI), even in the face of a global trend of declining AMI-related fatalities. We investigated deep machine learning models for in-hospital death prediction in patients on their first AMI. METHOD In this 2-center retrospective analysis, first AMI patients from Hospital I and Hospital II were included; 4783 patients from Hospital 1 were split in a 7:3 ratio between the training and testing sets. Data from 1053 AMI patients in Hospital II was used for further validation. 70 clinical information and laboratory examination parameters as predictive indicators were included. Logistic Regression Classifier (LR), Random Forests Classifier (RF), eXtreme Gradient Boosting (XGB), Support Vector Machine Classifier (SVM), Multilayer Perceptron (MLP), Gradient Boosting Machine (GBM), Bootstrapped Aggregation (Bagging) models with AMI patients were developed. The importance of selected variables was obtained through the Shapley Additive exPlanations (SHAP) method. The performance of each model was shown using the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (Average Precision; AP). RESULT The in-hospital mortality for AMI in the training, testing, and validation sets were 5.7 %, 5.6 %, and 6.0 %, respectively. The top 8 predictors were D-dimer, brain natriuretic peptide, cardiogenic shock, neutrophil, prothrombin time, blood urea nitrogen, cardiac arrest, and phosphorus. In the testing cohort, the models of LR, RF, XGB, SVM, MLP, GBM, and Bagging yielded AUROC values of 0.929, 0.931, 0.907, 0.868, 0.907, 0.923, and 0.932, respectively. Bagging has good predictive value and certain clinical value in external validation with AUROC 0.893. CONCLUSION In order to improve the forecasting accuracy of the risk of AMI patients, guide clinical nursing practice, and lower AMI inpatient mortality, this study looked into significant indicators and the optimal models for predicting AMI inpatient mortality.
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Affiliation(s)
- Xiaoli Zhu
- Department of Laboratory Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People's Republic of China
| | - Bojian Xie
- Department of Oncological Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People's Republic of China
| | - Yijun Chen
- Department of Laboratory Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People's Republic of China
| | - Hanqian Zeng
- Department of Oncological Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People's Republic of China
| | - Jinxi Hu
- Department of Oncological Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, People's Republic of China.
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36
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Kalra R, Yannopoulos D, Bartos JA. Left ventricular unloading during VA-ECMO: A Gordian knot of physiology. Resuscitation 2024; 195:110122. [PMID: 38266769 DOI: 10.1016/j.resuscitation.2024.110122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/12/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Rajat Kalra
- Cardiovascular Division, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - Demetris Yannopoulos
- Cardiovascular Division, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Jason A Bartos
- Cardiovascular Division, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States; Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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37
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Sundermeyer J, Kellner C, Beer BN, Besch L, Dettling A, Bertoldi LF, Blankenberg S, Dauw J, Dindane Z, Eckner D, Eitel I, Graf T, Horn P, Jozwiak-Nozdrzykowska J, Kirchhof P, Kluge S, Linke A, Landmesser U, Luedike P, Lüsebrink E, Majunke N, Mangner N, Maniuc O, Möbius Winkler S, Nordbeck P, Orban M, Pappalardo F, Pauschinger M, Pazdernik M, Proudfoot A, Kelham M, Rassaf T, Reichenspurner H, Scherer C, Schulze PC, Schwinger RHG, Skurk C, Sramko M, Tavazzi G, Thiele H, Villanova L, Morici N, Winzer EB, Westermann D, Gustafsson F, Schrage B. Clinical presentation, shock severity and mortality in patients with de novo versus acute-on-chronic heart failure-related cardiogenic shock. Eur J Heart Fail 2024; 26:432-444. [PMID: 37940139 DOI: 10.1002/ejhf.3082] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/22/2023] [Accepted: 11/06/2023] [Indexed: 11/10/2023] Open
Abstract
AIMS Heart failure-related cardiogenic shock (HF-CS) accounts for a significant proportion of CS cases. Whether patients with de novo HF and those with acute-on-chronic HF in CS differ in clinical characteristics and outcome remains unclear. The aim of this study was to evaluate differences in clinical presentation and mortality between patients with de novo and acute-on-chronic HF-CS. METHODS AND RESULTS In this international observational study, patients with HF-CS from 16 tertiary care centres in five countries were enrolled between 2010 and 2021. To investigate differences in clinical presentation and 30-day mortality, adjusted logistic/Cox regression models were fitted. Patients (n = 1030) with HF-CS were analysed, of whom 486 (47.2%) presented with de novo HF-CS and 544 (52.8%) with acute-on-chronic HF-CS. Traditional markers of CS severity (e.g. blood pressure, heart rate and lactate) as well as use of treatments were comparable between groups. However, patients with acute-on-chronic HF-CS were more likely to have a higher CS severity and also a higher mortality risk, after adjusting for relevant confounders (de novo HF 45.5%, acute-on-chronic HF 55.9%, adjusted hazard ratio 1.38, 95% confidence interval 1.10-1.72, p = 0.005). CONCLUSION In this large HF-CS cohort, acute-on-chronic HF-CS was associated with more severe CS and higher mortality risk compared to de novo HF-CS, although traditional markers of CS severity and use of treatments were comparable. These findings highlight the vast heterogeneity of patients with HF-CS, emphasize that HF chronicity is a relevant disease modifier in CS, and indicate that future clinical trials should account for this.
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Affiliation(s)
- Jonas Sundermeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt N Beer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeroen Dauw
- Department of Cardiology, AZ Sint-Lucas, Ghent, Belgium
| | - Zouhir Dindane
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Ingo Eitel
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Duesseldorf, Germany
| | - Joanna Jozwiak-Nozdrzykowska
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Linke
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Norman Mangner
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | | | - Alastair Proudfoot
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London
| | - Matthew Kelham
- Department of Perioperative Medicine, St. Bartholomew's Hospital, London
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Hermann Reichenspurner
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Carsten Skurk
- Department of Cardiology, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Marek Sramko
- Department of Cardiology, IKEM, Prague, Czech Republic
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Luca Villanova
- Intensive Cardiac Care Unit and De Gasperis Cardio-Center, Niguarda Hospital, Milan, Italy
| | - Nuccia Morici
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi, ONLUS, Milan, Italy
| | - Ephraim B Winzer
- Technische Universität Dresden, Heart Centre Dresden, University Hospital, Department for Internal Medicine and Cardiology, Dresden, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Finn Gustafsson
- Rigshospitalet and Department of Clinical Medicine, University of Copenhagen Copenhagen, Copenhagen, Denmark
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Dodoo SN, Kwapong YA, Agyemang-Sarpong A, Amoran E, Egolum UO, Ghasemzadeh N, Ramadan R, Henry G, Samady H. Comparative Healthcare Resource Utilization of Percutaneous Mechanical Circulatory Support Using Impella Versus Intra-aortic Balloon Pump Use for Patients With Acute Coronary Syndrome and Cardiogenic Shock Undergoing Percutaneous Coronary Interventions: Insights From National Inpatient Sample. Curr Probl Cardiol 2024; 49:102053. [PMID: 37640173 DOI: 10.1016/j.cpcardiol.2023.102053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
The use of percutaneous mechanical circulatory support (MCS) devices, including Impella and Intra-aortic balloon pump (IABP), in patients with cardiogenic shock has increased in recent times. We aimed to evaluate the impact of the choice of an MCS device on healthcare resource utilization. We queried the National Inpatient Sample registry between October 2016 and December 2018 to identify adults admitted for acute coronary syndrome-related cardiogenic shock and who received percutaneous coronary intervention (PCI). The study population was segregated into Impella and IABP groups using ICD 10 diagnosis codes. The primary endpoint was high healthcare resource utilization (HRU), while secondary outcomes included periprocedural complications. Propensity scoring matching was used to determine which patients in the Impella cohort had similar health to IABP patients. During the study period, 439,610 patients were admitted who received hemodynamic support using, Impella or IABP on account of acute coronary syndrome complicated by cardiogenic shock (CS). The median age (years) of the Impella cohort and IABP cohorts were similar (64.1 vs 65.1, P = 0.08). Gender distribution of the Impella CS patients was like IABP patients with female majorities in both groups, (71.9% vs 67.9%, P = 0.05). Impella CS patients had a higher representation of those with hypertension (P = 0.002), smoking (P = 0.040), obesity (P = 0.034), diabetes mellitus (P = 0.009), CHF (P = 0.030), COPD (P = 0.034), chronic liver disease (P = 0.028), and chronic kidney disease (P = 0.031). 1:1 Propensity score matching identified 2620 Impella patients' comparable severity index with the IABP patients. Patients with hemodynamic support using Impella had higher healthcare resource utilization, (HRU), the surrogate of length of stay (LOS) ≥7 or nonhome disposition at discharge, when compared with those with IABP (57.41% vs 42.76%, P < 0.0001). Impella CS patients had higher in-hospital mortality as compared to the IABP patients (55.45% vs 45.86%, P < 0.0001). Impella CS patients developed more periprocedural complications, including vascular injury (4.8% vs 1.4%, P < 0.0001), acute kidney injury (58.36% vs 41.64%, P < 0.0001), end-stage renal disease requiring dialysis (8.75% vs 1.25%, P = 0.002) when compared to the IABP patients. Among patients with ACS undergoing PCI and receiving MCS devices, those receiving Impella demonstrated higher healthcare resource utilization, higher LOS ≥7 days, and more nonhome disposition at discharge compared to patients receiving IABP. Further investigation is warranted to elucidate factors associated with these findings.
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Affiliation(s)
- Sheriff N Dodoo
- Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, GA.
| | - Yaa Adoma Kwapong
- Ciccarone Center for the Prevention of Cardiovascular Disease, School of Medicine, Johns Hopkins University, Lutherville, MD
| | | | - Emmanuel Amoran
- Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, GA
| | - Ugochukwu O Egolum
- Division of Cardiology, Advanced Heart Failure, and Transplantation, Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, GA
| | - Nima Ghasemzadeh
- Division of Cardiology, Interventional Cardiology, Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, GA
| | - Ronnie Ramadan
- Division of Cardiology, Interventional Cardiology, Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, GA
| | - Glen Henry
- Division of Cardiology, Interventional Cardiology, Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, GA
| | - Habib Samady
- Division of Cardiology, Interventional Cardiology, Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, GA
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Bhatt HV, Fritz AV, Feinman JW, Subramani S, Malhotra AK, Townsley MM, Weiner MM, Sharma A, Teixeira MT, Lee J, Linganna RE, Waldron NH, Shapiro AB, Mckeon J, Hanada S, Ramakrishna H, Martin AK. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023. J Cardiothorac Vasc Anesth 2024; 38:16-28. [PMID: 38040533 DOI: 10.1053/j.jvca.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 12/03/2023]
Abstract
This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.
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Affiliation(s)
- Himani V Bhatt
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Jared W Feinman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anita K Malhotra
- Division of Cardiothoracic Anesthesiology and Critical Care, Penn State Hershey Medical Center, Hershey, PA
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham School of Medicine, Birmingham, AL; Bruno Pediatric Heart Center, Children's of Alabama, Birmingham, AL
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Archit Sharma
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Miguel T Teixeira
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jennifer Lee
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Regina E Linganna
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nathan H Waldron
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Anna Bovill Shapiro
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - John Mckeon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Satoshi Hanada
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL.
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Javaid AI, Michalek JE, Gruslova AB, Hoskins SA, Ahsan CH, Feldman MD. Mechanical circulatory support versus vasopressors alone in patients with acute myocardial infarction and cardiogenic shock undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2024; 103:30-41. [PMID: 37997292 DOI: 10.1002/ccd.30913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 10/10/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Previous studies have compared Impella use to intra-aortic balloon pump (IABP) use in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI). Our objective was to compare clinical outcomes in patients with AMI-CS undergoing PCI who received Impella (percutaneous left ventricular assist device) without vasopressors, IABP without vasopressors, and vasopressors without mechanical circulatory support (MCS). METHODS We queried the National Inpatient Sample (NIS) using ICD-10 codes (2015-2018) to identify patients with AMI-CS undergoing PCI. We created three propensity-matched cohorts to examine clinical outcomes in patients receiving Impella versus IABP, Impella versus vasopressors without MCS, and IABP versus vasopressors without MCS. RESULTS Among 17,762 patients, Impella use was associated with significantly higher in-hospital major bleeding (31.4% vs. 13.6%; p < 0.001) and hospital charges (p < 0.001) compared to IABP use, with no benefit in mortality (34.1% vs. 26.9%; p = 0.06). Impella use was associated with significantly higher mortality (42.3% vs. 35.7%; p = 0.02), major bleeding (33.9% vs. 22.7%; p = 0.001), and hospital charges (p < 0.001), when compared to the use of vasopressors without MCS. There were no significant differences in clinical outcomes between IABP use and the use of vasopressor without MCS. CONCLUSIONS In this analysis of retrospective data of patients with AMI-CS undergoing PCI, Impella use was associated with higher mortality, major bleeding, and in-hospital charges when compared to vasopressor therapy without MCS. When compared to IABP use, Impella was associated with no mortality benefit, along with higher major bleeding events and in-hospital charges. A vasopressor-only strategy suggested no difference in clinical outcomes when compared to IABP. This study uses the NIS for the first time to highlight outcomes in AMI-CS patients undergoing PCI when treated with vasopressor support without MCS, compared to Impella and IABP use.
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Affiliation(s)
- Awad I Javaid
- Division of Cardiovascular Medicine, Kirk Kerkorian School of Medicine at the University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Joel E Michalek
- Department of Population Health Sciences, The University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Aleksandra B Gruslova
- Division of Cardiology, Department of Medicine, The University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Serene A Hoskins
- Division of Cardiology, Department of Medicine, The University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Chowdhury H Ahsan
- Division of Cardiovascular Medicine, Kirk Kerkorian School of Medicine at the University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Marc D Feldman
- Division of Cardiology, Department of Medicine, The University of Texas Health at San Antonio, San Antonio, Texas, USA
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Malik GMA, Samiullah F, Kumar S. Letter to the Editor: Right to Left Cardiac Power Output- New Prognosticator in STEMI Patients with Cardiogenic Shock (R-Shock). Curr Probl Cardiol 2024; 49:102171. [PMID: 37918498 DOI: 10.1016/j.cpcardiol.2023.102171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Ghulam Mustafa Ali Malik
- Dow International Medical College, Gulzar-e-Hijri Gulshan-e-Iqbal, Karachi, Karachi City, Sindh, Pakistan.
| | - Fnu Samiullah
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari Karachi.
| | - Satesh Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College Lyari Karachi.
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Groeneveld NTA, Swier CEL, Montero-Cabezas J, Elzo Kraemer CV, Klok FA, van den Brink FS. Mechanical Support Strategies for High-Risk Procedures in the Invasive Cardiac Catheterization Laboratory: A State-of-the-Art Review. J Clin Med 2023; 12:7755. [PMID: 38137824 PMCID: PMC10744085 DOI: 10.3390/jcm12247755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
Thanks to advancements in percutaneous cardiac interventions, an expanding patient population now qualifies for treatment through percutaneous endovascular procedures. High-risk interventions far exceed coronary interventions and include transcatheter aortic valve replacement, endovascular management of acute pulmonary embolism and ventricular tachycardia ablation. Given the frequent impairment of ventricular function in these patients, frequently deteriorating during percutaneous interventions, it is hypothesized that mechanical ventricular support may improve periprocedural survival and subsequently patient outcome. In this narrative review, we aimed to provide the relevant evidence found for the clinical use of percutaneous mechanical circulatory support (pMCS). We searched the Pubmed database for articles related to pMCS and to pMCS and invasive cath lab procedures. The articles and their references were evaluated for relevance. We provide an overview of the clinically relevant evidence for intra-aortic balloon pump, Impella, TandemHeart and ECMO and their role as pMCS in high-risk percutaneous coronary intervention, transcatheter valvular procedures, ablations and high-risk pulmonary embolism. We found that the right choice of periprocedural pMCS could provide a solution for the hemodynamic challenges during these procedures. However, to enhance the understanding of the safety and effectiveness of pMCS devices in an often high-risk population, more randomized research is needed.
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Affiliation(s)
- Niels T. A. Groeneveld
- Department of Anesthesiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands;
| | - Carolien E. L. Swier
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (C.E.L.S.); (C.V.E.K.)
| | - Jose Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Carlos V. Elzo Kraemer
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (C.E.L.S.); (C.V.E.K.)
| | - Frederikus A. Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands;
| | - Floris S. van den Brink
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands; (C.E.L.S.); (C.V.E.K.)
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Nishimoto Y, Inohara T, Kohsaka S, Sakakura K, Kawai T, Kikuchi A, Watanabe T, Yamada T, Fukunami M, Yamaji K, Ishii H, Amano T, Kozuma K. Changing Trends in Mechanical Circulatory Support Use and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Acute Coronary Syndrome Complicated With Cardiogenic Shock: Insights From a Nationwide Registry in Japan. J Am Heart Assoc 2023; 12:e031838. [PMID: 38038195 PMCID: PMC10727314 DOI: 10.1161/jaha.123.031838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Temporal trends in the management of acute coronary syndrome complicated with cardiogenic shock after the revision of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella require further investigation, because their impact remains uncertain. METHODS AND RESULTS Using the Japanese Percutaneous Coronary Intervention (J-PCI) registry database from 2019 to 2021, we identified 12 171 patients undergoing percutaneous coronary intervention for acute coronary syndrome complicated with cardiogenic shock under mechanical circulatory support. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella, and (3) venoarterial extracorporeal membrane oxygenation (VA-ECMO); the VA-ECMO group was further stratified into (3a) VA-ECMO alone, (3b) VA-ECMO in combination with IABP, and (3c) VA-ECMO in combination with Impella. The quarterly prevalence and outcomes were reported. The use of IABP alone decreased significantly from 63.5% in the first quarter of 2019 to 58.3% in the fourth quarter of 2021 (P for trend=0.01). Among 4245 patients requiring VA-ECMO, the use of VA-ECMO in combination with IABP decreased significantly from 78.7% to 67.3%, whereas the use of VA-ECMO in combination with Impella increased significantly from 4.2% to 17.0% (P for trend <0.001 for both). After adjusting for the confounders, the risk difference in the fourth quarter of 2021 relative to the first quarter of 2019 for in-hospital mortality was not significant (adjusted odds ratio, 0.84 [95% CI, 0.69-1.01]). CONCLUSIONS Our study revealed substantial changes in the use of different mechanical circulatory support modalities in acute coronary syndrome complicated with cardiogenic shock, but they did not significantly improve the outcomes.
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Affiliation(s)
- Yuji Nishimoto
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | - Taku Inohara
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Shun Kohsaka
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Tsutomu Kawai
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | - Atsushi Kikuchi
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | | | - Takahisa Yamada
- Division of CardiologyOsaka General Medical CenterOsakaJapan
| | | | | | - Hideki Ishii
- Department of Cardiovascular MedicineGunma University Graduate School of MedicineMaebashiJapan
| | - Tetsuya Amano
- Department of CardiologyAichi Medical UniversityNagakuteJapan
| | - Ken Kozuma
- Department of CardiologyTeikyo University HospitalTokyoJapan
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Funk A, Kilger E, Vlachea P, Höchter DJ. [Use of an intra-aortic balloon pump to improve cerebral oxygen saturation after resuscitation in a cardiac surgical intervention]. DIE ANAESTHESIOLOGIE 2023; 72:878-882. [PMID: 37855946 PMCID: PMC10692251 DOI: 10.1007/s00101-023-01351-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Anja Funk
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Erich Kilger
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
| | - Polyxeni Vlachea
- Klinik für Herzchirurgie, LMU Klinikum, Klinikum der Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377, München, Deutschland
| | - Dominik J Höchter
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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Sugimura Y, Bauer S, Immohr MB, Mehdiani A, Rellecke P, Tudorache I, Horn P, Westenfeld R, Boeken U, Aubin H, Lichtenberg A, Akhyari P. Clinical outcomes of hundred large Impella implantations in cardiogenic shock patients based on individual clinical scenarios. Artif Organs 2023; 47:1874-1884. [PMID: 37724611 DOI: 10.1111/aor.14646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 07/09/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Large Impella systems (5.0 or 5.5; i.e., Impella 5+) (Abiomed Inc., Danvers, MA, USA) help achieve better clinical outcomes through relevant left ventricular unloading in acute cardiogenic shock (CS). Here, we report our experience with Impella 5+, while focusing on the clinical outcomes depending on individual case scenarios in patients with acute CS. METHODS This single-center retrospective observational study included 100 Impella 5+ implantations conducted on patients with acute CS from November 2018 to October 2021. After excluding 10 reimplantation cases, 90 cases were enrolled for further analysis. RESULTS In-hospital and 30-day mortality rates were 56.7% (n = 51) and 48.9% (n = 44), respectively. In-hospital mortality was lower in patients with acute myocardial infarction (AMI) than in non-AMI patients (p = 0.07). Young age and low lactate levels were the independent predictors of successful transition and survival after permanent mechanical circulatory support/heart transplantation (pMCS/HTX) (age, p = 0.03; lactate level, p = 0.04; survived after pMCS/HTX, n = 11; died on Impella, n = 41). During simultaneous utilization of venoarterial extracorporeal membrane oxygenation therapy and Impella 5+, termed ECMELLA therapy, high dose of noradrenaline was a predictive factor for in-hospital mortality by multivariate analysis (n = 0.02). CONCLUSIONS Our results suggest that enhanced Impella support might have better clinical outcomes among acute CS patients supported with large Impella, those with AMI than those with no AMI. Young age and low lactate levels were predictors of successful bridging to pMCS/HTX and favorable clinical outcomes thereafter. The clinical outcomes of ECMELLA therapy might depend on noradrenaline dose at the time of Impella 5+ implantation.
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Affiliation(s)
- Yukiharu Sugimura
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Sebastian Bauer
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Moritz Benjamin Immohr
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Arash Mehdiani
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Philipp Rellecke
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Igor Tudorache
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Angiology and Pulmonology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- CARID-Cardiovascular Research Institute Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Angiology and Pulmonology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- CARID-Cardiovascular Research Institute Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Udo Boeken
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Hug Aubin
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
| | - Artur Lichtenberg
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- CARID-Cardiovascular Research Institute Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Düsseldorf, Germany
- Department of Cardiac Surgery, Medical Faculty and RWTH University Hospital Aachen, RWTH Aachen University, Aachen, Germany
- CARID-Cardiovascular Research Institute Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Delmas C, Vandenbriele C, Pappalardo F. Persistent high mortality in acute myocardial infarction-associated cardiogenic shock despite early mechanical circulatory support: Need for stepwise and integrated approach of care. Eur J Heart Fail 2023; 25:2034-2036. [PMID: 37828786 DOI: 10.1002/ejhf.3061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
| | | | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Sandoval Y, Basir MB, Lemor A, Lichaa H, Alasnag M, Dupont A, Hirst C, Kearney KE, Kaki A, Smith TD, Vallabhajosyula S, Kayssi A, Firstenberg MS, Truesdell AG. Optimal Large-Bore Femoral Access, Indwelling Device Management, and Vascular Closure for Percutaneous Mechanical Circulatory Support. Am J Cardiol 2023; 206:262-276. [PMID: 37717476 DOI: 10.1016/j.amjcard.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/30/2023] [Accepted: 08/05/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Alejandro Lemor
- Department of Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Hady Lichaa
- Ascension Saint Thomas Heart, Ascension Saint Thomas Rutherford, Murfreesboro, Tennessee
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | | | - Colin Hirst
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | | | - Amir Kaki
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan
| | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Schwarzman LS, Ishaaya EC, Patel D, Megowan N, Thomas JL. Characteristic adverse events with intra-aortic balloon pumps: An analysis of the U.S. Food and Drug Administration MAUDE database from 2016 to 2021. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 56:37-40. [PMID: 37302952 DOI: 10.1016/j.carrev.2023.05.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The United States Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) dataset represents a unique source for post-market surveillance data on adverse events (AE). An analysis of AE with percutaneous mechanical circulatory support (pMCS) devices has previously been reported specifically for microaxial flow pumps. The characteristic AE for the intra-aortic balloon pump (IABP) have not been similarly analyzed or reported. MATERIAL AND METHODS All events in the MAUDE dataset between January 1, 2016 and December 31, 2021 were reviewed involving the Linear, Mega and Sensation devices (Datascope/Getinge, Wayne New Jersey). Data was analyzed by two authors and categorized based on AE type, date, event type and device-related or patient-related AE. RESULTS A total of 2795 AE were reported over five years. Device malfunction (91.4 %) was the most frequent classification followed by death (5.6 %) and injury (3.0 %). Catheter deformation/fracture/leak accounted for 37.9 % of total AEs. The most common patient event categorization was asymptomatic (90.8 %). Vessel damage/hemorrhage occurred in 1.4 % of reports. Death occurred in 5.6 % of reports and was associated with cardiac arrest in 110 of 156 events. Thrombus formation was described in 1.1 % of AEs. Device optic AE were common and unique to Sensation catheters. Calibration errors were also more common with Sensation (4.6 % versus 1.3 %) compared to other models. CONCLUSIONS Publicly reported AE with IABPs are predominantly device malfunctions without clinical sequelae. Injury, vascular damage, bleeding and thrombosis AEs are not frequent amongst reported AEs. Emphasis should be placed on understanding mechanisms of device malfunction in order to improve both reliability and user experience.
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Affiliation(s)
| | - Ella C Ishaaya
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Dev Patel
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA; Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nichelle Megowan
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA; Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Joseph L Thomas
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA; Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA, USA.
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Hirai T, Grantham JA, Kandzari DE, Ballard W, Brown WM, Allen KB, Kirtane AJ, Argenziano M, Yeh RW, Khabbaz K, Lombardi W, Lasala J, Kachroo P, Karmpaliotis D, Gosch KL, Salisbury AC. Percutaneous ventricular assist device for higher-risk percutaneous coronary intervention in surgically ineligible patients: Indications and outcomes from the OPTIMUM study. Catheter Cardiovasc Interv 2023; 102:814-822. [PMID: 37676058 DOI: 10.1002/ccd.30834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/25/2023] [Accepted: 08/31/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Indications and outcomes for percutaneous ventricular assist device (pVAD) use in surgically ineligible patients undergoing percutaneous coronary intervention (PCI) remain poorly characterized. AIMS We sought to describe the use and timing of pVAD and outcome in surgically ineligible patients. METHODS Among 726 patients enrolled in the prospective OPTIMUM study, clinical and health status outcomes were assessed in patients who underwent pVAD-assisted PCI and those without pVAD. RESULTS Compared with patients not receiving pVAD (N = 579), those treated with pVAD (N = 142) more likely had heart failure, lower left ventricular ejection fraction (30.7 ± 13.6 vs. 45.9 ± 15.5, p < 0.01), and higher STS 30-day predicted mortality (4.2 [2.1-8.0] vs. 3.3 [1.7-6.6], p = 0.01) and SYNTAX scores (36.1 ± 12.2, vs. 31.5 ± 12.1, p < 0.01). While the pVAD group had higher in-hospital (5.6% vs. 2.2%, p = 0.046), 30-day (9.0% vs. 4.0%, p = 0.01) and 6-month (20.4% vs. 11.7%, p < 0.01) mortality compared to patients without pVAD, this difference appeared to be largely driven by significantly higher mortality among the 20 (14%) patients with unplanned pVAD use (30% in-hospital mortality with unplanned PVAD vs. 1.6% with planned, p < 0.01; 30-day mortality, 38.1% vs. 4.5%, p < 0.01). The degree of 6-month health status improvement among survivors was similar between groups. CONCLUSION Surgically ineligible patients with pVAD-assisted PCI had more complex baseline characteristics compared with those without pVAD. Higher mortality in the pVAD group appeared to be driven by very poor outcomes by patients with unplanned, rescue pVAD.
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Affiliation(s)
- Taishi Hirai
- Division of Cardiology, University of Missouri, Columbia, Missouri, USA
| | - J Aaron Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- Divison of Cardiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | | | | | | | - Keith B Allen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- Divison of Cardiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Michael Argenziano
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kamal Khabbaz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - William Lombardi
- Divsion of Cardiology, University of Washington, Seattle, Washington, USA
| | - John Lasala
- Division of Cardiology, Washington University, St. Louis, Missouri, USA
| | - Puja Kachroo
- Division of Cardiology, Washington University, St. Louis, Missouri, USA
| | | | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Adam C Salisbury
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- Divison of Cardiology, University of Missouri Kansas City, Kansas City, Missouri, USA
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