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Movahed MR, Talle A, Hashemzadeh M. Intra-aortic balloon pump is associated with the lowest whereas Impella with the highest inpatient mortality and complications regardless of severity or hospital types. Cardiovasc Interv Ther 2024; 39:252-261. [PMID: 38555535 DOI: 10.1007/s12928-024-00993-8] [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: 01/27/2024] [Accepted: 03/04/2024] [Indexed: 04/02/2024]
Abstract
Impella and intra-aortic balloon pumps (IABP) are commonly utilized in patients with cardiogenic shock. However, the effect on mortality remains controversial. The goal of this study was to evaluate the effect of Impella and IABP on mortality in patients with cardiogenic shock the large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of IABP or Impella on outcome. ICD-10 codes for Impella, IABP, and cardiogenic shock for available years 2016-2020 were utilized. A total of 844,020 patients had a diagnosis of cardiogenic shock. A total of 101,870 patients were treated with IABP and 39645 with an Impella. Total inpatient mortality without any device was 34.2% vs only 25.1% with IABP use (OR = 0.65, CI 0.62-0.67) but was highest at 40.7% with Impella utilization (OR = 1.32, CI 1.26-1.39). After adjusting for 47 variables, Impella utilization remained associated with the highest mortality (OR: 1.33, CI 1.25-1.41, p < 0.001), whereas IABP remained associated with the lowest mortality (OR: 0.69, CI 0.66-0.72, p < 0.001). Separating rural vs teaching hospitals revealed similar findings. In patients with cardiogenic shock, the use of Impella was associated with the highest whereas IABP was associated with the lowest in-hospital mortality regardless of comorbid condition.
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Affiliation(s)
- Mohammad Reza Movahed
- University of Arizona Sarver Heart Center, 1501 North Campbell Avenue, Tucson, Arizona, USA.
- University of Arizona, College of Medicine, Phoenix, Arizona, USA.
| | - Armin Talle
- University of Arizona, College of Medicine, Phoenix, Arizona, USA
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2
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Padberg JS, Feld J, Padberg L, Köppe J, Makowski L, Gerß J, Dröge P, Ruhnke T, Günster C, Lange SA, Reinecke H. Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock. J Clin Med 2024; 13:1167. [PMID: 38398478 PMCID: PMC10889198 DOI: 10.3390/jcm13041167] [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: 01/28/2024] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no tMCS or either intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella® for AMICS, with a particular focus on long-term outcomes. METHODS Using health claim data from AOK-Die Gesundheitskasse (local health care funds), we retrospectively analysed complications and outcomes of all insured patients with AMICS between 1 January 2010 and 31 December 2017. RESULTS A total of 39,864 patients were included (IABP 5451; Impella 776; V-A ECMO 833; no tMCS 32,804). In-hospital complications, including renal failure requiring dialysis (50.3% V-A ECMO vs. 30.5% Impella vs. 29.2 IABP vs. 12.1% no tMCS), major bleeding (38.1% vs. 20.9% vs. 18.0% vs. 9.3%) and sepsis (22.5% vs. 15.9% vs. 13.9% vs. 9.3%) were more common in V-A ECMO patients. In a multivariate analysis, the use of both V-A ECMO (HR 1.57, p < 0.001) and Impella (HR 1.25, p < 0.001) were independently associated with long-term mortality, whereas use of IABP was not (HR 0.89, p < 0.001). Kaplan-Meier estimates showed better survival for patients on IABP compared with Impella, V-A ECMO and no-tMCS. Short- and long-term mortality was high across all groups. CONCLUSIONS Our data show noticeably more in-hospital complications in patients on tMCS and higher mortality with V-A ECMO and Impella. The use of both devices is an independent risk factor for mortality, whereas the use of IABP is associated with a survival benefit.
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Affiliation(s)
- Jan-Sören Padberg
- Department for Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149 Münster, Germany
| | - Jannik Feld
- Institute of Biostatistics and Clinical Research, University of Münster, D-48149 Münster, Germany
| | - Leonie Padberg
- Department for Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149 Münster, Germany
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Münster, D-48149 Münster, Germany
| | - Lena Makowski
- Department for Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149 Münster, Germany
| | - Joachim Gerß
- Institute of Biostatistics and Clinical Research, University of Münster, D-48149 Münster, Germany
| | - Patrik Dröge
- AOK Research Institute (WIdO), AOK-Bundesverband, D-10178 Berlin, Germany
| | - Thomas Ruhnke
- AOK Research Institute (WIdO), AOK-Bundesverband, D-10178 Berlin, Germany
| | - Christian Günster
- AOK Research Institute (WIdO), AOK-Bundesverband, D-10178 Berlin, Germany
| | - Stefan Andreas Lange
- Department for Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149 Münster, Germany
| | - Holger Reinecke
- Department for Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Albert-Schweitzer-Campus 1, D-48149 Münster, Germany
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3
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Fang D, Yu D, Xu J, Ma W, Zhong Y, Chen H. Effects of intra-aortic balloon pump on in-hospital outcomes and 1-year mortality in patients with acute myocardial infarction complicated by cardiogenic shock. BMC Cardiovasc Disord 2023; 23:425. [PMID: 37644466 PMCID: PMC10466728 DOI: 10.1186/s12872-023-03465-8] [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: 04/05/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The role of intra-aortic balloon counterpulsation (IABP) in cardiogenic shock complicating acute myocardial infarction (AMI) is still a subject of intense debate. In this study, we aim to investigate the effect of IABP on the clinical outcomes of patients with AMI complicated by cardiogenic shock undergoing percutaneous coronary intervention (PCI). METHODS From the Medical Information Mart for Intensive Care (MIMIC)-IV 2.2, 6017 AMI patients were subtracted, and 250 patients with AMI complicated by cardiogenic shock undergoing PCI were analyzed. In-hospital outcomes (death, 24-hour urine volumes, length of ICU stays, and length of hospital stays) and 1-year mortality were compared between IABP and control during the hospital course and 12-month follow-up. RESULTS An IABP was implanted in 30.8% (77/250) of patients with infarct-related cardiogenic shock undergoing PCI. IABP patients had higher levels of Troponin T (3.94 [0.73-11.85] ng/ml vs. 1.99 [0.55-5.75] ng/ml, p-value = 0.02). IABP patients have a longer length of ICU and hospital stays (124 [63-212] hours vs. 83 [43-163] hours, p-value = 0.005; 250 [128-435] hours vs. 170 [86-294] hours, p-value = 0.009). IABP use was not associated with lower in-hospital mortality (33.8% vs. 33.0%, p-value = 0.90) and increased 24-hour urine volumes (2100 [1455-3208] ml vs. 1915 [1110-2815] ml, p-value = 0.25). In addition, 1-year mortality was not different between the IABP and the control group (48.1% vs. 48.0%; hazard ratio 1.04, 95% CI 0.70-1.54, p-value = 0.851). CONCLUSION IABP may be associated with longer ICU and hospital stays but not better short-and long-term clinical prognosis.
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Affiliation(s)
- Dingfeng Fang
- Shenzhen University Health Science Center, Shenzhen, 518060, China
- Department of Cardiology, Shenzhen Second People's Hospital, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, China
| | - Dongdong Yu
- Department of Cardiology, Shenzhen Second People's Hospital, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, China
| | - Jiabin Xu
- Department of Cardiology, Shenzhen Second People's Hospital, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, China
| | - Wei Ma
- Department of Cardiology, Shenzhen Second People's Hospital, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, China
| | - Yuxiang Zhong
- Department of Cardiology, Shenzhen Second People's Hospital, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, China
| | - Haibo Chen
- Department of Cardiology, Shenzhen Second People's Hospital, No. 3002, Sungang West Road, Futian District, Shenzhen, 518035, China.
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Singhvi A, Punnen J. Acute mechanical circulatory support for cardiogenic shock in India. Indian J Thorac Cardiovasc Surg 2023; 39:47-62. [PMID: 37525701 PMCID: PMC10387029 DOI: 10.1007/s12055-023-01530-7] [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: 08/24/2022] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 08/02/2023] Open
Abstract
Cardiogenic shock continues to have high morbidity and mortality, despite advances in the field. Temporary mechanical circulatory support (TMCS) devices, if instituted in a timely fashion, can help stabilize critically ill patients with cardiogenic shock from various aetiologies and cardiac arrest, and provide time for organ recovery or till durable support or transplantation can be achieved. Currently, several options for TMCS devices exist. In this review, we discuss indications, contraindications, characteristics of the various available devices, and important issues pertaining to their management.
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Affiliation(s)
- Aditi Singhvi
- Narayana Institute of Cardiac Sciences, Narayana Health, Bommasandra Industrial Area, Bengaluru, Karnataka 560099 India
| | - Julius Punnen
- Narayana Institute of Cardiac Sciences, Narayana Health, Bommasandra Industrial Area, Bengaluru, Karnataka 560099 India
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Gorder K, Rudick S, Smith TD. Advocacy and Legislation for Regionalization Practices in the Treatment of Cardiogenic Shock: The Time Is Now. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiogenic shock is a complex hemodynamic state that, despite improvements in care, often remains challenging to treat and confers a high mortality rate. Timely application of advanced strategies, including advanced hemodynamic management and mechanical circulatory support, is of the utmost importance for this critically ill patient population. Based on data and historic experiences with similar life-threatening conditions, a national system in the US of regionalized, structured care for patients with cardiogenic shock has the potential to improve outcomes and save lives. To enact this, national and state leaders, as well as federal regulatory bodies, physician thought leaders, industry representatives, and national organizations, must collaborate and advocate for a clear, structured cardiac shock center network with a tiered model for delivery of care for the sickest population of cardiac patients.
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Affiliation(s)
- Kari Gorder
- The Christ Hospital and Lindner Center for Research and Education, Cincinnati, OH
| | - Steve Rudick
- The Christ Hospital and Lindner Center for Research and Education, Cincinnati, OH
| | - Timothy D Smith
- The Christ Hospital and Lindner Center for Research and Education, Cincinnati, OH
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Bishawi M, Milano CA. Treatment of Perioperative Ischemia, Infarction, and Ventricular Failure in Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00013-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Basir MB, Pinto DS, Ziaeian B, Khandelwal A, Cowger J, Suh W, Althouse A. Mechanical circulatory support in acute myocardial infarction and cardiogenic shock: Challenges and importance of randomized control trials. Catheter Cardiovasc Interv 2021; 98:1264-1274. [PMID: 33682260 PMCID: PMC8421448 DOI: 10.1002/ccd.29593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/17/2021] [Accepted: 02/19/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with significant morbidity and mortality. METHODS We provide an overview of previously conducted studies on the use of mechanical circulatory support (MCS) devices in the treatment of AMI-CS and difficulties which may be encountered in conducting such trials in the United States. RESULTS Well powered randomized control trials are difficult to conduct in a critically ill patient population due to physician preferences, perceived lack of equipoise and challenges obtaining informed consent. CONCLUSIONS With growth in utilization of MCS devices in patients with AMI-CS, efforts to perform well-powered, randomized control trials must be undertaken.
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Affiliation(s)
- Mir B. Basir
- Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Duane S. Pinto
- Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Boback Ziaeian
- Cardiology, Riverside Medical Clinic, Chattaroy, Washington
| | | | | | - William Suh
- Cardiology, Riverside Medical Clinic, Chattaroy, Washington
| | - Andrew Althouse
- Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Chien SC, Hsu CY, Liu HY, Lin CF, Hung CL, Huang CY, Chien LN. Cardiogenic shock in Taiwan from 2003 to 2017 (CSiT-15 study). Crit Care 2021; 25:402. [PMID: 34794502 PMCID: PMC8600726 DOI: 10.1186/s13054-021-03820-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study investigated temporal trends in the treatment and mortality of patients with cardiogenic shock (CS) in Taiwan in relation to acute myocardial infarction (AMI) accreditation implemented in 2009 and the unavailability of percutaneous ventricular assist devices. METHODS Data of patients diagnosed as having CS between January 2003 and December 2017 were collected from Taiwan's National Health Insurance Research Database. Each case was followed from the date of emergency department arrival or hospital admission for the first incident associated with a CS diagnosis up to a 1-year interval. Measurements included demographics, comorbidities, treatment, mortality, and medical costs. Using an interrupted time-series (ITS) design with multi-level mixed-effects logistic regression model, we assessed the impact of AMI accreditation implementation on the mortality of patients with AMI and CS overall and stratified by the hospital levels. RESULTS In total, 64 049 patients with CS (mean age:70 years; 62% men) were identified. The incidence rate per 105 person-years increased from 17 in 2003 to 25 in 2010 and plateaued thereafter. Average inpatient costs increased from 159 125 points in 2003 to 240 993 points in 2017, indicating a 1.5-fold increase. The intra-aortic balloon pump application rate was approximately 22-25% after 2010 (p = 0.093). Overall, in-hospital, 30-day, and 1-year mortality declined from 60.3%, 63.0%, and 69.3% in 2003 to 47.9%, 50.8% and 59.8% in 2017, respectively. The decline in mortality was more apparent in patients with AMI-CS than in patients with non-AMI-CS. The ITS estimation revealed a 2% lower in-hospital mortality in patients with AMI-CS treated in district hospitals after the AMI accreditation had been implemented for 2 years. CONCLUSIONS In Taiwan, the burden of CS has consistently increased due to high patient complexity, advanced therapies, and stable incidence. Mortality declined over time, particularly in patients with AMI-CS, which may be attributable to advancements in AMI therapies and this quality-improving policy.
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Affiliation(s)
- Shih-Chieh Chien
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chien-Yi Hsu
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Hung-Yi Liu
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, No. 250 Wuxing Street, Taipei, Taiwan
| | - Chao-Feng Lin
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chung-Lieh Hung
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chun-Yao Huang
- Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Li-Nien Chien
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, No. 250 Wuxing Street, Taipei, Taiwan. .,School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan.
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Rossini R, Valente S, Colivicchi F, Baldi C, Caldarola P, Chiappetta D, Cipriani M, Ferlini M, Gasparetto N, Gilardi R, Giubilato S, Imazio M, Marini M, Roncon L, Scotto di Uccio F, Somaschini A, Sorini Dini C, Trambaiolo P, Usmiani T, Gulizia MM, Gabrielli D. ANMCO POSITION PAPER: Role of intra-aortic balloon pump in patients with acute advanced heart failure and cardiogenic shock. Eur Heart J Suppl 2021; 23:C204-C220. [PMID: 34456647 PMCID: PMC8387780 DOI: 10.1093/eurheartj/suab074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The treatment of patients with advanced acute heart failure is still challenging. Intra-aortic balloon pump (IABP) has widely been used in the management of patients with cardiogenic shock. However, according to international guidelines, its routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian Association of Hospital Cardiologists, reviews the available data derived from clinical studies. It also provides practical recommendations for the optimal use of IABP in the treatment of cardiogenic shock and advanced acute heart failure.
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Affiliation(s)
- Roberta Rossini
- Division of Cardiology, Emergency Department and Critical Areas, Azienda Ospedaliera Santa Croce e Carle, Via Michele Coppino 26, 12100 Cuneo, Italy
| | - Serafina Valente
- Clinical-Surgical-CCU Cardiology Department, Azienda Ospedaliero-Universitaria Senese Ospedale Santa Maria alle Scotte, Siena, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri-, ASL Roma 1, Roma, Italy
| | - Cesare Baldi
- Interventional Cardiology-Cath Lab Department, Azienda Ospedaliera Universitaria San Giovanni di Dio-Ruggi d'Aragona, Salerno, Italy
| | | | | | - Manlio Cipriani
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare "A. De Gasperis", ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Rossella Gilardi
- Department of Cardiac Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Simona Giubilato
- Cardiology-CCU -Cath Lab Department, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Massimo Imazio
- Division of Cardiology, Presidio Molinette, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Marini
- Cardiology-CCU -Cath Lab Department, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Loris Roncon
- U.O.C. Cardiologia, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | | | - Alberto Somaschini
- Department of Cardiology and Cardiac Intensive Care Unit, Ospedale San Paolo, Savona, Italy
| | | | - Paolo Trambaiolo
- Cardiology-ICU Department, Presidio Ospedaliero Sandro Pertini, Roma, Italy
| | - Tullio Usmiani
- Division of Cardiology, Presidio Molinette, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania, Italy.,Fondazione per il Tuo cuore-Heart Care Foundation, Firenze, Italy
| | - Domenico Gabrielli
- Cardiology Unit, Cardiotoracovascular Department, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
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10
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Shi Y, Wang Y, Sun X, Tang Y, Jiang M, Bai Y, Liu S, Jiang W, Yuan H, Lu Y, Cai J. Effects of mechanical circulatory support devices in patients with acute myocardial infarction undergoing stent implantation: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2021; 11:e044072. [PMID: 34187815 PMCID: PMC8245450 DOI: 10.1136/bmjopen-2020-044072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The survival benefit of using mechanical circulatory support (MCS) in patients with acute myocardial infarction (AMI) is still controversial. It is necessary to explore the impact on clinical outcomes of MCS in patients with AMI undergoing stenting. DESIGN Systematic review and meta-analysis. DATA SOURCES Embase, Cochrane Library, Medline, PubMed, Web of Science, ClinicalTrials.gov and Clinicaltrialsregister.eu databases were searched from database inception to February 2021. ELIGIBILITY CRITERIA Randomised clinical trials (RCTs) on MCS use in patients with AMI undergoing stent implantation were included. DATA EXTRACTION AND SYNTHESIS Data were extracted and summarised independently by two reviewers. Risk ratios (RRs) and 95% CIs were calculated for clinical outcomes according to random-effects model. RESULTS Twelve studies of 1497 patients with AMI were included, nine studies including 1382 patients compared MCS with non-MCS, and three studies including 115 patients compared percutaneous ventricular assist devices (pVADs) versus intra-aortic balloon pump (IABP). Compared with non-MCS, MCS was not associated with short-term (within 30 days) (RR=0.90; 95% CI 0.57 to 1.41; I2=46.8%) and long-term (at least 6 months) (RR=0.82; 95% CI 0.57 to 1.17; I2=37.6%) mortality reductions. In the subset of patients without cardiogenic shock (CS) compared with non-MCS, the patients with IABP treatment significantly had decreased long-term mortality (RR=0.49; 95% CI 0.27 to 0.90; I2=0), but without the short-term mortality reductions (RR=0.51; 95% CI 0.22 to 1.19; I2=17.9%). While in the patients with CS, the patients with MCS did not benefit from the short-term (RR=1.09; 95% CI 0.67 to 1.79; I2=46.6%) or long-term (RR=1.00; 95% CI 0.75 to 1.33; I2=22.1%) survival. Moreover, the application of pVADs increased risk of bleeding (RR=1.86; 95% CI 1.15 to 3.00; I2=15.3%) compared with IABP treatment (RR=1.86; 95% CI 1.15 to 3.00; I2=15.3%). CONCLUSIONS In all patients with AMI undergoing stent implantation, the MCS use does not reduce all-cause mortality. Patients without CS can benefit from MCS regarding long-term survival, while patients with CS seem not.
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Affiliation(s)
- Yunmin Shi
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yujie Wang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xuejing Sun
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yan Tang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mengqing Jiang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuanyuan Bai
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Suzhen Liu
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Weihong Jiang
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hong Yuan
- Clinical Research Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yao Lu
- Clinical Research Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jingjing Cai
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Clinical Research Center, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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11
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Chieffo A, Dudek D, Hassager C, Combes A, Gramegna M, Halvorsen S, Huber K, Kunadian V, Maly J, Møller JE, Pappalardo F, Tarantini G, Tavazzi G, Thiele H, Vandenbriele C, van Mieghem N, Vranckx P, Werner N, Price S. Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:570-583. [PMID: 34057173 DOI: 10.1093/ehjacc/zuab015] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/11/2021] [Indexed: 11/12/2022]
Abstract
There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland and Maria Cecilia Hospital GVM, Cotignola, Ravenna, Italy
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, and Department of Medical Intensive Care Unit, Cardiology Institute, Pitieé Salpeêtrieère Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, F-75013 Paris, France
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, and Sigmund Freud University, Medical School, Freudplatz 3, A-1020 Vienna, Austria
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Jiri Maly
- Cardiac Center, IKEM Prague, Videnska 1958/9, 14021 Prague 4, Czech Republic
| | - Jacob Eifer Møller
- Department of Cardiology, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Via Ernesto Triconi 5, 94100 Palermo, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Unit of Anaesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Struempellstr 30, 04289 Leipzig, Germany
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.,Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
| | - Nicolas van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium, and Faculty of Medicine and Life Sciences University of Hasselt Martelarenplein 42, 3500 Hasselt, Belgium
| | - Nikos Werner
- Heart Center Trier, Department of Internal Medicine III, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292 Trier, Germany
| | - Susanna Price
- Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
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12
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Kimman JR, Van Mieghem NM, Endeman H, Brugts JJ, Constantinescu AA, Manintveld OC, Dubois EA, den Uil CA. Mechanical Support in Early Cardiogenic Shock: What Is the Role of Intra-aortic Balloon Counterpulsation? Curr Heart Fail Rep 2021; 17:247-260. [PMID: 32870448 PMCID: PMC7496039 DOI: 10.1007/s11897-020-00480-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purpose of Review We aim to summarize recent insights and provide an up-to-date overview on the role of intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS). Recent Findings In the largest randomized controlled trial (RCT) of patients with CS after acute myocardial infarction (AMICS), IABP did not lower mortality. However, recent data suggest a role for IABP in patients who have persistent ischemia after revascularization. Moreover, in the growing population of CS not caused by acute coronary syndrome (ACS), multiple retrospective studies and one small RCT report on significant hemodynamic improvement following (early) initiation of IABP support, which allowed bridging of most patients to recovery or definitive therapies like heart transplant or a left ventricular assist device (LVAD). Summary Routine use of IABP in patients with AMICS is not recommended, but many patients with CS either from ischemic or non-ischemic cause may benefit from IABP at least for hemodynamic improvement in the short term. There is a need for a larger RCT regarding the role of IABP in selected patients with ACS, as well as in patients with non-ACS CS.
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Affiliation(s)
- Jesse R Kimman
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Alina A Constantinescu
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Eric A Dubois
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Corstiaan A den Uil
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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13
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Werdan K, Buerke M, Geppert A, Thiele H, Zwissler B, Ruß M. Infarction-Related Cardiogenic Shock- Diagnosis, Monitoring and Therapy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:88-95. [PMID: 33827749 DOI: 10.3238/arztebl.m2021.0012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 08/26/2020] [Accepted: 10/27/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The second edition of the German-Austrian S3 guideline contains updated evidence-based recommendations for the treatment of patients with infarction-related cardiogenic shock (ICS), whose mortality is several times higher than that of patients with a hemodynamically stable myocardial infarction (1). METHODS In five consensus conferences, the experts developed 95 recommendations-including two statements-and seven algorithms with concrete instructions. RESULTS Recanalization of the coronary vessel whose occlusion led to the infarction is crucial for the survival of patients with ICS. The recommended method of choice is primary percutaneous coronary intervention (pPCI) with the implantation of a drug-eluting stent (DES). If multiple coronary vessels are diseased, only the infarct artery (the "culprit lesion") should be stented at first. For cardiovascular pharmacotherapy-primarily with dobutamine and norepinephrine-the recommended hemodynamic target range for mean arterial blood pressure is 65-75 mmHg, with a cardiac index (CI) above 2.2 L/min/m2. For optimal treatment in intensive care, recommendations are given regarding the type of ventilation (invasive rather than non-invasive, lungprotective), nutrition (no nutritional intake in uncontrolled shock, no glutamine supplementation), thromboembolism prophylaxis (intravenous heparin rather than subcutaneous prophylaxis), und further topics. In case of pump failure, an intra-aortic balloon pump is not recommended; temporary mechanical support systems (Impella pumps, veno-arterial extracorporeal membrane oxygenation [VA-ECMO], and others) are hemodynamically more effective, but have not yet been convincingly shown to improve survival. CONCLUSION Combined cardiological and intensive-care treatment is crucial for the survival of patients with ICS. Coronary treatment for ICS seems to have little potential for further improvement, while intensive-care methods can still be optimized.
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Affiliation(s)
- Karl Werdan
- * Guideline group see eBox 1; Department of Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany; Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany; Department of Cardiology, Clinic Ottakring, Vienna Healthcare Group, Vienna, Austria; Department of Cardiology, University of Leipzig, Heart Center Leipzig, Leipzig, Germany; Department of Anesthesiology, University Hospital, LMU, Munich, Germany; Internists at the Maxplatz, Traunstein/Affiliate Cardiology Traunstein, Traunstein, Germany
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14
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Grant JK, Vincent L, Ebner B, Singh H, Maning J, Olorunfemi O, Olarte NI, Zablah G, Zaw K, Colombo R. In-Hospital Utilization and Outcomes of Palliative Care Consultation in Patients With Advanced Heart Failure Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support. Am J Cardiol 2021; 148:94-101. [PMID: 33684373 DOI: 10.1016/j.amjcard.2021.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/13/2021] [Accepted: 02/23/2021] [Indexed: 11/19/2022]
Abstract
Prior studies have shown that the early inclusion of palliative care (PC) specialist is associated with better end-of-life experiences. The National Inpatient Sample Database was queried from 2012 to 2017 for relevant of ICD)-9 and -10 procedural and diagnostic codes to identify patients above 18 years with advanced heart failure (HF) admitted with cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Baseline characteristics, utilization trends and invasive procedures and complications were compared among patients evaluated by PC and those who were not. There were 65,230 patients hospitalized for advanced HF complicated by CS requiring MCS, of these a PC consult was placed in in 9,200 patients (14.1%) and trended upward from 9.4 to 16.8%, between 2012 to 2017. The majority of patients, (37.3%) from the total population died in hospital. In reference to patients who were discharged alive, PC consultation was associated with a lower incidence of invasive procedures such as mechanical ventilation, pacemaker implantation, defibrillator implantation, insertion of percutaneous feeding tubes and tracheostomies performed (p <0.05 for all) whereas complications such as major bleeding, septic shock, transfusion of any blood product were comparable between both cohorts (nonsignificant p value for all). On the other hand, in those patients who died in hospital PC was associated with a lower incidence of pacemaker implantation, defibrillator implantation and insertion of percutaneous feeding tubes (p <0.05 for all). Despite the high morbidity and mortality associated with advanced HF patients with CS requiring MCS, the overall prevalence of PC consultation is exceedingly low. When utilized, the incidence of invasive procedures was lower. This study highlights the underutilization of PC services in this patient population, precluding any perceived benefit in end-of-life experiences.
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Affiliation(s)
- Jelani K Grant
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America.
| | - Louis Vincent
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Bertrand Ebner
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Harjit Singh
- University of Miami Leonard M. Miller School of Medicine, Miami/Florida/United States Of America
| | - Jennifer Maning
- Department of Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Odunayo Olorunfemi
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Neal I Olarte
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Gerardo Zablah
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
| | - Khin Zaw
- Palliative Care and Hospice Division, University of Miami Leonard M. Miller School of Medicine/Jackson Memorial Hospital/Bruce W. Carter Miami Veterans Affair Medical Center, Miami/Florida/United States Of America
| | - Rosario Colombo
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami/Florida/United States Of America
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15
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Suleiman T, Scott A, Tong D, Khanna V, Kunadian V. Contemporary device management of cardiogenic shock following acute myocardial infarction. Heart Fail Rev 2021; 27:915-925. [PMID: 33655387 DOI: 10.1007/s10741-021-10088-8] [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] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
Despite advances in the overall management of acute myocardial infarction (AMI), cardiogenic shock in the setting of AMI (CS-AMI) continues to be associated with poor patient outcomes. There are multiple devices that can be used in CS-AMI to support the failing circulation, although their utility in improving outcomes as compared with conventional pharmacotherapy of vasopressors and inotropes remains to be established. This contemporary review provides an update on the evidence base for each of these techniques. In CS-AMI, acute thrombotic occlusion of a major epicardial artery leads to hypoxia and myocardial ischaemia in the territory subtended by that vessel. The resultant regional dysfunction in myocardial contractility can severely compromise stroke volume and result in acute circulatory failure, systemic hypoperfusion, lactic acidosis, multi-organ failure and ultimately death.
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Affiliation(s)
- Tariq Suleiman
- Department of Respiratory Medicine, Royal Sussex County Hospital, Brighton & Sussex University Hospitals NHS Foundation Trust, Brighton, UK.
| | - Alexander Scott
- Department of Anaesthesia and Intensive Care Medicine, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - David Tong
- PG Diploma Clinical Trials, Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK
| | - Vikram Khanna
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vijay Kunadian
- PG Diploma Clinical Trials, Faculty of Medical Sciences, Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne, NE2 4HH, UK. .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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16
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Dhruva SS, Ross JS, Mortazavi BJ, Hurley NC, Krumholz HM, Curtis JP, Berkowitz AP, Masoudi FA, Messenger JC, Parzynski CS, Ngufor CG, Girotra S, Amin AP, Shah ND, Desai NR. Use of Mechanical Circulatory Support Devices Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock. JAMA Netw Open 2021; 4:e2037748. [PMID: 33616664 PMCID: PMC7900859 DOI: 10.1001/jamanetworkopen.2020.37748] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Mechanical circulatory support (MCS) devices, including intravascular microaxial left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs), are used in patients who undergo percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock despite limited evidence of their clinical benefit. OBJECTIVE To examine trends in the use of MCS devices among patients who underwent PCI for AMI with cardiogenic shock, hospital-level use variation, and factors associated with use. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the CathPCI and Chest Pain-MI Registries of the American College of Cardiology National Cardiovascular Data Registry. Patients who underwent PCI for AMI complicated by cardiogenic shock between October 1, 2015, and December 31, 2017, were identified from both registries. Data were analyzed from October 2018 to August 2020. EXPOSURES Therapies to provide hemodynamic support were categorized as intravascular microaxial LVAD, IABP, TandemHeart, extracorporeal membrane oxygenation, LVAD, other devices, combined IABP and intravascular microaxial LVAD, combined IABP and other device (defined as TandemHeart, extracorporeal membrane oxygenation, LVAD, or another MCS device), or medical therapy only. MAIN OUTCOMES AND MEASURES Use of MCS devices overall and specific MCS devices, including intravascular microaxial LVAD, at both patient and hospital levels and variables associated with use. RESULTS Among the 28 304 patients included in the study, the mean (SD) age was 65.4 (12.6) years and 18 968 were men (67.0%). The overall MCS device use was constant from the fourth quarter of 2015 to the fourth quarter of 2017, although use of intravascular microaxial LVADs significantly increased (from 4.1% to 9.8%; P < .001), whereas use of IABPs significantly decreased (from 34.8% to 30.0%; P < .001). A significant hospital-level variation in MCS device use was found. The median (interquartile range [IQR]) proportion of patients who received MCS devices was 42% (30%-54%), and the median proportion of patients who received intravascular microaxial LVADs was 1% (0%-10%). In multivariable analyses, cardiac arrest at first medical contact or during hospitalization (odds ratio [OR], 1.82; 95% CI, 1.58-2.09) and severe left main and/or proximal left anterior descending coronary artery stenosis (OR, 1.36; 95% CI, 1.20-1.54) were patient characteristics that were associated with higher odds of receiving intravascular microaxial LVADs only compared with IABPs only. CONCLUSIONS AND RELEVANCE This study found that, among patients who underwent PCI for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial LVAD use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use. These trends were observed despite limited clinical trial evidence of improved outcomes associated with device use.
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Affiliation(s)
- Sanket S. Dhruva
- University of California, San Francisco School of Medicine, San Francisco
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Bobak J. Mortazavi
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Computer Science and Engineering, Texas A&M University, College Station
- Center for Remote Health Technologies and Systems, Texas A&M University, College Station
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nathan C. Hurley
- Department of Computer Science and Engineering, Texas A&M University, College Station
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alyssa P. Berkowitz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Frederick A. Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - John C. Messenger
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Craig S. Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Che G. Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Digital Health Sciences, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Saket Girotra
- Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
| | - Amit P. Amin
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy Research, Mayo Clinic, Rochester, Minnesota
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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17
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Szlapka M, Hetzer R, Ennker J, Hausmann H. Conventional cardiac surgery in patients with end-stage coronary artery disease: yesterday and today. Cardiovasc Diagn Ther 2021; 11:202-212. [PMID: 33708493 DOI: 10.21037/cdt-20-284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Surgical therapy of combined coronary artery disease (CAD) and heart failure, also referred to as end-stage CAD, has evolved throughout the years and patients are currently being offered traditional coronary artery bypass grafting (CABG), with or without surgical ventricle restoration (SVR), interventions for ischemic mitral valve regurgitation, heart transplantation or implantation of mechanical cardiovascular support systems. Among surgical methods, operative myocardial revascularization (with or without ventricle restoration) is still playing an important role, aiming at restoration of proper myocardial perfusion, especially if heart muscle viability is present. Facing the donor shortage, CABG may constitute a valuable alternative to transplantation in selected patients. In individuals considered not suitable for surgical revascularization, implantation of mechanical circulatory support (MCS) not only appears as a salvage procedure, but also allows for reevaluation of future therapy directions. This article aims at providing an overview of evolving and current surgical practices in patients with end-stage CAD.
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Affiliation(s)
- Michal Szlapka
- Department of Cardiac and Vascular Surgery, MediClin Heart Center Coswig, Coswig, Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Immanuel Cardio Centrum Berlin, Berlin, Germany
| | - Jürgen Ennker
- Department of Cardiac and Vascular Surgery, Heart Center Niederrhein, Krefeld, Germany
| | - Harald Hausmann
- Department of Cardiac and Vascular Surgery, MediClin Heart Center Coswig, Coswig, Germany
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18
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Moghaddam N, van Diepen S, So D, Lawler PR, Fordyce CB. Cardiogenic shock teams and centres: a contemporary review of multidisciplinary care for cardiogenic shock. ESC Heart Fail 2021; 8:988-998. [PMID: 33452763 PMCID: PMC8006679 DOI: 10.1002/ehf2.13180] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/16/2020] [Accepted: 12/03/2020] [Indexed: 12/14/2022] Open
Abstract
Cardiogenic shock (CS) portends high morbidity and mortality in the contemporary era. Despite advances in temporary mechanical circulatory supports (MCS), their routine use in CS to improve outcomes has not been established. Delays in diagnosis and timely delivery of care, disparities in accessing adjunct therapies such revascularization or MCS, and lack of a systematic approach to care of CS contribute to the poor outcomes observed in CS patients. There is growing interest for developing a standardized multidisciplinary team-based approach in the management of CS. Recent prospective studies have shown feasibility of CS teams in improving survival across a spectrum of CS presentations. Herein, we will review the rationale for CS teams focusing on evidence supporting its use in streamlining care, optimizing revascularization strategies, and patient identification and MCS selection. The proposed structure and flow of CS teams will be outlined. An in-depth analysis of four recent studies demonstrating improved outcomes with CS teams is presented. Finally, we will explore potential implementation hurdles and future directions in refining and widespread implementation of dedicated cross-specialty CS teams.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.,Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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19
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Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther 2020; 5:287. [PMID: 33303763 PMCID: PMC7730152 DOI: 10.1038/s41392-020-00360-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/15/2022] Open
Abstract
Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.
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Affiliation(s)
- Weijian Hang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - John M Seubert
- Faculty of Pharmacy and Pharmaceutical Sciences University of Alberta, Edmonton, Alberta, T6G 2E1, Canada.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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20
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McCARTHY C, Spray D, Zilhani G, Fletcher N. Perioperative care in cardiac surgery. Minerva Anestesiol 2020; 87:591-603. [PMID: 33174405 DOI: 10.23736/s0375-9393.20.14690-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.
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Affiliation(s)
| | | | | | - Nick Fletcher
- St Georges University Hospitals, London, UK.,Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, UK
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21
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Liu Y, Li CP, Lu PJ, Wang XY, Xiao JY, Gao MD, Wang JX, Li XW, Zhang N, Li CJ, Ma J, Gao J. Percutaneous coronary intervention assisted by invasive mechanical ventilation and intra-aortic balloon pump for acute myocardial infarction with cardiogenic shock: Retrospective cohort study and meta-analyses. Bosn J Basic Med Sci 2020; 20:514-523. [PMID: 31782697 PMCID: PMC7664793 DOI: 10.17305/bjbms.2019.4500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/26/2019] [Indexed: 12/22/2022] Open
Abstract
There is little evidence to recommend the optimal invasive mechanical ventilation (IMV) modes and ideal positive end-expiratory pressure stress levels for acute myocardial infarction-cardiogenic shock (AMI-CS) patients. The aim of this study was to compare the mortality outcome in patients with AMI-CS who were treated with percutaneous coronary intervention (PCI) assisted by intra-aortic balloon pump (IABP) + IMV with historical controls. From January 1, 2016 to June 1, 2017, 60 patients were retrospectively enrolled at Tianjin Chest Hospital. Out of these, 88.3% of patients achieved thrombolysis in myocardial infarction (TIMI) flow 3 after PCI. The all-cause mortality rate in-hospital and at 1 year was 25% (95% CI: 0.14–0.36) and 33.9% (0.22–0.46), respectively. A systematic review followed by meta-analysis was performed with four historical studies of patients treated by PCI + IMV with partial IABP, which found an in-hospital mortality rate of 66.0% (95% CI: 0.62–0.71). Recently, a meta-analysis of patients receiving PCI + IABP with partial IMV showed that the 1 year mortality rate was 52.2% (95% CI: 0.47–0.58). In Cox regression analysis of patient data from the current study, lactic acid level ≥4.5 mmol/L, hyperuricemia, and TIMI flow <3 were independent predictors of death at 1 year. All-cause mortality, in-hospital and at 1 year, in patients with AMI-CS treated with PCI + IABP and IMV was lower than in those treated with PCI + partial IABP or IMV. Larger, longer-term direct comparisons are warranted.
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Affiliation(s)
- Yin Liu
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Chang-Ping Li
- Tianjin Medical University, Heping District, Tianjin, China
| | - Peng-Ju Lu
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Xu-Ying Wang
- Department of Prevention, Tianjin Children's Hospital, Beichen District, Tianjin, China
| | - Jian-Yong Xiao
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Ming-Dong Gao
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Ji-Xiang Wang
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Xiao-Wei Li
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Nan Zhang
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Chun-Jie Li
- Department of Cardiology, Tianjin Chest Hospital, Jinnan District, Tianjin, China
| | - Jun Ma
- Tianjin Medical University, Heping District, Tianjin, China
| | - Jing Gao
- Cardiovascular Institute, Tianjin Chest Hospital, Jinnan District, Tianjin, China
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Extracorporeal Membrane Oxygenation during Percutaneous Coronary Intervention in Patients with Coronary Heart Disease. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:196-202. [PMID: 32981957 DOI: 10.1182/ject-1900039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/16/2020] [Indexed: 12/23/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has become an effective method in the treatment of adults and children with severe cardiac and pulmonary dysfunction that is resistant to conventional therapy. The aim of this article was to summarize an experience of ECMO usage for cardiac dysfunction, which develops in patients with coronary heart disease (CHD) during percutaneous transluminal coronary angioplasty. The study comprised a retrospective, single-center analysis of 23 patients with CHD (19 men and four women, average age 65.7 ± 12.3 years), who undertook the ECMO technique during percutaneous transluminal coronary angioplasty. A total of 13 (56.52%) patients died directly in the hospital, or 30 days after a discharge. Independent predictors of fatal outcomes were diabetes mellitus (odds ratio [OR] = 17.58; 95% confidence interval [CI] = 6.47-47.48; p = .00125), chronic renal failure (CRF) (OR = 20.81; 95% CI = 5.95-72.21; p = .00014), and damage to the right coronary artery (RCA) (OR = 25.51; 95% CI = 8.27-79.12; p = .00013). For deceased patients, the "no reflow" phenomenon was indicated in a larger percentage of cases (23.1% in the group of deceased, vs. 10% in the group of survivors). A routine connection to ECMO before the occurrence of cardiac events was significantly more often used in the group of survived patients (90% of cases) than in the deceased (p = .0000001). Diabetes mellitus, CRF, and damage to the RCA were independent predictors of mortality during percutaneous transluminal coronary angioplasty in patients with CHD. The routine use of ECMO in high-risk patients with percutaneous transluminal coronary angioplasty was a positive prognostic factor of patient survival.
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Afana M, Altawil M, Basir M, Alqarqaz M, Alaswad K, Eng M, O'Neill WW, Lederman RJ, Greenbaum AB. Transcaval access for the emergency delivery of 5.0 liters per minute mechanical circulatory support in cardiogenic shock. Catheter Cardiovasc Interv 2020; 97:555-564. [PMID: 32902101 DOI: 10.1002/ccd.29235] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/02/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The purpose of this study was to describe the feasibility and early outcomes of transcaval access for delivery of emergency mechanical circulatory support (MCS) in cardiogenic shock. BACKGROUND Vascular access for implantation of MCS in patients with cardiogenic shock is often challenging due to peripheral arterial disease and vasoconstriction. Transcaval delivery of MCS may be an alternative. We describe a series of patients we implanted an Impella 5.0 device, on-table without CT planning, through a percutaneous transcaval access route. METHODS Ten patients with progressive or refractory cardiogenic shock underwent Impella 5.0 implantation via transcaval access. Demographic, clinical and procedural variables and in-hospital outcomes were collected. RESULTS All ten underwent emergency implantation of the 7 mm diameter Impella 5.0 device via transcaval access. Six were women, with median age of 55.5 years (range, 29-69). Cardiogenic shock was attributed to idiopathic nonischemic cardiomyopathy (n = 4), myocarditis (n = 2), ischemic cardiomyopathy (n = 2), heart transplant rejection (n = 1), and unknown etiology (n = 1). Median duration of support was 92.1 hr (range, 21.2-165.4). Seven (70%) survived to device explant, with six (60%) surviving to access port closure and discharge. Among survivors, five recovered heart function and one received destination therapy left ventricular assist device. CONCLUSIONS Transcaval access is feasible for emergency nonsurgical implantation of the Impella 5.0 device in cardiogenic shock with small or diseased iliofemoral arteries. This allows early institution of higher-flow MCS than conventional femoral artery implantation of the 3.5 L Impella CP device, and enables a bridge-to-recovery or bridge-to-destination strategy.
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Affiliation(s)
- Majed Afana
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Mahmoud Altawil
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Mir Basir
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Mohammad Alqarqaz
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Khaldoon Alaswad
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Marvin Eng
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA.,Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, USA
| | - William W O'Neill
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA.,Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, USA
| | - Robert J Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam B Greenbaum
- Structural Heart and Valve Center, Emory University, Atlanta, Georgia, USA
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Briasoulis A, Inampudi C, Hatzis G, Asleh R. Management of Patients with Heart Failure: Focus on New Pharmaceutical and Device Options. Curr Med Chem 2020; 27:4522-4535. [DOI: 10.2174/0929867326666190523083747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/06/2018] [Accepted: 02/19/2019] [Indexed: 01/14/2023]
Abstract
Hospitalization rates and survival of patients with Heart Failure (HF) have improved.
However, 5-year mortality rates remain high and the prevalence of the disease is rising likely due to
aging of the population and advances in diagnosis and treatment of other acute and chronic cardiovascular
diseases. Over the past three decades the therapeutic armamentarium of heart failure has improved
substantially with development of medications targeting neuro-hormonal activation and devices
preventing sudden cardiac death and improving cardiac synchrony. Recently, inhibition of angiotensin
receptors and neprilysin as well as sinoatrial pacemaker modulating f-current, have been
found safe and effective strategies that improve HF hospitalization rates and/or mortality. Antidiabetic
agents inhibiting sodium-glucose co-transporters 2, result in natriuresis and osmotic diuresis
and may further improve HF related outcomes. Furthermore, emerging therapies such as cardiac myosin
activators, soluble guanylate cyclase stimulators and non-steroidal mineralocorticoid receptor
antagonists are undergoing investigation in phase II and III studies of HF patients. Finally, rapid evolution
of in the management of advanced HF has occurred with the application of second and third
generation continuous flow left ventricular assist devices in clinical practice. Ongoing clinical studies
will validate the safety and efficacy of emerging therapeutic strategies in HF population underrepresented
in previous clinical trials.
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Affiliation(s)
- Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Chakradhari Inampudi
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Georgios Hatzis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN, United States
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25
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Lemor A, Gorgis S, Villablanca PA, Basir MB, Voeltz M, Alaswad K, O'Neill W. Regional Variation in Procedural and Clinical Outcomes Among Patients With ST Elevation Myocardial Infarction With Cardiogenic Shock. Am J Cardiol 2020; 125:1612-1618. [PMID: 32279842 DOI: 10.1016/j.amjcard.2020.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/23/2020] [Accepted: 02/27/2020] [Indexed: 11/16/2022]
Abstract
There is limited data on regional differences in patient characteristics, practice patterns, and clinical outcomes in patients with ST elevation myocardial infarction (STEMI) with cardiogenic shock (CS) in the United States (US). We aimed to identify variations in treatment methods and clinical outcomes in patients with STEMI CS between the 4 US regions. Using the National Inpatient Sample database, we identified adult patients admitted with STEMI associated with CS between 2006 and 2015 using ICD-9-DM codes. Based on the US regions (Northeast, Midwest, South, and West), we divided patients in 4 cohorts and compared baseline patient characteristics, clinical outcomes and procedural outcomes. A total of 186,316 patients with STEMI CS were included; 32,303 (17.3%) were hospitalized in the Northeast, 43,634 (23.4%) in the Midwest, 70,036 (37.8%) in the South, and 40,043 (21.5%) in the West. Although nonstatistically significant, the in-hospital mortality was higher in Northeast region (37.7%), followed by the South (36.6%), West (35.7%), and Midwest (35.2%). Rates of percutaneous coronary intervention were higher in the Midwest (68.5%) and lower in the Northeast (56%). The use of percutaneous ventricular assist device and ECMO was higher in the Northeast (3.3% and 2.2%) and lower in the West (2.1% and 0.4%). The median length of stay was similar among all 4 cohorts (6 days) but median hospital costs were higher in the West ($36, 614) and lower in the South ($28,795). In conclusion, there are significant geographic variations in practice patterns, healthcare cost, and in-hospital outcomes in patients with STEMI complicated by CS between 4 US regions.
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Affiliation(s)
- Alejandro Lemor
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan; Centro de Investigación de Epidemiología Clínica y Medicina Basada en la Evidencia, Facultad de Medicina, Universidad de San Martín de Porres, Lima, Peru.
| | - Sarah Gorgis
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | | | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Michele Voeltz
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | | | - William O'Neill
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
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26
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Fujino T, Imamura T, Kinugawa K. Future Perspectives of Intra-Aortic Balloon Pumping for Cardiogenic Shock. Int Heart J 2020; 61:424-428. [DOI: 10.1536/ihj.20-004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Takeo Fujino
- Department of Medicine, Section of Cardiology, University of Chicago Medicine
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27
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Gerbaud E, Elbaz M, Lattuca B. New insights into cardiogenic shock and coronary revascularization after acute myocardial infarction. Arch Cardiovasc Dis 2020; 113:276-284. [PMID: 32088156 DOI: 10.1016/j.acvd.2019.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
Cardiogenic shock complicating acute myocardial infarction is challenging, and continues to be associated with high rates of in-hospital and long-term mortality. Coronary revascularization is critical for improving prognosis in CS. Thus, a systematic protocol-driven approach to cardiogenic shock, the development of specialized cardiac care centres, technical advances in interventional cardiology enabling treatment of more complex and severe lesions, the availability of recent antithrombotic therapies and the evolution of new haemodynamic support devices are important considerations in current management of cardiogenic shock complicating acute ischaemic heart disease. Despite these potentially meaningful developments, several substantial gaps in knowledge still exist regarding optimal coronary revascularization of patients with cardiogenic shock. This review will describe current principles in the revascularization of these patients, with a focus on: the time to transfer and revascularize; the choice of vascular access site; the need for complete revascularization or only a culprit lesion strategy; the optimal antithrombotic therapy; the type, place and timing of haemodynamic support; and the medical care system network.
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Affiliation(s)
- Edouard Gerbaud
- Cardiology Intensive Care Unit and Interventional Cardiology, Hôpital Cardiologique du Haut Lévêque, 33600 Pessac, France; Bordeaux Cardio-Thoracic Research Centre, U1045, Bordeaux University, 33000 Bordeaux, France
| | - Meyer Elbaz
- Department of Cardiology, CARDIOMET Institute, Rangueil Medical School, University Paul Sabatier, 31059 Toulouse, France.
| | - Benoit Lattuca
- Cardiology Department, Caremeau University Hospital, ACTION Study Group, Montpellier University, 30029 Nîmes, France
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28
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Cui K, Lyu S, Liu H, Song X, Yuan F, Xu F, Zhang M, Zhang M, Wang W, Zhang D, Tian J, Yan Y, Zhou K, Chen L. Timing of initiation of intra-aortic balloon pump in patients with acute myocardial infarction complicated by cardiogenic shock: A meta-analysis. Clin Cardiol 2019; 42:1126-1134. [PMID: 31509267 PMCID: PMC6837021 DOI: 10.1002/clc.23264] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/06/2019] [Accepted: 09/04/2019] [Indexed: 01/11/2023] Open
Abstract
Background For patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) undergoing primary percutaneous coronary intervention (PCI), the optimal timing of the initiation of intra‐aortic balloon pump (IABP) therapy remains unclear. Therefore, we performed the first meta‐analysis to compare the outcomes of IABP insertion before vs after primary PCI in this population. Methods Electronic databases of PubMed, EMBASE, and Cochrane Library were comprehensively searched from inception to April 1, 2019, to identify the eligible studies. The main outcomes were short‐term (in‐hospital or 30 days) and long‐term (≥ 6 months) mortality. In addition, pooled analysis of risk‐adjusted data were also performed to control for confounding factors. Results Seven observational studies and two sub‐analysis of randomized controlled trials involving 1348 patients were included. Compared to patients inserted IABP after PCI, patients who received IABP therapy before primary PCI had similar risks of short‐term (odds ratio [OR] 0.88, 95% CI 0.49 to 1.59) and long‐term (OR 0.99, 95% CI 0.58 to 1.68) all‐cause mortality. Moreover, a pooled analysis of risk‐adjusted data also found similar effects of the two therapies on short‐term (OR 0.65, 95% CI 0.34 to 1.25) and long‐term (OR 0.68, 95% CI 0.17 to 2.72) mortality. Besides, no significant difference was found between the two groups with respect to reinfarction, repeat revascularization, stroke, renal failure, and major bleeding. Conclusions The timing of the initiation of IABP therapy does not appear to impact short‐term and long‐term survival in patients with AMI complicated by CS undergoing primary PCI.
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Affiliation(s)
- Kongyong Cui
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Shuzheng Lyu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Hong Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Fei Yuan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Feng Xu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Min Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Mingduo Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Dongfeng Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jinfan Tian
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yunfeng Yan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Kuo Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Lingxiao Chen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
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29
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferović PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. EUROINTERVENTION 2019; 14:1435-1534. [PMID: 30667361 DOI: 10.4244/eijy19m01_01] [Citation(s) in RCA: 300] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Franz-Josef Neumann
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Chinese society of cardiology expert consensus statement on the diagnosis and treatment of adult fulminant myocarditis. SCIENCE CHINA-LIFE SCIENCES 2018; 62:187-202. [PMID: 30519877 PMCID: PMC7102358 DOI: 10.1007/s11427-018-9385-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 08/02/2018] [Indexed: 01/02/2023]
Abstract
Fulminant myocarditis is primarily caused by infection with any number of a variety of viruses. It arises quickly, progresses rapidly, and may lead to severe heart failure or circulatory failure presenting as rapid-onset hypotension and cardiogenic shock, with mortality rates as high as 50%–70%. Most importantly, there are no treatment options, guidelines or an expert consensus statement. Here, we provide the first expert consensus, the Chinese Society of Cardiology Expert Consensus Statement on the Diagnosis and Treatment of Fulminant Myocarditis, based on data from our recent clinical trial (NCT03268642). In this statement, we describe the clinical features and diagnostic criteria of fulminant myocarditis, and importantly, for the first time, we describe a new treatment regimen termed life support-based comprehensive treatment regimen. The core content of this treatment regimen includes (i) mechanical life support (applications of mechanical respirators and circulatory support systems, including intraaortic balloon pump and extracorporeal membrane oxygenation, (ii) immunological modulation by using sufficient doses of glucocorticoid, immunoglobulin and (iii) antiviral reagents using neuraminidase inhibitor. The proper application of this treatment regimen may and has helped to save the lives of many patients with fulminant myocarditis.
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31
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Goins AE, Rayson R, Yeung M, Stouffer GA. The use of hemodynamics to predict mortality in patients undergoing primary PCI for ST-elevation myocardial infarction. Expert Rev Cardiovasc Ther 2018; 16:551-557. [DOI: 10.1080/14779072.2018.1497484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Allie E Goins
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Robert Rayson
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - Michael Yeung
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
| | - George A Stouffer
- Division of Cardiology and McAllister Heart Institute, University of North Carolina, Chapel Hill, NC, USA
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32
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[Infarct-related cardiogenic shock : Prognosis and treatment]. Med Klin Intensivmed Notfmed 2018; 113:267-276. [PMID: 29721682 DOI: 10.1007/s00063-018-0428-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
Abstract
Patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) experience cardiogenic shock in about 6-10% of cases during the hospital treatment. In recent years, the incidence seems to be decreasing due to invasive diagnostics and therapy after myocardial infarction. Early diagnosis is important to initiate immediate revascularization using percutaneous coronary intervention (PCI) with stent implantation as part of cardiogenic shock treatment. Thus, a significant improvement in survival can be achieved. Pharmacological and mechanical support is needed to maintain perfusion of the myocardium and organs. Drug therapy for infarct cardiogenic shock relies on dobutamine for inotropic agent and norepinephrine as a vasopressor. For further inotropic support, data on additional levosimendan treatment are available. The pharmacological therapy is supplemented by mechanical support systems such as Impella (ABIOMED, Danvers, MA, USA) or extracorporeal membrane oxygenation (ECMO). The intra-aortic balloon pump (IABP) is hardly used anymore. The majority of cardiogenic shock survivors have little functional cardiac impairment in the long term. This shows the transient damage component (stunning, inflammation), which underlines the need for a fast and effective cardiovascular supportive therapy.
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Hsu S, Kambhampati S, Sciortino CM, Russell SD, Schulman SP. Predictors of intra-aortic balloon pump hemodynamic failure in non-acute myocardial infarction cardiogenic shock. Am Heart J 2018; 199:181-191. [PMID: 29754660 DOI: 10.1016/j.ahj.2017.11.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/18/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To characterize patient profile and hemodynamic profile of those undergoing intra-aortic balloon pump (IABP) for cardiogenic shock and define predictors of hemodynamic failure of IABP support. BACKGROUND Clinical characteristics of IABP support in cardiogenic shock not related to acute myocardial infarction (AMI) remain poorly characterized. METHODS We retrospectively studied a cohort of 74 patients from 2010 to 2015 who underwent IABP insertion for cardiogenic shock complicating acute decompensated heart failure not due to AMI. RESULTS In the overall cohort, which consisted primarily of patients with chronic systolic heart failure (89%), IABP significantly augmented cardiac index and lowered systemic vascular resistance (P<.05). Despite this improvement, 28% of these patients died (24%) or require urgent escalation in mechanical circulatory support (MCS) (4%). Multivariable regression revealed that baseline left ventricular cardiac power index (LVCPI), a measure of LV power output derived from cardiac index and mean arterial pressure (P=.01), and history of ischemic cardiomyopathy (P=.003) were significantly associated with the composite adverse-event endpoint of death or urgent MCS escalation. An IABP Failure risk score using baseline LVCPI <0.28 W/m2 and ischemic history predicted 28-day adverse events with excellent discrimination. CONCLUSION Despite hemodynamic improvements with IABP support, patients with non-AMI cardiogenic shock still suffer poor outcomes. Patients with ischemic cardiomyopathy and low LVPCI fared significantly worse. These patients may warrant closer observation or earlier consideration of more advanced hemodynamic support.
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Abstract
Veno-arterial extracorporeal life support (VA-ECLS) provides circulatory and respiratory stabilisation in patients with severe refractory cardiogenic shock. Although randomised controlled trials are lacking, the use of VA-ECLS is increasing and observational studies repeatedly have shown treatment benefits in well-selected patients. Current clinical challenges in VA-ECLS relate to optimal management of the individual patient on extracorporeal support given its inherent complexity. In this review article we will discuss indications, daily clinical management and complications of VA-ECLS in cardiogenic shock refractory to conventional treatment strategies.
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Abstract
Cardiac transplantation is the gold standard treatment for patients with advanced congestive heart failure that is refractory to maximal medical therapy. However, donor heart availability remains the major limiting factor, resulting in a large number of patients waiting long periods of time before transplantation. As a result, mechanical circulatory support devices have been increasingly used as a 'bridge' in order to sustain organ function and stabilise haemodynamics while patients remain on the transplant waiting list or undergo left ventricular assist device surgery. Intra aortic balloon pumps (IABP) are commonly used for temporary circulatory support in patients with advanced heart failure. IABP is traditionally placed percutaneously through the transfemoral artery approach. The major limitation with this approach is ambulatory restriction that can promote deconditioning, particularly in situations of prolonged circulatory support. A subclavian/axillary artery approach IABP insertion allows patients to be ambulatory during the pre-transplant period. In this review, we aim to summarise the physiology of IABP, the evidence for its use in advanced CHF and the efficacy and safety of subclavian artery IABP insertion.
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Affiliation(s)
- Syed Yaseen Naqvi
- Department of Cardiology, Advanced Heart Transplant Program, University of Rochester Medical Center Rochester, USA
| | | | - Ayhan Yoruk
- Department of Cardiology, Advanced Heart Transplant Program, University of Rochester Medical Center Rochester, USA
| | - Leway Chen
- Department of Cardiology, Advanced Heart Transplant Program, University of Rochester Medical Center Rochester, USA
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Rathod KS, Koganti S, Iqbal MB, Jain AK, Kalra SS, Astroulakis Z, Lim P, Rakhit R, Dalby MC, Lockie T, Malik IS, Knight CJ, Whitbread M, Mathur A, Redwood S, MacCarthy PA, Sirker A, O’Mahony C, Wragg A, Jones DA. Contemporary trends in cardiogenic shock: Incidence, intra-aortic balloon pump utilisation and outcomes from the London Heart Attack Group. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:16-27. [DOI: 10.1177/2048872617741735] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: Cardiogenic shock remains a major cause of morbidity and mortality in patients with ST-segment elevation myocardial infarction. We aimed to assess the current trends in cardiogenic shock management, looking specifically at the incidence, use of intra-aortic balloon pump therapy and outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Methods and results: We undertook an observational cohort study of 21,210 ST-segment elevation myocardial infarction patients treated between 2005–2015 at the eight Heart Attack Centres in London, UK. Patients’ details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society percutaneous coronary intervention dataset. There were 1890 patients who presented with cardiogenic shock. The primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2–5.8 years). Increasing rates of cardiogenic shock were seen over the course of the study with consistently high mortality rates of 45–70%. A total of 685 patients underwent intra-aortic balloon pump insertion during primary percutaneous coronary intervention for cardiogenic shock with decreasing rates over time. Those patients undergoing intra-aortic balloon pump therapy were younger, more likely to have poor left ventricular function and less likely to have had previous percutaneous coronary intervention compared to the control group. Procedural success rates were similar (86.0% vs 87.1%, p=0.292) although crude, in-hospital major adverse cardiac event rates were higher (43.8% vs 33.7%, p<0.0001) in patients undergoing intra-aortic balloon pump therapy. Kaplan-Meier analysis demonstrated significantly higher mortality rates in patients receiving intra-aortic balloon pump therapy (50.9% intra-aortic balloon pump vs 39.9% control, p<0.0001) during the follow-up period. After multivariate Cox analysis (hazard ratio 1.04, 95% confidence interval 0.62–1.89) and the use of propensity matching (hazard ratio: 1.29, 95% confidence interval: 0.68–1.45) intra-aortic balloon pump therapy was not associated with mortality. Conclusion: Cardiogenic shock treated by percutaneous coronary intervention is increasing in incidence and remains a condition associated with high mortality and limited treatment options. Intra-aortic balloon pump therapy was not associated with a long-term survival benefit in this cohort and may be associated with increased early morbidity.
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Affiliation(s)
| | | | - M Bilal Iqbal
- Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, UK
| | | | - Sundeep S Kalra
- Kings College Hospital, King’s College Hospital NHS Foundation Trust, UK
| | - Zoe Astroulakis
- St George’s Healthcare NHS Foundation Trust, St George’s Hospital, UK
| | - Pitt Lim
- St George’s Healthcare NHS Foundation Trust, St George’s Hospital, UK
| | | | - Miles C Dalby
- Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, UK
| | - Tim Lockie
- Royal Free London NHS Foundation Trust, UK
| | - Iqbal S Malik
- Imperial College Healthcare NHS Foundation Trust, Hammersmith Hospital, UK
| | | | | | | | - Simon Redwood
- St Thomas’ NHS Foundation Trust, Guys and St Thomas Hospital, UK
| | - Philip A MacCarthy
- Kings College Hospital, King’s College Hospital NHS Foundation Trust, UK
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Lin HJ, Wang TD. Initiation of Intra-Aortic Balloon Counterpulsation before Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction and High-Risk Features Might be Beneficial: Questions Remain. ACTA CARDIOLOGICA SINICA 2017; 33:578-580. [PMID: 29167608 PMCID: PMC5694919 DOI: 10.6515/acs20170327a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Hung-Ju Lin
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tzung-Dau Wang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
OBJECTIVES To review temporary percutaneous mechanical circulatory support devices for the treatment of cardiogenic shock, including current evidence, contraindications, complications, and future directions. DATA SOURCES A MEDLINE search was conducted with MeSH terms: cardiogenic shock, percutaneous mechanical circulatory support, extracorporeal membrane oxygenation, Impella, and TandemHeart. STUDY SELECTION Selected publications included randomized controlled trial data and observational studies describing experience with percutaneous mechanical circulatory support in cardiogenic shock. DATA EXTRACTION Studies were chosen based on strength of association with and relevance to cardiogenic shock. DATA SYNTHESIS Until recently, there were few options if cardiogenic shock was refractory to vasopressors or intra-aortic balloon pump counterpulsation. Now, several percutaneous mechanical circulatory support devices, including Impella (Abiomed, Danvers, MA), TandemHeart (CardiacAssist, Pittsburgh, PA), and extracorporeal membrane oxygenation, are more accessible. Compared with intra-aortic balloon pump, Impella provides greater hemodynamic support but no reduction in mortality. Similarly, TandemHeart improves hemodynamic variables but not survival. Comparative studies have been underpowered for mortality because of small sample size. Veno-arterial extracorporeal membrane oxygenation offers the advantage of biventricular circulatory support and oxygenation, but there are significant vascular complications. Comparative studies with extracorporeal membrane oxygenation have not been completed. Despite lack of randomized controlled data, there has been a substantial increase in use of percutaneous mechanical circulatory support. Several ongoing prospective studies with larger sample sizes may provide answers, and newer devices may become smaller, easier to insert, and more effective. CONCLUSIONS Mortality from cardiogenic shock remains unacceptably high despite early coronary revascularization or other therapies. Although evidence is lacking and complications rates are high, improvements and experience with percutaneous mechanical circulatory support may offer the prospect of better outcomes.
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Hardy N, Starr N, Cosgrave J, Madhavan P. Intra-aortic balloon pump entrapment and surgical removal: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2017; 1:ytx002. [PMID: 31020061 PMCID: PMC6176874 DOI: 10.1093/ehjcr/ytx002] [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: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 11/28/2022]
Abstract
Intra-aortic balloon pump (IABP) use following myocardial infarction is now infrequent and reserved for cases of cardiogenic shock. As their use declines, so does our ability to promptly recognize and manage potential problems that may arise. A serious but rare complication of IABP insertion is balloon entrapment within the arterial tree. In this report, we share our experience of a case of balloon entrapment within the right common iliac artery and successful removal of the device via groin cut down under general anaesthesia.
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Affiliation(s)
- Niall Hardy
- Department of Vascular Medicine and Surgery, St James's Hospital, James's Street, Dublin 8, Ireland
| | - Neasa Starr
- Department of Cardiology. St James's Hospital, James's Street, Dublin 8, Ireland
| | - John Cosgrave
- Department of Cardiology. St James's Hospital, James's Street, Dublin 8, Ireland
| | - Prakash Madhavan
- Department of Vascular Medicine and Surgery, St James's Hospital, James's Street, Dublin 8, Ireland
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Unilateral Headache Status after Intra-Aortic Balloon Pump Placement. Case Rep Med 2017; 2017:5043471. [PMID: 28819361 PMCID: PMC5551466 DOI: 10.1155/2017/5043471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/02/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Intra-aortic balloon pump (IABP) counterpulsation is a catheter-based treatment for coronary artery disease and decompensated heart failure to increase coronary blood flow and improve cardiac output. IABP is generally well tolerated, and complications are usually related to peripheral vasculature or red blood cell and platelet consumption. The usual insertion site via femoral artery renders the patient bedbound. Recently, axillary artery has been used in patients with atherosclerotic peripheral vascular disease and documented small arteries or in those awaiting transplant to ensure ambulation and prevent deconditioning. Case Report We present a patient with ischemic cardiomyopathy and severe left ventricular dysfunction, awaiting Orthotropic Heart Transplant. His worsening intractable angina and dyspnea necessitated IABP placement via left axillary artery, significantly improving his condition. He subsequently experienced migraine-type persistent unilateral headache refractory to standard pain management. Multiple strategies were utilized to treat his pain, but the patient insisted that his pain commenced after IABP placement. Ultimately, the removal of the pump led to complete resolution with no recurrence. Conclusion The authors hypothesize that the unilaterally directed blood flow and direct increase in cerebral perfusion from the intra-aortic balloon pump may have caused vasodilation of the extracranial arteries, leading to a persistent and debilitating headache in this susceptible patient.
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Musa TA, Chue CD, Lim HS. Mechanical Circulatory Support for Decompensated Heart Failure. Curr Heart Fail Rep 2017; 14:365-375. [DOI: 10.1007/s11897-017-0349-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Trivella MG, Piersigilli A, Bernini F, Pelosi G, Burchielli S, Puzzuoli S, Kusmic C, L'Abbate A. Percutaneous cardiac support during myocardial infarction drastically reduces mortality: perspectives from a swine model. Int J Artif Organs 2017; 40:338-344. [PMID: 28604999 PMCID: PMC6159849 DOI: 10.5301/ijao.5000604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND/AIMS Acute myocardial infarction (AMI) with cardiogenic shock (CS) remains the leading cause of in-hospital death in acute coronary syndromes. In the AMI-CS pig model we tested the efficacy of temporary percutaneous cardiorespiratory assist device (PCRA) in rescuing the failing heart and reducing early mortality. METHODS In open-chest pigs we induced AMI by proximal left anterior descending coronary artery (LAD) ligation. Eight animals without PCRA (C group) were compared with 12 animals otherwise treated with PCRA (T group), starting approximately at 60 minutes post-occlusion and lasting 120-180 minutes. In 3 animals of the T group, regional myocardial oxygen content was also imaged by two-dimensional near infrared spectroscopy (2D-NIRS) with and without PCRA, before and after LAD reperfusion. RESULTS All animals without PCRA died despite unrelenting resuscitation maneuvers (120 minutes average survival time). Conversely, animals treated with PCRA showed a reduction in life-threatening arrhythmia and maintenance of aortic pressure, allowing interruption of PCRA in all cases early in the experiments, with sound hemodynamics at the end of the observation period. During LAD occlusion, NIRS showed severe de-oxygenation of the LAD territory that improved with PCRA. After PCRA suspension and LAD reperfusion, the residual de-oxygenated area proved to be smaller than the initial risk area. CONCLUSIONS In AMI, PCRA initiated during advanced CS drastically reduced early mortality from 100% to 0% in a 4-5 hour observation period. PCRA promoted oxygenation of the ischemic area during LAD occlusion. Results support the use of PCRA as first line of treatment in AMI-CS, improving myocardial rescue and short-term survival.
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Affiliation(s)
| | - Alessandra Piersigilli
- Weill Cornell Medicine, New York City, NY - USA
- />Prof. Alessandra Piersigilli and Dr. Stefano Puzzuoli participated in the study during their PhD at the Scuola Superiore Sant'Anna, Pisa - Italy
| | - Fabio Bernini
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa - Italy
| | | | | | - Stefano Puzzuoli
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa - Italy
- />Prof. Alessandra Piersigilli and Dr. Stefano Puzzuoli participated in the study during their PhD at the Scuola Superiore Sant'Anna, Pisa - Italy
| | | | - Antonio L'Abbate
- CNR Institute of Clinical Physiology, Pisa - Italy
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa - Italy
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43
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Affiliation(s)
- Sebastian Nuding
- Department of Medicine III, University Hospital Halle (Saale) of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Karl Werdan
- Department of Medicine III, University Hospital Halle (Saale) of the Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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Prondzinsky R, Werdan K. Extracorporeal life support during cardiac arrest and cardiogenic shock-how good is the evidence really? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:58. [PMID: 28251137 DOI: 10.21037/atm.2017.01.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Roland Prondzinsky
- Department of Medicine I, Carl-von-Basedow Hospital Merseburg, Merseburg, Germany
| | - Karl Werdan
- Department of Medicine III, University Hospital Halle (Saale) of the Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
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45
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Timóteo AT, Nogueira MA, Rosa SA, Belo A, Ferreira RC. Role of intra-aortic balloon pump counterpulsation in the treatment of acute myocardial infarction complicated by cardiogenic shock: Evidence from the Portuguese nationwide registry. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:23-31. [DOI: 10.1177/2048872615606600] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Ana T Timóteo
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Marta A Nogueira
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Silva A Rosa
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Adriana Belo
- National Centre for Data Collection in Cardiology, Portuguese Society of Cardiology, Coimbra, Portugal
| | - Rui C Ferreira
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
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Parissis H, Graham V, Lampridis S, Lau M, Hooks G, Mhandu PC. IABP: history-evolution-pathophysiology-indications: what we need to know. J Cardiothorac Surg 2016; 11:122. [PMID: 27487772 PMCID: PMC4972967 DOI: 10.1186/s13019-016-0513-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 07/27/2016] [Indexed: 11/18/2022] Open
Abstract
Treatment with the intraaortic balloon pump (IABP) is the most common form of mechanical support for the failing heart. Augmentation of diastolic pressure during balloon inflation contributes to the coronary circulation and the presystolic deflation of the balloon reduces the resistance to systolic output. Consequently, the myocardial work is reduced. The overall effect of the IABP therapy is an increase in the myocardial oxygen supply/demand ratio and thus in endocardial viability. This is an overall synopsis of what we need to know regarding IABP. Furthermore, this review article attempts to systematically delineate the pathophysiology linked with the hemodynamic consequences of IABP therapy. The authors also look at the future of the use of the balloon pump and conclude that the positive multi-systemic hemodynamic regulation during IABP treatment should further justify its use.
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Affiliation(s)
- H Parissis
- Cardiothoracics Department, Royal Victoria Hospital, Belfast, Northern Ireland
| | - V Graham
- Cardiothoracics Department, Royal Victoria Hospital, Belfast, Northern Ireland.
| | - S Lampridis
- Cardiothoracics Department, Royal Victoria Hospital, Belfast, Northern Ireland
| | - M Lau
- Cardiothoracics Department, Royal Victoria Hospital, Belfast, Northern Ireland
| | - G Hooks
- Cardiothoracics Department, Royal Victoria Hospital, Belfast, Northern Ireland
| | - P C Mhandu
- Cardiothoracics Department, Royal Victoria Hospital, Belfast, Northern Ireland
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Zhang H, Hu X, Wu Q, Shi B. Impact of diabetes on bleeding events in ST-elevation myocardial infarction patients after urgent percutaneous coronary intervention: A retrospective cohort study. Medicine (Baltimore) 2016; 95:e4470. [PMID: 27537568 PMCID: PMC5370795 DOI: 10.1097/md.0000000000004470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with diabetes mellitus (DM) have more ischemic events and a decreased survival rate after percutaneous coronary intervention (PCI) than non-DM patients. However, it is unknown whether short-term or long-term bleeding events are associated with DM. We aimed to determine the impact of DM on mortality and bleeding events in ST-elevation myocardial infarction (STEMI) patients after urgent PCI.This retrospective cohort study included 435 STEMI patients who had undergone urgent PCI between 2010 and 2013, comprising 97 DM patients and 338 non-DM patients. The primary outcomes were the 30-day bleeding and 30-day mortality rates. The median follow-up period was 2 years. Data regarding patient demographics, peri-PCI medication, and invasive procedures were compared between DM and non-DM patients. Multivariate logistic regression was applied to estimate the association between DM and bleeding events. Kaplan-Meier curves were calculated to elucidate the survival rate.Compared with non-DM patients, DM patients with STEMI had a higher incidence of left ventricular ejection fraction <40% (17.6% vs 4.2%, P < 0.05), Killip class >II (11.3% vs 3.8%, P < 0.05), and smoking (44.3% vs 63.0%, P < 0.05). Similar peri-PCI medication and invasive procedures were administered in the 2 groups. The incidence of 30-day bleeding events was significantly higher for DM patients than non-DM patients (6.2% vs 0.9%, P < 0.05). A multivariate analysis showed that DM was strongly associated with 30-day bleeding events after adjusting for confounders. DM patients had significant increased mortality rates at both the 30-day and 2-year end points.DM was an independent predictor for an increased risk of 30-day bleeding events and correlated with increased 30-day and 2-year mortality rates in STEMI patients with PCI. Our study has significant clinical implications for risk stratification before the application of urgent PCI.
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Affiliation(s)
- Huairong Zhang
- Department of Endocrinology, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Xiaowen Hu
- Division of Endocrinology and Metabolism, McGill University Health Center, Montreal General Hospital, Montreal, PQ, Canada
- Correspondence: Bingyin Shi, Department of Endocrinology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China (e-mail: ); Xiaowen Hu, Division of Endocrinology and Metabolism, McGIll University Health Center, Montreal General Hospital, 1650 avenue Cedar, room C6.240, Montreal, PQ, Canada H3G 1A4 (e-mail: )
| | - Qian Wu
- School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi, China
| | - Bingyin Shi
- Department of Endocrinology, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an Jiaotong University, Xi’an, Shaanxi, China
- Correspondence: Bingyin Shi, Department of Endocrinology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China (e-mail: ); Xiaowen Hu, Division of Endocrinology and Metabolism, McGIll University Health Center, Montreal General Hospital, 1650 avenue Cedar, room C6.240, Montreal, PQ, Canada H3G 1A4 (e-mail: )
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Zheng XY, Wang Y, Chen Y, Wang X, Chen L, Li J, Zheng ZG. The effectiveness of intra-aortic balloon pump for myocardial infarction in patients with or without cardiogenic shock: a meta-analysis and systematic review. BMC Cardiovasc Disord 2016; 16:148. [PMID: 27391391 PMCID: PMC4939027 DOI: 10.1186/s12872-016-0323-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/24/2016] [Indexed: 12/03/2022] Open
Abstract
Background Conflicting reports on the efficacy of intra-aortic balloon pump (IABP) during percutaneous coronary intervention (PCI) incited us to evaluate the utility of IABP in patients with acute myocardial infarction (AMI). Methods Randomized clinical trials comparing patients, who received IABP vs. control (no IABP) during PCI, were hand-searched from MEDLINE, Cochrane, and EMBASE databases using the terms “intra-aortic balloon pump, percutaneous coronary intervention, myocardial infarction, acute coronary syndrome”. Mortality rate (30-day and 6-month mortality) was the primary outcome, while the secondary outcomes included 30-day bleeding rate, reinfarction rate, revascularization rate and stroke rate. Results Pooled results of the seven trials identified indicated that the 30-day and 6-month mortality rate were not significantly different between the IABP and control groups. However, in patients with MI, but without cardiogenic shock (CS), IABP was associated with lower odds of 30-day mortality (OR = 0.35, p = 0.015) and 6-month mortality (OR = 0.41, p = 0.020). The pooled results of 30-day bleeding rate was not significantly higher in patients with IABP than the control group, but for the patients with high risk PCI without CS, it was higher in patients with IABP than the control group (OR = 1.58, p = 0.009). The re-infarction, revascularization, and the stroke rate at 30 days of follow-up were not significantly different between the two groups. Conclusions The present results do not favor the clinical utility of IABP in patients suffering high-risk PCI without CS and AMI complicated with CS. However, in patients with AMI, but without CS, IABP may reduce the 30-day and 6-month mortality rate.
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Affiliation(s)
- Xiao-Yun Zheng
- Department of Senior Official Ward, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China.
| | - Yi Wang
- Department of Senior Official Ward, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Yi Chen
- Department of Senior Official Ward, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Xi Wang
- Department of Senior Official Ward, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Lei Chen
- Department of Senior Official Ward, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Jun Li
- Department of Senior Official Ward, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
| | - Zhi-Gang Zheng
- Department of Senior Official Ward, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Beijing, 100029, China
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Soverow J, Parikh MA. Acute Myocardial Infarction/Thrombectomy. Interv Cardiol Clin 2016; 5:259-269. [PMID: 28582209 DOI: 10.1016/j.iccl.2015.12.010] [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: 12/01/2022]
Abstract
This article focuses on specialized techniques and devices used in the most challenging cases of acute myocardial infarction. Areas where high-quality evidence is either clear or absent are avoided. Controversies in the use of support or thrombectomy devices, the addition of adjunct pharmacology, and the decision to treat nonculprit lesions are discussed. Recent years have seen a shift in guidelines to downgrading the use of assist devices in cardiogenic shock and aspiration thrombectomy, whereas consideration of nonculprit coronary intervention has been revived. These changes come in the wake of a series of large, practice-changing clinical trials.
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Affiliation(s)
- Jonathan Soverow
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA.
| | - Manish A Parikh
- Center for Interventional Vascular Therapy, Columbia-Presbyterian Hospital, 161 Fort Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA
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Sung PH, Wu CJ, Yip HK. Is Extracorporeal Membrane Oxygenator a New Weapon to Improve Prognosis in Patients With Profound Cardiogenic Shock Undergoing Primary Percutaneous Coronary Intervention? Circ J 2016; 80:572-8. [PMID: 26853720 DOI: 10.1253/circj.cj-15-1398] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Despite advancements in pharmacological therapy and refinement of the tools and technique of primary percutaneous coronary intervention (PCI) and coronary artery bypass surgery, patients with acute myocardial infarction (AMI) complicated by profound cardiogenic shock (CS) still have unacceptably high in-hospital mortality and unfavorable long-term outcome. Thus, there is an imminent need of a new and safe treatment modality in the management of AMI complicated by profound CS. Growing evidence suggests that extracorporeal membrane oxygenator (ECMO)-supported primary PCI is an effective therapeutic option for saving lives under such conditions. In this review, we describe and interpret the potential role of circulatory mechanical support by ECMO in the setting of AMI complicated by profound CS for improving clinical outcomes. (Circ J 2016; 80: 572-578).
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Affiliation(s)
- Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine
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