Outcomes of mechanical circulatory support for acute myocardial infarction complicated by cardiogenic shock

Intra-aortic balloon pump is associated with the lowest whereas Impella with the highest inpatient mortality and complications regardless of severity or hospital types

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.

Impact of center volume on in-hospital mortality in adult patients with out‑of‑hospital cardiac arrest resuscitated using extracorporeal cardiopulmonary resuscitation: a secondary analysis of the SAVE-J II study

Recently, patients with out-of-hospital cardiac arrest (OHCA) refractory to conventional resuscitation have started undergoing extracorporeal cardiopulmonary resuscitation (ECPR). However, the mortality rate of these patients remains high. This study aimed to clarify whether a center ECPR volume was associated with the survival rates of adult patients with OHCA resuscitated using ECPR. This was a secondary analysis of a retrospective multicenter registry study, the SAVE-J II study, involving 36 participating institutions in Japan. Centers were divided into three groups according to the tertiles of the annual average number of patients undergoing ECPR: high-volume (≥ 21 sessions per year), medium-volume (11-20 sessions per year), or low-volume (< 11 sessions per year). The primary outcome was survival rate at the time of discharge. Patient characteristics and outcomes were compared among the three groups. Moreover, a multivariable-adjusted logistic regression model was applied to study the impact of center ECPR volume. A total of 1740 patients were included in this study. The center ECPR volume was strongly associated with survival rate at the time of discharge; furthermore, survival rate was best in high-volume compared with medium- and low-volume centers (33.4%, 24.1%, and 26.8%, respectively; P = 0.001). After adjusting for patient characteristics, undergoing ECPR at high-volume centers was associated with an increased likelihood of survival compared to middle- (adjusted odds ratio 0.657; P = 0.003) and low-volume centers (adjusted odds ratio 0.983; P = 0.006). The annual number of ECPR sessions was associated with favorable survival rates and lower complication rates of the ECPR procedure.Clinical trial registration: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

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

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

Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies

PURPOSE

Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit.

METHODS

We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model.

RESULTS

We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66).

CONCLUSION

In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.

Mechanical circulatory support versus vasopressors alone in patients with acute myocardial infarction and cardiogenic shock undergoing percutaneous coronary intervention

BACKGROUND

Previous studies have compared Impella use to intra-aortic balloon pump (IABP) use in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI). Our objective was to compare clinical outcomes in patients with AMI-CS undergoing PCI who received Impella (percutaneous left ventricular assist device) without vasopressors, IABP without vasopressors, and vasopressors without mechanical circulatory support (MCS).

METHODS

We queried the National Inpatient Sample (NIS) using ICD-10 codes (2015-2018) to identify patients with AMI-CS undergoing PCI. We created three propensity-matched cohorts to examine clinical outcomes in patients receiving Impella versus IABP, Impella versus vasopressors without MCS, and IABP versus vasopressors without MCS.

RESULTS

Among 17,762 patients, Impella use was associated with significantly higher in-hospital major bleeding (31.4% vs. 13.6%; p < 0.001) and hospital charges (p < 0.001) compared to IABP use, with no benefit in mortality (34.1% vs. 26.9%; p = 0.06). Impella use was associated with significantly higher mortality (42.3% vs. 35.7%; p = 0.02), major bleeding (33.9% vs. 22.7%; p = 0.001), and hospital charges (p < 0.001), when compared to the use of vasopressors without MCS. There were no significant differences in clinical outcomes between IABP use and the use of vasopressor without MCS.

CONCLUSIONS

In this analysis of retrospective data of patients with AMI-CS undergoing PCI, Impella use was associated with higher mortality, major bleeding, and in-hospital charges when compared to vasopressor therapy without MCS. When compared to IABP use, Impella was associated with no mortality benefit, along with higher major bleeding events and in-hospital charges. A vasopressor-only strategy suggested no difference in clinical outcomes when compared to IABP. This study uses the NIS for the first time to highlight outcomes in AMI-CS patients undergoing PCI when treated with vasopressor support without MCS, compared to Impella and IABP use.

Protocolised Management of Cardiogenic Shock and Shock Teams: A Narrative Review

Despite advances in therapy, the incidence of cardiogenic shock continues to increase, with significant mortality that has improved minimally over time. Treatment options for cardiogenic shock are complex and time-, resource-, and case volume-dependent, and involve multiple medical specialties. To provide early, more equitable, and standardised access to cardiogenic shock expertise with advanced therapies, cardiogenic shock teams with a protocolised treatment approach have been proposed. These processes have been applied across hospitals into integrated cardiogenic shock networks. This narrative review evaluates the role of cardiogenic shock teams, protocolised and regionalised shock networks, and the main individual components of protocolised shock management approaches.

Incidence and Predictors of Acute Limb Ischemia in Patients With Acute Myocardial Infarction-Insight from National Readmission Database

Acute limb ischemia (ALI) has been a rare complication of acute myocardial infarction (AMI), however, with the increasing use of mechanical circulatory devices it is seen more frequently. The incidence and predictors of ALI in patients with AMI in contemporary clinical practice are unknown. A retrospective review of patients with index hospitalization for AMI in the Nationwide Readmission Database from 2016 to 2019 was done. We evaluated the annual incidence of ALI and its impact on outcomes. We used multivariate logistic regression analysis to determine predictors of ALI. In 1,283,586 patients with AMI, 3,971 patients (0.31%) had ALI and 365 (0.03%) had limb amputation. The 3 major predictors of ALI were peripheral artery disease (odds ratio [OR] 11.91, 95% confidence interval [CI]: 10.78 to 13.51), intravascular microaxial left ventricular assist device (OR 4.39, 95% CI 3.86 to 5.00), and veno-arterial extracorporeal membrane oxygenation (OR 4.37, 95% CI 3.19 to 6.01). Intra-aortic balloon pump had a substantially lower predictive ability (OR 1.81, 95% CI 1.63 to 2.0, p <0.0001) than other forms of mechanical circulatory support. The mortality rate in patients with ALI was significantly higher than those without ALI (19.49% vs 4.85%, p <0.0001). Patients who developed ALI had higher rates of amputation (1.59% vs 0.02%, p <0.0001). This observational nationwide study showed that ALI is an important complication in patients with AMI and is more frequently seen in patients who have peripheral artery disease, and require a left ventricular assist device or venoarterial extracorporeal membrane oxygenation. This complication was also associated with significantly higher in-hospital mortality.

Pulmonary Artery Catheter Use and Outcomes in Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock Treated With Impella (a Nationwide Analysis from the United States)

The role of continuous hemodynamic assessment with pulmonary artery (PA) catheter placement in cardiogenic shock (CS) remains debated. We aimed to assess the association between PA catheter placement and clinical outcomes in patients with CS secondary to ST-elevation myocardial infarction (STEMI) treated with an intravascular microaxial flow pump. We identified patients hospitalized with STEMI complicated by CS on mechanical circulatory support with an intravascular microaxial flow pump (Impella, Abiomed, Danvers, Massachusetts) using the National Inpatient Sample database and compared the outcomes in those treated with and without PA catheters. The primary outcome was in-hospital mortality. The secondary outcomes included in-hospital complications, hospital length of stay, inpatient costs, and temporal trends. The total cohort included 14,635 hospitalizations for STEMI complicated by CS treated with Impella between 2016 and 2020, of whom 5,505 (37.6%) received PA catheters. Over the study period, the use of PA catheters increased significantly from 25.9% to 41.8% (ptrend <0.01). Similarly, the use of Impella increased from 9.9% to 18.9% (ptrend <0.01). After adjustment for baseline characteristics using a multivariate logistic regression analysis, PA catheter use was associated with lower in-hospital mortality (adjusted odds ratio 0.80, 95% confidence interval 0.67 to 0.96, p = 0.01) and similar cardiovascular, neurologic, renal, and hematologic complications; length of stay; and inpatient costs compared with no PA catheter use. In conclusion, PA catheter use in patients with STEMI complicated by CS treated with Impella is associated with reduced in-hospital mortality and similar complication rates. Given the mortality benefit, further research is necessary to optimize PA catheter use in patients with STEMI with CS.

Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction

Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.

When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI–CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

Cardiac power output index to define hemodynamic response to Impella support in cardiogenic shock

BACKGROUND

Early assessment of response to Impella in cardiogenic shock may guide escalation of mechanical circulatory support. Therapeutic goal and response to Impella have not previously been defined. This study tested the hypothesis that targeting 3-h post- Impella cardiac power output index (CPOi)-"hemodynamic response"-in cardiogenic shock is associated with 12-h lactate clearance.

METHODS

Single-center study of 37 consecutive patients who underwent left-sided Impella support for cardiogenic shock due to either acute myocardial infarction or decompensated heart failure. Patients who achieved 3-h post-Impella CPOi ⩾ 0.30 W/m² were defined as Impella "hemodynamic responder."

RESULTS

Twelve of the thirty-seven patients achieved 3-h post-impella CPOi  ⩾ 0.30 W/m² ("hemodynamic responders"). Post-Impella CPOi correlated with 12-h lactate (r = -0.779, p < 0.001) and lactate clearance (r = 0.747, p < 0.001). "Hemodynamic responders" had lower 12-h lactate level and greater 12-h lactate clearance (52 (44-58) vs 17 (14-26)%, p < 0.001). Higher pre-Impella norepinephrine dose (-0.341, p = 0.003) and baseline lactate (-0.009, p = 0.003) were independently associated with lower 3-h post-Impella CPOi. Eighteen patients died within 30 days (2/12 "hemodynamic responders" compared to 16/25 "non-responders," p < 0.001).

CONCLUSION

Patients who achieved early 3-h post-Impella CPOi of ⩾0.30 W/m² have greater lactate clearance and better short-term survival. Early post-Impella CPOi of 0.30 W/m² may be used as a therapeutic goal and define favorable response to Impella in cardiogenic shock.

Tolerance of sustained ventricular fibrillation during left ventricular assist device support with IMPELLA CP®

A 64-year-old man was admitted with subacute anterior ST-segment elevation myocardial infarction treated with implantation of four drug-eluting stents in proximal left anterior descending artery. Despite successful percutaneous coronary intervention, the patient developed a significant worsening of left ventricular ejection fraction because of late diagnosis. A percutaneous mechanical circulatory support device (Impella CP; Abiomed) was then required in order to preserve adequate systemic perfusion. Twelve hours later, the patient developed rapid ventricular tachycardia degenerated in ventricular fibrillation, without loss of consciousness. During the arrhythmia, lasting for 10 min, the patient was alert, with preserved mental status. After adequate sedation, a single unsynchronized 200 J DC shock converted the patient to sinus rhythm.