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Kochar A, Vallabhajosyula S, John K, Sinha SS, Esposito M, Pahuja M, Hirst C, Li S, Kong Q, Li B, Natov P, Kanwar M, Hernandez-Montfort J, Garan R, Walec K, Zazzali P, Sangal P, Ton VK, Zweck E, Kataria R, Guglin M, Vorovich E, Nathan S, Abraham J, Harwani NM, Hickey GW, Wencker D, Schwartzman AD, Khalife W, Mahr C, Kim JH, Bhimaraj A, Blumer V, Faugno A, Burkhoff D, Kapur NK. Factors associated with Acute Limb Ischemia in Cardiogenic Shock and downstream Clinical Outcomes: Insights from the Cardiogenic Shock Working Group. J Heart Lung Transplant 2024:S1053-2498(24)01705-4. [PMID: 38944132 DOI: 10.1016/j.healun.2024.06.012] [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: 01/31/2024] [Revised: 05/29/2024] [Accepted: 06/24/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND There are limited data depicting the prevalence and ramifications of acute limb ischemia (ALI) among cardiogenic shock (CS) patients. METHODS We employed data from the Cardiogenic Shock Working Group (CSWG), a consortium including 33 sites. We constructed a multi-variable logistic regression to examine the association between clinical factors and ALI, we generated another logistic regression model to ascertain the association of ALI with mortality. RESULTS There were 7,070 patients with CS and 399 (5.6%) developed ALI. Patients with ALI were more likely to be female (40.4% versus 29.4%) and have peripheral arterial disease (13.8% versus 8.3%). Stratified by maximum SCAI shock stage, the rates of ALI were stage B 0.0%, stage C 1.8%, stage D 4.1%, and stage E 10.3%. Factors associated with higher risk for ALI included: peripheral vascular disease OR 2.24 (95% CI: 1.53 - 3.23; p < 0.01) and ≥ 2 mechanical circulatory support (MCS) devices OR 1.66 (95% CI: 1.24 - 2.21, p < 0.01). ALI was highest for VA-ECMO patients (11.6%) or VA-ECMO + IABP/Impella CP (16.6%) yet use of distal perfusion catheters was less than 50%. Mortality was 38.0% for CS patients without ALI but 57.4% for CS patients with ALI. ALI was significantly associated with mortality, adjusted OR 1.40 (95% CI 1.01 - 1.95, p < 0.01). CONCLUSIONS The rate of ALI was 6% among CS patients. Factors most associated with ALI include peripheral vascular disease and multiple MCS devices. The downstream ramifications of ALI were dire with a considerably higher risk of mortality.
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Affiliation(s)
| | | | - Kevin John
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, VA
| | | | - Mohit Pahuja
- University of Oklahoma Health Science Center, Oklahoma City, OK
| | - Colin Hirst
- St. Peter's Health Partners Medical Associates, Albany, NY
| | - Song Li
- Institute for Advanced Cardiac Care, Medical City Healthcare, Dallas, TX
| | - Qiuyue Kong
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Borui Li
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Peter Natov
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Manreet Kanwar
- Cardiovascular Instittue at Allegheny Health Network, Pittsburgh, PA
| | | | - Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Karol Walec
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Peter Zazzali
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Paavni Sangal
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | - Van-Khue Ton
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA
| | - Elric Zweck
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rachna Kataria
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI
| | - Maya Guglin
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN
| | - Esther Vorovich
- Bluhm Cardiovascular Institute of Northwestern University, Chicago, IL
| | | | | | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Detlef Wencker
- Baylor Scott & White Health, Advanced Heart Failure Program Clinic, Temple, TX
| | | | | | - Claudius Mahr
- University of Washington Medical Center, Seattle, WA
| | - Ju H Kim
- Houston Methodist Research Institute, Houston, TX
| | | | - Vanessa Blumer
- Inova Heart and Vascular Institute, Inova Fairfax Campus, Falls Church, VA
| | - Anthony Faugno
- The Cardiovascular Center, Tufts Medical Center, Boston, MA
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA.
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Frye J, Tao M, Gupta S, Gier C, Masson R, Rahman T, Bench T, Mann N, Tam E. Safety and utility of mechanical circulatory support in patients with acute myocardial infarction complicated by cardiogenic shock: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00545-1. [PMID: 38965019 DOI: 10.1016/j.carrev.2024.06.016] [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: 04/23/2024] [Revised: 05/29/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a major cause of morbidity and mortality. Although mechanical circulatory support (MCS) is an increasingly utilized therapeutic option in AMI-CS, studies evaluating the efficacy and safety of different forms of MCS have yielded conflicting results. This systematic review and meta-analysis aims to evaluate the safety and efficacy of different forms of MCS. METHODS A database search was performed for studies reporting on the association of different forms of MCS with clinical outcomes in patients with AMI-CS. The primary efficacy endpoints were short term (≤30 days) and long term (>30 days) all-cause mortality. Secondary efficacy endpoints included recurrent AMI, cardiovascular (CV) mortality, device-related limb complications, moderate to severe bleeding events, and cerebrovascular accidents (CVA). RESULTS 2752 patients with AMI-CS met inclusion criteria. Results were available comparing ECMO to other MCS or medical therapy alone, comparing IABP to medical therapy alone, and comparing pLVAD to IABP. Use of ECMO was not associated with lower risk of 30-day or long-term mortality compared to pVAD or standard medical therapy with or without IABP placement but was associated with higher risk of device-related limb complications and moderate to severe bleeding compared to pVAD. IABP use was not associated with a lower risk of 30 day or long-term mortality but was associated with higher risk of recurrent AMI and moderate to severe bleeding compared to medical therapy. Compared to IABP, pVAD use was associated with lower risk of CV mortality but not recurrent AMI. pVAD was associated with a higher risk of device-related limb complications and moderate to severe bleeding compared to IABP use. CONCLUSION Use of ECMO or IABP in patients with AMI-CS is not associated with significant improvement in mortality. pVAD is associated with a lower risk of CV mortality. All MCS types are associated with increased risk of complications. Additional high-quality studies are needed to determine the optimal MCS therapy for patients with AMI-CS.
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Affiliation(s)
- Jesse Frye
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Michael Tao
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Shivani Gupta
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Chad Gier
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Ravi Masson
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Tahmid Rahman
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Travis Bench
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Noelle Mann
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Edlira Tam
- Department of Medicine, Division of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA.
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Ellauzi R, Erdem S, Salam MF, Kumar A, Aggarwal V, Koenig G, Aronow HD, Basir MB. Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism. J Clin Med 2024; 13:3161. [PMID: 38892871 PMCID: PMC11172824 DOI: 10.3390/jcm13113161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 06/21/2024] Open
Abstract
Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management.
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Affiliation(s)
- Rama Ellauzi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Saliha Erdem
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI 48202, USA;
| | - Mohammad Fahad Salam
- Department of Internal Medicine, Michigan State University, East Lansing, MI 48502, USA;
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, USA;
| | - Vikas Aggarwal
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Gerald Koenig
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Mir Babar Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
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Shapiro AB, Fritz AV, Kiley S, Sharma S, Patel P, Heckman A, Martin AK, Goswami R. Comparison of Intraoperative Blood Product Use During Heart Transplantation in Patients Bridged with Impella 5.5 versus Durable Left Ventricular Assist Devices. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00303-3. [PMID: 39003127 DOI: 10.1053/j.jvca.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE To determine if the intraoperative transfusion requirements differ based on the mechanical circulatory device used as a bridge to heart transplantation. DESIGN A single-center retrospective analysis of intraoperative transfusion requirements in all patients undergoing heart or heart/kidney transplantation between November 2018 and July 2021 who were bridged with a temporary (Impella 5.5) or durable left ventricular assist device (LVAD). SETTING A tertiary care hospital. PARTICIPANTS Forty-three adult patients bridged to heart or heart/kidney transplantation with a temporary or durable LVAD between 2018 and 2021 INTERVENTIONS: Recording of baseline characteristics and intraoperative transfusion requirements, including packed red blood cells, fresh frozen plasma, cryoprecipitate, autologous blood salvage, and platelets. The difference in cardiopulmonary bypass times, intensive care unit length of stay, and the vasoactive inotrope score following transplantation were also recorded. MEASUREMENTS AND MAIN RESULTS The primary outcome was the volume of blood products transfused intraoperatively. Patients who underwent bridge to transplantation using the Impella 5.5 had statistically significant lower median transfusions of cryoprecipitate (155 mL versus 200 mL, p = 0.015), autologous blood salvage (675 mL versus 1,125 mL, p ≤ 0.01), and platelets (412 mL versus 675 mL, p ≤ 0.01). Additionally, there was a trend toward lower transfusion of intraoperative packed red blood cells (4.5 units versus 6.5 units, p = 0.29) and fresh frozen plasma (675 mL versus 800 mL, p = 0.11), but these were not statistically significant. CONCLUSIONS The results suggest a reduction in certain intraoperative transfusion requirements in patients undergoing heart transplantation bridged with the Impella 5.5 versus durable left ventricular assist device.
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Affiliation(s)
- Anna Bovill Shapiro
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL.
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Sean Kiley
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Shriya Sharma
- Division of Transplantation and Advanced Heart Failure, Mayo Clinic, Jacksonville, FL
| | - Parag Patel
- Division of Transplantation and Advanced Heart Failure, Mayo Clinic, Jacksonville, FL
| | - Alexander Heckman
- Department of Cardiology, Oregon Health and Science University, Portland, OR
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Rohan Goswami
- Division of Transplantation and Advanced Heart Failure, Mayo Clinic, Jacksonville, FL
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Sinclair De Frías J, Isha S, Olivero L, Raavi L, Narra SA, Paghdar S, Jonna S, Satashia P, Hannon R, Blasavage J, White L, Olanipekun T, Bansal P, Kiley S, Leoni JC, Nativí J, Lyle M, Thomas M, Sareyyupoglu B, Pham S, Smith M, Moreno Franco P, Patel P, Sanghavi D. Association between Impella device support and elevated rates of gout flares: a retrospective propensity-matched study. BMC Rheumatol 2024; 8:9. [PMID: 38424614 PMCID: PMC10902952 DOI: 10.1186/s41927-024-00380-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/09/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Impella is an advanced ventricular assist device frequently used as a bridge to heart transplantation. The association of Impella with increased rates of gout flares has not been studied. Our primary aim is to determine the rates of gout flares in patients on Impella support. METHODOLOGY A retrospective study was conducted between January 2017 and September 2022 involving all patients who underwent heart transplantation. The cohort was divided into two groups based on Impella support for statistical analysis. In patients receiving Impella support, outcome measures were compared based on the development of gout flares. 1:1 nearest neighbor propensity match, as well as inverse propensity of treatment weighted analyses, were performed to explore the causal relationship between impella use and gout flare in our study population. RESULTS Our analysis included 213 patients, among which 42 (19.71%) patients were supported by Impella. Impella and non-Impella groups had similar age, race, and BMI, but more males were in the Impella group. Gout and chronic kidney disease were more prevalent in Impella-supported patients, while coronary artery disease was less common. The prevalence of gout flare was significantly higher in Impella patients (30.9% vs. 5.3%). 42 Impella-supported patients were matched with 42 patients from the non-impella group upon performing a 1:1 propensity matching. Impella-supported patients were noted to have a significantly higher risk of gout flare (30.9% vs. 7.1%, SMD = 0.636), despite no significant difference in pre-existing gout history and use of anti-gout medications. Impella use was associated with a significantly increased risk of gout flare in unadjusted (OR 8.07), propensity-matched (OR 5.83), and the inverse propensity of treatment-weighted analysis (OR 4.21). CONCLUSION Our study is the first to identify the potential association between Impella support and increased rates of gout flares in hospitalized patients. Future studies are required to confirm this association and further elucidate the biological pathways. It is imperative to consider introducing appropriate measures to prevent and promptly manage gout flares in Impella-supported patients.
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Affiliation(s)
- Jorge Sinclair De Frías
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Lorenzo Olivero
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Lekhya Raavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Sai Abhishek Narra
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Smit Paghdar
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Sadhana Jonna
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Parthkumar Satashia
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Rachel Hannon
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Jessica Blasavage
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
- Associate Clinical Consultant, Abiomed, Jacksonville, FL, USA
| | - Layton White
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Titilope Olanipekun
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pankaj Bansal
- Department of Rheumatology, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Sean Kiley
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Juan Carlos Leoni
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Jose Nativí
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Melissa Lyle
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Mathew Thomas
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Basar Sareyyupoglu
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Si Pham
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Michael Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA
| | - Parag Patel
- Division of Advanced Heart Failure and Transplantation, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road S, 32224, Jacksonville, FL, USA.
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Napoli F, Aleman R, Zadneulitca N, Navia J, Brozzi NA. Sepsis in cardiothoracic surgery. Surgery 2024; 175:556-558. [PMID: 37996343 DOI: 10.1016/j.surg.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/28/2023] [Accepted: 10/24/2023] [Indexed: 11/25/2023]
Abstract
Sepsis is a life-changing condition that can occur in patients undergoing cardiothoracic surgery. It is characterized by a dysregulated inflammatory response to infection, often leading to higher rates of organ dysfunction and mortality. The importance of early recognition and prompt intervention in managing sepsis-related complications in cardiothoracic surgery is pivotal to adequate surgical practice. Due to the multiple subsections that construct the broad spectrum of cardiothoracic surgery, it is important to address the presence of sepsis in elective cardiothoracic surgery, urgent/emergency cardiothoracic surgery, solid organ transplantation, and both temporary and permanent mechanical circulatory support (ie, left ventricular assist devices, extracorporeal membrane oxygenation, and percutaneous temporary devices [eg, Impella series]). Exploring the incidence, prevalence, and risk factors of said subsections can lead to improvement in postoperative outcomes. The impact of accompanying infections can progress into further operative morbidity and mortality. To this effect, the perioperative management of cardiothoracic surgery transcends surgical techniques and should undergo additional recognition of other occurrences such as wound infections, bloodstream infections, urinary tract infections, and pneumonia. Sepsis remains a concern in cardiothoracic surgery, as it can lead to devastating consequences. Hence, there is an evident need for heightened vigilance, early recognition, and effective management strategies to mitigate the risk of sepsis in this patient population. The purpose of this article is to provide an overview of sepsis in the different cardiothoracic surgery areas.
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Affiliation(s)
- Federico Napoli
- Heart, Vascular & Thoracic, Cleveland Clinic Florida, Weston, FL. https://twitter.com/fede_napo
| | - Rene Aleman
- Heart, Vascular & Thoracic, Cleveland Clinic Florida, Weston, FL. https://twitter.com/RAlemanMD
| | | | - Jose Navia
- Heart, Vascular & Thoracic, Cleveland Clinic Florida, Weston, FL. https://twitter.com/JoseNaviaMD
| | - Nicolas A Brozzi
- Heart, Vascular & Thoracic, Cleveland Clinic Florida, Weston, FL.
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7
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Corujo Rodriguez A, Richter E, Ibekwe SO, Shah T, Faloye AO. Postcardiotomy Shock Syndrome: A Narrative Review of Perioperative Diagnosis and Management. J Cardiothorac Vasc Anesth 2023; 37:2621-2633. [PMID: 37806929 DOI: 10.1053/j.jvca.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/29/2023] [Accepted: 09/09/2023] [Indexed: 10/10/2023]
Abstract
Postcardiotomy shock (PCS) is generally described as the inability to separate from cardiopulmonary bypass due to ineffective cardiac output after cardiotomy, which is caused by a primary cardiac disorder, resulting in inadequate tissue perfusion. Postcardiotomy shock occurs in 0.5% to 1.5% of contemporary cardiac surgery cases, and is accompanied by an in-hospital mortality of approximately 67%. In the last 2 decades, the incidence of PCS has increased, likely due to the increased age and baseline morbidity of patients requiring cardiac surgery. In this narrative review, the authors discuss the epidemiology and pathophysiology of PCS, the rationale and evidence behind the initiation, continuation, escalation, and discontinuation of mechanical support devices in PCS, and the anesthetic implications.
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Affiliation(s)
| | - Ellen Richter
- Department of Anesthesiology, Emory University, Atlanta, GA
| | | | - Tina Shah
- Department of Anesthesiology, Emory University, Atlanta, GA
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Maigrot JLA, Starling RC, Taimeh Z, Tong MZ, Soltesz EG, Weiss AJ. Association of timing of percutaneous left ventricular assist device insertion with outcomes in patients undergoing cardiac surgery. JTCVS OPEN 2023; 16:430-446. [PMID: 38204614 PMCID: PMC10775102 DOI: 10.1016/j.xjon.2023.10.028] [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: 05/05/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 01/12/2024]
Abstract
Objectives The aim of this study was to explore the associations between percutaneous ventricular assist device (pVAD) insertion timing relative to cardiac surgery and patient outcomes. Methods The Nationwide Inpatient Sample was queried for patients undergoing cardiac surgery and pVAD insertion in the same admission from 2016 to 2019. Patients were stratified by timing of pVAD insertion. Preoperative characteristics, postoperative complications, and mortality were compared among groups. Results Overall, 3695 patients underwent cardiac surgery and pVAD insertion during the same hospitalization (pre: 1130, intra: 1690, and post: 875). The distribution of cardiac surgery procedures was similar across groups. Median Elixhauser Comorbidity Index was 13 for pre-, 15 for intra-, and 17 for postoperative pVAD patients (P = .021). Patients who received a postoperative pVAD were associated with increased mortality (pre: 18%, intra: 39%, and post: 54%; P < .01). Increased complication rates were also associated with postoperative pVAD insertion (pre: 61%, intra: 55%, and post: 75%; P < .01). Preoperative pVAD insertion was associated with increase rates of sepsis (pre: 18%, intra: 9.8%, and post: 17%; P = .01) and pneumonia (pre: 38%, intra: 23%, and post: 31%; P < .01). Postoperative pVAD insertion was associated with increased rates of gastrointestinal bleeding (pre: 2.2%, intra: 3.0%, and post: 7.4%; P = .01), renal failure (pre: 10%, intra: 9.2%, and post: 17%; P = .01), and prolonged ventilation (pre: 44%, intra: 41%, and post: 54%; P = .02). Conclusions Postoperative pVAD insertion following cardiac surgery was associated with increased complications and mortality compared with preoperative or intraoperative insertion. Further studies should explore optimal utilization and timing of pVAD insertion in patients undergoing cardiac surgery.
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Affiliation(s)
- Jean-Luc A. Maigrot
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall C. Starling
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ziad Taimeh
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z.Y. Tong
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G. Soltesz
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aaron J. Weiss
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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9
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Castagna F, Viswanathan S, Chalhoub G, Ippolito P, Ovalle Ramos JA, Vukelic S, Sims DB, Madan S, Saeed O, Jorde UP. Predicting Hemodynamic Changes During Intra-Aortic Balloon Pump Support With a Longitudinal Evaluation. ASAIO J 2023; 69:977-983. [PMID: 37499684 PMCID: PMC10602221 DOI: 10.1097/mat.0000000000002014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
The use of intra-aortic balloon pump (IABP) has decreased in recent years due to negative outcome studies in cardiogenic shock complicating acute myocardial infarction, despite its favorable adverse-event profile. Acute hemodynamic response studies have identified potential super-responders with immediate improvements in cardiac index (CI) in heart failure patients. This single-center retrospective study aimed to predict CI and mean arterial pressure (MAP) changes throughout the entire duration of IABP support. The study analyzed 336 patients who received IABP between 2016 and 2022. Linear mixed-effect regression models were used to predict CI and MAP improvement during IABP support. The results showed that CI and MAP increases during the first days of support, and changes during IABP support varied with time and were associated with baseline parameters. Longitudinal CI change was associated with body surface area, baseline CI, baseline pulmonary artery pulsatility index, baseline need for pressors, and diabetes. Longitudinal MAP change was associated with baseline MAP, baseline heart rate, need for pressors, or inotropes. The study recommends considering these parameters when deciding if IABP is the most appropriate form of support for a specific patient. Further prospective studies are needed to validate the findings.
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Affiliation(s)
- Francesco Castagna
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Shankar Viswanathan
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - George Chalhoub
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Paul Ippolito
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Julio Andres Ovalle Ramos
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Sasa Vukelic
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Daniel B. Sims
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Shivank Madan
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Omar Saeed
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Ulrich P. Jorde
- From the Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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10
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Waksman R, Pahuja M, van Diepen S, Proudfoot AG, Morrow D, Spitzer E, Nichol G, Weisfeldt ML, Moscucci M, Lawler PR, Mebazaa A, Fan E, Dickert NW, Samsky M, Kormos R, Piña IL, Zuckerman B, Farb A, Sapirstein JS, Simonton C, West NEJ, Damluji AA, Gilchrist IC, Zeymer U, Thiele H, Cutlip DE, Krucoff M, Abraham WT. Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC). Circulation 2023; 148:1113-1126. [PMID: 37782695 PMCID: PMC11025346 DOI: 10.1161/circulationaha.123.064527] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 10/04/2023]
Abstract
The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.
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Affiliation(s)
- Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W.)
| | - Mohit Pahuja
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City (M.P.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK (A.G.P.)
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Germany (A.G.P.)
| | - David Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.M.)
| | - Ernest Spitzer
- Cardialysis, Rotterdam, The Netherlands (E.S.)
- Cardiology Department, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands (E.S.)
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington Harborview Center, Seattle (G.N.)
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (M.L.W.)
| | - Mauro Moscucci
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, Canada (P.R.L.)
- McGill University Health Centre, Montreal, Canada (P.R.L.)
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (P.R.L.)
| | - Alexandre Mebazaa
- Université Paris Cité, Department of Anesthesiology and Critical Care Medicine, Hôpital Lariboisière, France (A.M.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (E.F.)
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (N.W.D.)
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (M.S.)
| | - Robert Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, TX (R.K.)
| | - Ileana L Piña
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA (I.L.P.)
| | - Bram Zuckerman
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Andrew Farb
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - John S Sapirstein
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | | | | | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D.)
| | - Ian C Gilchrist
- Department of Interventional Cardiology/Heart and Vascular Institute, Penn State Health/Hershey Medical Center (I.C.G.)
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Germany (H.T.)
- Leipzig Heart Science, Germany (H.T.)
| | - Donald E Cutlip
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA (D.E.C.)
| | - Mitchell Krucoff
- Department of Medicine, Duke University School of Medicine, Durham, NC (M.K.)
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus (W.T.A.)
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11
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Kirigaya J, Iwahashi N, Terasaka K, Takeuchi I. Prevention and management of critical care complications in cardiogenic shock: a narrative review. J Intensive Care 2023; 11:31. [PMID: 37408036 PMCID: PMC10324237 DOI: 10.1186/s40560-023-00675-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is a common cause of morbidity and mortality in cardiac intensive care units (CICUs), even in the contemporary era. MAIN TEXT Although mechanical circulatory supports have recently become widely available and used in transforming the management of CS, their routine use to improve outcomes has not been established. Transportation to a high-volume center, early reperfusion, tailored mechanical circulatory supports, regionalized systems of care with multidisciplinary CS teams, a dedicated CICU, and a systemic approach, including preventing noncardiogenic complications, are the key components of CS treatment strategies. CONCLUSIONS This narrative review aimed to discuss the challenges of preventing patients from developing CS-related complications and provide a comprehensive practical approach for its management.
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Affiliation(s)
- Jin Kirigaya
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kengo Terasaka
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Ichiro Takeuchi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, 232-0024, Japan.
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12
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Cohen WG, Rekhtman D, Iyengar A, Shin M, Ibrahim M, Bermudez C, Cevasco M, Wald J. Extended Support With the Impella 5.5: Transplant, ECMO, and Complications. ASAIO J 2023; 69:642-648. [PMID: 37039780 DOI: 10.1097/mat.0000000000001931] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
We report midterm results of Impella 5.5 use with focus placed on bridge-outcomes, venoarterial extracorporeal membrane oxygenation (VA-ECMO) transition, complications, and risk factors for mortality. A retrospective review of patients implanted with the Impella 5.5 at our medical center was conducted. Forty patients were included with varying bridge strategies. Sixteen (40%) patients were supported for <14 days, 13 (32.5%) for 14-30 days, and 11 (27.5%) for >30 days. Thirty day mortality was 22.5% (9/40). Twenty-five (62.5%) were successfully bridged to transplant or durable left ventricular assist device (LVAD), while four (10.0%) recovered without the need for any further cardiac support. Five of 11 (60%) patients initially supported with VA-ECMO were either transitioned to durable left ventricular assist device (dLVAD; n = 3, 27.3%), transplanted (n = 1, 9.1%), or recovered (n = 1, 9.1%). Of nine patients with >moderate right ventricle (RV) dysfunction, five (55.6%) were successfully bridged to transplant or LVAD. Five (12.5%) patients required interval cannulation to VA-ECMO, often in the setting of RV dysfunction, and all (100%) were successfully transplanted. Lower pulmonary artery (PA) systolic pressure ( P = 0.029), among other factors, was associated with mortality. In summary, the Impella 5.5 may be able to effectively stabilize patients in refractory left ventricular predominant cardiogenic shock for extended durations, allowing time for mechanical circulatory support (MCS) and transplant evaluations.
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Affiliation(s)
- William G Cohen
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Ibrahim
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Kim JH, Mason J, Toyoda AY, Ji CS, Gandhi RG, Solomon EJ. Analysis of the use of empiric antimicrobial prophylaxis for temporary cardiac devices at a large academic medical center. Perfusion 2023:2676591231182249. [PMID: 37285484 DOI: 10.1177/02676591231182249] [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: 06/09/2023]
Abstract
INTRODUCTION Varying rates of access site infections with temporary percutaneous cardiac devices have been reported in the literature. The purpose of this study is to determine the impact of a change in institutional practice in utilizing antimicrobial prophylaxis to prevent access site infections in patients with these devices. METHODS This observational, pre-post implementation analysis evaluated the benefit of prophylactic antimicrobial therapy in adult patients with temporary percutaneous cardiac devices admitted to cardiac intensive care units. Patients in the pre-cohort received prophylactic antibiotics for the duration of device insertion. Patients in the post-cohort received a single dose of intravenous antibiotics for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or Impella® 5.5 device placement, and no antimicrobial prophylaxis for all other devices placed. The primary endpoint was the incidence of definitive access site infection. Secondary endpoints included the incidence of Clostridium difficile infection and initiation of broad-spectrum antibiotics. RESULTS Fifty patients in the pre-cohort and 45 patients in the post-cohort were evaluated. Devices included intra-aortic balloon pumps, VA-ECMO, Impella® CP and Impella® 5.5. The median duration of device insertion was four days. No significant difference in the primary outcome was seen between the two groups. A significant reduction in prophylactic antimicrobial utilization and total days of antimicrobial exposure was observed in the post-implementation cohort. CONCLUSION Based on the results of our study, the implemented guideline reduces the utilization of antimicrobial prophylaxis in patients with temporary percutaneous cardiac devices and does not result in an increased rate of infections.
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Affiliation(s)
- Ju Hee Kim
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jessica Mason
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | | | - Christine S Ji
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | | | - Edmond J Solomon
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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14
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Nanna MG, Sutton NR, Kochar A, Rymer JA, Lowenstern AM, Gackenbach G, Hummel SL, Goyal P, Rich MW, Kirkpatrick JN, Krishnaswami A, Alexander KP, Forman DE, Bortnick AE, Batchelor W, Damluji AA. Assessment and Management of Older Adults Undergoing PCI, Part 1: A JACC: Advances Expert Panel. JACC. ADVANCES 2023; 2:100389. [PMID: 37584013 PMCID: PMC10426754 DOI: 10.1016/j.jacadv.2023.100389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.
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Affiliation(s)
| | - Nadia R. Sutton
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, and Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Ajar Kochar
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Grace Gackenbach
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Scott L. Hummel
- University of Michigan School of Medicine and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Michael W. Rich
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - James N. Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California, USA
| | | | - Daniel E. Forman
- Divisions of Geriatrics and Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh GRECC, Pittsburgh, Pennsylvania, USA
| | - Anna E. Bortnick
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Abdulla A. Damluji
- Inova Center of Outcomes Research, Fairfax, Virginia, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Fortuni F, Zilio F, Iannopollo G, Ciliberti G, Trambaiolo P, Ceriello L, Musella F, Scicchitano P, Albani S, Di Fusco SA, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. Management of temporary mechanical circulatory support devices in cath-lab and cardiac intensive care unit. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2023; 1:qyad011. [PMID: 39044800 PMCID: PMC11195697 DOI: 10.1093/ehjimp/qyad011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2024]
Abstract
Different temporary mechanical circulatory support (tMCS) devices are available and can be used to maintain end-organ perfusion while reducing cardiac work and myocardial oxygen demand. tMCS can provide support to the right ventricle, left ventricle, or both, and its use can be considered in emergency situations such as cardiogenic shock or in elective procedures such as high-risk percutaneous coronary intervention to prevent haemodynamic deterioration. Invasive and, most importantly, non-invasive haemodynamic parameters should be taken into account when choosing the type of tMCS device and its initiation and weaning timing, determining the need for a device upgrade, and screening for complications. In this context, ultrasound tools, specifically echocardiography, can provide important data. This review aims to provide a description of the different tMCS devices, the invasive and non-invasive tools and parameters to guide their management, and their advantages and drawbacks.
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Affiliation(s)
- Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, via Massimo Arcamone, CAP 06034, Foligno (PG), Italy
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2330RC Leiden, The Netherlands
| | - Filippo Zilio
- Department of Cardiology, Santa Chiara Hospital, Trento, Italy
| | - Gianmarco Iannopollo
- Department of Cardiology, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | | | - Laura Ceriello
- Cardiology Department, Ospedale Civile G. Mazzini, Teramo, Italy
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | | | - Stefano Albani
- Division of Cardiology, U. Parini Hospital, Aosta, Italy
- Department of Cardiology, Cardiovascular Institute Paris Sud, Massy, France
| | | | | | - Domenico Gabrielli
- Cardio-Toraco-Vascular Department, San Camillo-Forlanini Hospital, Rome, Italy
- Heart Care Foundation, Florence, Italy
| | - Fabrizio Oliva
- Cardiologia 1, A. De Gasperis Cardicocenter, ASST Niguarda, Milan, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, Rome, Italy
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16
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Hisham M, Ghalib HH, Kakar V, Kumar GP, Bader F, Atallah B. Anticoagulation practices and complications associated with Impella® support at an advanced cardiac center in the Middle East gulf region. J Thromb Thrombolysis 2023:10.1007/s11239-023-02807-9. [PMID: 37097552 DOI: 10.1007/s11239-023-02807-9] [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: 04/01/2023] [Indexed: 04/26/2023]
Abstract
Anticoagulation during Impella® support is a challenge due to its complications and inconsistent practice across the globe. This observational, retrospective chart review included all patients with Impella® support at our advanced cardiac center at a quaternary care hospital in the Middle East gulf region. The study was conducted over six years (2016-2022), a time period during which manufacturer recommendations for purge solution, anticoagulation protocols as well as Impella® place in therapy and utilization were all evolving. We aimed to evaluate the efficacy of different anticoagulation practices and association with complications and outcomes. Forty-one patients underwent Impella® during the study period, including 25 patients with support for more than 12 h, and are the focus of our analysis. Cardiogenic shock (n = 25, 60.9%) was the primary indication for Impella®, followed by facilitating high-risk PCI (n = 15, 36.7%) and left ventricular afterload reduction in patients undergoing veno-arterial extracorporeal membrane oxygenation (n = 1, 2.4%). Our overall Impella® usage evolved over the years from a primary use to facilitate a high-risk PCI to the recent more common use of LV unloading in cardiogenic shock. No patients experienced device malfunction and the incidence of other complications including ischemic stroke and bleeding were comparable to those reported in the literature (12.2% and 24% respectively). The 30-day all-cause mortality of 41 patients was 53.6%. In line with the evolving recommendations and evidence, we observed an underutilization of non-heparin-based purge solutions and inconsistent management of anticoagulation in the setting of both Impella® and VA ECMO which necessitates more education and protocols.
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Affiliation(s)
- Mohamed Hisham
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Hussam H Ghalib
- Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - Vivek Kakar
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - G Praveen Kumar
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - Feras Bader
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - Bassam Atallah
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
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17
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Salter BS, Gross CR, Weiner MM, Dukkipati SR, Serrao GW, Moss N, Anyanwu AC, Burkhoff D, Lala A. Temporary mechanical circulatory support devices: practical considerations for all stakeholders. Nat Rev Cardiol 2023; 20:263-277. [PMID: 36357709 PMCID: PMC9649020 DOI: 10.1038/s41569-022-00796-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 11/12/2022]
Abstract
Originally intended for life-saving salvage therapy, the use of temporary mechanical circulatory support (MCS) devices has become increasingly widespread in a variety of clinical settings in the contemporary era. Their use as a short-term, prophylactic support vehicle has expanded to include procedures in the catheterization laboratory, electrophysiology suite, operating room and intensive care unit. Accordingly, MCS device design and technology continue to develop at a rapid pace. In this Review, we describe the functionality, indications, management and complications associated with temporary MCS, together with scenario-specific utilization, goal-directed development and bioengineering of future devices. We address various considerations for the use of temporary MCS devices in both prophylactic and rescue scenarios, with input from stakeholders from various cardiovascular specialties, including interventional and heart failure cardiology, electrophysiology, cardiothoracic anaesthesiology, critical care and cardiac surgery.
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Affiliation(s)
- Benjamin S Salter
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Caroline R Gross
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Menachem M Weiner
- Department of Anaesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregory W Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Noah Moss
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
| | - Anelechi C Anyanwu
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
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18
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Worku ET, Win AM, Parmar D, Anstey C, Shekar K. Haematological Trends and Transfusion during Adult Extracorporeal Membrane Oxygenation: A Single Centre Study. J Clin Med 2023; 12:2629. [PMID: 37048711 PMCID: PMC10095131 DOI: 10.3390/jcm12072629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
The temporal trends in haematological parameters and their associations with blood product transfusion requirements in patients supported with extracorporeal membrane oxygenation (ECMO) are poorly understood. We performed a retrospective data analysis to better understand the behaviour of haematological and coagulation parameters and their associations with transfusion requirements during ECMO. METHODS Patient demographics, haematological and coagulation parameters, plasma haemoglobin and fibrinogen concentrations, platelet count, the international normalised ratio (INR), the activated partial thromboplastin time (APTT), and blood product transfusion data from 138 patients who received ECMO in a single high-volume centre were analysed. RESULTS Ninety-two patients received venoarterial (VA) ECMO and 46 patients received venovenous (VV) ECMO. The median (IQR) duration of VA, and VV ECMO was 8 (5-13) days and 13 (8-23) days, respectively. There were significant reductions in haemoglobin, the platelet count, and the fibrinogen concentration upon initiation of ECMO. On average, over time, patients on VV ECMO had platelet counts 44 × 109/L higher than those on VA ECMO (p ≤ 0.001). Fibrinogen and APTT did not vary significantly based on the mode of ECMO (p = 0.55 and p = 0.072, respectively). A platelet count < 50 × 109/L or a fibrinogen level < 1.8 g/L was associated with 50% chance of PRBC transfusion, regardless of the ECMO type, and packed red blood cell (PRBC) transfusion was more common with VA ECMO. APTT was predictive of the transfusion requirement, and the decrement in APTT was discriminatory between VVECMO survivors and nonsurvivors. CONCLUSION ECMO support is associated with reductions in haemoglobin, platelet count, and fibrinogen. Patients supported with VA ECMO are more likely to receive a PRBC transfusion compared to those on VV ECMO. Thrombocytopaenia, hypofibrinogenaemia, and anticoagulation effect the likelihood of requiring PRBC transfusion. Further research is needed to define optimal blood management during ECMO, including appropriate transfusion triggers and the anticoagulation intensity.
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Affiliation(s)
- Elliott T. Worku
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
| | - April M. Win
- Intensive Care Unit, The Townsville Hospital, Townsville, QLD 4810, Australia
| | - Dinesh Parmar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
| | - Chris Anstey
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, University of Queensland, St Lucia, QLD 4072, Australia
- Faculty of Medicine, Bond University, Gold Coast, QLD 4226, Australia
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19
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Romero CM, Shafi I, Patil A, Secemsky E, Weinburg I, Kolluri R, Zhao H, Lakther V, Bashir R. Incidence and predictors of acute limb ischemia in acute myocardial infarction complicated by cardiogenic shock. J Vasc Surg 2023; 77:906-912.e4. [PMID: 36400364 DOI: 10.1016/j.jvs.2022.11.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the incidence and predictors of acute limb ischemia (ALI) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). METHODS Patients with index hospitalizations for AMI complicated by cardiogenic shock from 2016 to 2019 in the US National Readmission Database were identified. We evaluated the incidence of ALI and its associated mortality, length of stay, and cost of hospitalization. We used multivariable logistic regression to determine independent predictors of ALI in this population. RESULTS A total of 84,615 patients had AMI complicated by cardiogenic shock and 1302 (1.54%) developed ALI. The rates of ALI increased from 1.29% in 2016 to 1.66% in 2019 (P ≤ .002). The use of microaxial mechanical circulatory support increased from 2.25% in 2016 to 13.36% in 2019 (P = .0001). The major predictors of ALI included peripheral arterial disease (odds ratio [OR], 7.34; 95% confidence interval [CI], 6.12-8.81), venoarterial extracorporeal membrane oxygenation (OR, 4.40; 95% CI, 3.19-6.07), and microaxial mechanical circulatory support (OR, 3.12; 95% CI, 2.74-3.55). ALI in patients with cardiogenic shock was associated higher mortality (39.20% vs 33.53%; P ≤ .0001). CONCLUSIONS This nationwide observational study shows that ALI is an important complication of AMI with cardiogenic shock. This complication is associated with higher mortality. In addition to peripheral artery disease, the use of mechanical circulatory devices was associated with significantly higher rates of ALI.
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Affiliation(s)
- Carlos M Romero
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Irfan Shafi
- Division of Cardiovascular Medicine, Wayne State University/DMC, Detroit, MI
| | - Aadhar Patil
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Eric Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ido Weinburg
- VASCORE, Massachusetts General Hospital, Boston, MA
| | - Raghu Kolluri
- Vascular Medicine & Vascular Labs, OhioHealth, Columbus, OH
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Vladimir Lakther
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
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20
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Anticoagulation Strategies in Temporary Mechanical Circulatory Support. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023. [DOI: 10.1007/s11936-023-00978-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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21
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Dwaah H, Jain N, Kapur NK, Ortoleva JP, Chweich H, Couper GS, Kawabori M. The impact of temporary mechanical circulatory support strategies on thrombocytopenia. J Crit Care 2023; 73:154216. [PMID: 36434833 DOI: 10.1016/j.jcrc.2022.154216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/06/2022] [Accepted: 10/29/2022] [Indexed: 11/24/2022]
Abstract
One common but not well-understood phenomenon of temporary mechanical circulatory support (MCS) use is thrombocytopenia. This clinical issue increases the risk of bleeding and the need for platelet transfusion. Additionally, heparin-induced thrombocytopenia must be considered as part of the differential diagnosis, which complicates patient management. In what follows, we analyze the degree and relative rate of platelet count drop with various temporary MCS strategies - Impella 5.5; Veno-venous Extracorporeal Membrane Oxygenation (VV ECMO); Veno-arterial ECMO (VA ECMO); Intra-aortic Balloon Pump (IABP) and Centrimag Biventricular Assist Device (BIVAD). A total of 337 cohort was investigated. 77 was included for analysis after strict exclusion criteria were utilized (platelet transfusions, bleeding complications, etc.). Repeated measure mixed effect and linear regression models were used to assess the percent platelet drop on implantation of MCS and recovery after explantation of MCS. A statistically significant mean percent drop occurred in MCS types - VA ECMO(-69.6%, p < 0.001), VV ECMO(-40.9%, p < 0.001), Impella 5.5(-20.9%, p = 0.01) and IABP(-28.3%, p = 0.01), except Centrimag BIVAD(-6.5%, p = 0.61). Platelet recovery to or above baseline occurred in VA ECMO(+107.0%, p = 0.42), Impella 5.5(+117.2%, p = 0.28), IABP(+108.3%, p = 0.37), VV-ECMO(163.3%, p = 0.01*) and Centrimag BIVAD(+100.1%, p = 0.99). These results show that the degree of thrombocytopenia depends on MCS device type and is reversible.
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Affiliation(s)
- Henry Dwaah
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Nupur Jain
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Navin K Kapur
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Jamel P Ortoleva
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Haval Chweich
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Gregory S Couper
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA
| | - Masashi Kawabori
- The CardioVascular Center, Tufts Medical Center, Boston, MA 02111, USA.
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22
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Chung K, Parker WF. A bridge to nowhere: The durable left ventricular assist device dilemma in the new heart allocation system. J Heart Lung Transplant 2023; 42:87-88. [PMID: 36437169 PMCID: PMC10792764 DOI: 10.1016/j.healun.2022.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/12/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kevin Chung
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - William F Parker
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois; Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Department of Medicine, University of Chicago, Chicago, Illinois.
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23
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Muacevic A, Adler JR, Upadhyay HV, Konat A, Zalavadia P, Padaniya A, Patel P, Patel N, Prajjwal P, Sharma K. Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock. Cureus 2023; 15:e33372. [PMID: 36751242 PMCID: PMC9898582 DOI: 10.7759/cureus.33372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literature and examined various modalities pertaining to the use of ECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.
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24
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Damluji AA, Tehrani B, Sinha SS, Samsky MD, Henry TD, Thiele H, West NEJ, Senatore FF, Truesdell AG, Dangas GD, Smilowitz NR, Amin AP, deVore AD, Moazami N, Cigarroa JE, Rao SV, Krucoff MW, Morrow DA, Gilchrist IC. Position Statement on Vascular Access Safety for Percutaneous Devices in AMI Complicated by Cardiogenic Shock. JACC Cardiovasc Interv 2022; 15:2003-2019. [PMID: 36265932 PMCID: PMC10312149 DOI: 10.1016/j.jcin.2022.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 01/09/2023]
Abstract
In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.
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Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
| | - Behnam Tehrani
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Marc D Samsky
- New York University School of Medicine, New York, New York, USA
| | - Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education, Christ Hospital, Cincinnati, Ohio, USA
| | - Holger Thiele
- Heart Center Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | | | - Fortunato F Senatore
- Division of Cardiology and Nephrology, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Alexander G Truesdell
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - George D Dangas
- Division of Cardiology, Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | | | - Amit P Amin
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Adam D deVore
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nader Moazami
- New York University School of Medicine, New York, New York, USA
| | | | - Sunil V Rao
- New York University School of Medicine, New York, New York, USA
| | | | - David A Morrow
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ian C Gilchrist
- Penn State Heart and Vascular Institute, Hershey Medical Center, Hershey, Pennsylvania, USA
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25
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Tavazzi G, Dammassa V, Colombo CNJ, Arbustini E, Castelein T, Balik M, Vandenbriele C. Mechanical circulatory support in ventricular arrhythmias. Front Cardiovasc Med 2022; 9:987008. [PMID: 36304552 PMCID: PMC9593033 DOI: 10.3389/fcvm.2022.987008] [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: 07/05/2022] [Accepted: 09/15/2022] [Indexed: 11/27/2022] Open
Abstract
In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.
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Affiliation(s)
- Guido Tavazzi
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy,Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,*Correspondence: Guido Tavazzi
| | - Valentino Dammassa
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy,Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | | | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thomas Castelein
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, First Medical Faculty and General University Hospital, Charles University in Prague, Prague, Czechia
| | - Christophe Vandenbriele
- Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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26
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Evaluation of Thrombocytopenia in Patients Receiving Percutaneous Mechanical Circulatory Support With an Impella Device. Crit Care Explor 2022; 4:e0772. [PMID: 36248319 PMCID: PMC9553399 DOI: 10.1097/cce.0000000000000772] [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] [Indexed: 11/05/2022] Open
Abstract
Evaluate the time course of thrombocytopenia in patients with Impella devices (Abiomed, Danvers, MA).
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27
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González LS, Grady M. Intra-aortic balloon pump counterpulsation: technical function, management, and clinical indications. Int Anesthesiol Clin 2022; 60:16-23. [PMID: 35975922 DOI: 10.1097/aia.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Laura S González
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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28
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Hess NR, Ziegler LA, Kaczorowski DJ. The 10 Commandments of Microaxial Temporary Left Ventricular Assist Devices. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:368-376. [PMID: 36524534 DOI: 10.1177/15569845221134514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA, USA
| | - Luke A Ziegler
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA, USA
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, PA, USA
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29
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Geller BJ, Sinha SS, Kapur NK, Bakitas M, Balsam LB, Chikwe J, Klein DG, Kochar A, Masri SC, Sims DB, Wong GC, Katz JN, van Diepen S. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e50-e68. [PMID: 35862152 DOI: 10.1161/cir.0000000000001076] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.
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30
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Voigt I, Mighali M, Manda D, Aurich P, Bruder O. Radiographic assessment of lung edema (RALE) score is associated with clinical outcomes in patients with refractory cardiogenic shock and refractory cardiac arrest after percutaneous implantation of extracorporeal life support. Intern Emerg Med 2022; 17:1463-1470. [PMID: 35169942 DOI: 10.1007/s11739-022-02937-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/19/2022] [Indexed: 01/27/2023]
Abstract
VA-ECMO is a promising therapeutic option in refractory cardiogenic shock (RCS) and refractory cardiac arrest (RCA). However, increase in left ventricular afterload enhances further reduction of LV contractility and pulmonary edema. The aim of this study was to evaluate pulmonary edema based on the RALE score and the prognostic value of the score on ECLS weaning and mortality. In this retrospective study, data from 40 patients (16 RCAs and 24 RCSs) were analyzed. Demographic, clinical data and the RALE score for evaluating pulmonary edema were assessed. Descriptive statistics, intraclass correlation, and receiver operating characteristic (ROC) curves were computed. Weaning from ECLS was successful in 30 (75%) patients, 16 patients (40%) were discharged alive. Overall, the survivors were younger, presenting with a higher left ventricular ejection fraction (30 ± 2% vs.23 ± 9%;p < 0.01) and a lower initial serum lactate concentration 7.7 ± 4.5 mmol/l vs. 11.5 ± 4.9 mmol/l; p = 0.017). Survivors had lower RALE scores than non-survivors (16.3 ± 9.4 vs. 26.4 ± 10.4; p = 0.0034). The interobserver variability of the RALE score was good (0.832). The AUC predicting mortality and weaning from ECLS presented comparable results to the established parameters (SAVE, serum lactate). Implementation of the RALE score could support prediction of outcome parameters during VA-ECMO therapy.
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Affiliation(s)
- Ingo Voigt
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany.
- Ruhr-University, Bochum, Germany.
| | - Marco Mighali
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany
| | - Daniela Manda
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany
| | - Phillip Aurich
- Department of Acute and Emergency Medicine, Elisabeth-Hospital Essen, Essen, Germany
- Department of Cardiology and Angiology, Elisabeth-Hospital Essen, Essen, Germany
| | - Oliver Bruder
- Department of Cardiology and Angiology, Elisabeth-Hospital Essen, Essen, Germany
- Ruhr-University, Bochum, Germany
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31
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Papolos AI, Barnett CF, Tuli A, Vavilin I, Kenigsberg BB. Impella Management for the Cardiac Intensivist. ASAIO J 2022; 68:753-758. [PMID: 35184086 DOI: 10.1097/mat.0000000000001680] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The Impella mechanical circulatory support (MCS) system is a catheter-based continuous flow cardiac assist device that is widely used in the treatment of cardiogenic shock in medical and surgical cardiac intensive care units. As with all forms of MCS, device-related complications remain a major concern, the incidence of which can be mitigated by adhering to a few fundamental concepts in device management. The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter.
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Affiliation(s)
- Alexander I Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC
| | - Christopher F Barnett
- Department of Medicine, University of California, San Francisco, USA; Division of Cardiology, San Francisco, California
| | - Aakash Tuli
- Department of Medicine, MedStar Georgetown University, Washington, DC
| | - Ilan Vavilin
- Department of Medicine, MedStar Georgetown University, Washington, DC
| | - Benjamin B Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC
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32
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Patlolla SH, Kandlakunta H, Kuchkuntla AR, West CP, Murad MH, Wang Z, Kochar A, Rab ST, Gersh BJ, Holmes DR, Zhao DX, Vallabhajosyula S. Newer P2Y 12 Inhibitors vs Clopidogrel in Acute Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock: A Systematic Review and Meta-analysis. Mayo Clin Proc 2022; 97:1074-1085. [PMID: 35662424 DOI: 10.1016/j.mayocp.2022.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/18/2022] [Accepted: 02/15/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the outcomes, safety, and efficacy of dual antiplatelet therapy (DAPT) with newer P2Y12 inhibitors compared with clopidogrel in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) or cardiogenic shock (CS). PATIENTS AND METHODS MEDLINE, EMBASE, and the Cochrane Library were queried systematically from inception to January 2021 for comparative studies of adults (≥18 years) with AMI-CA/CS receiving DAPT with newer P2Y12 inhibitors as opposed to clopidogrel. We compared outcomes (30-day or in-hospital and 1-year all-cause mortality, major bleeding, and definite stent thrombosis) of newer P2Y12 inhibitors and clopidogrel in patients with AMI-CA/CS. RESULTS Eight studies (1 randomized trial and 7 cohort studies) comprising 1100 patients (695 [63.2%] receiving clopidogrel and 405 [36.8%] receiving ticagrelor or prasugrel) were included. The population was mostly male (68.5%-86.7%). Risk of bias was low for these studies, with between-study heterogeneity and subgroup differences not statistically significant. Compared with the clopidogrel cohort, the newer P2Y12 cohort had lower rates of early mortality (odds ratio [OR], 0.60; 95% CI, 0.45 to 0.81; P=.001) (7 studies) and 1-year mortality (OR, 0.51; 95% CI, 0.36 to 0.71; P<.001) (3 studies). We did not find a significant difference in major bleeding (OR, 1.21; 95% CI, 0.71 to 2.06; P=.48) (6 studies) or definite stent thrombosis (OR, 2.01; 95% CI, 0.63 to 6.45; P=.24) (7 studies). CONCLUSION In patients with AMI-CA/CS receiving DAPT, compared with clopidogrel, newer P2Y12 inhibitors were associated with lower rates of early and 1-year mortality. Data on major bleeding and stent thrombosis were inconclusive.
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Affiliation(s)
- Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Harika Kandlakunta
- Department of Medicine, Staten Island University Hospital, Staten Island, NY
| | | | - Colin P West
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Department of Medicine, Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ajar Kochar
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - S Tanveer Rab
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David X Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.
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33
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Masiero G, Cardaioli F, Tarantini G. Mechanical circulatory support in cardiogenic shock: a critical appraisal. Expert Rev Cardiovasc Ther 2022; 20:443-454. [PMID: 35587216 DOI: 10.1080/14779072.2022.2078702] [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] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encounter in patients with multivessel coronary artery disease (MVD). AREAS COVERED Despite prompt revascularization, in particular percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for CS related to AMI remains high. Differently from hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested in AMI-CS patients, based on the results of a recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have raised as a key therapeutic option in CS, especially in case of an early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of current evidences on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of MCS devices, and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes. EXPERT OPINION Emerging observational experience suggested that an early implantation of MCS (prior to PCI), the performance of an extensive revascularization and the implementation of shock teams and networks are key factors for improving clinical outcomes.
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Affiliation(s)
- Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
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Chahdi HO, Berbach L, Boivin-Proulx LA, Hillani A, Noiseux N, Matteau A, Mansour S, Gobeil F, Nauche B, Jolicoeur EM, Potter BJ. Percutaneous Mechanical Circulatory Support in Post-Myocardial Infarction Cardiogenic Shock: A Systematic Review and Meta-Analysis. Can J Cardiol 2022; 38:1525-1538. [DOI: 10.1016/j.cjca.2022.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/15/2022] [Accepted: 05/16/2022] [Indexed: 02/01/2023] Open
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Vallabhajosyula S, Kumar V, Sundaragiri PR, Cheungpasitporn W, Miller PE, Patlolla SH, Gersh BJ, Lerman A, Jaffe AS, Shah ND, Holmes DR, Bell MR, Barsness GW. Management and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Uninsured Compared With Privately Insured Individuals. Circ Heart Fail 2022; 15:e008991. [PMID: 35240866 PMCID: PMC9930186 DOI: 10.1161/circheartfailure.121.008991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are limited data on uninsured patients presenting with acute myocardial infarction-cardiogenic shock (AMI-CS). This study sought to compare the management and outcomes of AMI-CS between uninsured and privately insured individuals. METHODS Using the National Inpatient Sample (2000-2016), a retrospective cohort of adult (≥18 years) uninsured admissions (primary payer-self-pay or no charge) were compared with privately insured individuals. Interhospital transfers were excluded. Outcomes of interest included in-hospital mortality, temporal trends in admissions, use of cardiac procedures, do-not-resuscitate status, palliative care referrals, and resource utilization. RESULTS Of 402 182 AMI-CS admissions, 21 966 (5.4%) and 93 814 (23.3%) were uninsured and privately insured. Compared with private insured individuals, uninsured admissions were younger, male, from a lower socioeconomic status, had lower comorbidity, higher rates of acute organ failure, ST-segment elevation AMI-CS (77.3% versus 76.4%), and concomitant cardiac arrest (33.8% versus 31.9%; all P<0.001). Compared with 2000, in 2016, there were more uninsured (adjusted odds ratio, 1.15 [95% CI, 1.13-1.17]; P<0.001) and less privately insured admissions (adjusted odds ratio, 0.85 [95% CI, 0.83-0.87]; P<0.001). Uninsured individuals received less frequent coronary angiography (79.5% versus 81.0%), percutaneous coronary intervention (60.8% versus 62.2%), mechanical circulatory support (54% versus 55.5%), and had higher palliative care (3.8% versus 3.2%) and do-not-resuscitate status use (4.4% versus 3.2%; all P<0.001). Uninsured admissions had higher in-hospital mortality (adjusted odds ratio, 1.62 [95% CI, 1.55-1.68]; P<0.001) and resource utilization. CONCLUSIONS Uninsured individuals have higher in-hospital mortality and lower use of guideline-directed therapies in AMI-CS compared with privately insured individuals.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Vinayak Kumar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, North Carolina
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota,Department of Health Services Research, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Rajpal S, Kahwash R, Tong MS, Paschke K, Satoskar AA, Foreman B, Allen LA, Bhave NM, Gluckman TJ, Fuster V. Fulminant Myocarditis Following SARS-CoV-2 Infection. JACC Case Rep 2022; 4:567-575. [PMID: 35373150 PMCID: PMC8961314 DOI: 10.1016/j.jaccas.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 12/03/2022]
Abstract
A 60-year-old woman with a past medical history of asthma presented with fulminant myocarditis 9 days after testing positive for SARS-CoV-2 and 16 days after developing symptoms consistent with COVID-19. Her hospital course was complicated by the need for veno-arterial extracorporeal membrane oxygenation, ventricular arrhythmias, and pseudomonas bacteremia. She ultimately recovered and was discharged to home with normal left ventricular systolic function. Thereafter, she developed symptomatic ventricular tachycardia, for which she received an implantable cardioverter-defibrillator and antiarrhythmic drug therapy.
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Nishi T, Ishii M, Tsujita K, Okamoto H, Koto S, Nakai M, Sumita Y, Iwanaga Y, Matoba S, Kobayashi Y, Hirata KI, Hikichi Y, Yokoi H, Ikari Y, Uemura S. Outcomes of Venoarterial Extracorporeal Membrane Oxygenation Plus Intra-Aortic Balloon Pumping for Treatment of Acute Myocardial Infarction Complicated by Cardiogenic Shock. J Am Heart Assoc 2022; 11:e023713. [PMID: 35377180 PMCID: PMC9075437 DOI: 10.1161/jaha.121.023713] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Clinical outcomes of acute myocardial infarction complicated by cardiogenic shock remain poor with high in‐hospital mortality. Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) has been widely used for patients with acute myocardial infarction complicated by cardiogenic shock refractory to conservative therapy, which is likely fatal without mechanical circulatory support. However, whether additional intra‐aortic balloon pumping (IABP) use during VA‐ECMO support improves clinical outcomes remains controversial. This study sought to investigate prognostic impact of the combined VA‐ECMO plus IABP treatment compared with VA‐ECMO alone. Methods and Results From the nationwide Japanese administrative case‐mix Diagnostic Procedure Combination (DPC), the JROAD (Japanese Registry of All Cardiac and Vascular Diseases)–DPC, we identified 3815 patients with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention and managed with VA‐ECMO. Of these, 2964 patients (77.7%) were managed with IABP (VA‐ECMO plus IABP), whereas 851 (22.3%) were managed without IABP (VA‐ECMO alone). We compared in‐hospital, 7‐day, and 30‐day mortality between the VA‐ECMO plus IABP versus the VA‐ECMO alone support. Patients managed with VA‐ECMO plus IABP demonstrated significantly lower in‐hospital, 7‐day, and 30‐day mortality than those managed with VA‐ECMO alone (adjusted odds ratios [95% CI] of 0.47 [95% CI, 0.38–0.59], 0.41 [95% CI, 0.33–0.51], and 0.30 [95% CI, 0.25–0.37], respectively). The findings were consistent in the propensity matching and inverse probability of treatment‐weighting models. Conclusions This large‐scale, nationwide study demonstrated that the combination of VA‐ECMO plus IABP support was associated with significantly lower mortality compared with VA‐ECMO support alone in patients presenting with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention.
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Affiliation(s)
- Takeshi Nishi
- Department of Cardiology Kawasaki Medical School Kurashiki Okayama Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine Graduate School of Medical Sciences Kumamoto University Kumamoto City Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine Graduate School of Medical Sciences Kumamoto University Kumamoto City Japan
| | - Hiroshi Okamoto
- Department of Cardiology Kawasaki Medical School Kurashiki Okayama Japan
| | - Satoshi Koto
- Department of Cardiology Kawasaki Medical School Kurashiki Okayama Japan
| | | | - Yoko Sumita
- National Cerebral and Cardiovascular Center Suita Japan
| | | | - Satoaki Matoba
- Department of Cardiovascular Medicine Graduate School of Medical Science Kyoto Prefectural University of Medicine Kyoto Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Japan
| | - Yutaka Hikichi
- Department of Cardiology Saga-Ken Medical Centre Koseikan Saga Japan
| | | | - Yuji Ikari
- Department of Cardiovascular Medicine Tokai University School of Medicine Isehara Japan
| | - Shiro Uemura
- Department of Cardiology Kawasaki Medical School Kurashiki Okayama Japan
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Peripheral Artery Disease. J Am Coll Cardiol 2022; 79:1236-1238. [DOI: 10.1016/j.jacc.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/19/2022]
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Attinger-Toller A, Bossard M, Cioffi GM, Tersalvi G, Madanchi M, Bloch A, Kobza R, Cuculi F. Ventricular Unloading Using the Impella TM Device in Cardiogenic Shock. Front Cardiovasc Med 2022; 9:856870. [PMID: 35402561 PMCID: PMC8984099 DOI: 10.3389/fcvm.2022.856870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiogenic shock (CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.
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Affiliation(s)
- Adrian Attinger-Toller
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland,*Correspondence: Adrian Attinger-Toller
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Gregorio Tersalvi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mehdi Madanchi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Richard Kobza
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Florim Cuculi
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
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Lemor A, Dabbagh MF, Cohen D, Villablanca P, Tehrani B, Alaswad K, Alqarqaz M, Lasorda D, Kaki A, Genereux P, O'Neill W, Basir MB. Rates and impact of vascular complications in mechanical circulatory support. Catheter Cardiovasc Interv 2022; 99:1702-1711. [PMID: 35266287 DOI: 10.1002/ccd.30150] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices are increasingly used for hemodynamic support in cardiogenic shock or high-risk percutaneous coronary interventions. Vascular complications remain a major source of morbidity and mortality despite technological advances with percutaneous techniques. Little is known about the rates and predictors of vascular complications with large-bore access MCS in the contemporary era. METHODS The study cohort was derived from National Inpatient Sample using data from 2015 to 2019 for cardiac hospitalizations with the use of: intra-aortic balloon pump (IABP) Impella, and/or extracorporeal membrane oxygenation (ECMO). The rates of vascular complications and in-hospital outcomes were analyzed using multivariable logistic regression. RESULTS Of 221,700 hospitalizations with MCS use, the majority had only IABP (68%). The rates of vascular complications were greatest with ECMO (15.8%) when compared with IABP (3.0%) and Impella (5.6%). Among patients with vascular complications, in-hospital mortality was higher with ECMO (56.3%) when compared with IABP (26.2%) and Impella (33.8%). Peripheral arterial disease (PAD) was the strongest predictor of vascular complications, with 10 times higher odds when present (adjusted odds ratio [aOR] 10.96, p < 0.001). In risk-adjusted models, when compared with IABP, the use of Impella (aOR: 1.73, p < 0.001), ECMO (aOR: 5.35, p < 0.001), or a combination of MCS devices (aOR: 3.47, p < 0.001) was associated with higher odds of vascular complications. CONCLUSIONS In contemporary practice, the use of MCS is associated with significant vascular complications and in-hospital mortality. Predictors of vascular complications include larger arteriotomy size, female gender, and peripheral arterial disease. Vascular access management remains essential to prevent major complications.
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Affiliation(s)
- Alejandro Lemor
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mohammed F Dabbagh
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - David Cohen
- Saint Francis Hospital, Roslyn, NY, and Cardiovascular Research Foundation, New York, New York, USA
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Behnam Tehrani
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Khaldoon Alaswad
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mohammad Alqarqaz
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - David Lasorda
- Department of Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Amir Kaki
- Department of Cardiology, Ascension St. John Hospital-Detroit, Detroit, Michigan, USA
| | - Philippe Genereux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - William O'Neill
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Mir B Basir
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
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Vallabhajosyula S, Dewaswala N, Sundaragiri PR, Bhopalwala HM, Cheungpasitporn W, Doshi R, Miller PE, Bell MR, Singh M. Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction: An 18-Year Analysis of Temporal Trends, Epidemiology, Management, and Outcomes. Shock 2022; 57:360-369. [PMID: 34864781 DOI: 10.1097/shk.0000000000001895] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS). METHODS Adult (>18 years) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS In ∼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; P < 0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all P < 0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all P < 0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; P < 0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (P > 0.05). CONCLUSIONS In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Nakeya Dewaswala
- Department of Medicine, University of Miami/JFK Medical Center Palm Beach Regional GME Consortium, Miami, Florida
| | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, North Carolina
| | | | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajkumar Doshi
- Division of Cardiovascular Medicine, Department of Medicine, Saint Joseph University Medical Center, Paterson, New Jersey
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Rajpal S, Kahwash R, Tong MS, Paschke K, Satoskar AA, Foreman B, Allen LA, Bhave NM, Gluckman TJ, Fuster V. Fulminant Myocarditis Following SARS-CoV-2 Infection: JACC Patient Care Pathways. J Am Coll Cardiol 2022; 79:2144-2152. [PMID: 35364210 PMCID: PMC8961313 DOI: 10.1016/j.jacc.2022.03.346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Saurabh Rajpal
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
| | - Rami Kahwash
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew S Tong
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kelly Paschke
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anjali A Satoskar
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Beth Foreman
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nicole M Bhave
- Division of Cardiology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research, and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon, USA
| | - Valentin Fuster
- The Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
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Shankar A, Gurumurthy G, Sridharan L, Gupta D, Nicholson WJ, Jaber WA, Vallabhajosyula S. A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2022; 16:11795468221075064. [PMID: 35153521 PMCID: PMC8829716 DOI: 10.1177/11795468221075064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.
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Affiliation(s)
- Aditi Shankar
- Department of Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA
| | | | - Lakshmi Sridharan
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Divya Gupta
- Section of Heart Failure and Cardiac Transplantation, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Saraschandra Vallabhajosyula
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Vallabhajosyula S, Bhopalwala HM, Sundaragiri PR, Dewaswala N, Cheungpasitporn W, Doshi R, Prasad A, Sandhu GS, Jaffe AS, Bell MR, Holmes DR. Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study. Am Heart J 2022; 244:54-65. [PMID: 34774802 DOI: 10.1016/j.ahj.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/05/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio 2.03 [95% confidence interval 1.97-2.09]; P < .001). Rates of non-cardiac organ failure and cardiac arrest increased during the study period. Between 2000 and 2017, coronary angiography (43.9%-63.9%), early coronary angiography (13.6%-25.6%), percutaneous coronary intervention (14.8%-31.6%), and coronary artery bypass grafting use (19.0%-25.8%) increased (P < .001). Over the study period, the use of intra-aortic balloon pump remained stable (28.6%-28.8%), and both percutaneous left ventricular assist devices (0%-9.1%) and extra-corporeal membrane oxygenation (0.1%-1.6%) increased (all P < .001). In hospital mortality decreased from 50.2% in 2000 to 32.3% in 2017 (adjusted odds ratio 0.27 [95% confidence interval 0.25-0.29]; P < .001). During the 18-year period, hospital lengths of stay decreased, and hospitalization costs increased. CONCLUSIONS In the United States, prevalence of CS in NSTEMI has increased 2-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and percutaneous coronary intervention increased during the study period.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC.
| | | | - Pranathi R Sundaragiri
- Department of Primary Care Internal Medicine, Wake Forest Baptist Health, High Point, NC
| | - Nakeya Dewaswala
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rajkumar Doshi
- Division of Cardiovascular Medicine, Department of Medicine, Saint Joseph University Medical Center, Paterson, NJ
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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45
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Venkataraman S, Bhardwaj A, Belford PM, Morris BN, Zhao DX, Vallabhajosyula S. Veno-Arterial Extracorporeal Membrane Oxygenation in Patients with Fulminant Myocarditis: A Review of Contemporary Literature. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:215. [PMID: 35208538 PMCID: PMC8876206 DOI: 10.3390/medicina58020215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 11/16/2022]
Abstract
Fulminant myocarditis is characterized by life threatening heart failure presenting as cardiogenic shock requiring inotropic or mechanical circulatory support to maintain tissue perfusion. There are limited data on the role of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the management of fulminant myocarditis. This review seeks to evaluate the management of fulminant myocarditis with a special emphasis on the role and outcomes with VA-ECMO use.
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Affiliation(s)
- Shreyas Venkataraman
- Department of Medicine, Barnes-Jewish Hospital, Washington University of Saint Louis, St. Louis, MO 63110, USA;
| | - Abhishek Bhardwaj
- Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH 44106, USA;
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (P.M.B.); (D.X.Z.)
| | - Benjamin N. Morris
- Section of Cardiovascular and Critical Care Anesthesia, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA;
| | - David X. Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (P.M.B.); (D.X.Z.)
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (P.M.B.); (D.X.Z.)
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Voigt I, Spangenberg T, Ibrahim T, Bradaric C, Viertel A, Tallone EM, Skurk C, Abel P, Graf J, Rinne T, Böhm J, Ghanem A, Liebetrau C. Efficacy and safety of ECG-synchronized pulsatile extracorporeal membrane oxygenation in the clinical setting: The SynCor Trial. Artif Organs 2021; 46:387-397. [PMID: 34954849 DOI: 10.1111/aor.14147] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 10/30/2021] [Accepted: 11/29/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Mechanical circulatory support (MCS) devices are increasingly used as a treatment option in resuscitation or in patients with cardiogenic shock (CS). Prophylactic implantation in high-risk percutaneous coronary interventions (HRPCI) is another upcoming indication. The i-cor ECG-synchronized cardiac assist device combines the hemodynamic support of a veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with the ability to generate a pulsatile flow and thus decreasing adverse effects of VA-ECMO on myocardial function. Aim of this study was to obtain data concerning feasibility, safety and outcomes in both indications. METHODS A total of 47 patients (34 HRPCI, 13 CS) were included in nine German centers and participated in this study. Demographic and clinical parameters, procedural as well as follow-up data were prospectively recorded and analyzed. RESULTS Device implantation and initiation of ECG-synchronized cardiac assist was technical successful in all cases and no failures of the consoles or disposable parts were observed. Furthermore, intended percutaneous coronary interventions and successful weaning from cardiac assist was achieved in 97.1% of HRPCI patients. We observed a 30d-survival of 94.1% in the HRPCI group and 69.2% in the CS group. Main complications in both groups were bleeding events (14.7% HRPCI, 23.1% CS) and critical limb ischemia (2.9% HRPCI, 38.5% CS). CONCLUSION The i-cor ECG-synchronized cardiac assist device appears safe and feasible showing clinical outcomes comparable to existing data in the setting of high-risk percutaneous coronary interventions and acute cardiogenic shock. Further prospective trials are warranted to identify optimal patient and interventional characteristics that will benefit most of this novel kind of mechanical circulatory support.
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Affiliation(s)
- Ingo Voigt
- Department of Cardiology and Angiology, Elisabeth Hospital, Essen, Germany.,Department of Acute and Emergency Medicine, Elisabeth Hospital, Essen, Germany
| | | | - Tareq Ibrahim
- Department of Internal Medicine I, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Bradaric
- Department of Internal Medicine I, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Achim Viertel
- Department of Cardiology, Asklepios Clinic Barmbek, Hamburg, Germany
| | | | - Carsten Skurk
- Medical Clinic for Cardiology, University of Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Peter Abel
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Jochen Graf
- Department of Cardiology, SLK-Klinik Heilbronn GmbH, Heilbronn, Germany
| | | | | | - Alexander Ghanem
- Department of Cardiology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany.,Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
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47
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Mechanical circulatory support in post-cardiac arrest: One two many? Resuscitation 2021; 167:390-392. [PMID: 34437993 DOI: 10.1016/j.resuscitation.2021.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022]
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Vallabhajosyula S, Desai VK, Sundaragiri PR, Cheungpasitporn W, Doshi R, Singh V, Jaffe AS, Lerman A, Barsness GW. Influence of primary payer status on non-ST-segment elevation myocardial infarction: 18-year retrospective cohort national temporal trends, management and outcomes. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1075. [PMID: 34422987 PMCID: PMC8339860 DOI: 10.21037/atm-20-5193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 01/22/2021] [Indexed: 12/25/2022]
Abstract
Background The role of insurance on outcomes in non-ST-segment-elevation myocardial infarction (NSTEMI) patients is limited in the contemporary era. Methods From the National Inpatient Sample, adult NSTEMI admissions were identified [2000–2017]. Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes included in-hospital mortality, overall and early coronary angiography, percutaneous coronary intervention (PCI), resource utilization and discharge disposition. Results Of the 7,290,565 NSTEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 62.9%, 6.1%, 24.1%, 4.6% and 2.3%, respectively. Compared to others, those with Medicare insurance older (76 vs. 53–60 years), more likely to be female (48% vs. 25–44%), of white race, and with higher comorbidity (all P<0.001). Population from the Medicare cohort had higher in-hospital mortality (5.6%) compared to the others (1.9–3.4%), P<0.001. With Medicare as referent, in-hospital mortality was higher in other {adjusted odds ratio (aOR) 1.15 [95% confidence interval (CI), 1.11–1.19]; P<0.001}, and lower in Medicaid [aOR 0.95 (95% CI, 0.92–0.97); P<0.001], private [aOR 0.77 (95% CI, 0.75–0.78); P<0.001] and uninsured cohorts [aOR 0.97 (95% CI, 0.94–1.00); P=0.06] in a multivariable analysis. Coronary angiography (overall 52% vs. 65–74%; early 15% vs. 22–27%) and PCI (27% vs. 35–44%) were used lesser in the Medicare population. The Medicare population had longer lengths of stay, lowest hospitalization costs and fewer home discharges. Conclusions Compared to other types of primary payers, NSTEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota, USA.,Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Viral K Desai
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Pranathi R Sundaragiri
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Rajkumar Doshi
- Department of Medicine, University of Nevada Reno School of Medicine, Reno, Nevada, USA
| | - Vikas Singh
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Zaiser AS, Fahrni G, Hollinger A, Knobel DT, Bovey Y, Zellweger NM, Buser A, Santer D, Pargger H, Gebhard CE, Siegemund M. Adverse Events of Percutaneous Microaxial Left Ventricular Assist Devices-A Retrospective, Single-Centre Cohort Study. J Clin Med 2021; 10:jcm10163710. [PMID: 34442010 PMCID: PMC8396891 DOI: 10.3390/jcm10163710] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/08/2021] [Accepted: 08/17/2021] [Indexed: 12/16/2022] Open
Abstract
Worldwide, the left ventricular assist device Impella® (Abiomed, Danvers, MA, USA) is increasingly implanted in patients with acute cardiogenic shock or undergoing high-risk cardiac interventions. Despite its long history of use, few studies have assessed its safety and possible complications associated with its use. All patients treated with a left-sided Impella® device at the University Hospital of Basel from 1 January 2011 to 31 December 2019 were enrolled. The primary endpoint was the composite rate of mortality and adverse events (bleeding, acute kidney injury, and limb ischemia). Out of 281 included patients, at least one adverse event was present in 262 patients (93%). Rates of in-hospital, 90-day, and one-year mortality were 48%, 47%, and 50%, respectively. BARC type 3 bleeding (62%) and hemolysis (41.6%) were the most common complications. AKI was observed in 50% of all patients. Renal replacement therapy was required in 97 (35%) of all patients. Limb ischemia occurred in 13% of cases. Bleeding and hemolysis are common Impella®-associated complications. Additionally, we found a high rate of AKI. A careful selection of patients receiving microaxial LV support and defining the indication for its use are essential measures to be taken for the benefits to outweigh potential complications.
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Affiliation(s)
- Anna S. Zaiser
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Gregor Fahrni
- Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
| | - Demian T. Knobel
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Yann Bovey
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Núria M. Zellweger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Andreas Buser
- Regional Blood Transfusion Center SRK Basel and Department of Hematology, Transfusion Medicine, University Hospital Basel, 4031 Basel, Switzerland;
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland;
| | - Hans Pargger
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
| | - Caroline E. Gebhard
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
- Correspondence: ; Tel.: +41-61-328-53-85
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, 4031 Basel, Switzerland; (A.S.Z.); (A.H.); (D.T.K.); (Y.B.); (N.M.Z.); (H.P.); (M.S.)
- Department of Clinical Research, University of Basel, 4031 Basel, Switzerland
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Weisskopf M, Kron M, Giering T, Walker T, Cesarovic N. The sheep as a pre-clinical model for testing intra-aortic percutaneous mechanical circulatory support devices. Int J Artif Organs 2021; 44:703-710. [PMID: 34405723 PMCID: PMC8450982 DOI: 10.1177/03913988211025537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
The save deployment of intra-aortic percutaneous mechanical circulatory support devices is highly dependent on the inner aortic diameter. Finding the anatomically and ethically most suitable animal model for performance testing of new pMCS devices remains challenging. For this study, an ovine model using adult ewes of a large framed breed (Swiss White Alpine Sheep) was developed to test safety, reliability, and biocompatibility of catheter-mounted mechanical support devices placed in the descending thoracic aorta. Following the drawback of fluctuating aortic diameter and device malfunction in the first four animals, the model was improved by stenting the following animals with an aortic stent. Stenting the animals with an intra-aortic over the balloon stent was found to standardize the experimental set-up and to avoid early termination of the experiment due to non-device related issues.
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Affiliation(s)
- Miriam Weisskopf
- Center of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mareike Kron
- Center of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | | | - Nikola Cesarovic
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland.,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
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