Mechanical circulatory support in patients with cardiogenic shock in intensive care units: A position paper of the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology, endorsed by the "Groupe Athérome et Cardiologie Interventionnelle" of the French Society of Cardiology

Evaluating the efficacy and safety of temporary mechanical circulatory support devices in acute cardiogenic shock: A subgroup-specific systematic review

OBJECTIVE

This systematic review aims to assess the comparative effectiveness and safety of temporary mechanical circulatory support (MCS) devices in various subgroups of patients with acute cardiogenic shock, providing insights for personalized clinical decision-making.

METHODS

We conducted a comprehensive search across major databases to identify studies that reported on the use of temporary MCS devices like TandemHeart, Impella, and VA-ECMO in acute cardiogenic shock. Special attention was given to subgroup analyses based on etiologies of shock, patient demographics, and comorbid conditions.

RESULTS

Our analysis revealed that while devices like TandemHeart and Impella offer significant hemodynamic support, their effectiveness and safety profiles vary across different patient subgroups. VA-ECMO demonstrated the highest flow rates and potential for mortality benefits but requires careful management due to associated risks. The lack of randomized controlled trials in specific patient subgroups highlights a gap in the current literature, underscoring the need for targeted research.

CONCLUSION

The review underscores the necessity of a personalized approach in selecting temporary MCS devices for patients with acute cardiogenic shock, guided by specific patient characteristics and clinical scenarios. Future research should focus on addressing the identified evidence gaps through well-designed studies that provide robust subgroup-specific data, enabling clinicians to optimize treatment strategies and improve patient outcomes in this critical care context.

Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock

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.

Budget Impact Analysis of Impella CP® Utilization in the Management of Cardiogenic Shock in France: A Health Economic Analysis

INTRODUCTION

Early detection and treatment of cardiogenic shock (CS) is crucial to avoid irreparable multiorgan damage and mortality. Impella CP® is a novel temporary mechanical circulatory support (MCS) device associated with greater hemodynamic support and significantly fewer device-related complications compared with other MCS devices, e.g., intra-aortic balloon pumps (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study evaluated the budget impact of introducing Impella CP versus IABP and VA-ECMO in patients with CS following an acute myocardial infarction (MI) in France.

METHODS

A budget impact model was developed to compare the cost of introducing Impella CP with continuing IABP and VA-ECMO treatment from a Mandatory Health Insurance (MHI) perspective in France over a 5-year time horizon, with 700 patients with refractory CS assumed to be eligible for treatment per year. Costs associated with Impella CP and device-related complications for all interventions were captured and clinical input data were based on published sources. Scenario analyses were performed around key parameters.

RESULTS

Introducing Impella CP was associated with cumulative cost savings of EUR 2.7 million over 5 years, versus continuing current clinical practice with IABP and VA-ECMO. Cost savings were achieved in every year of the analysis and driven by the lower incidence of device-related complications with Impella CP, with estimated 5-year cost savings of EUR 22.4 million due to avoidance of complications. Total cost savings of more than EUR 250,000 were projected in the first year of the analysis, which increased as the market share of Impella CP was increased. Scenario analyses indicated that the findings of the analysis were robust.

CONCLUSION

Treatment with Impella CP in adult patients aged less than 75 years in a state of refractory CS following an MI was projected to lead to substantial cost savings from an MHI perspective in France, compared with continuing current clinical practice.

Hemodynamic-based Assessment and Management of Cardiogenic Shock

Cardiogenic shock (CS) remains a deadly disease entity challenging patients, caregivers, and communities across the globe. CS can rapidly lead to the development of hypoperfusion and end-organ dysfunction, transforming a predictable hemodynamic event into a potential high-resource, intense, hemometabolic clinical catastrophe. Based on the scalable heterogeneity from a cellular level to healthcare systems in the hemodynamic-based management of patients experiencing CS, we present considerations towards systematic hemodynamic-based transitions in which distinct clinical entities share the common path of early identification and rapid transitions through an adaptive longitudinal situational awareness model of care that influences specific management considerations. Future studies are needed to best understand optimal management of drugs and devices along with engagement of health systems of care for patients with CS.

Effectiveness and Safety of a Prolonged Hemodynamic Support by the IVAC2L System in Healthy and Cardiogenic Shock Pigs

Background

Mechanical circulatory supports are used in case of cardiogenic shock (CS) refractory to conventional therapy. Several devices can be employed, but are limited by their availability, benefit risk-ratio, and/or cost.

Aims

To investigate the feasibility, safety, and effectiveness of a long-term support by a new available device (IVAC2L) in pigs.

Methods

Experiments were carried out in male pigs, divided into healthy (n = 6) or ischemic CS (n = 4) groups for a median support time of 34 and 12 h, respectively. IVAC2L was implanted under fluoroscopic and TTE guidance under general anesthesia. CS was induced by surgical ligation of the left anterior descending artery. An ipsilateral lower limb reperfusion was created with the Solopath® system. Reperfusion was started after 1 h of support in healthy pigs and upon IVAC2L insertion in CS pigs. Hemodynamic and biological parameters were monitored before and during the whole period of support in each group.

Results

Occurrence of an ipsilateral lower limb ischemia was systematic in healthy and CS pigs in a few minutes after IVAC2L implantation, and could be reversed by the arterial reperfusion, as demonstrated by distal transcutaneous pressure in oxygen (TcPO₂) and lactate normalization. IVAC2L support decreased pulmonary capillary wedge pressure (PCWP) (15.3 ± 0.3 vs. 7.5 ± 0.9 mmHg, p < 0.001), increased systolic blood pressure (SBP) (70 ± 4.5 vs. 101.3 ± 3.1 mmHg, p < 0.01), and cardiac output (CO) (4.0 ± 0.3 vs. 5.2 ± 0.6 l/min, p < 0.05) in CS pigs; at CS onset and after 12 h of support, without effects on heart rate or pulmonary artery pressure (PAP). Non-sustained ventricular arrhythmias were frequent at implantation (50%). A non-significant hemolysis was observed under support in CS pigs. Bleedings were frequent at the insertion and/or operating sites (30%).

Conclusion

Long-term support by IVAC2L is feasible and associated with a significant hemodynamic improvement in a porcine model. These preclinical data open the door for a study of IVAC2L in human ischemic CS, keeping in mind the need for systematic reperfusion of the lower limb and the associated risk of bleeding.

[Training module extracorporeal life support (ECLS): consensus statement of the DIVI, DGTHG, DGfK, DGAI, DGIIN, DGF, GRC and DGK]

Mechanical circulatory support using extracorporeal life support systems (ECLS) has significantly increased in recent years. These critically ill patients pose special challenges to the multiprofessional treatment team and require comprehensive, interdisciplinary and interprofessional concepts. For this reason, to ensure the best possible patient care a standardized ECLS training module has been created at national specialist society level, taking emergency and intensive care management into account.

[Training module extracorporeal life support (ECLS): consensus statement of the DIVI, DGTHG, DGfK, DGAI, DGIIN, DGF, GRC and DGK]

Mechanical circulatory support using extracorporeal life support systems (ECLS) has significantly increased in recent years. These critically ill patients pose special challenges to the multiprofessional treatment team and require comprehensive, interdisciplinary and interprofessional concepts. For this reason, to ensure the best possible patient care a standardized ECLS training module has been created at national specialist society level, taking emergency and intensive care management into account.

Risk Scores in ST-Segment Elevation Myocardial Infarction Patients with Refractory Cardiogenic Shock and Veno-Arterial Extracorporeal Membrane Oxygenation

Although many risk models have been tested in patients implanted by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), few scores assessed patients’ prognosis in the setting of ST-segment elevation myocardial infarction (STEMI) with refractory cardiogenic shock. We aimed at assessing the performance of risk scores, notably the prEdictioN of Cardiogenic shock OUtcome foR AMI patients salvaGed by VA-ECMO (ENCOURAGE) score, for predicting mortality in this particular population. This retrospective observational study included patients admitted to Tours University Hospital for STEMI with cardiogenic shock and requiring hemodynamic support by VA-ECMO. Among the fifty-one patients, the 30-day and 6-month survival rates were 63% and 56% respectively. Thirty days after VA-ECMO therapy, probabilities of mortality were 12, 17, 33, 66, 80% according to the ENCOURAGE score classes 0–12, 13–18, 19–22, 23–27, and ≥28, respectively. The ENCOURAGE score (AUC of the Receiving Operating Characteristic curve = 0.83) was significantly better compared to other risk scores. The hazard ratio for survival at 30 days for each point of the ENCOURAGE score was 1.10 (CI 95% (1.06, 1.15); p < 0.001). Decision curve analysis indicated that the ENCOURAGE score had the best clinical usefulness of the tested risk scores and the Hosmer–Lemeshow test suggested an accurate calibration. Our data suggest that the ENCOURAGE score is valid and the most relevant score to predict 30-day mortality after VA-ECMO therapy in STEMI patients with refractory cardiogenic shock. It may help decision-making teams to better select STEMI patients with shock for VA-ECMO therapy.

IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA^® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA^® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA^®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA^® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA^® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA^® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA^® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA^® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

Budget Impact Associated with the Introduction of the Impella 5.0® Mechanical Circulatory Support Device for Cardiogenic Shock in France

AIM

Cardiogenic shock (CS), if not diagnosed and treated rapidly, can lead to irreversible multiorgan damage and death. An economic analysis was conducted to determine the budget impact of the introduction of Impella 5.0®, a mechanical circulatory support (MCS) device that directly unloads the left ventricle, into clinical practice in patients with left ventricular CS in France.

METHODS

A budget impact model was developed to compare the cost of Impella 5.0 with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) from the perspective of the French national healthcare insurer. Costs associated with Impella 5.0, plus complication-related costs for VA-ECMO or Impella 5.0 from 2019 were included and clinical input data relating to complication rates and time spent on device were sourced from published literature. Extensive scenario and one-way deterministic sensitivity analyses were performed to explore the influence of uncertainty around key input parameters.

RESULTS

Over a time horizon of 5 years, the introduction of Impella 5.0 was associated with cumulative savings of EUR 4.3 million. The results were driven by the lower risk of device-related complications associated with Impella 5.0. Savings were apparent from Year 1 onwards, with savings in excess of EUR 375,000 projected in Year 1 alone. On a per-patient level, in Year 1, estimated savings with the introduction of Impella 5.0 totaled EUR 616 per patient. Sensitivity analyses showed that the findings of the analysis were robust.

CONCLUSION

The Impella 5.0 device was associated with cumulative cost savings in excess of EUR 4 million over a 5-year period compared with current practice. Projected savings were driven by a lower rate of device-related complications with Impella 5.0 compared with VA-ECMO.

Effect of shenfu injection on microcirculation in shock patients: A protocol for systematic review and meta-analysis

BACKGROUND

Shock is a major public health problem worldwide. At present, the morbidity and mortality of shock patients are relatively high. Vasomotor dysfunction is 1 of the key pathological aspects of shock. Shenfu injection has been widely used for the treatment of shock in China. Pharmacological studies have suggested that Shenfu injection can reduce peripheral circulation resistance and improve microcirculation. The purpose of this study is to evaluate the effect and safety of Shenfu injection on the microcirculation of patients with shock.

METHODS

This review summarizes and meta-analyzes randomized controlled trials of Shenfu injection for the treatment of shock.Searched the following electronic databases: PubMed, Cochrane Library, Embase, CNKI, VIP and Wanfang Data. The Cochrane risk assessment tool was used to evaluate the methodological quality of randomized controlled trials. All tests are analyzed according to the standards of the Cochrane Handbook. Review Manager 5.3, R-3.5.1 software and Grading of Recommendations Assessment, Development, and Evaluation pro GDT web solution are used for data synthesis and analysis.

RESULTS

This review focuses on the effects of Shenfu injection on the microcirculation of shock patients (blood lactic acid level, arteriovenous oxygen saturation, arteriovenous carbon dioxide partial pressure difference, sublingual microcirculation), 28-day mortality, 28-day ICU hospitalization and adverse reaction rate.

CONCLUSION

This review provides a clear basis for evaluating the impact of Shenfu injection on the microcirculation of shock patients, as well as the effectiveness and safety of the treatment.

Comparison of Hemodynamic Support by Impella vs. Peripheral Extra-Corporeal Membrane Oxygenation: A Porcine Model of Acute Myocardial Infarction

Objectives: Several mechanical circulatory assist devices are used to treat critically ill patients requiring hemodynamic support during post-myocardial infarction or cardiogenic shock. However, little guidance is available to choose an appropriate device to match a particular patient's needs. An increased understanding of hemodynamic effects of the pump systems and their impact on myocardial pre-/afterload might help to better understand their behavior in different clinical settings. Methods: This was an open-labeled, randomized acute animal experiment. A model of acute univentricular myocardial injury by temporary balloon occlusion was used. The experiment was carried out in 10 juveniles female Piétrain pigs. The animals were randomized to mechanical hemodynamic support either by peripheral veno-arterial (VA-)ECMO or Impella CP. Results: While both devices were able to provide flows above 3 L/min and maintain sufficient end-organ perfusion, support by Impella resulted in a significantly more pronounced immediate effect on myocardial unloading: At the onset of device support, the remaining native cardiac output was reduced by 23.5 ± 15.3% ECMO vs. 66.2 ± 36.2% (Impella, p = 0.021). Native stroke volume was significantly decreased by Impella support compared to ECMO, indicating less mechanical work being conducted by the Impella-supported hearts despite similar total assisted cardiac output. Conclusions: Peripheral VA-ECMO and the transaortic Impella pump resulted in contrasting hemodynamic fingerprints. Both devices provided sufficient hemodynamic support and reduce left ventricular end-diastolic pressure in the acute setting. Treatment with the Impella device resulted in a more effective volume unloading of the left ventricle. A significant reduction in myocardial oxygen consumption equivalent was achieved by both devices: The Impella device resulted in a left-shift of the pressure-volume loop and a decreased pressure-volume-area (PVA), while VA-ECMO increased PVA but decreased heart rate. These data highlight the importance of specifically targeting heart rate in the management of AMI patients on hemodynamic support.

Trials of mechanical circulatory support with percutaneous axial flow pumps in cardiogenic shock complicating acute myocardial infarction: Mission impossible?

Cardiogenic shock is a complex clinical entity associated with very high mortality and intensive resource utilization. Despite the widespread use of timely reperfusion and appropriate pharmacotherapy, the survival rate remains at around 50%. Recently, percutaneous axial flow pumps have been integrated into the therapeutic spectrum of cardiogenic shock management. However, most of the literature supporting their use stems from observational studies. To date, attempts to perform randomized controlled trials with percutaneous axial flow pumps have failed. This underlines the challenge of performing a well-conducted randomized controlled trial that provides the highest level of evidence. Such a trial is warranted, because percutaneous axial flow pumps are costly, and are associated with serious complications. The major pitfalls of previous studies were lack of standardized cardiogenic shock definitions according to clinical severity, inappropriate patient and device selection, lack of standardized trial endpoints and high rates of crossovers; these issues must be carefully considered and evaluated. In light of recent trial failures, we aim to summarize the challenges associated with performing randomized controlled trials of percutaneous axial flow pumps in patients experiencing acute myocardial infarction complicated by cardiogenic shock, and to suggest potential means of overcoming them.

Etiology and Prognosis of Cardiogenic Shock in a Secondary Center without Surgical Back-Up

Background

Cardiogenic shock (CS) remains a major challenge in contemporary cardiology. Data regarding CS etiologies and their prognosis are limited and mainly derived from tertiary referral centers.

Aims

To investigate the current etiologies of cardiogenic shock and their associated short- and long-term outcomes in a secondary center without surgical back-up.

Methods

We performed an observational prospective monocenter study. All patients admitted for a first episode of CS related to left ventricular dysfunction were enrolled. The definition of CS was consistent with the European Society of Cardiology guidelines. Patients were followed for 6 months. Etiologies were analyzed, and survival rates derived from Kaplan-Meier estimates were compared with the log-rank test.

Results

Between January 2015 and January 2016, 152 patients were included. The first most common cause of CS was acute decompensation of chronic heart failure (CHF). Acute coronary syndromes (ACS) were the second most common cause of CS (35.4%). At one month, the all-cause mortality rate was 39.5% and was similar between ACS and CHF (43% vs 35%, respectively; p=0.7). In a landmark analysis between 1 and 6 months, we observed a significantly higher mortality in patients with CHF than in patients with ACS (18% vs. 0%; p=0.01).

Conclusions

In the present registry, acute decompensation of chronic heart failure was the most common cause of CS, while ACS complicated by CS was the second most common cause. Of importance, acute decompensation of CHF was associated with a significantly worse outcome than ACS in the long term.

A study of the predictive factors of mortality in acute poisoning with aluminum phosphide with special reference to echocardiography and SOFA score

Aluminum phosphide (AlP) is considered now one of the most common causes of poisoning among agricultural pesticides. Poisoning with AlP is extremely toxic to humans with high mortality rate. The aim of this work was to evaluate the prognostic factors and outcome of acute aluminum phosphide poisoning in Alexandria Main University Hospital during a period of 6 months from 1 November 2017 until the end of April 2018, highlighting the role of SOFA score and echocardiography in predicting the mortality. The prospective study was conducted on all patients admitted with acute AlP poisoning to Alexandria Main University Hospital for those 6 months. Patients' data were collected in a special sheet and included biosocial data, medical history, poisoning history, complete medical examination, investigations, duration of hospital stay, and the outcome. All patients were assessed according to SOFA score on admission. Thirty patients were admitted during the period of the current study. Females outnumbered males in all age groups with a sex ratio of 2.75:1. The mean age of patients was 22.77 ± 12.79 years. 96.6% of patients came from rural areas. 93.3% of the cases were exposed to poisoning at home, where suicidal poisoning accounted for (86.7%) of cases. 43.3% of patients died (n = 13), and the median value of SOFA score among non-survivors was 10, versus 1 among survivors. The median value of ejection fraction among non-survivors (25%) was half its value in survivors (50%). Although there were many predictors of severity of AlP poisoning, SOFA score was the most predictive factor of mortality detected by multivariate analysis.

Predictive factors for long-term mortality in miscellaneous cardiogenic shock: Protective role of beta-blockers at admission

BACKGROUND

Despite advances in intensive care medicine, management of cardiogenic shock (CS) remains difficult and imperfect, with high mortality rates, regardless of aetiology. Predictive data regarding long-term mortality rates in patients presenting CS are sparse.

AIM

To describe prognostic factors for long-term mortality in CS of different aetiologies.

METHODS

Two hundred and seventy-five patients with CS admitted to our tertiary centre between January 2013 and December 2014 were reviewed retrospectively. Mortality was recorded in December 2016. A Cox proportional-hazards model was used to determine predictors of long-term mortality.

RESULTS

Most patients were male (72.7%), with an average age of 64±16 years and a history of cardiomyopathy (63.5%), mainly ischaemic (42.3%). Leading causes of CS were myocardial infarction (35.3%), decompensated heart failure (34.2%) and cardiac arrest (20.7%). Long-term mortality was 62.5%. After multivariable analysis, previous use of beta-blockers (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.41-0.89; P=0.02) and coronary angiography exploration at admission (HR 0.57, 95% CI 0.38-0.86; P=0.02) were associated with a lower risk of long-term mortality. Conversely, age (HR 1.02 per year, 95% CI 1.01-1.04; P<0.001), catecholamine support (HR 1.45 for each additional agent, 95% CI 1.20-1.75; P<0.001) and renal replacement therapy (HR 1.66, 95% CI 1.09-2.55; P=0.02) were associated with an increased risk of long-term mortality.

CONCLUSIONS

Long-term mortality rates in CS remain high, reaching 60% at 1-year follow-up. Previous use of beta-blockers and coronary angiography exploration at admission were associated with better long-term survival, while age, renal replacement therapy and the use of catecholamines appeared to worsen the prognosis, and should lead to intensification of CS management.

Clinical scenarios for use of transvalvular microaxial pumps in acute heart failure and cardiogenic shock - A European experienced users working group opinion

For patients with myocardial infarct-related cardiogenic shock (CS), urgent percutaneous coronary intervention is the recommended treatment strategy to limit cardiac and systemic ischemia. However, a specific therapeutic intervention is often missing in non-ischemic CS cases. Though drug treatment with inotropes and/or vasopressors may be required to stabilize the patient initially, their ongoing use is associated with excess mortality. Coronary intervention in unstable patients often leads to further hemodynamic compromise either during or shortly after revascularization. Support devices like the intra-aortic balloon pump failed to improve clinical outcomes in infarct-related CS. Currently, more powerful and active hemodynamic support devices unloading the left ventricle such as transvalvular microaxial pumps are available and are being increasingly used. However, as for other devices large randomized trials are not yet available, and device use is based on registry data and expert consensus. In this article, a multidisciplinary group of experienced users of transvalvular microaxial pumps outlines the pathophysiological background on hemodynamic changes in CS, the available mechanical support devices, and current guideline recommendations. Furthermore, different hemodynamic situations in several case-based scenarios are used to illustrate candidate settings and to provide the theoretic and scientific rationale for left-ventricular unloading in these scenarios. Finally, organization of shock networks, monitoring, weaning, and typical complications and their prevention are discussed.