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Castillo Costa Y, Delfino F, Mauro V, D Imperio H, Adamowski M, Cortez Sandoval MA, Pow Chon Long F, Macín SM, Burgos Acosta J, Chacón-Díaz M, Soldán Patiño CP. Cardiogenic shock in the context of acute coronary syndromes in Latin America ("LATIN Shock"). Curr Probl Cardiol 2024; 49:102745. [PMID: 39128226 DOI: 10.1016/j.cpcardiol.2024.102745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 07/10/2024] [Indexed: 08/13/2024]
Abstract
Cardiogenic shock (CS) is a serious complication of heart attack and constitutes one of its main causes of death. To date, there is no data on its treatment and evolution in Latin America. OBJECTIVES To know the clinical characteristics, treatment strategies, evolution and in-hospital mortality of CS in Latin America. MATERIALS AND METHODS This is a prospective, multicenter registry of patients hospitalized with CS in the context of acute coronary syndromes (ACS) with and without ST segment elevation for 24 months. RESULTS 41 Latin American centers participated incorporating patients during the period between October 2021 and September 2023. 278 patients were included. Age: 66 (59-75) years, 70.1 % men. 74.8 % of the cases correspond to ACS with ST elevation, 14.4 % to ACS without ST elevation, 5.7 % to right ventricular infarction and 5.1 % to mechanical complications. CS was present from admission in 60 % of cases. Revascularization: 81.3 %, inotropic use: 97.8 %, ARM: 52.5 %, Swan Ganz: 17 %, intra-aortic balloon pump: 22.2 %. Overall in-hospital mortality was 52.7 %, with no differences between ACS with or without ST. CONCLUSIONS Morbidity and mortality is very high despite the high reperfusion used.
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Fu HY, Chen YS, Yu HY, Chi NH, Wei LY, Chen KPH, Chou HW, Chou NK, Wang CH. Emergent coronary revascularization with percutaneous coronary intervention and coronary artery bypass grafting in patients receiving extracorporeal cardiopulmonary resuscitation. Eur J Cardiothorac Surg 2024; 66:ezae290. [PMID: 39073911 PMCID: PMC11315652 DOI: 10.1093/ejcts/ezae290] [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: 12/28/2023] [Revised: 07/18/2024] [Accepted: 07/27/2024] [Indexed: 07/31/2024] Open
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue for refractory cardiac arrest, of which acute coronary syndrome is a common cause. Data on the coronary revascularization strategy in patients receiving ECPR remain limited. METHODS The ECPR databases from two referral hospitals were screened for patients who underwent emergent revascularization. The baseline characteristics were matched 1:1 using propensity score between patients who underwent coronary artery bypass grafting (CABG) and those who received percutaneous coronary intervention (PCI). Outcomes, including success rate of weaning from extracorporeal membrane oxygenation (ECMO), hospital survival, and midterm survival in hospital survivors, were compared between CABG and PCI. RESULTS After matching, most of the patients (95%) had triple vessel disease. Compared with PCI (n = 40), emergent CABG (n = 40) had better early outcomes, in terms of the rates of successful ECMO weaning (71.1% vs 48.7%, P = 0.05) and hospital survival (56.4% versus 32.4%, P = 0.04). After a mean follow-up of 2 years, both revascularization strategies were associated with favourable midterm survival among hospital survivors (75.3% after CABG vs 88.9% after PCI, P = 0.49), with a trend towards fewer reinterventions in patients who underwent CABG (P = 0.07). CONCLUSIONS In patients who received ECPR because of triple vessel disease, the hospital outcomes were better after emergent CABG than after PCI. More evidence is required to determine the optimal revascularization strategy for patients who receive ECPR.
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Affiliation(s)
- Hsun-Yi Fu
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Yih-Sharng Chen
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsi-Yu Yu
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Hsin Chi
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ling-Yi Wei
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Heng-Wen Chou
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Nai-Kuan Chou
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hsien Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
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García-Delgado M, Rodríguez-García R, Ochagavía A, Rodríguez-Esteban MDLÁ. The medical treatment of cardiogenic shock. Med Intensiva 2024; 48:477-486. [PMID: 38834498 DOI: 10.1016/j.medine.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/06/2024]
Abstract
Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.
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Affiliation(s)
- Manuel García-Delgado
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
| | - Raquel Rodríguez-García
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain; CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain.
| | - Ana Ochagavía
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Hong D, Choi KH, Ahn CM, Yu CW, Park IH, Jang WJ, Kim HJ, Bae JW, Kwon SU, Lee HJ, Lee WS, Jeong JO, Park SD, Park TK, Lee JM, Song YB, Hahn JY, Choi SH, Gwon HC, Yang JH. Clinical significance of residual ischaemia in acute myocardial infarction complicated by cardiogenic shock undergoing venoarterial-extracorporeal membrane oxygenation. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:525-534. [PMID: 38701179 DOI: 10.1093/ehjacc/zuae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/05/2024]
Abstract
AIMS Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction in residual ischaemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischaemia in patients undergoing mechanical circulatory supports. This study aimed to evaluate the effects of residual ischaemia on clinical outcomes in patients with AMI undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). METHODS AND RESULTS Patients with AMI with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischaemia evaluated using the residual Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score (rSS): rSS = 0, 0 < rSS ≤ 8, and rSS > 8. The primary outcome was 1-year all-cause death. A total of 408 patients were classified into the rSS = 0 (n = 100, 24.5%), 0 < rSS ≤ 8 (n = 136, 33.3%), and rSS > 8 (n = 172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9 vs. 55.4 vs. 66.1% for rSS = 0, 0 < rSS ≤ 8, and rSS > 8, respectively, overall P < 0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (adjusted hazard ratio 1.03, 95% confidence interval 1.01-1.05, P = 0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. CONCLUSION In patients with AMI with refractory CS who underwent VA-ECMO, residual ischaemia was associated with an increased risk of 1-year mortality. Future studies are needed to evaluate the efficacy and safety of revascularization strategies to minimize residual ischaemia in patients with CS supported with VA-ECMO. CLINICAL TRIAL REGISTRATION REtrospective and Prospective Observational Study to Investigate Clinical oUtcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock (RESCUE), NCT02985008.
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Affiliation(s)
- David Hong
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ik Hyun Park
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Woo Jin Jang
- Department of Cardiology, Ewha Woman's University Seoul Hospital, Ewha Woman's University School of Medicine, Seoul, Republic of Korea
| | - Hyun-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sung Uk Kwon
- Division of Cardiology, Department of Internal Medicine, Ilsan Paik Hospital, University of Inje College of Medicine, Seoul, Korea
| | - Hyun-Jong Lee
- Division of Cardiology, Department of Medicine, Sejong General Hospital, Bucheon, Korea
| | - Wang Soo Lee
- Division of Cardiology, Department of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Sang-Don Park
- Division of Cardiology, Department of Medicine, Inha University Hospital, Incheon, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
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Alkhunaizi FA, Smith N, Brusca SB, Furfaro D. The Management of Cardiogenic Shock From Diagnosis to Devices: A Narrative Review. CHEST CRITICAL CARE 2024; 2:100071. [PMID: 38993934 PMCID: PMC11238736 DOI: 10.1016/j.chstcc.2024.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Cardiogenic shock (CS) is a heterogenous syndrome broadly characterized by inadequate cardiac output leading to tissue hypoperfusion and multisystem organ dysfunction that carries an ongoing high mortality burden. The management of CS has advanced rapidly, especially with the incorporation of temporary mechanical circulatory support (tMCS) devices. A thorough understanding of how to approach a patient with CS and to select appropriate monitoring and treatment paradigms is essential in modern ICUs. Timely characterization of CS severity and hemodynamics is necessary to optimize outcomes, and this may be performed best by multidisciplinary shock-focused teams. In this article, we provide a review of CS aimed to inform both the cardiology-trained and non-cardiology-trained intensivist provider. We briefly describe the causes, pathophysiologic features, diagnosis, and severity staging of CS, focusing on gathering key information that is necessary for making management decisions. We go on to provide a more detailed review of CS management principles and practical applications, with a focus on tMCS. Medical management focuses on appropriate medication therapy to optimize perfusion-by enhancing contractility and minimizing afterload-and to facilitate decongestion. For more severe CS, or for patients with decompensating hemodynamic status despite medical therapy, initiation of the appropriate tMCS increasingly is common. We discuss the most common devices currently used for patients with CS-phenotyping patients as having left ventricular failure, right ventricular failure, or biventricular failure-and highlight key available data and particular points of consideration that inform tMCS device selection. Finally, we highlight core components of sedation and respiratory failure management for patients with CS.
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Affiliation(s)
- Fatimah A Alkhunaizi
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nikolhaus Smith
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Samuel B Brusca
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Furfaro
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Mehta A, Vavilin I, Nguyen AH, Batchelor WB, Blumer V, Cilia L, Dewanjee A, Desai M, Desai SS, Flanagan MC, Isseh IN, Kennedy JLW, Klein KM, Moukhachen H, Psotka MA, Raja A, Rosner CM, Shah P, Tang DG, Truesdell AG, Tehrani BN, Sinha SS. Contemporary approach to cardiogenic shock care: a state-of-the-art review. Front Cardiovasc Med 2024; 11:1354158. [PMID: 38545346 PMCID: PMC10965643 DOI: 10.3389/fcvm.2024.1354158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.
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Affiliation(s)
- Aditya Mehta
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ilan Vavilin
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Andrew H. Nguyen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Vanessa Blumer
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Lindsey Cilia
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Aditya Dewanjee
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehul Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Desai
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Michael C. Flanagan
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Iyad N. Isseh
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Jamie L. W. Kennedy
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Katherine M. Klein
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Hala Moukhachen
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Mitchell A. Psotka
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Anika Raja
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Palak Shah
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Daniel G. Tang
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Alexander G. Truesdell
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
- Department of Cardiovascular Disease, Virginia Heart, Falls Church, VA, United States
| | - Behnam N. Tehrani
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Shashank S. Sinha
- Department of Cardiovascular Disease, Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
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Iannaccone M, Franchin L, Burzotta F, Botti G, Pazzanese V, Briguori C, Trani C, Piva T, De Marco F, Masiero G, Di Biasi M, Pagnotta P, Casu G, Scandroglio AM, Tarantini G, Chieffo A. Impact of in-Hospital Left Ventricular Ejection Fraction Recovery on Long-Term Outcomes in Patients Who Underwent Impella Support for HR PCI or Cardiogenic Shock: A Sub-Analysis from the IMP-IT Registry. J Pers Med 2023; 13:826. [PMID: 37240996 PMCID: PMC10222801 DOI: 10.3390/jpm13050826] [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: 04/03/2023] [Revised: 05/03/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Percutaneous left ventricle assist devices (pLVADs) demonstrated an improvement in mid-term clinical outcomes in selected patients with severely depressed left ventricular ejection fraction (LVEF) undergoing percutaneous coronary interventions. However, the prognostic impact of in-hospital LVEF recovery is unclear. Accordingly, the present sub-analysis aims to evaluate the impact of LVEF recovery in both cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR PCI) supported with pLVADs in the IMP-IT registry. (2) Methods: A total of 279 patients (116 patients in CS and 163 patients in HR PCI) treated with Impella 2.5 or CP in the IMP-IT registry were included in this analysis, after excluding those who died while in the hospital or with missing data on LVEF recovery. The primary study objective was a composite of all-cause death, rehospitalisation for heart failure, left ventricle assist device (LVAD) implantation, or heart transplantation (HT), overall referred to as the major adverse cardiac events (MACE) at 1 year. The study aimed to evaluate the impact of in-hospital LVEF recovery on the primary study objective in patients treated with Impella for HR PCI and CS, respectively. (3) Results: The mean in-hospital change in LVEF was 10 ± 1% (p < 0.001) in the CS cohort and 3 ± 7% (p < 0.001) in the HR PCI group, achieved by 44% and 40% of patients, respectively. In the CS group, patients with less than 10% in-hospital LVEF recovery experienced higher rates of MACE at 1 year of follow-up (FU) (51% vs. 21%, HR 3.8, CI 1.7-8.4, p < 0.01). After multivariate analysis, LVEF recovery was the main independent protective factor for MACE at FU (HR 0.23, CI 0.08-0.64, p = 0.02). In the HR PCI group, LVEF recovery (>3%) was not associated with lower MACE at multivariable analysis (HR 0.73, CI 0.31-1.72, p = 0.17). Conversely, the completeness of revascularisation was found to be a protective factor for MACE (HR 0.11, CI 0.02-0.62, p = 0.02) (4) Conclusions: Significant LVEF recovery was associated with improved outcomes in CS patients treated with PCI during mechanical circulatory support with Impella, whereas complete revascularisation showed a significant clinical relevance in HR PCI.
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Affiliation(s)
- Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco Hospital, 10100 Turin, Italy
| | - Luca Franchin
- Department of Cardiology, San Giovanni Bosco Hospital, 10100 Turin, Italy
| | - Francesco Burzotta
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00100 Rome, Italy
| | - Giulia Botti
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, 20100 Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, 20100 Milan, Italy
| | - Carlo Briguori
- Interventional Cardiology Unit, Mediterranea Cardiocentro, 80100 Naples, Italy
| | - Carlo Trani
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00100 Rome, Italy
| | - Tommaso Piva
- Center for Exercise Science and Sport, Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy
| | - Federico De Marco
- Valvular and Structural Heart Cardiology, Centro Cardiologico Monzino, 20100 Milan, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, 35100 Padua, Italy
| | - Maurizio Di Biasi
- Interventional Cardiology Unit, Ospedale Luigi Sacco, 20100 Milan, Italy
| | - Paolo Pagnotta
- Cardiovascular Department, Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Gavino Casu
- Clinical and Interventional Cardiology, Sassari University Hospital, 07100 Sassari, Italy
| | - Anna Mara Scandroglio
- Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Vita Salute University, 20100 Milan, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, 35100 Padua, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, 20100 Milan, Italy
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8
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Choi KH, Yang JH, Park TK, Lee JM, Song YB, Hahn JY, Choi SH, Ahn CM, Yu CW, Park IH, Jang WJ, Kim HJ, Bae JW, Kwon SU, Lee HJ, Lee WS, Jeong JO, Park SD, Kang TS, Gwon HC. Culprit-Only Versus Immediate Multivessel Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction Complicating Advanced Cardiogenic Shock Requiring Venoarterial-Extracorporeal Membrane Oxygenation. J Am Heart Assoc 2023; 12:e029792. [PMID: 37158104 DOI: 10.1161/jaha.123.029792] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background Despite the benefit of culprit-only percutaneous coronary intervention (PCI) in the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multi-vessel PCI in Cardiogenic Shock) trial, the optimal revascularization strategy for refractory cardiogenic shock (CS) requiring mechanical circulatory support devices remains controversial. This study aimed to compare clinical outcomes between the culprit-only and immediate multivessel PCI strategies in patients with acute myocardial infarction complicated by CS who underwent venoarterial-extracorporeal membrane oxygenation before revascularization. Methods and Results This study included patient-pooled data from the RESCUE (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Devices for Korean Patients With Cardiogenic Shock) and SMC-ECMO (Samsung Medical Center-Extracorporeal Membrane Oxygenation) registries. A total of 315 patients with acute myocardial infarction with multivessel disease who underwent venoarterial-extracorporeal membrane oxygenation before revascularization attributable to refractory CS were included in this analysis. The study population was classified into culprit-only versus immediate multivessel PCI according to nonculprit lesion treatment strategies. The primary end point was 30-day mortality or renal-replacement therapy, and the key secondary end point was 12-month follow-up mortality. Among the study population, 175 (55.6%) underwent culprit-only PCI and 140 (44.4%) underwent immediate multivessel PCI. Compared with culprit-only PCI, immediate multivessel PCI was associated with significantly lower risks of 30-day mortality or renal-replacement therapy (68.0% versus 54.3%; P=0.018) and all-cause mortality during 12 months of follow-up (59.5% versus 47.5%; hazard ratio [HR], 0.689 [95% CI, 0.506-0.939]; P=0.018) in patients with acute myocardial infarction and CS who underwent venoarterial-extracorporeal membrane oxygenation before revascularization. These results were also consistent in the 99 pairs of propensity score-matched population (60.6% versus 43.6%; HR, 0.622 [95% CI, 0.420-0.922]; P=0.018). Conclusions Among patients with acute myocardial infarction with multivessel disease complicated by advanced CS requiring venoarterial-extracorporeal membrane oxygenation before revascularization, immediate multivessel PCI was associated with lower incidences of 30-day mortality or renal replacement therapy and 12-month follow-up mortality, compared with culprit-only PCI. Registration Information clinicaltrials.gov. Identifier: NCT02985008.
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Affiliation(s)
- Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital Yonsei University College of Medicine Seoul South Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine Korea University Anam Hospital Seoul Republic of Korea
| | - Ik Hyun Park
- Department of Cardiology Samsung Changwon Hospital, Sungkyunkwan University School of Medicine Changwon South Korea
| | - Woo Jin Jang
- Department of Cardiology Ewha Woman's University Seoul Hospital, Ehwa Woman's University School of Medicine Seoul Republic of Korea
| | - Hyun-Joong Kim
- Division of Cardiology, Department of Medicine Konkuk University Medical Center Seoul South Korea
| | - Jang-Whan Bae
- Department of Internal Medicine Chungbuk National University College of Medicine Cheongju South Korea
| | - Sung Uk Kwon
- Division of Cardiology, Department of Internal Medicine Ilsan Paik Hospital, University of Inje College of Medicine Seoul South Korea
| | - Hyun-Jong Lee
- Division of Cardiology, Department of Medicine Sejong General Hospital Bucheon South Korea
| | - Wang Soo Lee
- Division of Cardiology, Department of Medicine Chung-Ang University Hospital Seoul South Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine Chungnam National University Hospital Daejeon Republic of Korea
| | - Sang-Don Park
- Division of Cardiology, Department of Medicine Inha University Hospital Incheon South Korea
| | - Tae-Soo Kang
- Division of Cardiovascular Medicine, Department of Internal Medicine Dankook University Hospital, Dankook University College of Medicine Cheonan South Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Republic of Korea
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9
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Maksimczuk J, Galas A, Krzesiński P. What Promotes Acute Kidney Injury in Patients with Myocardial Infarction and Multivessel Coronary Artery Disease-Contrast Media, Hydration Status or Something Else? Nutrients 2022; 15:nu15010021. [PMID: 36615678 PMCID: PMC9824824 DOI: 10.3390/nu15010021] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Multivessel coronary artery disease (MVCAD) is found in approximately 50% of patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Although we have data showing the benefits of revascularization of significant non-culprit coronary lesions in patients with AMI, the optimal timing of angioplasty remains unclear. The most common reason for postponing subsequent percutaneous treatment is the fear of contrast-induced acute kidney injury (CI-AKI). Acute kidney injury (AKI) is common in patients with AMI undergoing PCI, and its etiology appears to be complex and incompletely understood. In this review, we discuss the definition, pathophysiology and risk factors of AKI in patients with AMI undergoing PCI. We present the impact of AKI on the course of hospitalization and distant prognosis of patients with AMI. Special attention was paid to the phenomenon of AKI in patients undergoing multivessel revascularization. We analyze the correlation between increased exposure to contrast medium (CM) and the risk of AKI in patients with AMI to provide information useful in the decision-making process about the optimal timing of revascularization of non-culprit lesions. In addition, we present diagnostic tools in the form of new biomarkers of AKI and discuss ways to prevent and mitigate the course of AKI.
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10
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Wollmuth J, Patel MP, Dahle T, Bharadwaj A, Waggoner TE, Chambers JW, Ruiz-Rodriguez E, Mahmud E, Thompson C, Morris DL. Ejection Fraction Improvement Following Contemporary High-Risk Percutaneous Coronary Intervention: RESTORE EF Study Results. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100350. [PMID: 39131473 PMCID: PMC11307872 DOI: 10.1016/j.jscai.2022.100350] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/12/2022] [Accepted: 04/18/2022] [Indexed: 08/11/2024]
Abstract
Background Despite many reports of clinical outcomes in patients undergoing high-risk percutaneous coronary intervention (HRPCI) with hemodynamic support, little is known about whether this approach improves left ventricular ejection fraction (LVEF). The purpose of the present observational study was to examine, in an ideal patient population with Impella-supported HRPCI, whether there is an impact on left ventricular function at midterm follow-up. Methods RESTORE EF is a multicenter, retrospective analysis of a prospectively collected observational data set that aimed to assess 90-day LVEF in patients undergoing Impella-supported nonemergent HRPCI (NCT04648306), who survived with no intervening cardiac procedures prior to the primary endpoint follow-up window (90-day LVEF assessment). Secondary endpoints included change in New York Heart Association Functional Classification and Canadian Cardiovascular Society Angina Grade at the last follow-up. Results From August 2019 to May 2021, 406 patients were enrolled at 22 US sites. Age was 70.2 ± 11.4 years; 26% were female. In paired assessment at 90-day follow-up, baseline LVEF improved from 35 ± 15% to 45 ± 14% (N = 251, P < .0001), with significantly greater improvement in patients with residual SYNTAX score I of 0. Percentage classified as New York Heart Association class III/IV decreased from 62% at baseline to 15% at last follow-up (P < .001), and percentage with Canadian Cardiovascular Society grade III/IV symptoms decreased from 72% to 2% (P < .0001). Conclusions In an ideal cohort of HRPCI patients, there is a signal that hemodynamically supported HRPCI affords significant improvement in 90-day LVEF, with complete revascularization associated with greater LVEF improvement. These hypothesis-generating findings merit further assessment in large, all-comer studies and randomized trials.
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Affiliation(s)
- Jason Wollmuth
- Providence Heart and Vascular Institute, Portland, Oregon
| | - Mitul P. Patel
- Division of Cardiovascular Medicine, UC San Diego Health System, La Jolla, California
| | - Thom Dahle
- Centracare Heart & Vascular Center, St. Cloud, Minnesota
| | - Aditya Bharadwaj
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
| | | | | | - Ernesto Ruiz-Rodriguez
- Baptist Health Heart Institute/Arkansas Cardiology Clinic-Little Rock, Little Rock, Arkansas
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, UC San Diego Health System, La Jolla, California
| | - Craig Thompson
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York
| | - D. Lynn Morris
- Division of Cardiology, East Carolina Heart Institute at ECU, Greenville, North Carolina
| | - RESTORE EF Investigators
- Providence Heart and Vascular Institute, Portland, Oregon
- Division of Cardiovascular Medicine, UC San Diego Health System, La Jolla, California
- Centracare Heart & Vascular Center, St. Cloud, Minnesota
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
- Pima Heart and Vascular, Tucson, Arizona
- Metropolitan Heart & Vascular Institute, Minneapolis, Minnesota
- Baptist Health Heart Institute/Arkansas Cardiology Clinic-Little Rock, Little Rock, Arkansas
- Division of Cardiology, Department of Medicine, NYU Langone Health, New York, New York
- Division of Cardiology, East Carolina Heart Institute at ECU, Greenville, North Carolina
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11
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Gill GS, Sánchez JS, Thandra A, Kanmanthareddy A, Alla VM, Garcia-Garcia HM. Multivessel vs. culprit-vessel only percutaneous coronary interventions in acute myocardial infarction and cardiogenic shock: a systematic review and meta-analysis of prospective randomized and retrospective studies. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:558-569. [PMID: 35680428 DOI: 10.1093/ehjacc/zuac072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/25/2022] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
Abstract
AIMS Studies comparing outcomes of multivessel (MV) vs. culprit-vessel (CV) only percutaneous coronary intervention (PCI) during index cardiac catheterization in patients presenting with acute myocardial infarction (MI) and cardiogenic shock (CS) have reported conflicting results. In this systematic review we aim to investigate outcomes with MV vs. CV-only revascularization strategies in patients with acute MI and CS. METHODS AND RESULTS PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing MV vs. CV PCI in patients with acute MI and CS. Data were extracted and pooled by means of random effects model. Primary outcome was early all-cause mortality (up to 30 days), while the secondary outcomes included late all-cause mortality (mean, 11.4 months), stroke, new renal replacement therapy, reinfarction, repeat revascularization, and bleeding. Pooled odds ratio (OR), 95% confidence intervals (CIs), and number needed to harm (NNH) were calculated. A total of 16 studies enrolling 75 431 patients were included. The MV PCI was associated with higher risk of early mortality [OR 1.17, 95% CI (1.00-1.35); P = 0.04; NNH = 62], stroke [1.15 (1.03-1.29); P = 0.01; NNH = 351], and new renal replacement therapy [1.33 (1.06-1.67); P = 0.01; NNH = 61]; and with lower risk of repeat revascularization [0.61 (0.41-0.89); P = 0.01] when compared with CV PCI. No significant difference was observed in late-term mortality [1.02 (0.84-1.25); P = 0.84], risk of reinfarction [1.13 (0.94-1.35); P = 0.18], or bleeding [1.21 (0.94-1.55); P = 0.13] between groups. CONCLUSION Among patients with acute MI and CS, MV PCI during index cardiac catheterization was associated with higher risk of early mortality, stroke, and renal replacement therapy.
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Affiliation(s)
- Gauravpal S Gill
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Jorge Sanz Sánchez
- Hospital Universitari i Politecnic La Fe, Valencia, Spain
- Centro de Investigación Biomedica en Red (CIBERCV), Madrid, Spain
| | - Abhishek Thandra
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Arun Kanmanthareddy
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata Mahesh Alla
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Hector M Garcia-Garcia
- Department of Medicine, Georgetown University, Washington, DC, USA
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
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12
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Masiero G, Cardaioli F, Rodinò G, Tarantini G. When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock. J Clin Med 2022; 11:jcm11113116. [PMID: 35683500 PMCID: PMC9180947 DOI: 10.3390/jcm11113116] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/21/2022] [Accepted: 05/26/2022] [Indexed: 12/20/2022] Open
Abstract
Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI–CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.
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13
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Manian N, Thakker J, Nair A. The Use of Mechanical Circulatory Assist Devices for ACS Patients with Cardiogenic Shock and High-Risk PCI. Curr Cardiol Rep 2022; 24:699-709. [PMID: 35403950 DOI: 10.1007/s11886-022-01688-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW There has been a significant expansion of the use of mechanical circulatory support (MCS) devices for patient with acute coronary syndromes (ACS) with cardiogenic shock (CS) and in patients undergoing high-risk percutaneous interventions (PCI). The purpose of this review is to provide an overview of the indications and outcomes of these devices in high-risk cardiac patients. RECENT FINDINGS Early revascularization of the culprit-lesion is the immediate goal in ACS patients with CS and the use of pulmonary artery catheters has been associated with improved outcomes in patients with cardiogenic shock. The MCS devices that are used for myocardial support include the intra-aortic balloon pump (IABP), the left ventricle (LV) to aorta pumps, left atrium (LA) to arterial pumps, and right atrial (RA) to arterial pumps. This review provides an overview on the use of these devices in patients with ACS and CS and those undergoing high-risk PCI. Attention is focused on the IABP, the Impella (LV-aorta pump), the TandemHeart (LA-arterial pump), and veno-arterial extracorporeal membrane oxygenation (RA-arterial pump). The indications, evidence, and complications of each device are reviewed. Each device varies in its physiological effect on native heart function, complexity in insertion, and complications. The use of MCS devices for high-risk PCI and CS has increased in recent years and have demonstrated efficacy in supporting a vulnerable myocardium. Although recommendations can be made for use of each device in certain clinical scenarios, further evidence through registries and clinical trials is necessary to guide appropriate device utilization.
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Affiliation(s)
- Nina Manian
- Texas A&M University College of Medicine, Bryan, TX, 77807, USA
| | - Janki Thakker
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA
| | - Ajith Nair
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA.
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14
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Tehrani BN, Damluji AA, Batchelor WB. Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories. Curr Cardiol Rev 2022; 18:e251121198293. [PMID: 34823461 PMCID: PMC9413732 DOI: 10.2174/1573403x17666211125090929] [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] [Received: 01/05/2021] [Revised: 07/07/2021] [Accepted: 07/28/2021] [Indexed: 11/22/2022] Open
Abstract
Despite advances in early reperfusion and a technologic renaissance in the space of Mechanical Circulatory Support (MCS), Cardiogenic Shock (CS) remains the leading cause of in-hospital mortality following Acute Myocardial Infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patients without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive, evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated into the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trials designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.
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Affiliation(s)
- Behnam N Tehrani
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
| | - Abdulla A Damluji
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States.,Department of Medicine, Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Wayne B Batchelor
- Interventional Cardiology, INOVA Heart and Vascular Institute, Virginia, VA 22042, United States
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15
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Thiele H, de Waha-Thiele S, Freund A, Zeymer U, Desch S, Fitzgerald S. Management of cardiogenic shock. EUROINTERVENTION 2021; 17:451-465. [PMID: 34413010 PMCID: PMC9724885 DOI: 10.4244/eij-d-20-01296] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/23/2022]
Abstract
Despite the rapidly evolving evidence base in modern cardiology, progress in the area of cardiogenic shock remains slow, with short-term mortality still reaching 40-50%, relatively unchanged in recent years. Despite advances with an increase in the number of clinical trials taking place in this admittedly difficult-to-study area, the evidence base on which we make day-to-day decisions in clinical practice remains relatively sparse. With only definitive evidence for early revascularisation and the relative ineffectiveness of intra-aortic balloon pumping, most aspects of patient management are based on expert consensus, rather than randomised controlled trials. This updated 2020 review will outline the management of CS mainly after acute myocardial infarction with major focus on state-of-the-art treatment based on randomised clinical trials or matched comparisons if available.
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Affiliation(s)
- Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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16
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Schäfer A, Westenfeld R, Sieweke JT, Zietzer A, Wiora J, Masiero G, Sanchez Martinez C, Tarantini G, Werner N. Complete Revascularisation in Impella-Supported Infarct-Related Cardiogenic Shock Patients Is Associated With Improved Mortality. Front Cardiovasc Med 2021; 8:678748. [PMID: 34307495 PMCID: PMC8299360 DOI: 10.3389/fcvm.2021.678748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/15/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients. Objectives: We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients. Methods: We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage (n = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was >8. Results: Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, p = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS > 8: 56%, p = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, p < 0.001). Conclusions: Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.
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Affiliation(s)
- Andreas Schäfer
- Department of Cardiology and Angiology, Cardiac Arrest Center, Hannover Medical School, Hanover, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Cardiac Arrest Center, Heinrich Heine University, Düsseldorf, Germany
| | - Jan-Thorben Sieweke
- Department of Cardiology and Angiology, Cardiac Arrest Center, Hannover Medical School, Hanover, Germany
| | - Andreas Zietzer
- Department of Cardiology, University Heart Center, Bonn, Germany
| | - Julian Wiora
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Cardiac Arrest Center, Heinrich Heine University, Düsseldorf, Germany
| | - Giulia Masiero
- Department of Cardiology, University of Padua, Padua, Italy
| | - Carolina Sanchez Martinez
- Department of Cardiology and Angiology, Cardiac Arrest Center, Hannover Medical School, Hanover, Germany
| | | | - Nikos Werner
- Department of Cardiology, University Heart Center, Bonn, Germany
- Department of Cardiology, Heart Center Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
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17
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Abstract
Acute myocardial infarction and cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Early mechanical revascularization improves survival, and development of STEMI systems of care has increased the utilization of revascularization in AMI-CS from 19% in 2001 to 60% in 2014. Mechanical circulatory support devices are increasingly used to support and prevent hemodynamic collapse. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Herein, the authors review the definition, incidence, pathophysiology, and treatment of AMI-CS.
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18
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Omer MA, Brilakis ES, Kennedy KF, Alkhouli M, Elgendy IY, Chan PS, Spertus JA. Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. JACC Cardiovasc Interv 2021; 14:1067-1078. [PMID: 33933384 DOI: 10.1016/j.jcin.2021.02.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock. BACKGROUND The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain. METHODS Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis. RESULTS Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20). CONCLUSIONS Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.
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Affiliation(s)
- Mohamed A Omer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
| | - Emmanouil S Brilakis
- Abbott Northwestern Hospital, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA
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19
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Lemor A, Ya'qoub L, Basir MB. Mechanical Circulatory Support in Acute Myocardial Infarction and Cardiogenic Shock. Interv Cardiol Clin 2021; 10:169-184. [PMID: 33745667 DOI: 10.1016/j.iccl.2020.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Mechanical circulatory support devices are increasingly used for the treatment of acute myocardial infarction complicated by cardiogenic shock. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Institutions require expert teams to safely implant and manage these devices. This article reviews the mechanism of action, physiologic effects, and data as they relate to the utilization of these devices.
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Affiliation(s)
- Alejandro Lemor
- Henry Ford Health Care System, 2799 West Grand Blvd, K-2 Cath Lab, Detroit, MI 48202, USA
| | - Lina Ya'qoub
- Louisiana State University, One University Place, Shreveport, LA 71115, USA
| | - Mir B Basir
- Henry Ford Health Care System, 2799 West Grand Blvd, K-2 Cath Lab, Detroit, MI 48202, USA; Henry Ford Hospital, 2799 West Grand Boulevard (K-2 Cath Lab), Detroit, MI 48202, USA.
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20
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Acute Cardiac Unloading and Recovery: Proceedings of the 5th Annual Acute Cardiac Unloading and REcovery (A-CURE) symposium held on 14 December 2020. Interv Cardiol 2021; 16:1-3. [PMID: 33986827 PMCID: PMC8108564 DOI: 10.15420/icr.2021.s2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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21
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Kochar A, Varshney AS, Wang DE. Residual SYNTAX Score After Revascularization in Cardiogenic Shock: When Is Complete Complete? J Am Coll Cardiol 2021; 77:156-158. [PMID: 33446308 PMCID: PMC8244621 DOI: 10.1016/j.jacc.2020.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Ajar Kochar
- Division of Cardiovascular Medicine, Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David E Wang
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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22
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Tehrani BN, Truesdell AG, Psotka MA, Rosner C, Singh R, Sinha SS, Damluji AA, Batchelor WB. A Standardized and Comprehensive Approach to the Management of Cardiogenic Shock. JACC. HEART FAILURE 2020; 8:879-891. [PMID: 33121700 PMCID: PMC8167900 DOI: 10.1016/j.jchf.2020.09.005] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Abstract
Cardiogenic shock is a hemodynamically complex syndrome characterized by a low cardiac output that often culminates in multiorgan system failure and death. Despite recent advances, clinical outcomes remain poor, with mortality rates exceeding 40%. In the absence of adequately powered randomized controlled trials to guide therapy, best practices for shock management remain nonuniform. Emerging data from North American registries, however, support the use of standardized protocols focused on rapid diagnosis, early intervention, ongoing hemodynamic assessment, and multidisciplinary longitudinal care. In this review, the authors examine the pathophysiology and phenotypes of cardiogenic shock, benefits and limitations of current therapies, and they propose a standardized and team-based treatment algorithm. Lastly, they discuss future research opportunities to address current gaps in clinical knowledge.
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Affiliation(s)
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia; Virginia Heart, Falls Church, Virginia
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia
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23
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Gaba P, Gersh BJ, Ali ZA, Moses JW, Stone GW. Complete versus incomplete coronary revascularization: definitions, assessment and outcomes. Nat Rev Cardiol 2020; 18:155-168. [PMID: 33067581 DOI: 10.1038/s41569-020-00457-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Coronary artery disease is the leading cause of morbidity and mortality worldwide. Selected patients with obstructive coronary artery disease benefit from revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Many (but not all) studies have demonstrated increased survival and greater freedom from adverse cardiovascular events after complete revascularization (CR) than after incomplete revascularization (ICR) in patients with multivessel disease. However, achieving CR after PCI or CABG surgery might not be feasible owing to patient comorbidities, anatomical factors, and technical or procedural considerations. These factors also mean that comparisons between CR and ICR are subject to multiple confounders and are difficult to understand or apply to real-world clinical practice. In this Review, we summarize and critically appraise the evidence linking various types of ICR to adverse outcomes in patients with multivessel disease and stable ischaemic heart disease, non-ST-segment elevation acute coronary syndrome or ST-segment elevation myocardial infarction, with or without cardiogenic shock. In addition, we provide practical recommendations for revascularization in patients with high-risk multivessel disease to optimize their long-term clinical outcomes and identify areas requiring future clinical investigation.
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Affiliation(s)
- Prakriti Gaba
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ziad A Ali
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Jeffrey W Moses
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, NY, USA. .,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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24
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Rao SV, Thiele H. Limitations of Observational Analyses of Multivessel PCI in Cardiogenic Shock. JACC Cardiovasc Interv 2020; 13:1836-1837. [PMID: 32763079 DOI: 10.1016/j.jcin.2020.06.007] [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: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/26/2022]
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25
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Khan M, Ilyas M, Cheema F, Ahmad M. Management of Patients With Acute Myocardial Infarction and Cardiogenic Shock. JACC Cardiovasc Interv 2020; 13:1837. [PMID: 32763080 DOI: 10.1016/j.jcin.2020.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 11/16/2022]
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26
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Reply: Cardiogenic Shock Management Will Never Be All or None. JACC Cardiovasc Interv 2020; 13:1837-1838. [PMID: 32763081 DOI: 10.1016/j.jcin.2020.06.048] [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: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 11/20/2022]
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27
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