Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial

CLINICAL OUTCOMES OF PATIENTS WITH CARDIOGENIC SHOCK COMPLICATING ACUTE MYOCARDIAL INFARCTION: THE GULF-CARDIOGENIC SHOCK REGISTRY

ABSTRACT

Background: There is a paucity of data regarding acute myocardial infarction (MI) complicated by cardiogenic shock (AMI-CS) in the Gulf region. This study addressed this knowledge gap by examining patients experiencing AMI-CS in the Gulf region and analyzing hospital and short-term follow-up mortality. Methods: The Gulf-Cardiogenic Shock registry included 1,513 patients with AMI-CS diagnosed between January 2020 and December 2022. Results: The incidence of AMI-CS was 4.1% (1,513/37,379). The median age was 60 years. The most common presentation was ST-elevation MI (73.83%). In-hospital mortality was 45.5%. Majority of patients were in SCAI (Society for Cardiovascular Angiography and Interventions shock classification) stage D and E (68.94%). Factors associated with hospital mortality were previous coronary artery bypass graft (odds ratio [OR]: 2.49; 95% confidence interval [CI]: 1.321-4.693), cerebrovascular accident (OR: 1.621; 95% CI: 1.032-2.547), chronic kidney disease (OR: 1.572; 95% CI: 1.158-2.136), non-ST-elevation MI (OR: 1.744; 95% CI: 1.058-2.873), cardiac arrest (OR: 5.702; 95% CI: 3.640-8.933), SCAI stage D and E (OR: 19.146; 95% CI: 9.902-37.017), prolonged QRS (OR: 10.012; 95% CI: 1.006-1.019), right ventricular dysfunction (OR: 1.679; 95% CI: 1.267-2.226), and ventricular septal rupture (OR: 6.008; 95% CI: 2.256-15.998). Forty percent had invasive hemodynamic monitoring, 90.02% underwent revascularization, and 45.80% received mechanical circulatory support (41.31% had intra-aortic balloon pump and 14.21% had extracorporeal membrane oxygenation/Impella devices). Survival at 12 months was 51.49% (95% CI: 46.44%-56.29%). Conclusions: The study highlighted the significant burden of AMI-CS in this region, with high in-hospital mortality. The study identified several key risk factors associated with increased hospital mortality. Despite the utilization of invasive hemodynamic monitoring, revascularization, and mechanical circulatory support in a substantial proportion of patients, the 12-month survival rate remained relatively low.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) in 2024

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018 and updated in 2022. Recently, the European Society of Cardiology (ESC) published the guidelines for the management of acute coronary syndrome in 2023. Major new updates in the 2023 ESC guideline include: (1) intravascular imaging should be considered to guide PCI (Class IIa); (2) timing of complete revascularization; (3) antiplatelet therapy in patient with high-bleeding risk. Reflecting rapid advances in the field, the Task Force on Primary PCI of the CVIT group has now proposed an updated expert consensus document for the management of ACS focusing on procedural aspects of primary PCI in 2024 version.

Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting

INTRODUCTION

Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined.

METHODOLOGY

A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates.

RESULTS

Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028).

CONCLUSION

Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Current practices in the management of temporary mechanical circulatory support: A survey of CICU directors in North America

INTRODUCTION

Despite the growing use of temporary mechanical circulatory support (tMCS), little data exists to inform management and weaning of these devices.

METHODS

We performed an online survey among cardiac intensive care unit directors in North America to examine current practices in the management of patients treated with intraaortic balloon pump and Impella.

RESULTS

We received responses from 84% of surveyed centers (n=37). Our survey focused on three key aspects of daily management: 1. Hemodynamic monitoring; 2. Hemocompatibility; and 3. Weaning and removal. We found substantial variability surrounding all three areas of care.

CONCLUSION

Our findings highlight the need for consensus around practices associated with improved outcomes in patients treated with tMCS.

Clinical characteristics and short-term outcomes in patients with cardiogenic shock undergoing mechanical circulatory support escalation from intra-aortic balloon pump to impella: From the J-PVAD registry

BACKGROUND

An escalation strategy from intra-aortic balloon pump (IABP) to Impella (AbioMed, Danvers, MA, USA) is proposed in patients with cardiogenic shock (CS) refractory to IABP therapy, but its clinical data are lacking. This study aimed to elucidate the clinical characteristics and short-term outcomes in patients undergoing IABP-Impella escalation.

METHODS AND RESULTS

From the Japanese nationwide registry of Impella (J-PVAD), a total of 2578 patients with CS receiving Impella support were classified into the IABP-Impella group (n = 189) or the Primary Impella group (n = 2389). We applied 1:3 propensity score (PS) matching, selecting 185 patients and 555 patients, respectively. Before matching, the IABP-Impella group presented longer shock-to-Impella time, worse laboratory data, and more frequent inotropes and pulmonary artery catheter use than the Primary Impella group. After matching, the baseline characteristics were well-balanced. Regarding the 30-day clinical outcomes in the PS-matched cohort, there were no significant differences in the rates of mortality and major complications (a composite of bleeding, hemolysis, infection, stroke, myocardial infarction, limb ischemia, and vascular injury) between the groups. However, The IABP-Impella group showed a significantly higher rate of infection (10.3 % vs. 5.6 %, p = 0.042) and additional mechanical circulatory support use (34.1 % vs. 23.8 %, p = 0.008) than the Primary Impella group.

CONCLUSIONS

Compared to patients with primary Impella support, those undergoing IABP-Impella escalation showed similar 30-day mortality and major complications despite poorer clinical conditions before Impella support and a more complicated clinical course after Impella insertion.

Temporary mechanical circulatory support in infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials with 6-month follow-up

BACKGROUND

Percutaneous active mechanical circulatory support (MCS) devices are being increasingly used in the treatment of acute myocardial infarction-related cardiogenic shock (AMICS) despite conflicting evidence regarding their effect on mortality. We aimed to ascertain the effect of early routine active percutaneous MCS versus control treatment on 6-month all-cause mortality in patients with AMICS.

METHODS

In this individual patient data meta-analysis, randomised controlled trials of potential interest were identified, without language restriction, by querying the electronic databases MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, and Embase, as well as ClinicalTrials.gov, up to Jan 26, 2024. All randomised trials with 6-month mortality data comparing early routine active MCS (directly in the catheterisation laboratory after randomisation) versus control in patients with AMICS were included. The primary outcome was 6-month all-cause mortality in patients with AMICS treated with early routine active percutaneous MCS versus control, with a focus on device type (loading, such as venoarterial extracorporeal membrane oxygenation [VA-ECMO] vs unloading) and patient selection. Hazard ratios (HRs) of the primary outcome measure were calculated using Cox regression models. This study is registered with PROSPERO, CRD42024504295.

FINDINGS

Nine reports of randomised controlled trials (n=1114 patients) were evaluated in detail. Overall, four randomised controlled trials (n=611 patients) compared VA-ECMO with a control treatment and five randomised controlled trials (n=503 patients) compared left ventricular unloading devices with a control treatment. Two randomised controlled trials also included patients who did not have AMICS, who were excluded (55 patients [44 who were treated with VA-ECMO and 11 who were treated with a left ventricular unloading device]). The median patient age was 65 years (IQR 57-73); 845 (79·9%) of 1058 patients with data were male and 213 (20·1%) were female. No significant benefit of early unselected MCS use on 6-month mortality was noted (HR 0·87 [95% CI 0·74-1·03]; p=0·10). No significant differences were observed for left ventricular unloading devices versus control (0·80 [0·62-1·02]; p=0·075), and loading devices also had no effect on mortality (0·93 [0·75-1·17]; p=0·55). Patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality with MCS use (0·77 [0·61-0·97]; p=0·024). Major bleeding (odds ratio 2·64 [95% CI 1·91-3·65]) and vascular complications (4·43 [2·37-8·26]) were more frequent with MCS use than with control.

INTERPRETATION

The use of active MCS devices in patients with AMICS did not reduce 6-month mortality (regardless of the device used) and increased major bleeding and vascular complications. However, patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality after MCS use. Therefore, the use of MCS should be restricted to certain patients only.

FUNDING

The Heart Center Leipzig at Leipzig University and the Foundation Institut für Herzinfarktforschung.

Management of cardiogenic shock: state-of-the-art

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

Temporary Mechanical Circulatory Support after Cardiac Surgery

Postcardiotomy shock in the cardiac surgical patient is a highly morbid condition characterized by profound myocardial impairment and decreased systemic perfusion inadequate to meet end-organ metabolic demand. Postcardiotomy shock is associated with significant morbidity and mortality. Poor outcomes motivate the increased use of mechanical circulatory support (MCS) to restore perfusion in an effort to prevent multiorgan injury and improve patient survival. Despite growing acceptance and adoption of MCS for postcardiotomy shock, criteria for initiation, clinical management, and future areas of clinical investigation remain a topic of ongoing debate. This article seeks to (1) define critical cardiac dysfunction in the patient after cardiotomy, (2) provide an overview of commonly used MCS devices, and (3) summarize the relevant clinical experience for various MCS devices available in the literature, with additional recognition for the role of MCS as a part of a modified approach to the cardiac arrest algorithm in the cardiac surgical patient.

Review of Advancements in Managing Cardiogenic Shock: From Emergency Care Protocols to Long-Term Therapeutic Strategies

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome of end-organ hypoperfusion that could be associated with multisystem organ failure, presenting a diverse range of causes and symptoms. Despite improving survival in recent years due to new advancements, CS still carries a high risk of severe morbidity and mortality. Recent research has focused on improving early detection and understanding of CS through standardized team approaches, detailed hemodynamic assessment, and selective use of temporary mechanical circulatory support devices, leading to better patient outcomes. This review examines CS pathophysiology, emerging classifications, current drug and device therapies, standardized team management strategies, and regionalized care systems aimed at optimizing shock outcomes. Furthermore, we identify gaps in knowledge and outline future research needs.

Ischemic Heart Disease in Pregnancy: Current Understanding and Management Strategies

Ischemic heart disease (IHD) during pregnancy poses a rare but significant risk to maternal and fetal health, with global incidence rates ranging from 0.7 to 10 cases per 100,000 pregnancies. This review synthesizes current literature on the epidemiology, pathophysiology, clinical presentation, diagnosis, management, and outcomes of IHD in pregnancy. Pregnancy-related IHD encompasses various conditions, including coronary artery disease, spontaneous coronary artery dissection, myocardial infarction with nonobstructive coronary arteries, coronary embolism, and coronary vasospasm. The pathophysiology is multifactorial, involving hemodynamic changes, hormonal influences, and increased hypercoagulability. Clinical presentation may mimic typical pregnancy symptoms, necessitating a high index of suspicion for timely diagnosis. A multidisciplinary strategy is needed for management, taking into account the hazards to the mother and fetus while also taking drug safety and procedural treatments such coronary artery bypass grafting and percutaneous coronary intervention into account. Careful observation and timely management are necessary for complications such as cardiogenic shock, arrhythmias, and thromboembolic events following myocardial infarction. With advancements in treatment techniques and early discovery, the prognosis has improved, although maternal mortality is still a worry. For the purpose of improving results and directing future research endeavors, knowledge and comprehension of IHD during pregnancy are essential.

Left Ventricular Unloading Using Intra-aortic Entrainment Pumping Before Reperfusion Reduces Post-AMI Infarct Size

BACKGROUND

Anterior myocardial infarction standard of care prioritizes swift coronary reperfusion. Recent studies show left ventricular (LV) unloading with transvalvular axial flow pumps for 30 minutes before reperfusion (vs immediate reperfusion) decreases 28-day infarct size. Intra-aortic entrainment pumping, using hardware located away from the heart to provide support throughout the cardiac cycle, decreases effective systemic vascular resistance and augments visceral blood flow and pressure, and may reproduce this benefit with a decreased risk. This study characterized the hemodynamic effects of unloading before and during reperfusion using intra-aortic entrainment pumping and investigated whether unloading decreased anterior myocardial infarction scar size.

METHODS AND RESULTS

Yorkshire swine were subjected to 90 minutes of left anterior descending artery balloon occlusion and randomly assigned to immediate reperfusion (n = 6) vs 30 minutes unloading before reperfusion followed by 120 minutes of further unloading (n = 7). Unloading was achieved using percutaneous entrainment pumping in the descending aorta. The anterior myocardial infarction model matches that used in recent transvalvular pumping studies. Mortality before randomization was 22%. After randomization, mortality was 36% for immediate reperfusion and 0% for unloading. Unloading showed immediate hemodynamic benefit that increased through reperfusion and continued support, leading to distinct differences in cardiac function between groups after 30 minutes of reperfusion. Unloading increased stroke volume and cardiac efficiency at this timepoint relative to preocclusion baseline and reduced 28-day LV scar size by 37%-45%.

CONCLUSIONS

We present the first preclinical data showing extracardiac LV unloading before coronary reperfusion using intra-aortic entrainment pumping decreases 28-day infarct size. Extracardiac unloading to decrease LV scar size may provide an alternative to transvalvular pumping with potential advantages, including reduced risk.

Cardioprotection in cardiovascular surgery

Since the invention of cardiopulmonary bypass, cardioprotective strategies have been investigated to mitigate ischemic injury to the heart during aortic cross-clamping and reperfusion injury with cross-clamp release. With advances in cardiac surgical and percutaneous techniques and post-operative management strategies including mechanical circulatory support, cardiac surgeons are able to operate on more complex patients. Therefore, there is a growing need for improved cardioprotective strategies to optimize outcomes in these patients. This review provides an overview of the basic principles of cardioprotection in the setting of cardiac surgery, including mechanisms of cardiac injury in the context of cardiopulmonary bypass, followed by a discussion of the specific approaches to optimizing cardioprotection in cardiac surgery, including refinements in cardiopulmonary bypass and cardioplegia, ischemic conditioning, use of specific anesthetic and pharmaceutical agents, and novel mechanical circulatory support technologies. Finally, translational strategies that investigate cardioprotection in the setting of cardiac surgery will be reviewed, with a focus on promising research in the areas of cell-based and gene therapy. Advances in this area will help cardiologists and cardiac surgeons mitigate myocardial ischemic injury, improve functional post-operative recovery, and optimize clinical outcomes in patients undergoing cardiac surgery.

GLP-1 in patients with myocardial infarction complicated by cardiogenic shock-an IABP-SHOCK II-substudy

BACKGROUND

Glucagon-like peptide-1 (GLP-1) is a gut-derived peptide secreted in response to nutritional and inflammatory stimuli. Elevated GLP-1 levels predict adverse outcome in patients with acute myocardial infarction or sepsis. GLP-1 holds cardioprotective effects and GLP-1 receptor agonists reduce cardiovascular events in high-risk patients with diabetes. In this study, we aimed to investigate the capacity of GLP-1 to predict outcome in patients with cardiogenic shock (CS) complicating myocardial infarction.

METHODS

Circulating GLP-1 levels were serially assessed in 172 individuals during index PCI and day 2 in a prospectively planned biomarker substudy of the IABP-SHOCK II trial. All-cause mortality at short- (30 days), intermediate- (1 year), and long-term (6 years) follow-up was used for outcome assessment.

RESULTS

Patients with fatal short-term outcome (n = 70) exhibited higher GLP-1 levels [86 (interquartile range 45-130) pM] at ICU admission in comparison to patients with 30-day survival [48 (interquartile range 33-78) pM; p < 0.001] (n = 102). Repeated measures ANOVA revealed a significant interaction of GLP-1 dynamics from baseline to day 2 between survivors and non-survivors (p = 0.04). GLP-1 levels above vs. below the median proved to be predictive for short- [hazard ratio (HR) 2.43; 95% confidence interval (CI) 1.50-3.94; p < 0.001], intermediate- [HR 2.46; 95% CI 1.62-3.76; p < 0.001] and long-term [HR 2.12; 95% CI 1.44-3.11; p < 0.001] outcome by multivariate Cox-regression analysis.

CONCLUSION

Elevated plasma levels of GLP-1 are an independent predictor for impaired prognosis in patients with myocardial infarction complicated by CS. The functional relevance of GLP-1 in this context is currently unknown and needs further investigations.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov Identifier: NCT00491036.

Cardiac arrest and cardiogenic shock complicating ST-segment elevation myocardial infarction in China: A retrospective multicenter study

Background

Data on the effect of cardiac arrest (CA), cardiogenic shock (CS), and their combination on the prognosis of Chinese patients with ST-segment elevation myocardial infarction (STEMI) are limited. The present study sought to evaluate the clinical outcomes of STEMI complicated by CA and CS, and to identify the risk factors for CA or CS.

Methods

This study included 7468 consecutive patients with STEMI in China. The patients were divided into 4 groups (CA + CS, CA only, CS only, and No CA or CS). The endpoints were 30-day all-cause death and major adverse cardiovascular events. A Cox proportional hazards regression analysis was performed.

Results

CA, CS, and their combination were noted in 332 (4.4 %), 377 (5.0 %), and 117 (1.6 %) among all patients. During the 30-day follow-up, 817 (10.9 %) all-cause deaths and 964 (12.9 %) major adverse cardiovascular events occurred, and the incidence of all-cause mortality (3.6 %, 62.3 %, 74.1 %, 83.3 %) and major adverse cardiovascular events (5.4 %, 67.1 %, 75.0 %, and 87.2 %) significantly increased in the No CA or CS, CS only, CA only, and CA + CS groups, respectively. In the multivariate Cox regression models, compared with the No CA or CS group, the CA + CS, CA, and CS-only groups were associated with an increased risk of all-cause death and major adverse cardiovascular events. Patients with CA + CS had the highest risk of all-cause death (hazard ratio [HR], 25.259 [95 % confidence interval (CI) 19.221-33.195]) and major adverse cardiovascular events (HR 19.098, 95%CI 14.797-24.648).

Conclusions

CA, CS, and their combination were observed in approximately 11 % of Chinese patients with STEMI, and were associated with increased risk for 30-day mortality and major adverse cardiovascular events in Chinese patients with STEMI.

US trends of in-hospital morbidity and mortality for acute myocardial infarctions complicated by cardiogenic shock

BACKGROUND

There is limited real-world data highlighting recent temporal in-hospital morbidity and mortality trends for cases of acute myocardial infarction complicated by cardiogenic shock. The role of mechanical circulatory support within this patient population remains unclear.

METHODS

The US National Inpatient Sample database was sampled from 2011 to 2018 identifying 206,396 hospitalizations with a primary admission diagnosis of ST- or Non-ST elevation myocardial infarction complicated by cardiogenic shock. The primary outcomes included trends of all-cause in-hospital mortality, mechanical circulatory support use, and sex-specific trends for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) over the study period.

RESULTS

The annual number of AMI-CS hospitalizations increased from 22,851 in 2011 to 30,015 in 2018 and in-hospital mortality trends remained similar (42.9 % to 43.7 %, ptrend < 0.001). The proportion of patients receiving any temporary MCS device decreased (46.4 % to 44.4 %). The use of intra-aortic balloon pump (IABP) decreased (44.9 % to 32.9 %) and the use of any other non-IABP MCS device increased (2.5 % to 15.6 %), ptrend<0.001. Sex-specific mortality indicate female in-hospital mortality remained similar (50.3 % to 51 %, ptrend<0.001), but higher than male in-hospital mortality, which increased non-significantly (38.8 % to 40.2 %, ptrend = 0.372).

CONCLUSIONS

From 2011 to 2018, hospitalizations for AMI-CS patients have increased in number. However, there has been no recent appreciable change in AMI-CS mortality despite a changing treatment landscape with decreasing use of IABPs and increasing use of non-IABP MCS devices. Further research is necessary to examine the appropriate use of MCS devices within this population.

Cardiogenic Shock: An Overview

Cardiogenic shock (CS) is a complex and dreadful condition for which effective treatments remain unclear. The concerningly high mortality rate of CS emphasizes a need for developing effective therapies to reduce its mortality and reverse its detrimental course. This article aims to provide an updated and evidence-based review of the pathophysiology of CS and the related pharmacotherapeutics with a special focus on vasoactive and inotropic agents.

Machine learning-based model development for predicting risk factors of prolonged intra-aortic balloon pump therapy in patients with coronary artery bypass grafting

Machine learning algorithms are frequently used to clinical risk prediction. Our study was designed to predict risk factors of prolonged intra-aortic balloon pump (IABP) use in patients with coronary artery bypass grafting (CABG) through developing machine learning-based models. Patients who received perioperative IABP therapy were divided into two groups based on their length of IABP implantation longer than the 75th percentile for the whole cohort: normal (≤ 10 days) and prolonged (> 10 days) groups. Seven machine learning-based models were created and evaluated, and then the Shapley Additive exPlanations (SHAP) method was employed to further illustrate the influence of the features on model. In our study, a total of 143 patients were included, comprising 56 cases (38.16%) in the prolonged group. The logistic regression model was considered the final prediction model according to its most excellent performance. Furthermore, feature important analysis identified left ventricular end-systolic or diastolic diameter, preoperative IABP use, diabetes, and cardiac troponin T as the top five risk variables for prolonged IABP implantation in patients. The SHAP analysis further explained the features attributed to the model. Machine learning models were successfully developed and used to predict risk variables of prolonged IABP implantation in patients with CABG. This may help early identification for prolonged IABP use and initiate clinical interventions.

Is preoperative IABP insertion significantly reducing postoperative complication in augmented high-risk coronary artery bypass grafting patients?

BACKGROUND

The aim of this study was to determine whether pre-operative intra-aortic balloon pump (IABP) insertion improves surgical outcomes in high-risk coronary artery bypass grafting (CABG) patients.

METHODS

Patients with a EuroSCORE II greater than 1.2% who underwent CABG from 2009 to 2016 were included in the study, while those who utilized intra-operative or post-operative IABP were excluded. The analysis included a total of 2907 patients, with 377 patients undergoing preoperative IABP insertion (EuroSCORE II > 5.018%) and 1198 patients in the non-IABP group before matching; after propensity score matching (PSM), both groups consisted of a matched cohort of 250 patients.

RESULTS

30-day mortality events occurred in 9 (3.6%) non-IABP group and in 12 (4.8%) IABP patients (OR: 1.33 95%CI: 0.52-3.58). Kaplan-Meier survival curve analysis showed no significant differences between the two groups in mortality up to one year after the operation (p = 0.72). On multivariate analysis, IABP usage among the PSM patients was associated with lower 30-day mortality (OR: 0.28, 95%CI: 0.07-0.92, P-value = 0.043), 90-day mortality (OR: 0.26, 95%CI: 0.08-0.78, P-value = 0.022) and reduced risk of developing severe respiratory disorders (OR: 0.10, 95%CI:0.01-0.50, P-value = 0.011).

CONCLUSION

Pre-operative IABP use in high-risk patients reduces 30- and 90-day mortality rates, along with a notable decrease in rates of severe respiratory disorders.

Safety and utility of mechanical circulatory support in patients with acute myocardial infarction complicated by cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is a major cause of morbidity and mortality. Although mechanical circulatory support (MCS) is an increasingly utilized therapeutic option in AMI-CS, studies evaluating the efficacy and safety of different forms of MCS have yielded conflicting results. This systematic review and meta-analysis aims to evaluate the safety and efficacy of different forms of MCS.

METHODS

A database search was performed for studies reporting on the association of different forms of MCS with clinical outcomes in patients with AMI-CS. The primary efficacy endpoints were short term (≤30 days) and long term (>30 days) all-cause mortality. Secondary efficacy endpoints included recurrent AMI, cardiovascular (CV) mortality, device-related limb complications, moderate to severe bleeding events, and cerebrovascular accidents (CVA).

RESULTS

2752 patients with AMI-CS met inclusion criteria. Results were available comparing ECMO to other MCS or medical therapy alone, comparing IABP to medical therapy alone, and comparing pLVAD to IABP. Use of ECMO was not associated with lower risk of 30-day or long-term mortality compared to pVAD or standard medical therapy with or without IABP placement but was associated with higher risk of device-related limb complications and moderate to severe bleeding compared to pVAD. IABP use was not associated with a lower risk of 30 day or long-term mortality but was associated with higher risk of recurrent AMI and moderate to severe bleeding compared to medical therapy. Compared to IABP, pVAD use was associated with lower risk of CV mortality but not recurrent AMI. pVAD was associated with a higher risk of device-related limb complications and moderate to severe bleeding compared to IABP use.

CONCLUSION

Use of ECMO or IABP in patients with AMI-CS is not associated with significant improvement in mortality. pVAD is associated with a lower risk of CV mortality. All MCS types are associated with increased risk of complications. Additional high-quality studies are needed to determine the optimal MCS therapy for patients with AMI-CS.

Early vs. delayed mechanical circulatory support in patients with acute myocardial infarction and cardiogenic shock

AIMS

Despite increased temporary mechanical circulatory support (tMCS) utilization for acute myocardial infarction complicated by cardiogenic shock (AMI-CS), data regarding efficacy and optimal timing for tMCS support are limited. This study aimed to describe outcomes based on tMCS timing in AMI-CS and to identify predictors of 30-day mortality and readmission.

METHODS AND RESULTS

Patients with AMI-CS identified in the National Readmissions Database were grouped according to the use of tMCS and early (<24 h) vs. delayed (≥24 h) tMCS. The correlation between tMCS timing and inpatient outcomes was evaluated using linear regression. Multivariate logistic regression was used to identify variables associated with 30-day mortality and readmission. Of 294 839 patients with AMI-CS, 109 148 patients were supported with tMCS (8067 veno-arterial extracorporeal membrane oxygenation, 33 577 Impella, and 79 161 intra-aortic balloon pump). Of patients requiring tMCS, patients who received early tMCS (n = 79 906) had shorter lengths of stay (7 vs. 15 days, P < 0.001) and lower rates of ischaemic and bleeding complications than those with delayed tMCS (n = 32 241). Patients requiring tMCS had higher in-hospital mortality [odds ratio (95% confidence interval)] [1.7 (1.7-1.8), P < 0.001]. Among patients requiring tMCS, early support was associated with fewer complications, lower mortality [0.90 (0.85-0.94), P < 0.001], and fewer 30-day readmissions [0.91 (0.85-0.97), P = 0.005] compared with patients with delayed tMCS.

CONCLUSION

Among patients receiving tMCS for AMI-CS, early tMCS was associated with fewer complications, shorter lengths of stay, lower hospital costs, and fewer deaths and readmissions at 30 days.

Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention?

Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.

Why VA-ECMO should not be used routinely in AMI-Cardiogenic Shock

This review summarizes the current evidence regarding efficacy and safety of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of cardiogenic shock. Currently, there is evidence from 4 randomized controlled trials which all do not support a mortality benefit and increased complication rates by VA-ECMO. Based on current evidence, possible subgroups will be discussed and indications in selected very small patient groups be discussed.

Immediate inflammatory response to mechanical circulatory support in a porcine model of severe cardiogenic shock

BACKGROUND

In selected cases of cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is combined with trans valvular micro axial flow pumps (ECMELLA). Observational studies indicate that ECMELLA may reduce mortality but exposing the patient to two advanced mechanical support devices may affect the early inflammatory response. We aimed to explore inflammatory biomarkers in a porcine cardiogenic shock model managed with V-A ECMO or ECMELLA.

METHODS

Fourteen landrace pigs had acute myocardial infarction-induced cardiogenic shock with minimal arterial pulsatility by microsphere embolization and were afterwards managed 1:1 with either V-A ECMO or ECMELLA for 4 h. Serial blood samples were drawn hourly and analyzed for serum concentrations of interleukin 6 (IL-6), IL-8, tumor necrosis factor alpha, and serum amyloid A (SAA).

RESULTS

An increase in IL-6, IL-8, and SAA levels was observed during the experiment for both groups. At 2-4 h of support, IL-6 levels were higher in ECMELLA compared to V-A ECMO animals (difference: 1416 pg/ml, 1278 pg/ml, and 1030 pg/ml). SAA levels were higher in ECMELLA animals after 3 and 4 h of support (difference: 401 ng/ml and 524 ng/ml) and a significant treatment-by-time effect of ECMELLA on SAA was identified (p = 0.04). No statistical significant between-group differences were observed in carotid artery blood flow, urine output, and lactate levels.

CONCLUSIONS

Left ventricular unloading with Impella during V-A ECMO resulted in a more extensive inflammatory reaction despite similar end-organ perfusion.

Circulating biomarkers of the CS4P and CLIP scores are not altered in a pig model of acute cardiogenic shock and additional short-term circulatory support

BACKGROUND

Cardiogenic shock (CS) is the leading cause of death in patients with myocardial infarction with a mortality rate greater than 50%. Recently, the CS 4 Proteins (CS4P) and CLIP scores have been developed to predict survival in CS patients. However, their impact in acute CS and additional short-term left ventricular (LV) circulatory support as prognostic markers is currently not known.

METHODS AND RESULTS

CS was induced in a porcine model by injecting microsphere particles into the left main coronary artery. Mechanical circulatory support was performed by additional percutaneous LV unloading using an Impella microaxial flow-pump for 30 minutes. Serum samples were collected at baseline, following the onset of CS, and additional LV unloading. Serum levels of biomarkers of the CS4P (beta-2-microglobulin, ALDOB, L-FABP, SerpinG1) and the CLIP scores (Cystatin C, Lactate, Interleukin-6, NT-proBNP) were neither different at any time point investigated nor did they correlate with cardiac output.

CONCLUSION

The CS4P and CLIP scores do not reflect immediate whole-body dysregulation in acute CS and have not been able to predict the potential reversal following additional short-term mechanical support by LV unloading in our experimental model. The impact of both scores as prognostic markers after the immediate onset of CS and following additional short-term LV unloading to identify patients at greatest risk remains to be determined.

Association between left ventricular ejection fraction, mortality and use of mechanical circulatory support in patients with non-ischaemic cardiogenic shock

BACKGROUND

Currently, use of mechanical circulatory support (MCS) in non-ischaemic cardiogenic shock (CS) is predominantly guided by shock-specific markers, and not by markers of cardiac function. We hypothesise that left ventricular ejection fraction (LVEF) can identify patients with a higher likelihood to benefit from MCS and thus help to optimise their expected benefit.

METHODS

Patients with non-ischaemic CS and available data on LVEF from 16 tertiary-care centres in five countries were analysed. Cox regression models were fitted to evaluate the association between LVEF and mortality, as well as the interaction between LVEF, MCS use and mortality.

RESULTS

N = 807 patients were analysed: mean age 63 [interquartile range (IQR) 51.5-72.0] years, 601 (74.5%) male, lactate 4.9 (IQR 2.6-8.5) mmol/l, LVEF 20 (IQR 15-30) %. Lower LVEF was more frequent amongst patients with more severe CS, and MCS was more likely used in patients with lower LVEF. There was no association between LVEF and 30-day mortality risk in the overall study cohort. However, there was a significant interaction between MCS use and LVEF, indicating a lower 30-day mortality risk with MCS use in patients with LVEF ≤ 20% (hazard ratio 0.72, 95% confidence interval 0.51-1.02 for LVEF ≤ 20% vs. hazard ratio 1.31, 95% confidence interval 0.85-2.01 for LVEF > 20%, interaction-p = 0.017).

CONCLUSION

This retrospective study may indicate a lower mortality risk with MCS use only in patients with severely reduced LVEF. This may propose the inclusion of LVEF as an adjunctive parameter for MCS decision-making in non-ischaemic CS, aiming to optimise the benefit-risk ratio.

Acute myocardial infarction complicated by cardiogenic shock in Ukraine: multicentre registry analysis 2021-2022

Background

Data on the results and management strategies in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) in the Low and Lower-Middle Income Countries (LLMICs) are limited. This lack of understanding of the situation partially hinders the development of effective cardiogenic shock treatment programs in this part of the world.

Materials and methods

The Ukrainian Multicentre Cardiogenic Shock Registry was analyzed, covering patient data from 2021 to 2022 in 6 major Ukrainian reperfusion centres from different parts of the country. Analysis was focusing on outcomes, therapeutic modalities and mortality predictors in AMI-CS patients.

Results

We analyzed data from 221 consecutive patients with CS from 6 hospitals across Ukraine. The causes of CS were ST-elevated myocardial infarction (85.1%), non-ST-elevated myocardial infarction (5.9%), decompensated chronic heart failure (7.7%) and arrhythmia (1.3%), with a total in-hospital mortality rate for CS of 57.1%. The prevalence of CS was 6.3% of all AMI with reperfusion rate of 90.5% for AMI-CS. In 23.5% of cases, CS developed in the hospital after admission. Mechanical circulatory support (MCS) utilization was 19.9% using intra-aortic balloon pump alone. Left main stem occlusion, reperfusion deterioration, Charlson Comorbidity Index >4, and cardiac arrest were found to be independent predictors for hospital mortality in AMI-СS.

Conclusions

Despite the wide adoption of primary percutaneous coronary intervention as the main reperfusion strategy for AMI, СS remains a significant problem in LLMICs, associated with high in-hospital mortality. There is an unmet need for the development and implementation of a nationwide protocol for CS management and the creation of reference CS centers based on the country-wide reperfusion network, equipped with modern technologies for MCS.

Contemporary approach to cardiogenic shock care: a state-of-the-art review

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.

Impella device in fulminant myocarditis: Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD) registry analysis on outcomes and adverse events

AIMS

Given that fulminant myocarditis, characterized by unstable haemodynamics, is a significant clinical challenge and that traditional pharmacological treatments have limitations, evaluating alternatives such as the Impella device is a crucial focus of this study. Further, this study presents pioneering large-scale registry data on its use in managing fulminant myocarditis.

METHODS AND RESULTS

Data from the Japanese Registry for Percutaneous Ventricular Assist Devices (J-PVAD) were analysed to assess Impella's role in managing fulminant myocarditis from February 2020 to December 2021. The primary outcome was 30-day mortality for those treated with Impella. Of the 269 patients treated with Impella, 107 used Impella standalone, and 162 used ECPELLA (Impella combined with extracorporeal membrane oxygenation). The average age was 54 years, with 42.8% females. Overall, 74.3% survived at 30 days. Specifically, the success rate was 68.5% for the ECPELLA group and 83.2% for the Impella standalone group. Cox regression highlighted that lower estimated glomerular filtration rate and pre-Impella systolic blood pressure increased adverse event risk, while Swan-Ganz catheterization use reduced it. Adverse events were noted in 48.7% of patients, such as bleeding (32.0%) and deteriorating renal function (8.6%).

CONCLUSION

Impella's use in fulminant myocarditis demonstrates encouraging short-term outcomes, albeit with significant adverse events. These findings align with previous mechanical circulatory support studies, emphasizing caution regarding haemorrhagic issues. Further studies are essential to enhance patient selection and treatment approaches.

Optimal Heart Failure Medical Therapy and Mortality in Survivors of Cardiogenic Shock: Insights From the FRENSHOCK Registry

BACKGROUND

The effects of pharmacological therapy on cardiogenic shock (CS) survivors have not been extensively studied. Thus, this study investigated the association between guideline-directed heart failure (HF) medical therapy (GDMT) and one-year survival rate in patients who are post-CS.

METHODS AND RESULTS

FRENSHOCK (French Observatory on the Management of Cardiogenic Shock in 2016) registry was a prospective multicenter observational survey, conducted in metropolitan French intensive care units and intensive cardiac care units. Of 772 patients, 535 patients were enrolled in the present analysis following the exclusion of 217 in-hospital deaths and 20 patients with missing medical records. Patients with triple GDMT (beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists) at discharge (n=112) were likely to have lower left ventricular ejection fraction on admission and at discharge compared with those without triple GDMT (n=423) (22% versus 28%, P<0.001 and 29% versus 37%, P<0.001, respectively). In the overall cohort, the one-year mortality rate was 23%. Triple GDMT prescription was significantly associated with a lower one-year all-cause mortality compared with non-triple GDMT (adjusted hazard ratio 0.44 [95% CI, 0.19-0.80]; P=0.007). Similarly, 2:1 propensity score matching and inverse probability treatment weighting based on the propensity score demonstrated a lower incidence of one-year mortality in the triple GDMT group. As the number of HF drugs increased, a stepwise decrease in mortality was observed (log rank; P<0.001).

CONCLUSIONS

In survivors of CS, the one-year mortality rate was significantly lower in those with triple GDMT. Therefore, this study suggests that intensive HF therapy should be considered in patients following CS.

Comparative efficacy of Chinese herbal injections in patients with cardiogenic shock (CS): a systematic review and Bayesian network meta-analysis of randomized controlled trials

Background: Cardiogenic shock (CS) is the primary cause of death in patients suffering acute myocardial infarction. As an emerging and efficacious therapeutic approach, Chinese herbal injections (CHIs) are gaining significant popularity in China. However, the optimal CHIs for treating CS remain uncertain. Method: We searched eight databases from inception to 30 September 2023. Subsequently, we conducted the Bayesian network meta-analysis (NMA). Interventions were ranked based on the surface under the cumulative ranking curve (SUCRA) probability values. To compare the effects of CHIs on two distinct outcomes, a clustering analysis was performed. Furthermore, the quality of the studies was assessed. Results: For the study, we included 43 RCTs, encompassing 2,707 participants. The study evaluated six herbal injections, namely, Shenfu injection (SF), Shengmai injection (SM), Shenmai injection (Sm), Danshen injection (DS), Huangqi injection (HQ), and Xinmailong injection (XML). The analysis findings suggested that Sm (MD = -1.05, 95% CI: -2.10, -0.09) and SF (MD = -0.81, 95% CI: -1.40, -0.25) showed better efficacy compared to Western medicine (WM) alone in reducing in-hospital mortality. The SUCRA values revealed that Sm + WM ranked first in terms of in-hospital mortality, cardiac index (CI), and hourly urine output but second in improving left ventricular ejection fraction (LVEF) and mean arterial pressure (MAP). SF + WM, however, had the greatest impact on raising the clinical effective rate. In MAP, SM + WM came out on top. Moreover, in terms of safety, only 14 studies (31.8%), including five types of CHIs: SF, Sm, SM, HQ, and XML, observed adverse drug reactions. Conclusion: To summarize, this analysis discovered that, in terms of patients suffering from CS, CHIs + WM yielded significantly greater advantages than WM alone. Based on in-hospital mortality and the remaining outcomes, Sm performed excellently among all the involved CHIs. Systematic Review Registration: https:// www.Crd.york.ac.uk/prospero/, identifier: CRD42022347053.

Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock

BACKGROUND

Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no tMCS or either intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella® for AMICS, with a particular focus on long-term outcomes.

METHODS

Using health claim data from AOK-Die Gesundheitskasse (local health care funds), we retrospectively analysed complications and outcomes of all insured patients with AMICS between 1 January 2010 and 31 December 2017.

RESULTS

A total of 39,864 patients were included (IABP 5451; Impella 776; V-A ECMO 833; no tMCS 32,804). In-hospital complications, including renal failure requiring dialysis (50.3% V-A ECMO vs. 30.5% Impella vs. 29.2 IABP vs. 12.1% no tMCS), major bleeding (38.1% vs. 20.9% vs. 18.0% vs. 9.3%) and sepsis (22.5% vs. 15.9% vs. 13.9% vs. 9.3%) were more common in V-A ECMO patients. In a multivariate analysis, the use of both V-A ECMO (HR 1.57, p < 0.001) and Impella (HR 1.25, p < 0.001) were independently associated with long-term mortality, whereas use of IABP was not (HR 0.89, p < 0.001). Kaplan-Meier estimates showed better survival for patients on IABP compared with Impella, V-A ECMO and no-tMCS. Short- and long-term mortality was high across all groups.

CONCLUSIONS

Our data show noticeably more in-hospital complications in patients on tMCS and higher mortality with V-A ECMO and Impella. The use of both devices is an independent risk factor for mortality, whereas the use of IABP is associated with a survival benefit.

DIFFERENCES IN MANAGEMENT AND PROGNOSTICATION OF CARDIOGENIC SHOCK PATIENTS IN THE PRESENCE AND ABSENCE OF OUT-OF-HOSPITAL CARDIAC ARREST

ABSTRACT

Background: The clinical spectrum of acute myocardial infarction complicated by cardiogenic shock (AMICS) varies. Out-of-hospital cardiac arrest (OHCA) can be the first sign of cardiac failure, whereas others present with various degrees of hemodynamic instability (non-OHCA). The aim of the present study was to explore differences in prehospital management and characteristics of survivors and nonsurvivors in AMICS patients with OHCA or non-OHCA. Methods: Data analysis was based on patient data from the RETROSHOCK cohort comprising consecutive AMICS patients admitted to two tertiary cardiac centers between 2010 and 2017. Results: 1,716 AMICS patients were included and 42% presented with OHCA. Mortality in OHCA patients was 47% versus 57% in the non-OHCA group. Almost all OHCA patients were intubated before admission (96%). In the non-OHCA group, prehospital intubation (25%) was associated with a better survival ( P < 0.001). Lactate level on admission demonstrated a linear relationship with mortality in OHCA patients. In non-OHCA, probability of death was higher for any given lactate level <12 mmol/L compared with OHCA. However, a lactate level >7 mmol/L in non-OHCA did not increase mortality odds any further. Conclusion: Mortality was almost doubled for any admission lactate level up to 7 mmol/L in non-OHCA patients. Above this level, mortality remained unchanged in non-OHCA patients but continued to increase in OHCA patients. Prehospital intubation was performed in almost all OHCA patients but only in one of four patients without OHCA. Early intubation in non-OHCA patients was associated with a better outcome.

The impact of chronic total occlusion in non-infarct related arteries on patient outcomes following percutaneous coronary intervention for STEMI superimposed with cardiogenic shock: A pilot systematic review and meta-analysis

INTRODUCTION

Chronic total occlusion (CTO) is defined as a near-total blockage of a coronary artery and often occurs in arteries that are not directly responsible for the event, known as non-infarct-related arteries (NIRA). Cardiogenic shock (CS) is a complication of ST-elevated myocardial infarction (STEMI) that carries significant mortality. We performed a meta-analysis to find an association between mortality in patients undergoing PCI for STEMI that have superimposed CS, with the presence of CTO in the NIRA.

MATERIALS AND METHODOLOGY

A comprehensive literature search was conducted using PubMed, EMBASE, Google Scholar and clinicaltrials.gov from inception till October 2023 to retrieve studies that compare the presence of CTO with the absence of CTO in NIRA in STEMI with CS patients undergoing PCI. The primary endpoint was 30-day mortality and the secondary endpoints were risk of all-cause mortality (ACM) and repeat myocardial infarction (MI). Forest plots were generated using the random effects model by pooling odds ratios (ORs) with a 95 % confidence interval. Statistical significance was set at p < 0.05.

RESULTS

5 observational studies with a total of 5186 patients (1031 with CTO in NIRA and 4155 with no CTO in NIRA) were included. The presence of CTO in NIRA was associated with higher odds of 30-day mortality [OR: 3.10; 95 % CI: 1.52, 6.32; p < 0.002], and ACM [OR: 2.37; 95 % CI: 1.83, 3.08; p < 0.00001]. The odds of repeat MI were comparable between the two groups [OR: 1.61, 95 % CI: 0.03, 74.36, p = 0.81].

CONCLUSIONS

The presence of CTO in the NIRA serves as an independent indicator of unfavorable clinical outcomes including increased risk of 30-day mortality and all-cause mortality. The risk of repeat MI was comparable between the two groups. Large-scale, multicenter trials are warranted to identify the most effective management approach for these patients.

Intra-aortic balloon pump versus percutaneous Impella© in emergency revascularisation for myocardial infarction and cardiogenic shock: systematic review

OBJECTIVES

Mortality rates in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) remain persistently high despite advances over the past decade in percutaneous mechanical circulatory support. This systematic review aims to analyse the existing literature to compare mortality outcomes in patients mechanically supported by intra-aortic balloon pump or percutaneous Impella 2.5/CP© for AMI-CS undergoing emergency revascularisation.

METHODS

The following MeSH terms were applied to the databases Ovid Medline, Ovid Embase, Cochrane and Web of Science: 'Intra-aortic balloon pump', 'Impella', 'Cardiogenic shock', 'Myocardial Infarction' and 'Mortality'. This yielded 2643 studies. Using predefined inclusion and exclusion criteria, the studies were initially screened by title and abstract before full text analysis.

RESULTS

Fourteen studies met eligibility criteria: two randomised controlled trials (RCTs) and 12 observational studies. Data from a total of 21,006 patients were included across the studies. Notably, one study claimed reduced mortality with IABP versus control, and one study concluded that Impella© improved survival rates over the IABP. The average 30-day all-cause mortality in patients supported by IABP was 38.1%, 54.3% in Impella© groups and 39.4% in control groups.

CONCLUSION

AMI-CS presents an important cohort of patients in whom conducting RCTs is difficult. As a result, the literature is limited. Analysis of the available literature suggests that there is insufficient evidence to support superior survival in those supported by IABP or Impella© when compared to control despite suggestions that the Impella© offers superior haemodynamic support. Limitations of the studies have been discussed to outline suggestions for future research.

The impact of extracorporeal membrane oxygenation on mortality in patients with cardiogenic shock post-acute myocardial infarction: a systematic review and meta-analysis

Aims

Cardiogenic shock remains the leading cause of death in patients hospitalized with acute myocardial infarction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in the treatment of infarct-related cardiogenic shock. However, there is limited evidence regarding its beneficial impact on mortality. The aim of this study was to systematically review studies reporting the impact of VA-ECMO on mortality in patients with acute myocardial infarction complicated by cardiogenic shock.

Methods and results

A comprehensive search of medical databases (Cochrane Register and PubMed) was conducted. Studies that reported mortality outcomes in patients treated with VA-ECMO for infarct-related cardiogenic shock were included. The database search yielded 1194 results, of which 11 studies were included in the systematic review. Four of these studies, with a total of 586 patients, were randomized controlled trials and were included in the meta-analysis. This demonstrated that there was no significant difference in 30-day all-cause mortality with the use of VA-ECMO compared with standard medical therapy [odds ratio (OR) 0.91; 95% confidence interval (CI) 0.65-1.27]. Meta-analysis of two studies showed that VA-ECMO was associated with a significant reduction in 12-month all-cause mortality (OR 0.31; 95% CI 0.11-0.86). Qualitative synthesis of the observational studies showed that age, serum creatinine, serum lactate, and successful revascularization are independent predictors of mortality.

Conclusion

Veno-arterial extracorporeal membrane oxygenation does not improve 30-day all-cause mortality in patients with cardiogenic shock following acute myocardial infarction; however, there may be significant reduction in all-cause mortality at 12 months. Further studies are needed to delineate the potential benefit of VA-ECMO in long-term outcomes.

Registration

The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42023461740).

The Role of Natriuretic Peptides in Predicting Adverse Outcomes After Cardiac Surgery: An Updated Systematic Review

The increasing global burden of cardiovascular disease, particularly, in the aging population, has led to an increase in high-risk cardiac surgical procedures. The current preoperative risk stratification scores, such as the European System for Cardiac Operative Risk Evaluation and the Society for Thoracic Surgeons score, have limitations in their predictive accuracy and tend to underestimate the mortality risk in higher-risk populations. This systematic review aimed to evaluate the utility of natriuretic peptides, brain natriuretic peptide (BNP) and its precursor prohormone (N-terminal prohormone BNP), as predictive biomarkers for adverse outcomes after cardiac surgery. A comprehensive search strategy was performed, and 63 studies involving 40,667 patients who underwent major cardiac operations were included for data extraction. Preoperative levels of BNP and N-terminal prohormone BNP seemed to be associated with an increased risk of short- and long-term mortality, postoperative heart failure, kidney injury, and length of intensive care unit stay. However, their predictive value for postoperative arrhythmias and myocardial infarction was less established. Our findings suggest that natriuretic peptides may play an important role in risk prediction in patients who underwent cardiac surgery. The addition of these biomarkers to the existing clinical risk stratification strategies may enhance their predictive accuracy. However, this needs to be endorsed by data derived from wide-scale clinical trials.

PEAL Score to Predict the Mortality Risk of Cardiogenic Shock in the Emergency Department: An Observational Study

BACKGROUND

The in-hospital mortality of cardiogenic shock (CS) remains high (28% to 45%). As a result, several studies developed prediction models to assess the mortality risk and provide guidance on treatment, including CardShock and IABP-SHOCK II scores, which performed modestly in external validation studies, reflecting the heterogeneity of the CS populations. Few articles established predictive scores of CS based on Asian people with a higher burden of comorbidities than Caucasians. We aimed to describe the clinical characteristics of a contemporary Asian population with CS, identify risk factors, and develop a predictive scoring model.

METHODS

A retrospective observational study was conducted between 2014 and 2019 to collect the patients who presented with all-cause CS in the emergency department of a single medical center in Taiwan. We divided patients into subgroups of CS related to acute myocardial infarction (AMI-CS) or heart failure (HF-CS). The outcome was all-cause 30-day mortality. We built the prediction model based on the hazard ratio of significant variables, and the cutoff point of each predictor was determined using the Youden index. We also assessed the discrimination ability of the risk score using the area under a receiver operating characteristic curve.

RESULTS

We enrolled 225 patients with CS. One hundred and seven patients (47.6%) were due to AMI-CS, and ninety-eight patients among them received reperfusion therapy. Forty-nine patients (21.8%) eventually died within 30 days. Fifty-three patients (23.55%) presented with platelet counts < 155 × 103/μL, which were negatively associated with a 30-day mortality of CS in the restrictive cubic spline plot, even within the normal range of platelet counts. We identified four predictors: platelet counts < 200 × 103/μL (HR 2.574, 95% CI 1.379-4.805, p = 0.003), left ventricular ejection fraction (LVEF) < 40% (HR 2.613, 95% CI 1.020-6.692, p = 0.045), age > 71 years (HR 2.452, 95% CI 1.327-4.531, p = 0.004), and lactate > 2.7 mmol/L (HR 1.967, 95% CI 1.069-3.620, p = 0.030). The risk score ended with a maximum of 5 points and showed an AUC (95% CI) of 0.774 (0.705-0.843) for all patients, 0.781 (0.678-0.883), and 0.759 (0.662-0.855) for AMI-CS and HF-CS sub-groups, respectively, all p < 0.001.

CONCLUSIONS

Based on four parameters, platelet counts, LVEF, age, and lactate (PEAL), this model showed a good predictive performance for all-cause mortality at 30 days in the all patients, AMI-CS, and HF-CS subgroups. The restrictive cubic spline plot showed a significantly negative correlation between initial platelet counts and 30-day mortality risk in the AMI-CS and HF-CS subgroups.

National Trends for Temporary Mechanical Circulatory Support Utilization in Patients With Cardiogenic Shock From Decompensated Chronic Heart Failure: Incidence, Predictors, Outcomes, and Cost

Background

Trends in temporary mechanical circulatory support (tMCS) use with associated outcomes and cost in cardiogenic shock secondary to decompensated chronic heart failure (HF-CS) remains poorly understood. We describe trends in tMCS use, associated outcomes, and cost in HF-CS.

Methods

We included adults enrolled in a national insurance claims dataset with HF-CS who received intra-aortic balloon pump (IABP), Impella, or extracorporeal membrane oxygenation (ECMO) without acute coronary syndrome, or postcardiotomy shock. We identified predictors of device use, associated outcomes, and inflation-adjusted costs.

Results

We studied 2722 HF-CS patients receiving tMCS: 1799 (66%) male, 1771 (65%) White, and 1836 (67%) with ischemic cardiomyopathy. Rate of tMCS use increased from 2010-2019. Impella use showed the largest increase (Δ+344%), followed by ECMO (Δ+112%). Patients receiving ECMO had a higher comorbidity burden, and patients receiving IABP were more likely to have valvular heart disease. Compared with IABP, 30-day mortality rate was no different for Impella (adjusted odds ratio, 1.24; 95% CI, 0.93-1.66) but was higher with ECMO (adjusted odds ratio, 3.08; 95% CI, 2.22-4.27). Adjusted hospitalization cost was highest for ECMO (median, $191,079 [IQR, $165,760-$239,373]), followed by Impella (median, $142,518 [IQR, $126,845-$179,938]), and IABP (median, $132,060 [IQR, $113,794-$160,244]). We observed a linear association between price standardized cost-quartile and complications, but not for 30-day mortality.

Conclusions

The use of Impella and ECMO is increasing with an associated cost increase. The use of ECMO coincided with higher 30-day mortality compared with IABP in HF-CS. These findings likely reflect increasing disease severity and evolving practice patterns rather than causation.

Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used in patients with cardiogenic shock despite the lack of evidence from adequately powered randomised clinical trials. Three trials reported so far were underpowered to detect a survival benefit; we therefore conducted an individual patient-based meta-analysis to assess the effect of VA-ECMO on 30-day death rate.

METHODS

Randomised clinical trials comparing early routine use of VA-ECMO versus optimal medical therapy alone in patients presenting with infarct-related cardiogenic shock were identified by searching MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and trial registries until June 12, 2023. Trials were included if at least all-cause death rate 30 days after in-hospital randomisation was reported and trial investigators agreed to collaborate (ie, providing individual patient data). Odds ratios (ORs) as primary outcome measure were pooled using logistic regression models. This study is registered with PROSPERO (CRD42023431258).

FINDINGS

Four trials (n=567 patients; 284 VA-ECMO, 283 control) were identified and included. Overall, there was no significant reduction of 30-day death rate with the early use of VA-ECMO (OR 0·93; 95% CI 0·66-1·29). Complication rates were higher with VA-ECMO for major bleeding (OR 2·44; 95% CI 1·55-3·84) and peripheral ischaemic vascular complications (OR 3·53; 95% CI 1·70-7·34). Prespecified subgroup analyses were consistent and did not show any benefit for VA-ECMO (pinteraction ≥0·079).

INTERPRETATION

VA-ECMO did not reduce 30-day death rate compared with medical therapy alone in patients with infarct-related cardiogenic shock, and an increase in major bleeding and vascular complications was observed. A careful review of the indication for VA-ECMO in this setting is warranted.

FUNDING

Foundation Institut für Herzinfarktforschung.

Beneficial Effects of IABP in Anterior Myocardial Infarction Complicated by Cardiogenic Shock

Background and Objectives. Recent guidelines have downgraded the routine use of the intra-aortic balloon pump (IABP) in patients with cardiogenic shock (CS) due to ST-elevation myocardial infarction (STEMI). Despite this, its use in clinical practice remains high. The aim of this study was to evaluate the prognostic impact of the IABP in patients with STEMI complicated by CS undergoing primary PCI (pPCI), focusing on patients with anterior MI in whom a major benefit has been previously hypothesized. Materials and Methods. We enrolled 2958 consecutive patients undergoing pPCI for STEMI in our department from 2005 to 2018. Propensity score matching and mortality analysis were performed. Results. CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. In the propensity-matched analysis, the use of the IABP was associated with a lower 30-day mortality (39.3% vs. 60.9%, p = 0.032) in the subgroup of patients with anterior STEMI. Conversely, in the whole group of CS patients and in the subgroup of patients with non-anterior STEMI, IABP use did not have a significant impact on mortality. Conclusions. The use of the IABP in cases of STEMI complicated by CS was found to improve survival in patients with anterior infarction. Prospective studies are needed before abandoning or markedly limiting the use of the IABP in this clinical setting.

Extracorporeal Life Support in Infarct-Related Cardiogenic Shock

BACKGROUND

Extracorporeal life support (ECLS) is increasingly used in the treatment of infarct-related cardiogenic shock despite a lack of evidence regarding its effect on mortality.

METHODS

In this multicenter trial, patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early ECLS plus usual medical treatment (ECLS group) or usual medical treatment alone (control group). The primary outcome was death from any cause at 30 days. Safety outcomes included bleeding, stroke, and peripheral vascular complications warranting interventional or surgical therapy.

RESULTS

A total of 420 patients underwent randomization, and 417 patients were included in final analyses. At 30 days, death from any cause had occurred in 100 of 209 patients (47.8%) in the ECLS group and in 102 of 208 patients (49.0%) in the control group (relative risk, 0.98; 95% confidence interval [CI], 0.80 to 1.19; P = 0.81). The median duration of mechanical ventilation was 7 days (interquartile range, 4 to 12) in the ECLS group and 5 days (interquartile range, 3 to 9) in the control group (median difference, 1 day; 95% CI, 0 to 2). The safety outcome consisting of moderate or severe bleeding occurred in 23.4% of the patients in the ECLS group and in 9.6% of those in the control group (relative risk, 2.44; 95% CI, 1.50 to 3.95); peripheral vascular complications warranting intervention occurred in 11.0% and 3.8%, respectively (relative risk, 2.86; 95% CI, 1.31 to 6.25).

CONCLUSIONS

In patients with acute myocardial infarction complicated by cardiogenic shock with planned early revascularization, the risk of death from any cause at the 30-day follow-up was not lower among the patients who received ECLS therapy than among those who received medical therapy alone. (Funded by the Else Kröner Fresenius Foundation and others; ECLS-SHOCK ClinicalTrials.gov number, NCT03637205.).

Effect of Concomitant Cardiac Arrest on Outcomes in Patients With Acute Coronary Syndrome-Related Cardiogenic Shock

Patients with acute coronary syndrome (ACS)-related cardiogenic shock (CS) with or without concomitant CA may have disparate prognoses. We compared clinical characteristics and outcomes of patients with CS secondary to ACS with and without cardiac arrest (CA). Between 2014 and 2020, 1,573 patients with ACS-related CS with or without CA who underwent percutaneous coronary intervention enrolled in a multicenter Australian registry were analyzed. Primary outcome was 30-day major adverse cardiovascular and cerebrovascular events (MACCE) (composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularization and stroke). Long-term mortality was obtained through linkage to the National Death Index. Compared with the no-CA group (n = 769, 49%), the CA group (n = 804, 51%) was younger (62 vs 69 years, p <0.001) and had fewer comorbidities. Patients with CA more frequently had ST-elevation myocardial infarction (92% vs 86%), occluded left anterior descending artery (43% vs 33%), and severe preprocedural renal impairment (49% vs 42%) (all p <0.001). CA increased risk of 30-day MACCE by 45% (odds ratio 1.45, 95% confidence interval 1.05 to 2.00, p = 0.024) after adjustment. CA group had higher 30-day MACCE (55% vs 42%, p <0.001) and mortality (52% vs 37%, p <0.001). Three-year survival was lower for CA compared with no-CA patients (43% vs 52%, p <0.001). In Cox regression, CS with CA was associated with a trend toward greater long-term mortality hazard (hazard ratio 1.19, 95% confidence interval 1.00 to 1.41, p = 0.055). In conclusion, concomitant CA among patients with ACS-related CS conferred a particularly heightened short-term risk with a diminishing legacy effect over time for mortality. CS survivors continue to exhibit high sustained long-term mortality hazard regardless of CA status.

Perspectives and Considerations of IABP in the Era of ECMO for Cardiogenic Shock

The development of mechanical circulatory support (MCS) has been rapid, and its use worldwide in patients with cardiogenic shock is increasingly widespread. However, current statistical data and clinical research do not demonstrate its significant improvement in the patient prognosis. This review focuses on the widely used intra-aortic balloon pumps (IABP) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO), analyzing and comparing their characteristics, efficacy, risk of complications, and the current exploration status of left ventricular mechanical unloading. Subsequently, we propose a rational approach to viewing the negative outcomes of current MCS, and look ahead to the future development trends of IABP.

Intra-Aortic Balloon Pump among Shockable Out-of-Hospital Cardiac Arrest Patients: A Propensity-Weighted Analysis in a Multicenter, Nationwide Observational Study in Japan (The JAAM-OHCA Registry)

BACKGROUND

The effectiveness of IABP for shockable out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. This study aimed to investigate whether the use of an intra-aortic balloon pump (IABP) for non-traumatic shockable OHCA patients was associated with favorable neurological outcomes.

METHODS

From the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a nationwide multicenter prospective registry, we enrolled adult patients with non-traumatic and shockable OHCA for whom resuscitation was attempted, and who were transported to participating hospitals between 2014 and 2019. The primary outcome was 1-month survival with favorable neurological outcomes after OHCA. After adopting the propensity score (PS) inverse probability of weighting (IPW), we evaluated the association between IABP and favorable neurological outcomes.

RESULTS

Of 57,754 patients in the database, we included a total of 2738 adult non-traumatic shockable patients. In the original cohort, the primary outcome was lower in the IABP group (OR with 95% confidence intervals (CIs)), 0.57 (0.48-0.68), whereas, in the IPW cohort, it was not different between patients with and without IABP (OR, 1.18; 95% CI, 0.91-1.53).

CONCLUSION

In adult patients with non-traumatic shockable OHCA, IABP use was not associated with 1-month survival with favorable neurological outcomes.