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Puri K, Jentzer JC, Spinner JA, Hope KD, Adachi I, Tume SC, Tunuguntla HP, Choudhry S, Cabrera AG, Price JF. Clinical Presentation, Classification, and Outcomes of Cardiogenic Shock in Children. J Am Coll Cardiol 2024; 83:595-608. [PMID: 38296404 DOI: 10.1016/j.jacc.2023.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/23/2023] [Accepted: 11/08/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Despite growing cardiogenic shock (CS) research in adults, the epidemiology, clinical features, and outcomes of children with CS are lacking. OBJECTIVES This study sought to describe the epidemiology, clinical presentation, hospital course, risk factors, and outcomes of CS among children hospitalized for acute decompensated heart failure (ADHF). METHODS We examined consecutive ADHF hospitalizations (<21 years of age) from a large single-center retrospective cohort. Patients with CS at presentation were analyzed and risk factors for CS and for the primary outcome of in-hospital mortality were identified. A modified Society for Cardiovascular Angiography and Interventions shock classification was created and patients were staged accordingly. RESULTS A total of 803 hospitalizations for ADHF were identified in 591 unique patients (median age 7.6 years). CS occurred in 207 (26%) hospitalizations. ADHF hospitalizations with CS were characterized by worse systolic function (P = 0.040), higher B-type natriuretic peptide concentration (P = 0.032), and more frequent early severe renal (P = 0.023) and liver (P < 0.001) injury than those without CS. Children presenting in CS received mechanical ventilation (87% vs 26%) and mechanical circulatory support (45% vs 16%) more frequently (both P < 0.001). Analyzing only the most recent ADHF hospitalization, children with CS were at increased risk of in-hospital mortality compared with children without CS (28% vs 11%; OR: 1.91; 95% CI: 1.05-3.45; P = 0.033). Each higher CS stage was associated with greater inpatient mortality (OR: 2.40-8.90; all P < 0.001). CONCLUSIONS CS occurs in 26% of pediatric hospitalizations for ADHF and is independently associated with hospital mortality. A modified Society for Cardiovascular Angiography and Interventions classification for CS severity showed robust association with increasing mortality.
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Affiliation(s)
- Kriti Puri
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA; Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Spinner
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Kyle D Hope
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sebastian C Tume
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Hari P Tunuguntla
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Swati Choudhry
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Antonio G Cabrera
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jack F Price
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Javaid AI, Michalek JE, Gruslova AB, Hoskins SA, Ahsan CH, Feldman MD. Mechanical circulatory support versus vasopressors alone in patients with acute myocardial infarction and cardiogenic shock undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2024; 103:30-41. [PMID: 37997292 DOI: 10.1002/ccd.30913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 10/10/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Previous studies have compared Impella use to intra-aortic balloon pump (IABP) use in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI). Our objective was to compare clinical outcomes in patients with AMI-CS undergoing PCI who received Impella (percutaneous left ventricular assist device) without vasopressors, IABP without vasopressors, and vasopressors without mechanical circulatory support (MCS). METHODS We queried the National Inpatient Sample (NIS) using ICD-10 codes (2015-2018) to identify patients with AMI-CS undergoing PCI. We created three propensity-matched cohorts to examine clinical outcomes in patients receiving Impella versus IABP, Impella versus vasopressors without MCS, and IABP versus vasopressors without MCS. RESULTS Among 17,762 patients, Impella use was associated with significantly higher in-hospital major bleeding (31.4% vs. 13.6%; p < 0.001) and hospital charges (p < 0.001) compared to IABP use, with no benefit in mortality (34.1% vs. 26.9%; p = 0.06). Impella use was associated with significantly higher mortality (42.3% vs. 35.7%; p = 0.02), major bleeding (33.9% vs. 22.7%; p = 0.001), and hospital charges (p < 0.001), when compared to the use of vasopressors without MCS. There were no significant differences in clinical outcomes between IABP use and the use of vasopressor without MCS. CONCLUSIONS In this analysis of retrospective data of patients with AMI-CS undergoing PCI, Impella use was associated with higher mortality, major bleeding, and in-hospital charges when compared to vasopressor therapy without MCS. When compared to IABP use, Impella was associated with no mortality benefit, along with higher major bleeding events and in-hospital charges. A vasopressor-only strategy suggested no difference in clinical outcomes when compared to IABP. This study uses the NIS for the first time to highlight outcomes in AMI-CS patients undergoing PCI when treated with vasopressor support without MCS, compared to Impella and IABP use.
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Affiliation(s)
- Awad I Javaid
- Division of Cardiovascular Medicine, Kirk Kerkorian School of Medicine at the University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Joel E Michalek
- Department of Population Health Sciences, The University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Aleksandra B Gruslova
- Division of Cardiology, Department of Medicine, The University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Serene A Hoskins
- Division of Cardiology, Department of Medicine, The University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Chowdhury H Ahsan
- Division of Cardiovascular Medicine, Kirk Kerkorian School of Medicine at the University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Marc D Feldman
- Division of Cardiology, Department of Medicine, The University of Texas Health at San Antonio, San Antonio, Texas, USA
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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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Hernandez-Montfort J, Sinha SS, Thayer KL, Whitehead EH, Pahuja M, Garan AR, Mahr C, Haywood JL, Harwani NM, Schaeffer A, Wencker D, Kanwar M, Vorovich E, Abraham J, Burkhoff D, Kapur NK. Clinical Outcomes Associated With Acute Mechanical Circulatory Support Utilization in Heart Failure Related Cardiogenic Shock. Circ Heart Fail 2021; 14:e007924. [PMID: 33905259 DOI: 10.1161/circheartfailure.120.007924] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiogenic shock occurring in the setting of advanced heart failure (HF-CS) is increasingly common. However, recent studies have focused almost exclusively on acute myocardial infarction-related CS. We sought to define clinical, hemodynamic, metabolic, and treatment parameters associated with clinical outcomes among patients with HF-CS, using data from the Cardiogenic Shock Working Group registry. METHODS Patients with HF-CS were identified from the multicenter Cardiogenic Shock Working Group registry and divided into 3 outcome categories assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable ventricular assist device or orthotopic heart transplant), or native heart survival. Clinical characteristics, hemodynamic, laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention stages were compared across the 3 outcome cohorts. RESULTS Of the 712 patients with HF-CS identified, 180 (25.3%) died during their index admission, 277 (38.9%) underwent HRT (durable ventricular assist device or orthotopic heart transplant), and 255 (35.8%) experienced native heart survival without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups (P<0.01 for all). Biventricular and isolated left ventricular congestion were common among patients who died or underwent HRT, respectively. Lactate, blood urea nitrogen, serum creatinine, and aspartate aminotransferase were highest in patients with HF-CS experiencing in-hospital death. Intraaortic balloon pump was the most commonly used AMCS device in the overall cohort and among patients receiving HRT. Patients receiving >1 AMCS device had the highest in-hospital mortality rate irrespective of the number of vasoactive drugs used. Mortality increased with deteriorating Society of Cardiovascular Angiography and Intervention stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, 1-way ANOVA=<0.001). CONCLUSIONS Patients with HF-CS experiencing in-hospital mortality had a high prevalence of biventricular congestion and markers of end-organ hypoperfusion. Substantial heterogeneity exists with use of AMCS in HF-CS with intraaortic balloon pump being the most common device used and high rates of in-hospital mortality after exposure to >1 AMCS device.
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Affiliation(s)
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA (S.S.S.)
| | - Katherine L Thayer
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
| | | | - Mohit Pahuja
- Medstar Georgetown University Hospital, Washington, D.C. (M.P.)
| | | | - Claudius Mahr
- University of Washington Medical Center, Seattle (C.M.)
| | - Jillian L Haywood
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
| | - Neil M Harwani
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
| | | | - Detlef Wencker
- Baylor Scott & White Advanced Heart Failure Clinic, Dallas, TX (D.W.)
| | | | | | | | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA (K.L.T., J.L.H., N.M.H., N.K.K.)
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Schwartz B, Jain P, Salama M, Kapur NK. The Rise of Endovascular Mechanical Circulatory Support Use for Cardiogenic Shock and High Risk Coronary Intervention: Considerations and Challenges. Expert Rev Cardiovasc Ther 2020; 19:151-164. [PMID: 33356662 DOI: 10.1080/14779072.2021.1863147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Cardiogenic shock due to acute myocardial infarction and decompensated advanced heart failure remains a source of significant morbidity and mortality. Endovascular mechanical circulatory support devices including intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (Impella and Tandemheart pumps), and veno-arterial extracorporeal oxygenation (VA-ECMO) are utilized for a broadening range of indications.Areas covered: This narrative review explores the specific devices, their distinctive hemodynamic profiles, and practical considerations. Furthermore, reviewed are the trials evaluating device outcomes which have generated significant controversy within the field of heart failure and shock. New applications and future directions are discussed.Expert opinion: Use of endovascular mechanical circulatory support has increased over the last decade, though evidence supporting their use is lacking. Development of large-scale prospective registries and clinical classification systems will facilitate patient enrollment and inform trial design. Furthermore, expansion of indications for these devices is revolutionizing how the field of heart failure and cardiogenic shock thinks about hemodynamic support. The ability to tailor therapy to a patient's specific hemodynamic profile appears to be the future of cardiogenic shock management.
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Affiliation(s)
- Benjamin Schwartz
- Department of Internal Medicine, Tufts Medical Center, Boston, MA, USATurkey
| | - Pankaj Jain
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
| | - Michael Salama
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
| | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, MA, USATurkey
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Management of perioperative acute coronary syndromes by mechanism: a practical approach. Int Anesthesiol Clin 2020; 59:61-65. [PMID: 33252573 DOI: 10.1097/aia.0000000000000310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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