When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock

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.

Mechanical circulatory support for cardiogenic shock: a network meta-analysis of randomized controlled trials and propensity score-matched studies

PURPOSE

Cardiogenic shock is associated with high mortality. In refractory shock, it is unclear if mechanical circulatory support (MCS) devices improve survival. We conducted a network meta-analysis to determine which MCS devices confers greatest benefit.

METHODS

We searched MEDLINE, Embase, and Scopus databases through 27 August 2023 for relevant randomized controlled trials (RCTs) and propensity score-matched studies (PSMs). We conducted frequentist network meta-analysis, investigating mortality (either 30 days or in-hospital) as the primary outcome. We assessed risk of bias (Cochrane risk of bias 2.0 tool/Newcastle-Ottawa Scale) and as sensitivity analysis reconstructed survival data from published survival curves for a one-stage unadjusted individual patient data (IPD) meta-analysis using a stratified Cox model.

RESULTS

We included 38 studies (48,749 patients), mostly reporting on patients with Society for Cardiovascular Angiography and Intervention shock stages C-E cardiogenic shock. Compared with no MCS, extracorporeal membrane oxygenation with intra-aortic balloon pump (ECMO-IABP; network odds ratio [OR]: 0.54, 95% confidence interval (CI): 0.33-0.86, moderate certainty) was associated with lower mortality. There were no differences in mortality between ECMO, IABP, microaxial ventricular assist device (mVAD), ECMO-mVAD, centrifugal VAD, or mVAD-IABP and no MCS (all very low certainty). Our one-stage IPD survival meta-analysis based on the stratified Cox model found only ECMO-IABP was associated with lower mortality (hazard ratio, HR, 0.55, 95% CI 0.46-0.66).

CONCLUSION

In patients with cardiogenic shock, ECMO-IABP may reduce mortality, while other MCS devices did not reduce mortality. However, this must be interpreted within the context of inter-study heterogeneity and limited certainty of evidence.

Differential Prognostic Impact of IABP-SHOCK II Scores According to Treatment Strategy in Cardiogenic Shock Complicating Acute Coronary Syndrome: From the RESCUE Registry

Background: Early risk stratification is necessary for optimal determination of the treatment strategy in cardiogenic shock (CS) complicating acute coronary syndrome (ACS). Therefore, we evaluated the prognostic impact of an intra-aortic balloon pump on the cardiogenic shock (IABP-SHOCK) II score according to the treatment strategies in ACS complicated by CS using the RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock) registry. Methods: The RESCUE registry contains multicenter observational retrospective and prospective cohorts that include 1247 patients with CS from 12 centers in Korea. A total of 865 patients with ACS complicated by CS were selected and stratified into low-, intermediate- and high-risk categories according to their IABP-SHOCK II scores and then according to treatment: non-mechanical support, IABP, and extracorporeal membrane oxygenators (ECMOs). The primary outcome was all-cause mortality during follow-up. Results: The observed mortality rates for the low-, intermediate-, and high-IABP-SHOCK II score risk categories were 28.8%, 52.4%, and 69.8%, respectively (p < 0.01). Patients in the non-mechanical support and IABP groups showed an increasingly elevated risk of all-cause mortality as their risk scores increased from low to high. In the ECMO group, the risk of all-cause mortality did not differ between the intermediate- and high-risk categories (HR = 1.21, 95% CI: 0.81-1.81, p = 0.33). The IABP-SHOCK II scores for the non-mechanical support and IABP groups showed a better predictive performance (area under curve [AUC] = 0.70, 95% CI: 0.65-0.76) for mortality compared with the EMCO group (AUC = 0.61, 95% CI 0.54-0.67; p-value for comparison = 0.02). Conclusions: Risk stratification using the IABP-SHOCK II score is useful for predicting mortality in ACS complicated by CS when patients are treated with non-mechanical support or IABP. However, its prognostic value may be unsatisfactory in severe cases where patients require ECMOs.

Timing and modality of complete revascularization in patients presenting with ST-segment elevation myocardial infarction and multivessel coronary artery disease

Approximately half of the patients presenting with ST-segment elevation myocardial infarction have also significant atherosclerotic disease affecting coronary segments other than the infarct-related artery. Optimal management of residual lesions in this clinical setting has been a topic of intense research in the last decade. On the one hand, a large body of evidence has consistently shown the benefit of complete revascularization for the reduction of adverse cardiovascular outcomes. On the other hand, some crucial aspects such as the optimal timing or the best strategy of the complete treatment approach remain a matter of controversy. In this review, we aim to provide a thorough critical appraisal of the available literature regarding this topic, by discussing areas of relative certainty, gaps in the knowledge, approach to specific clinical subsets and future research directions.

Influence on emergency digit replantation and outcome assessment after COVID-19 virus nucleic acid testing normalization

Objective

The study aims to compare the implementation and prognosis of emergency digit replantation surgery before and after normalized corona virus disease 2019 (COVID-19) nucleic acid testing for patients taking emergency operation and to explore the influence of normalized COVID-19 nucleic acid testing on replantation surgery.

Method

Normalized COVID-19 nucleic acid testing for patients taking emergency operation has been carried out since 1 August 2021 at our hospital, which means each patient who needs emergency surgical treatment has to obtain either positive or negative results of COVID-19 nucleic acid before entering the operating room. This research reviewed and compared the prognosis of the injured extremity that had emergency severed digit replantation between June and September 2021, at the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, and analyzed the impact of normalized COVID-19 nucleic acid testing on the outcome of the replanted fingers of different severity using disability of arm-shoulder-hand (DASH) and hand injury severity scoring (HISS) scoring systems.

Results

A total of 54 cases with 74 severed replanted phalanges were included replanted by the research group between 1 August and 30 September 2021, without any COVID-19 suspected/confirmed case detected. Compared with previous period (1 June to 31 July, 2021), although the interval between emergency visits and emergency replantation did increase significantly after normalized COVID-19 nucleic acid testing [(3.83 ± 0.94) to (1.77 ± 0.67) h, P < 0.05], we observed no significant difference in the improvement rate of the DASH scoring of the disabled upper extremity 3-month postoperatively (P = 0.538) nor in the complication rate (P = 0.344). Moreover, there was no significant difference in the improvement rate of the DASH scoring of the disabled upper extremity 3-month postoperatively in patients with different traumatic severities before and after normalized COVID-19 nucleic acid testing (moderate P = 0.269, severe P = 0.055, major P = 0.149).

Conclusion

Despite the preoperative delay, the policy of COVID-19 nucleic acid testing normalization does not have explicit influence on the short-term outcomes of emergency digit replantation surgery. With this evidence, microsurgeons could pay attention to the patients' anxiety and spend more effort in comforting them during the prolonged preoperative wait. These insights may have implications for other emergency department resource management whenever a social crisis occurs.