24h SCAI stage reclassification to predict outcome. Insights from the prospective Altshock-2 registry

Background

Cardiogenic shock (CS) includes several phenotypes of congestion or hypoperfusion with heterogenous hemodynamic features. Timely prognostication with scoring tools is warranted to identify patients requiring escalation to mechanical circulatory support (MCS) and to avoid futility.

Purpose

Accordingly, we explored the role of the updated Society for Cardiovascular Angiography and Interventions (SCAI) stages classification on in-hospital mortality using a prospective national registry.

Methods

The Altshock-2 Registry includes 237 patients with CS of all etiologies enrolled between March 2020 and February 2022 in 11 Italian Centers. Patients were classified according to the admission SCAI stages (assigned prospectively and independently updated according to the most recently released version); 24-hour re-assessment was prospectively performed in 201 patients. In-hospital mortality was evaluated for association with admission and 24 hours SCAI stages adjusted for the most relevant clinical covariates.

Results

Of the 237 patients included, 20 (8.4%) had SCAI shock stage B, 132 (55.8%) SCAI stage C, 60 (25.3) SCAI stage D and 25 (10.5%) SCAI stage E. Patients in stage B had the worst reclassification at 24-hours, with 42% of them showing worsened status and only 8% improving. In-hospital mortality was 38%. The revised SCAI stages at baseline were not independently associated with in-hospital mortality, whereas the SCAI classification at 24-h correctly and independently predicted mortality (the rate of in-hospital death was 18% for patients in SCAI shock stage B, 27% for SCAI shock stage C, 64% for SCAI shock stage D, 100% for SCAI shock stage E). At the multivariate analysis (adjusted for age, gender, eGFR, inotropic score and MCS) only SCAI classification at 24-hour evaluation was an independent predictor of in-hospital mortality (OR and 95% CI were, respectively, 3.32, 0.36–30.63, p=0.290 for SCAI stage C and 13.07, 1.69–146.3 for SCAI stage D, with E perfectly predicting because all patients died).

Conclusions

The revised SCAI stage classification may improve prognostication only at 24-hour evaluation. Aggressive treatment (either pharmacological or with MCS escalation) should be tailored in order to achieve prompt clinical improvement within the first 24-hours; refractory SCAI stage E at 24 hours portends dismal prognosis.

Funding Acknowledgement

Type of funding sources: None.

C76 A PARTICULAR CASE OF MULTIORGAN FAILURE

 

We reported a case of a 42–year–old man with no major pathologies, symptomatic for a few days for headache, fever and dysuria. For worsening dyspnea and tachycardia the patient was admitted to emergency room. He was markedly hypoxic with severe left ventricular dysfunction, therefore in the suspicion of myocarditis, the patient was centralized in our ICCU. The patient appeared tachycardic (sinus tachycardia 160 bpm), normotensive but hypoperfused (svO2 40%, lac 5 mmol/l, oliguric) and severely hypoxemic despite mechanical ventilation. In the first hours the condition of severe hypoxia persisted (P/F <100), despite optimization of ventilation and curarization, associated with bilateral interstitial edema, marked leukocytosis and PCT> 100. For this reason cultural exams were performed and large spectrum antibiotic therapy started. After about 4 hours the patient was still hypotensive and hypoperfused, despite support with IABP and vasopressors, therefore femoro–femoral VA–ECMO was implanted. There was a rapid improvement of hemodynamic status, peripheral perfusion and reduction of pulmonary congestion but a marked leukocytosis and PCT> 100 persisted with negative cultures. On the 4th day, during ECMO weaning we assisted to wide and rapid pressure fluctuations (SBP from 250 to 60 mmHg in a few minutes). Therefore total body CT was performed in the suspected pheochromocytoma and this showed a necrotized left adrenal mass of about 9 cm and multiple right cerebral hemorrhagic lesions. Therapy with IV alfa–blockers was promptly started and for the marked hemodynamic instability, in the presence of cerebral hemorrhage, left adrenalectomy was performed with removal of the mass approximately 10 hours after diagnosis. In the post–operative phase there was a stabilization of the pressure profile with complete recovery of the biventricular cardiac function, a rapid reduction in inflammation indices and recovery of renal function. The patient gradually recovered to a state of consciousness with residual hemiplegia. Histological examination confirmed the diagnosis of pheochromocytoma.

Conclusions

The present case represents an example of a catecholaminergic crisis, with fulminant onset and multiorgan dysfunction that initially made diagnosis difficult. Emergency adrenalectomy has conflicting evidence in the literature but in this case it was necessary for pressure instability in the context of cerebral hemorrhage.

P230 CARDIOGENIC SHOCK NETWORK: FROM PRIMARY PERCUTANEOUS CORONARY INTERVENTION TO VENTRICULAR ASSIST DEVICE IMPLANTATION

 

We report the clinical case of a 75 year–old man, previous smoker with mild lower extremity arterial disease, that presented a sudden and intensive chest pain. The emergency medical system documented an anterior STEMI quickly complicated by out–of–hospital cardiac arrest from a shockable rhythm, treated with DC–shock with rapid ROSC and recovery of consciousness. The patient was transported to the local hospital where coronary angiography showed extensive intraluminal thrombosis of ostial Cx and ostial LAD treated with thrombus aspiration and balloon angioplasty. During the procedure the patient was supported with inotropic agents, mechanical ventilation and IABP for a cardiogenic shock. After few hours he was transferred to level II hospital, equipped with all mechanical circulatory supports (MCS) and on–site cardiac surgery, where he was assisted with vaso–inotropic drugs, Impella CP and continuous renal replacement (CRRT). After 3 days for a refractory cardiogenic shock (stage D) the patient was referred and then transferred to our hospital, a level III hospital with cardiac transplantation program, for hemodynamic stabilization and eventual long term ventricular assist device (VAD). After 5 days the patient was weaned by Impella support, then weaned by mechanical ventilation, renal replacement therapy, without any neurological damage. The echocardiography showed a severe left ventricular dysfunction (EF 20%) with severe mitral regurgitation with good right ventricle function, confirmed also by strain assessment. In the following weeks were reported repeated episodes of pulmonary congestion treated with high doses of diuretics, NIV and nitroprusside infusion and episodes of low cardiac output treated with inotropes for prolonged periods. Mitraclip implantation was technically feasible but Heart Team decided to implantation an LVAD due to numerous episodes of low cardiac output and reduced cardiac index values. Screening for VAD showed no contraindications, therefore after 72 days from acute event LVAD was implanted with positive outcome.

Conclusion

the presence of a local network for cardiogenic shock allowed to optimize the clinical pathway of this patient and to manage in an integrated way the complex treatment of cardiogenic shock.

C74 ESCALATION AND DE–ESCALATION OF MECHANICAL CIRCULATORY SUPPORT IN PATIENT WITH CARDIOGENIC SHOCK DUE TO ELECTRICAL STORM

 

We describe a case of a 63 year–old man with familiar dilated cardiomyopathy, with severe left ventricle dysfunction (EF 20%) and severe mitral regurgitation.A progressive worsening of functional status was detected (peak VO2 11 ml/kg/min, NYHA III) with some episodes of VT interrupted by bicameral ICD,for which the patient was referred to our center and included in the heart transplant (HT) list. In the following months sustained VT with hemodynamic impact were recorded, with consequent worsening in class INTERMACS 2. The patient underwent to endocardial and epicardial VT ablation, complicated with electrical storm with deterioration towards cardiogenic shock (INTERMACS 1), requiring vaso–inotropic drugs,mechanical ventilation and femoro–femoral VA–ECMO.The patient was centralized in our ICCU, where he maintained a adequate MAP, SvcO2 50% and active diuresis but at echocardiography left ventricle appeared dilated with high filling pressure, X–ray and pulmonary ultrasonography showed congestion, lactate value rapidly increased (5 mmol/mol), renal and hepatic function worsened (creat 2 mg/dl, bil 2.8 mg/dl). After multidisciplinary discussion an escalation of mechanical circulatory support (MCS) was performed, changing ECMO configuration: an arterial cannula was positioned in the right axillary artery and venting cannula positioned in the apex of the left ventricle. The hemodynamic and respiratory parameters quickly improved,the right pulmonary catheterization showed good pulmonary resistence,organ perfusion improved and neurological status was intact, therefore the patient was inserted in emergency list for HT. After few days a de–escalation of MCS was performed,removing venous cannula and oxygenator, changing the circuit in para–corporeal left ventricle mid–term support as bridge to transplantation. The patient maintained conscious, in spontaneous breathing,able to perform physiotherapy and spontaneous nutrition. The de–escalation of MCS allowed to reduce potential complications of MCS and achieve the HT intervention in a better general and functional condition. After 36 days the patient underwent HT with positive outcome.

Conclusion

MCS are device that require a continuous re–assessment a re–modulation to ensure in the early stages the optimization of haemodynamic support, perfusion of vital organs and unloading of the Vsx and in the following stages an adjustment to long–term strategies (bridge to recovery, bridge to VAD, bridge to heart transplantation).

Risk stratification in cardiogenic shock: a focus on the available evidence

Cardiogenic shock is a clinical syndrome which is defined as the presence of primary cardiac disorder that results in hypotension together with signs of organ hypoperfusion in the state of normovolaemia or hypervolaemia. It represents a complex life-threatening condition, characterized by a high mortality rate, that requires urgent diagnostic assessment as well as treatment; therefore, it is of paramount important to advocate for a thorough risk stratification. In fact, the early identification of patients that could benefit the most from more aggressive and invasive approaches could facilitate a more efficient resource allocation. This review attempts to critically analyse the current evidence on prognosis in cardiogenic shock, focusing in particular on clinical, laboratoristic and echocardiographic prognostic parameters. Furthermore, it focuses also on the available prognostic scores, highlighting the strengths and the possible pitfalls. Finally, it provides insights into future direction that could be followed in order to ameliorate risk stratification in this delicate subset of patients.

Intravascular imaging to guide lithotripsy in concentric and eccentric calcific coronary lesions

Background

Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.

Purpose

The study aimed at the evaluation of the immediate procedural outcome of a novel treatment algorithm based on IVUS and/or OCT and including lithotripsy into a real-world consecutive based on intravascular imaging assessment by IVUS or OCT.

Methods and results

Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions in 370 patients treated between November 2018 and May 2019 met the clinical and angiographic criteria for treatment with IVL under intravascular imaging guidance. Patients were divided into two subgroups depending on the calcium arc measured with intravascular imaging. Twenty lesions showed a calcium arc greater than 180 degrees (289±53 degrees) and 11 lesions smaller than 180 (140±24 degrees). The following parameters were assessed with OCT and/or IVUS: post stent minimal lumen area (MLA) and area stenosis (AS), incomplete strut apposition (ISA), eccentricity index, strut fracture, and edge dissection. After optimization a satisfactory lumen enlargement (acute gain 1.28±0.46 mm; minimal stent area 7.09±2.77 mm2) was observed with good stent expansion (residual area stenosis <20% in 29 lesions, 93.5%) and OCT calcium fractures in 71% of cases. Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no in-hospital coronary perforations, no pericardial effusions, no stent failure or thrombosis, no deaths.

Conclusions

A standardized algorithm applying multimodality imaging to guide selection and application of IVL facilitated second generation DES implantation with final post-dilatation delivers excellent immediate procedural results and patient outcome, both in concentric or eccentric calcifications.

Funding Acknowledgement

Type of funding source: None

The prognostic role of renal dysfunction in STEMI patients submitted to primary PCI with adjunctive thrombus aspiration

AIM

The present investigation was aimed at assessing the prognostic impact of renal dysfunction rate in STEMI patients submitted to thrombectomy (TP).

METHODS

Out of 1268 consecutive ST elevation myocardial infarction (STEMI) patients treated with pPCI from January 1rst 2004 to December 31th 2012 in our hospital 671 patients (52.9%) underwent adjunctive thrombus aspiration and constituted the study population. Patients were divided into three groups according to eGFR: group 1 included patients with eGFR>60 mL/min/m2, group 2 eGFR>30 mL/min/m2 and <60 mL/min/m2, group 3 eGFR<30 mL/min/m2. The rate of utilization of thrombectomy, the rate of pPCI failure and the incidence of major bleeding were assessed in each subgroup. Patients in group 3 and group 2 were less likely to be submitted to TP, while more than 50% of patients with normal eGFR underwent TP (overall P=0.019). The rate of pPCI failure was significantly higher in group 2 and 3 when compared to group 1 (P=0.002). Worsening renal failure was associated with a higher mortality rate both at ICCU and at 1 year follow-up (P<0.001 and P<0.001, respectively). A higher incidence of major bleedings was reported in group 2 and group 3, despite the lower administration of glycoprotein IIb/IIIa inhibitors (P<0.001). Moderate and severe renal impairment was associated with a higher mortality rate both at ICCU and at 1 year follow-up (P<0.001 and P<0.001, respectively).

CONCLUSION

Thrombus aspiration is less like to be performed among patients with impaired renal function. Despite thrombus aspiration patients with reduced eGFR showed a higher incidence of pPCI failure.

Impact of age on the prognostic value of body mass index in ST-Elevation myocardial infarction

BACKGROUND AND AIM

No data are so far available on the impact of age and obesity in ST-elevation myocardial infarction (STEMI) submitted to percutaneous coronary intervention (PCI).

METHODS AND RESULTS

We assessed the impact of age on the prognostic value of body mass index (BMI) in 1268 consecutive STEMI patients admitted to our Intensive Cardiac Care Unit (ICCU). BMI categories were as follows: 37 "lean" patients (37/1268, 2.9%), 403 "normal" patients (403/1268, 31.8%), 656 "overweight" patients (656/1268, 51.7%), 172 "obese" patients (172/1268, 13.6%). Among patients aged <75 years, as BMI increased, the number of males and diabetic patients significantly increased (p < 0.001 and p = 0.004, respectively). Among STEMI patients aged ≥75 years, lean patients showed a higher in-ICCU mortality in respect to the other BMI categories but this did not reach statistical significance. BMI was an independent predictor of In-ICCU mortality in the whole population (lean vs. "normal": OR 3.47, 95%CI 1.08-11.14, p = 0.036) and it was associated with long term mortality only in patients <75 years since lean and overweight patients showed lower survival rate (lean vs. "normal": HR 9.25, 95%CI 3.09-27.63, p < 0.001; overweight vs. "normal": OR 2.10; 95%CI 1.04-4.23, p = 0.039).

CONCLUSIONS

In our series, underweight is associated with the highest mortality across all age subgroups, while only in patients <75 years, overweight patients showed increased in-hospital mortality rate and a poorer long term survival rate. According to our data, the "so called obesity paradox" should be probably age-contextualized.