Blood lactate predicts survival after percutaneous implantation of extracorporeal life support for refractory cardiac arrest or cardiogenic shock complicating acute coronary syndrome: insights from the CareGem registry

Italo Porto,Filippo Crea,Antonio Martellini,Piergiorgio Bruno,Roberta Della Bona,Rocco Vergallo,Alessio Mattesini,Simona Caporusso,Domenico D’Amario,Serafina Valente,Marco Scicchitano,Carlo Di Mario,Massimo Massetti,Carlotta Sorini Dini,Carlo Trani,Francesco Burzotta

doi:10.1007/s11739-020-02459-0

Abstract

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients’ condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01–18.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival.

Highlights

During last decades, the mortality rate of patients diagnosed with acute coronary syndrome (ACS) has been substantially reduced worldwide, due the combination of powerfulSerafina Valente and Massimo Massetti are to be considered joint senior authors for this submission.Extended author information available on the last page of the article pharmacological treatment with early revascularization, mainly employing percutaneous coronary intervention (PCI) [1, 2]
When ACS is complicated by refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA), the in-hospital mortality rate remains extremely high [3, 4]
We report here the in-hospital outcome and factors associated with survival from two tertiary Italian centers who have adopted a similar, structured approach to ECLS implantation for ACS patients complicated by RCS or RCA, favoring percutaneous cannulation and aggressive revascularization by early PCI

Summary

Introduction

The mortality rate of patients diagnosed with acute coronary syndrome (ACS) has been substantially reduced worldwide, due the combination of powerfulSerafina Valente and Massimo Massetti are to be considered joint senior authors for this submission.Extended author information available on the last page of the article pharmacological treatment with early revascularization, mainly employing percutaneous coronary intervention (PCI) [1, 2]. When ACS is complicated by refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA), the in-hospital mortality rate remains extremely high [3, 4]. In these critical conditions, mechanical circulatory support using veno-arterial extra-corporeal life support (VAECLS), able to provide haemodynamic stability during RCS or even total circulatory support during RCA, is considered appropriate in the most recent international guidelines, as ACS is classified as a potentially treatable etiology [5, 6]. For ACS patients, an emphasis shift has occurred, with several groups reporting relatively good outcomes for a team-based approach centered around the percutaneous suite, to provide rapid revascularization after the start of ECLS support [9, 10]

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Conclusion