Abstract
Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients.Objectives: We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients.Methods: We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage (n = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was >8.Results: Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, p = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS > 8: 56%, p = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, p < 0.001).Conclusions: Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.
Highlights
Acute myocardial infarction (AMI) is one of the major contributors to cardiogenic shock (CS) [1]
Since we previously demonstrated higher mortality in AMICS patients who suffered cardiac arrest [17, 19] or when hemodynamic support was initiated post-percutaneous coronary intervention (PCI) [13, 15, 19], the analysis of the overall cohort was stratified based on the presence or absence of cardiac arrest and timing of Impella implantation
The overall patient population consisted of 202 Acute myocardial infarction-related cardiogenic shock (AMI-CS) patients that had been treated with an Impella CP device
Summary
Acute myocardial infarction (AMI) is one of the major contributors to cardiogenic shock (CS) [1]. The “Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock” (SHOCK) trial demonstrated that urgent invasive assessment and revascularization improves long term survival [2]. Based on this trial, current society guidelines recommend urgent revascularisation in AMI-CS [3]. The intra-aortic balloon pump (IABP) was the most frequently used MCS device, it failed to improve survival compared to standard medical therapy [6, 8] and is no longer recommended for routine use (Class IIIA in the ESC Guidelines) [3]. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. Mechanical circulatory support was only used in a minority of patients
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