How Does a Protocolized Therapeutic Framework Improve Survival in Cardiogenic Shock Due to End-Stage Heart Failure?

Abstract

<h3>Purpose</h3> We hypothesized that a team-based protocolized treatment framework improve survival from mechanical circulatory support (MCS) bridging to heart transplantation (HT) or left ventricular assist device (LVAD) in patients with cardiogenic shock (CS) from end-stage heart failure (ESHF) by minimizing and reversing multi-organ dysfunction (MOD) before HT or LVAD. <h3>Methods</h3> We introduced a team-based protocolized Recognize/rescue-Optimization-Stabilization-Exit/de-Escalation (ROSE) framework for CS due to ESHF in 2018. We compared 6-month survival before (G1) and after (G2) adoption of this framework. The Sequential Organ Failure Assessment (SOFA) score was used as a measure of MOD. <h3>Results</h3> We included 101 consecutive patients with CS due to ESHF. Adoption of ROSE led to earlier MCS in G2 before severe MOD (INTERMACS 2, lower lactate and SOFA score - TABLE). Ecpella was more common in G2 (32% vs 3%, p<0.001) . MCS lowered SOFA score in both groups; achieving lower SOFA scores prior to HT/LVAD in G2 (4 (2-7) vs 2 (1-5), p=0.012 FIGURE). The duration of MCS bridging were comparable (p=0.417). In G1 and G2 - 44% vs 55% (p=0.292) were bridged to HT, 13% vs 13% (p=0.947) to LVAD; and 2% vs 3% to recovery. 6-month survival was higher in G2 (FIGURE p=0.001) due to lower pre-HT/LVAD SOFA score and lactate on Cox model. Pre-HT/LVAD SOFA score of ≥9 was 73% sensitive and 100% specific (AUC 0.932) for mortality post-HT/LVAD. <h3>Conclusion</h3> Our ROSE protocol improved 6-month survival in patients with CS due to ESHF by minimizing and reducing MOD prior to HT/LVAD therapy. Pre-HT/LVAD SOFA score of ≥9 is specific for mortality post-HT/LVAD.