How does protocolization improve outcomes in cardiogenic shock due to end-stage heart failure?

Abstract

BackgroundProtocolized team-based care has been shown to improve outcomes in cardiogenic shock (CS) in patients with end-stage heart failure (ESHF). This study tested the hypothesis that protocolized care improves survival by reducing multi-organ dysfunction prior to orthotopic heart transplantation (OHT) or durable left ventricular assist device (LVAD). MethodsWe developed a protocolized Recognize/rescue-Optimization-Stabilization-Exit/de-Escalation (ROSE) framework for CS due to ESHF. Six-month survival pre-ROSE (2014–2018) and post-ROSE (2018–2021) were compared. The Sequential Organ Failure Assessment (SOFA) score was calculated as a measure of multi-organ dysfunction pre-MCS and pre-“Exit” therapy (OHT, LVAD or recovery). Results101 consecutive patients with CS due to ESHF who were deteriorating on inotropes (INTERMACS 1 or 2) were included (63 in Pre-ROSE and 38 in Post-ROSE). The proportions of patients who died on support (26 (41%) vs 11 (29%), p = 0.213) or bridged to “Exit” therapy were comparable between Pre- and Post-ROSE: OHT (28 (44%) vs 21 (55%), p = 0.292); durable LVAD (8 (13%) vs 5 (13%), p = 0.947); or recovery (1 (2%) vs 1 (3%), p = 0.715). SOFA score prior to “Exit” therapy was higher Pre-ROSE compared to Post-ROSE (4 (2–7) vs 2 (1–5), p = 0.012). Six-month survival from initial MCS (71% vs 41%, p = 0.004) and in patients who underwent “Exit” therapy (100% vs 71%, p = 0.001) were higher Post-ROSE vs Pre-ROSE, respectively. Higher pre-“Exit” SOFA score was associated with 6-month survival. None of the patients with Pre-“Exit” SOFA score ≥ 9 survived at 6 months. ConclusionProtocolization of CS care in ESHF improved six-month survival by improving multi-organ dysfunction (SOFA score) prior to OHT and LVAD implant.