P42: Institutional Review of Temporary Circulatory Support Configurations for Cardiogenic Shock

Abstract

Patients experiencing cardiogenic shock continue to suffer a high mortality risk despite advances and innovation in temporary mechanical circulatory support (MCS). Providers now have many tools in the armamentarium to support patients in varied etiologies of cardiogenic shock ranging from acute coronary syndrome, non-ischemic cardiomyopathy (nICM) with end-stage heart failure and postoperative-cardiotomy biventricular dysfunction. Although instituting VA-ECMO rapidly restores circulation and perfusion in cardiopulmonary failure, alternative MCS configurations may be preferred depending on the unique etiology for cardiac decompensation. A retrospective observational review was performed on our institutional data for patients in cardiogenic shock requiring MCS stratifying into those receiving ECMO only versus VA ECMO and Impella (Ecpella) support. An analysis was conducted to evaluate whether metrics including ICU length of stay, days on CRRT ECMO and mechanical ventilation are affected by the MCS configuration in specific etiologies of cardiogenic shock. Charts were reviewed from present time to 2017 with inclusion criteria of patients having documentation of VA ECMO support. Patients who had ECMO for non-cardiac intraoperative arrests, septic shock or ARDS respiratory failure were excluded. 202 patient chart were included into the analysis in which patients received VA ECMO only or Ecpella support. Figure 1 delineates grouping into cohorts: ischemic cardiomyopathy (ICM) including acute coronary syndrome, non-ischemic cardiomyopathy (nICM), and postoperative cardiogenic shock. Data analyzed included duration of days on ECMO, CRRT and mechanical ventilation as well as ICU length of stay (LOS). Statistical analysis was performed using independent t-test to report significance between sample groups. The composite and stratified averages for the metrics in patients who survived are shown in tables 1 and 2. Although not statistically significant, the patients supported by Ecpella in the nICM cohort had reduced days on devices as well as ICU LOS. In contrast, patients receiving ECMO only in the ICM cohort had shorter days on devices and ICU LOS. The postoperative cardiogenic shock cohort did not appear to have any significant trends in the analyzed metrics. Composite mortality rate was 0.63 vs 0.72 in the ECMO only vs Ecpella group. nICM patients appear to benefit from ventricular unloading with impella support during MCS that allows for improved end-organ recovery as evident by shorter days on supportive devices while awaiting myocardial recovery versus bridge to durable therapy. In contrast, prompt restoration of perfusion in ICM patients with ECMO alone may facilitate and expedite myocardial recovery, obviating the need for a left ventricular decompression device. Further studies are necessary to confirm whether pathophysiologic differences of cardiogenic shock in nICM vs ICM cause recovery to be more receptive to particular MCS configurations.