Stepwise escalation and de-escalation of mechanical circulatory support as a bridge to heart transplantation for cardiogenic shock secondary to acute myocardial infarction.

Primary graft dysfunction in heart transplantation: How to recognize it, when to institute extracorporeal membrane oxygenation, and outcomes

We Enter the Bridge and Start to Run Out of Time

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

Mechanical cardiac support 2000: current applications and future trial design: June 15-16, 2000 Bethesda, Maryland.

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

It is my great privilege to have been entrusted with the launch of the Journal of the Society for Cardiovascular Angiography and Interventions (JSCAI). JSCAI is a powerful vehicle for authors to contribute and disseminate new clinical and scientific evidence related to all aspects of interventional cardiovascular medicine. As we release our first issue of the JSCAI, I hope you will enjoy the content and be motivated to contribute to our interventional community by submitting your next scientific manuscript.

2] Over the past decade, there has been an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the management of refractory cardiogenic shock, because it offers not only a high cardiac output with biventricular support but also respiratory support. 5 However, peripheral VA-ECMO is limited by the significant increase in afterload because of retrograde aortic flow, which may be deleterious in CS, especially from AMI. The IABP has remained the most commonly used modality of LV decompression studied in literature because of its ubiquitous availability, ease of insertion, relatively small arteriotomy, theoretical benefit of diastolic augmentation and therefore coronary perfusion, and lastly, the ease of maintenance in the cardiac intensive care unit.

Introduction: Impella and IABP are widely used temporary mechanical circulatory support (tMCS) devices in cardiogenic shock (CS). While Impella can be used as the initial support device or after IABP as an escalation strategy, comparative data on these two strategies remain limited. Hypothesis: We hypothesized that in-hospital mortality would be similar between direct Impella use and stepwise escalation from IABP to Impella. Methods: Using ICD-10 codes in the 2016–2022 National Inpatient Sample database, we identified patients with a primary diagnosis of CS who received Impella support. Patients were divided into two groups: direct Impella use and escalation from IABP to Impella. Propensity score matching was performed to adjust for patient and hospital demographics, comorbidities, and complications. The primary outcome was in-hospital mortality, with secondary outcomes including length of stay (LOS) and total hospital charges. A sensitivity analysis compared outcomes in patients receiving Impella 5.0/LD/5.5 directly versus after IABP escalation. Results: Among 107,007 patients requiring Impella support, 700 patients (0.65%) underwent IABP-to-Impella escalation. Before matching, mortality was similar between groups (39.0% vs. 39.4%, p=0.86), while the direct Impella group had significantly shorter LOS (11.4±13.97 vs 19.28±20.70 days, p<.001) and lower total hospital charges ($441,236 vs $726,021, p<.001). After propensity score matching, these differences persisted: the direct Impella group had shorter LOS (13.17±17.21 vs. 19.22±20.70 days, p<0.001) and lower total charges ($478,526 vs. $725,276, p<0.001) with no significant difference in mortality. Sensitivity analysis of Impella 5.0/LD/5.5 showed similar trends, with shorter LOS (39.01±28.32 vs. 47.16±29.65 days, p) and lower total charges ($1,331,529 vs. $1,661,216, p=.047) in the direct Impella group after matching. Conclusion: In this national real-world cohort, direct Impella use and IABP-to-Impella escalation had comparable in-hospital mortality among CS patients. However, direct Impella use was linked to shorter hospital stays and lower total costs, highlighting potential benefits in resource efficiency and utilization.

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Registry of the International Society for Heart and Lung Transplantation: Twenty-second Official Adult Heart Transplant Report—2005

The Registry of the International Society for Heart and Lung Transplantation: Twenty-seventh official adult heart transplant report—2010

The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) is a North American national registry for mechanical circulatory support devices (MCSDs) that are used to treat advanced heart failure. Durable MCSDs that have been approved by the US Food and Drug Administration (FDA) are included in this registry; however, MCSDs that remain in FDA trials pending initial approval (ie, investigational device exemption [IDE] trials) and devices intended for short-term use (eg, Abiomed BVS 5000 ventricular assist device [Abiomed, Danvers, MA]) are not included. The purposes of this article are to present a developmental history of INTERMACS, to outline the collaboration of INTERMACS with various constituencies (eg, FDA, National Institutes of Health, Center for Medicare & Medicaid Services, industry, and physicians), to present a summary of information generated to date by INTERMACS, and to describe the future directions of INTERMACS. The concept of using mechanical circulatory assistance for more than a brief time after a cardiac operation dates to the early 1960s with the development of MCSDs that fit the definitions of counterpulsation devices (eg, the intra-aortic balloon pump), ventricular assist devices (VADs), and total artificial hearts.1–5 The development and initial clinical evaluation of these devices were regulated by individual academic medical center review groups that evolved into institutional review boards. The FDA entered this arena in 1976 with the advent of the FDA section for device regulation based on passage of the 1976 Medical Device Amendments.6 By 1991, groups including the Institute of Medicine foresaw the need for a detailed longitudinal database for patients receiving MCSDs, stating in an Institute of Medicine report that “patients should be followed through a registry for the remainder of their lives….”7 The committee further recommended that the National Heart, Lung, and Blood Institute support long-term follow-up studies. Eventually, a …

The introduction of angioplasty to treat acute myocardial infarction (MI) demonstrated a substantial improvement in survival in patients without shock; however, mortality in patients with cardiogenic shock remains high. In the last 30 years, there has been no improvement in survival in acute myocardial infarction cardiogenic shock (AMICS) patients. Reperfusion therapy has improved survival, but only to 50%, as no other therapies have been employed until recently. Now, circulatory support agents like the Impella catheter allow rapid left ventricular support for patients with acute myocardial infarction in cardiogenic shock. The Detroit Cardiogenic Shock Initiative and the National Cardiogenic Shock Initiative have shown substantial improvement in survival with patients with acute MI cardiogenic shock dark treated with Impella mechanical circulatory support. These studies must be confirmed by randomized trials, but before optimal use of mechanical circulatory support is required, to optimize benefits, best practices need to be determined. This will be the main topic of this chapter. In addition, we will review the role of Impella in different structural interventions.

Ventricular septal rupture (VSR) is a rare but devastating complication of acute myocardial infarction (MI), associated with high mortality despite advances in reperfusion therapy. However, contemporary data examining national trends in VSR outcomes and the evolving role of mechanical circulatory support (MCS) in this population remain limited. This study aimed to evaluate modern trends in VSR incidence, inpatient mortality, and MCS utilization among patients with MI using a nationally representative database. We analyzed the Nationwide Inpatient Sample from 2016 to 2021, identifying MI hospitalizations in adults ≥ 40 years. Outcomes included in-hospital mortality (primary), length of stay, adverse disposition, cardiogenic shock (CS), and MCS use (secondary). Of 5.4 million acute MI admissions, 2605 (0.05%) involved VSR. Patients with VSR experienced significantly higher mortality (49.9% vs. 8.6%), CS (70.1% vs. 6.7%), and greater reliance on MCS (ECMO 4.4% vs. 0.1%, IABP 47.6% vs. 3.2%, LVAD 15.9% vs. 1.2%; all p < 0.001). Regression analysis revealed increased odds of mortality (aOR 4.53, 95% CI 3.41-6.02), prolonged hospitalization, shock, adverse disposition, and MCS use. Across the study period, VSR incidence (0.03%-0.06%), mortality (43%-55%), and MCS rates (53%-68%) remained stable. Despite advances in cardiovascular care, VSR outcomes in the acute MI setting have not substantially improved. However, the incidence of this mechanical complication has decreased in the contemporary era of early reperfusion and advanced therapies as suggested by our cohort. Use of MCS with MI complicated by VSR remains high, and a nuanced approach for modality selection is necessary, especially in candidates for delayed repair. Trends in VSR incidence, mortality, and MCS remained stable throughout the study period. These findings underscore the persistent challenge in post-MI VSR management and emphasize the need for prospective randomized trials to define optimal repair timing and clarify whether MCS modality selection influences outcomes in this high-risk population.

There are 0.9 catheterization labs per 100,000 inhabitants in Scotland for percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), which are much less accessible to patients in remote and rural areas. An uncommon but sinister sequalae following AMI is cardiogenic shock (CS) that could be refractory to inotropic support. CS complicates 5-15% of AMIs occurring in ST-segment elevation myocardial infarctions (STEMIs). Outcomes of CS are poor with mortalities of up to 90% reported in the literature in the absence of experienced care. We report our experience as the tertiary referral centre in Scotland for MCS and heart transplantation over 8 years. A retrospective review of prospectively collected data was undertaken on all patients registered to the MCS service. The database was interrogated for patient demographics, type of mechanical circulatory support (MCS) and duration of MCS support, PCI-outcomes and survival to 30 days. A time-to-event analysis was performed using patient survival as the primary outcome measure. Twenty-three patients (16 male, 7 females) were included. The median age of the patients as 50 years (range, 45-56 years). VA-ECMO was the initial MCS of choice in 17 (73.9%) patients with BIVAD for 4 (17.4%) patients and LVAD for 2 (8.7%) patients. Thirty-day mortality was 21.8% in this cohort, however survival to discharge was 52.2%. Eleven (47.8%) patients recovered without the need for any further support, however only 9 (81.8%) patients in this subgroup survived to discharge. Three (13.0%) patients received a durable LVAD. In this subgroup, one patient was transplanted whereas two patients died due to complications while on support. The median length of in-hospital MCS support was 4 days. Median in-hospital stay was 27 days. Long-term follow up of up to 8 years demonstrates a high mortality beyond 30-day up to the first 6-month post MCS support. MCS usage in these patients carries a high mortality in the early post-implantation period. However, there is a significant benefit to patients who survive the initial bridging period to recovery or destination therapy.