Abstract
Mechanical circulatory support (MCS) devices, including intravascular microaxial left ventricular assist devices (LVADs) and intra-aortic balloon pumps (IABPs), are used in patients who undergo percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock despite limited evidence of their clinical benefit. To examine trends in the use of MCS devices among patients who underwent PCI for AMI with cardiogenic shock, hospital-level use variation, and factors associated with use. This cross-sectional study used the CathPCI and Chest Pain-MI Registries of the American College of Cardiology National Cardiovascular Data Registry. Patients who underwent PCI for AMI complicated by cardiogenic shock between October 1, 2015, and December 31, 2017, were identified from both registries. Data were analyzed from October 2018 to August 2020. Therapies to provide hemodynamic support were categorized as intravascular microaxial LVAD, IABP, TandemHeart, extracorporeal membrane oxygenation, LVAD, other devices, combined IABP and intravascular microaxial LVAD, combined IABP and other device (defined as TandemHeart, extracorporeal membrane oxygenation, LVAD, or another MCS device), or medical therapy only. Use of MCS devices overall and specific MCS devices, including intravascular microaxial LVAD, at both patient and hospital levels and variables associated with use. Among the 28 304 patients included in the study, the mean (SD) age was 65.4 (12.6) years and 18 968 were men (67.0%). The overall MCS device use was constant from the fourth quarter of 2015 to the fourth quarter of 2017, although use of intravascular microaxial LVADs significantly increased (from 4.1% to 9.8%; P < .001), whereas use of IABPs significantly decreased (from 34.8% to 30.0%; P < .001). A significant hospital-level variation in MCS device use was found. The median (interquartile range [IQR]) proportion of patients who received MCS devices was 42% (30%-54%), and the median proportion of patients who received intravascular microaxial LVADs was 1% (0%-10%). In multivariable analyses, cardiac arrest at first medical contact or during hospitalization (odds ratio [OR], 1.82; 95% CI, 1.58-2.09) and severe left main and/or proximal left anterior descending coronary artery stenosis (OR, 1.36; 95% CI, 1.20-1.54) were patient characteristics that were associated with higher odds of receiving intravascular microaxial LVADs only compared with IABPs only. This study found that, among patients who underwent PCI for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial LVAD use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use. These trends were observed despite limited clinical trial evidence of improved outcomes associated with device use.
Highlights
Intra-aortic balloon pumps (IABPs) have been the mainstay of mechanical circulatory support (MCS) for patients with cardiogenic shock in the setting of acute myocardial infarction (AMI).[1]
This study found that, among patients who underwent percutaneous coronary intervention (PCI) for AMI complicated by cardiogenic shock, overall use of MCS devices was constant, and a 2.5-fold increase in intravascular microaxial left ventricular assist devices (LVADs) use was found along with a corresponding decrease in IABP use and a significant hospital-level variation in MCS device use
Understanding changes in use as well as the patients likely to receive MCS devices and the hospitals that are likely to use these devices is important given the recent safety concerns about intravascular microaxial LVADs.[12,13]. In this retrospective cross-sectional study, we collected data from 2 national US registries to examine trends in the use of MCS devices, providing greater granularity of the clinical characteristics and device type than previous studies, among a large cohort of patients who underwent percutaneous coronary intervention (PCI) for AMI complicated by cardiogenic shock
Summary
Intra-aortic balloon pumps (IABPs) have been the mainstay of mechanical circulatory support (MCS) for patients with cardiogenic shock in the setting of acute myocardial infarction (AMI).[1]. Understanding changes in use as well as the patients likely to receive MCS devices and the hospitals that are likely to use these devices is important given the recent safety concerns about intravascular microaxial LVADs.[12,13] In this retrospective cross-sectional study, we collected data from 2 national US registries (of the American College of Cardiology NCDR) to examine trends in the use of MCS devices, providing greater granularity of the clinical characteristics and device type than previous studies, among a large cohort of patients who underwent percutaneous coronary intervention (PCI) for AMI complicated by cardiogenic shock. We examined hospital-level use variation and factors associated with use
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