Acute Cardiogenic Shock Research Articles

Abstract 4138583: Incidence and Outcomes of Heparin-Induced Thrombocytopenia Among Patients Undergoing Left Ventricular Assist Device Implantation

Background: Left Ventricular Assist Devices (LVAD) are being increasingly used as a bridge to transplant and destination therapy for advanced (stage D) heart failure. Heparin-induced thrombocytopenia (HIT) increases the risk of thromboembolic and bleeding events. HIT is also a well-known complication in patients undergoing LVAD implantation. This study examines the incidence and impact of HIT on outcomes in LVAD implants using a nationwide database from 2016 to 2020. Methods: We queried the National Inpatient Sample database for 2016-2020 to identify all adults ≥ 18 who underwent LVAD insertion using ICD 10 codes. LVAD recipients were dichotomized into two cohorts by the presence of HIT. Our primary outcome was in-hospital mortality. Secondary outcomes included vascular complications, acute kidney injury (AKI), length of stay, and total cost. Outcomes were adjusted for demographic variables, hospital-level characteristics, and comorbidities using regression analysis. Results: A total of 19975 (95% CI: 18328 - 21622) hospitalization records for LVAD insertion were identified, out of which HIT occurred in 1.8%. There were significant differences in AKI requiring dialysis, (p < 0.03) cardiogenic shock, (p<0.01), mechanical ventilation (p<0.01), pulmonary embolism (PE) (p< 0.001) and acute deep vein thrombosis (DVT) (p< 0.001) which occurred more in HIT. In-hospital mortality was not significantly associated with HIT (adjusted odds ratio [aOR] 1.49, 95% CI :0.73-3.04, p value 0.28). Older age (aOR 1.02; 95% CI: 1.01-1.02) was associated with mortality after LVAD insertion. AKI, ischemic stroke, hemorrhagic stroke, acute coronary syndrome, arterial dissection, cardiogenic shock, and mechanical ventilation were significantly associated with in-hospital mortality. Our analysis did not show any differences in the incidence of vascular complications, stroke, intraoperative bleeding, blood transfusions and AKI between the HIT and non-HIT group. The HIT group stayed longer in the hospital 39 days (95% CI: 36- 38) vs 37 days (95% CI: 35- 44) and incurred higher total hospital cost of $1,101,638 vs. $1,245,616) although this was not statistically significant. Conclusion: Among US hospitalized patients undergoing LVAD implants, HIT was significantly associated with a higher risk of AKI requiring dialysis, PE, acute DVT, cardiogenic shock and need for mechanical ventilation. It was however not associated with a higher risk of in-hospital mortality.

Case report - Survival after ECPR for adolescent arrhythmogenic arrest - ECPELLA (ECMO with Impella®)

Abstract Background The combined therapy with venoarterial extracorporeal membrane oxygenation (V-A ECMO) and Impella (ECPella) has been shown to improve survival in acute cardiogenic shock (CS) in adult patient. Only 3 paediatric cases have been reported in a multicentre study. Case summary We present our case, the first described to our knowledge in the UK, of a 15 year old adolescent of Afro-Caribbean descent, weight 75kg, who received E-CPR (extracorporeal cardiopulmonary-resuscitation) and ECPella implantation. The patient suffered a sudden cardiac arrest at home, his mother called for an ambulance who arrived within 10 minutes and commenced life support with a LUCAS device. He received 3 doses of adrenaline and 3 desynchronised shocks for an underlying rhythm of ventricular fibrillation (VF) after which ROSC was achieved. He was then transferred to his local hospital where he had another VF arrest with successful cardioversion and was then transferred to our institution where on arrival he had another VF arrest and received E-CPR (extracorporeal cardiopulmonary-resuscitation) and ECPella implantation under the institutional adult shock program within 3 hours of in-hospital cardiac arrest. Following weaning from ECPella the patient underwent cardiac and brain MRI and serial echocardiograms with complete recovery of ventricular function. After implantation of cardiac defibrillator, he was discharged home without neurological sequelae. He remains asymptomatic from a cardiac perspective, with a normal cardiac examination and with no neurological sequelae at 2 year follow up. Discussion This is the first case description of ECPella use in a child in the United Kingdom and highlighted the importance of timely institution of E-CPR on survival benefit in fatal CS. The outcome success of post-resuscitation ECPella strategy in this adolescent was through collaborative interprofessional engagement of multiple supra-specialists within acute cardiology and critical care across paediatric and adult services and alignment with the institutional adult shock program.

Clinical characteristics and outcomes of Takotsubo syndrome in patients with chronic obstructive pulmonary disease

Backgroundtakotsubo syndrome (TTS) is an acute heart failure syndrome characterized by a relevant comorbid background, including chronic obstructive pulmonary disease (COPD). However, TTS patients with COPD are still not well characterized. Aimto describe the clinical characteristics and outcomes of patients with TTS and COPD. Methodsn = 440 TTS patients were dichotomized according to the presence of COPD. Endpoint of the study were in-hospital complications (composite of death, major arrhythmias, cardiogenic shock and acute pulmonary edema), TTS recurrence and long-term mortality at follow-up. Resultsmean age of the population was 72±11, 10 % males. COPD prevalence was 16 % (n = 69). On subgroup analysis, patients with COPD were more likely smokers (41 % vs 13 %, p < 0.001), with higher rates of dyspnea and physical triggers at presentation (52 % vs 18 %, p < 0.001 and 52 % vs 32 %, p = 0.001 respectively) and lower left ventricular ejection fraction (36 % vs 39 %, p = 0.035) In-hospital complications were more common in patients with COPD (26 % vs 13 %, p = 0.006), driven by higher rates of acute pulmonary edema (19 % vs 6 %, p < 0.001) and cardiogenic shock (10 % vs 4 %, p = 0.023). At multivariable logistic regression analysis, COPD was independently associated with in-hospital complications occurrence (Odds Ratio 2.10, 95 % CI 1.09–4.05; p = 0.027). At univariable Cox regression analysis COPD was associated with TTS recurrence (Hazard Ratio (HR 9.82, 95 % CI 3.2–30.12; p < 0.001)), at multivariable Cox regression analysis with long-term mortality (HR 2.97, 95 % CI 1.44–6.12; p = 0.003). ConclusionCOPD marks a vulnerable TTS phenotype including higher risk of in-hospital complications, long-term recurrence and mortality.

Clinical characteristics and outcomes of patients with takotsubo syndrome and dynamic left ventricular outflow tract obstruction

Abstract Background Left ventricular outflow tract obstruction (LVOTO) is recognized as a serious complication of Takotsubo syndrome (TTS). However, its impact on patient prognosis remains insufficiently investigated. Purpose This study aimed to assess clinical characteristics and short- and long-term outcomes of patients with TTS complicated by LVOTO. Methods Patients with TTS were enrolled from the Takotsubo Italian Network (TIN). The primary outcome was the composite of acute heart failure, cardiogenic shock, and mortality during hospitalization. Secondary outcomes included the single components of the primary outcome and the occurrence of death or TTS recurrence during follow-up. Results Overall, 881 patients were included in the study [median age 72.0 (63.0–78.0) years; 91.3% female], with LVOTO detected in 59 patients (6.7%). Low diastolic blood pressure, ST-segment elevation, and moderate-to-severe mitral regurgitation were independently associated with occurrence of LVOTO. Propensity score weighting regression analysis revealed a significant higher risk of the primary outcome (OR, 2.99; 95% CI, 2.22–4.02), acute heart failure (OR, 2.19; 95% CI, 1.59–3.02), cardiogenic shock (OR, 4.56; 95% CI, 3.07–6.78), and in-hospital mortality (OR, 2.42; 95% CI, 1.13–5.21) in patients with TTS complicated by LVOTO. No significant association between LVOTO and long-term mortality or TTS recurrence was observed during follow-up. Conclusions In this real-world evidence study, LVOTO was detected in about 7% of TTS patients and was associated with a significantly higher risk of adverse events during hospitalization, including mortality. Early detection of LVOTO can aid in prognostic assessment and guide therapeutic management in patients with TTS.

Intravascular imaging-guided PCI in patients with acute myocardial infarction and cardiogenic shock

Abstract Background There are no clinical data regarding efficacy of intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography-guided PCI in patients with acute myocardial infarction (AMI) and cardiogenic shock. Purpose The current study sought to evaluate the impact of intravascular imaging-guided PCI in patients with AMI and cardiogenic shock. Methods Among a total of 28,732 patients from the nationwide pooled registry of KAMIR-NIH and KAMIR-Ⅴ, a total of 1,833 patients (6.4%) with AMI and cardiogenic shock who underwent PCI of the culprit vessel were selected. The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, a composite of cardiac death, MI, repeat revascularization, and definite or probable stent thrombosis. Results Among the study population, 375 patients (20.5%) underwent intravascular imaging-guided PCI and 1,458 patients (79.5%) underwent angiography-guided PCI. Intravascular imaging-guided PCI showed significantly lower risk of 1-year MACE compared with angiography-guided PCI (19.5% vs 28.2%; adjusted hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.45-0.77; P&amp;lt;0.001), mainly driven by lower risk of cardiac death (13.7% vs. 24.0%; adjusted HR, 0.53; 95% CI, 0.39-0.72; P&amp;lt;0.001). These results were consistent in propensity score matching (HR, 0.68; 95% CI, 0.46-0.99), inverse probability weighting (HR, 0.61; 95% CI, 0.45-0.83), and Bayesian analysis (odds ratio, 0.66, 95% credible interval, 0.49-0.88). Conclusion In AMI patients with cardiogenic shock, intravascular imaging-guided PCI was associated with lower risk of MACE at 1-year than angiography-guided PCI, mainly driven by the lower risk of cardiac death. Further randomized controlled trial is warranted to confirm these findings.Central illustration

Transcatheter valve replacement as rescue treatment for heart failure in infective endocarditis. A multinational series.

Abstract Background Transcatheter valve replacement (TVR) could be a therapeutic alternative for refractory heart failure in patients with infective endocarditis (IE) unsuitable for open surgery. However, evidence of tis use in this scenario is limited to isolated case reports. Purpose We aimed to describe the clinical characteristics and outcome of IE patients in whom a TVR was performed during the active phase of infection in a multinational case series. Methods This retrospective study was conducted in 23 referral hospitals for IE and TVR procedure in 8 countries. All consecutive adult patients (≥18 y) with definite IE in whom a TVR was performed during antimicrobial treatment of within the 3 three months after its withdrawal were included. The inclusion period was between July 2011 and July 2023. Baseline, IE-related, TVR-related, outcome and follow-up (min. 3 months) variables were collected. Results Forty-five patients [median age 74 years (IQR 64 – 82), 35 males (78%), median Charlson comorbidity index 6 (4 – 7) points] were included in the study: 42 aortic TVR, 2 mitral TVR and 1 tricuspid TVR. In 20 patients (44%) TVR was performed on a native valve and in 25 on a prosthetic valve. The most frequent microorganisms causing IE were streptococci (n=16, 36%), staphylococci (n=13, 29%) and enterococci (n=5, 11%). Acute heart failure was present in 41 (91%). Of them, 23 (51%) developed acute pulmonary oedema or cardiogenic shock. The main reasons for excluding open surgery were: high surgical risk [n=39, 87%; median EuroSCORE 17 (9 – 28)] and technical impossibility (n=3, 7%). TVR was performed during antimicrobial treatment in 27 cases (60%) [median 25 (13 – 54) days after initiation] and within the first three months after its completion in 18 (40%) [median 25 (17 – 68) days after discontinuation]. Four patients (9%) died during admission. Over a median follow-up of 10 (6 -30) months, 7/41 patients (17%) died and there were 2/41 (5%) relapses, one of which required open valve replacement surgery 17 days after TVR procedure. Two other patients underwent open surgery due to paravalvular leaks (11 and 44 days after TVR). All cases of relapse and open surgery occurred when TVR was performed during antibiotic treatment. Conclusion TVR could be an option as rescue treatment for heart failure in selected IE patients unsuitable for open surgery. This represents a paradigm shift in the management of IE and may change the natural history of the disease in patients who would otherwise die.

Divergent hemometabolic dynamics: understanding the differences between acute myocardial infarction and heart failure related cardiogenic shock

Abstract Background Understanding the hemodynamic trajectories between acute myocardial infarction(AMI) &amp; non-AMI cardiogenic shock(CS) is crucial for tailored management. Purpose Describe different hemometabolic patterns in AMI vs AMI-CS, AMI vs AMI-CS survivors &amp; AMI vs AMI-CS non-survivors. Methods 354 AMI &amp; 81 Non-AMI CS patients with PAC-hemodynamics were included. ANOVA of repeated measures was used to compare trajectories. Cox regression analysis for hazard ratios of conventional cut-off values hemometabolic goals &amp; ideal with Youden index for LVSWi at baseline &amp; 24h(Fig2B/C). Results AMI-CS were older(62 vs 52,P&amp;lt;0.001), exhibit a higher prevalence of smoking, dyslipidemia, HTN, &amp; DM2(P&amp;lt;0.05). HF history &amp; AF were more prevalent in Non-AMI-CS(P&amp;lt;0.001). AMI-CS had lower heart rate, respiratory rate, BUN, pH; higher LVEF, hemoglobin, leucocytes, platelets, glucose, Cl-, Na+, AST, ALT, LDH(P&amp;lt;0.05). Treatment modalities, AMI-CS had higher mechanical circulatory support (P&amp;lt;0.001). AKI was more common in non-AMI(P=0.004). There were no differences in number of vasoactives(P=0.46), but non-AMI had more dobutamine use(P&amp;lt;0.001). MODS score, organ failures, VT/VF, Phenotype, SCAI, and mortality(46.9 vs 47.7% Non-AMI vs AMI-CS) had no differences(P&amp;gt;0.05). Dynamics congestion associated with phenotypes &amp; SCAI are shown in Fig 2A. SBP(F=12.39,P&amp;lt;0.001), DBP(4.72,0.03) &amp; MAP(9.98,0.002) (Fig1A) had differences in AMI vs non-AMI-CS, but none were seen in survivors(P&amp;gt;0.05), only in non-survivors (SBP 17.52, &amp;lt;0.001; DBP 6.59, 0.011 &amp; MAP 13.98, &amp;lt;0.001). RAP(7.4,0.007) &amp; PCWP(53.51,&amp;lt;0.001) (Fig1B/C) also differ among AMI vs non-AMI &amp; non-survivors(5.69,0.018 &amp; 28.77,&amp;lt;0.001); but only PCWP differs across survivors(27.49,&amp;lt;0.001). Cardiac output &amp; index(Fig1D)(13.65,&amp;lt;0.001 &amp; 18.88,&amp;lt;0.001) had both differences among survivors(4.17,0.042 &amp; 6.67,0.01) &amp; non-survivors(10.98,&amp;lt;0.001 &amp; 13.57,&amp;lt;0.001). Cardiac power, index, &amp; CPIRAP(Fig1E) also had this behavior being higher in AMI. Coronary perfusion pressure (Fig1F) differs among all 3 classes (P&amp;lt;0.001), AMI vs non-AMI(F=31.17), survivors(11.63) &amp; non-survivors(25.81). Perfusion pressure only had in AMI vs non-AMI(15.91,&amp;lt;0.001) &amp; non-survivors(20.39,&amp;lt;0.001). PAPI(Fig1G) had differences in AMI vs non-AMI(F=9.3,P=0.002) &amp; non-survivors(8.69,&amp;lt;0.001). API(Fig1H) differs across all spectrums(14.87 groups, 5.89 survivors &amp; 11.61 non-survivors). Finally, LVSWi &amp; RVSWi(Fig1I/J) had differences among AMI vs non-AMI in all categories: groups(22.5 &amp; 14.27 both &amp;lt;0.001), survivors(7.88,0.005 &amp; 9.29,0.003) &amp; non-survivors(21.27,&amp;lt;0.001 &amp; 5.17, 0.024). In the metabolic, only lactate(Fig1K) shows differences in AMI vs non-AMI(5.46,0.02) &amp; non-survivors(8.02,0.005); no differences were noted in survivors. Hazard ratios were assessed with the whole cohort, AMI, &amp; non-AMI; full data is shown in Fig 2B/C. Conclusion Our investigation elucidates nuanced hemodynamic disparities between AMI vs non AMI-CS, even in survivors and non-survivors of CS.Figure 1.Hemodynamic trajectoriesFigure 2.Alluvial. B/C Baseline &amp; 24h goals

Impact of Impella5.0/5.5 use on short-term prognosis in patients with AMI-related cardiogenic shock receiving Impella-incorporated MCS in Japan

Abstract Background The short-term prognosis in patients with acute myocardial infarction-related cardiogenic shock (AMI-CS) remains unsatisfactory even in the era of Impella. The survival benefit of Impella 5.0/5.5 use remains uncertain. Purpose This study examined the clinical impact of Impella device type on clinical outcomes among patients with AMI-CS receiving Impella support using the prospective multi-center J-PVAD registry data. Methods We included patients with AMI-CS who received Impella-incorporated temporary MCS and were enrolled in the J-PVAD registry between Feb 2022 and Dec 2023. The primary outcome was 30-day survival. Results A total of 2405 patients (average 71 y; LVEF 30%; Lac 5.6 mmol/L) were included. 1409 (58.6%) patients received Impella alone and the others (41.4%) received ECPELLA support. Patients who received ECPELLA had a lower 30-day survival compared to those receiving Impella alone (46.1% vs 62.3%, p &amp;lt; 0.0001). Of note, patients who received ECMO with Impella5.0/5.5 had a greater survival compared to those who received ECMO with Impella2.5/CP (64.4% vs 43.0%, Figure 1). Conclusions Patients who received ECPELLA had a lower 30-day survival compared to Impella alone. Impella 5.0/5.5 use may improve prognosis for those with ECMO support in AMI-CS.

Rationale and study design of the international randomized control trial MYocarditis THerapy with Steroids: the MYTHS trial

Abstract Background Immunosuppression is generally suggested in patients with specific subtypes of acute myocarditis, such as eosinophilic myocarditis or giant cell myocarditis or associated with systemic autoimmune disorders. In contrast, no specific treatment for most acute myocarditis complicated by acute heart failure (HF) or cardiogenic shock is recommended beyond the management of acute HF and supportive therapy. Nevertheless, large registries commonly reported using corticosteroids in severe forms without data supporting this strategy. Purpose To assess the safety and efficacy of high-dose pulse intravenous (IV) corticosteroid therapy to treat patients with complicated/fulminant acute myocarditis based on clinical suspicion. Methods An international pragmatic investigator-initiated single-blinded randomized controlled trial that screens patients between 18 and 70 years admitted to the hospital for suspected acute myocarditis (cardiac symptoms onset within three weeks) complicated by acute HF/cardiogenic shock and left ventricular (LV) ejection fraction&amp;lt;41% without significant LV dilation is ongoing. Patients are randomized in a 1:1 ratio to pulsed IV methylprednisolone (1 g) in saline solution (250 mL) daily for three days or placebo (saline without methylprednisolone) on top of standard therapy and maximal supportive care. A final diagnosis of myocarditis is confirmed by histology or cardiac magnetic resonance imaging. A population of 288 patients has been planned to assess a reduction in the probability of reaching the primary endpoint from 25% in the placebo arm to 12% in the methylprednisolone arm with a power of 0.80 (Figure). The main analysis will be conducted on an intention-to-treat basis. Results The primary efficacy endpoint of the trial is defined as the time from randomization to the first event occurring within 6 months, including all-cause death, heart transplantation, or long-term LV assist device implant, or need for an upgrading of the temporary mechanical circulatory support (t-MCS), or ventricular tachycardia (VT)/fibrillation (VF) treated with direct current (DC) shock, or first rehospitalization due to HF or VT/VF, or advanced atrioventricular block. The safety endpoints include a composite of potential complications that can occur, including serious infections, acute gastrointestinal bleeding, and other complications that can be related to corticosteroid therapy or prolonged stay on t-MCS. There are 32 active centers, and 48 patients have been randomized since December 2021. The trial is expected to be completed by the end of 2028. Conclusion The results of the MYTHS trial can define the role of IV methylprednisolone in the initial treatment of patients with complicated forms of acute myocarditis that currently have an unacceptably high mortality rate.

A Bayesian reanalysis of the CULPRIT-SHOCK trial.

The optimal revascularization strategy for patients with acute myocardial infarction (AMI), cardiogenic shock (CS), and multivessel disease remains controversial. The CULPRIT-SHOCK trial compared culprit lesion-only vs. immediate multivessel percutaneous coronary intervention (PCI), providing important data but leaving efficacy questions unresolved. To address lingering uncertainties and gain deeper insights, we performed a Bayesian reanalysis of the CULPRIT-SHOCK trial data. We conducted a Bayesian re-analysis of the CULPRIT-SHOCK trial data using non-informative, sceptical, and enthusiastic priors. Relative risks (RRs) with 95% highest posterior density (HPD) intervals were calculated. We defined the minimal clinically important difference (MCID) as RR < 0.84. We performed subgroup analyses for key patient characteristics and assessed secondary outcomes and safety endpoints. Probabilities of benefit, achieving MCID, and harm were computed. Results are presented as median RR with probabilities of effect sizes. Bayesian reanalysis showed a median RR of 0.82 (95% HPD 0.66-1.04) with a non-informative prior, indicating a 95% probability of benefit and 59% probability of achieving MCID. Subgroup analyses revealed potentially stronger effects in males (RR 0.78, 73% probability of MCID), patients without diabetes (RR 0.76, 79% probability of MCID), and those with non-anterior ST-segment elevation MI (STEMI; RR 0.74, 76% probability of MCID). Secondary outcomes suggested potential benefits in mortality (RR 0.85) and need for renal replacement therapy (RR 0.72) but increased risks of recurrent MI (RR 2.84) and urgent revascularization (RR 2.88). Our Bayesian reanalysis provides intuitive insights by quantifying probabilities of treatment effect sizes, offering further evidence favouring the culprit lesion-only PCI strategy in AMI patients with CS and multivessel disease. The analysis demonstrates a high probability of overall benefit, with a notable chance of achieving a minimally clinically important difference, particularly in specific subgroups. These findings not only support the consideration of culprit lesion-only PCI in certain patient populations but also underscore the need for careful risk-benefit assessment. Furthermore, our hypothesis-generating subgroup analyses, which show varying probabilities of achieving MCID, illuminate promising avenues for future targeted investigations in this critical patient population.

Adjustment of the SMART risk score by bioactive adrenomedullin enables a more accurate prediction of mortality in patients with ASCVD

Abstract Background Bioactive adrenomedullin 1-52 (bio-ADM) is a dynamic blood biomarker for real-time assessment of endothelial function. Bio-ADM was recently shown to be a prognostic marker in patients with acute heart failure and cardiogenic shock. The SMART (Second Manifestations of Arterial Disease) score is a validated tool for risk assessment in patients with established atherosclerotic cardiovascular disease (ASCVD). The aim of this study was to assess whether measurement of bio-ADM adds incremental value to the SMART score in stable patients with ASCVD. Methods Circulating bio-ADM levels were assessed in n=695 stable patients with ASCVD in an all-comer cohort. Endpoints evaluated were all-cause mortality and cardiovascular mortality; follow up was 3 years. Results Bio-ADM was higher in non-survivors (all-cause death: n=54, median 33.1 pg/mL) compared to survivors (n=641, median 17.9 pg/mL; p&amp;lt;0.0001). Univariable Cox regression analyses showed bio-ADM to be associated with adverse outcome [standardized hazard ratio (HR) of bio-ADM values: All-cause death: 2.4, 95% confidence interval (CI): 2.0-2.9; p&amp;lt;0.001, cardiovascular death: 2.5, 95% CI: 1.9-3.3; p&amp;lt;0.001]. This association remained significant in various multivariable Cox regression models. Bio-ADM was found to be a strong marker for mortality (c-index: 0.80, Chi²: 54.1) and proved to be superior to other markers including hs-Troponin T (c-index: 0.61, Chi²: 2.0) and eGFR CKD-EPI 2021 (c-index: 0.687, Chi²: 33.5). Addition of bio-ADM to the SMART score significantly improved model performance in predicting mortality (SMART score: c-index: 0.717, Chi²: 24.73; SMART score + bio-ADM: c-index: 0.832, Chi²: 63.24; Delta c-index: 0.115; Delta Chi²: 38.51; all p&amp;lt;0.001) and showed net reclassification improvement in risk categorization with 11.6% in the group of survivors and 9.8% for non-survivors. Conclusion Bio-ADM provides incremental added value (improved discrimination, calibration and reclassification) on top of the SMART risk score in patients with ASCVD.

Patient characteristics and clinical outcome in acute myocardial infarction related cardiogenic shock according to vascular access site for PCI

Abstract Background / Introduction The optimal vascular access site for percutaneous coronary interventions (PCI) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) remains uncertain. While observational data favor trans-radial access (TRA) due to lower complication rates and mortality, trans-femoral (TFA) PCI offers advantages such as shorter access and procedure times, along with quicker escalation to mechanical circulatory support (MCS). Purpose In this study, we aimed to investigate factors associated with a transfemoral approach and compare mortality rates between TRA and TFA in AMI-CS patients undergoing PCI. Methods Data from a nationwide registry of AMI-CS patients undergoing PCI (2017-2021) were analyzed. We compared patient demographics, procedural details, and outcomes between TRA and TFA groups. Logistic regression identified access site factors and radial-to-femoral cross-over predictors. Propensity score matched (PSM) analysis examined the impact of access site on mortality. Results Of 1562 patients, 45% underwent TRA PCI, with an increasing trend over time. TFA patients were more often female, had a history of coronary artery bypass grafting (CABG), lower blood pressure, higher resuscitation and intubation rates, and elevated lactate levels. After PSM, 30-day mortality was lower in TRA (33% vs. 46%, p &amp;lt;0.001). Predictors for cross-over included left coronary artery interventions, multivessel PCI, and MCS initiation. Conclusion Significant differences exist between TRA and TFA PCI in AMI-CS. TFA was more common in patients with worse hemodynamics and was associated with higher 30-day mortality compared to TRA. TRA should be the default access, given its feasibility and favorable outcomes in many patients.Baseline characteristicsPredictors for femoral access

Diastolic shock index: a novel prognostic parameter unveiling insights into vasodilatory cardiogenic shock

Abstract Introduction Systemic vasodilation is an increasingly acknowledged feature in cardiogenic shock (CS), defining a subset of patients with low systemic vascular resistances and higher vasopressor requirements. While a diastolic shock index (DSI) above 2.0 predicts vasoplegia and mortality in septic shock, its cut-off and prognostic significance in CS remain unclear. Our study aimed to characterize vasoplegia in CS using the DSI and assess its impact on prognosis. Methods Single-center retrospective cohort study on Cardiac Intensive Care Unit (CICU) admissions for CS from January 2017 to October 2023. Data included patient variables, CS features, vasoactive drugs, mechanical circulatory support, and 30-day mortality. DSI (heart rate (HR) to invasive diastolic blood pressure (DBP) ratio) impact on 30-day all-cause mortality was assessed with univariate Cox regression. Optimal DSI cut-off for adverse outcomes was determined through ROC curve analysis, and survival based on this cut-off was analyzed using Kaplan-Meier curves. Results 185 patients (mean age 59 ± 12 years, 63% male) were included. Acute myocardial infarction-related CS (47%) and heart failure-related CS (29%) were predominant. According to SCAI classification, 86% were class C, 22% class D, and 4% class E, with 26% experiencing previous cardiac arrest. Median Vasoactive-Inotropic Score (VIS) was 48 (IQR 21-85), and 25% used mechanical circulatory support. At admission, median HR was 105 bpm (IQR 90-125), DBP was 60 mmHg (IQR 55-65), and DSI was 1.71 (IQR 1.31-2.18). Thirty-day all-cause mortality was 36% (n=67), with median time to death of 4 days (IQR 1-10). DSI at 30 days predicted mortality (OR 1.42, 95%CI 1.06-1.91, p=0.020). DSI showed fair discriminative power for 30-day mortality (C-Statistic 0.60, 95% CI 0.51-0.68, p=0.031) with a cut-off of 2.2. Patients with DSI &amp;gt;2.2 exhibited heightened likelihood of prior cardiac arrest (38% vs. 20%, p=0.032), and higher serum lactate (5.5 vs. 3.9 mmol/L, p=0.008), and serum creatinine (2.64 vs. 1.88 mg/dL, p=0.003) at admission. Despite higher VIS at 48 hours (120±136 vs. 65±93.9, p=0.04), MCS need did not significantly differ. This group had superior 30-day mortality risk (log-rank p=0.011). Conclusion In our cohort, the admission Diastolic Shock Index (DSI) emerged as a promising identifier for CS vasoplegic patients and was a predictor of a higher risk for mortality. A DSI above 2.2 identified a subset of patients with previous cardiac arrest and higher lactate levels, enlightening possible risk factors associated with vasoplegia. Further studies are warranted to establish the robustness of this novel prognostic parameter in CS patients and its therapeutic implications.

Epidemiology of cardiogenic shock using the Shock Academic Research Consortium (SHARC) consensus definitions.

The Shock Academic Research Consortium (SHARC) recently proposed pragmatic consensus definitions to standardize classification of cardiogenic shock (CS) in registries and clinical trials. We aimed to describe contemporary CS epidemiology using the SHARC definitions in a cardiac intensive care unit (CICU) population. The Critical Care Cardiology Trials Network (CCCTN) is a multinational research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Cardiogenic shock was defined as a cardiac disorder resulting in SBP < 90 mmHg for ≥30 min [or the need for vasopressors, inotropes, or mechanical circulatory support (MCS) to maintain SBP ≥ 90 mmHg] with evidence of hypoperfusion. Primary aetiologic categories included acute myocardial infarction-related CS (AMI-CS), heart failure-related CS (HF-CS), and non-myocardial (secondary) CS. Post-cardiotomy CS was not included. Heart failure-related CS was further subcategorized as de novo vs. acute-on-chronic HF-CS. Patients with both cardiogenic and non-cardiogenic components of shock were classified separately as mixed CS. Of 8974 patients meeting shock criteria (2017-23), 65% had isolated CS and 17% had mixed shock. Among patients with CS (n = 5869), 27% had AMI-CS (65% STEMI), 59% HF-CS (72% acute-on-chronic, 28% de novo), and 14% secondary CS. Patients with AMI-CS and de novo HF-CS were most likely to have had concomitant cardiac arrest (P < 0.001). Patients with AMI-CS and mixed CS were most likely to present in more severe shock stages (SCAI D or E; P < 0.001). Temporary MCS use was highest in AMI-CS (59%). In-hospital mortality was highest in mixed CS (48%), followed by AMI-CS (41%), similar in de novo HF-CS (31%) and secondary CS (31%), and lowest in acute-on-chronic HF-CS (25%; P < 0.001). SHARC consensus definitions for CS classification can be pragmatically applied in contemporary registries and reveal discrete subpopulations of CS with distinct phenotypes and outcomes that may be relevant to clinical practice and future research.

Concurrent intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation for acute coronary syndrome-related cardiogenic shock: A meta-analysis of multivariate studies.

Concurrent intra-aortic balloon pump (IABP) use has been suggested to reduce mortality in patients with acute coronary syndrome (ACS)-related cardiogenic shock (CS) on veno-arterial extracorporeal membrane oxygenation (ECMO). However, this observation is primarily based on small-scale univariate studies. The aim of this meta-analysis was to evaluate whether concurrent IABP and ECMO were independently associated with reduced mortality in patients with ACS-related CS. We searched Medline, Web of Science, and Embase for studies published up to May 28, 2024. The inclusion criteria were longitudinal observational studies comparing concurrent IABP and ECMO to ECMO alone in ACS-related CS patients, reporting all-cause mortality with multivariate adjustments. The primary outcome was the risk ratio (RR) of short-term mortality. A random-effects model incorporating heterogeneity was used to pool the results. Seven cohort studies, involving 5467 patients, were included. Concurrent IABP and ECMO were associated with a significant reduction in short-term mortality (adjusted RR: 0.64; 95% CI: 0.48-0.87, P = 0.005; I² = 83%). Sensitivity analyses confirmed the robustness of these results. Meta-regression indicated that the proportion of men in each study significantly influenced the outcomes, fully explaining the heterogeneity (I² residual = 0%). Subgroup analyses showed consistent results across various study designs, patient ages, observational durations, and study quality scores. In conclusion, concurrent IABP and ECMO are independently associated with reduced short-term mortality in ACS-related CS patients, particularly in studies with higher proportions of men. These findings support the potential benefits of combined mechanical support in this high-risk population.

Machine learning-based prediction of mortality in acute myocardial infarction with cardiogenic shock.

In the ICU, patients with acute myocardial infarction and cardiogenic shock (AMI-CS) often face high mortality rates, making timely and precise mortality risk prediction crucial for clinical decision-making. Despite existing models, machine learning algorithms hold the potential for improved predictive accuracy. In this study, a predictive model was developed using the MIMIC-IV database, with external validation performed on the eICU-CRD database. We included ICU patients diagnosed with AMI-CS. Feature selection was conducted using the Boruta algorithm, followed by the construction and comparison of four machine learning models: Logistic Regression (LR), eXtreme Gradient Boosting (XGBoost), Adaptive Boosting (AdaBoost), and Gaussian Naive Bayes (GNB). Model performance was evaluated based on metrics such as AUC (Area Under the Curve), accuracy, sensitivity, specificity, and so on. The SHAP method was employed to visualize and interpret the importance of model features. Finally, we constructed an online prediction model and conducted external validation in the eICU-CRD database. In this study, a total of 570 and 391 patients with AMI-CS were included from the MIMIC-IV and eICU-CRD databases, respectively. Among all machine learning algorithms evaluated, LR exhibited the best performance with a validation set AUC of 0.841(XGBoost: 0.835, AdaBoost: 0.839, GNB: 0.826). The model incorporated five variables: prothrombin time, blood urea nitrogen, age, beta-blockers and Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers. SHAP plots are employed to visualize the importance of model features and to interpret the results. An online prediction tool was developed, externally validated with the eICU-CRD database, achieving an AUC of 0.755. Employing the LR algorithm, we developed a predictive model for assessing the mortality risk among AMI-CS patients in the ICU setting. Through model predictions, this facilitates early detection of high-risk individuals, ensures judicious allocation of healthcare resources.

Chronic Kidney Disease Predisposes to Acute Congestive Heart Failure, Cardiogenic Shock, and Mortality in Patients Undergoing Percutaneous Coronary Intervention

The relations between degrees of chronic kidney disease (CKD) and congestive heart failure (CHF) events after percutaneous coronary intervention (PCI) are not well characterized. We sought to determine the relation between different stages of CKD and acute CHF events, including HF and cardiogenic shock (CS), and the impact of CKD stages on all-cause mortality after PCI. Patients who underwent PCI from 2009 to 2017 were identified from our institution's National Cardiovascular Disease Registry CathPCI Database. Patients were stratified by CKD stage 1 (estimated glomerular filtration rate [eGFR] ≥90 ml/min/1.73 m2), 2 (60 to 89), 3a (45 to 59), 3b (30 to 44), 4 (16 to 29), 5 (≤15), and current dialysis. The primary end point was composite HF events defined as acute HF or CS within 30 days after PCI, or in-hospital mortality, stratified by CKD and analyzed by multivariable regression after screening with univariate analysis (p <0.05 entry criteria). Patients with CKD stage 3a or worse had more composite HF events, with an increase in all components, compared with patients with CKD stages 1 to 2 (p <0.0001 for all comparisons). After multivariable adjustment, CKD stages 3a to 5 remained independent predictors of composite HF or in-hospital mortality events. eGFR remained a strong predictor of acute HF events after multivariable adjustment, with a model including eGFR and baseline and procedural characteristics achieving excellent discriminatory ability with area under the curve 0.92. In conclusion, baseline eGFR is a strong, independent predictor of acute HF events after PCI. CKD stages 3a to 5 independently predict HF events including HF decompensation and CS and are predictors of in-hospital mortality after PCI. Patients with baseline CKD may benefit from targeted interventions to limit acute HF events after PCI.

7531 Spontaneous Coronary Artery Dissection Induced Diabetic Ketoacidosis In A Young Female: A Rare Complication Of Ketosis In A Priorly Non-Insulin Dependent Diabetic

Abstract Disclosure: F. farhat: None. P. Gonzalez: None. A.B. Ravin: None. H. Akhlaq: None. M. hossain: None. K. chalasani: None. S.W. Holland: None. R. Ong: None. J. Cheng: None. Introduction: Spontaneous Coronary Artery Dissection (SCAD) is a poorly understood and underdiagnosed condition that puts healthy young women at risk of Myocardial infarction (MI) and potential death. It occurs when a tear develops in a coronary artery. SCAD can have an atypical presentation especially in diabetic and young females; Diabetic ketoacidosis (DKA) is an uncommon, yet potentially fatal complication and can be the primary presentation in SCAD. We present a case of SCAD complicated by DKA in a non insulin dependent diabetic (NIDD).Case presentation: A 19 year old female with a past medical history of NIDDM presented to the Emergency Department with chest pain. She had troponemia and ECG revealed ST elevations. Patient was found in DKA initially. Insulin drip was started with DKA resolution in 24 hours. Hemoglobin A1c was 12.4% with negative antibody workup. Her course was complicated by SCAD found upon cardiac catheterization with unsuccessful recanalization; she was not a surgical candidate given late presentation and therefore, an intra aortic balloon pump was placed. Subsequently, she developed pericarditis and left ventricular thrombus. Discussion: SCAD is a rare condition, often presenting with acute MI and cardiogenic shock. MI may be complicated with DKA. One proposed mechanism for that is the activation of ketogenic pathways caused by excess catecholamines and cortisol; this increases physiologic stress on the body resulting in increased ketogenesis, lipolysis and free radicals causing further myocardial injury. DKA precipitated by MI increases the mortality rate to nearly 85% since the myocardium is denied glucose uptake. Signs and symptoms of SCAD are similar to MI symptoms including: chest tightness, shortness of breath and sweating. MI and SCAD can be differentiated by cardiac catheterization or by specialized contrasted CT scans. 20% of SCAD patients will experience a second episode within 5 years. Avoiding emotional stress, exercising regularly, following a healthy diet and controlling chronic conditions can help lower the risk for SCAD. Medical management is often preferred. Invasive treatments like coronary stenting or cardiac bypass may be needed if there is a complete blockage in the vessel, clinical instability or ongoing chest pain. Conclusion: SCAD is an important cause of MI in young females and can present initially as DKA in diabetics. For clinicians facing such rare cases, it is worth maintaining a broad approach to the diagnosis and treatment of these patients. The causes of SCAD remain fully unclear and genetic relations are still under investigation. Since DM type I and SCAD occur in young people, it is extremely important for clinicians to consider SCAD in the differential while managing DKA. Presentation: 6/3/2024

Prognostic Survey of ECPELLA in Japanese Patients With Acute Myocardial Infarction and Cardiogenic Shock - Findings From the Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD).

The short-term mortality associated with veno-arterial extracorporeal membrane oxygenation combined with the Impella device (termed ECPELLA) for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains unclear. The Japanese Registry for Percutaneous Ventricular Assist Devices (J-PVAD) includes data on all patients treated with an Impella in Japan. We extracted data for 922 AMI-CS patients who underwent ECPELLA support and conducted an exploratory analysis focusing on 30-day mortality. The median age of patients was 69 years, and 83.8% were male. The overall 30-day mortality was 46.1%. Factors associated with mortality included age >80 years, in-hospital cardiac arrest, systolic blood pressure <90 mmHg, serum creatinine >1.5 mg/dL, and serum lactate >4.0 mmol/L. In patients aged >80 years with any of these factors, mortality was significantly higher than in those without, ranging from 57.5% to 64.9%. The J-PVAD score assigns 1 point per predictor, with a C-statistic of 0.620 (95% confidence interval 0.586-0.654). The 30-day mortality was 20.0% for a J-PVAD score of 0, increasing to 70.0% for a score of 5. The J-PVAD data indicate high short-term mortality in AMI-CS patients treated with ECPELLA, particularly among older patients. Further studies are needed to validate this risk stratification in this patient subset.

TCT-278 Clinical Outcomes of Patients Who Experienced Loss of Pulse Pressure During Treatment With Impella for Acute Myocardial Infarction and Cardiogenic Shock

TCT-278 Clinical Outcomes of Patients Who Experienced Loss of Pulse Pressure During Treatment With Impella for Acute Myocardial Infarction and Cardiogenic Shock