Acute Mechanical Circulatory Support Devices Research Articles

Clinical Presentation and In-Hospital Trajectory of Heart Failure and Cardiogenic Shock

BackgroundHeart failure–related cardiogenic shock (HF-CS) remains an understudied distinct clinical entity. ObjectivesThe authors sought to profile a large cohort of patients with HF-CS focused on practical application of the SCAI (Society for Cardiovascular Angiography and Interventions) staging system to define baseline and maximal shock severity, in-hospital management with acute mechanical circulatory support (AMCS), and clinical outcomes. MethodsThe Cardiogenic Shock Working Group registry includes patients with CS, regardless of etiology, from 17 clinical sites enrolled between 2016 and 2020. Patients with HF-CS (non–acute myocardial infarction) were analyzed and classified based on clinical presentation, outcomes at discharge, and shock severity defined by SCAI stages. ResultsA total of 1,767 patients with HF-CS were included, of whom 349 (19.8%) had de novo HF-CS (DNHF-CS). Patients were more likely to present in SCAI stage C or D and achieve maximum SCAI stage D. Patients with DNHF-CS were more likely to experience in-hospital death and in- and out-of-hospital cardiac arrest, and they escalated more rapidly to a maximum achieved SCAI stage, compared to patients with acute-on-chronic HF-CS. In-hospital cardiac arrest was associated with greater in-hospital death regardless of clinical presentation (de novo: 63% vs 21%; acute-on-chronic HF-CS: 65% vs 17%; both P < 0.001). Forty-five percent of HF-CS patients were exposed to at least 1 AMCS device throughout hospitalization. ConclusionsIn a large contemporary HF-CS cohort, we identified a greater incidence of in-hospital death and cardiac arrest as well as a more rapid escalation to maximum SCAI stage severity among DNHF-CS. AMCS use in HF-CS was common, with significant heterogeneity among device types. (Cardiogenic Shock Working Group Registry [CSWG]; NCT04682483)

Remote monitoring in the use of extracorporeal membrane oxygenation and acute mechanical circulatory support.

To provide an overview of the role of remote monitoring tools in management of critically-ill patients requiring acute mechanical circulatory support (MCS). Tele-critical care systems have received new interest during the COVID-19 pandemic, which has stretched the capacity of health systems everywhere. At the same time, utilization of MCS and extracorporeal membrane oxygenation (ECMO) technologies has increased during the pandemic. The opportunity for remote monitoring and clinical decision support for ECMO and acute MCS devices has been recognized by industry partners, with several major platforms implementing technology infrastructure for it in available products. Healthcare systems face challenges interfacing multiple devices from multiple manufacturers with each other and with their designated electronic health records. Furthermore, the availability of data must be combined with algorithms for alerting on clinical events and with implementation systems to act upon these alerts. Studies are not yet published validating remote monitoring platforms for ECMO and MCS in clinical care. Remote monitoring for MCS devices represents a major opportunity for further investigation to improve the utilization of these devices and better serve patients.

Single Acute Mechanical Circulatory Support Device Use is Associated with Reduced Mortality Compared to Multi-Agent Drug Therapy Alone for Cardiogenic Shock: An Analysis of the Cardiogenic Shock Working Group Registry

<h3>Purpose</h3> Real world evidence evaluating outcomes in cardiogenic shock complicating heart failure or ST-segment elevation myocardial infarction (HF-CS and STEMI-CS) in the contemporary era of acute mechanical circulatory support (AMCS) remains a major unmet need. We studied the utility of the recently proposed Society for Cardiovascular Angiography and Interventions (SCAI) stages in HF- and STEMI-CS. <h3>Methods</h3> The Cardiogenic Shock Working Group registry includes CS patients from 15 US hospitals enrolled between 2016-2021. Patients were classified by the maximum SCAI stage (B-E) reached during hospitalization based on drug (vasopressors or inotropes) and device use. In-hospital mortality was evaluated for association with SCAI stages. <h3>Results</h3> Of the 3171 patients with CS, 1680 (53%) and 739 (23%) were due to HF or STEMI. In-hospital mortality was 24% vs 42% (p<0.01) for HF or STEMI CS respectively. In-hospital mortality was associated with increasing SCAI stage among patients with HF-CS (Odds Ratio [95% CI], 3.129 [2.59-3.78], p<0.001) or STEMI-CS (Odds Ratio [95% CI], 2.158 [1.78-2.62], p<0.001; Fig A-D). Compared to patients receiving ≥3 drugs and no AMCS device, in-hospital mortality was lower among HF-CS patients receiving 1 AMCS device with ≤2 drugs (Fig E) and lower among STEMI-CS patients receiving 1 AMCS device irrespective of concomitant drug use (Fig F). <h3>Conclusion</h3> Using one of the largest, contemporary, multi-center, real-world practice registries of CS, our findings support a direct association between SCAI stages and in-hospital mortality in HF-CS and STEMI-CS and further identify that compared to multi-agent drug therapy alone, single AMCS device use may be associated with lower mortality. These findings support the need for randomized clinical trials in HF- and STEMI-CS.

Clinical Outcomes and Factors Affecting in-Hospital Mortality among Coronary Artery Bypass Graft Patients with Intra-aortic Balloon Pump – Implications for Nursing Care

Aim: Intra-aortic balloon pump (IABP) is the most widely used acute mechanical circulatory support device in patients undergoing coronary artery bypass graft (CABG). The objectives of the study were to assess the clinical outcomes, risk factors, and variables predictive of in-hospital mortality in these patients. Materials and Methods: Retrospective analysis of the medical records of all the 96 patients who underwent isolated on-pump CABG with IABP inserted during the period from January 2016 to January 2020 in a selected tertiary care center. The risk factors and variables predictive of in-hospital mortality were analyzed. Results: The mean age of participants was 64 ± 7.9 years. In-hospital mortality occurred in 28.2% of study subjects. Those who were hypertensive (P = 0.012, OR = 5.85, 95%CI – 1.27–26.93), pre-operative renal insufficiency (P = 0.02, OR=2.83, 95% CI – 1.12–7.12), developed new-onset atrial and or ventricular arrhythmia(P &lt; 0.001, OR = 31.87, 95%CI - 4.09–248.28), post-operative renal insufficiency(P &lt; 0.001, OR = 6.72, 95% CI – 2.51–18.02), and thromboembolic events (P = 0.006, OR = 6.28, 95% CI – 2.51–18.02) had a higher odds of in-hospital mortality which was statistically significant. The variables predictive of in-hospital mortality were hypertension (Adjusted OR – 7.12, 95% CI – 1.25–40.38), occurrence of new-onset arrhythmia (Adjusted OR – 22.08, 95% CI 2.54–190.48), post-operative renal insufficiency (Adjusted OR – 7.38, 95% CI – 2.17–25.09), and thromboembolic events (Adjusted OR – 2.08, 95% CI – 0.33–12.83). Conclusion: Patients requiring IABP support belong to a high-risk group with significant risk of early post-operative mortality. Assessment and understanding of patient and clinical factors affecting outcomes should be one of the core nursing responsibilities in caring these patients.

Out-of-hospital cardiac arrest due to refractory pulseless ventricular tachycardia and/or ventricular fibrillation

Abstract Background Survival rates for out-of-hospital cardiac arrest (OOHCA) are extremely low and neurologic recovery is poor. Extracorporeal cardiopulmonary resuscitation (ECPR), which combines extracorporeal membrane oxygenation (ECMO) with cardiopulmonary resuscitation (CPR), has emerged as a viable strategy to improve outcomes in OOHCA. A collaborative ECPR program for out-of-hospital refractory pulseless ventricular tachycardia (VT) and/or ventricular fibrillation (VF) has been developed between The Ohio State University Wexner Medical Center and Columbus Division of Fire Emergency Medical Services (EMS). Purpose Outcomes for patients who present as an ECPR alert from the field, but did not meet predefined criteria for placement of extracorporeal membrane oxygenation (ECMO) in the cardiac catheterization laboratory (CCL) is described. Methods Between September 15, 2017 and October 12, 2019, 50 subjects presented as an ECPR alert for OOHCA secondary to pulseless VT/VF refractory to defibrillation. All subjects were placed on an automated CPR device prior to transfer to the CCL. From these 50 individuals, 28 (56%) did not meet prespecified laboratory criteria (lactate ≤15 mg/dL, partial pressure of oxygen (PaO2) ≥50 mm Hg, end-tidal carbon dioxide (ETCO2) of ≥10) and did not have a shockable rhythm in the CCL, thus ECMO was not placed and usual care for cardiac arrest was administered. Results Nine (32%) of the 28 patients achieved return of spontaneous circulation (ROSC), while the remaining 19 (68%) where pronounced deceased in the CCL. All 9 patients who achieved ROSC underwent a coronary angiography with 4 (44%) requiring percutaneous coronary intervention and 4 (44%) requiring an acute mechanical circulatory support device (Impella with 1 change out to ECMO). Of the patients that achieved ROSC, 4 (44%) were discharged from the hospital with good neurologic recovery; the remaining 5 (56%) ultimately expired during the hospitalization. From the initial 28 patient cohort, there were 4 (14%) patients discharged alive. Patients who achieved ROSC as compared to no ROSC were found on presentation in the CCL to have a significantly lower lactate (12.3±4.3 vs 16.2±3.6, respectively; p=0.03) and greater PaO2 (145±125 vs 47±9, respectively; p=0.01); there was no significant differences between groups in ETCO2, age or emergency services dispatch to CCL arrival time. Conclusion This study demonstrates that an ECPR program for OOHCA due to refractory VT/VF may provide benefit to patients that do not meet the predefined criteria for ECMO. This may be due to minimizing no flow/low flow time by early recognition and ongoing CPR en route to the CCL by a skilled EMS team, high efficiency citywide expedited transport/triage, the provision of high quality uninterrupted chest compressions using the mechanical CPR device during transport, and the care provided by highly trained multidisciplinary team members in the CCL. Funding Acknowledgement Type of funding sources: None.

Clinical Outcomes Associated With Acute Mechanical Circulatory Support Utilization in Heart Failure Related Cardiogenic Shock.

Cardiogenic shock occurring in the setting of advanced heart failure (HF-CS) is increasingly common. However, recent studies have focused almost exclusively on acute myocardial infarction-related CS. We sought to define clinical, hemodynamic, metabolic, and treatment parameters associated with clinical outcomes among patients with HF-CS, using data from the Cardiogenic Shock Working Group registry. Patients with HF-CS were identified from the multicenter Cardiogenic Shock Working Group registry and divided into 3 outcome categories assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable ventricular assist device or orthotopic heart transplant), or native heart survival. Clinical characteristics, hemodynamic, laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention stages were compared across the 3 outcome cohorts. Of the 712 patients with HF-CS identified, 180 (25.3%) died during their index admission, 277 (38.9%) underwent HRT (durable ventricular assist device or orthotopic heart transplant), and 255 (35.8%) experienced native heart survival without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups (P<0.01 for all). Biventricular and isolated left ventricular congestion were common among patients who died or underwent HRT, respectively. Lactate, blood urea nitrogen, serum creatinine, and aspartate aminotransferase were highest in patients with HF-CS experiencing in-hospital death. Intraaortic balloon pump was the most commonly used AMCS device in the overall cohort and among patients receiving HRT. Patients receiving >1 AMCS device had the highest in-hospital mortality rate irrespective of the number of vasoactive drugs used. Mortality increased with deteriorating Society of Cardiovascular Angiography and Intervention stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, 1-way ANOVA=<0.001). Patients with HF-CS experiencing in-hospital mortality had a high prevalence of biventricular congestion and markers of end-organ hypoperfusion. Substantial heterogeneity exists with use of AMCS in HF-CS with intraaortic balloon pump being the most common device used and high rates of in-hospital mortality after exposure to >1 AMCS device.

Clinical Outcomes Associated with Acute Mechanical Circulatory Support Utilization in Heart Failure Related Cardiogenic Shock

<h3>Purpose</h3> We sought to define clinical, hemodynamic, metabolic, and both drug and device treatment parameters associated with clinical outcomes among heart failure patients presenting with cardiogenic shock (HF-CS) patients using data from the Cardiogenic Shock Working Group (CSWG) Registry. HF-CS is increasingly common however most studies have focused exclusively on acute myocardial infarction related CS. <h3>Methods</h3> HF-CS patients were selected from the multi-center CSWG registry were divided into 3 outcome cohorts assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable VAD or heart transplant), or native heart survival (NHS: without heart replacement therapy). Clinical characteristics, hemodynamic and laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention (SCAI) stages were compared across the 3 outcome cohorts. <h3>Results</h3> Of the 712 HF-CS patients identified, 180 (25.3%) died during their hospitalization, 277 (38.9%) underwent HRT, and 255 (35.8%) experienced NHS without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups (<i>p</i><0.01 for all). BiV congestion was most common among patients who died, while isolated left-ventricular congestion was most common among patients who underwent HRT. Lactate, BUN, serum creatinine, and AST were highest in HF-CS patients experiencing in-hospital death. In-hospital mortality increased with deteriorating SCAI stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, p <0.001), and with the use of AMCS devices (IABP: 23%, Impella: 45.3%, or ECMO: 54.7%, p<0.001). <h3>Conclusion</h3> In patients with HF-CS biventricular profile, surrogates of end-organ dysfunction, increased SCAI staging and the use of AMCS devices were all associated with a higher probability of in-hospital mortality.

Right Atrial Pressure Is Associated With Outcomes in Patient With Cardiogenic Shock Receiving Acute Mechanical Circulatory Support.

Background: We describe the association between longitudinal hemodynamic changes and clinical outcomes in patients with cardiogenic shock (CS) receiving acute mechanical circulatory support devices (AMCS) at a single center. We hypothesized that improved right atrial pressure is associated with better survival in CS.Methods: Retrospective analysis of patients from Tufts Medical Center that received AMCS for CS. Baseline characteristics and invasive hemodynamics were collected, analyzed, and correlated against outcomes. Hemodynamics were recorded at different time intervals during index admission [pre-AMCS, 24 h after AMCS (post AMCS), and last available set of hemodynamics (final-AMCS)]. Logistic regression was performed to determine variables associated with in-hospital mortality.Results: A total of 76 patients had longitudinal hemodynamics available. In hospital mortality occurred in 46% of the cohort. Mean baseline right atrial pressure (RAP) was significantly higher among non-survivors vs. survivors (19.5+6.6 vs. 16.4+5.3 mmHg). Change in right atrial pressure from baseline to before device removal (ΔRA:final AMCS—pre AMCS) was significantly different between survivors and non survivors (−6.5 ± 6.9 mmHg vs. −2.5 ± 6.2 mmHg p = 0.03). Unadjusted logistic regression revealed baseline RAP (OR: 1.1 95% CI: 1.0–1.2), 24 h post device implant RAP (OR: 1.3 95% CI: 1.1–1.4), and final RAP (OR: 1.3 95% CI: 1.1–1.5) to be significant predictors of in-hospital mortality. In a multivariate logistic regression baseline RAP was no longer significantly associated with mortality in the overall cohort, while 24 h (OR: 1.26 95% CI: 1.1–1.5) and final RAP (OR: 1.3 95% CI: 1.1–1.6) remained statistically significant.Conclusion: We report a novel retrospective analysis of hemodynamic changes in patients with CS receiving AMCS. Our findings identify the potential importance of venous congestion as a prognostic marker of mortality. Furthermore, early decongestion or reduced RA pressure is associated with better survival in these critically ill CS patients. These observations suggest the need for further study in larger retrospective and prospective cohorts of patients with varying degrees of CS severity.

Clinical trials of acute mechanical circulatory support in cardiogenic shock and high-risk percutaneous coronary intervention.

Acute mechanical circulatory support devices have become widely used in cardiogenic shock and high-risk percutaneous coronary intervention (PCI) but there remains significant controversy over the evidence supporting their use and the specific roles of various devices. In this review, we summarize major recent studies and identify key areas of future investigation. In cardiogenic shock, uncontrolled single arm studies emphasizing early mechanical circulatory support (MCS) have showed promising results, but randomized trials have either been stopped prematurely or enrolled patients with advanced shock unlikely to benefit from MCS. In high-risk PCI, only one randomized controlled trail has been performed, with practice guided largely by observational data. Randomized trials of current-generation mechanical support devices incorporating contemporary best-practices and performed in clearly defined populations are badly needed to clarify the role of acute MCS devices in cardiogenic shock and high-risk PCI.

Outcomes of Patients Bridged with Acute Mechanical Circulatory Support Devices to HeartMate 3

Acute mechanical circulatory support devices (MCSD) are increasingly being used to stabilize and optimize patients for durable left ventricular assist device (LVAD) implantation. The primary objective of our study was to assess the outcomes of patients bridged with acute MCSD to HeartMate 3 (HM3). We retrospectively reviewed 165 consecutive patients implanted with a HM3 at our institution from November 2014 to July 2019. Baseline clinical characteristics, hemodynamic data, and post-operative outcomes were assessed. Patients bridged with intraaortic balloon pumps (IABP), extracorporeal membrane oxygenation (ECMO) and/or Impella percutaneous ventricular assist device (pVAD) were compared to patients that were directly implanted with HM3. Of the 165 patients, 69 (41.8%) were bridged to HM 3 LVAD with acute MCSD during the study period. The following device configurations were used: 3 patients with ECMO alone, 6 with ECMO + IABP, 2 ECMO + pVAD, 3 pVAD alone and 55 patients with IABP alone. Patients with acute MCSD were numerically younger (56.8 ±12.9 vs. 60.9 ±13.2, p =0.05) and had lower INTERMACS profile levels (1.71 ± 0.49 vs. 2.67 ± 0.64, p < 0.01). There was no difference in pre-operative cardiac index (1.88 ± 0.70 vs. 1.89 ± 0.46, p = 0.93); however, pre-device RA pressure (13.2 ± 6.5 vs. 8.3 ±5.2, p <0.01), pulmonary artery mean pressure (38.9 ±11.0 vs. 31.8 ± 8.7, p < 0.01) and pulmonary artery capillary wedge pressure (26.7 ± 9.3 vs. 20.5 ± 26.7, p < 0.01) were all higher in patients bridged with acute MCSD. There was no difference in survival at 1 year between patients bridged with acute MCSD and those who were not bridged (90.3% vs 89.5%, respectively, p=0.80, Figure 1). There was no difference in post-operative stroke or GI bleeding between the two groups. A large proportion of patients in the contemporary era are bridged with acute MCSD to HM3 and despite their increased severity of illness have outcomes comparable to patients who are not bridged with acute MCSD.

Clinical and Hemometabolic Status Impact Transitions in Acute on Chronic Heart Failure Shock: Insights from the CSWG Registry

Cardiogenic shock remains a complex global health entity associated with high mortality despite increased utilization and availability of acute mechanical circulatory support (AMCS) as a bridge to replacement, recovery and/or palliation. We sought to determine the disease trajectory of patients with chronic heart failure complicated with cardiogenic shock and the impact of surrogates related to clinical severity and impaired hemometabolic status. 712 cardiogenic shock patients with acute-on-chronic heart failure as cause of shock were identified from the CSWG Registry and were evaluated by treatment, metabolic indicators of renal and liver dysfunction and hemodynamics with respect to outcome. Treatment parameters analyzed across the duration of in-patient hospitalization included the use of more than 1 AMCS device, the use of more than 1 vasopressor/inotrope, and the use of mechanical ventilation. Metabolic indicators were measured prior to any AMCS usage and included elevated INR, serum creatinine, and total bilirubin. Elevated right atrial pressure (RAP), wedge pressure and cardiac index at baseline was used to evaluate hemodynamic status. Recovery (discharge w/o replacement), replacement (bridge to VAD or OHT) and in-hospital mortality were the primary outcomes of interest. Out of 712 HF CS patients, 255 (35.81%) recovered, 277 (38.90%) bridged to either a VAD or OHT, and 180 (25.28%) did not survive their hospitalization. The variation in hemometabolic status and clinical severity across outcomes is summarized in the figure below. Specific surrogates of worsening clinical (mechanical ventilation/increased inotropes/vasoactives), hemodynamic (increased RAP) and metabolic (increased SCr and Total Bilirubin) status in HF-CS were associated with impaired survival. Our findings support the value of studying dedicated system-based strategies for early clinical and hemometabolic situational awareness in HF-CS.

Nursing Management of Patients Requiring Acute Mechanical Circulatory Support Devices.

The growing use of acute mechanical circulatory support devices to provide hemodynamic support that has accompanied the increasing prevalence of heart failure and cardiogenic shock, despite significant improvement in the treatment of acute myocardial infarction. The critical care nurse plays a crucial role in managing patients receiving acute mechanical circulatory support devices and monitoring for potential complications. To review the anatomical placement and mechanics of each type of device so that nurses can anticipate patients' hemodynamic responses and avoid complications whenever possible, thereby improving patients' clinical outcomes. Nursing considerations regarding the intra-aortic balloon pump, the TandemHeart, the Impella, and extracorporeal membrane oxygenation.

Cardiogenic Shock in the Setting of Acute Myocardial Infarction.

Cardiogenic shock in the setting of acute myocardial infarction remains a major cause of morbidity and mortality. In fact, acute myocardial infarction accounts for 81% of patients in cardiogenic shock. Despite advances in pharmacologic and device-based approaches to support patients with cardiogenic shock, no significant improvement in mortality has been observed over the past 20 years, although multiple registries are providing new insight into this complex syndrome. Key elements for optimal treatment include integration of hemodynamic and metabolic data for diagnosis and risk stratification, early evaluation and appropriate initiation of acute mechanical circulatory support devices, and an organized algorithmic approach to decision making.

TCT-817 Changes in Right Atrial Pressure Are Associated With Outcomes in Patients With Cardiogenic Shock Receiving Acute Mechanical Circulatory Support Devices: Insights From the Cardiogenic Shock Working Group

TCT-817 Changes in Right Atrial Pressure Are Associated With Outcomes in Patients With Cardiogenic Shock Receiving Acute Mechanical Circulatory Support Devices: Insights From the Cardiogenic Shock Working Group

Deployment of acute mechanical circulatory support devices via the axillary artery

ABSTRACTIntroduction: Use of acute mechanical circulatory support (MCS) devices for high-risk cardiac intervention, cardiogenic shock, and advanced heart failure is growing. Alternate vascular access options for these devices remains a clinical challenge. Building on experience from trans-aortic valve replacement procedures, the axillary artery is becoming a common access route for acute MCS and represents an important advance in the development of acute MCS technologies.Areas covered: Authors review the clinical data and technical aspect of acute MCS deployment via the axillary artery. Axillary access is particularly useful for patients: 1) with severe peripheral vascular disease, 2) with hostile femoral access due to infection, indwelling endovascular devices, or obesity, and 3) to provide early mobility and ambulation. In this review, we discuss the deployment, technical issues and hemostasis regarding the use of intraaortic balloon pump, specifically, axillary intraaortic balloon pumps, trans-valvular left ventricular Impella pumps and arterial outflow of VA-ECMO.Expert opinion: Vascular comorbidities or device design may limit the traditional iliofemoral access route for acute mechanical circulatory support devices. Large bore access for the deployment of these devices through the axillary artery is feasible and safe when appropriate vascular access and closure techniques are used.

Inter-hospital transfer of extracorporeal membrane oxygenation-assisted patients: the hub and spoke network.

The treatment of cardiogenic shock (CS) in peripheral hospitals may be challenging when acute mechanical circulatory support (MCS) is not available. Tertiary care centers may provide mobile extracorporeal membrane oxygenation (ECMO) teams to support the treatment of CS-patients externally. We retrospectively analyzed our single-center experience with a mobile ECMO team focussing on decision-making and survival data of CS-patients retrieved by ECMO support from peripheral hospitals to our tertiary care center between January 2012 and October 2018. A total number of 134 CS-patients have been retrieved by ECMO support to our center within the observation period. Forty-three (32%) died on the acute MCS device, while 59 (44%) patients could be weaned from the acute MCS. Twenty-nine (22%) were bridged to implantation of a durable MCS system and 6 were finally transplanted. The overall 1-year survival was 33%. Interestingly, advanced patient age did not significantly affect survival. Acute MCS for CS may be provided by experienced mobile teams allowing for retrieval of patients from peripheral hospitals to tertiary care centers. Relatively low survival rates oppose intensive material and human resources. It is therefore mandatory to constantly refine logistics and selection criteria.

The Impella Microaxial Flow Catheter Is Safe and Effective for Treatment of Myocarditis Complicated by Cardiogenic Shock: An Analysis From the Global cVAD Registry

BackgroundMyocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella transvalvular microaxial flow catheters in the setting of myocarditis with cardiogenic shock. Methods and ResultsWe retrospectively analyzed data from 21 sites within the cVAD registry, an ongoing multicenter voluntary registry at sites in North America and Europe that have used Impella in patients with myocarditis. Myocarditis was defined by endomyocardial biopsy (n = 11) or by clinical history without angiographic evidence of coronary disease (n = 23). A total of 34 patients received an Impella 2.5, CP, 5.0, or RP device for cardiogenic shock complicating myocarditis. Baseline characteristics included age 42 ± 17 years, left ventricular ejection fraction (LVEF) 18% ± 10%, cardiac index 1.82 ± 0.46 L·min−1·m−2, pulmonary capillary wedge pressure 25 ± 7 mm Hg, and lactate 27 ± 31 mg/dL. Before Impella placement, 32% (n = 11) of patients required intra-aortic balloon pump. Mean duration of Impella support was 91 ± 74 hours; 21 of 34 patients (62%) survived the index hospitalization and were discharged with an improved mean LVEF of 37.32% ± 20.31% (P = .001); 15 patients recovered with successful support, 5 patients were transferred to another hospital on initial Impella support, 1 patient underwent orthotopic heart transplantation. Ten patients required transition to another mechanical circulatory support device. ConclusionsThis is the largest analysis of Impella-supported myocarditis cases to date. The use of Impella appears to be safe and effective in the settings of myocarditis complicated by cardiogenic shock.

Maximum level of mobility with axillary deployment of the Impella 5.0 is associated with improved survival.

Mobility is an important prognostic indicator for patients with cardiogenic shock. No studies have quantified peak mobility for patients with cardiogenic shock who are supported with the Impella 5.0 acute mechanical circulatory support device. The purpose of our study was to evaluate mobility levels among patients with cardiogenic shock being treated with an axillary Impella 5.0 pump. We retrospectively analyzed data from 19 patients receiving an Impella 5.0 device for cardiogenic shock at our institution from 2013 to 2016. We used the Johns Hopkins Highest Level of Mobility Scale to quantify maximum mobility level achieved during active Impella 5.0 support. Higher scores on a scale of 1-8 indicated more mobility. Activity Measure for Post Acute Care Scores were quantified for each patient to assess activity limitations, with a maximum score 24. The mean age of the total cohort was 60 ± 12 years, and the mean left ventricular ejection fraction was 16% ± 6%. In-hospital mortality was 47% (n = 9). Of the 19 Impella 5.0 implants, 10 survived, 6 died from withdrawal of care, and 3 died from worsening heart failure/cardiogenic shock. Similar rates of mobilization during the time of Impella implant were seen between groups. Compared to non-survivors, survivors achieved a higher maximum Johns Hopkins Highest Level of Mobility level, but similar Activity Measure for Post Acute Care scores. In conclusion, maximum mobility after Impella 5.0 implantation may be associated with improved survival. The clinical utility of exercise as a therapeutic intervention for patients requiring prolonged acute mechanical circulatory support requires further study.

Advancements in mechanical circulatory support for patients in acute and chronic heart failure.

Cardiogenic shock (CS) continues to have high mortality and morbidity despite advances in pharmacological, mechanical, and reperfusion approaches to treatment. When CS is refractory to medical therapy, percutaneous mechanical circulatory support (MCS) should be considered. Acute MCS devices, ranging from intra-aortic balloon pumps (IABPs) to percutaneous temporary ventricular assist devices (VAD) to extracorporeal membrane oxygenation (ECMO), can aid, restore, or maintain appropriate tissue perfusion before the development of irreversible end-organ damage. Technology has improved patient survival to recovery from CS, but in patients whom cardiac recovery does not occur, acute MCS can be effectively utilized as a bridge to long-term MCS devices and/or heart transplantation. Heart transplantation has been limited by donor heart availability, leading to a greater role of left ventricular assist device (LVAD) support. In patients with biventricular failure that are ineligible for LVAD implantation, further advancements in the total artificial heart (TAH) may allow for improved survival compared to medical therapy alone. In this review, we discuss the current state of acute and durable MCS, ongoing advances in LVADs and TAH devices, improved methods of durable MCS implantation and patient selection, and future MCS developments in this dynamic field that may allow for optimization of HF treatment.

Mechanical Circulatory Support Devices for Acute Right Ventricular Failure.

Right ventricular (RV) failure remains a major cause of global morbidity and mortality for patients with advanced heart failure, pulmonary hypertension, or acute myocardial infarction and after major cardiac surgery. Over the past 2 decades, percutaneously delivered acute mechanical circulatory support pumps specifically designed to support RV failure have been introduced into clinical practice. RV acute mechanical circulatory support now represents an important step in the management of RV failure and provides an opportunity to rapidly stabilize patients with cardiogenic shock involving the RV. As experience with RV devices grows, their role as mechanical therapies for RV failure will depend less on the technical ability to place the device and more on improved algorithms for identifying RV failure, patient monitoring, and weaning protocols for both isolated RV failure and biventricular failure. In this review, we discuss the pathophysiology of acute RV failure and both the mechanism of action and clinical data exploring the utility of existing RV acute mechanical circulatory support devices.