Acute Mechanical Circulatory Support Research Articles

(264) - Sublingual Microcirculation in Acute Mechanical Circulatory Support in Cardiogenic Shock

(264) - Sublingual Microcirculation in Acute Mechanical Circulatory Support in Cardiogenic Shock

(40) - Acute Limb Ischemia is an Important Target of Therapy to Decrease In-Hospital Mortality and is Associated with Endovascular Acute Mechanical Circulatory Support in Cardiogenic Shock

(40) - Acute Limb Ischemia is an Important Target of Therapy to Decrease In-Hospital Mortality and is Associated with Endovascular Acute Mechanical Circulatory Support in Cardiogenic Shock

Application of Cardiovascular Physiology to the Critically Ill Patient.

To use the ventricular pressure-volume relationship and time-varying elastance model to provide a foundation for understanding cardiovascular physiology and pathophysiology, interpreting advanced hemodynamic monitoring, and for illustrating the physiologic basis and hemodynamic effects of therapeutic interventions. We will build on this foundation by using a cardiovascular simulator to illustrate the application of these principles in the care of patients with severe sepsis, cardiogenic shock, and acute mechanical circulatory support. Publications relevant to the discussion of the time-varying elastance model, cardiogenic shock, and sepsis were retrieved from MEDLINE. Supporting evidence was also retrieved from MEDLINE when indicated. Data from relevant publications were reviewed and applied as indicated. The ventricular pressure-volume relationship and time-varying elastance model provide a foundation for understanding cardiovascular physiology and pathophysiology. We have built on this foundation by using a cardiovascular simulator to illustrate the application of these important principles and have demonstrated how complex pathophysiologic abnormalities alter clinical parameters used by the clinician at the bedside.

Early Clinical Outcomes of Patients With Stress-Induced Cardiomyopathy Receiving Acute Mechanical Support in the US

BackgroundThe role of acute mechanical circulatory support (aMCS) in patients with stress-induced cardiomyopathy (SIC) complicated by cardiogenic shock (CS) is not well studied. Here, we describe the incidence and outcomes of aMCS use in SIC-CS using a large national database. MethodsUsing the Nationwide Readmissions Database from January 2016 to November 2019, we identified patients hospitalized with SIC who received isolated intra-aortic balloon pump (IABP), microaxial flow pump (Impella, Abiomed), or extracorporeal membrane oxygenation (ECMO) during the index hospitalization. ResultsA total of 902 among 94,709 hospitalizations for SIC (1.0%) required aMCS during the index hospitalization: 611 had IABP (67.7%), 189 had Impella (21.0%) and 102 had ECMO (11.3%). Patients with ECMO or Impella had higher in-hospital mortality rates than those with IABP (37.3% vs 29.1% vs 18.5%, respectively). There was an increased adjusted risk of in-hospital death with Impella (adjusted odds ratio [aOR], 1.98; 95% CI, 1.12-3.49) and ECMO (aOR, 4.15; 95% CI, 1.85-9.32) vs IABP. Impella was associated with an increased adjusted risk of 30-day readmission compared to IABP (aOR, 2.53; 95% CI, 1.16-5.51). Patients with ECMO or Impella had a higher incidence of renal replacement therapy and vascular/bleeding complications compared to those who received IABP. ConclusionsIn this nationwide analysis using an administrative database, patients who received ECMO and Impella showed higher rates of in-hospital mortality, renal replacement therapy, and vascular/bleeding complications compared to those who received IABP. Patients with more comorbidities may receive more aggressive hemodynamic support which may account for observed mortality differences. Future prospective studies with objective and universal characterization of baseline clinical and hemodynamic characteristics of patients with CS secondary to SIC are needed.

Acute mechanical circulatory support for cardiogenic shock in India.

Cardiogenic shock continues to have high morbidity and mortality, despite advances in the field. Temporary mechanical circulatory support (TMCS) devices, if instituted in a timely fashion, can help stabilize critically ill patients with cardiogenic shock from various aetiologies and cardiac arrest, and provide time for organ recovery or till durable support or transplantation can be achieved. Currently, several options for TMCS devices exist. In this review, we discuss indications, contraindications, characteristics of the various available devices, and important issues pertaining to their management.

Mechanical circulatory support for adults in Japan: A 10-year perspective.

Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid-term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2-year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long-term LVAD support have become important. Five important topics including hemocompatibility-related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia-Pacific region and beyond.

Management of Cardiogenic Shock: Present and Future.

The prevalence of cardiogenic shock (CS) is high and involves approximately 1 in every 6 patients admitted to the cardiac intensive care unit. Despite the introduction of acute mechanical circulatory support (AMCS) and the institution of “shock teams,” in-hospital mortality for patients with CS remains between 30% and 40%.1 A striking paradox in the management of this critically ill population is that restoration of a more normal hemodynamic profile by means of mechanical circulatory support (MCS) has not been demonstrated to improve outcomes. This observation suggests that CS is a complex, systemic condition with poorly understood pathobiology that involves multiple interacting organ systems.Previous efforts to identify therapeutic interventions for CS have been limited in retrospective studies and clinical registries. The enrollment of patients with CS in prospective randomized clinical trials has been challenging because of the acuity of the presentation and the difficulty of obtaining informed consent in a timely manner. Another limitation is that the population enrolled in the clinical trials is not representative of the general CS population. Specifically, most of the clinical trials have enrolled patients with CS secondary to acute myocardial infarction (AMICS). Although AMI has been the prevalent etiology among patients with CS, recent studies have shown that the pathophysiology and outcomes of AMI-CS differ from those of CS caused by chronic heart failure exacerbation.2Current management options for CS fall into 4 categories: (1) coronary revascularization, (2) treatment with inotropes and vasopressors, (3) AMCS, and (4) institution of multidisciplinary shock teams. Among these interventions, early coronary revascularization and the institution of shock teams for the management of CS are the only interventions that have been shown to improve outcomes.3–6 In the seminal SHOCK trial, Hochman et al5 demonstrated that early coronary revascularization for AMI shock led to improved 6-month survival compared with that with medical therapy. Approximately 2 decades later, a study by Thiele et al3 showed that in patients with multivessel coronary artery disease presenting with AMI shock, culprit lesion revascularization decreased the 30-day risk of death and kidney failure compared with multivessel revascularization. Following the development of revascularization strategies and the establishment of circulatory support devices, the need for standardized management of CS in this population increased, leading to the idea of a multidisciplinary team of heart failure cardiologists, interventional cardiologists, cardiothoracic surgeons, and cardiac intensivists who would streamline the process of evaluation, monitoring, and treatment of CS. Data from 2 independent observational trials showed that a team-based approach to managing CS resulted in an increased 30-day survival rate.4,6Inotropes and the vasopressors remain the cornerstone of the medical therapy for CS, especially in its early stages. In the DOREMI trial, no significant difference was found between dobutamine and milrinone in the composite primary outcome, which included in-hospital death from any cause, resuscitated cardiac arrest, receipt of a heart transplant or MCS, nonfatal MI, transient ischemic attack, stroke diagnosed by a neurologist, or initiation of kidney replacement.7 In another multi-center trial, patients presenting with CS who were randomized to receive intravenous dopamine experienced a higher incidence of arrhythmias than did patients who received norepinephrine.8 Interestingly, the subgroup of patients who presented with shock of cardiac etiology and were treated with norepinephrine had lower rates of death than those treated with dopamine.8 Along the same lines, patients with CS treated with norepinephrine had better hemodynamic and metabolic profiles than did those treated with epinephrine, suggesting that norepinephrine is the vasopressor of choice in patients with CS.9Although inotropes and vasopressors remain important early therapeutic options, prolonged or escalating doses could result in adverse hemodynamic and metabolic effects. The adverse effects of inotropic support have led to a dramatic increase in the use of percutaneous circulatory support devices, which offer acute cardiac unloading and improve end-organ perfusion without the deleterious hemometabolic effects of prolonged inotropic support. Thus, AMCS can be used as bridge to decision, bridge to recovery, or bridge to more durable treatment (durable left ventricular assist device or transplantation). Despite this theoretical benefit of AMCS, randomized clinical trials have failed to demonstrate a survival benefit that would support their routine use in patient with CS. For example, use of an intra-aortic balloon pump (IABP) in patients with AMI-CS did not reduce the 30-day mortality in the IABP-SHOCK II trial.10 Similarly, randomized trials comparing transvalvular or transeptal circulatory support devices with an IABP failed to demonstrate a survival benefit.11The lack of randomized clinical data on AMCS led the American Heart Association to release a scientific statement providing a framework for implantation, escalation, and deescalation of percutaneous support devices.12 Implantation and management of AMCS should be carried out by a multidisciplinary team, and decisions on AMCS use should be guided by invasive hemodynamic data (Table I).12Patients with CS are a heterogenous and understudied population. They represent a closely monitored cohort that could serve as a unique research platform for clinical, hemodynamic, and echocardiographic data collection. Ongoing randomized clinical trials are trying to establish appropriate use criteria for AMCS support.13 At The Texas Heart Institute, we are moving a step further by initiating a prospective study of the phenotypic characterization of the CS population supported by AMCS (Fig. 1). We will prospectively and serially collect echocardiographic, hemodynamic, genetic, and proteomic data to identify clinical and molecular predictors of CS recovery. This project has the potential to change medical practice by introducing novel biomarkers of CS recovery and identifying potential adjuvant therapeutic targets for the improvement of CS outcomes.

(949) Fetal Viability via Maternal Acute Mechanical Circulatory Support as a Bridge to Durable Lvad

(949) Fetal Viability via Maternal Acute Mechanical Circulatory Support as a Bridge to Durable Lvad

Incidence, management, and prognosis of post-ischaemic ventricular septal defect: Insights from a 12-year tertiary centre experience.

Among mechanical complications of acute myocardial infarction, ventricular septal defect (VSD) is uncommon but still serious. The evolution of emergency coronary revascularisation paradoxically decreased our knowledge of this disease, making it even rarer. To describe ischaemic VSD incidence, management, and associated in-hospital and 1-year outcomes over a 12-years period. A retrospective single-centre register of patients managed for ischaemic VSD between January 2009 and December 2020. Ninety-seven patients were included representing 8 patients/ years and an incidence of 0.44% of ACS managed. The majority of the patients were 73-years-old males (n = 54, 56%) with STEMI presentation (n = 75, 79%) and already presented with Q necrosis on ECG (n = 70, 74%). Forty-nine (51%) patients underwent PCI, 60 (62%) inotrope/vasopressors infusion, and 70 (72%) acute mechanical circulatory support (IABP 62%, ECMO 13%, and Impella® 3%). VSD surgical repair was performed for 44 patients (45%) and 1 patient was transplanted. In-hospital mortality was 71%, and 86% at 1 year, without significant improvement over the decade. Surgery appears to be a protective factor [0.51 (0.28-0.94) p = 0.003], whereas age [1.06 (1.03-1.09), p < 0.001] and lactate [1.16 (1.09-1.23), p < 0.001] were linked to higher 1-year mortality. None of the patients that were managed medically survived 1 year. Post-ischaemic VSD is a rare but serious complication still associated with high mortality. Corrective surgery is associated with better survival, however, timing, patient selection, and a place for mechanical circulatory support need to be defined.

Abstract 12221: Work Improvement With Novel Remote Monitoring System (Impella Connect) in Clinical Engineer Involving Acute Mechanical Circulatory Support

Introduction: Recent innovations in mechanical circulatory support (MCS) enable physicians to deal with challenging cases with cardiogenic shock. As the number of MCS has increased, the excessive workload of clinical engineers (CEs) who manage MCS has become a serious problem. To overcome such situation, we introduced innovative remote monitoring system of circulatory assist pump catheters (Impella) called Impella Connect (IC) from 2020, which allows medical staff to monitor driving status and alarms of Impella in their mobile devices. Here we reported our experience of IC and the safety and efficacy of our protocol using IC for management of Impella. Methods: We identified 63 Impella cases for cardiogenic shock from 2018 to 2021 in our institution. We utilized Impella 2.5/CP in 53 cases and Impella 5.0 in 10 cases depending on their hemodynamic condition. Before introducing IC (nIC period: n=17), CEs were responsible for Impella management in all time periods and needed to work overtime to manage devices in night time. However, after introducing IC (IC periods: n=46), CEs were responsible only in daytime and non-MCS expert medical stuff were responsible in night time supporting by CEs’ remote monitoring with IC. We retrospectively evaluated the safety and efficacy of our management using IC. Results: Impella insertion was performed emergently in all cases and the 34 cases (53.9 %) were inserted in night time. Average support time was 6.5±0.6 days (nIC 7.7 vs. 6.0 days). We encountered 13 device trouble in nIC periods (purge system in 8, pressure sensor in 4 and pump malfunction in 1) and 14 in IC periods (purge system in 9, pressure sensor in 3 and pump malfunction in 2). Device trouble requiring intervention was not significantly different in both periods (nIC/IC 10 vs. 11 cases, p=0.85) and adverse event related to delayed or inappropriate response was not observed in both periods. The average of overtime working hours of CEs per month was significantly decreasing in IC periods (53.1±16.8 vs. 8.6±2.6 hours per month, p&lt;0.05). Conclusions: Our Impella management using novel remote monitoring system with Impella Connect was safe with no adverse events and effective to reduce overtime work of CEs, which resulted in work improvement of medical stuff involving MCS.

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)

Intensive Care Management of the Cardiogenic Shock Patient

Optimal management of patients with cardiogenic shock requires a detailed and systematic assessment of all organ systems, balancing the risks and benefits of any investigation and intervention, while avoiding the complications of critical illness. Overall prognosis depends upon a number of factors, including that of the underlying cardiac disease and its potential reversibility, the severity of shock, the involvement of other organ systems, the age of the patient and comorbidities. As with all intensive care patients, the mainstay of management is supportive, up to and including implementation and management of a number of devices, including acute mechanical circulatory support. The assessment and management of these most critically ill patients therefore demands in-depth knowledge and skill relating to cardiac intensive care, extending well beyond standard intensive care or cardiology practice.

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.

Circulating Proteomic Analysis Identifies Reduced Inflammation After Initiation of Hemodynamic Support with Either Veno-Arterial Extracorporal Membrane Oxygenation or Impella in Patients with Cardiogenic Shock

<h3>Purpose</h3> Use of acute mechanical circulatory support (AMCS) for cardiogenic shock (CS) is growing. We sought to determine whether plasma protein profiles are differentially regulated after initiation of veno-arterial extracorporeal membrane oxygenation (ECMO) or Impella in patients with CS. <h3>Methods</h3> Plasma samples were collected before device implantation and 72 hours after initiation of support in 11 CS patients receiving ECMO (n=5) or Impella (n=6). The aptamer-based SOMAscan assay was used to detect 1305 circulating proteins. Ingenuity Pathway Analysis identified cellular pathways and network interactions defined by proteins with a fold change >1.3 or <0.7 and p<0.05 after AMCS initiation. <h3>Results</h3> 67/1305 proteins were changed after ECMO (18 upregulated and 49 downregulated, p<0.05) and 38/1305 after Impella (10 upregulated and 28 downregulated, p<0.05). Only 8 proteins were commonly affected by ECMO and Impella. Despite minimal overlap in individual proteins, both devices were associated with markers of reduced inflammation including regulatory cytokines and increased apoptosis of leukocytes, phagocytes, and antigen-presenting cells (Figures A-B). <h3>Conclusion</h3> Using unbiased proteomic screening we identified that ECMO and Impella are associated with reduced expression of inflammatory markers and increased markers of inflammatory cell death. These circulating proteins may serve as novel targets of therapy or novel biomarkers to tailor AMCS device use and improve patient outcomes.

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.

Transcriptomic Analysis of Right Ventricular Adaptation and Failure in a Novel Ovine Model of Pulmonary Hypertension

<h3>Purpose</h3> Right ventricular failure (RVF) is a large contributor to morbidity and mortality in pulmonary hypertension (PH). Molecular understanding of RVF may facilitate identification of novel drug and device therapy targets. Using our previously published large animal model of PH-RVF, we performed RNA-seq analysis of RV tissues sampled from healthy sheep, PH sheep, and PH sheep that received mechanical circulatory support (MCS). <h3>Methods</h3> We assessed RV gene expression in adult sheep prior to and after completion of a previously described PH model. Three PH sheep subsequently underwent acute MCS for 3-6 hours. Right ventricular (RV) free wall tissues were collected prior to PA banding and at termination of MCS (pre-PH vs post-PH, N=3 each). One subject experienced severe maladaptive RVF and expired prior to MCS. This maladaptive characterization was based on its mixed venous saturation below 30% and several liters of ascites and pleural effusion found at necropsy. The pre-PH and post-PH RV tissue samples were analyzed for gene expression profile with RNAseq and studied with over-representation analysis to elucidate enriched pathways. <h3>Results</h3> RNAseq identified 358 genes with differential expression between pre-PH and post-PH tissue samples (p < 0.01, >2-fold change). Enrichment analysis showed that these genes were related to cardiomyocyte muscularization and proliferation, indicating adaptation to RV loading. The maladaptive RV sample, even when compared to the other PH sheep that received MCS, demonstrated markedly reduced expression of metabolic genes, especially in fatty acid oxidation. <h3>Conclusion</h3> RV load stress coincides with differential expression of genes related to cardiomyocyte muscularization and proliferation. Observations of reduced expression of fatty acid oxidation genes in a maladaptive subject with RVF warrants further investigation. The role of mechanical support on RV gene expression needs to be further studied in longer-term settings.

Antithrombotic management for Impella® temporary ventricular assist devices: An analysis of an academic health-system experience.

The use of acute mechanical circulatory support (MCS) has increased over the last decade. For patients with left-ventricular failure, an Impella® (Abiomed, Danvers, MA) may be used to improve cardiac output. The purpose of this study is to describe Impella® anticoagulation patterns and evaluate the safety and effectiveness of our protocol. This is a retrospective review of all adult patients who required at least 24 h of Impella® support and received a heparin-based purge solution. In total, 109 patients were included in the final analysis. The most common indication for Impella® device insertion was cardiogenic shock (76%) with the remaining patients receiving a device for a high-risk procedures; typically coronary artery bypass grafting or percutaneous coronary intervention. A total of 9 thrombotic events occurred among 8 (7%) patients and 50 bleeding events occurred among 43 (39%) patients, with the most common classification being BARC 3a (60%). A univariate analysis revealed that patients were more likely to bleed if they were less than 65 years old, had an indication of cardiogenic shock for Impella®, inserted the device peripherally, were on dual antiplatelet therapy, or had an intra-aortic balloon pump prior to Impella® insertion, the latter of which was confirmed with a multivariate analysis (OR 2.5 [1.072-5.830]; p = 0.034). For those monitored by anti-Xa, the presence of two or more values greater than 0.40 IU/mL was a risk factor for bleeding (p = 0.037). Our study identifies risk factors for bleeding in patients receiving temporary MCS with an Impella®.

Continuation Versus Interruption of Renin-Angiotensin System Inhibitors in Acute Decompensated Heart Failure: A Brief Report.

This article is temporarily under embargo.

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.

Outcomes From Long-Distance Interfacility Transport of Adult Patients on Acute Mechanical Circulatory Support

Cardiac and respiratory failure in adults has historically had very high mortality. Mechanical circulatory support (MCS) has shown promise to improve outcomes for these patients; however, only tertiary care centers typically have the critical care resources to manage patients on MCS. We investigated to see if we could provide safe, long-distance transport of MCS-supported patients to our tertiary center after MCS is initiated at community or regional hospitals. We also investigated if we could provide this service without using physicians or perfusionists for the en route management of MCS devices. Our outcome results, based on survival to discharge, are comparable with other published survival outcomes data for this patient population, suggesting that patients on MCS devices can be safely transported by air and ground without incurring additional mortality risk. Additionally, instead of perfusionists or physicians, specially trained nurses were used to manage all MCS devices en route. This change to the typical transport team structure has the potential to make the transport of MCS-supported patients more cost-effective for health care systems nationwide.