Acute Myocardial Infarction Cardiogenic Shock Research Articles

TCT-270 Contemporary Use of Mechanical Circulatory Support for the Treatment of Acute Myocardial Infarction Cardiogenic Shock (AMI-CS): Insights From the BMC2 Registry

TCT-270 Contemporary Use of Mechanical Circulatory Support for the Treatment of Acute Myocardial Infarction Cardiogenic Shock (AMI-CS): Insights From the BMC2 Registry

TCT-275 Clinical Outcomes in Acute Myocardial Infarction Cardiogenic Shock Patients Supported With Transvalvular Microaxial Pumps

TCT-275 Clinical Outcomes in Acute Myocardial Infarction Cardiogenic Shock Patients Supported With Transvalvular Microaxial Pumps

TCT-460 Left Atrial Venoarterial Extra-Corporeal Membrane Oxygenation (LAVA-ECMO) Compared to Combination VA-ECMO and Impella (ECPELLA) in the Management of Acute Myocardial Infarction Cardiogenic Shock (AMI-CS)

TCT-460 Left Atrial Venoarterial Extra-Corporeal Membrane Oxygenation (LAVA-ECMO) Compared to Combination VA-ECMO and Impella (ECPELLA) in the Management of Acute Myocardial Infarction Cardiogenic Shock (AMI-CS)

Optimal patient and mechanical circulatory support device selection in acute myocardial infarction cardiogenic shock

Optimal patient and mechanical circulatory support device selection in acute myocardial infarction cardiogenic shock

Relationships between sex and in-hospital outcomes of patients with acute cardiogenic shock receiving mechanical circulatory support

BackgroundCardiovascular disease is the leading cause of mortality in women. Despite this there is a paucity of data on the impact of sex on utilization and outcomes of temporary mechanical circulatory support (tMCS) in patients hospitalized with Acute Myocardial Infarction (AMI) Cardiogenic Shock (CS). MethodsWe examined the 2016–2019 National Inpatient Sample database to identify cases of AMI-CS. Men were used as our control group, while women comprised our cohort. The primary outcome was in-hospital mortality. Secondary outcomes included the use of tMCS including; left ventricular assist device (LVAD) use, Impella use, and Intra-Aortic Balloon Pump (IABP) use, length of stay (LOS) and total hospitalization cost (THC). Multivariate linear and logistic regression models were used to adjust for confounders. ResultsAmong patients hospitalized for AMI (N = 2,622,939), 37.7 % were Female. A Female sex was associated with a higher inpatient mortality (adjusted OR [aOR] 1.06, p < 0.001), a lower likelihood of LVAD use (2.3 % vs. 2.9 % and p < 0.001), IABP use (3.0 % vs. 4.4 % and p < 0.001), Impella use (1.0 % vs. 1.5 % and p < 0.001), a longer mean LOS (4.4 vs 4.3 days and p < 0.001) and lower THC ($88,097 vs. $104,101, p < 0.001) compared to male patients for AMI-CS. ConclusionFemale patients admitted for AMI-CS were less likely to receive tMCS despite a higher mortality rate and a slightly longer LOS compared to male patients. Further studies are necessary to confirm these findings and elucidate clearer causality for such disparities.

Serial invasive hemodynamics and clinical characteristics of patients with shock with and without invasive mechanical ventilation

Abstract Funding Acknowledgements None. Background Invasive mechanical ventilation (IMV) is commonly used in the Cardiac Intensive Care Unit (CICU) in patients with cardiogenic shock (CS). IMV causes hemodynamic changes that may impact outcomes based upon a patient’s profile. Our aim is to characterize the clinical profile and detailed serial hemodynamic parameters in the first 24-hours according to the use of IMV in patients with shock admitted to the CICU. Methods Retrospective analysis of consecutive patients with shock admitted to the CICU at Bellevue Hospital, undergoing pulmonary artery catheter (PAC) placement within the first 24 hours of admission, from February 2022 to June 2023. Clinical characteristics, as well as specific hemodynamic parameters collected and curated at times 0, 6, 12, 18 and 24 hours were from PAC placement compared between patients with and without IMV. Results A total of 101 patients were included (95% with cardiogenic shock), 59 receiving IMV (age 64 ± 15, 24% women) and 42 non-intubated (61 ± 13, 33% women). Non-intubated patients had higher prevalence of hypertension, prior coronary artery disease and heart failure with reduced ejection fraction (HFrEF), while acute coronary syndromes (44%) and cardiac arrest (12%) were more common causes of admission in patients undergoing IMV. Mixed shock predominated in IMV patients (51 vs 17%, p &amp;lt;0.001), whereas cardiogenic shock (CS) was more common in non-intubated patients (83 vs 41%, p &amp;lt;0.01). Patients with acute myocardial infarction CS (AMI-CS) were more likely to undergo IMV, while patients with heart failure CS (HF-CS) were more likely to be non-intubated. Patients undergoing IMV were more likely to have mechanical circulatory support (MCS) and ventricular dilatation compared to non-intubated patients (LVEDD 5.7 cm vs 4.9 cm, p 0.002). Patients undergoing IMV had a higher incidence of severe shock compared to the non-intubated group (31% vs 19% SCAI Shock D), higher lactate levels and greater use of vasoactive drugs (figure 1A). Patients undergoing IMV had significant improvements in cardiac power output (CPO), diastolic blood pressure and systemic vascular resistance (SVR) (figure 1B). Shock severity by SCAI SHOCK classification had a more notable improvement at 24 hours in patients with IMV compared to non-intubated patients (figure 1C), with a non-statistically significant improvement in lactate clearance in the first 24 hours (Figure 1D). Conclusions IMV in patients with CS is more commonly seen in patients with AMI-CS and among those with higher baseline shock severity and greater use of vasoactive medications. IMV is associated with significant improvements in shock severity, CPO and SVR at 24 hours when compared to patients with shock who are not intubated, which could be related to higher use of vasopressors. Further investigations are warranted to understand the impact of IMV on outcomes of patients with CS and how they might vary according to hemodynamic profile.

Impella as Bridge to Durable Left Ventricular Assist Device in Acute Myocardial Infarction Cardiogenic Shock Patients.

Implantation of durable left ventricular assist device (LVAD) in cardiogenic shock (CS) patients after acute myocardial infarction (AMI) poses specific challenges (small left ventricular size, acute infarct area, need for antithrombotic therapy, status Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 with impaired organ function and derangements in coagulation and inflammatory parameters) which may affect outcomes. We reviewed data of all AMI-CS patients who were implanted LVAD after Impella support at a referral center with the aim to analyze feasibility, timing, and outcomes of durable LVAD implantation after tMCS with Impella due to AMI-CS. Twenty-one patients were treated between 2013 and 2023: all were in Society for Cardiovascular Angiography & Interventions (SCAI) class D-E and INTERMACS 1-2 at presentation, median LV ejection fraction (EF) and LV end-diastolic diameter (EDD) were 15 (10-20)% and 57 (54-60) mm, respectively. Eleven patients (52%) were supported with Impella CP, seven with Impella 5.0 (33%), and three (14%) with Impella 2.5. Axillary cannulation was performed in nine patients (43%). Five patients (24%) had concomitant venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Median duration of Impella support was 12 (8-14) days. Overall, the use of Impella was characterized by low rate of complications and allowed successful bridge to durable LVAD in all patients, with 100% 30 day survival rate.

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

Structured Weaning From the Impella Left Ventricular Micro-Axial Pump in Acute Myocardial Infarction With Cardiogenic Shock and Protected Percutaneous Coronary Intervention: Experience From a Non-Cardiac Surgical Centre

The Impella (Abiomed, Danvers, MA, USA) temporary percutaneous left ventricular assist device is increasingly used as mechanical circulatory support in patients with acute myocardial infarction-cardiogenic shock (AMICS) or those undergoing high-risk protected percutaneous coronary intervention (PCI). The optimal weaning regimen remains to be defined. We implemented a structured weaning protocol in a series of 10 consecutive patients receiving Impella support for protected PCI or AMICS treated with PCI in a high volume non-cardiac surgery centre. Weaning after revascularisation was titrated to native heart recovery using both haemodynamic and echocardiographic parameters. Ten patients (eight male, two female; aged 43-70 years) received Impella support for AMICS (80%) or protected PCI (20%). Cardiogenic shock was of Society for Cardiac Angiography & Interventions grade C-E of severity in 80%, and median left ventricular end-diastolic pressure was 31 mmHg. Protocol implementation allowed successful weaning in eight of 10 patients with a median support time of 29 hours (range, 4-48 hours). Explantation was associated with an increase in heart rate (81 vs 88 bpm; p=0.005), but no significant change in Cardiac Index (2.9 vs 2.9 L/min/m2), mean arterial pressure (79 vs 82 mmHg), vasopressor requirement (10% vs 10%), or serum lactate (1.0 vs 1.0). Median durations of intensive care and hospital stay were 3 and 6 days, respectively. At 30 days, the mortality rate was 20%, with median left ventricular ejection fraction of 40%. A structured and dynamic weaning protocol for patients with AMICS and protected PCI supported by the Impella device is feasible in a non-cardiac surgery centre. Larger studies are needed to assess generalisability of such a weaning protocol.

A Decade of Inertia in Adopting Guidelines and Still Going on: Is It Time to Lay in Rest Intra-aortic Balloon Pump for Acute Myocardial Infarction Cardiogenic Shock?

A Decade of Inertia in Adopting Guidelines and Still Going on: Is It Time to Lay in Rest Intra-aortic Balloon Pump for Acute Myocardial Infarction Cardiogenic Shock?

Safety Of Mechanical Circulatory Support Use For Acute Myocardial Infarction Cardiogenic Shock Among Octogenerians: A Nationwide Cohort Analysis Of United States

Safety Of Mechanical Circulatory Support Use For Acute Myocardial Infarction Cardiogenic Shock Among Octogenerians: A Nationwide Cohort Analysis Of United States

Timing and treatment strategies according to SCAI classification in cardiogenic shock

Abstract In patients with cardiogenic shock (CS), particularly those with acute myocardial infarction (AMI), evidence suggests that timely diagnosis and treatment interventions are critical in the prevention of haemo-metabolic compromise. Temporary mechanical circulatory support (tMCS) has shown potential in facilitating revascularization and recovery of patients with acute myocardial infarction cardiogenic shock (AMI-CS). Timing of treatment strategies for CS patients needs to be optimized for use of tMCS devices that are applicable to this heterogeneous patient population. Here, the latest evidence as well as the gaps in knowledge surrounding the role of time in the management of patients with CS is summarized.

Abstract 15665: Lack of Association Between Inpatient Percutaneous Coronary Intervention Volume and Thirty-Day Readmissions After Acute Myocardial Infarction- Cardiogenic Shock

Introduction: Volume-outcome relationship data is limited for acute myocardial infarction-cardiogenic shock (AMI-CS). Revascularization is mainstay of therapy in AMI-CS. Objectives: Authors sought to examine relation between hospital inpatient percutaneous coronary intervention (PCI) volume and 30-day readmissions after an AMI-CS admission. Methods: Nationwide Readmissions Database (NRD) 2016-2019 was analyzed. Hospitals were categorized into quartiles (Q1, lowest to Q4, highest) based on annual inpatient PCI volume. Primary outcome of interest was 30-day unplanned all-cause readmissions. Secondary outcomes included cardiac, non-cardiac and heart-failure (HF) readmissions at 30-days. Results: A total of 49,558 index AMI-CS admissions were present in 3,954 PCI performing hospitals. Median hospital PCI volume was 174 (inter-quartile range 70-316). 59% admissions for AMI-CS were present in quartile Q4. Overall, 30-day readmission rate was 18.5% (n=9,179); of which 56.2% were cardiac, 43.8% were non-cardiac and 25.8% were related to HF. We did not find any difference in 30-day all-cause readmissions (Q1 = 17.6% vs. Q2 = 18.4% vs. Q3 = 18.2% vs. Q4 = 18.7%, p=0.55). Similarly, cardiac (Q1 = 10.9% vs. Q2 = 11.0% vs. Q3 = 10.6% vs. Q4 = 10.2%, p=0.29), and HF (Q1 = 5.0% vs. Q2 = 4.8% vs. Q3 = 4.8% vs. Q4 = 4.8%, p=0.99) readmissions were not different across quartiles. Non-cardiac readmissions were more-commonly observed in higher quartiles (Q1 = 6.7% vs. Q2 = 7.4% vs. Q3 = 7.7% vs. Q4 = 8.5%, p=0.001). However, no significance was noted with any outcome after multivariable adjustment. Similarly, no relationship was observed between hospital PCI volume as continuous variable and all-cause or cause-specific readmissions on restricted cubic spline analysis. Conclusions: In a national representative sample of 3,954 hospitals with 49,558 AMI-CS admissions, we found lack of an association between hospital PCI volume and 30-day all cause or cause-specific readmissions.

Network meta-analysis of temporary mechanical circulatory support in acute myocardial infarction cardiogenic shock

We performed a network meta-analysis of 11 published randomized clinical trials examining the use of temporary mechanical circulatory support (MCS) devices in adults with acute myocardial infarction cardiogenic shock (AMICS), including 1053 total patients with an observed in-hospital or 30-day mortality of 40.4%. None of the temporary MCS devices was associated with lower in-hospital or 30-day mortality compared with initial medical therapy or any other MCS device, either individually or in combination. These data do not support the routine use of temporary MCS devices for the purpose of reducing short-term mortality in unselected patients with AMICS.

Escalation strategies, management, and outcomes of acute myocardial infarction-cardiogenic shock patients receiving percutaneous left ventricular support.

There are limited national-level data on the contemporary practices of mechanical circulatory support (MCS) use in acute myocardial infarction-cardiogenic shock (AMI-CS). We utilized the Healthcare Cost and Utilization Project-National/Nationwide Inpatient Sampledata (2005-2017) to identify adult admissions (>18 years) with AMI-CS. MCS devices were classified as intra-aortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD), or extracorporeal membrane oxygenation (ECMO). We evaluated trends in the initial device used (IABP alone, pLVAD alone or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in-hospital mortality and device escalation. Among 327,283 AMI-CS admissions, 131,435 (40.2%) had an MCS device placed with available information on timing of placement. IABP, pLVAD, and ≥2 MCS devices were used as initial device in 120,928 (92.0%), 8202 (6.2%), and 2305 (1.7%) admissions, respectively. Most admissions were maintained on the initial MCS device with 1%-1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). Urban, medium, and large-sized hospitals and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in-hospital mortality (adjusted odds ratio:1.56, 95% confidence interval:1.38-1.75; p < 0.001). Admissions receiving durable LVAD/heart transplantation increased over time in those initiated on pLVAD and ≥2 MCS devices, resulting in lower in-hospital mortality. In this 13-year study, escalation of MCS in AMI-CS was associated with higher in-hospital mortality suggestive of higher acuity of illness. The increase in number of durable LVAD/heart transplantations alludes to the role of MCS as successful bridge strategies.

SHOCK1: Penn Medicine Multidisciplinary Shock Team Model for Improved Outcomes in Cardiogenic Shock and Temporary Mechanical Circulatory Support

Purpose/Background: The implementation of a protocol-based, multidisciplinary shock team approach in tertiary centers can lead to an organized approach to care and early implementation of temporary mechanical circulatory support (tMCS) in the appropriate patient. The Penn Medicine Cardiogenic Shock Team (PMCST) was established in November 2019. We have reviewed our data to demonstrate the utility and viability of the PMCST model by highlighting improved outcomes in our patient population compared to published outcomes in the literature. Methods: We collected data on our shock team since its inception from 11/2019-1/2023. These data include review of patient profiles, tMCS use, and outcomes of our shock patients, including overall disposition as well as disposition after tMCS. Results: From 11/25/2019-1/15/2023, our team had 498 total shock calls. Three hundred and forty-three (69%) were accepted by our shock team (“Go”) and included in our analysis. One hundred and sixty did not meet criteria (“No Go”), most commonly because they were not candidates for advanced support. All patients were characterized by SCAI and Intermacs classifications as well as shock etiology. The largest number of accepted patients were SCAI D (131), followed by SCAI C (105) and E (83), respectively. Eighty-nine percent of patients fell into Intermacs classifications 1-3, with the highest number of Intermacs 2 patients at 132. The predominant diagnosis was Acute Decompensated Heart Failure-Cardiogenic Shock (ADHF-CS) in 111 patients (32%), with 67 patients (20%) diagnosed with Acute Myocardial Infarction Cardiogenic Shock (AMI-CS). Our team also accepted 17 patients with diagnoses related to ventricular tachycardia (VT storm, recurrent VT). Shock team calls were predominantly outside hospital (OSH) referrals (93%), and the remaining 7% were internal consults to the PMCST. Of accepted OSH patients, 143 had tMCS present on arrival, with the majority being intra-aortic balloon pump (IABP) and Impella CP, while 183 patients utilized tMCS during admission. Multiple tMCS devices were used concomitantly in 61 patients, the majority of whom with either ECPella (Impella CP and VA-ECMO) or IABP with VA-ECMO at 37% and 28%, respectively. In patients requiring tMCS, 104 (57%) remain alive, 91 (69%) of whom have since been discharged. With regard to our 343 accepted shock team patients, 240 (70%) remain alive, while 230 (67%) of whom were discharged alive. Summary: Our results show that a multidisciplinary shock team model represents a successful strategy leading to a multidisciplinary approach to care and timely deployment of tMCS. These data suggest the PMCST model leads to improved outcomes in patients with cardiogenic shock.Figure 1. Disposition of PMCST Shock PatientsFigure 2. Types of Concomitant tMCS Utilized in PMCST Patients

Survival Differences Between In-hospital And Out-of-hospital Cardiac Arrest Complicated By Non Acute Myocardial Infarction Cardiogenic Shock

Survival Differences Between In-hospital And Out-of-hospital Cardiac Arrest Complicated By Non Acute Myocardial Infarction Cardiogenic Shock

(226) Comparison of In-Hospital Outcomes in Acute Myocardial Infarction-Cardiogenic Shock (AMICS) versus Non-AMICS Following ECPELLA

(226) Comparison of In-Hospital Outcomes in Acute Myocardial Infarction-Cardiogenic Shock (AMICS) versus Non-AMICS Following ECPELLA

Mechanical Circulatory Support Devices in Acute Myocardial Infarction-Cardiogenic Shock: Current Studies and Future Directions.

Cardiogenic shock (CS) caused by acute myocardial infarction (AMI) accounts for most deaths in the population with AMI and continues to be associated with high short-term mortality. Several temporary mechanical circulatory support (MCS) devices have been developed to treat CS and studied in randomized controlled trials (RCTs) of patients with AMI-CS. Unfortunately, none of these RCTs has demonstrated an improvement in survival with temporary MCS in AMI-CS. Potential reasons for these negative results in RCTs are numerous and reflect the challenges of enrolling critically ill patients with CS. Researchers have used observational study designs to provide insights about outcomes associated with the use of temporary MCS in AMI-CS. These observational studies have yielded conflicting results, in some cases contrary to the results of RCTs. Several limitations pertinent to both RCTs and observational analyses, mostly relating to selection bias and failure to consider unmeasured confounding variables and population heterogeneity, preclude drawing strong inferences regarding the effects of temporary MCS on survival in populations with AMI-CS. Understanding these limitations is essential to correctly interpreting the literature regarding temporary MCS to treat AMI-CS and is necessary to inform the design of future studies that will potentially provide stronger evidence. Optimally matching temporary MCS devices to the needs of individual patients with AMI-CS will presumably be more successful than indiscriminate application in unselected patients. In this review, we discuss the existing literature on temporary MCS to treat AMI-CS and describe the specific challenges that must be overcome to develop an improved evidence base for guiding clinical practice.

Abstract 15122: Escalation Strategies, Management, and Outcomes of Acute Myocardial Infarction-Cardiogenic Shock Patients Receiving Percutaneous Left Ventricular Support

Introduction: Despite well-established device selection algorithms, there remain wide variations in mechanical circulatory support (MCS) device utilization in patients with cardiogenic shock complicating acute myocardial infarction (AMI-CS). Further, there are limited national-level data on the contemporary practices of MCS device use. Methods: To evaluate national utilization patterns of MCS devices, we identified adult admissions (&gt;18 years) with AMI-CS from the HCUP-NIS data (2005-2017). Use of MCS devices including intraaortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD) (Impella/Tandem Heart), and extracorporeal membrane oxygenation (ECMO) during hospitalization was identified. We evaluated trends in the initial MCS device used (IABP alone, pLVAD alone, or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in-hospital mortality and device escalation. Results: Among a total of 327,283 AMI-CS admissions in this 13-year period, 132,146 (40.2%) had an MCS device with information on timing of placement. IABP, pLVAD, ≥2 MCS, and ECMO devices were used as initial device in 120,928 (92.0%), 8,202 (6.2%), 2,305 (1.7%), and 711 (0.1%) admissions, respectively. Most admissions were maintained on initiated MCS device with 1-1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). The median time to escalation across all devices categories was 2 (IQR 1-4) days. Urban, medium, and large-sized hospitals, and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in-hospital mortality (adjusted OR 1.56, 95% CI 1.38-1.75; p &lt;0.001). Admissions receiving durable LVAD/heart transplantation increased over time in those initiated on pLVAD and ≥2 MCS devices resulting in lower in-hospital mortality. Conclusions: In this 13-year study, escalation from initial MCS device was associated with higher in-hospital mortality suggestive of higher acuity of illness. However, the observed increase in number of durable LVADs or heart transplantations may be an indication of the utility of these MCS devices as successful bridge therapies.