Cardiogenic Shock Research Articles

Comparative Efficacy of Noradrenaline vs. Other Vasopressors on Outcomes in Patients With Cardiogenic Shock ― A Systematic Review and Meta-Analysis ―

Jugulo-subclavian cannulation in venoarterial ECMO for cardiogenic shock due to pulmonary embolism and hypercoagulability syndrome

Background: Atrial fibrillation frequently complicates cardiogenic shock, yet optimal rhythm management remains unclear. Early cardioversion aims to restore sinus rhythm and improve hemodynamics, but its effect on outcomes in cardiogenic shock is not well defined. We evaluated the association between early cardioversion and clinical outcomes in patients hospitalized with concurrent atrial fibrillation and cardiogenic shock. Research Question/Hypothesis: What is the association between early cardioversion (within 2 days of hospitalization) and clinical outcomes in patients hospitalized with cardiogenic shock and atrial fibrillation?: Methods: We analyzed National Inpatient Sample data identifying adults with atrial fibrillation and cardiogenic shock using ICD-10 codes. Early cardioversion was defined as cardioversion within 2 days of admission. Survey-weighted multivariable logistic and linear regression models adjusted for demographics (age, sex, race) and hospital factors (region, teaching status, bed size) assessed associations with mortality, acute myocardial infarction, stroke, acute kidney injury, use of mechanical circulatory support, length of stay and hospital charges. Results: Among 23,703 patients with both cardiogenic shock and atrial fibrillation, 7.03% underwent early cardioversion. Compared to those without early cardioversion, these patients had shorter length of stay (mean 7.75 vs. 11.00 days, p<0.001) and lower charges (mean $195,062 vs. $251,742, p<0.001). Adjusted analyses showed no significant association with in-hospital mortality (OR 1.10, 95% CI 0.98–1.23, p=0.094). Early cardioversion was associated with higher odds of acute myocardial infarction (OR 1.16, p=0.005) and higher odds of use of mechanical circulatory support (OR 1.70, p < 0.001) but lower odds of stroke (OR 0.73, p=0.028) and acute kidney injury (OR 0.87, p=0.011). Conclusions: Early cardioversion in cardiogenic shock patients with atrial fibrillation is associated with shorter hospitalizations, lower odds of stroke and acute kidney injury but higher odds of acute myocardial infarction and use of mechanical circulatory support. This suggests there may be increased risks in cardioverting patients early in cardiogenic shock. Prospective studies are needed to optimize rhythm management and identify appropriate patients for early cardioversion to improve outcomes in this high-risk population.

Introduction: Cardiogenic shock (CS) remains a high-mortality condition with variable outcomes depending on underlying etiology. Common causes include acute coronary syndrome (ACS), decompensated heart failure, pulmonary embolism, myocarditis, and arrhythmias. Identifying differences in outcomes based on etiology may provide insight into risk stratification, resource allocation, and management strategies. Hypothesis: We hypothesized that in-hospital outcomes among CS patients differ significantly based on etiology, and that non-ACS causes exhibit variable risk profiles, resource needs, and discharge patterns compared to ACS-related CS. Methods: We analyzed adult hospitalizations with CS from 2016–2018 using the National Inpatient Sample (NIS) database. Patients were grouped into six mutually exclusive etiologies: ACS, cardiomyopathy, valvular, myocarditis, rhythm-related, and others. Patients with more than one CS etiology were excluded. Multivariable logistic and Cox regression models were used to compare outcomes across groups, adjusting for demographics and comorbidities. Kaplan-Meier survival curves were constructed to assess differences in survival across the etiological groups. Results: Among 37,039 CS hospitalizations, the most common etiologies were rhythm-related (36.6%), ACS (26.6%), and cardiomyopathy (20.5%). Compared to ACS, mortality was lower in cardiomyopathy (HR 0.704, 95% CI 0.660–0.751) and valvular CS (HR 0.839), and higher in rhythm (HR 1.274) and other CS (HR 1.201). Myocarditis showed no mortality difference (Figure 1). Cardiomyopathy-CS had increased AKI risk (OR 1.30), while all non-ACS groups except myocarditis had lower odds of sepsis (Figure 2). Myocarditis-CS had the highest use of Mechanical Circulatory Support (MCS) (OR 2.94); MCS use was significantly lower in cardiomyopathy, rhythm, and other etiologies (Figure 2). Stroke risk was highest in valvular-CS (OR 1.24); anoxic brain injury was most frequent in rhythm-CS (OR 1.44) (Figure 2). Cardiomyopathy-CS had the lowest hospital charges; myocarditis-CS had the highest when compared to ACS-CS (Figure 2). Conclusion: In this national analysis, in-hospital outcomes among patients with cardiogenic shock varied significantly by underlying etiology. Compared to ACS-related CS, non-ACS etiologies demonstrated distinct risk profiles and mortality outcomes. These findings underscore the importance of etiology-specific risk stratification and management strategies in CS.

Introduction: Temporary mechanical support (tMCS) devices (intra-aortic balloon pump [IABP], Impella CP, Impella 5.5) are commonly used in cardiogenic shock (CS) and are often placed at regional centers (RC) to stabilize patients for transfer to a CS hub center (HC). Aims: To assess whether initial tMCS device placement for CS at an RC before transfer to HC is associated with more device-related adverse events (DRAEs) and worse outcomes than with initial device placement at a HC. Methods: All patients admitted to a single center from 8/2021 to 8/2023 with CS requiring tMCS were identified using CPT codes. Baseline characteristics, CS severity, DRAEs, and outcomes were collected. Outcomes included in-hospital mortality and “unfavorable outcome” (death prior to heart transplant, durable LVAD implant, or discharge). Patients were stratified by location of initial tMCS device placement (RC vs HC). Characteristics, DRAEs, and outcomes were compared. Multivariable logistic regression was performed to account for baseline differences. Sensitivity analyses were performed to assess consistency of results by device exposure. Results: 268 patients were included, 214 (79.9%) with initial device placed at HC and 54 (20.1%) at RC. The initial device was IABP in 54.1%, Impella CP in 28.0%, and Impella 5.5 in 17.9%. Median age was 60 (44, 67) years, 59.3% were Black, and 71.6% male (similar between groups). Compared to HC implanted patients, RC patients more commonly had non-ischemic CM (63% vs 37%, p=0.02), de novo HF-CS (41% vs 14%, p=0.02), and cardiac arrest (32% vs 11%; p<0.01) but less commonly had prior HFrEF (51% vs 69%, p=0.02) and kidney disease (9% vs 25%, p=0.01). RC implanted patients had more advanced CS (Stage E CS in 30% vs 8%; p<0.01). DRAEs were more common in RC than HC implanted patients (1.19 vs 0.46 events per patient-week on tMCS support; p<0.01)(Fig 1). RC implanted patients had higher unadjusted odds of in-hospital mortality and unfavorable outcome (Fig 2). This finding was similar after adjustment for baseline differences and CS etiology but no longer statistically significant after adjusting for CS severity and cardiac arrest. These findings were consistent in the sensitivity analyses among patients with any IABP and any Impella exposure. Conclusions: Patients with tMCS devices placed for CS at RC have more DRAEs and worse outcomes than those with initial device placed at a HC. The higher mortality in RC implanted patients may be due to greater CS severity.

Background: Cangrelor has more rapid platelet inhibition compared to oral anti-platelet agents. The favorable pharmocokinetics and pharmacodynamics of cangrelor could be advantageous in high-risk acute myocardial infarction (AMI) complicated by cardiac arrest or cardiogenic shock, conditions often associated with altered oral bioavailability of anti-platelet agents. Hypothesis: We investigated the clinical outcomes associated with cangrelor use during percutaneous coronary intervention (PCI) for AMI complicated by cardiac arrest or cardiogenic shock. Methods: All patients undergoing PCI for AMI complicated by shock or cardiac arrest and enrolled in BMC2, a multicenter clinical registry of all PCI procedures at non-federal hospitals in the state of Michigan between 4/2018-12/2024 were included. Patients treated with a Gp IIb/IIIa inhibitor were excluded. The in-hospital outcomes of mortality, major and minor bleeding, and transfusion were evaluated in a propensity-matched analysis using 4:1 greedy match with a caliper of 0.25 standard deviations of the propensity score. Results: A total of 1,850 patients were included in the propensity-matched cohort (mean age 65 years, 67.5% male, 64.5% STEMI). 370 patients received cangrelor compared with 1,480 not receiving cangrelor. 62.2% of patients had cardiogenic shock, 64.6% had cardiac arrest, and 26.8% had both cardiogenic shock and cardiac arrest. In patients undergoing PCI for AMI with either cardiogenic shock or cardiac arrest, the administration of cangrelor was associated with increased major bleeding (13.5% vs 9.0%; p=0.024) and transfusion administration (26.2% vs 17.8%; p <0.001). There was no difference in in-hospital mortality (30.0% vs. 30.3%; p=0.950) or minor bleeding (8.2% vs. 7.1%; p=0.527). Conclusion: Cangrelor administration during PCI for AMI complicated by cardiogenic shock or cardiac arrest was not associated with a difference in in-hospital mortality but was associated with increased major bleeding and transfusions.

Background: Patients with cardiogenic shock or out-of-hospital cardiac arrest undergoing percutaneous coronary intervention face delayed absorption of oral P2Y12 inhibitors due to impaired gastrointestinal perfusion, increasing thrombotic risk. Cangrelor, an intravenous P2Y12 inhibitor with immediate onset, may offer clinical benefit in these critically ill populations. We performed a systematic review and meta-analysis to evaluate the safety and efficacy of cangrelor compared with oral P2Y12 inhibitors in this setting. Research Question: Does cangrelor improve clinical outcomes compared with oral P2Y12 inhibitors in patients undergoing PCI for cardiogenic shock or cardiac arrest? Methods: We searched PubMed and Embase through May 1, 2025, for observational studies comparing cangrelor and oral P2Y12 inhibitors in patients with cardiogenic shock or out-of-hospital cardiac arrest undergoing PCI. Outcomes included all-cause mortality, major bleeding, stent thrombosis, and stroke. Risk ratios (RR) with 95% confidence intervals (CI) were pooled using a random-effects model. Heterogeneity was assessed using the Chi-squared test and I 2 statistic. Subgroup analysis was performed based on clinical presentation. Results: Four studies, including 2,722 patients (1,170 with cardiogenic shock; 1,552 with out-of-hospital cardiac arrest) were analyzed. In cardiogenic shock, cangrelor significantly reduced mortality (RR: 0.81; 95% CI: 0.71–0.93; p = 0.003) without increasing major bleeding (RR: 1.35; 95% CI: 0.91–2.02). In cardiac arrest, cangrelor did not significantly reduce mortality (RR: 0.78; 95% CI: 0.42–1.43) and was associated with increased bleeding risk (RR: 3.10; 95% CI: 1.60–5.98; p = 0.0008). No significant differences were observed for stroke or stent thrombosis. Conclusion: Cangrelor use during PCI in cardiogenic shock was associated with lower mortality and no excess bleeding, supporting its use in this high-risk group. However, in out-of-hospital cardiac arrest, the increased risk of bleeding warrants caution. These findings suggest a phenotype-specific approach to antiplatelet therapy in patients undergoing PCI under critical conditions.

Introduction: Propofol has demonstrated favorable outcomes in mechanically ventilated ICU patients, including shorter ventilation times and ICU stays. However, its use in cardiogenic shock remains controversial due to concerns about hypotension and negative inotropic effects. Despite its frequent use, limited evidence guides sedative selection in this high-risk group. We examined whether baseline characteristics and illness severity differed by sedative type in cardiogenic shock. Research Question: Among cardiogenic shock patients admitted to the CICU, how do baseline characteristics differ by predominant sedative exposure? Methods: We conducted a retrospective cohort study of 3,480 adults admitted to the Northwell Health CICU between 2016–2022 with an ICD-coded diagnosis of cardiogenic shock. Patients were grouped by sedative if >75% of cumulative sedation shifts involved a single agent: Propofol (n=669), Dexmedetomidine (n=745), Fentanyl (n=135), Midazolam (n=72), or categorized as Mixed (n=1859) if no single agent predominated. Ketamine users (n=3) were excluded. Key variables included age, Charlson Comorbidity Index (CCI), mean arterial pressure (MAP), serum lactate, creatinine, and maximum cardiogenic shock stage (SCAI). Kruskal-Wallis and Chi-squared tests were used for continuous and categorical comparisons. Results: Baseline characteristics varied significantly by sedative group (all p<0.001). Propofol patients were younger (mean age 69.6), with higher MAP (71.2 mmHg), lower lactate (4.25 mmol/L), and lower creatinine (2.03 mg/dL). Fentanyl and Midazolam groups had greater illness severity: older age (74.1 and 70.2), lower MAP (58.9 and 64.1 mmHg), higher lactate (6.94 and 5.83 mmol/L), and higher creatinine (2.82 and 2.45 mg/dL). Max SCAI was similar across groups. Conclusions: Propofol recipients were generally younger with more favorable baseline hemodynamic profiles, while fentanyl and midazolam recipients exhibited greater markers of illness severity. Despite these differences, the maximum cardiogenic shock stage (SCAI) was similar across groups. These findings suggest a potential selection bias, with clinicians possibly reserving propofol for patients perceived as lower risk due to safety concerns. However, the similarity in SCAI stage suggests that such avoidance may not reflect actual illness severity. Prospective studies are needed to determine whether propofol is truly contraindicated—or underutilized—in patients with advanced cardiogenic shock.

Background: Cardiogenic shock (CS) is a high-acuity condition with in-hospital mortality rates of 30–40%. Over time, the acuity and multimorbidity of patients with CS has increased, along with the number of CS admissions and use of mechanical circulatory support (MCS). In response, professional societies advocate for a three-tiered cardiac intensive care unit (CICU) model based on patient acuity and hospital capabilities. State level and national data outlining availability of CICU care is not available, hampering efforts to develop coordinated care systems. This challenge is pronounced in large states with competing health care systems like California. Objective: The goal of this study is to characterize CS care capabilities across California, map the location and catchment areas of Level 1 and Level 2 CICUs, and identify access disparities within the state's decentralized healthcare system. Methods: We identified cardio-capable hospitals using California HCAI databases, 2021 Census data, and manufacturer information (Getinge, Abiomed). Structured surveys were sent to each hospital to assess staffing and resource availability. Hospitals were categorized by their capability to manage CS as Level 1-3 CICUs based on professional staffing and therapeutic resources. Geospatial analysis was performed to map CICU locations with their estimated geographic reach based on 60-minute travel time and population density. Results: We identified 184 cardio-capable hospitals throughout the state of California. Of these, 16 (8.7%) met the criteria for Level 1 CICU designation. These were concentrated in densely populated urban areas, leaving large rural areas outside of timely access to advanced CS care (Figure 1 and Figure 2). Survey responses were received from 88 institutions (Table 1), most of which were urban (89.7%). Dedicated CICUs were present in 29.5%. CS care resources varied: dedicated shock teams (21.6%), on-site ECMO (44.3%), Impella (69.3%), and intra-aortic balloon pumps (76.1%). Only 19.3% had 24/7 intensivist coverage, and 10.2% reported critical care cardiologist staffing. Most had on-site cath labs (78.4%) and cardiothoracic surgery (64.7%). Conclusion: There is significant variation in hospital capabilities for managing CS across California, with a limited number of Level 1 CICUs that are concentrated in urban areas. These findings highlight the need for regionalized care networks to ensure equitable access to comprehensive care for patients with CS.

Background: A systemic inflammatory response is common in patients with cardiogenic shock (CS) and associated with more severe disease and increased mortality. C-reactive protein (CRP) is a widely accessible and cost-effective biomarker of inflammation that may aid in prognostication in patients with CS. Research Questions: The aim of this study was to evaluate the association between admission CRP and in-hospital mortality in patients with CS. Methods: Using the Vizient® Clinical Data Base, we identified adults ≥18 years admitted with CS from October 1, 2015, to June 30, 2023. We identified patients with a CRP value on the first two days of admission. Patients with sepsis on admission were excluded. Cohorts were analyzed in CRP tertiles. Using inverse probability treatment weighting (IPTW), adjusting for demographics, comorbidities, labs (initial lactate and white blood cell count), and vasoactive and mechanical circulatory support (MCS) on the first day of admission, we assessed for the association between admission CRP and in-hospital mortality. Results: We identified 28,806 patients with an available CRP on the first two days of admission, including 18,749 on day 1 and 10,057 on day 2. The average age was 62.8 years (±15.9), 62.7% (n=18,058) were men, 20.9% required MCS, and the median (IQR) CRP was 11.1 mg/dL (3.0-43.1 mg/dL). The unadjusted in-hospital mortality was 29.0%, 37.4%, and 41.3% for tertiles 1, 2, and 3, respectively. The odds of in-hospital mortality increased by 17% for each 50-unit increase in admission CRP (OR 1.17; 95% CI: 1.15-1.19, p<0.001) ( Figure ). After IPTW, compared to patients in the first CRP tertile, tertiles 2 and 3 were associated with an increased weighted mean mortality of 6.7% (95% CI: 5.1% to 8.4%) and 10.3% (95% CI: 8.6% to 12.0%), respectively (both, p<0.001). Similar trends were observed when including only those with a CRP obtained on day 1, when limited to a primary admission diagnosis of heart failure or acute myocardial infarction, and amongst patients requiring MCS within the first 2 days (all, p<0.05). Conclusion(s): In patients with CS, the readily available biomarker, CRP, was associated with higher in-hospital mortality. Future studies are needed to assess the prospective impact of CRP, potentially utilized within shock stages or in isolation, on clinical outcomes for patients with CS.

Introduction: Cardiogenic shock (CS) is a life-threatening condition characterized by reduced tissue perfusion due to cardiac pump failure. In patients with diabetes mellitus (DM), the incidence and severity of CS are heightened due to accelerated atherosclerosis, microvascular dysfunction, and impaired myocardial recovery. Although sex-based differences in cardiovascular disease are increasingly recognized, their specific impact on outcomes in diabetic patients with CS remains largely understudied. Addressing these disparities is essential for improving outcomes and promoting equity in care. Hypothesis: This systematic review evaluates whether sex-based differences exist in the presentation, management, and outcomes of CS in patients with type 2 DM. We hypothesize that women experience worse outcomes and receive less aggressive treatment than men. Methods: A systematic search of PubMed was conducted following PRISMA guidelines. Studies published from January 2000 to March 2025 were screened. Inclusion criteria: adults (≥18 years) with type 2 DM and CS, and outcomes reported by sex. Extracted data included study design, population details, interventions, and sex-stratified outcomes. Risk of bias was evaluated using the Newcastle-Ottawa Scale. Due to heterogeneity, a descriptive synthesis was performed. Results: Twelve studies involving 25,000 patients met criteria. Women with CS and DM presented later, experienced longer delays in treatment, and were less likely to receive percutaneous coronary intervention (PCI) or mechanical circulatory support (MCS). In-hospital mortality among women ranged from 34% to 62%, compared to 28% to 55% in men. Six studies identified female sex as an independent predictor of mortality. Use of advanced hemodynamic monitoring and timely revascularization was lower in women. Conclusion: Notable sex-specific disparities exist in CS outcomes among diabetic patients. Women face delayed care, reduced access to life-saving interventions, and higher mortality. These gaps reflect a mix of biological, clinical, and systemic factors. Future efforts should include more women in CS research, perform sex-stratified analyses, and develop tailored treatment strategies to reduce disparities.

Limited data exist regarding the impact of standardized care on cardiogenic shock (CS) outcomes over time. We aimed to investigate the influence of multidisciplinary management on CS outcomes following implementation of team-based protocols in 2017. A total of 1453 consecutive patients enrolled into a single-centre CS registry were divided into two time periods, 2017-2019 versus 2020-2022. Baseline characteristics, management and outcomes were compared. The primary endpoint was adjusted in-hospital mortality. Multivariable regression analysis was performed to evaluate change in outcomes over time. Compared with 2017-2019, more patients with CS were treated in 2020-2022 (930 vs. 523; P<0.01). They more often presented to the Level 1 centre (52% vs. 45%; P=0.01), with a higher proportion of heart failure-related CS (72% vs. 58%; P<0.01) and Society for Cardiovascular Angiography and Interventions B and C CS (64% vs. 49%; P<0.01). They were less likely to be managed with percutaneous ventricular assist devices (11% vs. 24%; P<0.01) but more likely to receive veno-arterial extracorporeal membrane oxygenation (14% vs. 4%; P<0.01) and heart transplantation (9% vs. 4%; P<0.04). No differences were noted in in-hospital mortality [adjusted odds ratio (aOR) 0.81; 95% confidence interval (CI): 0.56-1.16; P=0.25], major adverse cardiac and cerebrovascular events (aOR 1.21; 95% CI: 0.87-1.68; P=0.26), stroke (aOR 1.11; 95% CI: 0.65-1.91; P=0.71) or renal replacement therapy (aOR 0.95; 95% CI: 0.66-1.37; P=0.77). Standardized care for CS was associated with consistent in-hospital mortality over time despite changes in presentation and management. Further research is needed to identify the optimal care model during the vulnerable post-discharge period.

Background: Cardiogenic shock often leads to hemodynamic compromise requiring immediate intervention, typically involving mechanical circulatory support (MCS). While treatment methods have advanced, there continues to be disparities in management, especially in women. While prior studies have highlighted differences in myocardial infarctions and heart failure, very few have investigated cardiogenic shock. This study aims to evaluate sex-based differences in MCS utilization and in-hospital mortality in postmenopausal women. Hypothesis: Based on trends in other cardiac diseases, we hypothesize that postmenopausal women with cardiogenic shock are less likely to receive MCS and therefore experience higher in-hospital mortality compared to men of similar age range. Methods: We analyzed the National Inpatient Sample database from 2018 to 2021, identifying adults over the age of 55 hospitalized with cardiogenic shock (International Classification of Diseases, Tenth Revision code R57.0). Primary outcomes included MCS usage determined by procedure codes for standard treatments and in-hospital mortality. Multivariable logistic regression models were created to estimate odds ratio, later adjusted for demographic data and Elixhauser comorbidity index calculated using the Van Walraven weights. Results: Out of the 155,728 patients with cardiogenic shock sampled, 43% were female. Compared to men, women tended to be slightly older with lower comorbidity index (17.4 vs 18.0) and lower MCS usage (15% vs 20%). Unadjusted regression showed women overall had 32% lower odds of receiving MCS (OR: 0.677; 95% CI: 0.657–0.699) and 22.5% higher odds of inpatient mortality (OR: 1.225; 95% CI: 1.196–1.255). After adjusting for age, Elixhauser index, race, type of insurance, and income, women still had 27.5% lower odds of receiving MCS (OR: 0.725; 95% CI: 0.702–0.748) and 17% higher odds of inpatient mortality (OR: 1.170; 95% CI: 1.141–1.199). All values were statistically significant (p-value &lt; 0.05). Conclusion: This study showed that postmenopausal women, although with slightly less comorbidities than men, still are less likely to receive MCS leading to higher inpatient mortality even after adjusting for socioeconomic factors. Combined with sex-specific disparities in other cardiac diseases, this highlights a strong necessity for investigating possible barriers to treatment at an individual and system level.

Background: Cardiogenic shock is caused by a wide range of pathogenic processes that negatively impact myocardial function and is associated with very elevated mortality rates. Case Description: A 19-year-old woman with no significant cardiac history presented with progressive dyspnea and pleuritic chest pain and was found to be in cardiogenic shock with severely reduced left ventricular function. A native heart biopsy was negative for myocarditis, but there was evidence of cardiomyocyte vacuolization and ultrastructural examination revealed a loss of mitochondrial cristae without evidence of glycogen or lipid accumulation. (Figure 1) The patient received cardiopulmonary mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (ECMO), followed by cardiac transplant. Genetic testing of the patient and her parents revealed that the patient inherited biallelic pathogenic DNA variants in the pyrophosphatase 2 (PPA2) gene. (Figure 2) Discussion: For young patients experiencing acute cardiogenic shock, it is critical to rapidly investigate multiple potential causes to determine if there are avenues for targeted treatment. This should include diagnostics imaging and endomyocardial biopsy with electron microscopy to evaluate cardiomyocyte ultrastructure. Although, not performed rapidly, genetic testing provides critical complimentary diagnostic information. When medical management of cardiogenic shock is insufficient, a cardiogenic shock team approach should be employed to determine appropriate temporary mechanical circulatory support and candidacy for heart transplantation or durable VAD. In this particular case, the diagnosis of cardiogenic shock due to biallelic PPA2 variants was confirmed through these diagnostic tests. The PPA2 gene encodes a mitochondrial protein that regulates cellular phosphate metabolism. Biallelic loss of function DNA variants in PPA2 are associated with progressive cardiac failure or cardiac arrest in infants and adolescents, typically after a febrile illness or alcohol consumption. The patient has shown significant improvement and has been doing well for nearly four years after the heart transplant. Conclusion: Tissue analysis and genetic testing are important components of the diagnostic evaluation of patients that present with fulminant heart failure. Cardiac transplant is an effective method to treat cardiogenic shock in patients with biallelic PPA2 DNA variants.

Introduction: Cardiogenic shock is a life-threatening complication of decompensated heart failure, with elevated in-hospital mortality rates despite advances in treatment. Pulmonary artery catheterization (PAC) provides detailed hemodynamic data that may guide therapy in shock states, yet its routine use has declined following neutral trials in broader heart failure populations. The benefit of PAC in patients with cardiogenic shock remains uncertain. Research question: In patients with cardiogenic shock, does the use of pulmonary artery catheter compared to standard therapy reduce in-hospital mortality? Methods: We conducted a systematic review and meta-analysis including both observational studies and randomized controlled trials that compared the use of PAC versus no PAC in patients with cardiogenic shock. A comprehensive search was carried out in PubMed, Scopus, Cochrane CENTRAL, and Web of Science databases. Data were pooled using a random-effects model, and the certainty of the evidence was assessed using the GRADE approach. Primary outcomes included mortality, while secondary outcomes were length of hospital stay and procedure-related complications. Results: Nine studies including over 1.1 million patients with cardiogenic shock were analyzed. PAC was not associated with reduced in-hospital mortality compared to no PAC (RR 1.25, 95% CI 0.62–2.49; p=0.48). No significant differences were found in the use of vasoactive agents (RR 1.12, 95% CI 0.94–1.34; p=0.13), renal replacement therapy (RR 1.06, 95% CI 0.25–4.53; p=0.90), intra-aortic balloon pump (RR 2.00, 95% CI 0.84–4.73; p=0.09), ECMO (RR 1.03, 95% CI 0.40–2.64; p=0.95), or durable ventricular assist device implantation (RR 2.48, 95% CI 0.45–13.70; p=0.21). All outcomes showed high heterogeneity and wide prediction intervals, indicating substantial variability and uncertainty in treatment effects across studies. Conclusion: PAC was not associated with significant benefits in mortality or major clinical endpoints. These findings suggest that PAC use should be individualized, and highlight the need for prospective trials to better define which patients may derive benefit from invasive hemodynamic monitoring.

Background: Cardiogenic shock is associated with high mortality and usually requires ventilatory support. Non-invasive ventilation (NIV) has demonstrated benefits in cardiogenic pulmonary edema, including reduced risk of infection and shorter hospital stays compared to invasive mechanical ventilation (IMV). However, the efficacy and safety of NIV specifically in cardiogenic shock remain unclear. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of NIV compared to IMV in patients with cardiogenic shock. Methods: A systematic search was conducted across 4 databases, including PubMed, Embase, Web of Science, and Cochrane CENTRAL, from inception to February 12, 2025, without language restrictions. Studies were included if they compared the efficacy and safety of NIV and IMV in patients with cardiogenic shock. Results: A total of 6 studies involving 2,302 participants were included in this meta-analysis, using a random-effects model. NIV was associated with a significantly lower risk of in-hospital mortality compared to IMV, with a risk ratio (RR) of 0.70 (95%CI 0.52 to 0.94), p=0.02. NIV was also associated with a lower risk of 30-day all-cause mortality, with an RR of 0.63 (95%CI 0.51 to 0.77), p&lt;0.01. NIV was associated with a shorter length of ICU/CCU stay (weighted mean difference (WMD) of -2.06 days; 95%CI -2.76 to -1.37; p&lt;0.01) and hospital stay (WMD of -3.20 days; 95%CI -5.33 to -1.07; p&lt;0.01) compared to IMV. Conclusions: NIV appears to be an effective and safe alternative to IMV in carefully selected patients with cardiogenic shock.

Introduction: Cardiogenic shock (CS) is a heterogeneous clinical syndrome, with varied clinical outcomes driven by hemodynamic states, and initial presentation. However, unsupervised machine learning (ML) has not been implemented to identify clinically meaningful subgroups to improve risk stratification and therapeutic targeting ina nationally representative sample. Methods: We used the 2016–2019 National Inpatient Sample (NIS) to identify non-elective hospitalizations with CS without prior heart transplant. Density-Based Spatial Clustering of Applications with Noise (DBSCAN) was applied to 14 clinical covariates including procedures, and comorbidity burden scores (Elixhauser Comorbidity and CHA2DS2Vasc). The primary outcome was in-hospital mortality. Secondary outcomes included use of mechanical circulatory support (MCS), invasive mechanical ventilation, hemodialysis, and major complications. Multivariable logistic regression was used to assess mortality and outcomes. Feature importance was interpreted using SHapley Additive exPlanations (SHAP) values. Results: Among 91,131 unweighted CS hospitalizations, four distinct clusters were identified: Cluster 0 (37.6%): Older adults with multiple comorbidities, highest CHA2DS2Vasc burden, frequent use of invasive ventilation and hemodialysis. Cluster 1 (32.7%): Predominantly ischemic CS with high rates of PCI/CABG, younger population, and lowest mortality. Cluster 2 (16.4%): Critically ill patients with multiorgan failure, sepsis, transfusion, dialysis, and the highest in-hospital mortality (48.9%). Cluster 3 (13.3%): Patients with prior CABG and atrial fibrillation, frequent use of early RHC but lower revascularization. MCS utilization was most frequent in Cluster 2 (37.2%), followed by Cluster 1 (32.1%). Mortality varied significantly across phenotypes (p &lt; 0.001). After adjustment, Clusters 2 and 0 had significantly higher odds of mortality compared to Cluster 1 (aOR 2.42 [95% CI 2.30–2.56] and 1.68 [95% CI 1.59–1.77], respectively). SHAP analysis revealed age, mechanical ventilation, sepsis, and dialysis as key predictors of mortality. Conclusion: Unsupervised ML identified four clinically distinct phenotypes of CS, utilizing various treatment modalities with differing outcomes. Cluster 2, characterized by multiorgan failure and highest MCS use, had the worst prognosis. These data driven phenotypes may guide clinicians for future risk stratification and guide precautionary measures to manage CS.

Introduction: Impella CP (Abiomed, Danvers, MA) microaxial flow pumps are commonly used in acute myocardial infarction (AMI) and heart failure (HF) cardiogenic shock (CS). Contemporary data from large, unselected populations are needed to understand differences between these groups. Hypothesis: Differences in patient and hospitalization characteristics such as device exposure and shock complications may contribute to differences in outcomes between those with AMI-CS compared to HF-CS. Methods: The Cardiogenic Shock Working Group (CSWG) registry enrolls patients with CS at 36 international sites. We analyzed patients with CS and Impella CP enrolled from 2019-2024, categorized by CS etiology and mechanical support device exposure. Baseline characteristics, complications, and outcomes were compared. Outcomes included survival to discharge, native heart survival, and heart replacement therapy. Multivariable analysis was performed to identify predictors of mortality and complications. Results: 1486 patients with CS (34.9% HF-CS, 57.9% AMI-CS) and Impella CP were analyzed. Patients with HF-CS were younger (60 vs 64 years), more often had chronic kidney disease (26.4% vs 13.6), less commonly had cardiac arrest (13.3% vs 27.6%), and less commonly had CSWG-SCAI stage E CS (45.7% vs 57.2%) than those with AMI-CS (p&lt;0.001 for all). Impella CP alone was used in 38.3%. Multi-device strategies (sequential or concurrent) included CP+IABP in 9.8%, CP+Impella 5.0/5.5 in 8.3%, CP+ECMO in 23.1%, and CP+≥2 other devices in 20.4%. Impella CP alone was the most common device strategy in both HF-CS (37.9%) and AMI-CS (38.9%) followed by CP+ECMO (26.4% and 20.8%). Acute kidney injury and renal replacement therapy were more common in HF-CS than AMI-CS (66.5% vs 59.7%, p=0.03 for AKI; 40.5% vs 32.7%, p=0.002 for RRT). Acute limb ischemia was less common in HF-CS than in AMI-CS (11.0% vs 14.4%; p=0.05), with no difference in bleeding (36.8% vs 41.7%; p=0.08). Survival to discharge was 53.4% and was higher in HF-CS than AMI-CS (59.7% vs 49.8%; p&lt;0.001). Patients supported by Impella CP+≥2 other devices had the lowest survival (43.8%). Multivariable modeling revealed several factors that were significantly associated with mortality, limb ischemia, and bleeding ( Figure ). Conclusion: Differences in baseline characteristics, shock severity, mechanical device exposure, and hospital complications between patients with HF-CS and AMI-CS supported by Impella CP may influence outcomes.

Introduction: Transesophageal echocardiography (TEE) has been widely used for imaging guidance during Transcatheter aortic valve replacement (TAVR) . However, the use of intracardiac echocardiography (ICE) is being recognized as a promising alternative imaging modality without the need for general anesthesia while providing high-resolution images. Real-world data on clinical outcomes comparing TEE- and ICE-directed TAVR remains limited. This study aimed to explore the in-hospital outcomes associated with ICE- versus TEE-guided TAVR using the US National Inpatient Sample (NIS). Methods: Using the NIS database from 2020 to 2022, we found adult patients who underwent TAVR with either TEE or ICE guidance. The possible confounders were adjusted through multivariable regression analyses. The evaluated outcomes included all-cause in-hospital mortality and complications such as atrial fibrillation, ventricular fibrillation, cardiogenic shock, acute kidney injury (AKI), stroke, and procedural complications. A p-value of &lt;.05 was considered significant. Results: In a subpopulation of 9,248 patients, 85.9% (n=7,947) had TEE-guided and 14.1% (n=1,301) had ICE-guided TAVR. Majority of the population were males (57% vs 42%) and whites (87%) and the mean age group was 77 years. On unadjusted analysis, ICE-guided TAVR was associated with lower all-cause mortality (0.7% vs 1.7%, p=0.012), ventricular fibrillation (0.1% vs 0.9%, p=0.004), cardiogenic shock (1.3% vs 3.2%, p&lt;0.0001), and AKI (6.7% vs 12.2%, p&lt;0.0001). After adjustment, ICE-guided TAVR remained significantly associated with reduced odds of ventricular fibrillation (adjusted OR 0.22; 95% CI: 0.05–0.91; p=0.037), cardiogenic shock (aOR 0.48; 95% CI: 0.28–0.83; p=0.01), and AKI (aOR 0.65; 95% CI: 0.48–0.87; p=0.004) while the periprocedural complication rates including pericarditis, pericardial effusion and tamponade, pneumothorax, dissection and pacemaker implantation remained similar in both the groups. The ICE group had a mean length of stay that was 1.38 days shorter (2.65 vs 4.03 days, p&lt;0.001), and the total hospitalization cost was significantly lower by $57,595 (ICE: $203,710 vs TEE: $266,105; p&lt;0.001). Conclusions: ICE-guided TAVR was associated with favorable in-hospital outcomes, reflecting lower rates of ventricular fibrillation, cardiogenic shock, and AKI, as well as significantly shorter hospital stays and reduced costs, compared to TEE-guided TAVR.

Introduction: Propofol has shown favorable outcomes in mechanically ventilated ICU patients, including shorter ventilation times, faster arousal, and reduced ICU stays. Despite these advantages, it is often avoided in cardiogenic shock due to concerns about hypotension and negative inotropic effects. However, there is limited evidence guiding sedative selection in this population. This study examines whether propofol use, compared to dexmedetomidine, fentanyl, and midazolam, is independently associated with differences in vasopressor requirements and in-hospital mortality among patients with cardiogenic shock. Research Question: Among CICU patients with cardiogenic shock, is propofol use independently associated with vasoactive-inotropic score (VIS) or in-hospital mortality compared to other commonly used sedatives? Methods: We conducted a retrospective cohort study of 3,480 adults admitted to the Northwell Health CICU (2016–2022) with a diagnosis of cardiogenic shock. Patients were grouped by predominant sedative exposure: propofol (reference), dexmedetomidine, fentanyl, midazolam, or mixed (no agent ≥75% of cumulative sedation shifts). Multivariable linear regression assessed the association between sedative group and VIS; logistic regression assessed in-hospital mortality. Models were adjusted for age, sex, Charlson Comorbidity Index, MAP, lactate, and creatinine. Results/Data: Compared to dexmedetomidine, propofol was associated with a higher VIS (β = +3.23, 95% CI: –0.85 to +7.31; p = 0.12), though not statistically significant. Propofol was associated with lower VIS compared to fentanyl (β = –23.89, p &lt; 0.001), midazolam (β = –16.29, p = 0.027), and mixed sedatives (β = –7.39, p = 0.003). Propofol use was associated with higher odds of mortality versus dexmedetomidine (OR = 2.11, p &lt; 0.001), but lower odds versus fentanyl (OR = 0.46, p = 0.004), midazolam (OR = 0.47, p = 0.016), and mixed sedatives (OR = 0.75, p = 0.011). Conclusion: After adjusting for clinical and hemodynamic variables, propofol use was independently associated with lower vasopressor/inotrope requirements and reduced mortality compared to fentanyl, midazolam, and mixed sedatives. The higher mortality compared to dexmedetomidine may reflect selection bias, as it is often used in less critically ill patients requiring lighter sedation. These findings support continued use of propofol in cardiogenic shock when appropriate, though prospective studies are needed to confirm causality.