Cardiogenic Shock Research Articles

Cardiogenic shock.

Cardiogenic shock is a complex syndrome defined by systemic hypoperfusion and inadequate cardiac output arising from a wide array of underlying causes. Although the understanding of cardiogenic shock epidemiology, specific subphenotypes, haemodynamics, and cardiogenic shock severity staging has evolved, few therapeutic interventions have shown survival benefit. Results from seminal randomised controlled trials support early revascularisation of the culprit vessel in infarct-related cardiogenic shock and provide evidence of improved survival with the use of temporary circulatory support in selected patients. However, numerous questions remain unanswered, including optimal pharmacotherapy regimens, the role of mechanical circulatory support devices, management of secondary organ dysfunction, and best supportive care. This Review summarises current definitions, pathophysiological principles, and management approaches in cardiogenic shock, and highlights key knowledge gaps to advance individualised shock therapy and the evidence-based ethical use of modern technology and resources in cardiogenic shock.

Fatal rhabdomyolysis and fulminant myocarditis with malignant arrhythmias after one dose of ipilimumab and nivolumab.

Immune checkpoint inhibitors (ICIs) related myocarditis is a rare complication of modern immunotherapy. It can present as an asymptomatic subclinical condition or full-blown fulminant myocarditis with malignant arrythmias and cardiogenic shock. Myositis/rhabdomyolysis and/or myasthenic symptoms can be present concomitantly. We present a case of fatal fulminant myocarditis presenting with cardiac arrythmias and severe systolic dysfunction, with accompanying rhabdomyolysis after the first dose of ipilimumab and nivolumab immunotherapy. First working diagnosis of subacute late presenting acute myocardial infarction (ACS) was incorrect and the correct diagnosis was established only after additional testing and consultation. Treatment consisted of high-dose corticosteroids, intravenous immunoglobulins, sedation with mechanical ventilation, antibiotic coverage, hemodialysis, and sustained low-efficiency daily diafiltration (SLEDD) with CytoSorb or TheraNova membranes, and intra-aortic balloon pump mechanical cardiac support. No tangible improvement in the condition was observed during the whole treatment period and the patient died on the sixth day of intensive care treatment.

Dengue Cardiomyopathy Treatment Strategy Optimisation by Integrating Point-of-Care Ultrasound with VExUS

Dengue fever is an arthropod-borne viral disease that is widespread throughout the world. Herein, we report a case of dengue cardiomyopathy that was detected and treated to best effect using point-of-care ultrasound (POCUS) and the VExUS score. A 75-year-old lady with no known comorbidities presented with a 10-day history of fever, vomiting, loose stool, and poor appetite. Upon arrival, she was febrile and hypotensive. Bedside POCUS showed poor left ventricular systolic function, inferior vena cava measuring 2.27cm and VExUS grading of 2 to 3. Dengue serology IgM and IgG were positive and NT-proBNP raised at 12500pg/ml. Instead of fluid resuscitation, diuretic and inotropes were initiated along the line of cardiogenic shock secondary to dengue cardiomyopathy. Serial normal cardiac enzymes and electrocardiogram excluded acute coronary syndrome. She was discharged well, and repeated echocardiography one-month post discharge showed normal left ventricular systolic function with no clinical signs or symptoms of heart failure.

Utilization and Outcomes of Temporary Percutaneous Right Ventricular Assist Devices in Cardiogenic Shock

Acute right ventricular failure (RVF) is a common finding in cardiogenic shock (CS), yet the optimal method of supporting the failing RV remains unclear. This study aimed to describe CS patients receiving percutaneous right ventricular assist devices (pRVADs) using the multicenter Cardiogenic Shock Working Group (CSWG) registry. Among 6,201 patients with CS, 152 (2.4%) received pRVADs, with ProtekDuo and Impella RP being used in 71% and 29% of cases, respectively. The average age of this group was 58.5 years, with a higher proportion of men (66.4%). Heart failure–associated CS (HF-CS) was observed in 48% of patients, while myocardial infarction–associated CS (MI-CS) was seen in 27% (HF-CS versus MI-CS: 52.8% vs. 21.3% for ProtekDuo; 36.4% vs. 40.9% for Impella RP; p = 0.01). The overall in-hospital mortality rate was 54.6%, bleeding complications were more prevalent among ProtekDuo recipients (64.8% vs. 43.2%, p = 0.008), whereas Impella RP recipients had shorter hospital stays (20.4 ± 18.7 vs. 41.9 ± 31.5 days, p < 0.001). ProtekDuo was more commonly used in patients with HF-CS and was associated with higher rates of bleeding and longer hospital stays compared with Impella RP, although overall mortality was similar. Further investigation is required to determine the ideal timing and clinical conditions warranting pRVAD deployment in CS.

Sex disparities in myocardial infarction related cardiogenic shock.

Women are underrepresented In cardiovascular disease research, constituting only 30 % of the cardiogenic shock (CS) population. Consequently, guidelines are mainly based on male patients. This study aims to comprehensively examine the sex-specific aspects of acute myocardial infarction (AMI)-related CS, encompassing presentation, treatment and outcomes. Patients with CS undergoing percutaneous coronary intervention (PCI) between 2017 and 2021 were identified using the national Netherlands Heart Registration. Mortality was assessed using the Kaplan Meier method, and logistic regression was performed to investigate differences in clinical management between sexes. Furthermore, a sensitivity analysis excluding patients with out-of-hospital cardiac arrest (OHCA) was conducted. Among 2274 patients, 614 (27 %) were female. Women were older (70 vs. 66 years, p < 0.001) and presented with longer symptom duration (> 3 h: 52 % vs. 37 %, p < 0.001). Men more often presented with multivessel disease (62 % vs. 56 %, p < 0.001), a prior myocardial infarction (23 % vs. 15 %, p < 0.001) and after an OHCA (46 % vs. 29 %, p < 0.001). A trend towards more usage of mechanical circulatory support in men was observed (adjusted OR 0.86, 95 % CI 0.67-1.09). Mortality, both adjusted and unadjusted, was not statistically different for men and women. Women with CS present with distinct clinical characteristics, including longer symptom duration, underscoring the importance of symptom recognition. Furthermore, men present at younger age and with more OHCA. Mortality in men and women was similar despite differences in presentation and clinical management.

Cardiogenic shock in resource-limited settings

Cardiogenic shock in resource-limited settings

A novel mutation in FNIP1 associated with a syndromic immunodeficiency and cardiomyopathy.

Genetic variants in Folliculin interacting protein 1 (FNIP1) were recently discovered as monogenic causes for immunodeficiency and cardiomyopathy, with only a few patients diagnosed thus far. In this study, we describe a patient harboring a novel genetic variant in FNIP1 causing immunodeficiency with cardiac involvement. Clinical and immunological workups were performed. Genetic evaluation utilizing whole-exome sequencing (WES) and Sanger sequencing was conducted. The index patient (subject II-4) presented with hypertrophic cardiomyopathy, recurrent infections, and chronic diarrhea during infancy. Immune workup revealed agammaglobulinemia and a lack of B lymphocytes. Genetic evaluation identified a homozygous 13-bp duplication variant in FNIP1 (c.52_64dupGCGCCCGGCCGCG, p. Asp22GlyfsTer21) resulting in a frameshift in exon 1/18. She was treated with supplemental intravenous immunoglobulins (IVIg) with good control of sinopulmonary and gastrointestinal manifestations. Her sibling (subject II-1) had similar clinical features, along with dysmorphic facial features and hypotony, and succumbed to cardiogenic shock at the age of 2 months, prior to genetic evaluation. Diagnosis of novel immunodeficiencies promotes our understanding of the immune system, enabling genetic counseling as herein, and may assist in the development of novel medical therapies in the future. FNIP1 loss-of-function should be considered in patients presenting in infancy with cardiac manifestations along with agammaglobulinemia (and B-cell lymphopenia).

Complete heart block and subsequent sudden cardiac death following transcatheter tricuspid valve replacement in a heart transplant patient: a case report

Abstract Background Tricuspid regurgitation (TR) is a common valvular complication following heart transplantation. Transcatheter tricuspid valve replacement exists as a novel treatment option. However, as with any procedure, important complications can occur and warrant discussion. Case Summary A 46 year old woman, status-post orthotopic heart transplant (HT), developed symptomatic severe TR. She underwent transcatheter tricuspid valve replacement (TTVR; EVOQUE System, Edwards Lifesciences) and subsequently represented to hospital following a syncopal event. She was found to be in cardiogenic shock with complete heart block on electrocardiogram that degenerated into sudden cardiac death. Although the valve was well seated, autopsy revealed areas of focal necrosis where the bioprosthetic valve was seated in the region of the atrioventricular node and His bundle. Discussion This is the first case report of a complication of transcatheter tricuspid valve replacement in a heart transplant patient resulting in complete heart block and sudden cardiac death. While TTVR may be a good treatment option for select patients in this high-risk group, conduction system damage is a potential complication given the anatomy of the region and requires very close monitoring. This case further highlights the unique physiology of HT patients and illustrates the fact that bradyarrhythmias are often poorly tolerated and potentially lethal.

Characteristics and In-Hospital Outcomes of Single-Vessel Coronary Disease Intervention: A Propensity-Matched Analysis of the National Inpatient Sample Database 2016–2020

Background/Objectives: Few studies have analyzed in-hospital complications and events following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) procedures for patients who underwent these interventions for single-vessel coronary artery disease (CAD). This study aims to compare the outcomes of PCI and CABG in such patients using a large propensity-matched real-world database based on procedural codes. Methods: Adult patients receiving PCI or CABG for single-vessel CAD were identified from the 2016–2020 National Inpatient Sample (NIS) database. Any cases targeting multi-vessel disease or employing a multi-treatment approach were excluded using appropriate procedural codes. Differences in events and complications from admission to discharge were studied between the two procedures (PCI vs. CABG) via logistic regression analysis. Results: After propensity matching with 273,380 patients in both groups, complication risks such as cardiac tamponade (aOR: 3.6 [3.27–3.96]), acute kidney injury (aOR: 1.53 [1.51–1.56]), cardiogenic shock (aOR: 1.38 [1.34–1.40]), procedural bleeding (aOR: 1.75 [1.67–1.83]), acute ischemic stroke (aOR: 1.89 [1.80–1.97]), and all-cause mortality (aOR: 1.05 [1.02–1.08]) were higher among CABG patients. No differences were observed for events of cardiac perforation (aOR: 0.92, [0.84–1.01]). Conclusions: In this large real-world propensity-matched analysis, CABG was associated with higher risks of multiple in-hospital complications and all-cause mortality compared to PCI following a single-vessel coronary intervention.

Hemodynamic Effects and Clinical Outcomes of Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation (LAVA-ECMO) in Cardiogenic Shock.

Left atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO) in CS is a novel mechanical cardiocirculatory support strategy that provides robust cardiocirculatory support and simultaneous left and right atrial venting via a multi-fenestrated transeptal catheter. We performed a single-center retrospective analysis of all patients aged ≥ 18 years with CS who underwent LAVA-ECMO at a quaternary care institution from 2018-2023. Clinical outcomes as well as pre- and post-hemodynamics were evaluated. A total of 68 patients were analyzed (75% male, 72% white, median age 63). Indications for LAVA-ECMO were CS due to myocardial infarction (29.4%), biventricular failure (26.5%), and/or valvular heart disease (26.5%). Trans-septal puncture was guided by intracardiac echocardiography (86.8%) or transesophageal echocardiography (13.2%). Arterial cannulation was performed via transcaval access in 25% of the cases. Post-LAVA-ECMO cannulation was associated with substantial improvement in the hemodynamics within 24 hours post cannulation, including reduction in right atrial pressure (absolute mean difference: -5.0 mmHg, p<0.001), mean pulmonary artery pressure (-9.0 mmHg, p<0.001), pulmonary capillary wedge pressure (-10.0 mmHg, p<0.001), and LV end-diastolic pressure (-14.0 mmHg, p<0.001). Survival to decannulation occurred in 69.1%, while 30-day survival from cannulation was 51.5%. In-hospital all-cause mortality was 51.5%. Only 5 patients (7.4%) required additional MCS (4 Impella, 1 VAV-ECMO). There were no complications related to transeptal placement of the venous ECMO cannula. In conclusion, LAVA-ECMO, a MCS strategy providing bi-atrial drainage, appears to also provide simultaneous LV venting as demonstrated by improved invasive hemodynamics. Although the procedure itself appears safe, with no direct complications to interatrial septal cannulation, post-cannulation complications remain high, and further studies are needed to evaluate the full safety profile of LAVA-ECMO compared to alternative MCS strategies.

Extended use of axillary impella 5.5 as a bridge to post-infarct ventricular septal defect repair.

Post-infarct ventricular septal defect (VSD) carries high mortality. Since emergent repair of post-infarct VSD is challenging, hemodynamic stabilization utilizing temporary mechanical circulatory support crucially provides time to delay intervention and allows necessary scar tissue formation which improves the fragility of myocardium and leads to a definitive repair. To date, there remains no standard for achieving hemodynamic stability, including usage and mode of temporary mechanical circulatory support. We describe a patient with acute post-infarct VSD in cardiogenic shock successfully supported with Impella 5.5 for 67days as a bridge to surgical repair and coronary artery bypass grafting.

Abstract 4138552: Prevalence, Complications, and Outcomes of Cardiogenic Shock in Breast Cancer Patients; A Population Based Study

Background: Cardiovascular disease and cancer are the leading causes of mortality in developed countries. Recent evidence suggests that these conditions share common underlying factors, such as inflammation and oxidative stress. However, there is a lack of data on the association between cardiogenic shock and cancer. Purpose: Our study aimed to investigate the prevalence and outcomes of cardiogenic shock in patients with a history of breast cancer. Methods: We conducted a retrospective analysis of data from the National Inpatient Sample Database (2018-2020) to identify patients with a primary diagnosis of breast cancer. We employed the International Classification of Diseases (ICD-10) diagnostic criteria. Our analysis focused on the impact of cardiogenic shock on mortality, morbidity, and resource utilization. We used chi-square tests for categorical variables and t-tests for continuous variables. Results: Our analysis identified 516,125 breast cancer patients admitted between 2018 and 2020, with 11.3% experiencing cardiogenic shock. The mean age of these patients was 64 years, with 1.2% males and 98.8% females. The mortality rate among patients with cardiogenic shock was 11.8%, which was significantly higher than the 4.1% mortality rate in those without cardiogenic shock (OR 1.9, CI 1.5-2.4, p-value &lt;0.05). Patients with cardiogenic shock were more likely to experience arrhythmias (OR 1.2, CI 1.13-1.4, p-value &lt;0.05) cardiac arrest (OR 2.1, CI 1.3-2.9, p-value &lt;0.05), acute kidney injury (OR 2.2, CI 2.1-2.3, p-value &lt;0.05), and systemic inflammatory response syndrome (SIRS) (OR 2.8, CI 2.5-3, p-value &lt; 0.05). These complications were associated with increased hospitalization costs, with patients with cardiogenic shock incurring $77,185 in costs compared to $64,300 for those without cardiogenic shock (p-value 0.00). Conclusion: Our study highlights the significant prevalence of cardiogenic shock in patients with breast cancer (11.3%) and its association with increased mortality rates. These findings highlights the importance of immediate management of cardiogenic shock to prevent adverse outcomes and emphasize the need for close monitoring and early intervention to minimize the risk of related complications. Multidisciplinary cooperation between cardiologists, intensivists, and oncologists is crucial during these critical situations.

Abstract 4138252: Association between Pressure-Adjusted Heart Rate and Mortality in Cardiogenic Shock

Introduction: Among patients with cardiogenic shock (CS), high right atrial pressure (RAP) and low mean arterial pressure (MAP) are associated with in-hospital mortality. Pressure-adjusted heart rate (PAHR), defined as heart rate * RAP-to-MAP ratio (HR * [RAP/MAP]), integrates these parameters and has been used to identify cardiovascular dysfunction in critical illness. Higher PAHR values associate with higher surgical ICU mortality, but the prognostic significance of PAHR has not been assessed in cardiac intensive care unit (CICU) patients with CS. Hypothesis: We hypothesized that higher PAHR values are associated with higher risk of in-hospital mortality in patients with CS. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multinational registry of CICUs coordinated by the TIMI Study Group. Among CS admissions (2018-2023) undergoing invasive hemodynamic assessment within 24h of CICU admission, we calculated PAHR (in bpm) and assessed its relationship with in-hospital mortality. Patients on temporary mechanical circulatory support were excluded. Odds ratios were adjusted for age, sex, vasoactive-inotropic score (VIS), SCAI stage, and preceding cardiac arrest. Subgroup analyses stratifying by CS subtype were performed. Results: Among the 1411 CS admissions in the analysis cohort (mean age 61 years, 31% women), 18% had AMI-CS, 75% had HF-CS, and 7% had secondary CS. At the time of assessment (median 1.4h after CICU admission), 75% were on vasoactive support (median VIS 3.8). Median HR was 92 (Q1-Q3 77-109) bpm, RAP 15 (Q1-Q3 10-19) mmHg, MAP 75 (Q1-Q3 67-87) mmHg, and PAHR 17 (Q1-Q3 11-24) bpm. A stepwise gradient of higher in-hospital mortality with increasing PAHR values (p-trend &lt;0.001; Fig ) was observed. In adjusted models, a higher PAHR was associated with higher in-hospital mortality (aOR per 10-bpm, 1.35 [95% CI, 1.15-1.58]), and had stronger prognostic associations with mortality than its individual hemodynamic components (Fig) . Conclusion: Higher PAHR is strongly associated with in-hospital mortality in CS patients. PAHR, a simple parameter which is readily calculable without needing a pulmonary artery catheter, may aid in identifying CS patients at higher risk of death.

Abstract 4137009: Treating Elderly Cardiogenic Shock Patients with a Microaxial Flow Pump; Is It DANGERous?

Background: The Danish German Cardiogenic Shock trial (DanGer Shock) recently showed a reduction in all-cause mortality when treating selected patients with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock with a microaxial flow pump (mAFP). Whether there is an age-related differential survival benefit is unknown. Objective: To assess the influence of age on 180-day all-cause mortality in patients with STEMI and cardiogenic shock randomized in DanGer Shock. Methods: In DanGer Shock (an open-label, international, multicenter trial), 355 adult patients (aged ≥18 years with no upper age limit) with STEMI and cardiogenic shock were included and randomized to a mAFP (Impella CP) plus standard care or standard care alone. Patients were stratified in quartiles according to age, and logistic regression analyses were used to assess mortality according to age quartiles, and to evaluate whether age modified the treatment effect of the mAFP. Results: From lowest to highest quartile, patients’ ages ranged from 31-59, 60-69, 70-76, and 77-92, respectively. There were no differences in blood pressure, lactate level, left ventricular ejection fraction and shock severity across age groups. However, the proportion of females (41%) and the prevalence of hypertension (64%) was higher in patients aged ≥77 years (highest quartile), while more patients aged &lt;60 years (lowest quartile) had been resuscitated before randomization. Mortality increased incrementally from the lowest quartile to the highest (31% vs. 47% vs. 61% vs. 73%, p log-rank &lt;0.001), with an adjusted odds ratio for death at 180 days of 5.50 (95%CI 2.65-11.8, p&lt;0.001) in the highest quartile compared to the lowest. Patients in the three lower quartiles had a lower absolute mortality at 180 days if randomized to the mAFP group, whereas patients in the highest quartile had a higher mortality if randomized to the mAFP group, p=0.028 for interaction, Figure. Conclusion: In patients with STEMI-related cardiogenic shock, the overall mortality increased with advancing age, and treatment benefit of the mAFP appeared to diminish in the eldest patients. (DanGer Shock, NCT01633502)

Abstract 4127071: Pulmonary Artery Catheter Utilization in Cardiogenic Shock: Clinical Characteristics and Outcomes

Background: The pulmonary artery catheter (PAC) is used for hemodynamic monitoring, but its impact on patient outcomes, especially in cardiogenic shock (CS), is controversial. Several studies have shown no significant benefits and noted complications, leading to a decline in PAC use. However, PAC use appears to have increased recently in guiding management decisions in CS. Our study aims to assess the clinical characteristics and outcomes of CS patients receiving PACs versus not. Methods: We included patients with CS admitted to a tertiary academic medical center between May 2015 and December 2023. Variables were compared using Kruskal-Wallis, chi-squared, and Fisher's exact tests. Hemodynamic parameters were collected from either right heart catheterization or from a PAC. Endpoints included native heart survival to discharge, durable left ventricular assist device (LVAD) implantation, heart transplant (HTx), and 30-day and 1-year survival from discharge. Results: The study group consisted of 742 patients with CS. Of these, 385 (52%) received a PAC and 357 (48%) did not. The baseline characteristics of the two groups are shown in Table 1A . PAC patients had more severe shock, worse hemodynamics, and higher rates of temporary mechanical circulatory support (MCS) use. Hemodynamic measurements at shock onset differed, with PAC patients having higher right atrial pressures and lower cardiac index by Fick. Clinical outcomes and MCS related complications are shown in Table 1B. There was no significant difference in native heart survival at discharge, but HTx and durable LVAD implantation was higher in the PAC group. PAC placement was associated with longer hospital stays and more MCS related complications, including bleeding and hemolysis. The 30-day survival rate was similar between groups, and 1-year survival was marginally higher in the PAC group. Conclusion: PAC patients exhibited more severe clinical characteristics, longer hospital stays, higher rates of temporary MCS use and complications, durable LVAD implantation, and HTx. Short-term survival rates were similar, but 1-year survival was slightly better for PAC patients. Further studies are needed to provide clearer insights into PAC use in CS.

Abstract 4137205: Management Patterns and Outcomes in the Use of Invasive Mechanical Ventilation for Patients with Cardiogenic Shock

Background: Approximately half of all patients with cardiogenic shock (CS) require invasive mechanical ventilation (IMV). While there have been significant advances in the management of patients requiring IMV based on data primarily derived from medical intensive care patients with respiratory failure, little is known regarding the management and outcomes of IMV in patients with CS. Methods: We conducted an analysis of patients treated for CS who required IMV at an academic safety net hospital from 2017-2023. Indications for IMV, ventilator settings, and medications were obtained from the medical record. The primary outcome was unsuccessful extubation, defined as reintubation within 48 hours of extubation. Results: A total of 110 patients with CS who received IMV were identified. Median age was 60yo; 28% of the cohort was female, 39% of Hispanic ethnicity, and 38% of Black race. Primary reasons for intubation included ongoing cardiac arrest (35%) and hypoxic respiratory failure (34%). Most patients were on minimal ventilator support at 24 hours after intubation (median FiO2 40% [IQR 30-50%], post-end expiratory pressure [PEEP] 5cm H2O [IQR 5-8]). Mechanical circulatory support (MCS) was present in 40% of patients at 24 hours post-intubation. Protocolized spontaneous breathing trials (SBTs) were delayed in 77% of patients, primarily due to hemodynamic instability (88%). Planned or unplanned extubation occurred in 63% of patients after a median of 4.8 days [IQR 2.1-8.0]. Ten percent of patients transferred hospitals while on IMV, while 27% were palliatively extubated or died on IMV. The majority (58%) of patients undergoing non-palliative extubation were on vasoactive medications preceding extubation, with only 2% on MCS. Most patients (58%) were extubated to nasal cannula or room air. A total of 13% of patients experienced unsuccessful extubation. Conclusions: In a cohort of patients with CS requiring IMV, most patients were on minimal ventilator settings within 24 hours yet remained intubated with SBTs delayed due to hemodynamic instability. Rates of failed extubation were comparable to published data from other forms of critical illness. Further work is necessary to determine optimal approaches to ventilator liberation and circulatory support in intubated patients with CS where hemodynamic derangements rather than respiratory insufficiency represent the primary barrier to extubation.

Abstract 4119250: Partial versus Full ECMO Support in Combined Cardiogenic and Septic Shock – ELSO Registry Analysis

Background: There remains paucity of data on patient outcomes with combined cardiogenic and septic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. While guidelines exist on target VA-ECMO flow in cardiogenic shock patients, optimal (partial versus full) flow in combined shock remains largely unknown. Methods: We queried the Extracorporeal Life Support Organization registry to identify patients in combined cardiogenic and septic shock supported with VA-ECMO between 2017 and 2022. Patients were categorized into either partial or full ECMO support based on ECMO flow at 24 hours indexed to body surface area. Partial support was defined as &lt; 2.2 liters/m2 while full support was ≥2.2 liters/m2. Patients with other forms of mechanical circulatory support, VA-ECMO as bridge to advanced therapies or discharged on VA-ECMO were excluded from the analysis. Primary outcome of interest was survival to discharge. Baseline characteristics including center volumes and Charlson co-morbidity index were compared between survivors and non survivors. Predictors of mortality were identified using multivariable logistical regression model. Results: A total of 452 patients with combined shock supported with VA-ECMO were identified. Overall mortality was 63%. Patients that survived to discharge were younger (46.3 vs 53 years, p &lt; 0.001) and had lower BMI (29.3 vs 31.1, p = 0.041), Charlson co-morbidity index (1.4 vs 2.0, p = 0.01) and rates of pre-ECMO cardiac arrest (28.7% vs 39.4%, p = 0.023). Survivors were also more likely to be at high [&gt; 25 ECMO runs per year] volume centers compared to low [≤ 10 ECMO runs per year] volume centers (62.3% vs 20.4%, p = 0.04). Patients receiving full ECMO support had a higher likelihood of survival to discharge than partial support (42.6% vs 33.8%, p = 0.063), although it did not reach statistical significance. [Table 1] Indexed VA-ECMO flow at 24 hours was also associated with improved outcomes when assessed as continuous variable. [ Figure 1] Advanced age [aOR 1.02, 95% CI 1.01-1.04, p &lt; 0.001], pre-ECMO cardiac arrest [aOR 1.71, 95% CI 1.11-2.65, p = 0.016] and baseline Charlson co-morbidity index [aOR 1.13, 95% CI 1.01-1.28, p = 0.043] were all associated with increased mortality after adjustment for baseline differences. Conclusion: Mortality among patients requiring VA-ECMO for combined cardiogenic and septic shock is high. Full circulatory support may be associated with improved survival in this cohort.

Abstract 4134825: Diabetic ketoacidosis and hyperglycemic hyperosmolar state outcomes in diabetes patients hospitalized with ST-elevation myocardial infarction

Background: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute life-threatening hyperglycemia conditions. Aims: We aimed to assess their impact on type 2 diabetes patients admitted for ST-elevation myocardial infarction (STEMI). Methods: Data was extracted from the National Readmission Database (2016-2019). The primary endpoint was in-hospital mortality. Secondary endpoints included in-hospital arrhythmias, cardiogenic shock, and 30-day readmission and mortality. Results: A total of 112,829 patients hospitalized for STEMI with a concomitant diagnosis of type 2 diabetes were hospitalized between 2016 and 2019, of whom 112,799 were included in our analysis after the exclusion of patients with missing data ( Figure 1 ). Of those patients, 330 had a diagnosis of DKA, and 292 had a diagnosis of HHS. After 30 days from the initial hospitalization, 118 (35.7%) out of the initial DKA group, 102 (34.9%) out of the initial HHS group, and 26,523 (23.6%) of STEMI patients with diabetes were readmitted. The presence of DKA increased the odds of in-hospital mortality and cardiogenic shock by almost 2-fold (aOR = 2.30 [1.70-3.12], 2.055 [1.602-2.637], respectively) and renal failure by almost 5-fold (aOR = 5.175 [4.090-6.546]) ( Table 1 ). HHS was also associated with higher odds of mortality, acute renal failure, and cardiogenic shock. Within 30 days of initial admission, DKA and HHS increased the risk of readmission (aOR= 1.815 [1.449-2.75], 1.751 [1.376 - 2.228], respectively), but not mortality. Cardiovascular disease was the most common etiology of readmission in all patients ( Figure 2) . The prevalence of non-STEMI was the highest in DKA patients (22.9%), and the prevalence of STEMI was the highest in the HHS group (37.9%). Conclusion: The presence of diabetic ketoacidosis or hyperglycemic hyperosmolar states is associated with higher odds of mortality, renal failure, cardiogenic shock, and 30-day readmission in STEMI patients with type 2 diabetes.

Abstract 4119078: Adjunctive pulmonary artery catheter for patients with cardiogenic shock treated with impella: a meta-analysis

Introduction: The efficacy and safety of use and impact of pulmonary artery catheter (PAC) in patients with cardiogenic shock (CS) treated with Impella remains unclear. The use of PAC in conjunction with Impella for patients with CS might be associated with improved clinical outcomes and increased safety compared to the use of Impella alone. We aimed to perform a systematic review and meta-analysis comparing Impella with versus without PAC for patients with CS. Methods: We systematically searched PubMed, Embase, and Cochrane databases for studies comparing PAC use in patients with CS treated with Impella. We pooled odds ratios (OR) with 95% confidence intervals (CI) applying random-effects model. We used R version 4.3.2 for statistical analyses. Results: We included two observational studies comprising 11,463 patients, of whom 6,058 (53%) had PAC. Compared with no PAC, the use of PAC was associated with a significantly lower in short-term mortality rates (37% vs. 42%; OR 0.83; 95% CI 0.77-0.90; p&lt;0.01; Figure 1A). There was no significant difference in the incidence of arrhythmias 59% vs. 63%; OR 1.14; 95% CI 0.92-1.41 p=0.44; Figure 1B) or renal complications between groups (47% vs. 50%; OR 1.08; 95% CI 1.00-1.17; p=0.06; Figure 1C). Conclusions: In patients with CS, adjunctive PAC to Impella is associated with lower mortality rates, but no significant difference in arrhythmias and renal complications. Randomized controlled trials are warranted to further validate this results.

Abstract 4136694: Impact of left ventricular support devices on myocardial and pulmonary recovery in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation

Background: Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is used to treat cardiogenic shock. However, retrograde arterial perfusion from the femoral artery can increase left ventricular (LV) afterload, resulting in LV distention which may hamper myocardial recovery and worsen pulmonary congestion. An intra-aortic balloon pump (IABP) can mitigate LV afterload, and Impella (Abiomed, Danvers, MA) can directly unload LV pressure. This study aimed to evaluate the efficacy of LV support devices during VA-ECMO in patients with cardiogenic shock. Methods: We retrospectively collected data from 213 consecutive patients treated with VA-ECMO due to cariogenic shock at our institution between January 2013 and December 2023. Patients were categorized as either receiving VA-ECMO alone or VA-ECMO with an LV support device. The LV support device was characterized as VA-ECMO with IABP or Impella. Data were analyzed for mortality, weaning from VA-ECMO, and changes in pulmonary congestion using the congestion score index (CSI), which is a semi-quantitative approach to pulmonary congestion based on a 6-zone evaluation of chest radiography, scoring each zone from 0 (no congestion) to 3 (intense pulmonary edema). Results: In this study, 95 patients received VA-ECMO alone, whereas 118 patients received an LV support device (101 VA-ECMO with IABP and 17 VA-ECMO with Impella). LV support devices improved weaning from VA-ECMO (odds ratio, 3.09 [95% confidence interval (CI), 1.75–5.55]; p&lt;0.0001) whereas there was no difference in IABP versus Impella cohorts. Compared with VA-ECMO alone, patients with VA-ECMO with an LV support device had better survival at 30 days (OR, 3.04 [95% CI, 1.73–5.43]; p&lt;0.0001). The rate of survival to discharge was better in VA-ECMO with an LV support device versus VA-ECMO alone (hazard ratio, 2.51 [95% CI, 1.72–3.65]; p&lt;0.0001). The evaluation of pulmonary congestion using the CSI revealed that congestion significantly improved in VA-ECMO with Impella (changes of CSI: 1.86 to 1.36) but not in VA-ECMO with IABP (1.80 to 1.96) and VA-ECMO alone (1.94 to 2.14). Conclusion: An LV support device may be associated with reduced mortality and increased success in weaning off VA-ECMO in patients with cardiogenic shock. Impella may be particularly effective in reducing pulmonary congestion.