Early Mechanical Circulatory Support Research Articles

Timing of veno-arterial extracorporeal membrane oxygenation support in patients with cardiogenic shock.

The optimal timing for implementing mechanical circulatory support (MCS) in cardiogenic shock (CS) remains indeterminate. This study aims to evaluate patient characteristics and outcome associated with the time interval between CS onset and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implementation. In this study, patients with CS treated with MCS at 15 tertiary care centres in three countries were enrolled. Patients treated with MCS were stratified into early (<2 h), intermediate (2-12 h) and delayed (≥12-24 h) MCS implantation by using the time interval between CS onset and MCS device implementation. Adjusted logistic and Cox regression models were fitted to assess the association between timing of MCS implementation, patient characteristics and 30-day mortality. A total of 330 patients with CS treated with VA-ECMO and/or microaxial flow pump were included in this study; 20.9% received early, 55.8% intermediate, and 23.3% delayed MCS. Although crude 30-day mortality was slightly lower in patients with early MCS (58.1% vs. 64.7% vs. 64.3%), adjusted analyses showed no significant association between timing of MCS implantation and 30-day all-cause mortality (hazard ratio [HR] for early vs. intermediate MCS: 0.93, 95% confidence interval [CI] 0.59-1.46, p = 0.74; HR for early vs. delayed MCS: 1.29, 95% CI 0.78-2.13, p = 0.33). Moreover, the incidence of complications, related and unrelated to MCS, did not differ significantly among groups. In this exploratory study of patients with CS treated with MCS, the timing of device implantation within 24 h after CS onset was not associated with mortality. This supports a restrictive MCS approach, reserving its application for patients experiencing CS deterioration despite conventional therapy.

Sex Differences in Management, Time to Intervention, and In-Hospital Mortality of Acute Myocardial Infarction and Non-Myocardial Infarction Related Cardiogenic Shock.

Limited data are available on sex differences in the time to treatment of cardiogenic shock (CS) with and without acute myocardial infarction (AMI). For this retrospective cohort study, we used nationally representative hospital survey data from the National Inpatient Sample (years 2016-2021) to assess sex differences in interventions, time to treatment (within versus after 24 hours of admission), and in-hospital mortality for AMI-CS and non-AMI-CS, adjusting for age, race, income, insurance, comorbidities, and prior cardiac interventions. We identified 1,052,360 weighted CS hospitalizations (60% non-AMI-CS; 40% AMI-CS). Women with CS had significantly lower rates of all interventions. For AMI-CS, women had a higher likelihood of in-hospital mortality after: revascularization (adjusted odds ratio (aOR) 1.15 [95% CI 1.09-1.22]), mechanical circulatory support (MCS) (1.15 [1.08-1.22]), right heart catheterization (RHC) (1.10 [1.02-1.19]) (all p<0.001). Similar trends were found for the non-AMI-CS group. Women with AMI-CS were less likely to receive early (within 24 hours of admission) revascularization (0.93 [0.89-0.96]), MCS (0.76 [0.73-0.80]), or RHC (0.89 [0.84-0.95]) than men; women with non-AMI-CS were less likely to receive early revascularization (0.78 [0.73-0.84]), IABP (0.85 [0.78-0.94]), pLVAD (0.88 [0.77-0.99]) or RHC (0.83 [0.79-0.88]) than men (all p<0.001). For both types of CS, in-hospital mortality was not significantly different between men and women receiving early ECMO, pLVAD, or PCI. Sex disparities in the frequency of treatment of CS persist on a national scale, with women being more likely to die following treatment and less likely to receive early treatment. However, when comparing patients who received early treatment, in-hospital mortality does not differ significantly when men and women are treated equally within 24 hours of admission. Early intervention if clinically indicated could mitigate sex-based differences in CS outcomes and should be made a priority in the management of CS.

Temporary mechanical circulatory support in infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials with 6-month follow-up

Percutaneous active mechanical circulatory support (MCS) devices are being increasingly used in the treatment of acute myocardial infarction-related cardiogenic shock (AMICS) despite conflicting evidence regarding their effect on mortality. We aimed to ascertain the effect of early routine active percutaneous MCS versus control treatment on 6-month all-cause mortality in patients with AMICS. In this individual patient data meta-analysis, randomised controlled trials of potential interest were identified, without language restriction, by querying the electronic databases MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, and Embase, as well as ClinicalTrials.gov, up to Jan 26, 2024. All randomised trials with 6-month mortality data comparing early routine active MCS (directly in the catheterisation laboratory after randomisation) versus control in patients with AMICS were included. The primary outcome was 6-month all-cause mortality in patients with AMICS treated with early routine active percutaneous MCS versus control, with a focus on device type (loading, such as venoarterial extracorporeal membrane oxygenation [VA-ECMO] vs unloading) and patient selection. Hazard ratios (HRs) of the primary outcome measure were calculated using Cox regression models. This study is registered with PROSPERO, CRD42024504295. Nine reports of randomised controlled trials (n=1114 patients) were evaluated in detail. Overall, four randomised controlled trials (n=611 patients) compared VA-ECMO with a control treatment and five randomised controlled trials (n=503 patients) compared left ventricular unloading devices with a control treatment. Two randomised controlled trials also included patients who did not have AMICS, who were excluded (55 patients [44 who were treated with VA-ECMO and 11 who were treated with a left ventricular unloading device]). The median patient age was 65 years (IQR 57-73); 845 (79·9%) of 1058 patients with data were male and 213 (20·1%) were female. No significant benefit of early unselected MCS use on 6-month mortality was noted (HR 0·87 [95% CI 0·74-1·03]; p=0·10). No significant differences were observed for left ventricular unloading devices versus control (0·80 [0·62-1·02]; p=0·075), and loading devices also had no effect on mortality (0·93 [0·75-1·17]; p=0·55). Patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality with MCS use (0·77 [0·61-0·97]; p=0·024). Major bleeding (odds ratio 2·64 [95% CI 1·91-3·65]) and vascular complications (4·43 [2·37-8·26]) were more frequent with MCS use than with control. The use of active MCS devices in patients with AMICS did not reduce 6-month mortality (regardless of the device used) and increased major bleeding and vascular complications. However, patients with ST-elevation cardiogenic shock without risk of hypoxic brain injury had a reduction in mortality after MCS use. Therefore, the use of MCS should be restricted to certain patients only. The Heart Center Leipzig at Leipzig University and the Foundation Institut für Herzinfarktforschung.

Mechanical circulatory support early after pediatric heart transplantation—an analysis from the Pediatric Heart Transplant Society

BackgroundThe use of early Mechanical Circulatory Support (MCS) following pediatric heart transplantation is not well-published. This paper attempts to uncover the incidence, predisposing factors and outcomes of MCS in a large, international cohort. MethodsThe Pediatric Heart Transplant Society Database (an international, prospective, event-driven database) was retrospectively analyzed for all cases of primary heart transplant over an 11-year period (2010-2020), dividing the cohort based on need for MCS within 30 days of transplantation. ResultsOf 4321 primary transplants, 249 (5.8%) required MCS (230 ECMO, 19 VAD). In a Cox proportional hazard model, congenital heart disease (p = 0.0002), older donor age (p < 0.0001), and longer ischemic time (p = 0.018) were each related to an increased need for MCS; increasing recipient body surface area (p < 0.0001) and increasing donor left ventricular ejection fraction (p = 0.016) were both correlated with less MCS use. 1-year survival in those requiring MCS was 54.2%, compared with 94.8% in those who did not need MCS (p < 0.0001). Later survival in patients surviving to one year was similar between the groups. ConclusionsMCS is used infrequently following pediatric heart transplant, and is related to donor, recipient and transplant factors. Although mortality is high, those surviving the first year post-transplant have excellent outcomes. Judicious use in those patients who would otherwise perish is therefore justified.

Mixed Shock Complicating Cardiogenic Shock: Frequency, Predictors, and Clinical Outcomes.

Patients presenting with cardiogenic shock (CS) are at risk of developing mixed shock (MS), characterized by distributive-inflammatory phenotype. However, no objective definition exists for this clinical entity. We assessed the frequency, predictors, and prognostic relevance of MS complicating CS, based on a newly proposed objective definition. MS complicating CS was defined as an objective shock state secondary to both an ongoing cardiogenic cause and a distributive-inflammatory phenotype arising at least 12 hours after the initial CS diagnosis, as substantiated by predefined longitudinal changes in hemodynamics, clinical, and laboratory parameters. Among 213 consecutive patients admitted at 2 cardiac intensive care units with CS, 13 with inflammatory-distributive features at initial presentation were excluded, leading to a cohort of 200 patients hospitalized with pure CS (67±13 years, 96% Society of Cardiovascular Angiography and Interventions CS stage class C or higher). MS complicating CS occurred in 24.5% after 120 (29-216) hours from CS diagnosis. Lower systolic arterial pressure (P=0.043), hepatic injury (P=0.049), and suspected/definite infection (P=0.013) at CS diagnosis were independent predictors of MS development. In-hospital mortality (53.1% versus 27.8%; P=0.002) and hospital stay (21 [13-48] versus 17 [9-27] days; P=0.018) were higher in the MS cohort. At logistic multivariable analysis, MS diagnosis (odds ratio [OR], 3.00 [95% CI, 1.39-6.63]; Padj=0.006), age (OR, 1.06 [95% CI, 1.03-1.10] years; Padj<0.001), admission systolic arterial pressure <100 mm Hg (OR, 2.41 [95% CI, 1.19-4.98]; Padj=0.016), and admission serum creatinine (OR, 1.61 [95% CI, 1.19-2.26]; Padj=0.003) conferred higher odds of in-hospital death, while early temporary mechanical circulatory support was associated with lower in-hospital death (OR, 0.36 [95% CI, 0.17-0.75]; Padj=0.008). MS complicating CS, objectively defined leveraging on longitudinal changes in distributive and inflammatory features, occurs in one-fourth of patients with CS, is predicted by markers of CS severity and inflammation at CS diagnosis, and portends higher hospital mortality.

Protected cardiac surgery: strategic mechanical circulatory support to improve postcardiotomy mortality.

To examine the evolving landscape of cardiac surgery, focusing on the increasing complexity of patients and the role of mechanical circulatory support (MCS) in managing perioperative low cardiac output syndrome (P-LCOS). P-LCOS is a significant predictor of mortality in cardiac surgery patients. Preoperative risk factors, such as cardiogenic shock and elevated lactate levels, can help identify those at higher risk. Proactive use of MCS, rather than reactive implementation after P-LCOS develops, may lead to improved outcomes by preventing severe organ hypoperfusion. The emerging concept of "protected cardiac surgery" emphasizes early identification of these high-risk patients and planned MCS utilization. Additionally, specific MCS strategies are being developed and refined for various cardiac conditions, including AMI-CS, valvular surgeries, and pulmonary thromboendarterectomy. This paper explores the shifting demographics and complexities in cardiac surgery patients. It emphasizes the importance of proactive, multidisciplinary approaches to identify high-risk patients and implement early MCS to prevent P-LCOS and improve outcomes. The concept of protected cardiac surgery, involving planned MCS use and shared decision-making, is highlighted. The paper also discusses MCS strategies tailored to specific cardiac procedures and the ethical considerations surrounding MCS implementation.

Early temporary mechanical circulatory support for cardiogenic shock: Real-life data from a regional cardiac assistance network

BackgroundTemporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network. MethodsProspective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centres organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality. Results246 patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95%CI:0.65-1.26). Patients with mechanical assistance had a higher rate of complications than others with longer ICU and hospital stays. ConclusionsIn the conditions of a cardiac assistance regional network, in-hospital mortality was not improved by early mechanical assistance implantation. A high incidence of complications of temporary mechanical circulatory support may have jeopardized its potential benefit.

The Utility of the Vasoactive-Inotropic Score and Its Nomogram in Guiding Postoperative Management in Heart Transplant Recipients.

In the early postoperative stage after heart transplantation, there is a lack of predictive tools to guide postoperative management. Whether the vasoactive-inotropic score (VIS) can aid this prediction is not well illustrated. In total, 325 adult patients who underwent heart transplantation at our center between January 2015 and December 2018 were included. The maximum VIS (VISmax) within 24h postoperatively was calculated. The Kaplan-Meier method was used for survival analysis. A logistic regression model was established to determine independent risk factors and to develop a nomogram for a composite severe adverse outcome combining early mortality and morbidity. VISmax was significantly associated with extensive early outcomes such as early death, renal injury, cardiac reoperation and mechanical circulatory support in a grade-dependent manner, and also predicted 90-day and 1-year survival (p < 0.05). A VIS-based nomogram for the severe adverse outcome was developed that included VISmax, preoperative advanced heart failure treatment, hemoglobin and serum creatinine. The nomogram was well calibrated (Hosmer-Lemeshow p = 0.424) with moderate to strong discrimination (C-index = 0.745) and good clinical utility. VISmax is a valuable prognostic index in heart transplantation. In the early post-transplant stage, this VIS-based nomogram can easily aid intensive care clinicians in inferring recipient status and guiding postoperative management.

TCTAP A-044 Early Mechanical Circulatory Support in Myocardial Infarction Complicated by Cardiogenic Shock: A Nationwide Experience in Comparison to International Experience

TCTAP A-044 Early Mechanical Circulatory Support in Myocardial Infarction Complicated by Cardiogenic Shock: A Nationwide Experience in Comparison to International Experience

Mechanical circulatory support in severe primary graft dysfunction: Peripheral cannulation but not earlier implantation improves survival in heart transplantation

Primary graft dysfunction (PGD) still affects 2% to 28% of heart transplants (HT). Severe PGD requires mechanical circulatory support (MCS) and is the main cause of death early after HT. Earlier initiation has been suggested to improve prognosis but the best cannulation strategy is unknown. Analysis of all HT in Spain between 2010 and 2020. Early (<3 hours after HT) vs late initiation (≥3 hours after HT) of MCS was compared. Special focus was placed on peripheral vs central cannulation strategy. A total of 2376 HT were analyzed. 242 (10.2%) suffered severe PGD, 171 (70.7%) received early MCS and 71 (29.3%) late MCS. Baseline characteristics were similar. Patients with late MCS had higher inotropic scores and worse renal function at the moment of cannulation. Early MCS had longer cardiopulmonary bypass times and late MCS was associated with more peripheral vascular damage. No significant differences in survival were observed between early and late implant at 3 months (43.82% vs 48.26%; log-rank p=0.59) or at 1 year (39.29% vs 45.24%, log-rank p=0.49). Multivariate analysis did not show significant differences favoring early implant. Survival was higher in peripheral compared to central cannulation at 3 months (52.74% vs 32.42%, log-rank p=0.001) and 1 year (48.56% vs 28.19%, log-rank p=0.0007). In the multivariate analysis, peripheral cannulation remained a protective factor. Earlier MCS initiation for PGD was not superior, compared to a more conservative approach with deferred initiation. Peripheral compared to central cannulation showed superior 3-month and 1-year survival rates.

SCAI stage reclassification at 24 hpredicts outcome of cardiogenic shock: Insights from the Altshock-2 Registry.

Key points SCAI Shock staging is dynamic and reclassification is expected to occur over time. SCAI Shock classification at 24 hours is an independent predictor of in‐hospital mortality. Further studies investigating the role of early invasive hemodynamic monitoring and mechanical circulatory support are still needed.

Early Mechanical Circulatory Support for Cardiogenic Shock.

Reversal of cardiogenic shock depends on its early recognition and prompt initiation of therapy. Recognition of the clinical and hemodynamic deterioration that precedes cardiogenic shock is a crucial step in its early detection. Treatment of pre-cardiogenic shock is chiefly pharmacologic with intravenous administration of pressor, inotropic, and loop diuretic agents. Failure to reverse the preshock state with pharmacotherapy entails progression to cardiogenic shock and the need for prompt mechanical circulatory support with membrane oxygenation and possibly left ventricular decompression.

Riding The Storm: Utilizing VA-ECMO As A Bridge To Recovery In A Patient With Fulminant Necrotizing Eosinophilic Myocarditis

<h3>Background</h3> Fulminant necrotizing eosinophilic myocarditis (FNEM) is a rare form of eosinophilic myocarditis characterized by new onset heart failure often requiring inotropic and mechanical circulatory support (MCS). Early endomyocardial biopsy (EMB) and prompt immunosuppressive therapy can prevent further decompensation and death, especially in patients presenting with cardiogenic shock. <h3>Case presentation</h3> A 52-year-old female with prior history of mild asthma presented with dyspnea and chest tightness. Vital signs were significant for temperature of 100.9 F, pulse of 140 in sinus rhythm and blood pressure of 89/70. Physical exam was remarkable for crackles at the mid-lower lung fields bilaterally. Baseline EKG showed sinus tachycardia, septal Q waves with ST elevation in V1, V2 and diffuse subtle ST-depressions in the other leads (Figure 1A). Troponin T was elevated to 3.25 ng/ml, pro-BNP was 23,424 pg/ml, CRP was 26.2mg/dl and ESR to 116mm/hour . A 2D echo showed severely reduced left ventricular systolic function with left ventricular ejection fraction (LVEF) of 25-29%, normal left ventricular dimensions, and mildly reduced right ventricular systolic function. Emergent coronary angiography demonstrated no significant coronary artery disease. Right heart catheterization showed a pulmonary artery saturation of 55%, fick cardiac index 1.72, systemic vascular resistance (SVR) of 2128 dynes and elevated bi-ventricular filling pressure (mean right atrial pressure; 23, mean pulmonary capillary wedge pressure; 30mmHg). An endomyocardial biopsy was performed which was consistent with necrotizing eosinophilic myocarditis (Figure 1B). The patient was started on pulse dose steroids. During the first 24 hours she continued to be hemodynamically unstable and required two inotropes to maintain adequate end-organ perfusion. She was placed on VA-ECMO simultaneous with an IABP for left ventricular unloading. Eventually, after being on mechanical support for 7 days, her hemodynamic status improved and her biventricular function completely normalized by day 9. Mechanical and inotropic support was successfully weaned. Patient was discharged on day 23 with a goal to continue a long steroid taper for 6 months. <h3>Conclusion</h3> FNEM is an extremely rare and life threatening pathology that often presents with cardiogenic shock. It is eminently treatable if recognized early during its course. Early EMB should be performed to guide decisions for immunosuppressive therapy. We present a case of FNEM with extremis shock successfully managed with early MCS as bridge-to-recovery.

Impact of Vasoplegic Syndrome on Early Clinical Outcome After Orthotopic Heart Transplantation

<h3>Purpose</h3> Vasoplegic syndrome (VS) is a possible complication after cardiac surgery using cardiopulmonary bypass (CPB) and is mainly characterized by a loss of systemic resistance leading to refractory hypotension and inadequate peripheral tissue perfusion. The objective of this retrospective study is to determine the impact of VS on short- and long-term morbidity and mortality after heart transplantation (OHT). <h3>Methods</h3> We retrospectively reviewed data of 156 consecutive adult patients who underwent OHT at our center between 2010 and 2021. VS was defined as persistent low systemic vascular resistance (<800 dynes/s/cm⁵) with preserved cardiac index (>2.5 L/min/m²) and catecholamine resistant hypotension despite intravenous vasopressors at a high dose (>0.2μg/kg/min norepinephrine) within the first 6-24 hours after surgery. Patients were divided into two groups classified by the presence or absence of vasoplegia. <h3>Results</h3> The incidence of VS was 11.5% (18 patients) with comparable donor and recipient characteristics in both groups. The mean age of vasoplegic patients was 51±10 (vs. 50±12) years and 88.9 % (vs.71.0%) were male. 61.6% (vs. 48.1%) had a history of prior cardiac surgery of which 44.4 % (vs. 28.1%) were implantations of left ventricular assist devices. Vasoplegic patients showed increased lactate levels at the end of CPB (9.0±5.3 vs. 4.9±3.1 mmol/L, p<.001) and higher rate of reoperation for bleeding (55,6% vs. 15.2% p<.001). Of the 18 vasoplegic patients, five patients (27.8%) received immediate mechanical circulatory support (MCS) at the end of CPB for a mean of 5±2.7 days, six patients (33.3%) received delayed MCS after a mean of 7.8±5.7 hours postoperatively for 6.1±4.6 days and seven patients (38.9%) were treated without MCS. 30-day survival rates were 100 % in patients receiving immediate MCS, 50% in patients with delayed MCS and 71.4% in patients without MCS, respectively. Overall 30-day survival rate was lower in vasoplegic patients (72.2% vs 94.9%, p<.001). If patients survived the first 30 days there was no significant difference in 1-year survival (92.3 % vs 90.2%). <h3>Conclusion</h3> Vasoplegic syndrome following heart transplantation was associated with increased perioperative 30-day mortality. Early MCS implantation seemed to be beneficial for short-term survival. Vasoplegic patients surviving the first 30 days had a comparable and good long-term outcome.

Mechanical circulatory support in cardiogenic shock and post-myocardial infarction mechanical complications.

Despite advanced therapies, the mortality of patients with myocardial infarction (MI) complicated by cardiogenic shock (CS) remains around 50%. Mechanical complications of MI are rare nowadays but associated with high mortality in patients who present with CS. Different treatment strategies and mechanical circulatory support (MCS) devices have been increasingly used to improve the grim prognosis of refractory CS. This article discusses current evidence regarding the use of MCS in MI complicated by CS, ventricular septal rupture, free wall rupture and acute mitral regurgitation. Device selection should be tailored according to the cause and severity of CS. Early MCS initiation and multidisciplinary team cooperation is mandatory for good results. MCS associated bleeding remains a major complication and an obstacle to better outcomes. Ongoing prospective randomized trials will improve current knowledge regarding MCS indications, timing, and patient selection in the coming years.

Sex disparities in management and outcomes of cardiac arrest complicating acute myocardial infarction in the United States

BackgroundThere have been limited large scale studies assessing sex disparities in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI). Methods and resultsUsing the National Inpatient Sample (2000–2017), we identified adult admissions (≥18 years) with AMI and CA. Outcomes of interest included sex disparities in coronary angiography (early [hospital day zero] and overall), time to angiography, percutaneous coronary angiography (PCI), mechanical circulatory support (MCS) use, in-hospital mortality, hospitalization costs, hospital length of stay and discharge disposition. In the period between January 1, 2000-December 31, 2017, 11,622,528 admissions for AMI were identified, of which 584,216 (5.0%) were complicated by CA. Men had a higher frequency of CA compared to women (5.4% vs. 4.4%; p < 0.001). Women were on average older (70.4 ± 13.6 vs 65.0 ± 13.1 years), of black race (12.6% vs 7.9%), with higher comorbidity, presenting with non-ST-segment-elevation AMI (36.4% vs 32.3%) and had a non-shockable rhythm (47.6% vs 33.3%); all p < 0.001. Women received less frequent coronary angiography (56.0% vs 66.2%), early coronary angiography (32.0% vs 40.2%), PCI (40.4% vs 49.7%), MCS (17.6% vs 22.0%), and CABG (8.3% vs 10.8%), with a longer median time to angiography (all p < 0.001). Women had higher in-hospital mortality (52.6% vs 40.6%, adjusted odds ratio 1.13 [95% confidence interval 1.11–1.14]; p < 0.001), shorter length of hospital stays, lower hospitalization costs and less frequent discharges to home. ConclusionDespite no difference in guideline recommendations for men and women with AMI-CA, there appears to be a systematic difference in the use of evidence-based care that disadvantages women.

Management of P Management of Patients with Refr atients with Refractory Cardiogenic Shock and diogenic Shock and Cardiointestinal Syndrome with Impella 5.5 as Bridge to Decision: Case Series

Patients with advanced heart failure require multi-system management as a majority succumb to end-organ dysfunction, including gastrointestinal sequelae. Temporizing measures, such as early mechanical circulatory support, can assist in the recovery of patients with acute cardiogenic shock. The temporary support can improve patient characteristics to enable future definitive heart failure therapies such as durable left ventricular assist devices and orthotopic heart transplantation. We present two cases of cardiogenic shock that were successfully bridged with an Impella 5.5 (Abiomed). The management enabled the patients to recover from reversible cardiointestinal syndrome and undergo successful definitive therapies.

The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion

Abstract Introduction Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes. Methods In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)]. Results Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p&amp;lt;0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68). Conclusion A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients. Funding Acknowledgement Type of funding sources: None.

Severe Myocardial Dysfunction after Non-Ischemic Cardiac Arrest: Effectiveness of Percutaneous Assist Devices.

Introduction: Despite the improvements in standardized cardiopulmonary resuscitation, survival remains low, mainly due to initial myocardial dysfunction and hemodynamic instability. Our goal was to compare the efficacy of two left ventricular assist devices on resuscitation and hemodynamic supply in a porcine model of ventricular fibrillation (VF) cardiac arrest. Methods: Seventeen anaesthetized pigs had 12 min of untreated VF followed by 6 min of chest compression and boluses of epinephrine. Next, a first defibrillation was attempted and pigs were randomized to any of the three groups: control (n = 5), implantation of an percutaneous left ventricular assist device (Impella, n = 5) or extracorporeal membrane oxygenation (ECMO, n = 7). Hemodynamic and myocardial functions were evaluated invasively at baseline, at return of spontaneous circulation (ROSC), after 10–30–60–120–240 min post-resuscitation. The primary endpoint was the rate of ROSC. Results: Only one of 5 pigs in the control group, 5 of 5 pigs in the Impella group, and 5 of 7 pigs in the ECMO group had ROSC (p < 0.05). Left ventricular ejection fraction at 240 min post-resuscitation was 37.5 ± 6.2% in the ECMO group vs. 23 ± 3% in the Impella group (p = 0.06). No significant difference in hemodynamic parameters was observed between the two ventricular assist devices. Conclusion: Early mechanical circulatory support appeared to improve resuscitation rates in a shockable rhythm model of cardiac arrest. This approach appears promising and should be further evaluated.

Temporary mechanical circulatory support devices: updates from recent studies.

Over the past several years, the role of short-term mechanical circulatory support (MCS) devices has become the dominant focus in efforts to improve outcomes in patients with cardiogenic shock (CS). Alongside these efforts, temporary MCS devices have been increasingly used to support patients prior to cardiac surgery, during high-risk percutaneous coronary intervention, awaiting cardiac transplantation, and in the setting of refractory cardiac arrest. The present review aims to provide an update on the recent literature evaluating the evolving role of temporary MCS devices, and to provide insights into the current challenges and future directions of MCS research. Recent observational data have demonstrated potential roles for intra-aortic balloon pump preoperatively in high-risk patients awaiting coronary artery bypass grafting, and advanced heart failure patients awaiting transplantation. Impella continues to demonstrate promising results as part of an early MCS strategy in CS, as a temporary bridge to transplantation, and as a mechanism for left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation (ECMO). Finally, the first randomized trial of ECMO facilitated resuscitation in the United States demonstrated improved survival in patients with refractory out of hospital cardiac arrest. Though randomized data remains limited, observational data continue to support the role of temporary MCS devices in a variety of clinical settings.