Escalation Of Mechanical Circulatory Support Research Articles

Acute Triple Coronary Artery Occlusion Leading to Cardiogenic Shock and Cardiac Arrest Emphasizing the Role of Mechanical Circulatory Support (Escalate before It’s Too Late)

We report a case of cardiac arrest in a 38-year-old male with no past medical history who presented as a case of ST-segment elevation myocardial infarction, and coronary angiography showed triple coronary artery thrombosis complicated with cardiogenic shock (CS) that warrants starting on inotropic support and insertion of intra-aortic balloon pump. CS diagnosis with a high likelihood of deterioration was established based on hemodynamics assessment; hence, an early prompt decision for escalation of mechanical circulatory support to Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was made, which helped to prevent the patient’s further deterioration and organ damage. The patient had uneventful VA-ECMO decannulation and was transferred to the ward and discharged after 28 days in stable condition on oral medical therapy and was following up regularly in the cardiology clinic. Therefore, early hemodynamics assessment in acute myocardial infarction CS cases will help predict rapid worsening, which may require prompt escalation of mechanical circulatory support and perhaps improve the outcome.

Prognostic impact of lung computed tomography density in cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation.

Pulmonary complications often occur in patients receiving veno-arterial extracorporeal membrane oxygenation (VA ECMO). However, the prognostic impact of lung damage has not been fully elucidated. This single-center retrospective observational study targeted patients with cardiogenic shock who received VA ECMO between 2012 and 2021. This study included 65 patients who underwent chest computed tomography (CT) on VA ECMO, followed by escalation to central mechanical circulatory support (MCS) with left ventricular venting. The average density of lung CT images was measured using region-of-interest methods, and the primary endpoint was 180-day all-cause death after escalation to the central MCS. Twenty-two patients (34%) developed 180-day all-cause death. According to the Cox regression analysis, age (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.03-1.14; p = 0.001), ischemic etiology (HR, 5.53; 95% CI, 2.09-14.62; p < 0.001), duration of VA ECMO support (HR, 1.19; 95% CI, 1.00-1.40; p = 0.045), and lung CT density (≥ -481 Hounsfield unit [HU]) (HR, 6.33; 95% CI, 2.26-17.72; p < 0.001) were independently associated with all-cause death. Receiver operating characteristic curve analysis determined that lung CT density ≥ -481 HU is an optimal cutoff value for predicting all-cause death (area under the curve [AUC], 0.72). The 180-day overall survival rate for patients with high lung CT density (≥ -481 HU) was significantly lower than that for those with low lung CT density (< -481 HU) (44.4% vs. 81.6%, respectively, p = 0.002). Higher lung CT density could be a useful predictor of death in patients with VA ECMO requiring central MCS escalation.

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

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

(787) Escalation of Mechanical Circulatory Support in a Patient with an Acute Myocardial Infarction, Cardiogenic Shock and Refractory Ventricular Tachycardia

(787) Escalation of Mechanical Circulatory Support in a Patient with an Acute Myocardial Infarction, Cardiogenic Shock and Refractory Ventricular Tachycardia

1119 INTRA-AORTIC BALLOON PUMP AS BRIDGE TO HEART REPLACEMENT THERAPY IN CARDIOGENIC SHOCK COMPLICATING CHRONIC HEART FAILURE

Abstract Background Temporary mechanical circulatory support (MCS) could provide stabilization and improve prognosis in selected patients with cardiogenic shock (CS). Intra-aortic balloon pump (IABP) is a common percutaneous MCS device, characterized by wide availability, easy deployment and low complication rate. Despite its use in CS caused by acute myocardial infarction has been discouraged based on available evidence, recent data have renewed the interest in IABP as bridge to heart replacement therapy (HRT; heart transplantation or durable LVAD implant) in patients with cardiogenic shock complicating acutely decompensated chronic heart failure. We sought to review our experience with IABP support in this population eligible for HRT at a large-volume transplant center. Methods We retrospectively reviewed all adult patients (&amp;gt; 18 years old) who received IABP at our center between 2016 and 2021. We included patients with chronic heart failure with reduced ejection fraction (LVEF &amp;lt; 40% for at least 3 months) eligible for heart replacement therapy (i.e. &amp;lt; 70 years old). Primary endpoint was IABP success defined as weaning to discharge or successful bridge to HRT without need for MCS escalation. In addition, in-hospital mortality without HRT and MCS complications were assessed. Results Study population consisted of 49 patients with mean age of 54±9 years, 84% of whom were male. Etiology was non-ischemic dilated cardiomyopathy in 72% of patients and mean LVEF was 19±5%. 12 patients (24%) were already listed for heart transplantation. 26 patients (53%) developed cardiogenic shock during hospitalization for acutely decompensated heart failure, while the others presented CS upon admission. IABP success was achieved in 32 (65%) of patients, of whom 13 (39%) were bridged to heart transplantation, 6 (18%) to durable LVAD, while 13 (43%) were weaned from support and discharged. 11 patients (22%) died without MCS upgrade or HRT, including one death occurring 18 days after IABP weaning. 6 patients (12%) required escalation of mechanical circulatory support: 5 with extracorporeal membrane oxygenator (ECMO), 2 of whom were transplanted, and 1 with axillary-implanted Impella 5.0 as effective bridge to durable LVAD. In-hospital mortality without HRT was 28%. Median duration of IABP support was 8 days (0-107). 66% of patients were treated with at least one and 12% with two or more inotropes. Complications occurred in 4 (9%) patients in IABP group, including 3 cases of limb ischemia without sequelae and one fatal bleeding not related to insertion site. Ischemic and bleeding complications were found in 4 out of 5 ECMO-supported patients. Among demographic and laboratory characteristics assessed at baseline and after 24 hours from shock, persistence of increased lactates (&amp;gt;2 mmol/l) at 24 hours and number of inotropic drugs were independently associated with both IABP failure and mortality. Conclusions In patients with cardiogenic shock complicating chronic heart failure, IABP appears a safe and effective bridge strategy to heart replacement therapy with favorable outcomes and acceptable complication rates. Persistence of markers of hypoperfusion and increased need for cardioactive drugs are associated with worse outcomes and should trigger evaluation for MCS escalation. More studies are needed to fully characterize the role and timing of IABP support in this clinical scenario.

Abstract 13175: The Effect of Impella Placement on Morbidity and Mortality in Cardiogenic Shockcomparing Outcomes of Two Percutaneous Mechanical Circulatory Support Modalities as Bridges to Advanced Heart Failure Therapy

Objectives: The use of percutaneous mechanical circulatory support (PMCS) devices offers a means to maintain hemodynamic stability in pre-transplant patients. The Impella Heart Pump and the intra-aortic balloon pump (IABP) are two devices commonly employed for this purpose. We sought to compare the relative safety and efficacy of Impella vs IABP using a retrospective cohort of patients at our institution from 2014-2021. Methods: 239 patients received Impella support, and 220 patients received IABP. Of these patients, 26 receiving Impella and 49 receiving IABP were identified as pre-transplant/VAD. The incidences of 30-day mortality, major bleeding, hemolysis, limb ischemia, stroke, repositioning, and infection were recorded. The number of patients receiving transplants, VADs, Mechanical Circulatory Support escalation, and ECMO were also recorded. The relative risks of complications were calculated, and an alpha of 0.05 was assigned to identify significance. Results: The average age of the IABP group was 54.8 +/- 12.1 years with 39 males to 10 females. The average age of the Impella group was 44.8 +/- 15 years with 15 males to 11 females. There was no significant difference in pre-placement EF between these two groups (IABP EF = 19.28+/-8.62, Impella EF = 21.15+/-9.69; p = 0.4016). A significantly higher relative risk of mortality (RR = 3.23; 95% CI = 1.45-7.20, p = 0.0041), major bleeding (RR = 8.48; 95% CI = 3.2 - 22.45, p &lt; 0.00001), and hemolysis (RR = 35.2; 95% CI = 2.12-582, p = 0.0128) was noted in patients receiving Impella support. No significant difference in the incidence of limb ischemia, stroke, repositioning, or infection was observed between these two groups. A significantly higher number of patients receiving Impella support also required ECMO (p = 0.0003) Conclusions: These data suggest that a higher risk of mortality or major complications may exist for patients receiving Impella support pre-transplant/VAD. Further analysis is needed to correct for baseline differences between these two cohorts.

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

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

Effects of Escalating Temporary Mechanical Circulatory Support in Patients With Worsening Cardiogenic Shock

Cardiogenic shock-related mortality is substantial, and temporary mechanical circulatory support (MCS) devices are frequently used. The authors aimed to describe patient characteristics and outcomes in patients with worsening cardiogenic shock requiring escalation of temporary MCS devices. Worsening cardiogenic shock was defined as persistent hypotension, increasing doses of vasopressors/inotropes, worsening hypoperfusion, or worsening invasive hemo-dynamics. Escalation of temporary MCS devices was defined as adding or exchanging an existing MCS device. Variables were evaluated by logistic regression models and receiver operating characteristic curves. From July 1, 2016, to July 1, 2018, a total of 81 consecutive patients experienced worsening cardiogenic shock requiring temporary MCS escalation. The etiology of cardiogenic shock was heterogeneous (33.3% acute myocardial infarction and 61.7% decompen-sated heart failure). Younger age (<62 years), lower body mass index (<28.7 kg/m2), lower preescalation lactate levels (<3.1 mmol/L), higher postescalation blood pressure (>85 mm Hg), and lower postescalation lactate levels (<2.9 mmol/L) were associated with greater odds of survival. The presence of a pulmonary artery catheter at the time of escalation was associated with greater odds of survival (P = .05). Escalation of temporary MCS in Society for Cardiovascular Angiography and Interventions stage E shock was associated with 100% mortality (P = .05). The rate of overall survival to discharge was 32%. Patients requiring temporary MCS escalation represent a high-risk cohort. Further work is needed to improve outcomes in this patient population.

24h SCAI stage reclassification to predict outcome. Insights from the prospective Altshock-2 registry

Abstract Background Cardiogenic shock (CS) includes several phenotypes of congestion or hypoperfusion with heterogenous hemodynamic features. Timely prognostication with scoring tools is warranted to identify patients requiring escalation to mechanical circulatory support (MCS) and to avoid futility. Purpose Accordingly, we explored the role of the updated Society for Cardiovascular Angiography and Interventions (SCAI) stages classification on in-hospital mortality using a prospective national registry. Methods The Altshock-2 Registry includes 237 patients with CS of all etiologies enrolled between March 2020 and February 2022 in 11 Italian Centers. Patients were classified according to the admission SCAI stages (assigned prospectively and independently updated according to the most recently released version); 24-hour re-assessment was prospectively performed in 201 patients. In-hospital mortality was evaluated for association with admission and 24 hours SCAI stages adjusted for the most relevant clinical covariates. Results Of the 237 patients included, 20 (8.4%) had SCAI shock stage B, 132 (55.8%) SCAI stage C, 60 (25.3) SCAI stage D and 25 (10.5%) SCAI stage E. Patients in stage B had the worst reclassification at 24-hours, with 42% of them showing worsened status and only 8% improving. In-hospital mortality was 38%. The revised SCAI stages at baseline were not independently associated with in-hospital mortality, whereas the SCAI classification at 24-h correctly and independently predicted mortality (the rate of in-hospital death was 18% for patients in SCAI shock stage B, 27% for SCAI shock stage C, 64% for SCAI shock stage D, 100% for SCAI shock stage E). At the multivariate analysis (adjusted for age, gender, eGFR, inotropic score and MCS) only SCAI classification at 24-hour evaluation was an independent predictor of in-hospital mortality (OR and 95% CI were, respectively, 3.32, 0.36–30.63, p=0.290 for SCAI stage C and 13.07, 1.69–146.3 for SCAI stage D, with E perfectly predicting because all patients died). Conclusions The revised SCAI stage classification may improve prognostication only at 24-hour evaluation. Aggressive treatment (either pharmacological or with MCS escalation) should be tailored in order to achieve prompt clinical improvement within the first 24-hours; refractory SCAI stage E at 24 hours portends dismal prognosis. Funding Acknowledgement Type of funding sources: None.

Epidemiology, monitoring, and treatment strategy in cardiogenic shock. A multinational cross-sectional survey of ESC-acute cardiovascular care association research section

Cardiogenic shock (CS) is a life-threatening condition burdened by mortality in up to 50% of cases. Few recommendations exist with intermediate-low level of evidence on CS management and no data on adherence across centres exist. We performed a survey to frame CS management at multinational level. An international cross-sectional survey was created and approved by European Society of Cardiology-Acute Cardiovascular Care Association board. A total of 337 responses from 60 countries were obtained. Data were assessed by the hospital level of care of the participants. The most common cause of CS was AMI (AMI-CS-79.9%) with significant difference according to hospital levels (P = 0.001), followed by acutely decompensated heart failure (HF) (13.4%), myocarditis (3.5%), and de novo HF (1.75%). In 37.8%, percutaneous coronary intervention (PCI) is performed to all CS-patients as a standard approach, whereas 42.1% used PCI if electrocardiogram suggestive of ischaemia and 20.1% only if Universal definition of myocardial infarction criteria are fulfilled. Management (catecholamine titration and mechanical circulatory support escalation) is driven by mean arterial pressure (87.1%), echocardiography (84.4%), and lactate levels (83.4%). Combination of vasopressor and inotrope is chosen with the same frequency (37.7%) than inotrope alone as first-line pharmacological therapy (differences amongst hospital levels; P > 0.5). Noradrenaline is first-line vasopressor (89.9%) followed by dopamine (8.5%), whereas dobutamine is confirmed as the first-line inotrope (65.9%). Cardiogenic shock management is heterogenous and often not adherent to current recommendations. Quality improvement on an international level with evidence-based quality indicators should be developed to standardize diagnostic and therapeutic pathways.

C74 ESCALATION AND DE–ESCALATION OF MECHANICAL CIRCULATORY SUPPORT IN PATIENT WITH CARDIOGENIC SHOCK DUE TO ELECTRICAL STORM

Abstract We describe a case of a 63 year–old man with familiar dilated cardiomyopathy, with severe left ventricle dysfunction (EF 20%) and severe mitral regurgitation.A progressive worsening of functional status was detected (peak VO2 11 ml/kg/min, NYHA III) with some episodes of VT interrupted by bicameral ICD,for which the patient was referred to our center and included in the heart transplant (HT) list. In the following months sustained VT with hemodynamic impact were recorded, with consequent worsening in class INTERMACS 2. The patient underwent to endocardial and epicardial VT ablation, complicated with electrical storm with deterioration towards cardiogenic shock (INTERMACS 1), requiring vaso–inotropic drugs,mechanical ventilation and femoro–femoral VA–ECMO.The patient was centralized in our ICCU, where he maintained a adequate MAP, SvcO2 50% and active diuresis but at echocardiography left ventricle appeared dilated with high filling pressure, X–ray and pulmonary ultrasonography showed congestion, lactate value rapidly increased (5 mmol/mol), renal and hepatic function worsened (creat 2 mg/dl, bil 2.8 mg/dl). After multidisciplinary discussion an escalation of mechanical circulatory support (MCS) was performed, changing ECMO configuration: an arterial cannula was positioned in the right axillary artery and venting cannula positioned in the apex of the left ventricle. The hemodynamic and respiratory parameters quickly improved,the right pulmonary catheterization showed good pulmonary resistence,organ perfusion improved and neurological status was intact, therefore the patient was inserted in emergency list for HT. After few days a de–escalation of MCS was performed,removing venous cannula and oxygenator, changing the circuit in para–corporeal left ventricle mid–term support as bridge to transplantation. The patient maintained conscious, in spontaneous breathing,able to perform physiotherapy and spontaneous nutrition. The de–escalation of MCS allowed to reduce potential complications of MCS and achieve the HT intervention in a better general and functional condition. After 36 days the patient underwent HT with positive outcome. Conclusion MCS are device that require a continuous re–assessment a re–modulation to ensure in the early stages the optimization of haemodynamic support, perfusion of vital organs and unloading of the Vsx and in the following stages an adjustment to long–term strategies (bridge to recovery, bridge to VAD, bridge to heart transplantation).

Cardiac power output index to define hemodynamic response to Impella support in cardiogenic shock.

Early assessment of response to Impella in cardiogenic shock may guide escalation of mechanical circulatory support. Therapeutic goal and response to Impella have not previously been defined. This study tested the hypothesis that targeting 3-h post- Impella cardiac power output index (CPOi)-"hemodynamic response"-in cardiogenic shock is associated with 12-h lactate clearance. Single-center study of 37 consecutive patients who underwent left-sided Impella support for cardiogenic shock due to either acute myocardial infarction or decompensated heart failure. Patients who achieved 3-h post-Impella CPOi ⩾ 0.30 W/m2 were defined as Impella "hemodynamic responder." Twelve of the thirty-seven patients achieved 3-h post-impella CPOi ⩾ 0.30 W/m2 ("hemodynamic responders"). Post-Impella CPOi correlated with 12-h lactate (r = -0.779, p < 0.001) and lactate clearance (r = 0.747, p < 0.001). "Hemodynamic responders" had lower 12-h lactate level and greater 12-h lactate clearance (52 (44-58) vs 17 (14-26)%, p < 0.001). Higher pre-Impella norepinephrine dose (-0.341, p = 0.003) and baseline lactate (-0.009, p = 0.003) were independently associated with lower 3-h post-Impella CPOi. Eighteen patients died within 30 days (2/12 "hemodynamic responders" compared to 16/25 "non-responders," p < 0.001). Patients who achieved early 3-h post-Impella CPOi of ⩾0.30 W/m2 have greater lactate clearance and better short-term survival. Early post-Impella CPOi of 0.30 W/m2 may be used as a therapeutic goal and define favorable response to Impella in cardiogenic shock.

Clinical Impact of Computed Tomography Lung Density in Patients with Peripheral Extracorporeal Life Support Receiving Escalation of Mechanical Circulatory Support

<h3>Purpose</h3> Peripheral veno-arterial extracorporeal membrane oxygenation (p-VA-ECMO) is an essential option for patients with cardiogenic shock, whereas several clinical issues remain due to its unphysiological hemodynamic conditions. Lung damage especially due to massive lung congestion is one of the critical complications related to p-VA-ECMO and has been also recognized as a trigger for escalation of mechanical circulatory support (MCS) using left ventricular (LV) venting. However, the prognostic impact of lung damage in patient with p-VA-ECMO has not been fully elucidated. <h3>Methods</h3> This is a single-center retrospective observational study, targeting patients with cardiogenic shock treated with p-VA-ECMO in our institution from 2013 to 2020. Fifty consecutive patients who underwent chest computed tomography (CT) on VA-ECMO followed by escalation to central ECMO with LV venting including LVAD assist devices were enrolled for this study. The average density of lung CT images [Hounsfield unit (HU)] in both upper field at the levels of bifurcation of trachea that indicates lung congestion were measured in all enrolled patients with region-of-interest methods. The primary endpoint of this study was 180-day mortality after escalation to central ECMO. <h3>Results</h3> Twenty-two patients (44%) developed primary endpoint during the follow-up period [169 (48-180) days]. According to the univariate and multivariable Cox proportional hazard analysis, age [hazard ratio (HR), 1.10; 95% confidential interval (CI), 1.05-1.18; <i>p</i> <0.001], ischemic etiology (HR, 2.91; 95% CI, 1.22-6.96; <i>p</i> =0.017) and high lung density (HR, 1.00; 95% CI, 1.00-1.01; <i>p</i> =0.004) were independently associated with the primary endpoint. Furthermore, optimal cutoff value of lung density to predict primary endpoint was determined as -481 HU. The 180-day overall survival rate after MCS escalation for patients with high lung density (≥ -481 HU) was significantly lower than that of patients with low lung density (40.0% vs. 72.0%, respectively, <i>p</i> =0.025). <h3>Conclusion</h3> This study demonstrates the important clinical implications of lung damages assessed by CT lung density as useful predictors of outcomes in patients with p-VA-ECMO requiring escalation of MCS.

Cardiogenic Shock Following Successful CTO Revascularization

<h3>Introduction</h3> The role of urgent mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied. This case highlights myocardial recovery in a patient with ventricular fibrillation following a CTO PCI supported with MCS. <h3>Case Report</h3> A 45 year-old man with recent non-ST elevation myocardial infarction, found to have triple vessel coronary artery disease treated with drug-eluting stent to LAD and OM1, due to patient preference, presents for an elective revascularization of CTO of RCA. Left ventricular function at time of discharge from his prior hospitalization was preserved. Revascularization of CTO was accomplished with placement of Resolute Onyx 3.5x38 mm stent and Resolute Onyx 3.0x26 mm stent to the mid RCA and a Resolute Onyx 3.0x22 mm stent to the distal RCA. There were no complications, and the patient was transferred to a telemetry floor. Soon after transfer he suffered cardiac arrest with ventricular fibrillation. He was defibrillated with return of spontaneous circulation however remained hemodynamically tenuous. Bedside echocardiogram demonstrated severe biventricular dysfunction. Coronary angiography showed stable anatomy with patent stents. Given declining hemodynamic status an Impella CP was placed emergently via the left femoral artery. He was transferred to the cardiac critical care unit where he subsequently developed monomorphic ventricular tachycardia with further hemodynamic deterioration. He was cannulated for VA ECMO and hemodynamic stability was achieved. Due to ongoing hemolysis, Impella CP was exchanged for an axillary Impella 5.5. As results of medical management and aggressive supportive care, subsequent echocardiograms demonstrated recovery of left and right ventricular function. He was decannulated from VA ECMO and Impella 5.5 after four days. Outpatient transthoracic echocardiogram performed four weeks later demonstrate preserved biventricular function. LV ejection fraction was measured at 55% and global longitudinal strain -16.7%. RV longitudinal strain -21.4%. He is tolerating guideline-directed medical therapy for heart failure. <h3>Summary</h3> This case describes ventricular fibrillation following CTO revascularization and highlights the positive outcomes associated with early recognition of deteriorating cardiogenic shock and rapid escalation of mechanical circulatory support.

Isolated congenital cleft mitral valve leaflet: a rare cause of refractory cardiogenic shock complicating acute myocardial infarction

We report a unique presentation of isolated congenital cleft mitral valve complicating cardiogenic shock from acute myocardial infarction. Isolated cleft mitral valve is an uncommon diagnosis that can have significant clinical implications, especially if not recognized in patients presenting to the catheterization lab with acute myocardial infarction and cardiogenic shock. A review of this rare diagnosis including the options and timing of therapeutic interventions, which can include MitraClip, is important for publication.The case is of a patient who presented with an anterior acute ST elevation myocardial infarction. Despite early coronary revascularization and conventional support, refractory cardiogenic shock ensued requiring mechanical circulatory support escalation to Veno-arterial extracorporeal membrane oxygenation. Subsequently, left ventriculography revealed a massively dilated left atrium and severe mitral regurgitation raising concerns for a mechanical mitral valve complication. The patient was taken to the operating room for possible mitral valve surgery, but a preoperative transesophageal echocardiogram revealed an isolated posterior cleft mitral valve. Since the patient had stabilized on mechanical circulatory support, emergent surgery was deferred. The patient successfully recovered during index hospitalization with mechanical circulatory support and discharged on guideline directed medical therapy.In conclusion, isolated cleft mitral valve is a rare diagnosis that can often be underrecognized without comprehensive 3-dimensional transesophageal echocardiography evaluation. If diagnosed early with significant regurgitation, surgical treatment results in good outcomes and preservation of LV systolic function. Percutaneous correction of a CMVL with MitraClip has been described and may offer an alternative approach for high risk surgical patients.

Escalation and de-escalation of mechanical circulatory support in cardiogenic shock.

Cardiogenic shock (CS) is a clinical entity that includes a wide spectrum of different scenarios. Mechanical circulatory support (MCS) plays a fundamental role in the contemporary treatment of CS, and device selection is a key element in determining optimal treatment in this complex population. Cardiac support with mechanical devices should allow reduction and complete weaning from inotropes. Persistence of elevated left ventricular (LV) filling pressures, pulmonary congestion, metabolic decompensation, and end-organ damage during current MCS are criteria for MCS escalation. Precise diagnosis of the underlying cause of right ventricular (RV) failure is fundamental for undertaking the correct escalation strategy. In the setting of both MCS escalation and de-escalation, it is important to select a strategy in relation to long-term perspectives (bridge-to-recovery, bridge-to-LV assist device, or bridge-to-heart transplantation). Small retrospective studies have demonstrated that the BiPella approach is feasible, reduces cardiac filling pressures and improves cardiac output across a range of causes of CS. Simultaneous LV and RV device implantation and lower RV afterload may be associated with better outcomes in biventricular CS, but prospective studies are still required.

IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock.

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

Impella percutaneous left ventricular assist device as mechanical circulatory support for cardiogenic shock: A retrospective analysis from a tertiary academic medical center.

To describe hemodynamic efficacy and clinical outcomes of Impella percutaneous left ventricular assist device (pLVAD) in patients with cardiogenic shock (CS). Percutaneous LVADs are increasingly used in CS management. However, device-related outcomes and optimal utilization remain active areas of investigation. All CS patients receiving pLVAD as mechanical circulatory support (MCS) between 2011 and 2017 were identified. Clinical characteristics and outcomes were analyzed. A multivariable logistic regression model was created to predict MCS escalation despite pLVAD. Outcomes were compared between early and late implantation. A total of 115 CS patients (mean age 63.6 ± 13.8 years; 69.6% male) receiving pLVAD as MCS were identified, the majority with CS secondary to acute myocardial infarction (AMI; 67.0%). Patients experienced significant cardiac output improvement (median 3.39 L/min to 3.90 L/min, p=.002) and pharmacological support reduction (median vasoactive-inotropic score [VIS] 25.4 to 16.4, p=.049). Placement of extracorporeal membrane oxygenation (ECMO) occurred in 48 (41.7%) of patients. Higher pre-pLVAD VIS was associated with subsequent MCS escalation in the entire cohort and AMI subgroup (OR 1.27 [95% CI 1.02-1.58], p=.034 and OR 1.72 [95% CI 1.04-2.86], p=.035, respectively). Complications were predominantly access site related (bleeding [9.6%], vascular injury [5.2%], and limb ischemia [2.6%]). In-hospital mortality was 57.4%, numerically greater survival was noted with earlier device implantation. Treatment with pLVAD for CS improved hemodynamic status but did not uniformly obviate MCS escalation. Mortality in CS remains high, though earlier device placement for appropriately selected patients may be beneficial.

Short-term use of \u201cECMELLA\u201d in the context of fulminant eosinophilic myocarditis with cardiogenic shock

BackgroundEosinophilic myocarditis (EM) is a rare form of myocarditis. Clinical presentation is various, includes cardiogenic shock and can often be fatal. Diagnosis is based on myocardial eosinophilic infiltration in endomyocardial biopsy. Mechanical circulatory support (MCS) is often required in patients suffering from severe cardiogenic shock. Among the available MCS options the “ECMELLA” concept, a combination of left ventricular venting by Impella® device and extracorporeal life support (ECLS) is possibly able to provide the necessary time frame for diagnostics and initiation of anti-inflammatory medication in patients with fulminant myocarditis.Case presentationWe report a case of a 38‐year‐old woman who was presented to us in severe cardiogenic shock, quickly requiring hemodynamic support by an Impella CP® device. Further dramatic hemodynamic deterioration accompanied by multi-organ dysfunction required escalation of MCS via ECLS as veno‐arterial extracorporeal membrane oxygenation (VA-ECMO). After histopathological diagnosis of EM, our patient was put on immunosuppressive therapy with prednisolone. Recovery of both right and left ventricular function allowed explanation of VA-ECMO on day 4 and further hemodynamic improvement allowed removal of the Impella® device on day 9. The patient was discharged after 7 weeks with fully restored cardiac function and in a good neurological state.ConclusionsIn severe cardiac shock due to fulminant EM the ECMELLA concept as bridge-to-recovery seems to be a valid option to provide the required time for diagnostics and specific therapy.

Percutaneous Left Axillary Artery Placement of Intra-Aortic Balloon Pump in Advanced Heart Failure Patients

ObjectivesThis study presents the largest clinical experience of percutaneously placed axillary intra-aortic balloon pump (IABP) in patients with advanced heart failure. BackgroundTransfemoral placement of IABP limits mobility and recuperation in patients who need prolonged support. We had previously reported a novel percutaneous method of IABP placement in the axillary artery and now present our expanded experience with this technique. MethodsWe performed a retrospective chart review of patients with advanced heart failure with percutaneous axillary IABP placement from November 2007 to June 2018 at Houston Methodist Hospital. We defined successful cardiac replacement therapy as heart transplant or left ventricular assist device implantation. We compared patients who had successful cardiac replacement with those who died and those who needed unplanned escalation of mechanical circulatory support. ResultsOf the 195 patients identified, 133 (68%) underwent successful cardiac replacement (120 transplants and 13 left ventricular assist device) as planned. End-organ function improved on IABP support in patients bridged to next therapy. There were 16 patients that died while on IABP support and 18 needed escalation of support. Higher right atrial/wedge ratio, higher right atrial pressure, smaller left ventricular end diastolic dimension, and ischemic cardiomyopathy were associated with death on the IABP in multivariate analysis. Post-transplant and post left ventricular assist device survival for those bridged successfully was 87% and 62%, respectively. Although bedside repositioning was frequent, 37% needed replacement for malfunction. Vascular complications occurred in a minority. ConclusionsPercutaneous axillary approach for IABP placement is a feasible strategy for prolonged mechanical circulatory support in patients with advanced heart failure.