Etiology Of Cardiogenic Shock Research Articles

International cooperation in cardiogenic shock is key to improving outcomes: Cardiogenic Shock Working Group impacts a single-center in a developing country

Abstract Background Management of cardiogenic shock (CS) poses a formidable challenge in healthcare, necessitating innovative approaches and collaborative efforts, not only local, to improve outcomes. Purpose To demonstrate that CSWG international cooperation and research in CS can lower mortality, change practices, and improve outcomes. Methods From our institutional registry 28,054 patients, we selected 9,430 with CS in SCAI CWSG-score B-E 2022-23 CSWG incorporation (n=1112) against previous years (05-21, n=8318). The primary outcome was in-hospital mortality. Univariate and multivariate analyses were performed, and with PAC use as a a priori subgroup. Adjusted analysis was carried out with age, sex, DM, HTN, previous MI, PCI, CABG, or stroke; CKD, CS etiology, PAC, hemodialysis, number of vasoactives; the presence of MCS, use of mechanical ventilation, and SCAI-CSWG stage. Also, propensity score matching was used to explore differences using the a priori selected variables using K-nearest neighbors (K=2), radius of 1:2, caliper 0.2, and exact SCAI stage matching without replacement (Pre-CSWG n=2198, CSWG era n=1106). Results In the CSWG era, there's a increase in mean age (P=0.049) and a higher proportion of men (72.2 vs. 68%, p=0.005). Clinical risk factors show changes, including increased weight (P=0.037), higher smoking (53.3 vs. 48.6%, P=0.003), diabetes (40.1 vs. 34.8%, P=0.001), and hypertension (46.8 vs. 50%, p=0.043). Prior MI and CABG decreased significantly in the CSWG era. Therapeutic shifts are evident, with increased use of PAC (7.9 vs. 4.2%, P<0.001) and significant changes in mechanical circulatory support (p<0.001). Mortality substantially decreases in the CSWG era (15.3 vs. 22.3%, P<0.001). The unadjusted Cox Pre-CSWG era, the HR 1.41 (1.2-1.65, P< 0.001) a restricted mean survival time (RSMT) of 1.73 days (0.92-2.54, P<0.001). In PAC subgroup, the relationship between PAC use and outcomes appears to be consistent across the levels of the interacting variable (Pint=0.918), with a HR Pre-CSWG era 0.51 (0.44-0.59, P <0.001) and CSWG era HR 0.48 (0.33-0.71,P <0.001)(Fig1C) The adjusted analysis, the Pre-CSWG era had a HR 1.21 (1.03-1.42, P=0.019). PAC outcomes were consistent across eras (Pint= 0.923). In the Pre-CSWG era HR 0.71 (0.59-0.84,P<0.001), and similarly in the CSWG era 0.54 (0.34-0.87,P=0.01). (Fig1D) The PS-cohort had a Pre-CSWG era HR 1.21 (1.01-1.45, P=0.034) of the Pre-CSWG era vs CSWG era and a RSMT at 30 days of 1.07 (0.14-2.01 P=0.025). (Fig2) Conclusion Shifts in patient demographics, clinical risk factors, hemodynamic parameters, and therapeutic strategies were observed. Notably, mortality significantly decreased with the CSWG incorporation, with consistent benefits of PAC use in both eras. The PS cohort underscored the impact of CSWG incorporation on outcomes. Overall, these findings highlight the transformative influence of CSWG on CS management, as international cooperation is key to improving outcomes.Figure 1.Mortality through erasFgure 2.Propensity score cohort

S1003 Incidence and Outcomes of Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device Varies Depending on Etiology of Cardiogenic Shock

S1003 Incidence and Outcomes of Gastrointestinal Bleeding in Patients With Left Ventricular Assist Device Varies Depending on Etiology of Cardiogenic Shock

Cardiogenic shock in general intensive care unit: a nationwide prospective analysis of epidemiology and outcome

Abstract Aims Cardiogenic shock (CS) is a life-threatening disease burdened by a mortality up to 50%. The epidemiology has changed with non-ischaemic aetiologies being predominant, although data were mainly derived from patients admitted to dedicated acute cardiac care. We report the epidemiology and outcome of patients with CS admitted to general intensive care unit (ICU). Methods and results Prospective multicentric epidemiological study including 314 general ICU adhering to the GiViTI nationwide registry from 2011 to 2018, excluding cardiac arrest. The primary endpoint of the study was mortality. The association between clinical factors and mortality was evaluated using a logistic regression model. The odds ratios (ORs) of the covariates quantify their association with mortality during hospitalization. A total of 11 052 patients admitted to general ICU {incidence 2.17%; median age 72 [interquartile range (66–81)], 38.7% were women} with CS were included. Forty-seven per cent of patients had more than three organ insufficiency at the time of admission. The most common CS aetiologies were left heart failure (LHF, 5247—47.5%); acute myocardial infarction (3612—32.6%); right heart failure (RHF, 515—4.6%); and biventricular failure (532—4.8%). A total of 85.5% were mechanically ventilated during the ICU hospitalization. The overall ICU mortality was 44.8%, increasing to 53.4% during the hospitalization in the index hospital and to 54.3% at the latest hospital. Right heart failure–cardiogenic shock patients exhibited the highest mortality risk [OR: 1.19, 95% confidence interval (CI) (0.94–1.50); P < 0.001], followed by biventricular CS [OR 1.04, 95% CI (0.82–1.32)]. Respiratory failure [OR 1.13 (95% CI 1.08–1.19)], coagulation disorder [1.17 (95% CI 1.1–1.24)], renal dysfunction [OR 1.55 (95% CI 1.50–1.61)], and neurological alteration [OR 1.45 (95% CI 1.39–1.50)] were associated with worsen outcome along with severe hypotension [systolic blood pressure < 70 mmHg—OR 2.35, 95% CI (2.06–2.67)], increasing age [OR 2.21 95% CI (2.01–2.42)], and longer ICU stay prior to admission (two-fold increase for each 4.7 days). Conclusion In the general ICU, the aetiology of CS, excluding cardiac arrest, remains characterized mostly by LHF with RHF–CS burdened by higher mortality. Multiorgan failure at admission and longer hospital stay before ICU admission predispose to worsen outcome.

Myocardial Recovery in Cardiogenic Shock.

The overarching goal of cardiogenic shock (CS) therapy is ensuring long-term survival. In recent years, increasing emphasis has been placed on analyzing mechanisms to improve outcomes in CS. This includes averting in-hospital mortality, modifying the disease process by promoting heart recovery while avoiding multiorgan failure, and circumventing complications related to both CS and treatment strategies deployed to treat CS. Heart replacement therapies represent a viable strategy for long-term survival but are restricted to a small, select percentage of patients. In this review we focus on pathophysiology of the shock state, with an emphasis on addressing reversible etiologies contributing to the decompensated state, optimizing physiological factors for recovery, and identifying therapeutic targets to promote recovery. We also review the known predictors of myocardial recovery, regardless of the etiology of CS. Lastly, we highlight the current gaps in knowledge in this field and support additional high-quality studies focusing on myocardial recovery in CS.

Building a cardiogenic shock response team: key considerations necessary to improve outcomes.

This review provides key information about cardiogenic shock (CS) teams, including published evidence and practical recommendations to create a CS team and program. CS is a complex disease process with a high in-hospital mortality rate ranging from 30% to 70% according to recent registries and randomized studies. The explanation for the elevated rates is likely multifactorial, including the various etiologies of cardiogenic shock as well as delays in recognition and deployment of appropriate therapies. Accordingly, the use of cardiogenic shock team has been implemented with the aim of improving outcomes in these patients. The CS team typically consists of members with critical care or cardiac critical care expertise, heart failure, cardiothoracic surgery, and interventional cardiology. A number of retrospective studies have now supported the benefits of a CS team, particularly in selecting the appropriate candidates for tailored mechanical circulatory support therapies and providing interventions in a timely manner, which have translated into improved outcomes. CS teams provides a platform for expedited recognition of CS and timely, standardized, and multidisciplinary discussions regarding appropriate management and care.

Cardiogenic shock in general intensive care unit: a nationwide prospective analysis of epidemiology and outcome

Abstract Funding Acknowledgements None. Background Cardiogenic shock (CS) is a heterogenous, life-threatening disease burdened by a mortality up to 50%. An increasing incidence of the CS related to other etiological causes, including acute decompensated heart failure, has been reported. However, most of the epidemiological data are derived from patients admitted to dedicated acute cardiac care units. Epidemiology and management of CS patients admitted to general intensive care unit (ICU) in Italy is yet unexplored. Purpose To describe the epidemiology, patients feature, management and outcome of CS patients admitted to Italian general ICUs. Methods Prospective multicentric epidemiological study. Over 600 thousand patients admitted to 316 hundred Italian general intensive care units from 2011 to 2018 were screened trough PROSAFE software. The Margherita PROSAFE project is an observational project for the continuous electronic collection of data on patients admitted to ICUs; it is developed by the GiViTI (Gruppo italiano per la valutazione degli interventi in terapia intensiva - Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The primary outcome of the analysis was hospital mortality. Secondary outcomes included description of patients features and management. Results 11661 patients (72.1±12.1 years old.; 39.5% women) with a diagnosis of CS were included in the analysis. ICU and in-hospital mortality were respectively 45.5 % and 53.9%. Highest mortality was observed for pulmonary embolism (58.4%), right heart failure (56.3%) and acute decompensated heart failure (ADHF) (44.2%). 46.9% of patients presented with more than 3 organ failure (panel A). CS commonest aetiologies were ADHF (63,3%), acute myocardial infarction (19.8%) and right heart failure (11%). Invasive mechanical ventilation was used in the 88.6% of cases. Intra-aortic balloon pump was placed in 15.2%, with higher frequency in ischemic aetiologies (43.9%) and ADHF (13.7%); VA-ECMO was most frequently placed in the right heart failure (3.7%) and acute myocardial infarction (2.6%) groups. The factors independently associated with increased hospital mortality were increasing age (p <0.001), lower Glasgow coma scale (p <0.001), hypoxemia (PaO2 <100, OR: 1.91; 95% Cl: 1.58 – 2.3; p <0.001), bradycardia (OR: 1.84; 95% Cl: 1.49 – 2.26; p <0.001), hypotension (OR: 1.27; 95% Cl: 1.12 – 1.43; p <0.001), bilirubin above 12 mg/dl (OR: 7.90; 95% Cl: 2.56 – 24.3), increased creatinine (p <0.001) and reduced platelets (<50000 U/mL, OR: 2.43; 95% Cl: 1.78 – 3.31; p <0.001) (panel B). Curiously, in the predictive model a BMI above normal values was protective as well as tachycardia compared to severe bradycardia (panel C). Conclusions The etiology of CS in general intensive care units is heterogeneous with acute heart failure being the commonest. The mortality rate remains unacceptably high with right heart failure and acute heart failure being burden by the worst outcome.

Outcomes of Impella 5.0 and 5.5 for cardiogenic shock: A single-center 137 patient experience.

This study evaluated the outcomes of patients with cardiogenic shock (CS) supported with Impella 5.0 or 5.5 and identified risk factors for in-hospital mortality. Adults with CS who were supported with Impella 5.0 or 5.5 at a single institution were included. Patients were stratified into three groups according to their CS etiology: (1) acute myocardial infarction (AMI), (2) acute decompensated heart failure (ADHF), and (3) postcardiotomy (PC). The primary outcome was survival, and secondary outcomes included adverse events during Impella support and length of stay. Multivariable logistic regression was performed to identify risk factors for in-hospital mortality. One hundred and thirty-seven patients with CS secondary to AMI (n = 47), ADHF (n = 86), and PC (n = 4) were included. The ADHF group had the highest survival rates at all time points. Acute kidney injury (AKI) was the most common complication during Impella support in all 3 groups. Increased rates of AKI and de novo renal replacement therapy were observed in the PC group, and the AMI group experienced a higher incidence of bleeding requiring transfusion. Multivariable analysis demonstrated diabetes mellitus, elevated pre-insertion serum lactate, and elevated pre-insertion serum creatinine were independent predictors of in-hospital mortality, but the etiology of CS did not impact mortality. This study demonstrates that Impella 5.0 and 5.5 provide effective mechanical support for patients with CS with favorable outcomes, with nearly two-thirds of patients alive at 180 days. Diabetes, elevated pre-insertion serum lactate, and elevated pre-insertion serum creatinine are strong risk factors for in-hospital mortality.

Blood glucose and lactate levels as early predictive markers in patients presenting with cardiogenic shock: A retrospective cohort study.

Lactate and glucose are widely used biochemical parameters in current predictive risk scores for cardiogenic shock. Data regarding the relationship between lactate and glucose levels in cardiogenic shock are limited. Thus, we aimed to analyze glucose and lactate as early markers for in-hospital mortality in cardiogenic shock. In this retrospective cohort study, 312 patients presenting with cardiogenic shock to a tertiary-care hospital between 2016 and 2018 were included. Apparent cardiogenic shock was defined as hypoperfusion with hemodynamic compromise and biochemical marker increase due to diminished tissue perfusion, corresponding to SCAI shock stages. In-hospital mortality was assessed as the primary endpoint. The median age of the study population was 71 (60-79) years and the etiology of cardiogenic shock was acute myocardial infarction in 45.8%. Overall in-hospital mortality was 67.6%. In the receiver operating curve analysis, the area under the receiver-operating curve (AUC) for prediction of in-hospital mortality was higher for lactate (AUC: 0.757) than for glucose (AUC: 0.652). Both values were significantly associated with outcome (groups created with best cutoff values obtained from the Youden index). Correlation analysis showed a significant non-linear association of both values. In a multivariable stepwise Cox regression analysis, lactate remained an independent predictor for in-hospital mortality, whilst glucose, despite being implicated in energy metabolism, was not independently predictive for mortality. Together, these data suggest that lactate at admission is superior for mortality prediction in patients with apparent cardiogenic shock. Glucose was not independently predictive for mortality.

Concomitant use of extracorporeal membrane oxygenation and percutaneous microaxial assist device support for cardiogenic shock

ObjectivesVenoarterial extracorporeal membrane oxygenation (VA-ECMO) with concomitant percutaneous microaxial left ventricular assist device support is an emerging treatment modality for cardiogenic shock (CS). Survival outcomes by CS etiology with this support strategy have not been well described. MethodsThis study was a retrospective, single-center analysis of patients with CS due to acute myocardial infarction (AMI-CS) or decompensated heart failure (ADHF-CS) supported with VA-ECMO with concomitant percutaneous microaxial left ventricular assist device support from December 2020 to January 2023. ResultsA total of 44 patients were included (AMI-CS, n = 20, and ADHF-CS, n = 24). Patients with AMI-CS and ADHF-CS had similar survival at 90 days postdischarge (P = .267) with similar destinations after support (P = .220). Patients with AMI-CS initially supported with VA-ECMO were less likely to survive 90 days postdischarge (P = .038) when compared with other cohorts. Limb ischemia and acute kidney injury occurred more frequently in patients presenting with AMI-CS (P =.013; P = .030). Subanalysis of ADHF-CS patients into acute-on-chronic decompensated HF and de novo HF demonstrated no difference in survival or destination. ConclusionsVA-ECMO with concomitant percutaneous microaxial left ventricular assist device support can be used to successfully manage patients with CS. There is no difference in survival or destination for AMI-CS and ADHF-CS with this support strategy. AMI-CS patients with initial VA-ECMO support have increased mortality in comparison to other cohorts. Future multicenter studies are required to fully analyze the differences between AMI-CS and ADHF-CS with this support strategy.

Cardiogenic shock etiology and exit strategy impact survival in patients with Impella 5.5.

Despite historical differences in cardiogenic shock (CS) outcomes by etiology, outcomes by CS etiology have yet to be described in patients supported by temporary mechanical circulatory support (MCS) with Impella 5.5. This study aims to identify differences in survival and post-support destination for these patients in acute myocardial infarction (AMI) and acute decompensated heart failure (ADHF) CS at a high-volume, tertiary, transplant center. A retrospective review of patients who received Impella 5.5 at our center from November 2020 to June 2022 was conducted. Sixty-seven patients underwent Impella 5.5 implantation for CS; 23 (34%) for AMI and 44 (66%) for ADHF. AMI patients presented with higher SCAI stage, pre-implant lactate, and rate of prior MCS devices, and fewer days from admission to implantation. Survival was lower for AMI patients at 30 days, 90 days, and discharge. No difference in time to all-cause mortality was found when excluding patients receiving transplant. There was no significant difference in complication rates between groups. ADHF-CS patients with Impella 5.5 support have a significantly higher rate of survival than patients with AMI-CS. ADHF patients were successfully bridged to heart transplant more often than AMI patients, contributing to increased survival.

Abstract 15831: Characterization of Patient-Specific Care Pathways in Cardiogenic Shock

Background: Heterogeneity in patient characteristics and clinical severity may affect treatment goals and associated management in cardiogenic shock (CS). We sought to better describe the development over time of specific care pathways and the associated patient phenotypes informing such decisions in CS. Methods: We consented and prospectively enrolled 60 patients presenting with CS from November 2022 to May 2023. Provider notes were reviewed for language describing 3 distinct care pathways: Advanced Group (AG): urgent evaluation for left ventricular assist device and/or heart transplantation; Recovery Group (RG): eligible for native myocardial recovery only; and Palliation Group (PG): unlikely to recover. Remaining patients were classified as No Decision (ND). Pathway decisions were assessed at days 3 and 7. Results: Median cohort age was 59 years (IQR 42-66), and 67% (n = 40) were men. Initial SCAI stages D and E comprised 63% (n = 38) of cases. By hospital days 3 and 7, care pathways were defined in 11 (18%) and 36 (60%) patients, respectively ( Figure ). There were no ND deaths before day 7. Patient characteristics were similar regardless of whether a pathway was specified by day 7. Across care pathways, recovery options decreased with increased age (AG 45, RG 53, PG 66 years; p = 0.037) and new dialysis requirement (AG 0%, RG 36% [n = 5], PG 56% [n = 5]; p = 0.007). Initial SCAI stage, CS etiology (AMI 20% [n = 12], HF 58% [n = 35]), rate of shock team activation (15% [n = 9]), and mechanical circulatory support use (43% [n = 26]) were numerically similar. Palliative care was involved in 78% (n = 47) of cases overall and in all PG cases. In-hospital mortality was 29% (n = 16) and was highest in PG (88.9% [n = 8], p <0.0001). Conclusion: Even after 7 days in an intensive care unit at an academic medical center, 40% of patients with CS did not have a care pathway defined. These data suggest that structured interventions to expedite such decision-making should be tested to improve care in patients with CS.

Abstract 17891: Underutilization of Palliative Care Consults and End-of-Life Care Planning After Cardiogenic Shock

Background: Cardiogenic shock (CS) is associated with significant mortality. The 2022 ACC/AHA/HFSA guidelines discuss the importance of palliative care (PC) in advanced heart disease, but PC and end-of-life care (EOLC) integration after CS is not well characterized. We aimed to study the use of PC and EOLC planning after CS. Hypothesis: We assessed the hypothesis that PC consults and EOLC planning are underutilized after CS. Methods: This is a retrospective observational study of 63 consecutive patients at a quaternary care center in Boston diagnosed with CS between January and April 2022. CS onset and etiology were adjudicated by treating physicians. Results: Of 63 patients with CS (mean age 61±14 years, 30% Female, 73% White), 26 (41%) died during admission and 31 (49%) survived 1 year after CS onset. Only 6 patients (10%) received PC consults for EOLC considerations (consults placed on average 9 days from CS onset) (Table 1). Only 24 (38%) had documented advanced care plans after developing CS, of which 14 were documented by PC consultants. Of 44 patients with MCS or ICD placed, only 1 had a documented discussion about the option of discontinuing the therapy in the future. After CS, 28 (44%) had changes in resuscitation limits. Only 1 patient had their preferred location of death documented. Palliative inotropes were prescribed to 2 patients at discharge, and 3 patients were discharged to hospice. Readmission rates at 3 and 6 months were 24% and 36%, respectively. Conclusions: PC and EOLC planning are underutilized after CS, despite the significant mortality of CS. Secondary PC models may not be optimal for CS, given the acute presentation of CS and bimodal distribution of survival after onset. These data demonstrate a compelling need to address key considerations that impact EOLC after CS, such as resuscitation limits, duration of advanced therapies, and goal-concordant discharge locations. Further research is needed to explore optimal models of PC and EOLC integration after CS.

Abstract 16254: Short and Long-Term Outcomes of Patients With Cardiac Amyloidosis Presenting in Cardiogenic Shock

Background: The characteristics and outcomes of patients with cardiac amyloidosis who present in cardiogenic shock (CS) remains poorly defined. Methods: All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1 st , 2010, to Dec 31 st , 2021, with a diagnosis of cardiogenic shock (CS) were retrospectively identified through electronic medical records and confirmed via physician chart review. Patients were further categorized into those with CS with cardiac amyloidosis (C-Amyloid) and CS without cardiac amyloidosis. 30-day and 1-year all-cause mortality was compared between the two groups with Kaplan-Meier (KM) estimates. Results: During the study period, a total of 2775 were patients were admitted to our CICU with CS of which, 29 patients (1%) had confirmed cardiac amyloidosis (C-amyloid). Amongst patients with CS and c-amyloid, 18 patients (62%) had TTR amyloid, 8 (28%) had AL amyloid and 3 were undefined. Compared to patients with other forms of CS, patients with C-amyloid were significantly older (median age of 70 vs 65, p=0.024), had lower prevalence of prior myocardial infarction (21% vs 42%, p=0.037) or coronary artery bypass grafting, and a higher prevalence of chronic kidney disease (69% vs 39%, p=0.002). There were no significant differences in the utilization of right heart catheterization, mechanical circulatory support or mechanical ventilation between the two groups. Comparison of survival probabilities revealed that CS patients with amyloid had similar 30-day (17% vs 21%, p=0.56) and 1-year all-cause mortality (38% vs 31%, p=0.6). Conclusion: Amyloid cardiomyopathy is a rare but unique etiology of CS in the CICU. Observed mortality rates are similar to patients with other forms of CS. Given breakthroughs in therapeutics for this condition, the proportion of patients with this clinical entity is expected to rise.

Abstract 12328: Impact of Female Sex on Cardiogenic Shock Outcomes - A Cardiogenic Shock Working Group Report

Introduction: Studies reporting cardiogenic shock (CS) outcomes in women are scarce. Hypothesis: Among patients with CS complicating acute myocardial infarction (AMI-CS) and heart failure (HF-CS), women have worse survival at discharge and more vascular complications than men. Methods: We analyzed 5,083 CS patients in the Cardiogenic Shock Working Group. Propensity score matching (PSM) was performed using baseline characteristics. Logistic regression was performed for log odds of survival. Results: Among 5,083 patients, 1,522 were women (30%) with a mean age of 66.5±13.2 years. There were 30% women and 29.1% men with AMI-CS (p=0.03). More women presented with de novo HF-CS compared to men (26.2% vs. 19.3%, p<0.001). Before PSM, differences in baseline characteristics and sex-specific outcomes were seen in the HF-CS cohort, with worse survival at discharge (69.9% vs. 74.4%, p=0.009) (Figure A) and higher maximum SCAI stage E (26% vs. 21%, p=0.04) in women than men (Figure B). Women were less likely to receive pulmonary artery catheters (52.9% vs. 54.6%, p<0.001), heart transplant (6.5% vs. 10.3%, p<0.001) or left ventricular assist device (7.8% vs. 10%, p=0.01). Differences in AMI-CS cohort were less discrepant. Regardless of CS etiology, women had more vascular complications (8.8% vs. 5.7%, p<0.001), bleeding (7.1% vs. 5.2%, p=0.01), and limb ischemia (6.8% vs. 4.5%, p=0.001) (Figure C). More vascular complications persisted in women after PSM (10.4% women vs. 7.4% men, p=0.06). Conclusions: Women with HF-CS had worse outcomes and more vascular complications than men with HF-CS. More studies are needed to identify barriers to advanced therapies, decrease complications and improve outcomes of women with CS.

Impact of Female Sex on Cardiogenic Shock Outcomes: A Cardiogenic Shock Working Group Report

BackgroundStudies reporting cardiogenic shock (CS) outcomes in women are scarce. ObjectivesThe authors compared survival at discharge among women vs men with CS complicating acute myocardial infarction (AMI-CS) and heart failure (HF-CS). MethodsThe authors analyzed 5,083 CS patients in the Cardiogenic Shock Working Group. Propensity score matching (PSM) was performed with the use of baseline characteristics. Logistic regression was performed for log odds of survival. ResultsAmong 5,083 patients, 1,522 were women (30%), whose mean age was 61.8 ± 15.8 years. There were 30% women and 29.1% men with AMI-CS (P = 0.03). More women presented with de novo HF-CS compared with men (26.2% vs 19.3%; P < 0.001). Before PSM, differences in baseline characteristics and sex-specific outcomes were seen in the HF-CS cohort, with worse survival at discharge (69.9% vs 74.4%; P = 0.009) and a higher rate of maximum Society for Cardiac Angiography and Interventions stage E (26% vs 21%; P = 0.04) in women than in men. Women were less likely to receive pulmonary artery catheterization (52.9% vs 54.6%; P < 0.001), heart transplantation (6.5% vs 10.3%; P < 0.001), or left ventricular assist device implantation (7.8% vs 10%; P = 0.01). Regardless of CS etiology, women had more vascular complications (8.8% vs 5.7%; P < 0.001), bleeding (7.1% vs 5.2%; P = 0.01), and limb ischemia (6.8% vs 4.5%; P = 0.001). More vascular complications persisted in women after PSM (10.4% women vs 7.4% men; P = 0.06). ConclusionsWomen with HF-CS had worse outcomes and more vascular complications than men with HF-CS. More studies are needed to identify barriers to advanced therapies, decrease complications, and improve outcomes of women with CS.

Defining levels of care in cardiogenic shock.

Expert opinion and professional society statements have called for multi-tier care systems for the management of cardiogenic shock (CS). However, little is known about how to pragmatically define centers with different levels of care (LOC) for CS. Eleven of 23 hospitals within our healthcare system sharing a common electronic health record were classified as different LOC according to their highest mechanical circulatory support (MCS) capabilities: Level 1 (L-1)-durable left ventricular assist device, Level 1A (L-1A)-extracorporeal membrane oxygenation, Level 2 (L-2)-intra-aortic balloon pump and percutaneous ventricular assist device; and Level 3 (L-3)-no MCS. All adult patients treated for CS (International Classification of Diseases, ICD-10 code R57.0) between 2016 and 2022 were included. Etiologies of CS were identified using associated diagnostic codes. Management strategies and outcomes across LOC were compared. Higher LOC centers had higher volumes: L-1 (n = 1): 2,831 patients, L-1A (n = 4): 3,452, L-2 (n = 1): 340, and L-3 (n = 5): 780. Emergency room admissions were more common in lower LOC (96% at L-3 vs. 46% L-1; p < 0.001), while hospital transfers were predominant at higher LOC (40% at L-1 vs. 2.7% at L-3; p < 0.001). Men comprised 61% of the cohort. Patients were younger in the higher LOC [69 (60-78) years at L-1 vs. 77 (67-85) years at L-3; p < 0.001]. Patients with acute myocardial infarction (AMI)-CS and acute heart failure (AHF)-CS were concentrated in higher LOC centers while other etiologies of CS were more common in L-2 and L-3 (p < 0.001). Cardiac arrest on admission was more prevalent in lower LOC centers (L-1: 2.8% vs. L-3: 12.1%; p < 0.001). Patients with AMI-CS received more percutaneous coronary intervention in lower LOC (51% L-2 vs. 29% L-1; p < 0.01) but more coronary arterial bypass graft surgery at higher LOC (L-1: 42% vs. L-1A: 23%; p < 0.001). MCS use was consistent across levels for AMI-CS but was more frequent in higher LOC for AHF-CS patients (L-1: 28% vs. L-2: 10%; p < 0.001). Despite increasing in-hospital mortality with decreasing LOC, no significant difference was seen after multivariable adjustment. This is the first report describing a pragmatic classification of LOC for CS which, based on MCS capabilities, can discriminate between centers with distinct demographics, practice patterns, and outcomes. This classification may serve as the basis for future research and the creation of CS systems of care.

SHOCK2: Single-center Experience and Outcomes with Impella 5.0 and 5.5 in Patients with Cardiogenic Shock

Background: Over the past decade, there have been significant technological advancements in managing patients with cardiogenic shock (CS). Temporary mechanical circulatory support devices are increasingly being employed. In this study, we present the largest single-center experience with Impella 5.0 and 5.5. Methods: Adults with severe CS who were supported with Impella 5.0 or 5.5 between 2010 to 2022 at a single institution were included. Patients were stratified into 3 groups according to their CS etiology: 1) acute myocardial infarction (AMI), 2) acute heart failure (AHF), and 3) post-cardiotomy (PC). The primary outcome was survival, and secondary outcomes included complications during Impella support. Multivariable logistic regression was performed to identify risk factors of mortality prior to discharge. Results: A total of 126 patients were included in this study with CS secondary to AMI (n=37), AHF (n=79), and PC (n=10). The AMI group tended to have older patients with a higher rate of hypertension. Patients in the PC group had a higher rate of preoperative atrial fibrillation and elevated total bilirubin. Among all the groups, the AHF group had a longer hospital length of stay and Impella support duration. Intra-aortic balloon pump and coronary revascularization were more commonly employed in the AMI group. Impella with extracorporeal membrane oxygenation (ECPella) support was utilized in 32 patients (25.4%) from the entire study cohort (Table 1). Impella bridge to transplant was most common in the AHF group, and native cardiac recovery was the most common destination in the AMI and PC groups (Table 1). Rates of survival on discharge, 30-day, 90-day, and 180-day were comparable among the 3 groups (Table 2). Acute kidney injury was the most common complication during Impella support followed by infection requiring antibiotics in all 3 groups (Table 2). An increased rate of limb ischemia was observed in the PC group, and the AMI group experienced a higher incidence of bleeding requiring transfusion. Multivariable analysis demonstrated diabetes mellitus (OR 4.90, CI 1.89-12.72, p=0.001), elevated pre-insertion serum lactate (OR 1.24, CI 1.06-1.44, p=0.008), and acute kidney injury (OR 4.81, CI 1.31-17.62, p=<0.001) were independent predictors of mortality prior to discharge, but etiology of CS did not impact mortality prior to discharge (all, p>0.05). Conclusions: The present study is the largest single-center experience with Impella 5.0 and 5.5 to date. This study demonstrates that Impella 5.0 and 5.5 provide appropriate therapeutic support for patients with profound CS with more than half of patients being alive at 180 days. Etiology of CS did not significantly impact survival. Additional ECMO support was required in more than a quarter of the cohort. Diabetes mellitus, elevated pre-insertion serum lactate, and acute kidney injury were strong risk factors for mortality prior to discharge.

Predictors of successful weaning from VA-ECMO: the role of CS etiology and related treatment

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a short-term mechanical circulatory support for refractory cardiogenic shock (CS). Successful weaning from VA ECMO is defined as device removal without further requirement for re-cannulation over the following 30 days. Few data exist regarding timing and reliable parameters for weaning from VA-ECMO: most study focused on echocardiographic and invasively monitored parameters during weaning trial(1,2). No data exist concerning pharmacological support and standard haemodynamic parameters in the first 24 hours since VA-ECMO implantation. Purpose We sought to evaluate hemodynamic predictors of VA-ECMO weaning. Methods Single-center retrospective observational study of patients with refractory CS who underwent VA-ECMO insertion from 2013 to 2020 in Intensive Care Unit (ICU). Primary endpoint was successful weaning from VA ECMO. Demographic, clinical, hemodynamic data within the first 24 hours and outcome were collected. We also recorded maximum dose of each vasoactive medication, Vasoactive Inotropic Score (VIS)(3) after VA-ECMO implantation and the total amount of time exposition to vasoactive drugs. Results 100 patients (26% female; 52,6±12,6 y.o.) who underwent VA-ECMO cannulation were enrolled (Table 1). 31 were successfully weaned (31%) at a median time of 140,0 [74,3-229,0] hours; 30-days mortality was 47%. 79 (79%) patients were admitted for cardiac arrest (CA); 48 (48%) had acute myocardial infarction (AMI)-CS. CA patients were less likely to be weaned: 20,3% of CA patients had successful VA-ECMO removal while 79,4% was not weaned (p &amp;lt;0,001). In the weaned group, mean blood pressure was significantly higher (75,3±18,2 vs 61,4±18,3 mmHg; p &amp;lt;0,01).Patients who successfully removed VA-ECMO had lower serum lactate (8,8±5,2 vs 11,3±5,0 mmol/L; p &amp;lt;0,05), lower fluid balance (+2,3 [0,5-5,5] vs +4,1 [1,7-8,3] L/die; p &amp;lt;0,05) and lower Sequential Organ Failure Assessment (SOFA) score (11,2±2,6 vs 13,2±3,4; p &amp;lt;0,01). Lower doses of norepinephrine was administered in patient successfully weaned (0,27±0,17 vs 0,44±0,25 mcg/kg/min; p &amp;lt;0,01). Despite not significant, lower VIS and time to exposition to vasoactive drugs amongst weaned patients were observed (p=0,08 and p=0,09, respectively). Stepwise logistic regression confirmed the worst outcome of CA patients (OR 0,64; p &amp;lt;0,001), SOFA score (OR 0,81; p &amp;lt;0,05) and time to exposition to vasoactive drugs (OR 0,81; p &amp;lt;0,05) on successful weaning from VA-ECMO. Conclusions Mortality of patients undertaking VA-ECMO still remains high. Amongst the data in the model, the strongest negative association with successful weaning from VA-ECMO was found for CA, according to the latest classification entailing CA as CS severity modifier(4). Other results show higher requirement of norepinephrine and fluid administration for vasoplegia mostly related to hypoxic organ injury and related infection (i.e. bowel translocation).

Does sex affect the risk of 30-day all-cause mortality in cardiogenic shock?

BackgroundMortality rates following cardiogenic shock (CS) have stagnated on an unacceptably high level. Limited data regarding the prognostic value of sex in patients suffering from CS is available. Therefore, this study aims to investigate the prognostic value of sex in patients with CS. MethodsConsecutive patients with CS of any cause were included from 2019 to 2021. Prognosis of females was compared to males regarding 30-day all-cause mortality. Further risk stratification was performed according to the presence or absence of CS related to acute myocardial infarction (AMI). Kaplan-Meier and multivariable Cox proportional regression analyses were applied for statistics. ResultsFrom a total of 273 CS patients (AMI-CS: 49%; non-AMI-CS: 51%), 60% were males and 40% females. The risk of 30-day all-cause mortality did not differ among males and females (56% vs. 56%; log rank p = 0.775; HR = 1.046; 95% CI 0.756–1.447; p = 0.785). Even after multivariable adjustment, sex was not associated with prognosis in CS patients (HR = 1.057; 95% CI 0.713–1.564; p = 0.784). Comparable risks of short-term mortality in both sexes were observed irrespective of the presence of AMI-related CS (64.0% vs. 64.6%; log rank p = 0.642; HR = 1.103; 95% CI 0.710–1.713; p = 0.664) and non-AMI-related CS (46.2% vs. 49.2%; log rank p = 0.696; HR = 1.099; 95% CI 0.677–1.783; p = 0.704). ConclusionSex was not associated with the risk of 30-day all-cause mortality in CS patients irrespective of CS etiology.(clinicaltrials.gov identifier: NCT05575856)

Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices.

Cardiogenic shock (CS) is a complex clinical entity that continues to carry a high risk of mortality. The landscape of CS management has changed with the advent of several temporary mechanical circulatory support (MCS) devices designed to provide hemodynamic support. It remains challenging to understand the role of different temporary MCS devices in patients with CS, as many of these patients are critically ill, requiring complex care with multiple MCS device options. Each temporary MCS device can provide different types and levels of hemodynamic support. It is important to understand the risk/benefit profile of each one of them for appropriate device selection in patients with CS. MCS may be beneficial in CS patients through augmentation of cardiac output with subsequent improvement of systemic perfusion. Selecting the optimal MCS device depends on several variables including the underlying etiology of CS, clinical strategy of MCS use (bridge to recovery, bridge to transplant or durable MCS, or abridge to decision), amount of hemodynamic support needed, associated respiratory failure, and institutional preference. Furthermore, it is even more challenging to determine the appropriate time to escalate from one MCS device to another or combine different MCS devices. In this review, we discuss the current available data published in the literature on the management of CS and propose a standardized approach for escalation of MCS devices in patients with CS. Shock teams can play an important role to help in hemodynamic-guided management and algorithm-based step-by-step approach in early initiation and escalation of temporary MCS devices at different stages of CS. It is important to define the etiology of CS, and stage of shock and recognize univentricular vs biventricular shock for appropriate device selection and escalation of therapy.