Etiology Of Cardiogenic Shock Research Articles

(575) - High Mortality With Acute Kidney Injury After Mechanical Support for Cardiogenic Shock

(575) - High Mortality With Acute Kidney Injury After Mechanical Support for Cardiogenic Shock

Feasibility of smaller arterial cannulas in venoarterial extracorporeal membrane oxygenation

To facilitate venoarterial extracorporeal membrane oxygenation (ECMO) insertion for cardiogenic shock, we recently adopted a strategy of using a 15F arterial cannula in all patients, rather than 1 designed to maximize flow. We aimed to compare the clinical outcomes of these 2 strategies. In this retrospective study, 101 consecutive patients supported with ECMO via femoral cannulation between March 2007 and March 2013 were divided into 2 groups: Group L (17F-24F arterial cannula to accommodate full flow [ie, cardiac index of 2.5 L/m(2)/min]; n = 51) and Group S (15F arterial cannula; n = 50). The primary outcomes of interest were patients' overall status at 24 hours of support and cannulation-related adverse events. There were no significant differences in patient demographics, etiology of cardiogenic shock, or severity of illness before ECMO initiation between the 2 groups. Group L had significantly higher ECMO flow than Group S (flow index at 24 hours: 2.2 ± 0.7 vs 1.7 ± 0.3 L/m(2)/min; P < .001). However, there was no significant difference in use of vasoactive medication/hemodynamic parameters/laboratory parameters. Group L had higher incidence of cannulation-related adverse events (35% vs 22% in Group S [P = .14]), particularly in cannulation site bleeding (28% vs 10% [P = .03]). Thirty-day survival was 55% in Group L versus 52% in Group S (P = .77). Bleeding complication occurred in 53% in Group L versus 32% in Group S (P = .03). Compared with the use of larger cannulas, ECMO with a 15F arterial cannula appears to provide comparable clinical support with reduced bleeding complications.

Abstract 17229: Survival after Veno-arterial Extracorporeal Membrane Oxygenation Support is Dependent on Underlying Etiology of Cardiogenic Shock

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an emerging therapy for refractory cardiogenic shock (CS); however, characteristics of patients most likely to benefit from this therapy remain to be determined. We hypothesized that the underlying etiology of CS and patient specific characteristics predict survival to discharge. Methods: We compared outcomes in patients supported with VA-ECMO for refractory CS resulting from (1) acute myocardial infarction (AMI; with or without revascularization); (2) acute pulmonary embolism (PE); (3) acute cardiomyopathy; (4) chronic cardiomyopathy; (5) post-cardiotomy; and (6) other etiologies of shock. Chi-square analysis was used to identify predictors of survival to discharge after VA-ECMO. Results: From 2009-2013, 102 patients were initiated on VA-ECMO for refractory CS. The average age was 52 ±15 (mean ± SD) years old with 71 (70%) males. Overall, 39 (38%) patients survived to discharge. In the cohort, 22 patients were post-cardiotomy and 5 (23%) of those survived to discharge. Of the 80 patients without prior cardiotomy, survival to discharge was 27% (8/30) after AMI, 64% (9/14) after PE, 75% (6/8) with acute cardiomyopathy, 50% (5/10) with chronic cardiomyopathy, and 39% (7/18) with other CS etiologies. Survivors were younger (45 ±13 vs 56 ±14, p = 0.0002) and none of the 24 patients over the age of 64 years old survived to discharge. There was a significant difference in survival when comparing etiologies of shock (p = 0.012 by Chi-square comparison among etiologies). There was no significant difference in survival by gender. Conclusions: Survival in patients with refractory CS requiring VA-ECMO may depend on age and underlying etiology of shock. Further research into predictors of survival after institution of VA-ECMO is warranted.

Cardiogenic Shock Masquerading as Septic Shock

Shock is an acute, dynamic process that occurs when there is inadequate delivery of oxygen to meet tissue metabolic demands. In children, shock is relatively uncommonly encountered in the emergency department and has a high mortality rate. Recognition and differentiation of shock can be challenging. Early recognition of the etiology of shock and aggressive, prompt treatment may be lifesaving. As cardiac disorders are responsible for only 5% of cases of pediatric shock, recognition of cardiogenic shock requires a high index of suspicion. In this article, we will review the presentation of the most common etiologies of cardiogenic shock in the pediatric population and discuss the early treatment and stabilization of these disease processes.

Using the Impella 5.0 with a Right Axillary Artery Approach as Bridge to Long-Term Mechanical Circulatory Assistance

Impella 5.0 is a short-term left ventricle assist device (LVAD), inserted retrograde into the left ventricle across the aortic valve through a surgical peripheral access. Impella has been utilized for various indications but in the setting of bridge-to-bridge application there are limited reports. We performed a retrospective observational analysis of Impella utilization at our institution as bridge to long-term LVADs. The primary end-point was survival during Impella support. Between December 2010 and February 2012, we implanted 20 Impella in patients with cardiogenic shock and, among these, 5 were implanted as bridge to long-term LVADs. In this latter group, mean age at the time of implantation was 44 ± 15.6 (range 27-68) years and there was a prevalence of males (80%). Etiology of cardiogenic shock was: decompensated anthracycline-induced cardiomyopathy (n = 1), myocardial infarction (n = 4). There was no major bleeding requiring surgical revision or infectious complications at the right axillary access. One patient required Impella replacement due to a pump stop. After a mean period of 14.2 ± 9.0 (range 6-27) days of Impella support, patients were switched to a long-term LVAD (Jarvik 2000, n = 2; HeartMate II, n = 3). One patient died 70 days after implantation of the long-term LVAD due to multi-organ failure, while the remaining patients are still alive after a mean period of follow-up of 108.6 ± 66.2 (range 19-191) days. Our experience shows that an Impella 5.0 implanted through the right axillary artery approach is a valid option as bridge to long-term LVADs.

Thromboembolic Events in Patients on Extracorporeal Membrane Oxygenation without Anticoagulation

: Heparinization is thought to be mandatory to avoid thromboembolic complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, bleeding complications are common. We report our experience of VA-ECMO without systemic anticoagulation. : A prospectively assembled database describing all ECMO cases from 2000 to 2008 was analyzed. A heparin coated circuit (Medtronic, Inc., Minneapolis, MN USA) and membrane oxygenator (Quadrox D Bioline oxygenator; MAQUET, Rastatt, Germany) were used in all cases. After the initiation of VA-ECMO support, all coagulation parameters were corrected. No further systemic maintenance anticoagulant was given, except at the time of weaning. : Thirty-two patients received VA-ECMO support; 20 patients (62.5%) were males with a median age of 52.5 years (interquartile range, 40.4-61.1 years). Central and peripheral cannulations were 53% and 47%, respectively. Etiologies of cardiogenic shock were postcardiotomy (75%, n = 24) and as a support to cardiopulmonary resuscitation in 25% of cases (n = 8). Thirty-day mortality was 43.8%. Median duration of ECMO support was 46.3 hours (interquartile range, 26.8-87.8 hours). The median number of packed red blood cell transfusions was 18 ± 25. Complications include five patients (16%) with limb ischemia requiring intervention, 15 patients (46.9%) had acute renal failure, two patients had deep vein thrombosis, and two patients had intracardiac clots detected on echocardiograms. No patient had a cerebrovascular event. Incidence of membrane oxygenator failure was low, requiring replacement in three patients; no adverse event occurred during replacement. Fourteen patients (43.8%) were reexplored for bleeding. Fourteen patients (44%) were discharged home and were long-term survivors. : VA-ECMO support without systemic anticoagulation may reduce bleeding complications and transfusion requirement, without increasing the risk of thromboembolism.

Thromboembolic events in patients on extracorporeal membrane oxygenation without anticoagulation.

: Heparinization is thought to be mandatory to avoid thromboembolic complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, bleeding complications are common. We report our experience of VA-ECMO without systemic anticoagulation. : A prospectively assembled database describing all ECMO cases from 2000 to 2008 was analyzed. A heparin coated circuit (Medtronic, Inc., Minneapolis, MN USA) and membrane oxygenator (Quadrox D Bioline oxygenator; MAQUET, Rastatt, Germany) were used in all cases. After the initiation of VA-ECMO support, all coagulation parameters were corrected. No further systemic maintenance anticoagulant was given, except at the time of weaning. : Thirty-two patients received VA-ECMO support; 20 patients (62.5%) were males with a median age of 52.5 years (interquartile range, 40.4-61.1 years). Central and peripheral cannulations were 53% and 47%, respectively. Etiologies of cardiogenic shock were postcardiotomy (75%, n = 24) and as a support to cardiopulmonary resuscitation in 25% of cases (n = 8). Thirty-day mortality was 43.8%. Median duration of ECMO support was 46.3 hours (interquartile range, 26.8-87.8 hours). The median number of packed red blood cell transfusions was 18 ± 25. Complications include five patients (16%) with limb ischemia requiring intervention, 15 patients (46.9%) had acute renal failure, two patients had deep vein thrombosis, and two patients had intracardiac clots detected on echocardiograms. No patient had a cerebrovascular event. Incidence of membrane oxygenator failure was low, requiring replacement in three patients; no adverse event occurred during replacement. Fourteen patients (43.8%) were reexplored for bleeding. Fourteen patients (44%) were discharged home and were long-term survivors. : VA-ECMO support without systemic anticoagulation may reduce bleeding complications and transfusion requirement, without increasing the risk of thromboembolism.

Comparative outcomes in cardiogenic shock patients managed with Impella microaxial pump or extracorporeal life support

Cardiogenic shock is associated with poor clinical outcomes. Extracorporeal life support is used in most centers for short-term circulatory support. Alternatively, the Impella LP 5.0 and right direct (RD) microaxial ventricular assist device (Abiomed, Danvers, Mass) can provide isolated left and right ventricular support, respectively. A retrospective, single center review was performed on all patients receiving circulatory assistance with either extracorporeal life support or Impella ventricular assist device. All Impella LP 5.0 were inserted via the femoral artery, while the RD system required sternotomy. Twenty-nine patients received ventricular assist device support (Impella LP 5.0; n = 24; and Impella RD; n = 5), whereas 32 patients were placed on extracorporeal life support. The baseline characteristics of patients with cardiogenic shock, assisted by Impella or extracorporeal life support, were similar, but the etiology of cardiogenic shock was distributed differently in the 2 groups (P = .008). Forty-one percent of the Impella patients and 47% of the extracorporeal life support patients were weaned from support. The 30-day mortality (44% in the extracorporeal life support vs 38% in the Impella group) and proportion of patients discharged home (41% in the extracorporeal life support vs 59% in the Impella group) were not statistically different between the 2 groups. Arterial thrombosis was less frequent in the Impella group (3.4% vs 18.8%; P = .04). Blood product transfusions were less frequent in the Impella group (P < .001). Both extracorporeal life support and axial flow pumps provided adequate support in patients with various etiologies of cardiogenic shock. Axial-flow pump may be an optimal type of support for patients with univentricular failure, whereas extracorporeal life support could be reserved for patients with biventricular failure or combined respiratory and circulatory failure.

Echocardiographic and Angiographic Correlations in Patients With Cardiogenic Shock Secondary to Acute Myocardial Infarction

In patients with cardiogenic shock (CS) complicating acute myocardial infarction, echocardiographic and angiographic findings are used to aid diagnosis, determine prognosis, and guide management. The purpose of this analysis from the Should we emergently revascularize Occluded Coronary arteries for Cardiogenic ShocK (SHOCK) trial is to identify relations between the angiographic and echocardiographic features of patients with CS. Such an analysis of the correlations between echocardiographic and angiographic findings in patients with CS may provide insights into the etiology and treatment of CS. In 302 randomized patients, an echocardiogram and an angiogram before revascularization were available in 127 patients. Although the median ejection fraction derived by echocardiography and left ventricular angiography was identical (30%), the positive correlation was weak (R2 = 0.209, p = 0.019). Patients with a larger number of diseased vessels had worse mitral regurgitation (MR) by echocardiography (p = 0.005). There was a significant but weak association between left ventricular angiographic MR grade and echocardiographic MR severity (R2 = 0.162, p = 0.015), but there was no association between culprit vessel and degree of MR. In conclusion, worse coronary artery disease is associated with more severe MR. Echocardiography and angiography are valuable and result in similar estimated ejection fractions in a large cohort, but there is wide variation between the techniques in patients.

Cardiogenic shock complicating acute myocardial infarction—etiologies, management and outcome: a report from the SHOCK Trial Registry

OBJECTIVESThis SHOCK Study report seeks to provide an overview of patients with cardiogenic shock (CS) complicating acute myocardial infarction (MI) and the outcome with various treatments. The outcome of patients undergoing revascularization in the SHOCK Trial Registry and SHOCK Trial are compared.BACKGROUNDCardiogenic shock is the leading cause of death in patients hospitalized for acute MI. The randomized SHOCK Trial reported improved six-month survival with early revascularization.METHODSPatients with CS complicating acute MI who were not enrolled in the concurrent randomized trial were registered. Patient characteristics were recorded as were procedures and vital status at hospital discharge.RESULTSBetween April 1993 and August 1997, 1,190 patients with CS were registered and 232 were randomized in the SHOCK Trial. Predominant left ventricular failure (78.5%) was most common, with isolated right ventricular shock in 2.8%, severe mitral regurgitation in 6.9%, ventricular septal rupture in 3.9% and tamponade in 1.4%. In-hospital Registry mortality was 60%, with ventricular septal rupture associated with a significantly higher mortality (87.3%) than all other categories (p < 0.01). The risk profile and mortality were lower for Registry patients who were managed with thrombolytic therapy and/or intra-aortic balloon counterpulsation, coronary angiography, angioplasty and/or coronary artery bypass surgery. After adjusting for these differences, the extent to which survival was improved with early revascularization was similar to that observed in the randomized SHOCK Trial.CONCLUSIONSIn this prospective Registry the etiology of CS was a mechanical complication in 12%. The similarity of the beneficial treatment effect in patients undergoing early revascularization in the SHOCK Trial Registry and SHOCK Trial provides strong support for the generalizability of the SHOCK Trial results.