Initiation Of Mechanical Circulatory Support Research Articles

Clinical Value of Troponin Levels to Cardiac Function and Prognosis in Patients with Fulminant Myocarditis.

Troponin (Tn) is a biomarker related to myocardial necrosis and is elevated in patients with myocarditis. This study aimed to investigate the association between cardiac Tn levels and the course of cardiac function, and prognosis in patients with fulminant myocarditis (FM) receiving percutaneous mechanical circulatory support (MCS).We used data from a multicenter retrospective registry, CHANGE PUMP 2, which included 216 patients with FM who required MCS. Among them, 141 patients whose Tn levels were available were analyzed. The patients were divided into low and high Tn groups according to the median values of TnT and TnI.The median age was 54 years, and 59.6% were male. The TnT and TnI on day 1 (at MCS initiation) were 3.8 (1.4-10.0) and 21.4 (8.4-68.8) ng/mL. While the left ventricular ejection fraction (LVEF) was similar on day 1 (25.0% versus 24.5%), the low Tn group showed better LVEF improvement on day 7 than the high Tn group (45.0% versus 25.3%, P < 0.001). LVEF at 1 year after admission was higher in the low Tn group (65.0% versus 59.7%, P = 0.039). The low Tn group had a better 90-day composite endpoint in death, durable left ventricular assist device implantation, and heart transplantation compared to the high Tn group (hazard ratio 0.47, 95% CI 0.23-0.95).Tn levels were associated with short- and long-term cardiac recovery and adverse outcomes in patients with FM receiving MCS due to cardiogenic shock.

Beating Heart Transplant Procedures Using Organs From Donors With Circulatory Death

The use of ex vivo normothermic organ perfusion has enabled the use of deceased after circulatory death (DCD) donors for heart transplants. However, compared with conventional brain death donation, DCD heart transplantation performed with ex vivo organ perfusion involves an additional period of warm and cold ischemia, exposing the allograft to multiple bouts of ischemia reperfusion injury and may contribute to the high rates of extracorporeal membrane oxygenation usage after DCD heart transplantation. To assess whether the beating heart method of DCD heart transplantation is safe and whether it has an acceptable rate of extracorporeal membrane oxygenation use postoperatively. This case series includes 10 patients with end-stage heart failure undergoing DCD heart transplantation at a single academic medical center from October 1, 2022, to August 3, 2023. Data were analyzed from October 2022 to August 2023. Using a beating heart method of implantation of the donor allograft. The main outcome was primary graft dysfunction necessitating postoperative initiation of mechanical circulatory support. Survival and initiation of mechanical circulatory support were secondary outcomes. In this case series, 10 consecutive patients underwent DCD heart transplantation via the beating heart method. Ten of 10 recipients were male (100%), the mean (SD) age was 51.2 (13.8) years, and 7 (70%) had idiopathic dilated cardiomyopathy. Ten patients (100%) survived, and 0 patients had initiation of extracorporeal membrane oxygenation postoperatively. No other mechanical circulatory support, including intra-aortic balloon pump, was initiated postoperatively. Graft survival was 100% (10 of 10 patients), and, at the time of publication, no patients have been listed for retransplantation. In this study of 10 patients undergoing heart transplantation, the beating heart implantation method for DCD heart transplantation was safe and may mitigate ischemia reperfusion injury, which may lead to lower rates of primary graft dysfunction necessitating extracorporeal membrane oxygenation. These results are relevant to institutions using DCD donors for heart transplantation.

Mechanical Circulatory Support During Surgical Revascularization for Ischemic Cardiomyopathy

BackgroundThis study aimed to describe the use of perioperative mechanical circulatory support (MCS) and its impact on outcomes in patients with ischemic cardiomyopathy who were undergoing surgical revascularization. MethodsPatients with an ejection fraction <35% who underwent isolated coronary artery bypass grafting (CABG) from 2015 to 2021 were identified (N = 378). Patients were divided into no MCS, preoperative MCS, and postoperative MCS groups on the basis of timing of MCS initiation, which included intraaortic balloon pump, extracorporeal membrane oxygenation, or Impella device (Abiomed) use. The primary outcome of interest was operative mortality. ResultsThe median Society of Thoracic Surgeons Predicted Risk of Mortality was 2.4%. Sixty-six percent (n = 246) of patients had a previous myocardial infarction, and 61.8% of these patients were within 21 days of CABG. Twenty-one patients (5.6%) presented in cardiogenic shock. The preoperative MCS cohort consisted of 31 patients (8.2%) who underwent CABG a median of 2 days after MCS initiation. Thirty (7.9%) patients required postoperative MCS. Independent risk factors for requiring postoperative MCS included the preoperative ejection fraction (odds ratio, 0.93; P = .01 and the presence of preoperative MCS (odds ratio, 3.06; P = .02). Overall, operative mortality was 3.4%, and 3-year survival was 87.0%. Operative mortality in patients who did and did not receive preoperative MCS was 7.7% and 2.9% (P = .12) with no difference in long-term survival (P = .80), whereas patients requiring postoperative MCS had significantly increased operative (16.7%) and late mortality (63%; P <.01). ConclusionsCABG can be performed safely in patients with ischemic cardiomyopathy with selective use of perioperative MCS. Despite advanced disease severity, patients requiring preoperative MCS demonstrate acceptable short- and long-term survival. Patients requiring postoperative MCS have increased postoperative morbidity and mortality.

Fulminant Myocarditis Mimicking Myocardial Infarction in a Young Woman: A Challenging Diagnosis and Treatment

BACKGROUND: Fulminant myocarditis is a rare and serious condition with high mortality. It poses diagnostic challenges due to myocardial infarction-like symptoms and rapid deterioration. Timely diagnosis and access to advanced interventions are vital for optimal management and improved outcomes. CASE PRESENTATION: A 34-year-old woman presented with typical chest pain, ST changes, positive cardiac biomarkers, and impaired left ventricle function. The presumptive diagnosis was fulminant myocarditis complicated with cardiogenic shock, respiratory failure, and acute kidney injury. Leukocytosis and high anti-streptolysin O (ASO) titer suggested a recent streptococcal infection as a possible cause. Advanced intervention limitations hindered patient management. On the second day, the patient had a cardiac arrest. CONCLUSION: The diagnosis can be challenging due to the similarity of symptoms and signs to myocardial infarction, combined with the rapid deterioration of the patient’s condition. Prompt initiation of mechanical circulatory support is vital. However, its limited availability in developing countries hinders routine implementation, leading to unfavorable outcomes when life support measures are unavailable.

Urinary biomarkers associated with acute kidney injury in pediatric mechanical circulatory support patients.

In patients requiring mechanical circulatory support (MCS), the incidence of acute kidney injury (AKI) is between 37 and 63%. In this study, we performed an exploratory analysis evaluating the relationship of multiple urine biomarkers with AKI development in pediatric MCS patients. This is asingle center retrospective study in a pediatric cohort receiving MCS from August 2014 to November 2020. We measured 14 urine biomarkers of kidney injury on day 1 following MCS initiation and analyzed their association with development of AKI in the first 7days of MCS initiation. Sixty patients met inclusion criteria. Patients with AKI were more likely to be supported by venoarterial extracorporeal membrane oxygenation (65% vs. 8.3%, p < 0.001), compared to the no AKI group and less likely to have ventricular assist devices (10% vs. 50%, p < 0.001). There was a significant increase in the median urine albumin and urine osteoactivin in the AKI group, compared to the no AKI group (p = 0.020 and p = 0.018, respectively). When normalized to urine creatinine (UCr), an increased log osteoactivin/UCr was associated with higher odds of AKI development (OR: 2.05; 95% CI: 1.07, 4.44; p = 0.028), and higher log epidermal growth factor (EGF)/UCr (OR: 0.41; 95% CI: 0.15, 0.96) was associated with decreased odds of AKI. Early increase in urine osteoactivin is associated with AKI development within 7days of MCS initiation in pediatric patients. Contrary, an increased urine EGF is associated with kidney protection. A higher resolution version of the Graphical abstract is available as Supplementary information.

Inhaled Epoprostenol Compared With Nitric Oxide for Right Ventricular Support After Major Cardiac Surgery.

Right ventricular failure (RVF) is a leading driver of morbidity and death after major cardiac surgery for advanced heart failure, including orthotopic heart transplantation and left ventricular assist device implantation. Inhaled pulmonary-selective vasodilators, such as inhaled epoprostenol (iEPO) and nitric oxide (iNO), are essential therapeutics for the prevention and medical management of postoperative RVF. However, there is limited evidence from clinical trials to guide agent selection despite the significant cost considerations of iNO therapy. In this double-blind trial, participants were stratified by assigned surgery and key preoperative prognostic features, then randomized to continuously receive either iEPO or iNO beginning at the time of separation from cardiopulmonary bypass with the continuation of treatment into the intensive care unit stay. The primary outcome was the composite RVF rate after both operations, defined after transplantation by the initiation of mechanical circulatory support for isolated RVF, and defined after left ventricular assist device implantation by moderate or severe right heart failure according to criteria from the Interagency Registry for Mechanically Assisted Circulatory Support. An equivalence margin of 15 percentage points was prespecified for between-group RVF risk difference. Secondary postoperative outcomes were assessed for treatment differences and included: mechanical ventilation duration; hospital and intensive care unit length of stay during the index hospitalization; acute kidney injury development including renal replacement therapy initiation; and death at 30 days, 90 days, and 1 year after surgery. Of 231 randomized participants who met eligibility at the time of surgery, 120 received iEPO, and 111 received iNO. Primary outcome occurred in 30 participants (25.0%) in the iEPO group and 25 participants (22.5%) in the iNO group, for a risk difference of 2.5 percentage points (two one-sided test 90% CI, -6.6% to 11.6%) in support of equivalence. There were no significant between-group differences for any of the measured postoperative secondary outcomes. Among patients undergoing major cardiac surgery for advanced heart failure, inhaled pulmonary-selective vasodilator treatment using iEPO was associated with similar risks for RVF development and development of other postoperative secondary outcomes compared with treatment using iNO. URL: https://www. gov; Unique identifier: NCT03081052.

Lactate Clearance – A surrogate for Mortality in Cardiogenic Shock

Objectives: Raised blood lactate levels are strongly associated with mortality in patients with cardiogenic shock. Recent practices of the early identification and initiation of mechanical circulatory support have improved outcomes in cardiogenic shock, but therapeutic targets to guide real-time clinical decision making are lacking. Recent evidence suggests that the degree and rate at which blood lactate levels decrease after the initiation of treatment is important in patient prognosis. With this background, lactate clearance has been suggested as a potential treatment target due to its independent association with morality. Materials and Methods: Lactate levels were measured at baseline and at 6, 12, and 24 h. Patients were grouped into survivors and non-survivors based on in-hospital mortality. Patients who had normal lactate (&lt;2.0 mmoL/L) at baseline were excluded from the study. Statistical analysis done using appropriate tests. Results: Absolute lactate levels were compared between groups at baseline and 6, 12, and 24 h. Lactate clearance was calculated at 6, 12, and 24 h among survivors and non-survivors. In total, 90 patients were enrolled, and 65 (72.2%) of them survived to hospital discharge. Absolute blood lactate levels were 4.71 ± 1.36 mmoL/lit in survivors and 6.17 ± 2.88 mmoL/lit in non-survivors at baseline (P = 0.007). The mean lactate clearance at 6 h was 12.22 ± 85.96% in survivors and 12.98 ± 30.97% in non-survivors (P = 0.3). At 24 h, the mean lactate clearance was 54.63 ± 22.34% and 26.34 ± 19.3% in survivors and non-survivors, respectively (P &lt; 0.01). Conclusion: Survivors had significantly greater lactate clearance at 12 and 24 h compared with non-survivors, suggesting that lactate clearance is an important prognostic marker in cardiogenic shock. These results further support the validity of lactate clearance as an appropriate surrogate for mortality and as a potential therapeutic target in clinical practice. Especially in centers lacking invasive hemodynamic monitoring.

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

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

Successful TAVI Despite Sudden Low Output and Ventricular Fibrillation in a Patient with Cardiac Amyloidosis

Management of patients with cardiac amyloidosis and concomitant high-grade aortic stenosis is challenging. Here, we report the case of a 79-year-old man with transcatheter aortic valve implantation (TAVI) complicated by low cardiac output during release of a Medtronic Evolut R 34 mm valve. After initiation of mechanical circulatory support, the TAVI valve was successfully implanted despite ongoing ventricular fibrillation. The ventricular fibrillation was successfully treated with injection of potassium into the aorta, with subsequent defibrillation and ventricular pacing. Moreover, pharmacological management of transient severe LV dysfunction and high-grade mitral regurgitation finally led to a favourable course.

Effect of Portable, In-Hospital Extracorporeal Membrane Oxygenation on Clinical Outcomes.

The time between onset of cardiogenic shock and initiation of mechanical circulatory support is inversely related to patient survival as delays in transporting patients to the operating room (OR) for venoarterial extracorporeal membrane oxygenation (VA ECMO) could prove fatal. A primed and portable VA ECMO system may allow faster initiation of ECMO in various hospital locations and subsequently improve outcomes for patients in cardiogenic shock. We reviewed our institutional experience with VA ECMO based on two time periods: beginning of our VA ECMO program and from initiation of our primed and portable in-hospital ECMO system. The primary endpoint was patient survival to discharge. A total of 137 patients were placed on VA ECMO during the study period; n = 66 (48%) before and n = 71 (52%) after program initiation. In the second era, the proportion of OR ECMO initiation decreased significantly (from 92% to 49%, p < 0.01) as more patients received ECMO in other hospital units, including the emergency department (p < 0.01) and during cardiac arrest (12% vs. 38%, p < 0.01). Survival to hospital discharge was equivalent between the two groups (30% vs. 42%, p = 0.1) despite more patients being placed on ECMO during ongoing cardiac arrest. Finally, we observed increased clinical volume since initiation of the in-hospital, portable ECMO system. Developing an in-hospital, primed and portable VA ECMO program resulted in increased clinical volume with equivalent patient survival despite a sicker cohort of patients. We conclude that more rapid deployment of VA ECMO may extend the treatment eligibility to more patients and improve patient outcomes.

Abstract 14006: Circulating microRNAs Predict Recovery in Pediatric Dilated Cardiomyopathy Patients

Introduction: microRNAs (miRs) are small single stranded RNAs capable of targeting expression of several genes. Circulating miRs are stable and can be important biomarkers of disease progression and diagnosis. Hypothesis: We hypothesized circulating miRs could be a reliable prognostic biomarker of recovery for pediatric dilated cardiomyopathy (DCM). Methods: TaqMan Open Array miR panel (ThermoFisher Scientific) was used to investigate expression of 381 circulating miRs. Samples originated from the Pediatric Cardiomyopathy Registry (PCMR) and were collected within 3 months of a new diagnosis of DCM. Inclusion criteria included &lt;18 years of age at diagnosis of idiopathic or familial DCM (EF&lt;50% or left ventricular end-diastolic dimension [LVEDd] z-score ≥+2). Patients with DCM secondary to musculoskeletal diseases or anthracycline toxicity were excluded. Primary outcomes, occurring within 1 year of enrollment, were defined as: [1] Death, transplant (tx) listing or initiation of mechanical circulatory support; [2] Recovered- normalization of ventricular size and function (EF≥50% and LVEDd z-score &lt;+2) or [3] Stable- persistent DCM with EF&lt;50% or LVEDd z-score ≥+2. Statistical analysis included random forest, hierarchical clustering and area under the receiver operator curve (AUC). Results: N=10 subjects were included in Group 1, of which 70% were female, 6 were white, 2 Hispanic and 3 of other/unknown races, median age 9.5y. N=5 samples were included in Group 2, of which 60% were female, 3 were white, 1 black and 1 native American, median age 1.9y. N=20 samples were included in Group 3, of which 40% were female, 10 were white, 5 black, 1 Pacific islander, 2 Hispanic and 4 of other/unknown races, median age 2.1y. The top 3 miRs differentiating Group 2 (Recovered) from Group 1 (Death/Tx) (AUC of 0.92) were hsa-miR-655, -410 and -636. The top 3 miRs differentiating Group 2 (Recovered) from Group 3 (Stable) were hsa-miR-17, -410 and -345 (AUC of 0.76). Conclusions: These results indicate circulating miRs can predict recovery in the pediatric DCM population. A unique biomarker signature of miRs specific to patients who have the potential to recover would improve risk stratification of this population.

PSAT021 Hemorrhagic Pheochromocytoma Presenting With Cardiogenic Shock: Challenges in Diagnosis and Treatment.

Abstract Introduction Pheochromocytomas are rare catecholamine producing tumors with heterogenous clinical presentations. Although acute catecholamine-induced cardiomyopathy is well described in the literature, it is rarely suspected as a cause of cardiogenic shock. Timely diagnosis is challenging and appropriate preoperative treatment is crucial for successful management, as this condition carries a high mortality rate. We describe a case of hemorrhagic pheochromocytoma presenting with refractory hypotension and discuss the difficulties in diagnosis and treatment we encountered. Case Presentation A 57-year-old man presented with pallor, severe headache, and hypotension. After administration of intravenous fluids, the patient developed flash pulmonary edema and was found to have acute systolic heart failure. He was taken for emergent left heart catheterization, which did not show any evidence of coronary obstruction. Therefore, he was treated for presumed myocarditis and received stress dose steroids. His condition quickly deteriorated to cardiogenic shock and was further complicated by cardiac arrest. He required extracorporeal membrane oxygenation (ECMO) treatment for 2 days, during which time his systolic blood pressures were extremely labile (47–270 mmHg). CT angiography incidentally noted a 4.3 cm right para-adrenal lesion, at which time urine metanephrines were ordered and noted to be markedly high. Ga-68 DOTATATE scan was negative, however, dedicated abdominal CT revealed a likely hemorrhagic right adrenal mass. With supportive care, the patient's cardiac function recovered by the fifth hospital day, and labetalol was slowly introduced, followed by doxazosin. Sixteen days after the initial presentation, laparoscopic right adrenalectomy was successfully performed. Pathology confirmed pheochromocytoma with few positive cells in a hemorrhagic and necrotic adrenal lesion. Discussion Our case underlines several important points in the diagnosis and management of pheochromocytoma. First, it is crucial to have a high level of suspicion for a catecholamine-secreting tumor in the setting of labile blood pressures and acute cardiomyopathy, especially in cases without evidence of coronary artery or valvular disease. Notably, steroids should be used cautiously, as they may further precipitate catecholamine crisis and have been associated with hemorrhagic pheochromocytomas. While catecholamine-induced cardiomyopathy is associated with a high mortality rate, the majority of cases are reversible with timely management. Treatment is complex, as standard initial pheochromocytoma management with alpha-blockers and hydration is often precluded due to cardiogenic shock, and vasopressors such as norepinephrine and epinephrine can worsen cardiomyopathy. Furthermore, early initiation of mechanical circulatory support (specifically ECMO) was a life-saving modality, as it facilitated cardiac function recovery and enabled bridging with alpha blockers. Better prognosis is associated with surgery performed after improvement of cardiomyopathy and alpha blockade. And finally, a multidisciplinary approach is crucial for the successful treatment of pheochromocytoma in emergency situations. Given this rare presentation of pheochromocytoma more, data are needed to define an optimal strategy. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Feasibility of Very Early Identification of Cardiogenic Shock by Semi-automated Ultrasound Exam in the Emergency Department.

Background Cardiogenic shock (CS) is critical end-organ hypoperfusion due to reduced cardiac output. Early therapy, such as vasoactive agents or the initiation of mechanical circulatory support (MCS), requires early diagnosis and is associated with better outcomes. A novel ultrasound platform (GE Healthcare, Milwaukee, WI) has semi-automated imaging software (SAIS), which could simplify the point-of-care ultrasound (POCUS) diagnosis of CS. We assessed the feasibility of using POCUS with SAIS in patients in shock, determined the ability of SAIS to identify the subset of patients with CS, and described the process and outcome of care of patients with vs. without CS after presenting to Emergency Department (ED) with hypotension. Methods This prospective case-control study was conducted at an urban ED. Physicians with prior POCUS education received one hour of training with the study device. The qualitative ejection fraction was determined by visual assessment. SAIS measurements of hemodynamics were made with the study device and included left ventricle outflow tract velocity time integral (LVOT VTI), inferior vena cava collapsibility or distensibility indices, and pulmonary B-line assessment.ED patients with a systolic blood pressure ≤ 90 mmHg or need for a vasopressor initiation in the ED were enrolled. The diagnosis of CS was determined by a medical record review. All data were summarized descriptively. Results Twenty-ninecases underwent POCUS, and 87 controls did not. Baseline characteristics, process, and outcome of care were similar between groups. Seventy-nine percent (79%) of cases had a complete POCUS with SAIS. Of these, 55% had reduced LVOT VTI, 38% had IVC collapsibility <50%, and 48% of cases had a B-line pattern consistent with pulmonary edema. The mean LVOT VTI for cases with CS was 9.4± 5.4 cm; the mean LVOT VTI for cases without CS was 15.2 ± 6.0 cm. Among patients who did not undergo POCUS, 31 (36%) had a formal echocardiogram, and eight (9%) had a final diagnosis of cardiogenic shock during hospitalization. Conclusion Physicians with one hour of platform-specific training were able to implement POCUS with SAIS among patients who present with shock. POCUS with SAIS may aid in the early recognition of CS.

Impact of the elevated angiopoietin-2 levels during Impella support on the short-term prognosis.

Elevated serum angiopoietin-2 levels in patients with acute myocardial infarction-related cardiogenic shock with and without intra-aortic balloon pump as well as acute decompensated heart failure are associated with short-term mortality. However, its prognostic impact in patients with cardiogenic shock supported by Impella-incorporated mechanical circulatory support (MCS) remains unknown. Patients who received temporary MCS (Impella alone or Impella and veno-arterial extracorporeal membrane oxygenation) in our institute between August 2018 and January 2022 were included in this prospective study. The serum levels of angiopoietin-2 were measured just before and following the initiation of temporary MCS therapy. Association between the levels of serum angiopoietin-2 and 30-day mortality was investigated. A total of 38 patients (median 72years old, 63% men) were included. The median levels of serum angiopoetin-2 tended to decrease from baseline to 4days following the initiation of temporary MCS from 5.2 (3.3, 10.5)ng/mL to 4.8 (2.7, 6.8)ng/mL (p = 0.132). A higher angiopoietin-2 (> 6.8ng/mL) following the initiation of temporary MCS was associated with higher 30-day mortality (89.7% versus 44.4%, p = 0.0048) with an odds ratio 18.946 (95% confidence interval 1.624-218.695, p = 0.018) adjusted for potential confounders. A higher serum angiopoietin-2 level following the initiation of Impella-incorporated temporary MCS, instead of baseline angiopoetin-2 level, was associated with higher short-term mortality.

Mechanical circulatory support in the treatment of cardiogenic shock.

Cardiogenic shock is a condition that is characterized by end-organ hypoperfusion secondary to reduced cardiac output, and is associated with substantial mortality. The mainstay of therapy for cardiogenic shock is reversal of the underlying cause, and concomitant supportive care with vasoactive medications (vasopressors and inotropes). Patients who continue to deteriorate despite these measures may require mechanical circulatory support (MCS). Here, we review the devices available for MCS, and their associated benefits and risks. Despite growing use worldwide, there is little randomized evidence supporting the routine use of any specific device for MCS in cardiogenic shock. A large randomized trial of the intra-aortic balloon pump did not demonstrate short- or long-term improvement in mortality. The TandemHeart and Impella devices which assist in left ventricular unloading have only been evaluated in small randomized trials, which showed an increase in adverse events without improvement in mortality. Finally, venoarterial extracorporeal membrane oxygenation (provides both circulatory and respiratory support) and is currently being evaluated in large randomized clinical trials. Various devices for MCS in cardiogenic shock are available, but routine use is not supported by high-quality randomized evidence. Given the resources required for initiation of MCS, use of these treatments should be limited to centers experienced in advanced cardiac care, and future research should focus on what role (if any) these devices have in clinical practice.

Outcomes in cardiogenic shock: the role of surrogate endpoints.

Early revascularization, invasive hemodynamic profiling, and initiation of temporary mechanical circulatory support (MCS) have all become routine components of cardiogenic shock (CS) management. Despite this evolution in clinical practice, patient selection and timing of treatment initiation remain a significant barrier to achieving sustained improvement in CS outcomes. Recent efforts to standardize CS management, through the development of treatment algorithms, have relied heavily on surrogate endpoints to drive therapeutic decisions. The present review aims to provide an overview of the basis of evidence for those surrogate endpoints commonly employed in clinical trials and CS management algorithms. Recent publications from both observational and randomized cohorts have demonstrated the utility of surrogate endpoints in risk stratifying patients with CS. In particular, invasive hemodynamics using pulmonary artery catheters to guide initiation and weaning of MCS, biochemical markers that portend imminent end-organ failure, and clinical risk scores that combine multiple hemodynamic and laboratory parameters have demonstrated an ability to prognosticate outcomes in patients with CS. Although further validation is necessary, multiple clinical, hemodynamic, and biochemical markers have demonstrated utility as surrogate endpoints in CS, and will undoubtedly assist physicians in clinical decision-making.

The shock team: a multidisciplinary approach to early patient phenotyping and appropriate care escalation in cardiogenic shock.

Cardiogenic shock (CS) is a highly morbid condition with mortality remaining greater than 30% despite improved pathophysiologic understanding and access to mechanical circulatory support (MCS). In response, shock teams modeled on successful multidisciplinary care structures for other diseases are being implemented nationwide. Primary data supporting a benefit of shock team implementation on patient outcomes are relatively limited and entirely observational. Four single-center before-and-after studies and one multicenter registry study have demonstrated improved outcomes in patients with CS, potentially driven by increased pulmonary artery catheter (PAC) utilization and earlier (and more appropriate) initiation of MCS. Shock teams are also supported by a growing body of literature recognizing the independent benefit of the interventions they seek to implement, including patient phenotyping with PAC use and an algorithmic approach to CS care. Though debated, MCS is also highly likely to improve CS outcomes when applied appropriately, which further supports a multidisciplinary shock team approach to patient and device selection. Shock teams likely improve patient outcomes by facilitating early patient phenotyping and appropriate intervention. Institutions should strongly consider adopting a multidisciplinary shock team approach to CS care, though additional data supporting these interventions are needed.

Temporary mechanical circulatory support for COVID-19 patients: A systematic review of literature.

ObjectiveMyocardial damage occurs in up to 25% of coronavirus disease 2019 (COVID‐19) cases. While veno‐venous extracorporeal life support (V‐V ECLS) is used as respiratory support, mechanical circulatory support (MCS) may be required for severe cardiac dysfunction. This systematic review summarizes the available literature regarding MCS use rates, disease drivers for MCS initiation, and MCS outcomes in COVID‐19 patients.MethodsPubMed/EMBASE were searched until October 14, 2021. Articles including adults receiving ECLS for COVID‐19 were included. The primary outcome was the rate of MCS use. Secondary outcomes included mortality at follow‐up, ECLS conversion rate, intubation‐to‐cannulation time, time on ECLS, cardiac diseases, use of inotropes, and vasopressors.ResultsTwenty‐eight observational studies (comprising both ECLS‐only populations and ECLS patients as part of larger populations) included 4218 COVID‐19 patients (females: 28.8%; median age: 54.3 years, 95%CI: 50.7–57.8) of whom 2774 (65.8%) required ECLS with the majority (92.7%) on V‐V ECLS, 4.7% on veno‐arterial ECLS and/or Impella, and 2.6% on other ECLS. Acute heart failure, cardiogenic shock, and cardiac arrest were reported in 7.8%, 9.7%, and 6.6% of patients, respectively. Vasopressors were used in 37.2%. Overall, 3.1% of patients required an ECLS change from V‐V ECLS to MCS for heart failure, myocarditis, or myocardial infarction. The median ECLS duration was 15.9 days (95%CI: 13.9–16.3), with an overall survival of 54.6% and 28.1% in V‐V ECLS and MCS patients. One study reported 61.1% survival with oxy‐right ventricular assist device.ConclusionMCS use for cardiocirculatory compromise has been reported in 7.3% of COVID‐19 patients requiring ECLS, which is a lower percentage compared to the incidence of any severe cardiocirculatory complication. Based on the poor survival rates, further investigations are warranted to establish the most appropriated indications and timing for MCS in COVID‐19.

Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock

Intra‐Aortic Balloon Pump for Left Ventricular Unloading in Veno‐Arterial Extracorporeal Membrane Oxygenation: The Last Remaining Indication in Cardiogenic Shock

Efficacy Of Bedside Cannulation For Percutaneous Ventricular Assist Devices

AbstractPercutaneous ventricular assist devices (pVAD) have become a mainstay in the treatment of cardiogenic shock, but their use is limited by the need for specialized staff, equipment, and facilities which may not be readily available. Moreover, the COVID-19 pandemic has further limited such interventions due to possible staff exposure, need for additional protective personal equipment, and efforts to limit patient transport. We have implemented a bedside intensive care unit pVAD cannulation strategy using a mobile fluoroscopy arm with transesophageal echocardiogram to guide placement. Table 1 shows characteristics and outcomes of 6 patients cannulated with a percutaneous right or left ventricular assist device (pRVAD or pLVAD). All patients were previously supported with Veno-Arterial or Veno-Venous Extracorporeal Membrane Oxygenation (VA or VV ECMO). 3 patients had pLVAD placed for worsening LV distention after VA-ECMO initiation. 3 patients had pRVAD placed for severe RV failure in the setting of severe COVID infection and hypoxia. In all cases pVADs were successfully placed and patients anticoagulated with IV heparin afterwards. Although one patient with pLVAD placement had an access site compartment syndrome that required fasciotomy, we were able to maintain pLVAD support. Hemodynamic data showed that each patient was supported by their pVAD; unfortunately, 4 of the 6 passed away due to their underlying condition. ConclusionsBedside placement of pVAD can be performed safely and effectively. Mortality remains high, though this was unrelated to device function in our patients. Our approach limits the need for specialized staff and facilities and may allow for more rapid initiation of mechanical circulatory support while decreasing healthcare costs.