Mechanical Circulatory Support Device Implantation Research Articles

The Evolution and Complications of Long-Term Mechanical Circulatory Support Devices

Heart failure, a common clinical syndrome caused by functional and structural abnormalities of the heart, affects 64 million people worldwide. Long-term mechanical circulatory support can offer lifesaving treatment for end-stage systolic heart failure patients. However, this treatment is not without complications. This review covers the major complications associated with implantable mechanical circulatory support devices, including strokes, pump thrombosis and gastrointestinal bleeding. These complications were assessed in patients implanted with the following devices: Novacor, HeartMate XVE, CardioWest, Jarvik 2000, HeartMate II, EVAHEART, Incor, VentrAssist, HVAD and HeartMate 3. Complication rates vary among devices and remain despite the introduction of more advanced technology, highlighting the importance of device design and flow patterns. Beyond clinical implications, the cost of complications was explored, highlighting the difference in costs and the need for equitable healthcare, especially with the expected rise in the use of mechanical circulatory support. Future directions include continued improvement through advancements in design and technology to reduce blood stagnation and mitigate high levels of shear stress. Ultimately, these alterations can reduce complications and enhance cost-effectiveness, enhancing both the survival and quality of life for patients receiving mechanical circulatory support.

Abstract 14290: Prospective Clinical Validation of the STOPSHOCK Smartphone Application - Artificial Intelligence Model for Prediction of Cardiogenic Shock in Patients With Acute Coronary Syndrome

Background: Cardiogenic shock (CS) complicating acute coronary syndrome (ACS) is a life-threatening condition with mortality reaching 50% despite the use of mechanical circulatory support devices (MCS). It is hypothesized that early implantation of MCS before hemodynamic deterioration could prevent CS. For this purpose, we have developed and externally validated an AI model for CS prediction available as a smartphone application (STOPSHOCK app). Research question: Could the STOPSHOCK app identify ACS patients at high risk of CS development in contemporary clinical practice? Methods: The STOPSHOCK model was derived on a population of 3232 and validated on an external cohort of 5123 patients with high discrimination (c-statistics: 0.84 in external validation). The model was based on variables that were available at first medical contact. A dedicated app was developed to test the performance of the model in the clinical setting. 103 consecutive ACS patients were enrolled in intensive cardiac care units in 8 centers from USA, Europe, and Asia. Results: Heart rate, respiration rate, SpO2, blood glucose level, systolic BP, age, sex, shock index, heart rhythm, type of ACS, history of hypertension, congestive heart failure and hypercholesterolemia were used as input variables. Clinical outcome (presence of CS) was reported at hospital discharge. STOPSHOCK model had a c-statistics of 0.97. Conclusions: Our machine learning model for CS prediction in patients with ACS available at first medical contact showed high discrimination and feasibility in clinical settings as a smartphone app.

Impact of left bundle branch block on heart failure with preserved ejection fraction.

The implications of LBBB in heart failure with preserved ejection fraction (HFpEF) is unclear. Our study assesses clinical outcomes among patients with LBBB and HFpEF who were admitted with acute decompensated heart failure. This is a cross-sectional study was conducted using the National Inpatient Sample (NIS) database from 2016-2019. We found 74,365 hospitalizations with HFpEF and LBBB and 3,892,354 hospitalizations with HFpEF without LBBB. Patients with LBBB were older (78.9 vs 74.2 years) and had higher rates of coronary artery disease (53.05% vs 40.8%), hypertension (74.7% vs 70.8%), atrial fibrillation (32.8% vs 29.4%), sick sinus rhythm (3.4% vs 2.02%), complete heart block (1.8% vs 0.66%), ventricular tachycardia (3.5% vs 1.7%), and ventricular fibrillation (0.24% vs 0.11%). Patients with LBBB were found to have decreased in-hospital mortality (OR: 0.85; 0.76-0.96; p-0.009) but higher rates of cardiac arrest (OR: 1.39; 1.06-1.83; p- 0.02) and need for mechanical circulatory support (OR: 1.7; 1.28-2.36; p- 0.001). Patients with LBBB underwent a higher rate of pacemaker (OR: 2.98; 2.75 - 3.23; p<0.001) and ICD (implantable cardioverter-defibrillator) placement (OR: 3.98; 2.81 - 5.62; p<0.001). Patients with LBBB were also found to have a higher mean cost of hospitalization ($81,402 vs $60,358; p<0.001) but lower length of stay (4.8 vs 5.4 days; p<0.001). In patients admitted with decompensated heart failure with preserved ejection fraction, left bundle branch block is associated with increased odds of cardiac arrest, mechanical circulatory support requirement, device implantation and mean cost of hospitalization but decreased odds of in-hospital mortality. This article is protected by copyright. All rights reserved.

ADAMTS13 inhibition to treat acquired von Willebrand syndrome during mechanical circulatory support device implantation

BackgroundAcquired von Willebrand syndrome (aVWS) is common in patients with mechanical circulatory support (MCS) devices. In these patients, the high shear stress in the device leads to increased shear‐induced proteolysis of von Willebrand factor (VWF) by A Disintegrin And Metalloprotease with Thrombospondin type 1 repeats, number 13 (ADAMTS13). As a result, the high molecular weight (HMW) VWF multimers are lost, leading to a decreased VWF function and impaired hemostasis that could explain the bleeding complications that are frequently observed in these patients. To counteract this abnormal VWF degradation by ADAMTS13, we developed a novel targeted therapy, using an anti‐ADAMTS13 monoclonal antibody (mAb) that inhibits the shear‐induced proteolysis of VWF by ADAMTS13. MethodsHuman or bovine blood was circulated through in vitro MCS device systems with either inhibitory anti‐ADAMTS13 mAb 3H9 or 17C7 (20 μg/ml) or control anti‐ADAMTS13 mAb 5C11 or phosphate buffered saline (PBS). VWF multimers and function (collagen binding activity) were determined at different time points. Next, Impella pumps were implanted in calves and the calves were injected with PBS and subsequently treated with mAb 17C7. VWF, ADAMTS13, and blood parameters were determined. ResultsWe demonstrated that blocking ADAMTS13 could prevent the loss of HMW VWF multimers in in vitro MCS device systems. Importantly, our antibody could reverse aVWS in a preclinical Impella‐induced aVWS calf model. ConclusionHence, inhibition of ADAMTS13 could become a novel therapeutic strategy to manage aVWS in MCS device patients.

Artificial intelligence model for prediction of cardiogenic shock in patients with acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Education, Science, Research and Sport of the Slovak Republic VEGA Background Cardiogenic shock (CS) is a serious life-threatening condition affecting almost 10% of patients suffering from acute coronary syndrome (ACS). Despite recent treatment improvements such as mechanical circulatory support devices (MCS), mortality remains 50%. It is hypothesized that early implantation of MCS before hemodynamic deterioration could prevent CS. Therefore, knowing which ACS patient will progress into CS would be of paramount importance. Purpose We aimed to develop a model based on machine learning algorithms for CS prediction in patients with ACS. Method Over 40 000 patients from critical care units of the Beth Israel Deaconess Medical Center database were extensively analyzed and sorted. Patients suffering from acute coronary syndrome undergoing cardiac catheterizations were selected and divided into two groups based on the development of CS. Patients in CS at the time of admission were excluded. The study population consisted of 3056 patients who didn’t develop CS and of 176 patients who did develop CS. Important information was also extracted manually from textual summaries of hospital stays. Potentially relevant clinical variables for shock prediction were selected using supervised feature selection, and missing values were supplemented using imputation methods. Seven well-known and established machine learning algorithms were used. Based on preliminary evaluation of classifier performance (AUC on random train-test split with 30% test data), we selected two best-performing algorithms: Logistic Regression and Gaussian Process classifier with Radial Basis Function (RBF) kernel. Both models were subsequently validated using Repeated Stratified K-Fold cross-validation with 5 folds and 20 repeats each. Results Age, heart rate, mean arterial pressure, respiratory rate, oxygen flow (liters per minute), peripheral oxygen saturation, blood glucose, pain type, heart rhythm and ectopy frequency were chosen as input variables. Both models showed good discrimination. The Logistic Regression model scored AUC of 0.76 ± 0.04. The Gaussian Process classifier with Radial Basis Function (RBF) kernel scored AUC of 0.77 ± 0.03. Conclusion According to our knowledge this is the first study that uses machine learning algorithms to predict CS in patients with ACS based on easily obtainable clinical variables. Further explorations and refinement of used imputation, feature selection, machine learning techniques and validation on an external cohort might result in even better performance of the proposed prediction models. Furthermore, these prediction models could be transformed into a simple predictive scoring system available in clinical practice.

Abstract 9833: Incidence and Predictors of Acute Limb Ischemia in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock - Insight from National Readmission Database

Introduction: Cardiogenic shock (CS) is an ominous complication of acute myocardial infarction (AMI) that has a mortality as high as 50%. Use of percutaneous mechanical circulatory support devices (MCSD) has increased in attempts to improve outcomes, however its use can be complicated by acute limb ischemia (ALI). In contemporary clinical practice the incidence and predictors of this complication not known. Methods: Patients with index hospitalizations for AMI complicated by CS in the U.S. Nationwide Readmissions Database were identified from January 2016 to December 2018 using International Classification of Diseases (ICD) 10 codes (“I21-”, “I214”, “R57-”). We evaluated the incidence of ALI and its impact on mortality, length of stay, and cost of hospitalization. We used logistic regression analysis to determine independent predictors of ALI in this population. Results: Amongst a total of 61,950 patients had AMI complicated by CS and 922 (1.49%) developed ALI. The rates of ALI increased from 1.29% in 2016 to 1.66% in 2018. Utilization of microaxial MCSD increase from 2.245% in 2016 to 14.03% in 2018. The major predictors of ALI included peripheral arterial disease (PAD) (OR, 7.86, 95% CI 6.34 to 9.76), veno-arterial extracorporeal membrane oxygenation (ECMO-VA) cannulation (OR, 2.96, 95% CI of 1.53 to 5.73), and microaxial MCSD implantation (OR, 2.91, 95% CI of 2.48 to 3.41). (Figure 1). ALI patients had higher mortality (41.37% vs 34.07%, p=&lt;0.001), longer length of stay (17.33 ± 17.92 vs 9.73 ± 11.43) and higher charges (507,955 ± 610,337 vs 249,904 ± 305,385). Conclusions: This nationwide observational study shows that ALI is not an infrequent complication in patients with AMI complicated by CS. This complication is associated with higher mortality, and longer length of stay. Presence of PAD and use of MCSD is associated with significantly higher risk of ALI.

Timing of Impella implantation and outcomes in cardiogenic shock or high-risk percutaneous coronary revascularization.

ObjectiveTo evaluate the role of the microaxial percutaneous mechanical circulatory support device (Impella® pump) implantation pre‐percutaneous coronary intervention (PCI) versus during/after PCI in cardiogenic shock (CS) and high‐risk PCI populations.BackgroundA better understanding of the safety and effectiveness of the Impella and the role of timing of this support initiation in specific clinical settings is of utmost clinical relevance.MethodsA total of 365 patients treated with Impella 2.5/CP in the 17 centers of the IMP‐IT Registry were included. Through propensity‐score weighting (PSW) analysis, 1‐year clinical outcomes were assessed separately in CS and HR‐PCI patients, stratified by timing of Impella support.ResultsPre‐procedural insertion was associated with an improvement in 1‐year survival in patients with CS due to acute myocardial infarction (AMI) treated with PCI (p = .04 before PSW, p = .009 after PSW) and HR‐PCI (p < .01 both before and after PSW). Among patients undergoing HR‐PCI, early Impella support was also associated with a lower rate of the composite of mortality, re‐hospitalization for heart failure, and need for left‐ventricular assist device/heart transplantation at 1‐year (p = .04 before PSW, p = .01 after PSW). Furthermore, Impella use during/after PCI was associated with an increased in‐hospital life‐threatening and severe bleeding among patients with AMI‐CS receiving PCI (7 vs. 16%, p = .1) and HR‐PCI (1 vs. 9%, p = .02).ConclusionsOur findings suggested a survival benefit and reduced rates of major bleeding when a pre‐PCI Impella implantation instead of during‐after procedure was used in the setting of HR‐PCI and AMI‐CS.

Incidence of Heparin Induced Thrombocytopenia in Patients Undergoing Implantation of Durable and Non-Durable Mechanical Circulatory Support Devices

Purpose Unfractionated heparin exposure in patients undergoing mechanical circulatory support device (MCSD) implantation increases the risk for developing heparin-induced-thrombocytopenia (HIT). The false positive rate of HIT in this population using current standard testing is unknown. Postoperative and device related thrombocytopenia complicate the HIT diagnosis. Methods A retrospective analysis of patients undergoing MCSD pre-implantation assessment or implantation of MCSD (October 2014 - August 2020) was performed. The primary objective was to assess the incidence of HIT with positive PF4 IgG ELISA (PF4) and serotonin release (SRA) assays. False positive HIT was defined as PF4 ≥0.4 optical density (OD) and negative SRA. Argatroban usage was also assessed. Results 366 patients with 512 tests were analyzed. PF4 tests were performed in 128 patients (158 tests) undergoing pre-implantation assessment, 136 patients (185 tests) with non-durable devices (primarily Impella®), and 102 (169 tests) patients with durable devices (72 ventricular assist devices, 30 total artificial hearts). 25% (92/366) of patients had positive PF4 ≥0.4 OD and had subsequent SRA performed (92 patients, 122 tests). True positive HIT was documented in 13% (12/92) of PF4 positive patients consisting of 1 pre-implantation, 9 non-durable MCSD, and 2 durable MCSD patients. The mean PF4 for true positive HIT was 2.2±0.7 OD. False positive HIT was documented in 15% (19/128) of pre-implantation patients (mean PF4 0.9±0.6 OD), 14% (19/136) of non-durable MCSD patients (mean PF4 0.8±0.5 OD), and 41% (42/102) of durable MCSD patients (mean PF4 1.1±0.6 OD). Argatroban was administered in 40% (37/92) of patients with a positive PF4 and 67% (25/37) of patients with a negative SRA. Conclusion Without clinical suspicion of HIT, preoperative PF4 testing is not recommended. Patients with non-durable MCSD devices are at the highest risk of developing HIT (7%). Although a PF4 ≥0.4 OD is considered a positive screening test for HIT, a higher threshold should be considered for MCSD patients. To our knowledge, this is the first in depth assessment of the incidence of HIT in patients undergoing pre-implantation evaluation for both non-durable and durable MCS devices.

Cardiac donation after circulatory death.

Increasing number of patients with end-stage heart failure and those with improved survivorship from selective utilization of implantable mechanical circulatory support devices have added further burden and complexity to the transplant waitlist and on the rate-limiting availability of donor hearts from the standard pathway of donation after brain death. Unlike this conventional route, the increasing clinical use of donation after circulatory death (DCD) donor hearts necessitates a closer understanding of the logistics involved in the DCD process as well as of the risks associated with the unique pathophysiological consequences in this setting. Notwithstanding a higher incidence of delayed graft function, the clinical utilization of DCD hearts for cardiac transplantation over the past five years has demonstrated this to be a well-tolerated and strategic alternative with excellent medium-term clinical outcomes. The uptake of DCD heart transplantation remains selective and currently confined to Australia, the United Kingdom, Belgium, and more recently the USA. A more significant adoption will only come about through: a concerted effort to resolve the ethical and clinical controversies; a better understanding of postconditioning strategies; continued resolve to reduce the obligatory period of warm ischemia; and from better extracorporeal platforms that permit functional viability assessment of the DCD donor heart.

Durable mechanical circulatory support device use in the United States by geographic region and minority status

BackgroundDurable mechanical circulatory support device (MCSD) therapy has experienced rapid dissemination in the United States. Few studies have evaluated geographic patterns of its dissemination based upon patient characteristics that could identify potential variation in its application. MethodsA combined Interagency Registry for Mechanically Assisted Circulatory Support and Medicare dataset identified durable MCSD implants from 2008 through 2014. MCSD implant rates were estimated using yearly US Census population data, estimated from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database and stratified by age, race, and United Network for Organ Sharing (UNOS) region. ResultsOverall, 16,331 patients received an MCSD implant from 232 unique centers. Annual MCSD implant rate (per 1 million population) significantly increased in each UNOS region (absolute range of increase, 5.3-16.4) with UNOS Region 7 demonstrating the highest overall absolute rate (20.9) in 2014 and UNOS Region 11 demonstrating the greatest relative increase in rate (430.5%). Geographical differences in the rate of MCSD implants were observed among whites and minorities with higher rates of MCSD implants observed for minorities for nearly all UNOS regions across all years. Significantly greater relative increases in MCSD implants for minorities compared with whites were observed within UNOS Regions 2, 3, 6, 7, 8, 9, and 11 (P < .001). ConclusionsGeographical differences exist in rates of MCSD implantation among whites and minorities. The reasons for these differences are unknown, but may reflect underlying differences in disease burden or disparities in access to heart transplantation and warrant further study.

Review of Thoracic Causes of Systemic Arterial Air Embolism on Computed Tomography.

Systemic arterial air embolism (SAAE) is a rare but potentially life-threatening condition that may occur when air enters into pulmonary veins or directly into the systemic circulation after pulmonary procedures (biopsy or resection) or penetrating trauma to the lung. While venous air embolism is commonly reported, arterial air embolism is rare. Even a minor injury to the chest along with positive-pressure ventilation can cause SAAE. Small amounts of air may cause neurological or cardiac symptoms depending on the affected arteries, while massive embolism can result in fatal cardiovascular collapse. We discuss the various causes of SAAE, including trauma, computed tomography-guided lung biopsy, and various intervention procedures such as mechanical circulatory support device implantation, coronary catheterization, and atrial fibrillation repair. SAAE diagnosis can be overlooked because its symptoms are not specific, and confirmation of the presence of air in the arterial system is difficult. Although computed tomography is the optimal imaging tool for diagnosis, patient instability and resuscitation often precludes its use. When imaging is performed, awareness of the causes of SAAE allows the radiologist to promptly diagnose the condition and relay findings to the clinicians so that treatment, namely hyperbaric oxygen therapy, may be started promptly.

Performance Evaluation of Series-Compensated IPT Systems for Transcutaneous Energy Transfer

Today's implantable mechanical circulatory support devices, such as left ventricular assist devices, still rely on a percutaneous driveline, which is a frequent cause of severe infections and which reduces the quality of life for the patients. Inductive power transfer (IPT) is therefore a promising technology to replace the driveline and, hence, reducing the likelihood of an infection. This paper focuses on the series–series compensated IPT system and provides an in-depth comparison of two operating modes, i.e., the operation at resonance and the operation above resonance, and highlights the advantages and disadvantages with respect to the requirements set by the application at hand. In addition, the paper presents the design and the realization of a fully functional transcutaneous energy transfer (TET) implant hardware prototype, which includes the IPT front-end, the control circuit, the backup battery and its charging converter, as well as the communication electronics in a boxed volume of only 10.3 cl. The experimental verification shows that overall dc–dc efficiencies of up to 90% can be achieved for both operating modes when transmitting 25–30 W from the external battery to the implant backup battery, each having a nominal voltage of 14.8 V, using TET coils with 70 mm diameter and 10 mm coil separation distance.

Association of pro-inflammatory cytokines and monocyte subtypes in older and younger patients on clinical outcomes after mechanical circulatory support device implantation

Noninvasive immunologic analysis of peripheral blood holds promise for explaining the mechanism of development of adverse clinical outcomes, and may also become a method for patient risk stratification before or after mechanical circulatory support device (MCSD) implantation. Dysregulation of the innate immune system is associated with increased patient age but has yet to be evaluated in the older patient with advanced heart failure undergoing MCSD surgery.Patients pre- and post-MCSD implantation had peripheral blood mononuclear cells (PBMC) and serum isolated. Multiparameter flow cytometry was used to analyze markers of innate cell function, including monocyte subtypes. Multiplex cytokine analysis was performed. MELD-XI and SOFA scores were utilized as surrogate markers of outcomes.Increased levels of pro-inflammatory cytokines including IL-15, TNF-α, and IL-10 were associated with increased MELD-XI and SOFA scores. IL-8, TNF- α, and IL-10 were associated with risk of death after MCSD implantation, even with correction for patient age. Increased frequency of ‘classical’ monocytes (CD14 + CD16−) were associated with increased MELD-XI and SOFA scores.This suggests that inflammation and innate immune system activation contribute to progression to multiorgan system failure and death after MCSD surgery. Development of noninvasive monitoring of peripheral blood holds promise for biomarker development for candidate selection and patient risk stratification.

Frequency of Monocyte Subtypes and TLR4 Expression Correlate with Clinical Outcomes After Mechanical Circulatory Device Implantation

After mechanical circulatory support device (MCSD) implantation, a subset of patients will progress to multiorgan dysfunction. Noninvasive monitoring of immune cells holds promise to understand the mechanism behind adverse clinical outcomes. This is of special importance in the growing group of older patients with advanced heart failure. We hypothesized that pro-inflammatory monocyte subsets and decreased anti-bacterial activity would be associated with adverse clinical outcomes after MCSD.

Reduced Readmissions with Enoxaparin Bridging for Subtherapeutic INR in MCS

Readmissions following mechanical circulatory support (MCS) device implantation continue to be frequent, and supra/subtherapeutic INR remain a major indication for readmission. Several studies have shown the relative safety and efficacy of enoxaparin bridging in MCS. Nonetheless, there is no consensus on optimal management of subtherapeutic INR in MCS recipients. We sought to assess whether outpatient enoxaparin in MCS recipients significantly reduced hospital readmissions while maintaining safe and effective anticoagulation.

T cell dysfunction and patient age are associated with poor outcomes after mechanical circulatory support device implantation

Immunologic impairment may contribute to poor outcomes after implantation of mechanical circulatory support device (MCSD), with infection often as a terminal event. The study of immune dysfunction is of special relevance given the growing numbers of older patients with heart disease. The aim of the study was to define which immunologic characteristics are associated with development of adverse clinical outcomes after MCSD implantation.We isolated peripheral blood mononuclear cells (PBMC) from patients pre- and up to 20 days post-MCSD implantation and analyzed them by multiparameter flow cytometry for T cell dysfunction, including terminal differentiation, exhaustion, and senescence. We used MELD-XI and SOFA scores measured at each time point as surrogate markers of clinical outcome.Older patients demonstrated increased frequencies of terminally differentiated T cells as well as NKT cells. Increased frequency of terminally differentiated and immune senescent T cells were associated with worse clinical outcome as measured by MELD-XI and SOFA scores, and with progression to infection and death.In conclusion, our data suggest that T cell dysfunction, independently from age, is associated with poor outcomes after MCSD implantation, providing a potential immunologic mechanism behind patient vulnerability to multiorgan dysfunction and death. This noninvasive approach to PBMC evaluation holds promise for candidate evaluation and patient monitoring.

Revealing a new mode of sensitization induced by mechanical circulatory support devices: Impact of anti‐AT1R antibodies

Increased levels of angiotensin II type 1 receptor (AT1 R) antibody have been shown to be associated with allograft rejection. This study aims to determine the rate of development of antibody to AT1 R after mechanical circulatory support device (MCS) implantation, and if the development of strong binding AT1 R antibodies is associated with survival. Eighty-eight patients who had one MCS implantation were accessed based on serum availability. Mechanical circulatory support devices in this cohort included pneumatic bilateral paracorporeal ventricular assist device, continuous flow left ventricular assist device, and total artificial heart. Of 88 patients, seven patients had AT1 R antibodies ≥40U/mL preimplantation. For 81 patients who had AT1 R antibodies <40U/mL, the median value was 8U/mL. Of these 81 patients, AT1 R antibody levels in 55 (68%) patients reached the saturated concentration (≥40U/mL) postimplantation (P<.0001), with the highest percentage of patients with the saturated level of AT1 R antibody observed in the pneumatic bilateral paracorporeal ventricular assist device group. Compared to patients without the saturated level of AT1 R antibodies, patients with the saturated AT1 R antibody level had lower 18-month survival (P=.040). Mechanical circulatory support devices implantation significantly increases AT1 R antibody levels. The saturated level of AT1 R antibodies is associated with lower patient survival postimplantation.

Executive Summary - Guidelines for Mechanical Circulatory Support of the Brazilian Society of Cardiology.

Evaluation of candidates for mechanical circulatory support devices In advanced heart failure (HF), the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) proposed seven clinical profiles (and modifiers) for a convenient, easy classification of disease status, risk of implantation of mechanical circulatory support devices (MCSDs) and adequate time for intervention (). One of the main determinant factors for a successful MCSD implantation is patient eligibility. Correct selection of patients involves – (1) patients with advanced HF to which the risk [...]

Predictors of survival and ability to wean from short-term mechanical circulatory support device following acute myocardial infarction complicated by cardiogenic shock.

Cardiogenic shock following acute myocardial infarction (AMI-CS) portends a poor prognosis. Short-term mechanical circulatory support devices (MCSDs) provide hemodynamic support for patients with cardiogenic shock but predictors of survival and the ability to wean from short-term MCSDs remain largely unknown. All patients > 18 years old treated at our institution with extra-corporeal membrane oxygenation or short-term surgical ventricular assist device for AMI-CS were studied. We collected acute myocardial infarction details with demographic and hemodynamic variables. Primary outcomes were survival to discharge and recovery from MCSD (i.e. survival without heart replacement therapy including durable ventricular assist device or heart transplant). One hundred and twenty-four patients received extra-corporeal membrane oxygenation or short-term surgical ventricular assist device following acute myocardial infarction from 2007 to 2016; 89 received extra-corporeal membrane oxygenation and 35 short-term ventricular assist device. Fifty-five (44.4%) died in the hospital and 69 (55.6%) survived to discharge. Twenty-six (37.7%) required heart replacement therapy (four transplant, 22 durable ventricular assist device) and 43 (62.3%) were discharged without heart replacement therapy. Age and cardiac index at MCSD implantation were predictors of survival to discharge; patients over 60 years with cardiac index <1.5 l/min per m2 had a low likelihood of survival. The angiographic result after revascularization predicted recovery from MCSD (odds ratio 9.00, 95% confidence interval 2.45-32.99, p=0.001), but 50% of those optimally revascularized still required heart replacement therapy. Cardiac index predicted recovery from MCSD among this group (odds ratio 4.06, 95% confidence interval 1.45-11.55, p=0.009). Among AMI-CS patients requiring short-term MCSDs, age and cardiac index predict survival to discharge. Angiographic result and cardiac index predict ventricular recovery but 50% of those optimally revascularized still required heart replacement therapy.

Cardiogenic shock : Current evidence

This CME article addresses the pathophysiology, incidence, current survival outcome and treatment options for patients with cardiogenic shock as a complication of acute myocardial infarction. The shock spiral of left heart failure due to cardiac infarction, subsequent vasoconstriction and paradoxical vasodilation due to the systemic inflammation response syndrome (SIRS) is a vicious circle which must be interrupted. Treatment focuses on the evidence from randomized clinical trials and the current guideline recommendations. With respect to interventional and surgical treatment the question of culprit lesion vs. complete revascularization is still unsolved. For medicinal treatment acetylsalicylic acid (ASA) and heparin are more often supplemented with prasugrel and ticagrelor. In the case of inotropes, dobutamine remains the first-line treatment option and for vasopressors norepinephrine. The calcium sensitizer levosimendan has not provided the hoped for superiority over conventional treatment in randomized trials. The use of intra-aortic balloon pumps (IABP) is no longer recommended as circulatory support in acute heart failure (reduced to classIII). The use of percutaneous implantable mechanical circulatory support devices has not shown asurvival benefit in the few randomized trials carried out so far even when compared with IABP, due to increased bleeding complications.