Mechanical Circulatory Support Devices Research Articles

Cardiogenic shock.

Cardiogenic shock is a complex syndrome defined by systemic hypoperfusion and inadequate cardiac output arising from a wide array of underlying causes. Although the understanding of cardiogenic shock epidemiology, specific subphenotypes, haemodynamics, and cardiogenic shock severity staging has evolved, few therapeutic interventions have shown survival benefit. Results from seminal randomised controlled trials support early revascularisation of the culprit vessel in infarct-related cardiogenic shock and provide evidence of improved survival with the use of temporary circulatory support in selected patients. However, numerous questions remain unanswered, including optimal pharmacotherapy regimens, the role of mechanical circulatory support devices, management of secondary organ dysfunction, and best supportive care. This Review summarises current definitions, pathophysiological principles, and management approaches in cardiogenic shock, and highlights key knowledge gaps to advance individualised shock therapy and the evidence-based ethical use of modern technology and resources in cardiogenic shock.

Abstract 4115816: Enhancing Cardiogenic Shock Management: Insights from MCS utilization and Patient Outcomes

Cardiogenic shock (CS) remains a challenge with high mortality rates despite advances in treatment modalities. This study investigates the utilization and impact of mechanical circulatory support (MCS) devices, including intra-aortic balloon pump (IABP), Impella, and Extracorporeal Membrane Oxygenation (ECMO) on patient outcomes in CS management. A retrospective analysis was performed using National Inpatient Sample data (2017 to 2019). Inclusion criteria included patients aged ≥18 years with primary diagnosis of CS using ICD10(R570). Multivariate regression analysis was used to assess MCS duration, mortality, length of stay (LOS), and costs. Among 462,685 included patients, 38% were female, with a mean age of 66 years. Majority were White (67%), followed by Black (16.5%), and Hispanic (9%). IABP was utilized in 13% of cases, Impella in 6%, and ECMO in 0.9%. No significant difference was observed in MCS placement between weekdays vs weekends. However, weekend admissions showed higher mortality rates with an odd ratio (OR) of 1.06(p <0.00, CI 1.03-1.09), particularly among females OR 1.25(p<0.00, CI 1.22 – 1.289). Urban non-teaching hospitals exhibited highest mortality rate, followed by Urban teaching. ECMO was associated with highest mortality OR 2.08(p < 0.00, CI 1.93-2.82), followed by Impella OR of 1.47 (p < 0.00, CI 1.37 – 1.59), and IABP OR 0.723 (p < 0.00, 0.685-0.765). LOS was lowest in Impella group, followed by IABP, while ECMO showed non-significant LOS increase. Mean total charge varied among MCS groups with ECMO being highest. The findings highlight several important aspects of CS management. Elevated mortality rates during weekend admissions suggest potential disparities in care access or delivery, necessitating investigation and interventions to ensure consistent quality of care throughout the week. Increased mortality among females, variations across different hospital settings, impact of MCS devices on LOS and costs emphasize the need for tailored approaches to enhance patient outcomes and resource utilization efficiency.

Abstract 4129945: Risk of stroke for AMI treated with temporary mechanical circulatory support: ten-year data from National Inpatient Sample

Objectives: The aim of this study was to assess the risk of stroke for temporary mechanical circulatory support (tMCS) device treated acute myocardial infarction (AMI). Background: Data are limited regarding risk of stroke for temporary mechanical circulatory support (tMCS) device treated acute myocardial infarction (AMI). Methods: The national inpatient sample database was analyzed to identify adults who were hospitalized for AMI between 2012 and 2021, hospitalizations were grouped based on the temporary mechanical circulatory support device. Study design: In the final cohort, there are 8,272,163 (96.0%) weighted hospitalizations treated without tMCS, 265,870 (3.1%) with Intra-Aortic Balloon Pump (IABP) alone, 59,240 (0.7%) with Impella alone, and 16,225 (0.2%) with Extracorporeal Membrane Oxygenation (ECMO) used during the hospitalization. Results: The overall stroke rates for patients who treated without tMCS, IABP alone, Impella alone, and ECMO group were 3.41%, 3.46%, 4.51%, and 13.34% respectively. Specifically, the rates of ischemic stroke for these groups were 2.95%, 3.12%, 3.96% and 10.11% respectively. The rates for hemorrhagic stroke were 0.68%, 0.55%, 0.81%, and 4.90% for the same groups. In the stepwise forward Cox regression analysis, the adjusted OR (aOR) of ECMO use for overall stroke was 3.04 (95%CI [2.66-3.48]), followed by Impella only use with an aOR of 1.79 (95%CI [1.61-2.00]), and atrial fibrillation (aOR 1.34, 95%CI [1.31-1.38]). The subgroup analysis revealed that hospitalization with age younger than 50 years old, those without hypertension, and those presented with ST-elevation myocardial infarction are at particularly high risk of stroke for ECMO treated AMI. Conclusion: This ten years AMI hospitalizations analysis revealed that ECMO and Impella treatment associated with increased risk of both ischemic and hemorrhagic stroke. Particularly for those younger than 50, those without hypertension, and those presented with ST-elevation myocardial infarction. However, treatment with IABP alone does not increase the risk of stroke.

Abstract Su701: The Influence of Public Assistance Among Patients Who Received Extracorporeal Cardiopulmonary Resuscitation after Cardiac Arrest in Japan

Background: This study aimed to evaluate the influence of public assistance on patients with out-of-hospital cardiac arrest (OHCA) who received extracorporeal cardiopulmonary resuscitation (ECPR) in Japan. Methods: We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter registry study involving 36 participating institutions in Japan. Patients with cardiac arrest who received ECPR were divided into two groups depending on whether or not they had received public assistance. The primary outcome was 30-day survival. Secondary outcomes were as follows: 30-day favorable neurological outcomes (cerebral performance category scores 1-2); survival at discharge; favorable neurological outcome at discharge; number of intensive care unit, hospital, ventilator, and extracorporeal membrane oxygenation days; medical expenses; proportion of percutaneous coronary intervention; target temperature management; mechanical circulatory support (MCS) device use; and withdrawal of life-sustaining therapy. Results: Of 2,157 patients registered in the SAVE-J II study, 1,885 patients were enrolled in this study; 99 patients (5.3%) received public assistance and 1,786 patients (94.7%) did not. Multivariable logistic regression analysis did not show a significant difference in 30-day survival (OR 1.22, 95% CI 0.77-1.95, p=0.40). The log-rank test for the Kaplan-Meiercurve on 30-day survival did not demonstrate a significant difference (p=0.46). Except for the use of MCS devices, there were no significant differences in secondary outcomes. Conclusions: The use of public assistance did not influence the prognoses of OHCA patients receiving ECPR. Treatment option during hospitalization may be affected by the use of public assistance.

Improving the hemocompatibility of centrifugal mechanical circulatory support devices at low flow rates.

An innovative solution has been recently proposed for the treatment of heart failure with preserved ejection fraction (HFpEF), using a centrifugal mechanical circulatory support (MCS) device. We sought firstly to assess the hemocompatibility of the proposed device. HFpEF treatment requires the blood pump to operate at low blood flow rate (0.05-0.5 L/min). Given high blood trauma expected in these conditions, we sought secondly to investigate design improvements in order to reduce this risk. Computational fluid dynamics was used to analyze the blood fluid filled within the centrifugal pump and to estimate the blood trauma due to its operation. This assessment is based on the computation of integrated quantities such as the hemolysis index and the turbulent dissipation energy. The hemolysis index associated with the present device is comparable to the figures from HVAD. With the proposed pump, for instance, an index of 0.0036 is obtained at 1 L/min and 3000 rpm. Using thinner blades for the impeller allows a 12% reduction of the hemolysis index in average, while reducing its diameter leads to an index 2.8 folds lower at 0.5 L/min. The present investigation shows the promising hemocompatibility of our centrifugal pump. Concerns about very high hemolysis generated at low flow rates could be overcome by reducing the impeller diameter. Experimental validations are planned to support our findings.

Hematologic and biochemical reference values for anesthetized juvenile German crossbred farm pigs

Juvenile crossbred pigs are widely used for acute and chronic animal testing due to their anatomical and physiological resemblance to humans. They are particularly prevalent in preclinical cardiovascular research, including studies investigating extracorporeal resuscitation and mechanical circulatory support devices. However, the availability of comprehensive laboratory reference values is limited. In a single-center study at the University Medical Center Freiburg, Germany, the hematologic and biochemical laboratory values of anesthetized healthy juvenile German crossbred farm pigs were determined. Blood samples were collected at the beginning of surgical procedures, either arterially or venously. Females and males were compared, and correlation with body weight was assessed. In total, 268 animals (weight 57.8 ± 12.4 kg) were included, thereof 180 castrated males (55.2 ± 7.7 kg) and 79 females (63.6 ± 18.3 kg). There were significant differences between males and females in 11 of 45 parameters and a moderate correlation between body weight and creatinine (R = 0.41, p < 0.001). The reference intervals and insights into sex and body weight correlations enhance the utility of healthy juvenile German crossbred farm pigs in translational research, providing a robust reference for future studies.

Breaking Down Cardiogenic Shock: An Analytical Reflection on the DanGer-SHOCK and ECLS-SHOCK Trials

Mechanical circulatory support (MCS) devices, particularly the microaxial flow pump (mAFP), have gained traction in managing cardiogenic shock (CS) in patients with acute myocardial infarction (AMI). However, trials like DanGer-Shock and ECLS-Shock have reported differing outcomes, making it challenging to draw definitive conclusions. To explore this further, we conducted a comparative analysis of the 30-day and 6-month mortality rates from the DanGer-Shock and ECLS-Shock trials, examining differences in patient populations and risk profiles. The goal was to determine whether these differences could explain the conflicting outcomes or if the benefits observed in the DanGer-Shock trial were directly attributable to the mAFP strategy. One key finding is that, despite similar control group mortality rates, the intervention group in DanGer-Shock demonstrated a notably lower mortality rate at both 30 days and 6 months compared to the ECLS trial, with an absolute difference of about 8%. This benefit is not due to inherent risk differences but is instead attributed to the Impella-based strategy. Compared to standard care, mAFP data revealed a 7% mortality reduction at 30 days, which grew to 12.7% at 180 days, highlighting the long-term effectiveness of the mAFP strategy in maintaining hemodynamic stability and improving survival. These results suggest that, in CS management, the DanGer unloading strategy, when combined with percutaneous coronary intervention (PCI), plays a significant role in improving long-term survival through early intervention and ventricular unloading, independent of control group factors. Further research is needed to confirm the broader applicability of this approach in different patient populations.

STEMI SHOCK outcomes with SCAI classification

Abstract Background Patients with ST-elevation myocardial infarction who develop cardiogenic shock (STEMI-SHOCK) face significantly increased risk compared to those without shock. Mechanical circulatory support (MCS) devices are commonly utilized in STEMI-SHOCK patients, but the benefits of MCS remain uncertain. This study aims to apply the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification system to STEMI-SHOCK patients, examining outcomes and identifying subgroups that may benefit from MCS. Purpose Our study assessed SHOCK severity in STEMI-SHOCK patients using the updated 2021 SCAI-SHOCK classification system and determined survival at various endpoints (30 days, 1 year, and 3 years), along with other outcomes such as vascular access complications and major adverse cardiac events, based on the severity class. Methods Patients with angiograms and indications of STEMI-SHOCK between 2012 and 2021 admitted to Liverpool Hospital Australia, were included after adjudication they had STEMI-SHOCK. Angiograms were eligible for adjudication if they met criteria for both STEMI and SHOCK. Each patient underwent individual adjudication by three researchers to confirm STEMI-SHOCK status. Patients were followed from the time of the first SHOCK diagnosis until censoring at the last follow-up. Data were retrieved from electronic and paper-based patient records. The primary outcome was 30-day survival, and secondary outcomes were 1-year and 3-year survival. Results The SCAI stages of 160 (Estimated 220) STEMI-SHOCK patients were determined, with 17 in Stage A, 39 in Stage B, 53 in Stage C, 25 in Stage D, and 26 in Stage E. Worse SCAI stages were associated with significantly lower 30-day, 1-year, and 3-year survival. No difference in survival between the time periods 2013-2015 and 2018-2021 was found. An eGFR &amp;lt; 60 millilitres/minute/1.73 meters^2 (hazard ratio [HR] 3.41; 95% confidence interval [CI] 1.18 – 9.92, p=0.024) and lactate greater than 4.15 millimoles/liter (HR 6.48; 95% CI [2.84 – 51.64], p=0.001) at shock were associated with lower 30-day and 3-year survival. Patients in the SCAI C subgroup treated with an IABP had significantly higher 1-year (p=0.001) and 3-year (p=0.001) survival compared to those not treated with an IABP. Conclusion The SCAI classification system successfully predicted short and long-term survival in STEMI-CS patients, with worse stages having progressively worse outcomes. No improvement in survival outcomes was observed in the overall SCAI C-E group of patients treated with mechanical support. However, patients in the SCAI C subgroup of SHOCK treated with mechanical support showed a statistically significant improvement in survival outcomes compared to those treated without mechanical support. Further studies with adequate sample sizes are required to investigate sub-populations of SCAI classes that may benefit from MCS devices.

The true incidence and risk factors of hemolysis in patients with Impella CP placement

Abstract Background The Impella, a micro axial-flow pump, is effective in treating cardiogenic shock. However, compared to other mechanical circulatory support devices, its high pump speeds can result in complications like hemolysis and subsequent renal failure. Previous reports have defined hemolysis based on the elevation of LDH levels or the presence of hemoglobinuria, but this approach may underestimate its occurrence. Hemolysis is commonly assessed using the hemolysis index, which is calculated through biochemical auto-analysis based on the absorbance measure of the red color change. However, since the hemolysis index is not highly sensitive, it is recommended to measure plasma free hemoglobin (PFHb) for accurate diagnosis of hemolysis. Purpose The aim of this single-center retrospective cohort study is to investigate the frequency of hemolysis in Impella CP using PFHb measurements and its association with the Impella support level. Methods Between December 2019 and June 2023, we included 116 patients who had the Impella CP device implanted at our hospital. For these patients, PFHb was measured twice daily during the Impella placement period (up to 13 days). A PFHb value of 0.06 or higher was considered indicative of hemolysis, at which point a haptoglobin preparation of 4000 units was administered. Separately, the hemolysis index was defined as hemolysis at a level of 41 mg/dL. We investigated the relationship between daily Impella settings, PFHb, and hemolysis index for each patient. Results The average age was 70 ± 13 years. 59% underwent ECPELLA, and 15% were introduced to renal replacement therapy (RTT) due to severe renal failure. During Impella placement, hemolysis was diagnosed in 33% of patients based on PFHb, while only 18% were diagnosed with hemolysis according to the hemolysis index. Upon separate analysis for Impella and ECPELLA during the initial three days, the support levels of Impella were significantly higher in the Impella group on Days 1 and 2, with no significant difference noted on Day 3. Moreover, PFHb levels were significantly higher in the Impella group on Day 1, while on Day 3, the levels were higher in the ECPELLA group. Patients on RRT had significantly higher max PFHb levels than those not on RRT (0.19 vs. 0.06 g/dL; p &amp;lt; 0.001). Next, we investigated the relationship between PFHb levels and Impella support levels in patients with either Impella or ECPELLA over 711 data points. Dividing Impella support into low (P1-3), middle (P4-6), and high (P7-9) categories, PFHb values were significantly higher at high P levels compared to low and middle P levels. Similar results were observed for both Impella and ECPELLA. Conclusion There is a possibility of underestimating hemolysis associated with Impella if PFHb measurement is not performed. Hemolysis showed a significant correlation with higher P levels (P7 and above) for both Impella and ECPELLA.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational monocentric prospective study

Abstract Background Although temporary mechanical circulatory support (MCS) devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process and decision although there are no standardized protocols for the trial nor accordance on the parameters to apply. Purpose We sought to evaluate the overall accuracy of echocardiographic indices in predicting successful weaning from VA ECMO in patients with CS. Specifically, we tested total isovolumic time (tIVT), an index of ventricular performance, and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Monocentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Weaning trials were performed daily, starting 48 hours after VA-ECMO institution, when patients were hemodynamically stable: mean arterial pressure &amp;gt;65 mmHg, no or minimum adrenergic support (vasoactive inotropic score &amp;lt;10), heart rate &amp;lt;110 bpm, lactate &amp;lt;2 mmol/L, and no signs of respiratory distress. Weaning trials were performed with a stepwise decrease of VA-ECMO blood flow until reaching 1 or 1.5 L/min under adequate anticoagulation. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (table): stroke volume &amp;gt;13.9 mL (p 0.002), tIVT &amp;gt;23.6 min/sec (p 0.053), LV VTI &amp;gt;6.6 cm (p&amp;lt;0.001), MAPSE &amp;gt;6.15 mm (p 0.001), TAPSE &amp;gt;11 mm (p 0.023), RV S’ &amp;gt;10 cm/s (p 0.012). LVEF did not reach the statistical significance. Figure shows Kaplan-Meier analysis on echocardiographic indices collected at time of cannulation (panel A) and during the last weaning trial (panel B). Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Considering the known limitations of LVEF (heart rate, loading and left ventricular dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation of patients in the acute setting.TableFigure

TAVI for treating severe aortic valve disease in cardiogenic shock: a single centre experience

Abstract Introduction Recent evidence shows the safety and efficacy of TAVI in patients with aortic valve disease (AVD) presenting in cardiogenic shock (CS). However, there is limited data regarding CS management in the cardiac intensive care unit (CICU) and its outcomes. We aimed to describe the CS features, pre-TAVI management and short-term clinical outcomes of a cohort of CS patients (pts) submitted to TAVI. Methods Single-centre retrospective registry of consecutive pts with AVD undergoing TAVI in CS, from January 2020 to October 2023. CS was defined as pre-procedural hypotension/hypoperfusion requiring vasoactive drugs or mechanical circulatory support (MCS) devices. The severity of CS was defined according to the SCAI classification. Procedural related outcomes according to the VARC-3 criteria and 30-day mortality were assessed. Results A total of 16 pts (1% of our global TAVI cohort, 62% male, mean age 79±5 years) meet the inclusion criteria. The majority (n=13) presented severe aortic stenosis, two had degenerated aortic bioprosthesis with severe regurgitation and one had native valve severe regurgitation. 6 pts (38%) had isolated left ventricle (LV) dysfunction and 10 (62%) had biventricular dysfunction. The admission LVEF was 33±8% and the mean transaortic gradient for those with aortic stenosis was 46±13mmHg. The EuroSCORE II estimated for a single non-CABG emergency procedure was 37±15%. All patients were refused for surgical treatment upon Heart Team discussion. At admission, 12 (75%) patients presented in CS SCAI-C, 1 (6%) in SCAI-D and 3 (19%) in SCAI-E. These last 3 patients presented in cardiac arrest upon admission to the CICU (time to ROSC from 2 to 15 minutes). The peak lactate level at 48 hours was 3.4 mmol/L [2.1-5.1] and the highest Vasoactive-Inotropic Score (VIS) during admission was 21 [11-45]. None of the patients needed MCS pre-TAVI. 5 (31%) patients required invasive mechanical ventilation and 5 (31%) renal replacement therapy. Median time between CICU admission and transfemoral TAVI was 2.5 days [IQR 1-7]. Procedural success was 100%, with 57% receiving a balloon-expandable and 43% a self-expandable valve. Post-TAVI CICU length of stay was 6 days [IQR 5-9]. Most common procedural complication were the need for permanent pacemaker implantation (n=2, 12%) and access-related bleeding (n=2, 12%). Hospital length-of-stay was 20±15 days. Thirty-day mortality was 12% (n=2). Conclusion In this cohort of CS patients selected for TAVI treatment, procedural success was achieved in all cases. While complications were similar to the general TAVI population, in-hospital mortality remained high but very acceptable. These results suggest that, if correctly selected, aortic valve disease patients in CS represent a niche for whom brief stabilization and urgent percutaneous valve treatment might impact their dismal prognosis.

Direct comparison of mechanical circulatory support devices in porcine model of acute myocardial infarction complicated by ventricular septal defect and cardiogenic shock

Abstract Introduction Despite urgent clinical need, until now optimal strategy for mechanical circulatory support in acute myocardial infarction (AMI) complicated by ventricular septal defect (VSD) and cardiogenic shock has not been determined. Purpose The aim of our study was to compare hemodynamic effects of intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO) and Impella CP in the animal model of AMI complicated by VSD and cardiogenic shock. Methods Under general anesthesia and mechanical ventilation in pigs (sus scrofa domestica), using partial sternotomy, AMI was induced by ligation of left anterior descending. VSD was simulated by insertion of 25F cannulas into the left and right ventricles and their extracorporeal connection by 3/8 tubes generating left-to-right shunt. The hemodynamic effect of ECMO (2 L/min), IABP, and Impella CP (2 L/min) was evaluated by the measurement of the left ventricular end-diastolic pressure (LVEDP), mean arterial pressure (MAP), carotid flow (CAR) as a surrogate of total circulatory output, and VSD flow. Data are presented as mean (SD), P &amp;lt; 0.05 was considered statistically significant. Results Eleven animals were used, one died after induction of AMI, ten pigs completed all study procedures. Baseline (no mechanical support) LVEDP was 13.8 (3.0) mmHg, MAP 54.5 (11.0) mmHg, CAR 290.9 (37.3) mL/min, and VSD 1174.0 (499.3) mL/min (Table 1). IABP significantly improved all parameters in comparison to Baseline (Table 1). ECMO significantly improved MAP and CAR not only in comparison to Baseline but also in comparison to IABP and Impella; on the other hand, ECMO increased VSD flow (Table 1). Impella significantly improved all parameters with the largest effect on LVEDP and VSD flow (Table 1). Conclusions All tested devices improved the key hemodynamic parameters of MAP and CAR, however each to different extent. Individual devices influenced differently LVEDP and VSD flow. The results of this study may help in selection of optimal therapeutic strategy in AMI complicated by VSD and cardiogenic shock.Table 1.Hemodynamic outcomes.

Post-PCI anticoagulation with unfractionated heparin in acute coronary syndrome: insight from the STOPDAPT-3 trial

Abstract Background The guidelines recommend the post-procedural anticoagulation should be discontinued after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) except for the specific indications.(1) However, these guideline recommendations were not well supported by data, and therefore, post-PCI parental anticoagulation has been commonly implemented in patients with ACS in the previous studies.(2-5) Purpose To clarify the preference and clinical situations of post-PCI unfractionated heparin (UFH) in ACS patients and to explore the influence of post-PCI UFH on cardiovascular and bleeding outcomes. Methods STOPDAPT-3 trial is a randomized controlled trial to demonstrate the efficacy and safety of the aspirin-free prasugrel monotherapy strategy compared to the conventional dual antiplatelet therapy after PCI in patients with high-bleeding risk or ACS.(6) Data on periprocedural heparin use and its doses were vigorously collected. The current study population was the ACS patients enrolled in the STOPDAPT-3 without use of mechanical circulatory support devices. The two co-primary endpoints were the bleeding outcome defined as the BARC 3 or 5 criteria and the cardiovascular outcome defined as a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke. Outcomes were assessed at 30 days from index PCI. Results Among 4088 ACS study patients, 2339 (57.2%) patients received post-PCI UFH. Median dose of UFH was 7.1 (IQR 6.0-8.8) units/kg/hour and the median duration was 25 (IQR 24-48) hours. As many as 57.7% of patients received 10000 units/day of heparin after PCI irrespective of body weight. STEMI patients more frequently received post-PCI UFH compared to NSTE-ACS (72.3% and 38.8%, P&amp;lt;0.001) and the patients with intraprocedural adverse angiographic findings such as thrombus, slow-flow, no-reflow, or final TIMI flow &amp;lt;=2 also more frequently received post-PCI UFH than those without (67.6% and 47.5%, P&amp;lt;0.001). Post-PCI UFH was associated with a significantly increased risk of bleeding endpoint (4.75% and 2.52%, adjusted HR 1.69 [95%CI 1.15-2.46], P=0.007) and a numerically increased risk of cardiovascular endpoint (3.16% and 1.72%, adjusted HR 1.56 [95%CI 0.98-2.46], P=0.06). Even in the patients with intraprocedural adverse angiographic findings, post-PCI UFH did not show a clear benefit for cardiovascular endpoint (3.15% and 1.72%, adjusted HR 1.73 [95%CI 0.88-3.41]. P=0.11). Conclusion(s) Post-PCI anticoagulation with UFH was frequently implemented in ACS patients enrolled in the latest large Japanese clinical trial. Post-PCI UFH use was associated with harm in terms of bleeding without a benefit in reducing cardiovascular events.

Research Progress on Acute Kidney Injury in Patients with Cardiogenic Shock Undergoing Venoarterial Extracorporeal Membrane Oxygenation

Cardiogenic shock (CS) is a life-threatening syndrome characterized by peripheral hypoperfusion and organ dysfunction caused by primary heart disease. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a temporary mechanical circulatory support device for CS, used in cases of profound shock, biventricular failure, respiratory failure, and cardiac arrest that require urgent maximal support. While VA-ECMO provides effective tissue perfusion and ensures oxygen supply to organs, it is also associated with severe complications, among which acute kidney injury (AKI) is one of the most common and serious. To date, no comprehensive review has been conducted on the pathophysiology, influencing factors, and treatment of AKI associated with VA-ECMO. This paper aims to elaborate on the pathophysiological mechanisms, influencing factors, and treatment options for AKI in patients with CS undergoing VA-ECMO, providing clinical and nursing references.

Extending the window in clinical decision making: the role for Impella 5.5 in cardiogenic shock

Abstract Background Acute decompensated heart failure (HF) refractory to medical management deteriorates quickly to cardiogenic shock, ultimately requiring mechanical circulatory support (MCS). These devices aim to provide circulatory support as a bridge to advanced therapies. We report patient outcomes with the latest minimally invasive temporary MCS device: Impella 5.5 with SmartAssist. Methods All patients who underwent Impella 5.5 implantation between January 2020 and December 2023 were analyzed. Duration of Impella support and peri-implant parameters were collected from electronic medical records. ANOVA was performed and utilized a p-value of &amp;lt;0.05 as significant for statistical analysis. Results During our review period, a total of 99 patients were supported with Impella 5.5 in the setting of cardiogenic shock. 92 were bridged to heart transplant (BTT), of which 17 also received combined kidney transplantation. Two underwent durable VAD implantation (BTVAD), and 3 had native heart recovery (BTR) and explant. Two patients died, yielding a survival rate of 98%. For BTT group, the median age was 60 years (52-65) at implant and a median BMI of 27 kg/m² (24-31) with a mean support duration of 29 days (SD ±24). Baseline GFR was 49 mL/min/1.73m² (35-65). In the BTVAD group, the median BMI was 43 kg/m² (39-46) with an average duration of support of 22 days (SD ±8) with a GFR of 55 mL/min/1.73m² (38-73). The BTR group had a median BMI of 29 kg/m² (27-30) with an average duration of support of 15 days (SD ±7) and a lower baseline GFR of 36 mL/min/1.73m² (26 – 37) compared to BTT or BTVAD. The two patients that died were supported for an average of 42 days (SD ±9.2) and expired due to non-candidacy in the setting of newly detected prostate cancer in one patient and multi-organ failure in another. All BTVAD and BTT patients did not have a stroke or major vascular complications before terminal therapy. Conclusion Our center highlights the role of early Impella 5.5 placement in the stabilization of patients in cardiogenic shock, thereby providing both patients and providers time for decision-making while optimizing end-organ perfusion beyond the accepted duration of 14 days.Impella Data - Entire CohortImpella Data - Stratified by Outcome

Reassess Hospital Costs and Mortality Between Myocardial Infarction With and Without ST-Segment Elevation in a Modern Context.

Patients with ST-segment elevation myocardial infarction (STEMI) may have higher hospitalization costs and poorer prognosis than non-ST-segment elevation myocardial infarction (NSTEMI). A single-center retrospective study was conducted on 758 STEMI patients and 386 NSTEMI patients from January 1, 2020 to May 30, 2023 aimed to investigate the differences in cost and mortality. STEMI patients had higher maximal troponin I (15,222.5 (27.18, 40,000.00) vs. 2731.5 (10.73, 27,857.25), p < 0.001) and lower left ventricular ejection fraction (LVEF) (56% (53%, 59%) vs. 57% (55%, 59%), p < 0.001) compared to NSTEMI patients. The clinical symptoms were mainly persistent or interrupted chest pain/distress in either STEMI or NSTEMI patients. STEMI patients had a significantly higher risk of combined hypotension than NSTEMI patients (8.97% vs. 3.89%, p = 0.002), and IABP was much more frequently used in the STEMI group with a statistical difference (2.90% vs. 0.52%, p = 0.015). STEMI patients have statistically higher hospitalization costs (RMB, ¥) (31,667 (25,337.79, 39,790) vs. 30,506.91 (21,405.96, 40,233.75), p = 0.006) and longer hospitalization days (10 (8, 11) vs. 9 (8, 11), p = 0.001) compared to NSTEMI patients. Although in-hospital mortality was higher in STEMI patients, the difference was not statistically significant (3.56% vs. 2.07%, p = 0.167). Multivariable logistic regression was performed and found that systolic blood pressure and NT-proBNP were risk factors for patient death (OR ≥ 1). STEMI patients are more likely comorbid cardiogenic shock, heart failure complications with higher hospitalization costs and longer hospitalization days. And relatively more use of acute mechanical circulatory support devices such as IABP. ChiCTR2300077885.

Hemodynamic Support With the Impella 5.5 Acute Mechanical Circulatory Support Device.

The Impella 5.5 is increasingly used as a bridge to recovery or heart replacement therapies despite lack of clinical trial evidence. We report real-world outcomes and hemodynamic effects of 150 consecutive patients from a single, high-volume center. Primary outcome was incidence of recovery, durable left ventricular assist device (LVAD), or heart transplant compared with incidence of death at 90 days. Secondary outcomes included hemodynamic trends and upgrade to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The composite endpoint occurred in 59.3% and death in 18.8% of patients (incidence rate ratio: 8.1 [95% confidence interval {CI}: 5.4-12.2], p < 0.001). Decreases in pulmonary artery diastolic pressure (PADP) (p = 0.026), estimated pulmonary effective arterial elastance (Ea) (p < 0.001), and vasoactive-inotropic score (VIS) (p < 0.001) occurred during Impella 5.5 support. Pulmonary artery diastolic pressure correlated with estimated Ea (p < 0.001), suggesting improved right ventricle (RV) afterload with left ventricle (LV) unloading. Veno-arterial extracorporeal membrane oxygenation upgrade occurred in 11.3% of patients who had higher baseline right atrial pressure (RAP) (16.0 [9.0-20.5] vs. 9.0 [7.0-12.0], p = 0.022), PADP (28.5 [25.0-31.0] vs. 23.0 [18.0-28.0], p = 0.011), and lower pulmonary artery pulsatility index (PAPi) (1.45 [0.82-3.45] vs. 2.5 [1.65-3.86], p = 0.029). Upgrade patients had higher repeated measures trends in RAP (p < 0.001) and PADP (p = 0.015). The Impella 5.5 improved hemodynamics and effectively bridged to recovery or heart replacement therapies. Co-existing RV dysfunction can be supported on Impella 5.5 with careful hemodynamic trend monitoring.

Left ventricular unloading to facilitate ventricular remodelling in heart failure: A narrative review of mechanical circulatory support.

Heart failure represents a dynamic clinical challenge with the continuous rise of a multi-morbid and ageing population. Yet, the evolving nature of mechanical circulatory support offers a variety of means to manage candidates who might benefit from such interventions. This narrative review focuses on the role of the main mechanical circulatory support devices, such as ventricular assist device, extracorporeal membrane oxygenation, Impella and TandemHeart, in the physiological process of ventricular unloading and remodelling in heart failure, highlighting their characteristics, mechanism and clinical outcomes. The outcome measures described include physiological changes (i.e., stroke volume or preload and afterload), intracardiac pressure (i.e., end-diastolic pressure) and extracardiac pressure (i.e., pulmonary capillary wedge pressure). Overall, all the above mechanical circulatory support strategies can facilitate the unloading of the ventricular failure through different mechanisms, which subsequently affects the ventricular remodelling process. These physiological changes start immediately after ventricular assist device implantation. The devices are indicated in different but overlapping populations and operate in distinctive ways; yet, they have evidenced performance to a favourable standard to improve cardiac function in heart failure, although this proved variable for different devices, and further high-quality trials are vital to assess their clinical outcomes further. Both Impella and TandemHeart are indicated mainly in cardiogenic shock and high-risk percutaneous coronary intervention patients; at the time the literature was evaluated, both devices were found to yield a significant improvement in haemodynamics but not in survival. Nevertheless, the choice of device strategy should be based on individual patient factors, including indication, to optimize clinical outcomes.

Ambulation in patients with peripheral veno-arterial extracorporeal membrane oxygenation and concomitant femoral intra-aortic balloon pump support.

The mobilization and ambulation of patients with severe cardiogenic shock supported with peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) and concomitant femoral intra-aortic balloon pump (IABP) support is not well-described. This technical paper describes an ambulation protocol to prevent deconditioning in this critically ill patient population. A protocol for the ambulation of patients with pVA-ECMO and concomitant IABP support was created in December 2022 and implemented at a single center. To initiate ambulation, patients were initially placed in a vertical position utilizing the VitalGo Total Lift Bed (VitalGo Systems, Miramar, FL) with mechanical circulatory support device monitoring performed by a critical care multidisciplinary team. Retrospective analysis of successfully ambulated patients was performed from December 2022 to January 2024. A total of 35 patients out of 112 patients with ECMO support were ambulated in the study period. Four of these patients had pVA-ECMO with concomitant IABP support with this cohort completing a total of 11 sessions during the study period. Patients ambulated an average of 200 feet per session without any adverse events, including cannula and balloon pump migration or displacement. Three of the four patients studied were either bridged to an advanced therapy including orthotopic heart transplant or durable left ventricular assist device or were discharged. A protocol for ambulation of CS patients with pVA-ECMO support and concomitant femoral IABP support is feasible and can safely be implemented in this critically ill patient population. Further multicenter studies are necessary to determine the overall impact of ambulation on patient outcomes.

TCT-787 Outcomes of Mechanical Circulatory Support Device Use in Female Patients With Cardiogenic Shock Undergoing Percutaneous Coronary Interventions

TCT-787 Outcomes of Mechanical Circulatory Support Device Use in Female Patients With Cardiogenic Shock Undergoing Percutaneous Coronary Interventions