Utilization Of Mechanical Circulatory Support Research Articles

Mechanical Support in High-Risk Pulmonary Embolism: Review Article.

Acute pulmonary embolism (PE) may manifest with mild nonspecific symptoms or progress to a more severe hemodynamic collapse and sudden cardiac arrest. A substantial thrombotic burden can precipitate sudden right ventricular strain and failure. Traditionally, systemic thrombolytics have been employed in such scenarios; however, patients often present with contraindications, or these interventions may prove ineffective. Outcomes for this medically complex patient population are unfavorable, necessitating a compelling argument for advanced therapeutic modalities or alternative approaches. Moreover, patients frequently experience complications beyond hemodynamic instability, such as profound hypoxia and multiorgan failure, necessitating assertive early interventions to avert catastrophic consequences. The existing data on the utilization of mechanical circulatory support (MCS) devices are not exhaustive. Various options for percutaneous MCS devices exist, each possessing distinct advantages and disadvantages. There is an imminent imperative to develop a tailored approach for this high-risk patient cohort to enhance their overall outcomes.

Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy.

Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.

In-hospital Outcomes And Trends Of Racial Differences In Utilization Of Mechanical Circulatory Support

In-hospital Outcomes And Trends Of Racial Differences In Utilization Of Mechanical Circulatory Support

Abstract 18298: 10-Year Trends of In-Hospital Outcomes of Patients That Underwent Percutaneous Coronary Intervention for Cardiogenic Shock Complicating Acute Coronary Syndrome

Background: Cardiogenic shock complicating acute coronary syndrome (CS-ACS) is a life-threatening condition and percutaneous coronary intervention (PCI) remains a fundamental approach in its management. In recent years, notable advancements have emerged, including the utilization of mechanical circulatory support (MCS) devices and an enhanced understanding of patient selection for PCI. This study aims to assess the temporal trends in patient background and outcomes of patients who underwent PCI for CS-ACS. Methods: The Keio interhospital Cardiovascular Studies (KiCS)-PCI registry prospectively collects approximately 200 variables, which were defined in accordance with the National Cardiovascular Data Registry (NCDR), from the major teaching hospitals in Tokyo metropolitan area in Japan. Between 2009 and 2019, 24,671 consecutive cases were registered, 10,053 patients (40.7%) undergoing PCI for ACS, of which 870 patients (8.5%) had CS-ACS. We stratified CS-ACS patients into 4-time frame groups (T1: 2009-2011, T2: 2012-2013, T3: 2014-2016, and T4: 2017-2019), and examined the temporal trends in patient risk profiles using the NCDR score (ranging 0-100, reflecting predicted mortality rates). Additionally, we assessed the incidence and types of employed MCS as well as the in-hospital mortality rate. Results: During the study period, the proportion of CS-ACS remained stable, accounting for 8.0% in T1 to 8.2% in T4 of ACS-related PCI cases. The calculated NCDR risk score demonstrated minimal variation, ranging from 70.6 in T1 to 70.1 in T4. There was a notable decrease in the utilization of MCS (66.5% in T1 to 56.7% in T4), mainly driven by a reduction in the use of intra-aortic balloon pump (70.3% to 55.0%, p for trend<0.001), with a increase in the concomitant use of veno-arterial-extracorporeal membrane oxygenation (27.6% to 36.2%, p for trend<0.001). However, the in-hospital mortality rate for CS-ACS patients remained persistently high at 30%. Conclusion: Over the past decade, there have been notable changes in the peri-procedural management of CS-ACS, albeit no significant improvements in patient outcomes was observed. The result calls for additional efforts to enhance their management.

Hypertension: An Important But Reversible Cause of Systolic Dysfunction in a Cohort of Pediatric Patients.

Cardiac dysfunction due to hypertension (CDHTN) in pediatrics is not well described. We aimed to describe the presentation and outcomes of pediatric CDHTN and identify clinical features associated with resolution of dysfunction. A single-center retrospective cohort study of patients ≤ 21years with CDHTN from January 2005-September 2020 was performed. Patients with systolic dysfunction without another cause, blood pressure > 95th percentile, and physician judgment that dysfunction was secondary to hypertension were included. Demographics, clinical characteristics, echocardiographic findings, and outcomes were examined using Fisher's exact and Mann-Whitney U tests. Multiple correspondence analysis was used to explore the relationship of resolution of dysfunction to clinical features. Thirty-four patients were analyzed at a median age of 10.9 (IQR 0.3-16.9) years. Patients were divided into groups < 1year (n = 12) and ≥ 1year (n = 22). Causes of hypertension were varied by age, with renovascular disease most common in infants (42%) and medical renal disease most common in older patients (77%). Echocardiography demonstrated mild LV dilation (median LV end-diastolic z-score 2.6) and mild LV hypertrophy (median LV mass z-score 2.4). Most patients (81%) had resolution of dysfunction, particularly infants (92%). One patient died and one patient was listed for heart transplant. None required mechanical circulatory support (MCS). No clinical features were statistically associated with resolution of dysfunction. Hypertension is an important but reversible cause of systolic dysfunction in children. Patients are likely to recover with low mortality and low utilization of MCS or transplantation. Further studies are needed to confirm features associated with resolution of dysfunction.

Trends in the Incidence of Cardiogenic Shock, and Utilization of Mechanical Circulatory Support in Myocarditis: Insights from the National Inpatient Sample 2016 to 2019

A subset of patients with myocarditis present with cardiogenic shock. There is a lack of contemporary data assessing the use of mechanical circulatory support (MCS) in these patients. Myocarditis hospitalizations were analyzed using the National Inpatient Sample between 2016 and 2019. Characteristics of patients with and without cardiogenic shock were assessed. Trends in mortality, MCS, right-sided cardiac catheterization (RHC) and endomyocardial biopsy were evaluated. The impact of RHC on consequent MCS and mortality was studied. A total of 38,300 hospitalizations for myocarditis were included in the study, of which 3,490 hospitalizations (9.1%) had cardiogenic shock. Patients with cardiogenic shock were older (p <0.001) and had more chronic kidney disease and atrial fibrillation. Between 2016 and 2019, there was an increase in myocarditis admissions but no difference in rates of cardiogenic shock and mortality and the use of extracorporeal membrane oxygenation, percutaneous ventricular assist devices, intra-aortic balloon pumps, left ventricular assist devices, and cardiac transplant. The most common form of MCS used in myocarditis was extracorporeal membrane oxygenation. The rates of RHC (p=0.02) and endomyocardial biopsy (p=0.03) increased over time. Patients who underwent RHC were more likely to receive mechanical support, and in patients with shock, RHC was associated with lower mortality (adjusted odds ratio 0.34, p <0.01). Myocarditis admissions increased over time but with no increase in the rates of cardiogenic shock and MCS. In patients with cardiogenic shock, RHC resulted in lower mortality.

National Trends of Percutaneous Mechanical Support Utilization During Percutaneous Coronary Interventions in Chronic Total Occlusion

Coronary chronic total occlusion (CTO) is common in patients with multivessel coronary artery disease. Percutaneous coronary artery (PCI) interventions have shown favorable outcomes in patients with CTO. Nevertheless, the data regarding the utilization of mechanical circulatory support in CTO PCIs is not well established. We sought to investigate the trends in utilization and periprocedural complications in this population. Using the National Inpatient Sample database from 2011 to 2019, we identified patients diagnosed with CTO who underwent PCI. We investigated the presence of a linear trend in the utilization of mechanical circulatory support (MCS) during those procedures and the associated periprocedural complications using the Cochran-Armitage method. A total of 208,123 patients who were diagnosed with CTO and underwent PCI from 2011 to 2019, of which in 6,319 patients MCS was used during the procedure. Patients in the MCS group were older (67.4 vs 66.4 years), less likely to be women (24.0% vs 26.4%), and equally likely to be African-American (9.4% vs 8.8%) with a higher burden of co-morbidities in terms of coronary artery disease, congestive heart failure, and atrial fibrillation (p<0.001 for all). Using the Cochrane-Armitage method, we found a statistically significant linear uptrend in the utilization of MCS from 269 (1.4%) to 990 cases (7.0%) from 2011 to 2019. Using multivariable logistic regression, female gender, renal failure, alcohol abuse, coagulopathy, and fluid and electrolyte disorders were identified as independent predictors of mortality in CTO PCI procedures assisted with MCS (p≤0.007). In conclusion, the utilization of MCS in CTO PCI procedures has been increasing over the years. Female gender and renal failure are independently associated with a higher mortality risk.

A-14 | Outcomes Among Patients With Systolic Heart Failure Hospitalized for ST-Elevation Myocardial Infarction (STEMI) Undergoing Coronary Artery Bypass Grafting (CABG): A Nationwide Population-Based Study

Previous studies suggested that coronary artery bypass grafting (CABG) among ST-elevation myocardial infarction (STEMI) patients with systolic heart failure (HF) resulted in low mortality rates. However, there is paucity of data regarding the impact of systolic HF among STEMI patients undergoing CABG (STEMI-CABG) in terms of in-hospital outcomes and use of mechanical circulatory support (MCS). We queried the National Inpatient Sample (NIS) to identify patients with STEMI who underwent CABG using appropriate ICD-10 codes between 2018-2020. We aim to investigate the impact of systolic HF among STEMI-CABG patients based on in-hospital mortality, length of stay (LOS), risk for cardiogenic shock (CS) and MCS utilization. A multivariable logistic regression analysis was used to calculate adjusted odds ratios (ORs) for the outcomes of interest. A total of 486,075 patients hospitalized for STEMI were identified, of which 4.94% (24,015/486,075) underwent CABG. Among STEMI-CABG patients, 23.15% (5,560/24,015) had systolic HF. The overall in-hospital mortality rate among hospitalized STEMI-CABG patients was 6.48% (1555/24,015). Among those with systolic HF, the in-hospital mortality rate was significantly higher at 8.18% (454/5560, p=0.01). After adjusting for possible confounders, concomitant systolic HF among hospitalized STEMI-CABG patients was not an independent predictor of overall in-hospital mortality (aOR 0.69; 95% CI, 0.40-1.21; p=0.20) and MCS utilization including percutaneous left ventricular assist device (aOR 1.51; 95% CI, 0.87-2.62; p=0.15), extracorporeal membrane oxygenation (aOR 1.12; 95% CI, 0.48-2.64; p=0.79), and intraaortic balloon pump (aOR 1.33; 95% CI, 0.98-1.76; p=0.06). However, systolic HF among hospitalized STEMI-CABG patients was found to be an independent predictor for the development of CS (aOR 1.68; 95% CI, 1.26-2.23; p=0.00) and longer LOS (aOR 1.86; 95% CI, 1.54-3.18; p=0.01). Our analysis showed that systolic HF among STEMI-CABG patients was not an independent predictor of increased in-hospital mortality and MCS utilization. However, it increased the risk for CS and longer LOS.

CE-452776-4 ATRIAL FIBRILLATION IS ASSOCIATED WITH HIGHER INPATIENT MORTALITY AS COMPARED WITH SINUS TACHYCARDIA IN PATIENTS WITH CARDIOGENIC SHOCK

Cardiogenic shock (CS) is commonly associated with a compensatory atrial stress response like sinus tachycardia (ST) or atrial fibrillation (AF). However, there is paucity of data comparing inpatient outcomes in patients with cardiogenic shock presenting with AF versus ST. To compare the impact of AF and ST on in-hospital outcomes in patients admitted with cardiogenic shock. We queried the National Inpatient Sample database to identify primary hospitalizations of CS using ICD-9/ICD-10 CM codes between 2009 and 2019. The study cohort was further divided into three groups based on the concurrent diagnosis of AF, ST, and a comparator group of no AF/ST. Our cohort included a total of 1,376,187 hospitalizations with a diagnosis of CS. Multivariate analysis showed CS hospitalizations with AF as compared with ST, had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.03-1.11) p=0.0005], CRT implantation [aOR 2.38 (1.88-3.03) p<0.001] and AV node ablation [aOR 3.22 (2.63-4.00) p<0.001]. Patients hospitalized with CS without concurrent AF/ST vs concurrent AF had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.06-1.08) p<0.001] and utilization of mechanical circulatory support [aOR 1.33 (1.31-1.34) p<0.001] but lower odds of CRT [aOR 0.76 (0.73-0.80) p<0.001] and AV node ablation [aOR 0.38 (0.37-0.40) p<0.001]. Our data suggest that patients admitted for CS and AF have worse outcomes including higher inpatient mortality, compared to those with CS and ST. However, compared to those without ST or arrhythmias, AF patients had a lower in-hospital mortality. These data are hypothesis generating and merit further study to better inform management of patients with CS and atrial arrhythmias.

Comparing Clinical Outcomes of COVID-19 and Influenza-Induced Acute Respiratory Distress Syndrome: A Propensity-Matched Analysis.

Acute respiratory distress syndrome (ARDS) is one the leading causes of mortality and morbidity in patients with COVID-19 and Influenza, with only small number of studies comparing these two viral illnesses in the setting of ARDS. Given the pathogenic differences in the two viruses, this study shows trends in national hospitalization and outcomes associated with COVID-19- and Influenza-related ARDS. To evaluate and compare the risk factors and rates of the adverse clinical outcomes in patients with COVID-19 associated ARDS (C-ARDS) relative to Influenza-related ARDS (I-ARDS), we utilized the National Inpatient Sample (NIS) database 2020. Our sample includes 106,720 patients hospitalized with either C-ARDS or I-ARDS between January and December 2020, of which 103,845 (97.3%) had C-ARDS and 2875 (2.7%) had I-ARDS. Propensity-matched analysis demonstrated a significantly higher in-hospital mortality (aOR 3.2, 95% CI 2.5-4.2, p < 0.001), longer mean length of stay (18.7 days vs. 14.5 days, p < 0.001), higher likelihood of requiring vasopressors (aOR 1.7, 95% CI 2.5-4.2) and invasive mechanical ventilation (IMV) (aOR 1.6, 95% CI 1.3-2.1) in C-ARDS patients. Our study shows that COVID-19-related ARDS patients had a higher rate of complications, including higher in-hospital mortality and a higher need for vasopressors and invasive mechanical ventilation relative to Influenza-related ARDS; however, it also showed an increased utilization of mechanical circulatory support and non-invasive ventilation in Influenza-related ARDS. It emphasizes the need for early detection and management of COVID-19.

Trends and Outcomes in Cardiac Arrest Among Heart Failure Admissions

There is limited large, national data investigating the prevalence, characteristics, and outcomes of cardiac arrest (CA) in patients hospitalized for heart failure (HF). The goal of this study was to examine the characteristics, trends, and outcomes of HF hospitalizations complicated by in-hospital CA. We used the National Inpatient Sample to identify all primary HF admissions from 2016 to 2019. Cohorts were built based on the presence of a codiagnosis of CA. Diagnoses were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. Associations with CA were then analyzed using multivariate logistic regression. We identified a total of 4,905,564 HF admissions, 56,170 (1.1%) of which had CA. Hospitalizations complicated by CA were significantly more likely to be male, to have coronary artery disease, renal disease, and less likely to be White (p <0.001, all). Age <65 (odds ratio [OR] 1.18, p <0.001), renal disease (OR 2.41, p <0.001), and coronary artery disease (OR 1.26, p <0.001) had higher odds of CA while female gender (OR 0.84, confidence interval [CI] 0.83 to 0.86, p <0.001) or HFpEF (OR 0.49, CI 0.48 to 0.50, p <0.001) had lower odds of CA. Patients with CA had higher inpatient mortality (CA 54.2% vs no CA 2.1%, p <0.001), which persisted after multivariate adjustment (OR 64.8, CI 63.5 to 66.0, p <0.001). CA occurs in >1 in 1,000 HF hospitalizations and remains a prominent and serious event associated with a high mortality. Further research is needed to examine long-term outcomes and mechanical circulatory support utilization with more granularity in HF patients with in-hospital CA.

Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction

ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n=71] COVID-19+/MCS positive [MCS+] vs 12.4% [n=98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p=0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p=0.001) because of very high in-hospital mortality (59% vs 28%; p=0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.

Abstract 14303: Disparities in Mechanical Circulatory Support Utilization in Patients With End Stage Heart Failure

Despite optimum guideline directed medical therapy, one-year mortality rate of patients with end stage heart failure exceeds 50%. The use of mechanical circulatory support (MCS) has been shown to improve the overall quality of life in patients with advance stage heart failure. Studies have explored disparities in clinical outcome of patients undergoing mechanical circulatory support for acute myocardial infarction and cardiogenic shock. Data on sex-specific, racial, and socioeconomic disparities in patients with end stage heart failure requiring MCS as a bridge-to-transplant or destination therapy is limited. Using the most recent National Inpatient Sample database, we hypothesized that disparities found among other patient populations also exist in patients with end stage heart failure needing MCS. In our study, 1.5% of patients with end stage heart failure underwent MCS with a mean age of 55±16 yrs. Females accounted for 20.7% (20.69% vs 79.3%, p =0.002). Patients who received MCS had lower comorbities; Diabetes (38.8% vs 43.5%, p =0.308), COPD (8.6% vs 24.9%, p &lt;0.001), CKD (47.4% vs 63.1%, p =0.001), and Hyperlipidemia (43.1% vs 47.5%, p =0.347). Among patients with end stage heart failure, mean charlson index by race were 4.4 vs 4.6 vs 4.5 for Whites, Blacks, and Hispanics respectively, p =0.008. After controlling for age, comorbities, charlson index, insurance types, household income and place of residence, compared to Whites, Blacks and Hispanic with end stage heart failure were significantly less likely to undergo MCS (Blacks: aOR=0.50, 95% CI: 0.29-0.87, p =0.014) (Hispanics: aOR=0.68, 95% CI: 1.48, p =0.337). Females compared to males also had lower odds of receiving MCS in end stage heart failure (aOR=0.56, 95% CI: 0.34-0.92, p =0.021). We observed patients with end stage heart failure who received MCS were younger and had less comorbidities. After controlling for age, comorbidities and potential confounders, the odds of females and minority patients with end stage heart failure receiving MCS was about half. These findings underscore the importance of addressing social determinants of health in minority populations. Further implementation studies are required to help bridge the health equity gap in patients with end stage heart failure.

UNOS listing status-related changes in mechanical circulatory support utilization and outcomes in adult congenital heart disease patients.

The aim of this study was to investigate the impact of the new United Network for Organ Sharing (UNOS) listing criteria on mechanical circulatory support (MCS) utilization and outcomes in adult congenital heart disease (ACHD) patients. We identified all ACHD and non-ACHD heart transplant candidates in the Scientific Registry of Transplant Recipients database listed during the 590 days prior to (historical cohort) or following (recent cohort) the UNOS allocation revision on October 18, 2018. Patients were grouped based on whether they received central temporary MCS (tMCS), peripheral tMCS, durable MCS, or no MCS. A total of 535 ACHD (242 historical, 293 recent) and 12,188 non-ACHD (6,258 historical, 5,930 recent) patients were included in our study. For ACHD patients, we found no differences in the historical versus recent cohort in utilization of central tMCS (3.31% vs 3.07%, p=.88) or durable MCS (3.31% vs 3.41%, p=.95), whereas the rate of peripheral tMCS increased (2.07% historical vs 6.83% recent, p=.009). Across both cohorts, ACHD patients supported with peripheral tMCS had shorter time-to-transplant than non-supported patients (25.7 vs 121.7 days, p=.002). ACHD patients supported with central tMCS had greater rates of post-transplant mortality relative to other ACHD patients (40.0% vs 12.6%, p=.006), while those supported with durable or peripheral temporary MCS had no differences in waitlist or post-transplant mortality compared to non-supported ACHD patients. The 2018 UNOS allocation changes increased utilization of peripheral temporary MCS in ACHD patients, decreasing waitlist time without impact on post-transplant outcomes.

Remote monitoring in the use of extracorporeal membrane oxygenation and acute mechanical circulatory support.

To provide an overview of the role of remote monitoring tools in management of critically-ill patients requiring acute mechanical circulatory support (MCS). Tele-critical care systems have received new interest during the COVID-19 pandemic, which has stretched the capacity of health systems everywhere. At the same time, utilization of MCS and extracorporeal membrane oxygenation (ECMO) technologies has increased during the pandemic. The opportunity for remote monitoring and clinical decision support for ECMO and acute MCS devices has been recognized by industry partners, with several major platforms implementing technology infrastructure for it in available products. Healthcare systems face challenges interfacing multiple devices from multiple manufacturers with each other and with their designated electronic health records. Furthermore, the availability of data must be combined with algorithms for alerting on clinical events and with implementation systems to act upon these alerts. Studies are not yet published validating remote monitoring platforms for ECMO and MCS in clinical care. Remote monitoring for MCS devices represents a major opportunity for further investigation to improve the utilization of these devices and better serve patients.

UNOS Listing Status-Related Changes in Mechanical Circulatory Support Utilization and Outcomes in Adult Congenital Heart Disease Patients

<h3>Purpose</h3> The population of adult congenital heart disease (ACHD) patients requiring advanced heart failure therapies is growing. The aim of this study was to investigate the impact of the new United Network for Organ Sharing (UNOS) listing criteria on mechanical circulatory support (MCS) utilization and outcomes in ACHD patients. <h3>Methods</h3> We identified all ACHD (≥18 years) heart transplant candidates in the Scientific Registry of Transplant Recipients database listed during the 590 days prior to (historical cohort) or following (recent cohort) the UNOS allocation revision on October 18, 2018. Patients were grouped based on whether they received central temporary MCS (surgically inserted temporary ventricular assist device [VAD] or extracorporeal membrane oxygenation), peripheral temporary MCS (percutaneous VAD or intra-aortic balloon pump), durable MCS, or no MCS. <h3>Results</h3> A total of 535 patients were included in our study (242 historical, 293 recent). There were no significant differences between the historical and recent cohorts in baseline characteristics. We found no differences in utilization of central temporary MCS (3.31% vs. 3.07%, p=0.88) or durable MCS (3.31% vs. 3.41%, p=0.95), whereas the rate of peripheral temporary MCS increased (2.07% historical vs. 6.83% recent, p=0.009; Figure 1). Across both cohorts, patients supported with peripheral temporary MCS had shorter time-to-transplant than non-supported patients (25.7 vs. 121.7 days, p=0.002). Central temporary MCS patients had greater rates of post-transplant mortality relative to other patients (40.0% vs. 12.6%, p=0.006), while those supported with durable or peripheral temporary MCS had no differences in waitlist (p=0.82) or post-transplant (p=0.32) mortality compared to non-supported patients. <h3>Conclusion</h3> The 2018 UNOS allocation changes increased utilization of peripheral temporary MCS in ACHD patients, decreasing waitlist time without impact on post-transplant outcomes.

Outcomes Associated With Peripheral Artery Disease in Myocardial Infarction With Cardiogenic Shock

BackgroundMortality rates for patients presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remain high despite advances in revascularization strategies and mechanical circulatory support (MCS) devices. ObjectivesThis study sought to elucidate the association between comorbid lower extremity peripheral artery disease (PAD) and outcomes in CS and AMI. MethodsPAD status was defined in Medicare beneficiaries hospitalized with CS and AMI from October 1, 2015 to June 30, 2018. Primary outcomes ascertained through December 31, 2018 included in- and out-of-hospital mortality. Secondary outcomes included bleeding, amputation, stroke, and lower extremity revascularization. Multivariable regression models with adjustment for confounders were used to estimate risk. Subgroup analyses included patients treated with MCS and those who underwent coronary revascularization. ResultsAmong 71,690 patients, 5.9% (N = 4,259) had PAD. Mean age was 77.8 ± 7.9 years, 58.7% were male, and 84.3% were White. Cumulative in-hospital mortality was 47.2%, with greater risk among those with PAD (56.3% vs 46.6% without PAD; adjusted OR: 1.50; 95% CI: 1.40-1.59). PAD patients also had greater risk of in-hospital amputation (1.6% vs 0.2%; adjusted OR: 7.0; 95% CI: 5.26-9.37) and out-of-hospital mortality (67.9% vs 40.7%; adjusted HR: 1.78; 95% CI: 1.67-1.90). MCS was less frequently utilized in PAD patients (21.5% vs 38.6% without PAD; P < 0.001) and was associated with higher mortality, need for lower extremity revascularization, and amputation risk. Findings were consistent in patients who underwent coronary revascularization. ConclusionsAmong patients presenting with AMI and CS, PAD was associated with worse limb outcomes and survival. In addition to lower MCS utilization rates, those with PAD who received MCS had increased mortality, lower extremity revascularization, and amputation rates.

Associated factors and clinical outcomes in mechanical circulatory support use in patients undergoing high risk on-pump cardiac surgery: Insights from the LEVO-CTS trial

We describe variables and outcomes associated with peri-operative mechanical circulatory support (MCS) utilization among patients enrolled in the Levosimendan in patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial. In the LEVO-CTS trial, MCS utilization (defined as intra-aortic balloon pump, extracorporeal membrane oxygenation, or surgical ventricular assist device) within 5 days of surgery was examined. The association between MCS use and outcomes including 90-day mortality, 30-day renal-replacement therapy, and hospital and critical stay length of stay were determined. Among the 849 patients from 70 centers randomized to levosimendan or placebo, 85 (10.0%) patients were treated with MCS (71 intra-aortic balloon pump, 7 extracorporeal membrane oxygenation, 7 ventricular assist device); with 89.4% started on post-operative day 0. Inter-institutional use ranged from 0% to 100%. Variables independently associated with MCS utilization included combined coronary artery bypass grafting and valve surgery (adjusted odds ratio [OR] 2.73, 95% confidence interval [CI] 1.70-4.37, P < .001), history of lung disease (OR 1.70, 95% CI 1.06-2.70, P=.029), and history of heart failure (OR 2.44, 95% CI 1.10-5.45, P=.027). Adjusted 90-day mortality (22.4% vs 4.1%, hazard ratio 6.11, 95% CI 3.95-9.44, P < .001) was higher, and median critical care length of stay (8.0 vs 4.0 days, P < .001) was longer in patients managed with MCS. In a randomized controlled trial of high-risk cardiac surgical patients in North America, we observed patient, and surgical variables associated with MCS utilization. MCS use was associated with a higher risk of post-operative mortality.

Impact of Socioeconomic Status on Mechanical Circulatory Device Utilization and Outcomes in Cardiogenic Shock

<h2>Abstract</h2><h3>Objectives</h3> This study evaluates the impact of socioeconomic status (SES) on utilization of mechanical circulatory support (MCS) devices and outcomes in cardiogenic shock (CS). <h3>Background</h3> CS is associated with significant mortality. There is increasing use of temporary MCS devices in CS, and its impact on outcomes is currently under investigation. There is a lack of data on the effect of SES on the utilization of MCS devices in CS. <h3>Methods</h3> CS hospitalizations were obtained from the State Inpatient Databases in 2016 from 9 states representing various regions in the United States. The study had exempt institutional review board status as the database includes deidentified data. Hospitalizations were separated into SES cohorts based on the median household income of the patient residence zip code. Utilization of MCS devices and revascularization procedures along with clinical outcomes with CS were compared across the quartiles. <h3>Results</h3> There were 38,520 hospitalizations identified with CS, 42.6% of which were secondary to acute myocardial infarction. Patients from higher SES areas were significantly older but had lower burden of comorbidities. Utilization of temporary MCS devices was higher for hospitalizations from higher SES regions (frequency from the lowest SES quartile to the highest SES quartile: 21.3%, 21.5%, 23.5, and 24.1%, <i>P</i> < .01), though revascularization rates were similar. However, there was no significant difference in overall mortality from CS among the 4 quartiles. Patients from regions of higher SES experienced increased hospital costs. <h3>Conclusions</h3> Higher SES regions had increased use of temporary MCS. There was no difference in mortality between SES cohorts.

The Predictive Value of the 4Ts and HEP Score at Recommended Cutoffs in Patients With Mechanical Circulatory Support Devices

Despite the increasing utilization of mechanical circulatory support (MCS) devices, the 4Ts and heparin-induced thrombocytopenia (HIT) Expert Probability (HEP) scores have not been validated in patients with suspected HIT requiring MCS. A retrospective cohort study. At a tertiary university hospital. Adults with suspected HIT requiring any MCS. A diagnostic investigation of HIT. Of the 299 patients included, there were 374 diagnostic investigations of HIT, of which 32 (8.6%) were HIT-probable (heparin PF4 immunoassay optical density ≥1 or positive serotonin release assay). The 4Ts score ≥4 demonstrated a pretest sensitivity of 0.56 (95% confidence interval [CI]: 0.39-0.72) and specificity of 0.8 (95% CI: 0.75-0.83). The HEP score ≥3 demonstrated a pretest sensitivity of 0.31 (95% CI: 0.18-0.49) and specificity of 0.83 (95% CI: 0.79-0.87). The area under the receiver operating characteristic curve for the 4Ts and HEP scores were 0.68 (95% CI: 0.63-0.73) and 0.63 (95% CI: 0.59-0.68), respectively, and were not statistically different (p=0.21). In patients with an intra-aortic balloon pump, neither the 4Ts nor HEP score had discriminatory ability to differentiate probable HIT. The HEP score had no discriminatory ability in patients with concomitant MCS devices. The 4Ts and HEP scores have a modest predictive performance for probable HIT in patients requiring MCS devices. A low 4Ts or HEP score does not reliably rule out HIT in patients requiring MCS, and clinical suspicion for HIT should be investigated, utilizing laboratory tests in this population.