Mechanical Circulatory Support Research Articles

SCAI SHOCK stage classification: valid for all indications and devices in patients with short-term mechanical circulatory support?

Abstract Funding Acknowledgements None. Background The Society for Cardiovascular Angiography and Intervention (SCAI) SHOCK stage has demonstrated prognostic value in patients with cardiogenic shock (CS), including patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. It has also been validated in different scenarios as acute coronary syndrome -ACS- or out-of-hospital cardiac arrest. Purpose Our objective was to study the prognostic value of SCAI SHOCK stage in different indications and etiologies requiring different types of short-term mechanical circulatory support (MCS). Methods Retrospective analysis of consecutive patients supported with VA-ECMO or Impella CP® in a referral center. We studied the SCAI SHOCK stage at MCS implantation according different devices, indication and etiology, and its relationship with in-hospital and follow-up survival. Results 263 patients were included between 2014-March 2023 (Table). The SCAI SHOCK stage was less advanced in complex high risk percutaneous coronary intervention (CHIP-PCI) indication and more advanced in postcardiotomy shock, myocarditis, pulmonary embolism (PE), refractory cardiac arrest or electric storm (Figure A). In-hospital survival was 41.1% and it was significantly lower as SCAI SHOCK stage increased (A 83.9%, B 100%, C 66.7%, D 39.2%, E 24.5%; p=0.000), as well as in follow-up for a median time of 24.5 [47] months (figure B). This association was maintained with both types of devices separately: VA-ECMO (A 80%, B 100%, C 33.3%, D 38.9%, E 24.5%, p=0.001) and Impella (A 84%, B 100%, C 75%, D 42.9%, E 25%, p=0.005). Regarding the indication and etiology for MCS, SCAI SHOCK classification was significantly related with survival in CS indication, as well as in ACS and heart failure (HF) etiology (Figure B). However, no relationship between SCAI and survival was observed in indications as CHIP-PCI (A 83.9%, B 100%, C 50%; p=0.386), electrical storm (C 0%, D 100%, E 70%; p=0.075) and postcardiotomy shock (D 35.6%, E 20%; p=0.470), neither in etiologies as PE (D 0%, E 28.6%; p=1), infective endocarditis (D 28.6%, E 0%; p=1), myocarditis (D 100%, E 0%; p=0.250),and other causes of cardiac arrest (D 0%, E 25%; p=1), nor in patients admitted for elective cardiac surgery. Conclusions SCAI SHOCK stage classification showed prognostic value in patients with short-term MCS indicated by diverse etiologies, including both VA-ECMO and Impella CP devices. The prognostic value was maintained for the indication of CS, and in ACS and HF etiologies, but not in electrical storm, CHIP-PCI, PE, myocarditis or postcardiotomy shock. Studies are needed to validate this classification in other settings.TableFigure

Discordance between aPTT and anti-Xa in monitoring heparin anticoagulation in mechanical circulatory support.

It is unclear whether activated partial thromboplastin time (aPTT) or anti-Xa is more accurate for monitoring heparin anticoagulation in mechanical circulatory support (MCS) patients. This study investigates the relationship between aPTT and anti-Xa in MCS patients and identifies predictors of discordance. aPTT and anti-Xa were simultaneously measured in a prospective cohort of MCS patients receiving unfractionated heparin at a tertiary academic medical centre. Therapeutic aPTT and anti-Xa levels were 60-100s and 0.3-0.7IU/mL, respectively, and concordance was defined as both levels being subtherapeutic, therapeutic, or supratherapeutic. To identify predictors of discordance, both a machine learning random forest model and a multivariate regression model were applied to patient demographics, device type, and 14 laboratory variables; 23001 pairs of simultaneously measured aPTT/anti-Xa were collected from 699 MCS patients. aPTT and anti-Xa were concordant in 35.5% of paired observations and discordant in 64.5% (aPTT>antiXa 61.5%; aPTT<antiXa 3.0%). Discordance with a high aPTT relative to anti-Xa (aPTT>antiXa) was associated with high INR, eGFR, and total bilirubin, as well as low platelets, haemoglobin, pre-albumin, white blood cell count, and haptoglobin. Total artificial heart and durable ventricular assist devices were more likely to be associated with aPTT>anti-Xa than temporary MCS devices. aPTT and anti-Xa were frequently discordant in MCS patients receiving heparin anticoagulation. Clinical conditions common in MCS patients such as concurrent warfarin use, malnutrition, haemolysis, and thrombocytopenia, as well as durable type of MCS devices were associated with a high aPTT relative to anti-Xa.

Intravenous angiotensin II as an add-on to standard of care vasopressors in patients with refractory shock on mechanical circulatory support: a single centre retrospective case series

Abstract Funding Acknowledgements None. Background Refractory shock is life-threatening condition characterized by hypotension with mean arterial pressure (MAP) less than 65 mmHg and end-organ dysfunction, despite volume resuscitation and high doses of vasopressors. Mortality rates in refractory shock exceeds 90%. Angiotensin II (Ang II) is a non-catecholamine vasopressor that targets the renin-angiotensin-aldosterone system by agonism of the angiotensin type 1 receptors. Ang II has been studied in settings of vasodilatory shock, however there is paucity of data regarding the usage of Ang II in patients with preexisting heart failure or in patients requiring mechanical circulatory support (MCS), either short term such as venoarterial extracorporeal membrane oxygenation (VA-ECMO) or long term such as left ventricular assist device (LVAD) (1,2). Purpose This report is aimed to analyse baseline characteristics of patients who have received Ang II from the moment it became available in our institution (January 2023). Methods Five patients were included in this retrospective analyses. Demographic, clinical and laboratory parameters as well as hourly changes of vasopressors doses, MAP, lactates, and diuresis were collected and analysed. Results Median age of 5 included patients, 4 of whom were male, was 53 years old (range 18-57). The most common comorbidities were chronic kidney disease (n=3), diabetes mellitus (n=3) and arterial hypertension (n=3), treated with valsartan as chronic therapy. All patients presented with severe shock. 4 patients were on VA-ECMO support, 1 had additionally implanted Impella for left ventricular unloading and 2 had implanted LVAD. All patients had severely reduced left ventricular ejection fraction (median 15%, range 10-25%). In 4 cases vasopressors were initiated due to sepsis and in 1 case during cardiopulmonary resuscitation. Median values prior to administration of Ang II were as following: MAP 51 mmHg (range 41-56 mmHg), lactates 6.7 mmol/L (range 2.4-10.7 mmol/L) and Sequential Organ Failure Assessment (SOFA) score 9 (range 5-11). Four hours following administration of Ang II median MAP was 61 mmHg (range 54-77 mmHg). Patient who ultimately survived had better response to Ang II, with median rise of MAP of 22 mmHg (range 12-22 mmHg). In contrast, patients who ultimately died didn’t respond to Ang II, with rise of MAP of only 2.5 mmHg. Median duration of Ang II administration was 52 h (range 20-96 h). 60% of patients are alive up to the present day. Complete patient data are shown in Table 1. Hourly changes of vasopressor doses and MAP are shown in Figure 1. Conclusion Ang II is an effective vasopressor with rapid effect. This case series suggests that it may be considered as salvage treatment option in patients on MCS with refractory shock. Patients who responded to Ang II had better survival, similar to previous findings. Therefore, Ang II should be considered in earlier phases of shock when maximum doses of vasopressors have not yet been reached.

Mechanical circulatory support in high-risk PE for more than a decade

Abstract Funding Acknowledgements None. Background/Introduction Absence of solid evidence in clinical practice guidelines on the management of patients with a severe pulmonary thromboembolism (PTE) in a situation of cardiogenic shock requiring mechanical circulatory support (veno-arterial ECMO). A registry has been carried out in a tertiary hospital of patients admitted to the Cardiological Critical Care Unit (CCCU) with a diagnosis of high-risk PTE and V-A ECMO implantation. Purpose The objective is to describe the experience of our center due to the paucity of evidence from current guidelines in this area iin terms of morbimortality and expected outcomes. Methods Data were collected from all patients admitted with a diagnosis of high-risk PE in the CCCU from 05/01/2010 to 05/01/2023. Of these, only those in whom V-A ECMO was implemented during admission were analyzed and described below. Clinical, analytical and survival variables were explored. Results A total of 11 patients were included, 3 (27.27%) being women. The mean age was 53 years (SD 10.64). Every V-A ECMO cannulation was performed in a femoro-femoral configuration by a surgical approach. The mean length of stay in the Critical Care Unit, total hospital stay length and circulatory support time were respectively: 8 days (SD 5.5); 20.7 days (DS 16.5) and 3 days (DS 1.9). The indication for the implantation of V-A ECMO was in a situation of SCAI-E in 7 patients (in 2 of them, V-A ECMO was implanted during cardiac arrest, and a 100% of mortality was described in the first 24 hours). On the other hand, in the remaining 4 patients, the indication for support was a deteriorating evolution despite amines. Of these, in 2 of them, there was a formal contraindication for the administration of systemic fibrinolytic treatment (recent major surgery, in one of them oncology). It should be noted that VA ECMO without adjuvant fibrinolysis was used in 6 of the patients (54.5%), and in 1 of them (16%) of them died (anoxic encephalopathy). However, the remaining 5 patients received combined VA ECMO therapy and systemic fibrinolysis (45.5%), with 2 deaths reported in this subgroup (40%). Those deceases happened both due to adequacy of the therapeutic effort in the context of multiple organ failure. No major bleeding was reported, even in the combination therapy group. Conclusions Support with V-A ECMO has allowed survival &amp;gt;70% in patients diagnosed with high-risk pulmonary embolism, including in those cases with absolute contraindication for systemic fibrinolysis. High safety profile in terms of bleeding even in those patients with a combined approach.

Long-term outcome after unprotected left main percutaneous coronary intervention in patients with acute myocardial infarction complicated by cardiogenic shock: a landmark analysis

Abstract Funding Acknowledgements None. Background Early revascularization of culprit arteries has demonstrated to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), however, little is known about long-term outcome after unprotected left main (LM) percutaneous coronary intervention (PCI) in patients with AMI-CS. Methods We retrospectively investigated 2325 consecutive patients with AMI who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death up to 3yrs. Results Among the 2325 eligible patients, 272 AMI patients (11.7%) were complicated by CS on admission (AMI-CS). The mean age was 71 years, 75% of patients were male, STEMI was seen in 86%, and mechanical circulatory support was used in 61%. Of 272 AMI-CS, 35 (14.0%) patients were treated with PCI for LM and had significantly higher 30-day cardiovascular mortality (52.6%) compared with those treated with PCI for non-LM (24.8%) (p = 0.0001). Kaplan-Meier analysis showed that mortality up to 3 years was significantly higher in AMI-CS patients with LM compared those with non-LM (p &amp;lt; 0.0001). Multivariate Cox regression analysis showed LM was significantly associated with higher cardiovascular mortality (adjusted HR 1.90, 95%CI 1.18-3.07, p = 0.0088). Conclusions Primary PCI of the LM was performed in 14.0% of patients with AMI-CS. Short- and long-term CV mortality was significantly higher with LM AMI-CS than non-LM AMI-CS. Further studies should evaluate to improve both short- and long-term outcome among AMI-CS with LM.

Serial invasive hemodynamics and clinical characteristics of patients with shock with and without invasive mechanical ventilation

Abstract Funding Acknowledgements None. Background Invasive mechanical ventilation (IMV) is commonly used in the Cardiac Intensive Care Unit (CICU) in patients with cardiogenic shock (CS). IMV causes hemodynamic changes that may impact outcomes based upon a patient’s profile. Our aim is to characterize the clinical profile and detailed serial hemodynamic parameters in the first 24-hours according to the use of IMV in patients with shock admitted to the CICU. Methods Retrospective analysis of consecutive patients with shock admitted to the CICU at Bellevue Hospital, undergoing pulmonary artery catheter (PAC) placement within the first 24 hours of admission, from February 2022 to June 2023. Clinical characteristics, as well as specific hemodynamic parameters collected and curated at times 0, 6, 12, 18 and 24 hours were from PAC placement compared between patients with and without IMV. Results A total of 101 patients were included (95% with cardiogenic shock), 59 receiving IMV (age 64 ± 15, 24% women) and 42 non-intubated (61 ± 13, 33% women). Non-intubated patients had higher prevalence of hypertension, prior coronary artery disease and heart failure with reduced ejection fraction (HFrEF), while acute coronary syndromes (44%) and cardiac arrest (12%) were more common causes of admission in patients undergoing IMV. Mixed shock predominated in IMV patients (51 vs 17%, p &amp;lt;0.001), whereas cardiogenic shock (CS) was more common in non-intubated patients (83 vs 41%, p &amp;lt;0.01). Patients with acute myocardial infarction CS (AMI-CS) were more likely to undergo IMV, while patients with heart failure CS (HF-CS) were more likely to be non-intubated. Patients undergoing IMV were more likely to have mechanical circulatory support (MCS) and ventricular dilatation compared to non-intubated patients (LVEDD 5.7 cm vs 4.9 cm, p 0.002). Patients undergoing IMV had a higher incidence of severe shock compared to the non-intubated group (31% vs 19% SCAI Shock D), higher lactate levels and greater use of vasoactive drugs (figure 1A). Patients undergoing IMV had significant improvements in cardiac power output (CPO), diastolic blood pressure and systemic vascular resistance (SVR) (figure 1B). Shock severity by SCAI SHOCK classification had a more notable improvement at 24 hours in patients with IMV compared to non-intubated patients (figure 1C), with a non-statistically significant improvement in lactate clearance in the first 24 hours (Figure 1D). Conclusions IMV in patients with CS is more commonly seen in patients with AMI-CS and among those with higher baseline shock severity and greater use of vasoactive medications. IMV is associated with significant improvements in shock severity, CPO and SVR at 24 hours when compared to patients with shock who are not intubated, which could be related to higher use of vasopressors. Further investigations are warranted to understand the impact of IMV on outcomes of patients with CS and how they might vary according to hemodynamic profile.

Out of hospital sudden cardiac arrest as a prognostic factor for in-hospital mortality in patients admitted with cardiogenic shock

Abstract Funding Acknowledgements None. Background The mortality in cardiogenic shock (CS) is still high despite new comprehensive therapies. Cardiac arrest (CA) frequently complicates CS which can have an unfavourable effect on the course after admission. Purpose The study aimed to analyse the clinical characteristics and prognosis of patients admitted with CS after out-of-hospital cardiac arrest (OHCA) compared to the group without OHCA. Methods The studied group consisted of a total of 80 patients with an average age of 62 ± 13 years (81 % male) admitted to tertiary hospital with CS in the period 2021-2022. The severity of the shock according to the Society for Cardiac Angiography and Interventions (SCAI) SHOCK classification among the whole population was from C to E: 7 (9%), 38 (48%), and 35 (43%), respectively. The cohort was divided into 2 subgroups: the OHCA group consisted of 23 individuals (29%) and the without OHCA (non-OHCA group) consisted of 57 individuals. Results The groups did not differ in terms of demographic parameters and comorbidities. There were no differences in baseline heart rate 95 [50;114] vs. 91 [77;105] beats per minute and mean artery pressure 75 [70;97] vs. 82 [70;97] mmHg for OHCA vs. non-OHCA, respectively, all p&amp;gt; 0.05. Patients from OHCA group had higher baseline creatinine level 1.65 [1.35;1.88] vs. 1.37 [1.08; 1.65] mg/dL, p=0.019, white blood cell count 12 [9;16] vs. 17 [12;23] × 109/L, p=0.015 and lower pH from blood gas analysis 7.0 [6.9;7.2] vs. 7.3 [7.2;7.4], p&amp;lt;0.001). In the OHCA group, 90% of cases of CS were caused by acute coronary syndrome (ACS), while in the group without OHCA, 76% were due to ACS and 20 % due to the progression of chronic heart failure, p=0.032. Mechanical Circulatory Support (MCS) was used in almost every patient (98% non-OHCA vs. 95% OHCA), however, the OHCA group was more often treated with V-A ECMO 14 (64%) vs. 16 (28%) in the non-OHCA, p=0.004. The overall number of in-hospital deaths was 57 (71%). The OHCA group had significantly higher in-hospital mortality 22 (96%) compared to the non-OHCA patients 35 (61%), p=0.002. Conclusion Patients experiencing CS complicated by OHCA have more often ischaemic ethology of shock, have a greater degree of organ damage and a lower pH in blood gas analysis at admission, and have extremely high in-hospital mortality rates when compared with patients facing CS but without prior OHCA, which underscores the urgent need for improved prevention methods, interventions, and public awareness.

Global longitudinal strain as a predictor of mortality in patients with cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Aarhus University Dagmar Marshalls Fond. Background The assessment of left ventricular (LV) function through transthoracic echocardiography (TTE) is essential for guiding diagnosis and treatment in cases of cardiogenic shock (CS). Myocardial global longitudinal strain (GLS) provides an objective and reproducible measure of systolic function, independently predicting outcomes in acute heart failure, regardless of left ventricular ejection fraction (LVEF). However, whether assessment of GLS can predict mortality in patients with CS remains unknown. Purpose In this study, we aimed to evaluate the prognostic significance of GLS in patients with CS. Methods Data from cardiac intensive care unit (CICU) patients admitted between 2007 and 2018 with CS who received vasoactive agents and/or mechanical circulatory support were analysed. GLS (as absolute values) and biplane LVEF were measured via TTE performed within 24 hours of CICU admission. Patients with CS were categorised based on the GLS quartile: mild (GLS &amp;gt;9.7%), moderate (7.0% &amp;lt; GLS &amp;lt;9.6%), severe (5.0% &amp;lt; GLS &amp;lt; 6.9%), and very severe (GLS ≤ 4.9%). CICU and in-hospital mortality were compared across GLS categories, and the relationship between GLS and mortality was assessed using multivariable logistic regression. Results The study included 626 patients with a median age of 68.6 years, a median LVEF of 31% (IQR 24 to 40%), and a median GLS of 7.0% (IQR 5.0 to 9.7%). In-hospital mortality was 29.1%. As GLS deteriorated, there was an increasing need for vasopressors (P&amp;lt;0.001). Patients with progressively lower GLS exhibited significantly higher CICU and in-hospital mortality across the GLS quartiles (Figure A; P&amp;lt;0.001). Patients in the severe (adjusted OR 2.67; p&amp;lt;0.001) and very severe category (adjusted OR 3.54; P&amp;lt;0.001) had significantly increased risk of in-hospital death compared with mild category. In multivariable analysis, every 1% decrease in GLS corresponded to a 14% higher risk of in-hospital mortality (P&amp;lt;0.001). Finally, GLS outperformed LVEF for discrimination of in-hospital mortality (P=0.002), and when both measurements were included in the same multivariable model, only GLS remained significant. When patients were divided according to whether they had GLS and/or LVEF below the median value, patients with low GLS had higher mortality irrespective of the LVEF (Figure B). Conclusion In patients with CS, GLS assessment surpasses LVEF in its prognostic value and improves risk stratification. Routine evaluation of GLS should be considered for patients with CS.Figure AFigure B

Acute kidney injury in acute decompensated heart failure related cardiogenic shock: data from the Alt-Shock2 registry

Abstract Funding Acknowledgements None. Background Acute kidney injury (AKI) is one of the most common complications in patients with cardiogenic shock (CS), proving the strict relationship between heart and kidney (the so-called cardio-renal syndrome). AKI is a marker of shock severity, but also independently associated with worse outcomes. Purpose Many data are available on the prevalence of AKI in acute heart failure, but very few studies assessed the role of AKI in CS and they were mainly focused on acute myocardial infarction (AMI)-related CS. Aim of our study was to analyze the impact of AKI on acute decompensated heart failure (ADHF)-CS. Methods Between March 2020 and August 2022, we prospectively enrolled 375 CS patients from a Cardiac Intensive Care Units Network of 12 centers. Among these patients 121 (33.9% of the whole cohort) with ADHF-CS were included for the present analysis. AKI was defined according to KDIGO 2012 criteria as serum creatinine increase ≥ 0.3 mg/dl or 1.5 times compared to admission value, or urinary output &amp;lt; 0.5 ml/kg/h. Results Table 1 shows the baseline characteristics of the cohort. Patients with AKI were older (70 years old [55.5; 76] vs 61 [54; 69], p&amp;lt;0.05), had more comorbidities and a worse CS profile on admission. On multivariable analysis, SCAI stage D-E on admission was independently associated with a higher risk of AKI 24 hours after admission (OR 5.54 and p = 0.01). Treatment with mechanical circulatory support did not prevent AKI (OR 0.84 and p = 0.8). Notably, patients with a greater reduction in central venous pressure (CVP) 24 hours after admission had a lower risk of AKI (deltaCVP in AKI group 0 [-3;0] versus deltaCVP in no-AKI group -3 [-6;0], p = 0.025). Kaplan-Meier curves showed significantly worse survival in patients with AKI (Figure 1A). Cox regression analysis confirmed an association between AKI and increased risk of death (HR 2.14, CI 95% 1.16-3.96, p = 0.01). Notably, this association was even more pronounced in patients with SCAI stages A-B-C (HR 2.81, CI 95% 1.30-6.09, p = 0.01). Finally, in patients treated with renal replacement therapy (RRT) there was no association with lower survival at 180-days follow up (Figure 1B). Conclusions Our study confirms that AKI is a predictor of adverse outcomes in patients with ADHF-CS. Effective decongestion 24 hours after admission was associated with a lower risk of AKI. Considering that AKI had a negative impact even at lower SCAI stages, our findings underscore the importance of early identification of renal injury to promptly target decongestion with pharmacologic therapy and, ultimately, early use of RRT.

V-A ECMO window of opportunity: identification of potential responders after an acute myocardial infarction complicated by cardiogenic shock

Abstract Funding Acknowledgements None. Background V-A ECMO is designed to supply oxygen demands in patients with circulatory failure. Neutral results obtained in recent cardiogenic shock (CS) trials are probably related to the inclusion of a high proportion of patients with SCAI C stage, in many of whom, the device might not provide hemodynamic benefit despite the addition of inherent complications. Mechanical circulatory support could potentially have a role only for patients in SCAI D-E stages. Purpose Our aim was to explore the excess in mortality explained by a SCAI D-E stage at 12h, compared to a SCAI A-C stages at 12h, in patients admitted due to an acute myocardial infarction (AMI) complicated by CS (stages C-E at admission). Additionally, we aimed to identify those factors at admission—clinical, electrocardiographic, gasometrical, echocardiographic, and angiographic—which predict whether a patient will progress to SCAI D-E stages within the subsequent 12h from CS onset. Main Outcome: SCAI D and E stage at 12h. Methods We retrospectively analysed those patients admitted due to an AMI in SCAI C-E stages at admission, that had been prospectively screened for EUROSHOCK trial. We classified the patients in two groups: "SCAI A-C" and "SCAI D-E" at 12 hours and conducted a survival analysis. Additionally, we conducted a univariate and multivariate analysis including arrival potential predictors for SCAI D-E at 12 hours. Results A total of 72 patients were included. At admission 25 patien were in SCAI D-E. At 12 hours, 42 patients were in SCAI D-E, and this group showed a higher 30-day mortality rate particularly explained by an excess of mortality within the first 7 days (Figure 1). There were no significant differences between groups in most baseline characteristics (Table 1) such as age or gender. We observed a fewer proportion of previous chronic treatment with negative inotropes (betablockers and calcium channel antagonists) in the SCAI D-E group. Overall, anterior ST elevation on EKG was more prevalent among SCAI D-E group, median pH lower and median glycaemia and lactate higher. In the multivariate analysis after adjustment by confounders, the independently predictors at arrival for the development of a SCAI D-E stage at 12h were culprit LAD, cardiac arrest in the cath Lab, low initial median pH and final TIMI &amp;lt;3 result. Conclusions In a cohort of AMI patients complicated by CS, those patients who remained in a SCAI D-E stage at 12 hours from CS onset, compared to those in A-C, showed a 26% excess mortality at 30-day follow-up, especially during the first week. Patients who presented with LAD as the culprit artery, low initial pH, cardiac arrest in the cath lab, and got a TIMI &amp;lt;3 result after PCI were independently associated with the development of SCAI D-E within 12 hours from admission. Patients meeting these criteria could benefit from early selective mechanical support and be taken into consideration in the design of future randomized controlled trials.

Echocardiographic image monitoring during Impella use: our experience

Abstract Funding Acknowledgements None. Introduction Impella CP is a type of percutaneous left ventricular (LV) mechanical circulatory support located inside LV and placed through the aortic valve. There is little information about the incidence of valvular complications related to its use or other complications assessable by echocardiography. Purpose To determine the existence of complications assessable by echocardiography in patients treated with Impella CP in our centre. Methods Retrospective analysis of patients treated with Impella CP in 2020 and 2021 in our centre. Baseline clinical characteristics were studied and pre- and post-procedure echocardiograms of these patients were reviewed. Results A total of 32 echocardiograms were analysed in 16 patients with a mean age of 70 years. Clinical and echocardiographic features are described in table 1. After device removal, the presence or degree of aortic regurgitation did not change in the patients, including 2 patients who had moderate aortic regurgitation pre-implantation. However, on echocardiograms after device removal, intraventricular thrombus was detected in 2 patients, who also had severe LV systolic dysfunction and who had the longest duration in days of implantation (6 and 7 days). The mean number of days of implantation was 1.68 days. Conclusion Echocardiography is a useful tool for the management and detection of complications during the time of support with Impella CP, such as valve dysfunction and the presence of intraventricular thrombus. In our centre, the use of Impella is not related to the onset or worsening of aortic valve pathology.

Heparin monitoring in ImpellaTM-supported cardiogenic shock patients: the benefit of parallel dual testing

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds Wetenschappelijk Onderzoek Flanders. Background Coagulopathic complications often jeopardize the outcome of critically ill patients in cardiogenic shock (CS) during percutaneous mechanical circulatory support (pMCS). Therefore, meticulous management of heparin therapy is mandatory to ensure appropriate anticoagulation management. In this context, the most convenient and most frequently used test is the activated partial thromboplastin time (APTT). However, the APTT-test can be prolonged or shortened independent of the patient's anticoagulation status due to various confounding factors during critical illness (e.g., sepsis, liver failure, factor XI/XII consumption). Alternatively, the anti-Xa assay directly measures heparin activity. Therefore, to optimize heparin anticoagulation during critical illness, an anti-Xa-guided protocol for heparin titration combined with parallel APTT measurements to assess both bleeding and thrombotic risk has recently been proposed. (1) Purpose We aimed to investigate the correlation between parallel anti-Xa and APTT-measurements in an anti-Xa-guided heparin anticoagulated CS population during left-sided ImpellaTM support. Methods Between April-2017 and June-2022, all CS patients with isolated left-sided ImpellaTM-support (&amp;gt;24h) and heparin anticoagulation monitored by anti-Xa with APTT in parallel were assessed at two high-volume tertiary institutions. Anti-Xa was considered in range between 0.20-0.30IU/mL or 0.31-0.50IU/mL based on the patient’s profile (per center protocol, underlying atrial fibrillation or venous thromboembolism). In range APTT values were considered 40-55s and 55-80s respectively. Correlation between parallel anti-Xa and APTT values was assessed by Pearson correlation. A Pearson correlation coefficient of 0.7 or lower was considered to confer a weak correlation. Results Ninety-three ImpellaTM-patient runs (77 men, 83%) with a median age of 56 years (IQR 46-66) were analyzed. Median support duration was 6 days (IQR 4-12). In total, 2447 parallel anti-Xa/APTT samples were analyzed, showing an overall Pearson correlation coefficient of 0.50 (p&amp;lt;0.001) (Fig. 1A). For samples with in-range anti-Xa (N=1914), matching APPT was shortened in 460 (24%), in-range in 986 (52%) and prolonged in 468 (24%) samples (Fig. 1B). Conclusions We highlight a weak correlation between anti-Xa and APTT in an anti-Xa guided heparin anticoagulated CS population during left-sided ImpellaTM support. Heparin titration based on APTT alone would result in over- (24%) or undertitration (24%) in 48% of our cases, due to confounding factors influencing the APTT-assay in critically ill, exposing these patients to coagulopathy associated problems. Therefore, we strongly advocate a combined (anti-Xa/APTT) testing anticoagulation monitoring strategy to adequately manage the coagulation state of this critically ill population. Future trials will investigate whether this approach will effectively reduce the high coagulopathy associated morbidity and mortality on pMCS.

Comparison between acute and chronic refractory cardiogenic shock: is prognosis different?

Abstract Funding Acknowledgements None. Background Short-term mechanical circulatory support (ST-MCS) is essential to reverse refractory cardiogenic shock (RCS). Since compensatory mechanisms are differently activated depending on whether the cause of CS is acute injury or decompensation of advanced chronic heart failure, hypothetically, the prognosis could also be different. Purposes The aim of our study was to compare the prognosis of patients with RCS supported with ST-MCS (venoarterial-extracorporeal membrane oxygenation (VA-ECMO), Centrimag, Impella CP and Impella 5.0) according to whether the cause of cardiogenic shock was an acute myocardial injury (acute myocardial infarction, myocarditis...) or a worsening of advanced cardiomyopathy. Methods Consecutive patients ≥ 18 years with RCS requiring ST-MCS at a tertiary center from January 2020 to August 2023 were prospectively included. They were stratified according to whether the cause of shock was acute or chronic. Demographic, clinical characteristics before insertion, and outcomes were included in the analysis. Results A total of 86 patients with RCS were supported with ST-MCS in that period, 55 of them (64%) for acute injury and the rest (n=31; 36%) as decompensation of chronic heart failure, with a significantly higher Charlson Comorbidity Index in the chronic group (2(0-3) vs 3(2-4); p=0.01). Acute shock was predominantly supported with VA-ECMO (49.1%) and Impella CP (41.8%), while Impella 5.0 was the most commonly used device in chronic patients (32.2%). The severity of CS was significantly higher in the acute shock group, assessed by SCAI (p=0.005), VIS Score (55.1 (26.19-90.5) vs 8 (3.1-30); p=0.005) and lactate level (5.3 (3-10.3) vs 1.2 (1-2.2) mmol/l; p&amp;lt;0.005) and a higher but non-significant SOFA score (8 (6-10) vs 6 (4-9); p=0,06). However, no differences were found in prognosis, both in-hospital mortality, mortality during support and 30-day and 1-year mortality (Figure 1). Most patients with chronic shock were referred to cardiac transplantation (54.8%) while most patients with acute shock were weaned by myocardial recovery(30.9%), but there were no differences in the final destination of these patients (p=0.089). There were no differences in systemic and local complications between the three groups, except for the rate of device-related ischemia (21.8% vs. 6.4%, p=0.015). Conclusions In our center, most patients in CS who required short-term mechanical circulatory support debut after an acute cardiac injury. Percutaneous ST-MCS is preferentially selected in the acute group, probably because of its easy accessibility in emergency situations. Although patients with acute CS present a more severe overall situation than patients worsening due to advanced heart failure, there were no differences in the short- and long-term prognosis or in the destination treatment of these patients.Table of resultsFigure 1.Mortality in RCS

Anti-Xa/APTT discrepancy in heparinized ImpellaTM-supported cardiogenic shock patients can predict mortality

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds Wetenschappelijk Onderzoek Flanders. Background Meticulous management of unfractionated heparin (UFH) is important to avoid complications in patients receiving percutaneous mechanical circulatory support (pMCS) for cardiogenic shock (CS). Whereas the anti-Xa assay directly measures UFH activity, the activated partial thromboplastin time (APTT) remains the most frequently used test. The APTT covers the intrinsic and common coagulation pathway and can be influenced by various confounding (laboratory) factors during critical illness, unrelated to the patient’s (anti)coagulation state. Purpose We investigated a CS population supported with isolated left-sided Impella™ and UFH-anticoagulation. UFH-levels were guided by anti-Xa with APTT in parallel. Here, we focus on those samples with anti-Xa in-range and discrepantly prolonged parallel APTT-measurements. We differentiated the APTT-prolongation according to reduced fibrinogen levels and/or prolonged INR (factor XI/XII consumption vs. concomitant conditions) and correlated this with mortality during Impella™-support. Methods Between April-2017 and June-2022, all CS patients with isolated left-sided ImpellaTM-support (&amp;gt;24h) and UFH anticoagulation monitored by anti-Xa with APTT in parallel were assessed at two high-volume tertiary institutions. In-range anti-Xa samples (between 0.20-0.30IU/mL or 0.31-0.50IU/mL based on the patient’s profile) were selected. In-range APTT values were considered between 40-55s and 55-80s respectively. Samples with prolonged APTT as compared to the in-range anti-Xa were allocated in 4 groups based on fibrinogen (&amp;lt;1.5g/dL or ≥ 1.5g/dL) and INR (&amp;lt;1.5 or ≥1.5) on the same day as the sample with prolonged APTT. Mortality of patients with normal fibrinogen ànd INR was then compared to those with abnormal fibrinogen and/or INR via a Chi² test. Results Ninety-three ImpellaTM-runs (77 men, 83%) with a median age of 56 years (IQR 46-66) were analyzed. Median support was 6 days (IQR 4-12). Among the 1914 in-range anti-Xa samples, parallel APTT was prolonged in 468 samples (24%) across 59 patients. 80 Samples from 2 patients were excluded due to absence of fibrinogen and/or INR measurements on the same day. The mortality in patients with prolonged APTT but normal fibrinogen levels and normal INR (N=29; due to FXI/FXII-consumption) was significantly lower compared to the remaining 28 patients who showed samples with reduced fibrinogen levels and/or prolonged INR (10% vs. 32%; p=0.043). Conclusions Fibrinogen-levels and INR uncover the underlying etiology in discrepant APTT-prolongation as compared to an in-range anti-Xa value in a CS population during left-sided ImpellaTM support. In patients with prolonged APTT and reduced fibrinogen (&amp;lt;1.5 g/dL) and/or prolonged INR (≥1.5), the risk of mortality is significantly elevated. This is due to concomitant conditions with high mortality (liver failure, sepsis, DIC,…). We advocate to monitor such patients carefully and treat them in a patient/disease tailored approach.

Unveiling new horizons: revolutionary insights into acute myocarditis and optimal mechanical circulatory support timing.

Unveiling new horizons: revolutionary insights into acute myocarditis and optimal mechanical circulatory support timing.

European practices on antithrombotic management during percutaneous mechanical circulatory support in adults: an international survey of the ACVC Association of the ESC joint with EuroELSO

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds Wetenschappelijk Onderzoek Flanders. Background/introduction Bleeding and thrombotic complications impair the outcomes of patients on percutaneous mechanical circulatory support (pMCS) with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and/or microaxial flow pumps such as the Impella™. Very recent MCS-trials still show a 23.9% moderate/major bleeding incidence during V-A ECMO. Antithrombotic practices are an important determinant of the meticulous coagulopathic risk management, but guidelines here are non-existing. Purpose Providing an overview of the current European practices in antithrombotic management in adults on pMCS is a first but crucial step to design trials, standardize practice and improve outcome. Methods This online cross-sectional survey was distributed via a digital newsletter and social media platforms through the Association of Acute Cardiovascular Care (ACVC) and the European Extracorporeal Life Support Organization (EuroELSO). The survey was accessible between 17.04 and 23.05.2023. The target population were European clinicians involved in adult critical care and pMCS-management. Results We included responses from 105 different units from 26 European countries. 72.4% Of the European responders have an institutional anticoagulation protocol installed. Unfractionated heparin is the predominantly used anticoagulant (Impella™: 97.0% and V-A ECMO: 96.1%). Argatroban is the preferred alternative in case of heparin-induced thrombocytopenia (Impella™: 52.3% and V-A ECMO: 50.7%). 10.8% And 14.5% of the anticoagulation protocols rely on anti-factor-Xa assay with activated partial thromboplastin time (APTT) in parallel for Impella™ and V-A ECMO, respectively. Up to 43.1% (Impella™) and 32.9% (V-A ECMO) of the European respondents rely on a monitoring strategy with APTT alone. Anticoagulant targets for heparin vary significantly between institutions. 54.0% And 42.7% of the European survey participants administer dual antiplatelet therapy (DAPT) during Impella™ and V-A ECMO support after acute coronary syndrome without percutaneous coronary intervention (PCI), increasing to 93.7% and 84.0% after recent PCI, respectively. Typical thresholds for transfusion or administration of blood products without acute bleeding also vary substantially and are frequently not predefined. Conclusion Large heterogeneity in antithrombotic practices is observed across Europe. Consequently, device-associated coagulopathic complications may largely vary due to non-standardized management and heterogeneity between institutions. This survey underpins the importance of urgent prospective trials investigating important basic questions concerning antithrombotic therapy during pMCS (anticoagulation targets, monitoring strategy, concomitant use of DAPT among others).

Is there a role for intra-aortic balloon pump in patients with cardiogenic shock? predictors of success

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Clínico San Carlos Madrid. Background Cardiogenic shock (CS) remains a clinical challenge associated with unacceptable high mortality rates. Early revascularization is the cornerstone for CS management. However, CS patients usually requires further advanced therapies such as vasopressors and mechanical circulatory support devices. Intra-aortic balloon pump (IABP) is not routinely used in patients with CS according to the current recommendations. However, this device could be associated with potential benefit in selected patients and we believe it is underutilized. Our aim was to assess for potential predictors of success after IABP implantation in patients with CS. Methods From 2013 to 2023, 136 consecutive patients diagnosed with CS and admitted to an Acute Cardiac Care Unit in a tertiary care hospital were recruited. Demographic, clinical, and analytical variables were retrospectively collected. SCAI classification was used to define shock state. Patient were followed-up to November-2023 and clinical events were also recorded. For purposes of analysis, patients were classified in two groups: IABP success (N=70) and IABP failure (N=66). Success, in terms of IABP use, was defined as patient’s survival to the index event. Failure of IABP was defined as in-hospital death. A multivariate logistic regression analysis was performed to identify potential predictors of success. Results Mean age was 67.2±12.2 years and 64.7% were females. There were no significant differences in cardiovascular risk factors and comorbidities between groups: hypertension (56.6% vs 43.5%, p 0.132), diabetes (40.9% vs 59.1%, p 0.088), chronic kidney disease (50% vs 50%, p 0.800), previous stroke (53.9% vs 41.2%, p 0.857) in "Success-group" vs "Failure-group" respectively. STEMI was the most frequent cause of CS requiring an IABP (65.9%). Non-ST elevation myocardial infarction was more common in the "Success-group", whereas cardiac arrest was more common in the "Failure-group" (Table 1). Regarding the CS classification, patients with IABP failure were more frequently in SCAI D and E categories (Table 1). In addition, patients in the failure-group had worse hemodynamic and analytic parameters (Table 1) and the IABP failed to significantly improve them. There were no significant differences in coronary artery disease burden and treatment. Complete revascularization was accomplished in a similar proportion of patients in both groups (Table 1). The multivariate analysis showed that SCAI B&amp;C states were independently associated with success after IABP implantation, whereas lactate level prior to IABP implantation was associated with failure (Table 2). Conclusion Selecting the appropriate timing for IABP implantation is critical for the prognosis, as success rates are higher in less advanced stages of cardiogenic shock. Preimplantation lactate levels are also associated with success rates.

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

Abstract Funding Acknowledgements None. Background Although temporary mechanical circulatory support 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 from VA-ECMO although there are no standardized protocols. Purpose We sought to evaluate the accuracy of echocardiographic indices in predicting successful weaning from VA-ECMO in CS patients. We tested total isovolumic time (tIVT), an index of ventricular performance(1,2), and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; E/e’ at mitral valve; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Multicentric 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. Waning trials were performed daily starting from 48 hours after VA-ECMO institution. A stepwise decrease of VA-ECMO blood flow was applied, until reaching 1 or 1.5 L/min. 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 in hospital for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (Figure 1-A): stroke volume (SV) &amp;gt;13.2 ml (HR 4.12 [1.71-9.95], p 0.002), tIVT &amp;gt;23.6 min/sec (HR 0.14 [0.02-1.03], p 0.053), LV VTI &amp;gt;6.6 cm (HR 4.99 [1.94-12.87], p&amp;lt;0.001), MAPSE &amp;gt;6.15 mm (HR 4.42 [1.90-10.24], p 0.001), TAPSE &amp;gt;11 mm (HR 10.13 [1.37-7.02], p 0.023), RV S’ &amp;gt;7 cm (HR 5.40 [1.45-20.12], p 0.012). LVEF, E/e’ and S’ at mitral valve did not reach the statistical significance. Figure 1-B shows Kaplan-Meier analysis on echocardiographic indices collected during the last weaning trial; figure 2 details HR of all these parameters. 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. Parameters reflecting ventricular activation and systo-diastolic interaction already demonstrated superiority in defining ventricular performance. Considering the known limitations of LVEF (HR, loading and LV dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation in the acute setting.

The Perioperative Period of Heart Transplantation Is Affected by Thyroid Hormone Status.

Background: Orthotopic heart transplantation (HTx) is a long-term surgical therapeutic approach for patients with end-stage heart failure. The objective of the present study was to uncover associations between altered thyroid hormone (TH) status and adverse outcomes after HTx. Methods: In this prospective, single-center cohort study, 283 patients underwent HTx between 2013 and 2020 at the Heart and Vascular Center of Semmelweis University in Hungary. We measured serum free triiodothyronine (fT3), free thyroxine (fT4), and thyrotropin (TSH) pre- and postoperatively. TaqMan qPCR was used to measure type 2 deiodinase and type 3 deiodinase mRNA (Dio2 and Dio3, respectively) levels from the diseased heart bioptates. To assess the local TH action of the heart, mRNA levels of Hcn2 and Myh7 were measured in a subgroup of patients receiving extracorporeal membrane oxygenation (ECMO) postoperatively. Groups were compared using nonparametric tests. Cox regression analysis and logistic regression test were used to investigate the outcomes. The connection between serum TH parameters and cardiac gene expressions was assessed using linear regression. Results: Serum TSH (p = 0.009), fT3 (p < 0.001), and fT4 (p < 0.001) levels were lower after HTx than preoperatively. Levothyroxine (LT4) administered to donors was associated with better survival after 30 days (p = 0.049). LT4 replacement given to recipients after HTx was associated with better survival after 30 days (p = 0.018), 1 year (p = 0.002), and 2 years (p = 0.001). Dio3 mRNA level was significantly increased in patients who were treated with ECMO (p = 0.026), left ventricular assist device (LVAD) (p = 0.008), and biventricular assist device (BiVAD) (p = 0.013) preoperatively, and ECMO (p = 0.042) postoperatively, compared with those who did not require any type of mechanical circulatory support (MCS). We found no significant difference in the expression of the Hcn2 and Myh7 marker genes between patients on postoperative ECMO and those without MCS, and neither did they correlate with serum hormone levels (p = 0.519 and p = 0.056, respectively). Conclusions: We conclude that TH status plays an important role in HTx patients, and monitoring of TH status in the perioperative period may contribute to improved treatment outcomes. Our findings require independent confirmation in a randomized controlled clinical trial.

In vitro study on device-induced damage to blood cellular components and degradation of von Willebrand factor in a CentriMag pump-assisted circulation.

High mechanical shear stress (HMSS) generated by blood pumps during mechanical circulatory support induces blood damage (or function alteration) not only of blood cell components but also of plasma proteins. In the present study, fresh, healthy human blood was used to prime a blood circuit assisted by a CentriMag centrifugal pump at a flow rate of 4.5 L/min under three pump pressure heads (75, 150, and 350 mm Hg) for 4 h. Blood samples were collected for analyses of plasma-free hemoglobin (PFH), von Willebrand factor (VWF) degradation and platelet glycoprotein (GP) IIb/IIIa receptor shedding. The extent of all investigated aspects of blood damage increased with increasing cross-pump pressure and duration. Loss of high-molecular-weight multimers (HMWM)-VWF in Loop 2 and Loop 3 significantly increased after 2 h. PFH, loss of HMWM-VWF, and platelet GPIIb/IIIa receptor shedding showed a good linear correlation with mean shear stress corresponding to the three pump pressure heads. HMSS could damage red blood cells, cause pathological VWF degradation, and induce platelet activation and platelet receptor shedding. Different blood components can be damaged to different degrees by HMSS; VWF and VWF-enhanced platelet activation may be more susceptible to HMSS.