Mechanical Circulatory Support 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.

Population Pharmacokinetics of Vancomycin in Intensive Care Patients with the Time-Varying Status of Temporary Mechanical Circulatory Support or Continuous Renal Replacement Therapy.

This study characterized the population pharmacokinetics (PK) of vancomycin in patients treated with and without continuous renal replacement therapy (CRRT) or temporary mechanical circulatory support (tMCS), including extracorporeal membrane oxygenation or extracorporeal ventricular assist device. Critically ill adults with and without tMCS or CRRT prescribed vancomycin were enrolled for population PK modeling. MonteCarlo simulation provided dosing recommendations based on the probability of target attainment (PTA), achieving a 24-h area under curve (AUC24h) of 400-600mg*h/L. Twenty-five patients with 184 plasma samples were analyzed. The median age was 61.0years. The final model was a two-compartment PK model. CRRT, serum creatinine, and body weight were significant predictors of clearance. CRRT was a covariate on the central volume of distribution. tMCS significantly decreased the intercompartmental clearance. The simulated mean trough levels at the 48th hour were lower in the tMCS group (13.4 versus 14.2mg/dL in non-tMCS, p < 0.001) in a 70-kg subject with a creatinine of 1mg/dL and a daily dose of 20mg/kg, but the PTA was similar (61.8% versus 62.2%). A reduction of maintenance dose from 30 to 10mg/kg/day with loading dose from 25 to 15mg/kg is recommended while serum creatinine progresses from 0.5 to 4.0mg/dL. For CRRT, the optimal regimen consists of 20-25mg/kg loading and maintenance of 15mg/kg/day. The dosing strategy of vancomycin can be based on body weight or renal function, regardless of tMCS. Intercompartmental clearance decreases under tMCS, which can mislead a dosing adjustment based on trough level.

Sex disparities in myocardial infarction related cardiogenic shock.

Women are underrepresented In cardiovascular disease research, constituting only 30 % of the cardiogenic shock (CS) population. Consequently, guidelines are mainly based on male patients. This study aims to comprehensively examine the sex-specific aspects of acute myocardial infarction (AMI)-related CS, encompassing presentation, treatment and outcomes. Patients with CS undergoing percutaneous coronary intervention (PCI) between 2017 and 2021 were identified using the national Netherlands Heart Registration. Mortality was assessed using the Kaplan Meier method, and logistic regression was performed to investigate differences in clinical management between sexes. Furthermore, a sensitivity analysis excluding patients with out-of-hospital cardiac arrest (OHCA) was conducted. Among 2274 patients, 614 (27 %) were female. Women were older (70 vs. 66 years, p < 0.001) and presented with longer symptom duration (> 3 h: 52 % vs. 37 %, p < 0.001). Men more often presented with multivessel disease (62 % vs. 56 %, p < 0.001), a prior myocardial infarction (23 % vs. 15 %, p < 0.001) and after an OHCA (46 % vs. 29 %, p < 0.001). A trend towards more usage of mechanical circulatory support in men was observed (adjusted OR 0.86, 95 % CI 0.67-1.09). Mortality, both adjusted and unadjusted, was not statistically different for men and women. Women with CS present with distinct clinical characteristics, including longer symptom duration, underscoring the importance of symptom recognition. Furthermore, men present at younger age and with more OHCA. Mortality in men and women was similar despite differences in presentation and clinical management.

Extended use of axillary impella 5.5 as a bridge to post-infarct ventricular septal defect repair.

Post-infarct ventricular septal defect (VSD) carries high mortality. Since emergent repair of post-infarct VSD is challenging, hemodynamic stabilization utilizing temporary mechanical circulatory support crucially provides time to delay intervention and allows necessary scar tissue formation which improves the fragility of myocardium and leads to a definitive repair. To date, there remains no standard for achieving hemodynamic stability, including usage and mode of temporary mechanical circulatory support. We describe a patient with acute post-infarct VSD in cardiogenic shock successfully supported with Impella 5.5 for 67days as a bridge to surgical repair and coronary artery bypass grafting.

Abstract 4136267: Racial and ethnic disparities in-hospital outcomes after out-of-hospital cardiac arrest: Insight from the United States national inpatient sample

Background: Out-of-hospital cardiac arrest (OHCA) continues to have a high mortality with an overall survivability to hospital discharge of less than 10%. Increased bystander cardiopulmonary resuscitation has resulted in better survival after OHCA. Some studies have tackled sociodemographic characteristics and rates of survival, but these are mostly localized studies with varied results. We investigated racial disparities in in-hospital mortality and mechanical circulatory support (MCS) use in OHCA. Methods: Retrospective cohort study based on the 2019-2020 National Inpatient Sample database of the Healthcare Utilization Project. Our population included patients 18 years or older with out-of-hospital cardiac arrest (OHCA) identified using ICD-10 codes. The primary risk factors examined were race/ethnicity categorized into White, Black, and Hispanic. The primary outcome was in-hospital mortality among patients with OHCA. The secondary outcome was mechanical circulatory support (MCS) use. Left ventricular assist device (LVAD), extracorporeal membrane oxygenation (ECMO), and intra-aortic balloon pump (IABP) were identified as MCS. Multivariate regression analysis was used to estimate the odds ratio. Results: During the study period, 26,640 hospitalizations with OHCA were identified, of whom 67,4% were White, 22,9% were Black, and 9,7% were Hispanic. The mean (SD) age of patients with OHCA was 65.2 (16) years old, and Black patients well as Hispanic patients had lower mean age compared to White patients (63.1 vs 63 vs 66.3 years old, p&lt;0.001). A total of 19,425 died (72.9%) and 0.9% needed MCS. Notably, more Hispanics needed MCS, compared to White and Black patients (1.7% vs 0.9% vs 0.4%, p=0.049). In the multivariate analysis, we did not find statistical significance among racial/ethnic groups regarding in-hospital mortality. However, Hispanic patients had higher odds of MCS (OR=2.4; CI 95% 1.05-5.55, p=0.039) compared to White patients. No statistical significance was found regarding the use of IABP or LVAD. Conclusion: Overall, in-hospital mortality was elevated. Moreover, our findings highlight significant racial disparities after OHCA regarding MCS use. More research is needed to identify factors of racial disparities to improve outcomes.

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 &lt;0.00, CI 1.03-1.09), particularly among females OR 1.25(p&lt;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 &lt; 0.00, CI 1.93-2.82), followed by Impella OR of 1.47 (p &lt; 0.00, CI 1.37 – 1.59), and IABP OR 0.723 (p &lt; 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 4135194: Safety and Efficacy of Mechanical Circulatory Support during VT ablation

Introduction: Ventricular arrythmias are prevalent in patients with advanced heart failure and associated with increased mortality. Outcomes of electrophysiology ablation on patients requiring mechanical circulatory support (MCS) are not well described. We aimed to analyze the safety and efficacy of ventricular tachycardia (VT) ablation in patients requiring MCS at the Emory system. Methods: Patients were identified via retrospective chart review from October 2022 through August 2023. Patients who underwent VT ablation with the support of Impella, left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), and venoarterial extra-corpeal membrane oxygenation (VA ECMO), or any combination of these were included. Results: A total of 7 patients of average age 56 ± 10 years, predominantly male (85.7%), with cardiomyopathy of mean EF 18.6% +/- 8.5 (ischemic 71.4%) underwent MCS supported VT ablation. One patient had 2 separate VT ablation procedures for refractory VT. Of these 8 procedures, 4 utilized a single type of MCS (2 impella, 2 LVAD) while 4 used a second type of MCS in combination with an Impella (2 impella RP, 1 VA ECMO, 1 IABP). Success at time of ablation was present in 75% of cases. Average time of outpatient follow up was 82 ± 31 days. At time of follow up, 50% of patients remained free of VT or with a single VT episode not requiring implantable cardioverter-defibrillator (ICD) shock. One patient had gone on to undergo successful heart transplantation. Procedural complications were noted in one patient, who suffered cardioembolic cerebrovascular accident (CVA) 2 days post-op. Transthoracic echo (TTE) 5 days post-op revealed LV mural thrombus as likely etiology of CVA. Conclusion: While there are no clear guidelines directing the use of MCS during VT ablation, our single academic institution experience suggests safety and feasibility of its use to support select, high risk cases.

Abstract 4137135: Trends in Mechanical Circulatory Support After the New Heart Allocation Policy

Background: In October 2018 a new heart allocation policy (NHAP) was implemented, which resulted in patients with Intra-aortic balloon pumps (IABP) being upgraded to status-two. We sought to determine practice pattern changes in mechanical circulatory support (MCS) use as a result of the NHAP. Hypothesis: Changes in the new heart allocation policy may lead to shifts in choice of mechanical circulatory support. Methods: A retrospective analysis was conducted using the National Inpatient Sample (NIS) between 2017–2020. Hospitalizations for cardiogenic shock were identified, and stratified based on whether the patients were admitted before or after the NHAP. Baseline characteristics were compared between these cohorts, and the primary outcome of interest was the use of MCS and transplant before and after the NHAP. Subgroup analyses included patients only in transplant centers, non-transplant centers, and those who eventually underwent transplant. Results: A total of 689,935 hospitalizations were included in the final analysis, of which 279,230 (40.5%) were before the NHAP, and 410,705 (59.5%) were after. In allcomers, hospitalizations after the NHAP were less likely to undergo IABP (Adjusted odds ratio [OR] 0.81, p&lt;0.01) and LVAD (Adjusted OR 0.73, p&lt;0.01). These findings were consistent in most subgroup analyses. Patients who underwent transplant after the NHAP however were more than twice as likely to have received a IABP compared to those admitted prior to the NHAP (adjusted OR 2.58; p&lt;0.01). Conclusion: IABP placement after the NHAP increased in patients who underwent transplant, as opposed to allcomers or patients who did not undergo transplant. This change in utilization of MCS may be reflective of perceived benefits and biases in regards to transplantation candidacy.

Abstract 4134777: Predictive Factors for Early Recovery from Mechanical Circulatory Support in Patients with Fulminant Myocarditis

Background: Fulminant myocarditis (FM) requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is fatal and has a complicated clinical course. In such FM cases, predicting which cases are likely to achieve early recovery is crucial for developing acute-phase treatment strategies. We aimed to examine the factors predicting early recovery in fatal cases of FM requiring VA-ECMO using multicenter cohort of patients with myocarditis. Methods: We retrospectively analysed 343 patients with FM requiring VA-ECMO between April 2012 and March 2017. The early recovery group was defined as patients who were successfully weaned off mechanical circulatory support (MCS) within 7 days from MCS deployment and discharged with favorable outcomes. We divided patients into early recovery group and non-early recovery group. Predictors of early recovery were investigated by performing a multivariate analysis, including significant variables ( p &lt;0.05) identified from a univariate analysis of baseline clinical parameters and meaningful variables from previous reports. Results: Among the eligible patients, 71 were assigned to the early recovery group, whereas 272 were assigned to the non-early recovery group. The baseline patient demographics showed the early recovery group was significantly younger (45 [30-63] years vs. 56.5 [40-67] years, p =0.003), had higher WBC counts (11,400 [8,500-16,000] /μL vs. 9,900 [7,162.5-13,297.5] /μL, p =0.009), and had lower CK-MB levels (38.5 [18.0-75.3] U/L vs. 73.0 [42.5-137.0] U/L, p &lt;0.001), than the non-early recovery group. In the histological diagnosis, the proportions of lymphocytic and eosinophilic myocarditis were similar between the two groups, whereas the proportions of giant cell myocarditis tended to be higher in the non-early recovery group. Multivariate analysis showed the independent predictors of early recovery were age ≤40 years (OR: 3.25; 95% CI: 1.42-7.44), WBC ≥ 11,000 /μL (OR: 3.10; 95% CI: 1.39-6.86) and CK-MB ≤ 61 U/L (OR: 2.46; 95% CI: 1.06-5.72), and if all conditions were fulfilled, the early recovery rate increased to 61.5%. Conclusions: Early recovery group had higher inflammatory parameter levels but lower myocardial damage marker levels on admission in addition to age ≤40 years, suggesting that patients having a strong acute-phase inflammatory response with a lower degree of myocardial damage, could recover earlier.

Abstract 4139144: "Comparative Analysis of Inpatient Outcomes: Decompensated Systolic Heart Failure (HFrEF) with and without Iron Deficiency Anemia, Propensity-Matched Nationwide Study (2017-2021)."

Background: Iron deficiency anemia (IDA) affects approximately one-third of patients with systolic heart failure, yet comprehensive population-based analyses of its impact on in-hospital outcomes remain limited. This study seeks to examine how IDA influences in-hospital outcomes among individuals with decompensated systolic congestive heart failure (HFrEF). Methods: Using data from the National Inpatient Sample (NIS) database spanning from 2017 to 2021, this study identified patients hospitalized for decompensated systolic congestive heart failure (HFrEF) with a secondary diagnosis of IDA using ICD-10 codes such as I5020-23 and D500, D501, D508, D509. Propensity score matching (PSM) was then employed to create cohorts without and with IDA at a 1:3 ratio. Multivariate regression analyses were conducted to evaluate various outcomes, including in-hospital mortality, cardiogenic shock (CS), acute myocardial injury (AMI), cardiac arrest, ventricular tachycardia (VT), ventricular fibrillation (VF), length of stay (LOS), and total hospitalization charges. Furthermore, the utilization rate of mechanical ventilation and circulatory support, including intra-aortic balloon pump and extracorporeal membrane oxygenation, was evaluated in both cohorts. Results: Among 253,034 HFrEF hospitalizations, 16,200 (6.4%) had a secondary diagnosis of IDA. After PSM, multivariate regression analyses revealed no significant differences in the odds of cardiogenic shock (10% vs. 10%, p=0.86), in-hospital mortality (2.6% vs. 2.8%, p=0.71), and LOS (7.19 vs. 7.27 days) between the two groups. Additionally, the likelihood of cardiac arrest, ventricular arrhythmias, AMI, and utilization of mechanical ventilation and circulatory support did not reach statistical significance. However, patients with IDA and HFrEF had higher hospitalization charges ($85,516 vs. $93,000). Conclusion: HFrEF patients, with or without IDA, had similar odds of cardiogenic shock, in-hospital mortality, mechanical circulatory support utilization, as well as LOS. However, IDA with HFrEF correlated with higher hospitalization charges.

Abstract 4135252: Associations between Group 2 Pulmonary Hypertension and 30-Day Readmissions Following Acute Myocardial Infarction Hospitalizations.

Background: Pulmonary hypertension (PH) is a major contributor to cardiovascular disease-related morbidity and mortality. Despite this, little is known regarding the outcomes of 30-day re-admissions following Acute Myocardial Infarction (AMI) in the context of group 2 PH. Hypothesis: Group 2 PH is associated with a higher likelihood of 30-day readmissions in patients presenting with AMI. Goal: To assess the relationship between group 2 PH and adverse hospitalization outcomes in cases of AMI. Methods: We queried the 2016-2020 Nationwide Readmission Database (NRD) and identified AMI as the primary diagnosis. We compared in-hospital outcomes based on the presence versus absence of Group 2 PH. The primary outcome was 30-day readmissions. Secondary outcomes included the odds of in-patient mortality, mechanical ventilation use, vasopressor use, and mechanical circulatory support (MCS) use. Multivariable regression models were used to adjust for confounders. Results: Among 182,308 AMI hospitalizations, 364 (0.2%) had a secondary diagnosis of Group 2 PH. Group 2 PH was associated with a higher likelihood of re-admission within 30 days (adjusted OR [aOR] 1.21, 95% CI 1.07–1.36, p=0.002). Additionally among patients presenting with AMI, group 2 PH was associated with higher odds of in-patient mortality (aOR 2.64, 95% CI 1.52–4.58, p=0.001), mechanical ventilation use (aOR 2.07, 95% CI 1.19–3.6, p=0.010), vasopressor use (aOR 5.4, 95% CI 2.7-10.9, p&lt;0.001) and MCS use (aOR 2.39, 95% CI 1.46-3.91, p&lt;0.001) during index hospitalization compared to the patients without group 2 PH. Conclusion: Patients with Group 2 PH admitted for AMI had higher odds of 30-day readmissions and both fatal and non-fatal adverse outcomes compared to patients without PH. Further studies are needed to confirm these findings and develop strategies to improve outcomes for this high-risk population.

Abstract 4127071: Pulmonary Artery Catheter Utilization in Cardiogenic Shock: Clinical Characteristics and Outcomes

Background: The pulmonary artery catheter (PAC) is used for hemodynamic monitoring, but its impact on patient outcomes, especially in cardiogenic shock (CS), is controversial. Several studies have shown no significant benefits and noted complications, leading to a decline in PAC use. However, PAC use appears to have increased recently in guiding management decisions in CS. Our study aims to assess the clinical characteristics and outcomes of CS patients receiving PACs versus not. Methods: We included patients with CS admitted to a tertiary academic medical center between May 2015 and December 2023. Variables were compared using Kruskal-Wallis, chi-squared, and Fisher's exact tests. Hemodynamic parameters were collected from either right heart catheterization or from a PAC. Endpoints included native heart survival to discharge, durable left ventricular assist device (LVAD) implantation, heart transplant (HTx), and 30-day and 1-year survival from discharge. Results: The study group consisted of 742 patients with CS. Of these, 385 (52%) received a PAC and 357 (48%) did not. The baseline characteristics of the two groups are shown in Table 1A . PAC patients had more severe shock, worse hemodynamics, and higher rates of temporary mechanical circulatory support (MCS) use. Hemodynamic measurements at shock onset differed, with PAC patients having higher right atrial pressures and lower cardiac index by Fick. Clinical outcomes and MCS related complications are shown in Table 1B. There was no significant difference in native heart survival at discharge, but HTx and durable LVAD implantation was higher in the PAC group. PAC placement was associated with longer hospital stays and more MCS related complications, including bleeding and hemolysis. The 30-day survival rate was similar between groups, and 1-year survival was marginally higher in the PAC group. Conclusion: PAC patients exhibited more severe clinical characteristics, longer hospital stays, higher rates of temporary MCS use and complications, durable LVAD implantation, and HTx. Short-term survival rates were similar, but 1-year survival was slightly better for PAC patients. Further studies are needed to provide clearer insights into PAC use in CS.

Abstract 4144512: Impact of Nutritional Status on Transcatheter Edge-to-Edge Repair Outcomes in Mitral Regurgitation: Insights from a National Database Analysis

Introduction: Transcatheter edge-to-edge repair of the mitral valve with the MitraClip has offered a less invasive percutaneous alternative to surgical repair in select candidates with mitral regurgitation. Various factors impact the outcomes of MitraClip. We investigated the impact of nutritional status on the outcomes of MitraClip. Methods: Utilizing the nationwide inpatient sample data for years from January 1, 2016, and December 31, 2021, patients who underwent MitraClip were identified. They were categorized based on obesity and protein energy malnutrition (PEM). Statistical significance was assigned at p&lt;05. Results: Out of the 8115 patients undergoing MitraClip, 2215 had PEM, and 5900 had obesity—table 1. Patients in the PEM group were older, with a higher prevalence of comorbidities, including anemia, pneumonia, liver disease, and fluid and electrolyte disorders, compared to the obese group. Conversely, the obesity group had a higher prevalence of hypertension, diabetes, and hypertension with complications. Our analysis revealed that PEM subgroups had significantly higher in-hospital mortality, cardiogenic shock, mechanical circulatory support (MCS) requirement, post-procedural worsening heart failure, spontaneous cardiac arrest, and major adverse cardiovascular and cerebrovascular events (MACCE). After adjusting for potential confounders, PEM remained an independent predictor of increased odds of death, cardiac arrest, ECMO, MCS, and MACCE compared to obesity. The propensity score matching analysis confirmed that PEM was associated with significantly higher rates of in-hospital mortality, cardiac arrest, and MACCE compared to obesity. (Figure 1) Conclusion: Our results reveal that PEM is associated with significantly worse outcomes in patients undergoing MitraClip procedures compared to obesity. These findings are consistent across multivariate and propensity score matching analyses.

Abstract 4137205: Management Patterns and Outcomes in the Use of Invasive Mechanical Ventilation for Patients with Cardiogenic Shock

Background: Approximately half of all patients with cardiogenic shock (CS) require invasive mechanical ventilation (IMV). While there have been significant advances in the management of patients requiring IMV based on data primarily derived from medical intensive care patients with respiratory failure, little is known regarding the management and outcomes of IMV in patients with CS. Methods: We conducted an analysis of patients treated for CS who required IMV at an academic safety net hospital from 2017-2023. Indications for IMV, ventilator settings, and medications were obtained from the medical record. The primary outcome was unsuccessful extubation, defined as reintubation within 48 hours of extubation. Results: A total of 110 patients with CS who received IMV were identified. Median age was 60yo; 28% of the cohort was female, 39% of Hispanic ethnicity, and 38% of Black race. Primary reasons for intubation included ongoing cardiac arrest (35%) and hypoxic respiratory failure (34%). Most patients were on minimal ventilator support at 24 hours after intubation (median FiO2 40% [IQR 30-50%], post-end expiratory pressure [PEEP] 5cm H2O [IQR 5-8]). Mechanical circulatory support (MCS) was present in 40% of patients at 24 hours post-intubation. Protocolized spontaneous breathing trials (SBTs) were delayed in 77% of patients, primarily due to hemodynamic instability (88%). Planned or unplanned extubation occurred in 63% of patients after a median of 4.8 days [IQR 2.1-8.0]. Ten percent of patients transferred hospitals while on IMV, while 27% were palliatively extubated or died on IMV. The majority (58%) of patients undergoing non-palliative extubation were on vasoactive medications preceding extubation, with only 2% on MCS. Most patients (58%) were extubated to nasal cannula or room air. A total of 13% of patients experienced unsuccessful extubation. Conclusions: In a cohort of patients with CS requiring IMV, most patients were on minimal ventilator settings within 24 hours yet remained intubated with SBTs delayed due to hemodynamic instability. Rates of failed extubation were comparable to published data from other forms of critical illness. Further work is necessary to determine optimal approaches to ventilator liberation and circulatory support in intubated patients with CS where hemodynamic derangements rather than respiratory insufficiency represent the primary barrier to extubation.

Abstract 4134712: Pheochromocytoma-Induced Cardiomyopathy Requiring Mechanical Support with Ejection Fracture Recovery Following Surgical Resection

Introduction: Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla. The annual incidence is approximately 0.8 per 100,000 persons, though this is an underestimate given a high percentage diagnosed at autopsy. Classically, patients present with episodic headache, sweating, and tachycardia, however, pheochromocytomas can be associated with cardiomyopathy secondary to the catecholamine excess. We present an unusual case of pheochromocytoma-induced cardiogenic shock highlighting an excellent use of mechanical circulatory support with Impella and Extracorporeal Membrane Oxygenation (ECMO) bridging to surgical intervention resulting in left ventricular ejection fraction (LVEF) recovery. Case Description: A 49-year-old female with past medical history of asthma initially presented to an outside hospital for palpitations, chest pain, and hypertension. Transthoracic echo (TTE) showed preserved left ventricle ejection fraction (LVEF) while cardiac MRI showed a LVEF of 43% with dilated left ventricle and diffuse global hypokinesis consistent with a dilated cardiomyopathy. She underwent a coronary angiogram demonstrating nonobstructive CAD. She was then discharged with readmission a month later at our hospital for chest tightness, palpitations, vomiting, weakness, and dizziness. Repeat TTE showed a drop in LVEF to 10-15%. She progressed to cardiogenic shock requiring BiPAP and inotrope initiation, with progressive shock and hypotension ultimately requiring Impella 5.5 and venoartrial ECMO. Abdominal imaging was notable for 4.7 x 4.2 cm right adrenal nodule and further workup with serum and urine metanephrines confirmed pheochromocytoma. While supported, the patient underwent right adrenalectomy with subsequent wean of mechanical circulatory support and biventricular recovery on TTE. Discussion: Pheochromocytoma-induced heart failure is a rare but potentially life-threatening complication from excess catecholamine effects on the myocardium. Pheochromocytomas should be considered in the evaluation of idiopathic heart failure even in the absence of symptoms related to catecholamine excess. Early detection, pharmacological management, and surgical resection may prevent progression of myocardial remodeling. Mechanical circulatory support can be a valuable adjunct in managing refractory heart failure in these patients by providing temporary hemodynamic stabilization while awaiting definitive tumor resection.

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.

Abstract 4128187: Does Health-related Quality of Life Differ by Race over time in Older Patients with Heart Failure from Before to After Heart Transplantation or Long-term Mechanical Circulatory Support?

Background: Minority patients are disproportionately affected by heart failure. Therefore, we aimed to determine the impact of race on health-related quality of life in three groups of older patients (60-80 years) with heart failure who underwent advanced surgical therapies (within race and by surgery group): (1) heart transplantation (HT, with pre-transplant mechanical circulatory support [HT MCS]), (2) HT without pre-transplant MCS (HT Non-MCS), or (3) long-term MCS, if ineligible for HT. Methods: Secondary analyses were conducted using data from the Sustaining Quality of Life of the Aged: Heart Transplant or Mechanical Support study. From 10/1/15 to 12/31/18, 396 patients with heart failure were recruited at 13 U.S. medical centers, of which 305 patients underwent HT (n=161 [68 HT MCS and 93 HT Non-MCS]) or long-term MCS (n=144) and had data through 1 year follow-up. Analysis included non-inferiority testing (Long-term MCS vs HT MCS; Long-term MCS vs HT Non-MCS). To demonstrate non-inferiority, the surgical strategies by race needed to show a difference of at least 5 percentage points, with a 95% lower confidence boundary and a two-tailed p-value&lt;0.05 in health-related quality of life, using the Kansas City Cardiomyopathy-12 Questionnaire Overall Summary Score at baseline and 3-, 6-, and 12 months. Results: The entire cohort was on average 66.2±4.7 years, 78% male, and 84% White. All three surgical groups experienced improved health-related quality of life from before to 1 year follow-up; with the largest gain through 3-months. Using non-inferiority testing, the long-term MCS minority group did not demonstrate non-inferiority when compared to both the HT MCS minority group and HT Non-MCS minority group confidence limits above the non-inferiority margin of -5 (Figure). Also, the White long-term MCS group did not demonstrate non-inferiority when compared to the White HT MCS and White HT Non-MCS groups. Conclusion: Differences in health-related quality of life among groups based on race were not statistically significant. Per non-inferiority testing, HT is superior to long-term MCS for health-related quality of life, regardless of race.

Abstract 4138475: Comparative Outcomes of Transcatheter Aortic Valve Implantation and Surgical Aortic Valve Replacement in Patients with Right Heart Failure: Insights from Nationwide Readmission Database

Background: The annual number of transcatheter aortic valve implantation (TAVI) performed has surpassed that of surgical aortic valve replacement (SAVR) as its use expands to patient populations not included in initial clinical trials. However, in patients with Right Heart Failure (RHF), the outcomes of TAVI and SAVR remain unclear. Methods: We conducted a retrospective cohort study using the Nationwide Readmission Database from 2018 to 2021. Using ICD-10 codes, we identified all adult admissions for TAVI and SAVR with the presence of RHF. The primary outcome was in-hospital mortality. Secondary outcomes included in-hospital complications, 30-day readmission rate, length of stay, and total hospitalization charges. Results: The study included 3,712 adult patients with RHF, of which 1,386 (37.3%) underwent TAVI and 2,326 (62.7%) underwent SAVR. Compared to SAVR patients, TAVI patients were older (63 years vs. 76 years, p&lt;0.01) and had a higher burden of peripheral vascular disease, chronic liver disease, and coagulopathy, while SAVR patients had a higher burden of hypertension, diabetes mellitus, coronary artery disease, left heart failure, chronic lung disease, smoking, malignancy, and anemia. On multivariable analysis, compared to TAVI, SAVR was associated with higher odds of mortality (26.6% vs. 9.3%, p&lt;0.01), mechanical circulatory support use (41.5% vs. 9.22%, p&lt;0.01), respiratory failure (34.2% vs. 10.2%, p&lt;0.01), acute kidney injury (58.1% vs. 37.7%, p&lt;0.01), and need for blood transfusion (31.4% vs. 11.0%, p&lt;0.01). There was no difference in 30-day readmission (13.8% vs. 14.3%, p=0.51) and permanent pacemaker implantation (7.0% vs. 8.7%, p=0.33). SAVR was associated with a longer median hospital stay (14 days vs. 8 days, p&lt;0.01) and higher hospitalization charges ($406,826 vs $265,303, p&lt;0.01). When compared to patients wihout RHF, the presence of RHF predicted higher in-hospital mortality for both TAVI (9.3% vs. 1.2%, p&lt;0.01) as well as SAVR (26.6% vs. 3.7%, p&lt;0.01). Conclusions: From 2018 to 2021, more RHF patients underwent SAVR (62.7%) than TAVI (37.3%), but SAVR was associated with worse short-term outcomes, including higher in-hospital mortality, in-hospital complications, and healthcare resource utilization.

Abstract 4129440: Ventricular Stunning Following Direct Current Cardioversion: A Case Report

Background: Ventricular stunning refers to a transient mechanical dysfunction of the myocardium, typically manifesting in response to ischemic insults, reperfusion injury, inflammatory states, or neurohormonal overload. Here, we present an unusual case of ventricular stunning precipitated by direct current electrical cardioversion (DEC). Case Report: A 73-year-old man with a history of heart failure with reduced ejection fraction, paroxysmal atrial fibrillation (AF), coronary artery disease, and chronic kidney disease was admitted to a Veterans Affairs hospital for heart failure exacerbation. His hospitalization was complicated by recurrent episodes of symptomatic AF with ventricular rates in the 120-150’s. This was initially managed with intravenous amiodarone and eventually DEC. He continued to experience symptomatic episodes of AF. Later in the hospitalization a repeat DEC with a single 200 joule shock was performed with restoration of sinus rhythm. Several hours afterwards he was found to be unresponsive and hypotensive. Cool extremities and rising serum lactate raised suspicion for cardiogenic shock resulting in transfer to the intensive care unit where vasopressor and inotropic support were initiated. Echocardiogram revealed a precipitous decrease in left ventricular ejection fraction from 25% to 5%. Serum troponin concentrations were unchanged from prior and ECGs demonstrated rate-controlled AF. Clinical Decision Making: This case highlights an episode of unexpected decrease in cardiac output following an otherwise routine repeat DEC for recurrent AF requiring escalation to mechanical circulatory support. His decompensation worsened, necessitating transfer to the local university center for placement of catheter-based miniaturized ventricular assist device (Impella 5’5). Over the subsequent days, with supportive care, his left ventricular ejection fraction recovered to baseline, and mechanical and inotropic support were withdrawn. Conclusion: Ventricular stunning, leading to cardiogenic shock, is a rare and incompletely understood complication of DEC. It warrants consideration when monitoring patients after cardioversion. Implementing vigilant observation protocols post-DEC to detect ventricular stunning and predisposing risk factors could significantly enhance clinical management strategies.

Abstract 4119250: Partial versus Full ECMO Support in Combined Cardiogenic and Septic Shock – ELSO Registry Analysis

Background: There remains paucity of data on patient outcomes with combined cardiogenic and septic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. While guidelines exist on target VA-ECMO flow in cardiogenic shock patients, optimal (partial versus full) flow in combined shock remains largely unknown. Methods: We queried the Extracorporeal Life Support Organization registry to identify patients in combined cardiogenic and septic shock supported with VA-ECMO between 2017 and 2022. Patients were categorized into either partial or full ECMO support based on ECMO flow at 24 hours indexed to body surface area. Partial support was defined as &lt; 2.2 liters/m2 while full support was ≥2.2 liters/m2. Patients with other forms of mechanical circulatory support, VA-ECMO as bridge to advanced therapies or discharged on VA-ECMO were excluded from the analysis. Primary outcome of interest was survival to discharge. Baseline characteristics including center volumes and Charlson co-morbidity index were compared between survivors and non survivors. Predictors of mortality were identified using multivariable logistical regression model. Results: A total of 452 patients with combined shock supported with VA-ECMO were identified. Overall mortality was 63%. Patients that survived to discharge were younger (46.3 vs 53 years, p &lt; 0.001) and had lower BMI (29.3 vs 31.1, p = 0.041), Charlson co-morbidity index (1.4 vs 2.0, p = 0.01) and rates of pre-ECMO cardiac arrest (28.7% vs 39.4%, p = 0.023). Survivors were also more likely to be at high [&gt; 25 ECMO runs per year] volume centers compared to low [≤ 10 ECMO runs per year] volume centers (62.3% vs 20.4%, p = 0.04). Patients receiving full ECMO support had a higher likelihood of survival to discharge than partial support (42.6% vs 33.8%, p = 0.063), although it did not reach statistical significance. [Table 1] Indexed VA-ECMO flow at 24 hours was also associated with improved outcomes when assessed as continuous variable. [ Figure 1] Advanced age [aOR 1.02, 95% CI 1.01-1.04, p &lt; 0.001], pre-ECMO cardiac arrest [aOR 1.71, 95% CI 1.11-2.65, p = 0.016] and baseline Charlson co-morbidity index [aOR 1.13, 95% CI 1.01-1.28, p = 0.043] were all associated with increased mortality after adjustment for baseline differences. Conclusion: Mortality among patients requiring VA-ECMO for combined cardiogenic and septic shock is high. Full circulatory support may be associated with improved survival in this cohort.