Cardiogenic Shock Patients Research Articles

Clinical outcomes among cardiogenic shock patients supported with high-capacity Impella axial flow pumps: A report from the Cardiogenic Shock Working Group

BackgroundThe Impella 5.0 and 5.5 pumps (Abiomed, Danvers, MA) are large-bore transvalvular micro-axial assist devices used in cardiogenic shock (CS) for patients requiring high-capacity flow. Despite their increasing use, real-world data regarding indications, rates of utilization and clinical outcomes with this therapy are limited. ObjectivesTo examine clinical profiles and outcomes of patients in a contemporary, real-world CS registry of patients who received an Impella 5.0/5.5 alone or in combination with other temporary mechanical circulatory support (tMCS) devices. MethodsThe CS Working Group (CSWG) Registry includes patients from 34 US hospitals. For this analysis, data from patients who received an Impella 5.0/5.5 between 2020-2023 were analyzed. Use of Impella 5.0/5.5 with or without additional tMCS therapies, duration of support, adverse events and outcomes at hospital discharge were studied. Adverse events including stroke, limb ischemia, bleeding and hemolysis were not standardized by the registry but reported per individual CSWG Primary Investigator discretion. For those who survived, rates of native heart recovery (NHR) or heart replacement therapy (HRT) including heart transplant (HT), or durable ventricular assist device (VAD) were recorded. We also assessed outcomes based on based on shock etiology (acute myocardial infarction or MI-CS vs. heart failure-related CS or HF-CS). ResultsAmong 6,205 patients, 754 received an Impella 5.0/5.5 (12.1%), including 210 MI-CS (27.8%) and 484 HF-CS (64.1%) patients. Impella 5.0/5.5 was used as the sole tMCS device in 32% of patients, while 68% of pts received a combination of tMCS devices. Impella cannulation sites were available for 524/754 (69.4%) of patients, with 93.5% axillary configuration. Survival to hospital discharge for those supported with an Impella 5.0/5.5 was 67%, with 20.4% NHR and 45.5% HRT. Compared to HF-CS, patients with MI-CS supported on Impella 5.0/5.5 had higher in-hospital mortality (45.2% vs 26.2%, p<0.001) and were less likely to receive HRT (22.4% vs 56.6%, p<0.001. For patients receiving a combination of tMCS during hospitalization, this was associated with higher rates of limb ischemia (9% vs. 3%, p<0.01), bleeding (52% vs. 33%, p<0.01), and mortality (38% vs 25%; p<0.001) compared to Impella 5.0/5.5 alone. Among Impella 5.5 recipients, the median duration of pump support was 12.9 days (IQR: 6.8-22.9) and longer in patients bridged to HRT (14 days; IQR: 7.7-28.4). ConclusionsIn this multi-center cohort of patients with CS, use of Impella 5.0/5.5 was associated with an overall survival of 67.1% and high rates of HRT. Lower adverse event rates were observed when Impella 5.0/5.5 was the sole support device used. Further study is required to determine whether a strategy of early Impella 5.0/5.5 use for CS improves survival. Condensed abstractHigh capacity Impella heart pumps provide up to 5.5 L/min of flow, while axillary surgical cannulation allows for ambulation. Patients with advanced cardiogenic shock from acute myocardial infarction or heart failure requiring temporary mechanical circulatory support may benefit from upfront use of Impella 5.5 to improve overall survival, including native heart recovery or successful bridge to durable left ventricular assist device surgery or heart transplantation, and to reduce adverse event rates.

Factors associated with acute limb ischemia in cardiogenic shock and downstream clinical outcomes: Insights from the Cardiogenic Shock Working Group

BackgroundThere are limited data depicting the prevalence and ramifications of acute limb ischemia (ALI) among cardiogenic shock (CS) patients. MethodsWe employed data from the Cardiogenic Shock Working Group (CSWG), a consortium including 33 sites. We constructed a multi-variable logistic regression to examine the association between clinical factors and ALI, we generated another logistic regression model to ascertain the association of ALI with mortality. ResultsThere were 7,070 patients with CS and 399 (5.6%) developed ALI. Patients with ALI were more likely to be female (40.4% versus 29.4%) and have peripheral arterial disease (13.8% versus 8.3%). Stratified by maximum SCAI shock stage, the rates of ALI were stage B 0.0%, stage C 1.8%, stage D 4.1%, and stage E 10.3%. Factors associated with higher risk for ALI included: peripheral vascular disease OR 2.24 (95% CI: 1.53 – 3.23; p < 0.01) and ≥ 2 mechanical circulatory support (MCS) devices OR 1.66 (95% CI: 1.24 – 2.21, p < 0.01). ALI was highest for VA-ECMO patients (11.6%) or VA-ECMO + IABP/Impella CP (16.6%) yet use of distal perfusion catheters was less than 50%. Mortality was 38.0% for CS patients without ALI but 57.4% for CS patients with ALI. ALI was significantly associated with mortality, adjusted OR 1.40 (95% CI 1.01 – 1.95, p < 0.01). ConclusionsThe rate of ALI was 6% among CS patients. Factors most associated with ALI include peripheral vascular disease and multiple MCS devices. The downstream ramifications of ALI were dire with a considerably higher risk of mortality.

Comparing Outcomes of Post-Cardiotomy Cardiogenic Shock Patients: On-Site Cannulation vs. Retrieval for V-A ECMO Support.

Background: Post-cardiotomy cardiogenic shock (PCCS) remains a life-threatening complication after cardiac surgery. Extracorporeal membrane oxygenation (ECMO) represents the mainstay of mechanical circulatory support for PCCS; however, its availability is limited to larger experienced centers, leading to a mismatch between centers performing cardiac surgery and hospitals offering ECMO management beyond cannulation. We sought to evaluate the outcomes and complications of PCCS patients requiring veno-arterial (V-A) ECMO cannulated at our hospital compared to those cannulated at referral hospitals. Methods: A retrospective analysis of PCCS patients requiring V-A ECMO was conducted between October 2014 to December 2022. Results: A total of 121 PCCS patients required V-A ECMO support, of which 62 (51%) patients were cannulated at the referring institutions and retrieved (retrieved group), and 59 (49%) were cannulated at our hospital (on-site group). The baseline demographics and pre-ECMO variables were similar between groups, except retrieved patients had higher lactic acid levels (retrieved group: 8.5 mmol/L ± 5.8 vs. on-site group: 6.6 ± 5; p = 0.04). Coronary artery bypass graft was the most common surgical intervention (51% in the retrieved group vs. 47% in the on-site group). There was no difference in survival-to-discharge rates between the groups (45% in the retrieved group vs. 51% in the on-site group; p = 0.53) or in the rate of patient-related complications. Conclusions: PCCS patients retrieved on V-A ECMO can achieve similar outcomes as those cannulated at experienced centers. An established network in a hub-and-spoke model is critical for the PCCS patients managed at hospitals without ECMO abilities to improve outcomes.

Cardiogenic Shock in Takotsubo Syndrome, a Systematic Review

Background: Takotsubo syndrome is a cardiomyopathy induced by physical or emotional stress, characterized by ventricular apical dilatation, knowledge of the pathophysiological mechanisms of the disease is still incomplete. The most widely accepted hypothesis today is that excess catecholamines cause calcium overload in cardiac myocytes, which leads to interruption of contraction and ventricular function. Material and methods: A synthesis of the available evidence about takotsubo syndrome was carried out through a systematic review type study and the maximum number of articles that reported cases of treatment of this entity was included. For this, specific searches were launched with MESH type keywords. Results: 12 articles were selected. This included a total of 351,124 patients with Takotsubo syndrome, with a mean of 70,224 per study, of whom 5.82% (20,418 of 351,124) were complicated by cardiogenic shock. Among the risk factors associated with cardiogenic shock were found: Use of drugs such as cocaine, peaks of emotional stress, physical stress from surgeries, menopause, hypoglycemia, massive blood loss, hypotension and use of drugs such as atropine, adrenaline, dobutamine, ergonovine, nortriptyline. Conclusion: From the analysis of the results obtained, physical and mental stress are risk factors associated with cardiogenic shock in patients with Takotsubo syndrome, this corresponds to the most accepted hypothesis today that justifies this syndrome with the excess in the production of catecholamines, hormones secreted under stress

Differential Effects of Pharmacologic and Mechanical Support on Right-Left Ventricular Coupling.

Percutaneous ventricular assist devices are increasingly relied on to maintain perfusion for cardiogenic shock patients. Optimal medical management strategies however remain uncertain from limited understanding of interventricular effects. This study analyzed the effects of pharmacologic and left-sided mechanical support on right ventricular function. A porcine model was developed to assess biventricular function during bolus pharmacologic administration before and after left-sided percutaneous ventricular assist and in cardiogenic shock. The presence of mechanical support increased right ventricular load and stress with respect to the left ventricle. This shifted and exaggerated the relative effects of commonly used vasoactive agents. Furthermore, induction of cardiogenic shock led to differential pulmonary vascular and right ventricular responses. Left ventricular ischemia and mechanical support altered interventricular coupling. Resulting impacts of pharmacologic agents indicate differential right heart responses and sensitivity to treatments and the need for further study to optimize biventricular function in shock patients.

Gender-based differences in clinical profile, management and mortality in cardiogenic shock. Prognostic accuracy of CardShock vs IABP Score, the Shock-CAT study

Abstract Funding Acknowledgements None. Background Mortality in cardiogenic shock (CS) remains very high. Gender could influence in aetiology, management, outcomes and risk stratification predictors. Purpose The aim is to analyse differences in clinical profile, management, in-hospital prognosis and mortality risk in CS patients depending on sex and compare the prognostic accuracy of CardShock and IABP scores between sexes in a Mediterranean cohort. Method Shock-CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Spain, including CS patients of different aetiologies. Data on clinical presentation, biomarkers, management, including mechanical cardiac/circulatory support (MCS) were analysed comparing women and men. Cardshock and IABP score have been compared to assess 90-days mortality risk between sexes. Results A total of 382 CS patients (p) were included: women 24.9% (n=95 p) and men 75.1% (n=287p). Women were older than men (68.9 vs 64.1 years, P=0.004). CS due to acute coronary syndrome (ACS) was more frequent in men (66.6% vs 43.2%), and myocarditis (1.7 vs 6.3%), stress cardiomyopathy (0.3% vs 8.4%) and severe aortic stenosis (2.4% vs 6.3%) were more prevalent in women, all p&amp;lt;0.001. Cardiac arrest was more prevalent in men than women (38.4% vs 25.3%, p=0.020). MCS was implanted in 35.3% of patients, without gender differences (men 36.6%, women 31.6%, p=0.376). Even though there was a non-significant trend to lower use in women of IABP (31.1% vs 26.5%), Impella (13.5% vs 7.4%) or ECMO (10.4% vs 7.4%). Risk scores were similar between sexes: Cardshock (men:4.32 vs 4.40 women, p=0.674) and IABP score (men: 2.31 vs 2.04 women, p=0.190). There were no differences between men and women in in-hospital mortality (32.4% vs 34.7%, p=0.675) or 6-months mortality (41.5% vs 40%, p=0.989). Receiver-operating characteristic curves demonstrated that IABP shock score had superior prognostic power for predicting 90-days mortality when compared with Cardshock score in men (area under the curve -AUC- 0.72 vs 0.64) respectively, p=0.009, although both scores were similar in women (AUC 0.70 vs 0.72, p=0.635), Figures 1-2. Conclusions Women with CS were older than men and had less ACS and cardiac arrest at admission. There is a non-significant lower use of mechanical assistance devices in women, although in-hospital or 6-months mortality were similar in both sexes. IABP score provided better 90-days mortality risk prediction than CardShock score in men, but both scores were similar in women with cardiogenic shock.Men ROC Curves 90-days MortalityWomen ROC Curves 90-days Mortality

Respiratory support modalities in cardiogenic shock: insights from a prospective multicenter registry

Abstract Funding Acknowledgements None. Background Respiratory support is a vital component of the comprehensive management of cardiogenic shock (CS). However, there is a lack of data comparing the application of different respiratory support modalities in CS patients. Purpose Aim of this study was to examine the use of low-flow oxygen (LFO), non-invasive ventilation (NIV), and invasive mechanical ventilation (IMV) in a cohort of CS patients and assess their effects on 60-day mortality. Methods We analyzed a cohort of CS patients enrolled in a multicenter prospective registry from twelve cardiac intensive care units from March 2020 to August 2022. Patients were categorized according to the maximum intensity of respiratory support during intensive care unit stay into three groups: LFO, NIV, and IMV. Clinical characteristics and mortality were compared between groups. Results A total of 375 patients were included in our analysis. The median age of the population was 65 years, with 77% being males. During their ICU stay, 139 patients (37%) received LFO, 61 (16%) were treated with NIV, and 175 (47%) underwent IMV. Patients treated with IMV presented more frequently with cardiac arrest (41% vs 8% in the LFO group and 5% in the NIV group, p = 0.00). Patients treated with LFO and NIV had a higher prevalence of CS related to acute decompensated heart failure (40% and 57% vs 21% in the IMV group, p = 0.00); moreover, they presented with less severe respiratory distress, milder tissue hypoperfusion, and better SCAI class upon admission. At sixty days follow-up 128 patients (34%) died: 41% in the IMV group, 28% in the LFO group and 26% in the NIV group (p = 0.02). Multivariate analysis revealed that NIV was independently associated with improved survival (OR 0.47, 95% CI 0.22-0.99, p = 0.05), while age, lactate levels, and glomerular filtration rate were predictors of mortality. A tendency towards improved survival with NIV was observed even after excluding patients with cardiac arrest. Conclusions Compared to previous registries, our study highlights a significant shift in the management of CS, marked by a growing preference for NIV. Notably, this approach, when employed in well-selected patients in the early stages of CS, correlates with lower mortality rates. These findings underscore the significance of personalized treatment strategies for CS patients, considering their clinical presentation, the degree of respiratory distress, and tissue perfusion.60-day survival curvesMultivariate regression analysis

Use of Levosimendan in patients with INTERMACS 3 profile: weaning from inotropic support and short- to medium-term evolution

Abstract Funding Acknowledgements None. Introduction Patients with advanced heart failure (HF) in cardiogenic shock (CS) present a markedly high mortality rate. For CS patients dependent on inotropes, management is difficult with few therapeutic options available, especially in the absence of a suitability for heart transplantation (HTX) or left ventricular assist device implantation (LVAD), thus associating an even worse prognosis. Purpose With our study we aim to analyse the rate of weaning from inotropic support when Levosimendan, a calcium sensitizer with positive inotropic effects, is used in INTERMACS 3 CS patients and their short to medium-term evolution. We then evaluate if the absence of right ventricular dysfunction, of renal dysfunction, non-ischemic aetiology and QRS width could be predicting factors of a successful weaning from inotropes. Materials and methods We conducted a monocentric retrospective analysis of patients from a tertiary cardiac intensive care unit that have received a 24 hours Levosimendan infusion in the context of INTERMACS 3 cardiogenic shock between August 2015 – April 2023. Results Of the 137 subjects included in the analysis, 62 patients received Levosimendan for INTERMACS 3 CS. The median age was 59±15.3 and 91.9% (n=57) were male. Baseline LVEF was 19±6%, cardiac index 1.67±0.4L/min/m2, median NTproBNP 13 378 ± 11 126ng/L. 51.6% (n=32) had ischemic heart disease and 40.3% (n=25) had dilated cardiomyopathy. After Heart Team discussion, only 37% (n=23) were considered eligible for HTX or LVAD. Successful inotrope weaning was experienced in 68% (n=42). Amongst patients with weaning failure, most outcomes resulted in either death (45%), ambulatory continuous Dobutamine infusion (30%), or benefited from a HTX if eligible (15%). The weaning failure rates were similar amongst patients eligible and non-eligible to HTX or LVAD with different outcomes after weaning failure as shown in Figure 1. The overall survival rates at 1 month and 6 months were of 83.8% and 53.2% respectively, with a significant difference between survival rates according to inotrope weaning success or failure as shown in Figure 2. We found no clinical, biological, or echocardiographic parameter to be significantly associated with an increased probability of weaning. Conclusion Levosimendan use in INTERMACS 3 CS patients provides a good rate of success in weaning from inotropic support and could be a useful tool in allowing treatment optimization and stabilization in non HTX or LVAD eligible patients, as well as being a "bridge to transplantation" alternative. No predicting factors for successful weaning have been identified.

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.

Cardiogenic shock following ST-segment elevation myocardial infarction in women: complications and outcomes

Abstract Funding Acknowledgements None. Background Differences in women’s prognosis have been described for both ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS). These might reflect asymmetries in clinical management, but also gender-specific comorbidities and pathologic mechanisms. Purpose We aimed to evaluate the risk of in-hospital complications and mid-term outcomes of women with CS following STEMI. Methods We retrospectively studied STEMI patients treated by primary percutaneous coronary intervention (PCI) from 2008 to 2017 in a tertiary care centre, presenting or evolving in Killip class IV (defined as cardiogenic shock or hypotension and organ hypoperfusion). Clinical and demographic characteristics, as well as complications and outcomes, were collected. Major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up was a composite of death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization. Results Among 1131 patients presenting with STEMI, our study included 117 (10.3%) patients in CS, of which 40 (34.2%) were women. Women were older [71.8(±13.4) vs 64.6(±11.72) years, p=0.002] and less frequently smokers (25.0% vs 50.7%, p=0.008). Prevalence of classic cardiovascular risk factors, namely diabetes (34,1% vs 39.2%, p=0.860), hypertension (71.5% vs 60.8%, p=0.212), and dyslipidaemia (47.5% vs 70.0%, p=0.799), was the same for both groups. Body mass index was also similar [26.6(±5.2) vs 26.1(±3.4) kg/m2, p=0.539]. Women had lower haemoglobin [12.4(±1.9) vs 13.8(±1.9) g/dl, p&amp;lt;0.001] and lower creatinine clearance at admission [52.4(±30.6) vs 67.3(±29.4) ml/min, p=0.017]. Door-to-balloon times [80(59-180) vs 68(48-105) min, p=0.302], total ischemic time [210(120-360) vs 203(120-476) min, p=0.302] and prevalence of anterior STEMI (35.0% vs 50.0%, p=0.123) were not significantly different between sexes. The prevalence of in-hospital complications was generally similar for both sexes (Table 1), except for the risk of advanced atrioventricular (AV) block that was higher in women (32.5% vs 10.7%, p=0.004). Also, haemoglobin nadir was lower in women [10.6(±2.1) vs 11.7(±2.1) g/dl, p=0.023]. In a 1-year follow-up, the occurrence of MACCE was similar for both sexes (60.0% vs 59.7%, log-rank P 0.734) (Figure 1). Conclusion Women with STEMI complicated by CS submitted to PCI had a similar prevalence of in-hospital complications as men. Also, mid-term outcomes, assessed by MACCE at 1 year, did not differ between groups.

Acute heart failure in patients with valvular infective endocarditis: a one-year consecutive cohort from a Spanish tertiary centre

Abstract Funding Acknowledgements None. Background Infective endocarditis (IE) is associated with substantial morbidity and mortality. Acute decompensated heart failure (AHF) is a frequent complication of IE and it is often an indication for urgent cardiac surgery. Purpose The aim of this study was to describe clinical data and short term outcomes of patients admitted for valvular IE complicated with AHF. Methods We collected data from all the patients with IE admitted or referred to our Spanish tertiary centre from September 1st, 2022 to August 31st, 2023. Patients with non-valvular IE were not included. Results Two patients did not consent to participate in the study. 87 consenting patients were included. Of them, 38 (44%) presented with AHF, of whom 14 (16.1%) had acute pulmonary oedema, and 6 (6.9%) suffered cardiogenic shock. Mean age was 67.4 years old in the AHF group vs 64.0 in patients without AHF (non significant), 74% of male sex in both groups, Charlson Comorbidity Index of 4.9 vs 5.6 points (n.s.); prosthetic-valve endocarditis was more frequent in the AHF group compared to patients without AHF (42% vs 28%, p &amp;lt; 0.05). Urgent cardiac surgery was indicated in 91% of patients with AHF vs 44% of patients without heart failure (p &amp;lt; 0.01); when indicated, surgery was eventually performed in 65% vs 57% of the patients (n.s.). In AHF patients with surgical indication, in-hospital mortality rate was significantly higher in those that did not undergo surgery (64% vs 16%, p &amp;lt; 0.01). Compared to native-valve IE, prosthetic-valve IE was associated with higher rates of AHF (42% vs 28%, p &amp;lt; 0.05). In-hospital mortality rate was significantly higher in AHF patients (33.3% vs 3.0%, p &amp;lt; 0.01). Acute pulmonary oedema and cardiogenic shock patients had the highest in-hospital mortality (respectively, 43% and 67%). Similarly, mortality rate 30 days after hospital discharge was higher in the AHF group (16.0% vs 6.3%, p &amp;lt; 0.05). Conclusions In this population, presentation with AHF was associated with worse short-term outcomes. Surgery was indicated in the majority of AHF patients, and not performing it was associated with worse outcome.

Impella vs Veno-arterial extracorporeal membrane oxygenation in cardiogenic shock: a systematic review and meta-analysis of propensity score matched studies

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abiomed Singapore PTE. Ltd. Background/Introduction Cardiogenic shock is a life-threatening condition associated with multi-organ failure and death. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is well-established in the management of cardiogenic shock; however, mortality rates have remained relatively consistent over the past two decades. Impella is a transluminal microaxial ventricular assist device that improves haemodynamics by unloading the left ventricle and represents an alternative to VA-ECMO. No randomised controlled trials exist to date comparing Impella versus VA-ECMO given difficulties in recruiting patients due to the acute nature of the condition. Whilst a plethora of non-randomised, comparative studies have been published, many are confounded by underlying differences in baseline disease characteristics. Propensity score matched / adjusted studies may mitigate confounding by accounting for differences in important covariates that impact outcomes. Purpose The objective of this study was to conduct a systematic review and meta-analysis of propensity score matched / adjusted studies to assess the clinical outcomes of Impella versus VA-ECMO in cardiogenic shock patients. Methods A systematic review was undertaken to identify all comparative studies of Impella and VA-ECMO in cardiogenic shock which performed propensity score matching / adjustment of outcomes to account for important covariates. The study limitations were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach. In-hospital/30-day survival and bleedings requiring transfusion were meta-analysed using the random effects method. Results Six propensity score matched / adjusted studies comparing Impella versus VA-ECMO in cardiogenic shock were included in the meta-analysis. A statistically significant difference in in-hospital/30-day mortality was detected between patients treated with Impella (39.6%) versus VA-ECMO (53.8%) (odds ratio [OR] 95% confidence interval [95% CI]: 0.57 [0.44, 0.74]; p&amp;lt;0.0001). Similarly, Impella (19.9%) was associated with statistically significantly fewer bleeding events requiring transfusion compared with VA-ECMO (28.8%) (OR=0.61 [0.46, 0.80]; p=0.0004). Conclusion(s) This systematic review identified no randomised controlled trials of Impella versus VA-ECMO. The meta-analysis of propensity matched observational trials, represents the highest level of evidence available to date, and suggests that Impella may be associated with increased survival rates and decreased bleeding. Randomised controlled trials are urgently needed to assess cardiac support modalities in cardiogenic shock.

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.

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.

VA-ECMO weaning strategy using adjusted pulse pressure by vasoactive inotropic score in AMI complicated by cardiogenic shock.

This study evaluated how well serial pulse pressure (PP) and PP adjusted by the vasoactive inotropic score (VIS) predicted venoarterial extracorporeal membrane oxygenation (VA-ECMO) weaning success and clinical outcomes in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) patients. A total of 213 patients with AMI-CS who received VA-ECMO between January 2010 and August 2021 were enrolled in the institutional ECMO registry. Serial PP and VIS were measured immediately, 12, 24, and 48h after VA-ECMO insertion. PP adjusted by VIS was defined as PP/√VIS. The primary outcome was successful VA-ECMO weaning. Successful weaning from VA-ECMO was observed in 151 patients (70.9%). Immediately after VA-ECMO insertion, PP [successful vs. failed weaning, 26.0 (15.5-46.0) vs. 21.0 (12.5-33.0), P=0.386] and PP/√VIS [11.1 (5.1-25.0) vs. 6.0 (3.1-14.2), P=0.118] did not differ between the successful and failed weaning groups. Serial PP and PP adjusted by VIS at 12, 24, and 48h after VA-ECMO insertion were significantly higher in patients with successful weaning than those with failed weaning [successful vs. failed weaning, 24.0 (4.0-38.0) vs. 12.5 (6.0-25.5), P=0.007 for 12h PP, and 10.1 (5.7-22.0) vs. 2.9 (1.7-5.9), P<0.001 for 12h PP/√VIS]. The 12h PP/√VIS showed better discriminative function for successful weaning than 12h PP alone [area under the curve (AUC) 0.80, 95% confidence interval (CI) 0.72-0.88, P<0.001 vs. AUC 0.67, 95% CI 0.57-0.77, P=0.002]. Patients with a low 12h PP/√VIS (≤7) had higher rates of in-hospital mortality (44.4% vs. 19.8%, P<0.001) and 6month follow-up mortality (hazard ratio 2.41, 95% CI 1.49-3.90, P<0.001) than those with a high 12h PP/√VIS (>7). PP adjusted by VIS taken 12h following VA-ECMO initiation can predict weaning from VA-ECMO more successfully than PP alone, and its low value was associated with a higher risk of mortality in AMI-CS patients.

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.

De-escalating treatments and transitioning care in a cardiac intensive care units network

Abstract Funding Acknowledgements None. Background Recent data (1) have shown that end-of-life (EOL) management of patients with acute decompensated heart failure (ADHF) in Cardiac Intensive Care Units (CICU) is aggressive, with late or no involvement of palliative care (PC) teams. Purpose To evaluate current PC and EOL practices in a contemporary multicenter registry of patients with ADHF who deteriorated to cardiogenic shock (CS). Methods A survey-based approach was used to collect data on PC and EOL management practices. We enrolled CS patients from 12 participating centers. A subset of 153 patients with ADHF-CS, enrolled between March 2020 and March 2023, was analyzed. We asked participating centers to report their practice regarding de-escalating treatments and transitioning care in the context of EOL, focusing on 1) discussion of implantable cardioverter defibrillator (ICD) deactivation with patients, 2) documentation of do-not-resuscitate (DNR) orders in the patient's medical record, and 3) documentation of advance directives in the patient's medical record. We also examined early PC team involvement and ICD deactivation as indicators of de-escalating treatments and transitional care in ADHF-CS. Results are presented as numbers and percentages (%) for categorical variables and medians (interquartile range, IQR) for continuous variables. Results Baseline characteristics of the population are shown in Table 1. Figure 1 describes the practices of the participating centers. DNR was routinely documented in the medical records in only 5 of 12 centers (41.7%). PC teams were involved in 21 of 153 enrolled ADHF-CS patients (13.7%). Of the 51 patients with an ICD, 17 died: 13 patients (76%) died in the hospital and 4 (24%) died within 6 months of discharge. ICD deactivation occurred in 6 of 17 deceased patients (35.3%). One patient had ICD deactivation supported by home PC services. Conclusions This study shows that the practice of de-escalating therapy, including ICD deactivation, is not routine in the participating centers. Our findings highlight the importance of integrating PC as a concurrent process with intensive care to effectively address the unmet needs of these patients and their families.

Cardiogenic shock in general intensive care unit: a nationwide prospective analysis of epidemiology and outcome

Abstract Funding Acknowledgements None. Background Cardiogenic shock (CS) is a heterogenous, life-threatening disease burdened by a mortality up to 50%. An increasing incidence of the CS related to other etiological causes, including acute decompensated heart failure, has been reported. However, most of the epidemiological data are derived from patients admitted to dedicated acute cardiac care units. Epidemiology and management of CS patients admitted to general intensive care unit (ICU) in Italy is yet unexplored. Purpose To describe the epidemiology, patients feature, management and outcome of CS patients admitted to Italian general ICUs. Methods Prospective multicentric epidemiological study. Over 600 thousand patients admitted to 316 hundred Italian general intensive care units from 2011 to 2018 were screened trough PROSAFE software. The Margherita PROSAFE project is an observational project for the continuous electronic collection of data on patients admitted to ICUs; it is developed by the GiViTI (Gruppo italiano per la valutazione degli interventi in terapia intensiva - Italian Group for the Evaluation of Interventions in Intensive Care Medicine). The primary outcome of the analysis was hospital mortality. Secondary outcomes included description of patients features and management. Results 11661 patients (72.1±12.1 years old.; 39.5% women) with a diagnosis of CS were included in the analysis. ICU and in-hospital mortality were respectively 45.5 % and 53.9%. Highest mortality was observed for pulmonary embolism (58.4%), right heart failure (56.3%) and acute decompensated heart failure (ADHF) (44.2%). 46.9% of patients presented with more than 3 organ failure (panel A). CS commonest aetiologies were ADHF (63,3%), acute myocardial infarction (19.8%) and right heart failure (11%). Invasive mechanical ventilation was used in the 88.6% of cases. Intra-aortic balloon pump was placed in 15.2%, with higher frequency in ischemic aetiologies (43.9%) and ADHF (13.7%); VA-ECMO was most frequently placed in the right heart failure (3.7%) and acute myocardial infarction (2.6%) groups. The factors independently associated with increased hospital mortality were increasing age (p &amp;lt;0.001), lower Glasgow coma scale (p &amp;lt;0.001), hypoxemia (PaO2 &amp;lt;100, OR: 1.91; 95% Cl: 1.58 – 2.3; p &amp;lt;0.001), bradycardia (OR: 1.84; 95% Cl: 1.49 – 2.26; p &amp;lt;0.001), hypotension (OR: 1.27; 95% Cl: 1.12 – 1.43; p &amp;lt;0.001), bilirubin above 12 mg/dl (OR: 7.90; 95% Cl: 2.56 – 24.3), increased creatinine (p &amp;lt;0.001) and reduced platelets (&amp;lt;50000 U/mL, OR: 2.43; 95% Cl: 1.78 – 3.31; p &amp;lt;0.001) (panel B). Curiously, in the predictive model a BMI above normal values was protective as well as tachycardia compared to severe bradycardia (panel C). Conclusions The etiology of CS in general intensive care units is heterogeneous with acute heart failure being the commonest. The mortality rate remains unacceptably high with right heart failure and acute heart failure being burden by the worst outcome.

D-12 | Single Center Outcomes of Patient in Cardiogenic Shock after Implementation of a Cardiogenic Shock Program

D-12 | Single Center Outcomes of Patient in Cardiogenic Shock after Implementation of a Cardiogenic Shock Program