Patients In Refractory Cardiogenic Shock Research Articles

Outcomes Of Refractory Cardiogenic Shock Patients Supported By Impella 5.5: Single Center Experience

Outcomes Of Refractory Cardiogenic Shock Patients Supported By Impella 5.5: Single Center Experience

Influence of Venoarterial Extracorporeal Membrane Oxygenation Integrated Hemoadsorption on the Early Reversal of Multiorgan and Microcirculatory Dysfunction and Outcome of Refractory Cardiogenic Shock.

Background: The purpose of this investigation was to evaluate the impact of venoarterial extracorporeal membrane oxygenation (VA−ECMO) integrated hemoadsorption on the reversal of multiorgan and microcirculatory dysfunction, and early mortality of refractory cardiogenic shock patients. Methods: Propensity score−matched cohort study of 29 pairs of patients. Subjects received either VA−ECMO supplemented with hemoadsorption or standard VA−ECMO management. Results: There was a lower mean sequential organ failure assessment score (p = 0.04), lactate concentration (p = 0.015), P(v−a)CO2 gap (p < 0.001), vasoactive inotropic score (p = 0.007), and reduced delta C−reactive protein level (p = 0.005) in the hemoadsorption compared to control groups after 72 h. In−hospital mortality was similar to the predictions in the control group (62.1%) and was much lower than the predicted value in the hemoadsorption group (44.8%). There were less ECMO-associated bleeding complications in the hemoadsorption group compared to controls (p = 0.049). Overall, 90-day survival was better in the hemoadsorption group than in controls without statistical significance. Conclusion: VA−ECMO integrated hemoadsorption treatment was associated with accelerated recovery of multiorgan and microcirculatory dysfunction, mitigated inflammatory response, less bleeding complications, and lower risk for early mortality in comparison with controls.

Anticoagulant management for transition from failed thrombolysis to extra-corporeal membrane oxygenation in patients with high-risk pulmonary embolism: A thoughtful approach

Acute venous thromboembolism represents a spectrum of clinical syndromes of which high-risk pulmonary embolism (PE) with consecutive right ventricular failure and cardiogenic shock (CS) is the most severe presentation. First-line treatment options are surgical pulmonary embolectomy, systemic thrombolysis or catheter-based therapies. The role of mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is multifarious in this setting and can be considered as either a bridge to pulmonary artery reperfusion by any of the aforementioned options or as salvage bridge intervention for patients in refractory CS after failure of another treatment. In the subpopulation of patients that are placed on V-A-ECMO after failed thrombolysis, the mortality rates are among the highest, partially due to the high rates of bleeding events. The challenges in the interpretation of anticoagulant monitoring and, consequently, the titration of anticoagulation at least contribute to this high mortality. Here, we discuss the strengths and limitations of different anticoagulant parameters in this setting and propose an approach based on monitoring of Heparin anti-factor Xa (anti-Xa) assay and activated partial thromboplastin time (APTT) in parallel to drive unfractionated heparin (UFH) titration in patients with high-risk PE after fibrinolysis during the first 24 h on V-A-ECMO.

PRospective REgistry of PAtients in REfractory cardiogenic shock-The PREPARE CardShock registry.

AimCardiogenic shock (CS) is a hemodynamically complex multisystem syndrome associated with persistently high morbidity and mortality. As CS is characterized by progressive failure to provide adequate systemic perfusion, supporting end‐organ perfusion using mechanical circulatory support (MCS) seems intriguing. Since most patients with CS present in the catheterization laboratory, percutaneously implantable systems have the widest adoption in the field. We evaluated feasibility, outcomes, and complications after the introduction of a full‐percutaneous program for both the Impella CP device and venoarterial extracorporeal membrane oxygenator (VA‐ECMO).MethodsPREPARE CardShock (PRospective REgistry of PAtients in REfractory cardiogenic shock) is a prospective single‐center registry, including 248 consecutive patients between May 2019 and April 2021, who underwent cardiac catheterization and displayed advanced cardiogenic shock. The median age was 70 (58–77) years and 28% were female. Sixty‐five percent of the cases had cardiac arrest, of which 66% were out‐of‐hospital cardiac arrest. A local standard operating procedure (SOP) indicating indications as well as relative and absolute contraindications for different means of MCS (Impella CP or VA‐ECMO) was used to guide MCS use. The primary endpoint was in‐hospital death and secondary endpoints were spontaneous myocardial infarction and major bleedings during the hospital stay.ResultsOverall mortality was 50.4% with a median survival of 2 (0–6) days. Significant independent predictors of mortality were cardiac arrest during the index event (odds ratio [OR] with 95% confidence interval [CI]: 2.53 [1.43–4.51]; p = 0.001), age > 65 years (OR: 2.05 [1.03–4.09]; p = 0.036]), pH < 7.30 (OR: 2.69 [1.56–4.66]; p < 0.001), and lactate levels > 2 mmol/L (OR: 4.51 [2.37–8.65]; p < 0.001).ConclusionsConclusive SOPs assist target‐orientated MCS use in CS. This study provides guidance on the implementation, validation, and modification of newly established MCS programs to aid centers that are establishing such programs.

Time course and prognostic impact of venoarterial extracorporeal membrane flow throughout cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: None. Background In VA-ECMO supported patients because of refractory cardiogenic shock (CS), there is a lack of evidence on what is the "optimal" ECMO flow. Purpose To describe the evolution of VA-ECMO flow in a CS population according to the degree of support and analyze the impact of early high-ECMO flows on short-term outcomes. Methods We performed a retrospective, single-center study including patients in refractory CS supported with peripheral VA-ECMO admitted at an University Hospital. Based on the median flow over the first 48 hours of ECMO run, patients were classified as "high-flow" or "low-flow" when median ECMO flow was ⋝ or &amp;lt; than 3.6 L/min, respectively. All statistical tests were two-sided, with a p value ≤ 0.05 considered significant. Results Two hundred and nine patients were included. Median age was 51 (40-59) years, 78% were males, and the median SAPS II was 51 (32 - 66). The most frequent etiology leading to CS was end-stage-dilated cardiomyopathy (57%). "High-flow" and "low-flow" groups each represented 50% of the study population, respectively (Figure 1). Median flows between both groups were continuously lower in "low-flow" patients at any time-point, with the "low-flow" group maintaining VA-ECMO flows around 3.0-3.1 L/min. The "high-flow" group had a higher frequency of ischemic etiology and was significantly sicker at admission. Almost 70% of the study population was managed with LV unloading. More than 40% of patients were managed with an awake strategy, with much higher rates of awake ECMO in the "low-flow" group (52% vs 30%, p&amp;lt;0.001). Patients with "high-flow" had 50% more VAP than "low-flow" patients and median days on mechanical ventilation were significantly less in the "low-flow" group (4 [1.5 - 7.5] vs 6 [3 - 12] days, p=0.009, respectively). No differences were either found in total days in ICU or days of hospitalization. Finally, global in-hospital mortality was 46%, with less but not statistically significant differences in the "low-flow" group (41% vs 51%, p=0.144, respectively). Mortality at 60-days were alike for both groups. Conclusions In patients with refractory CS supported with VA-ECMO, sicker patients were managed with higher degree of support from early phases. Patients with high flows presented with higher rates of VAP, but presented similar in-hospital and short-term survival compared to patients with lower flows. Future research is now warranted to address the specific, direct, impact of higher flows in lung injury or length of MV.

Abstract 12994: Invasive Left Atrial Pressure Monitoring and Survival on Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Introduction: Elevated left atrial pressures (LAP) are associated with worse outcomes among patients with cardiogenic shock (CS), yet there are limited data on the utility of continuous invasive monitoring of LAPs on outcomes for CS. This is additionally true among refractory CS patients on peripheral VA ECMO, which itself can increase arterial afterload. Hypothesis: Our objective was to determine whether invasive LAP monitoring impacts survival for patients with refractory CS after 24 hours of VA ECMO support. Methods: We performed a cohort analysis among 10,906 patients ≥18yrs of age from the Extracorporeal Life Support Organization (ELSO) Registry from 2015 - 2020, with refractory CS treated with VA ECMO. The presence of invasive LAP monitoring was defined as either pulmonary capillary wedge pressure (PCWP) or pulmonary arterial diastolic pressure (PAD) values at 24 hours on VA ECMO. The exposure was measurement of LAPs at 24 hours on VA ECMO support, and the primary outcome was 30 day survival. We performed Kaplan Meier survival analysis, adjusting for age, PaO2/FiO2, pH, SCAI classification stage prior to ECMO, presence of a pre-ECMO cardiac arrest, mean arterial blood pressure on ECMO and year. Results: Median age of patients was 57 [IQR,46; 65] years with 31% females. Thirty two percent (n=3,465) presented with acute myocardial infarction, 29% (n=3,112) with acute heart failure and 1% (n=965) with both etiologies. Invasive LAP monitoring at 24 hours was performed in 33% (n=3608) of patients. The use of invasive LAP was associated with lower mortality (adjusted Hazard Ratio 0.88 [95% CI 0.81 to 0.95]; p=0.002). Conclusions: Implementation of invasive LAP monitoring may be associated with higher adjusted hospital survival in patients with refractory CS requiring VA-ECMO support. These findings merit further investigation and prospective validation to assess the relationship between invasive hemodynamic monitoring and outcomes in this patient population.

Awake venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock.

Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is currently one of the first-line therapies for refractory cardiogenic shock (CS), but its applicability is undermined by the high morbidity associated with its complications, especially those related to mechanical ventilation (MV). We aimed to assess the prognostic impact of keeping patients in refractory CS awake at cannulation and during the VA-ECMO run. A 7-year database of patients given peripheral VA-ECMO support was used to conduct a propensity-score (PS)-matched analysis to balance their clinical profiles. Patients were classified as 'awake ECMO' or 'non-awake ECMO', respectively, if invasive MV was used during ≤50% or >50% of the VA-ECMO run. Primary outcomes included ventilator-associated pneumonia and ECMO-related complication rates, and secondary outcomes were 60-day and 1-year mortality. A multivariate logistic-regression analysis was used to identify whether MV at cannulation was independently associated with 60-day mortality. Among 231 patients included, 91 (39%) were 'awake' and 140 (61%) 'non-awake'. After PS-matching adjustment, the 'awake ECMO' group had significantly lower rates of pneumonia (35% vs. 59%, P = 0.017), tracheostomy, renal replacement therapy, and less antibiotic and sedative consumption. This strategy was also associated with reduced 60-day (20% vs. 41%, P = 0.018) and 1-year mortality rates (31% vs. 54%, P = 0.021) compared to the 'non-awake' group, respectively. Lastly, MV at ECMO cannulation was independently associated with 60-day mortality. An 'awake ECMO' management in VA-ECMO-supported CS patients is feasible, safe, and associated with improved short- and long-term outcomes.

Prognostic implication of risk scoring systems in patients with cardiogenic shock supported by ECMO and Impella.

We experienced two refractory cardiogenic shock patients receiving veno-arterial extracorporeal membrane oxygenation and Impella percutaneous left ventricular assist device (ECPELLA). TVAD score, which was originally proposed to predict one-year mortality following left ventricular assist device implantation using four objective parameters, was retrospectively calculated using data of day 3 following ECPELLA initiations. One patient with estimated intermediate risk could achieve successful explantation of ECPELLA, whereas another patient with estimated high risk was expired despite explantation of extracorporeal membrane oxygenation. TVAD score might be a useful tool to risk stratify and construct next strategy (i.e., bridge to recovery or bridge to more intensive therapy) for those with ECPELLA, although further studies are warranted to validate this hypothesis.

Clinical predictors of in-hospital mortality in venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is utilized as a life-saving procedure and bridge to myocardial recovery for patients in refractory cardiogenic shock. Despite technical advancements, VA-ECMO retains high mortality. This study aims to identify the clinical predictors of in-hospital mortality after VA-ECMO to improve risk stratification for this tenuous patient population. The REgistry for Cardiogenic Shock: Utility and Efficacy of Device Therapy database is a multicenter, observational registry of ECMO patients. From 2013 to 2018, 789 patients underwent VA-ECMO. Bivariate analysis was performed on more than 300 variables regarding their association with in-hospital mortality. Logistic regression analyses were performed with variables chosen based upon clinical and statistical significance in the bivariate analysis. Tests were considered significant at a two-sided P < .05. Although 63.5% patients were successfully weaned from VA-ECMO, in-hospital mortality was 57.9%. Nonsurvivors were older (P < .0001), had higher body mass index (P = .01), higher rates of hypertension (P = .02), coronary artery disease (P = .02), chronic obstructive pulmonary disease (P = .02), chronic liver disease (P = .008), percutaneous coronary intervention (P = .02), and surgical revascularization (P = .02). Multivariate predictors for in-hospital mortality include older age (odds ratio [OR], 1.019; P = .007), cardiac arrest (OR, 2.76; P = .006), chronic liver disease (OR, 8.87; P = .04), elevated total bilirubin (OR, 1.093; P < .0001), and the presence of a left ventricular vent (OR, 2.018; P = .03). Pre-ECMO sinus rhythm was protective (OR, 0.374; P = .006). In a large study of recent VA-ECMO patients, in-hospital mortality remains significant, but acceptable given the severe pathology manifested in this population. Identification of pre-ECMO predictors of mortality helps stratify high-risk patients when deciding on ECMO placement, prolonged support, and prognosis.

Initial outcomes of a multidisciplinary network for the care of patients with cardiogenic shock

Introduction and objectivesMortality remains high in cardiogenic shock (CS), especially in refractory CS involving the use of mechanical circulatory support (MCS) devices. The aim of this study was to analyze the results of a care program for patients in CS after the creation of a multidisciplinary team in our center and a regional network of hospitals in our area. MethodsObservational and retrospective study of patients attended in this program from September 2014 to January 2019. We included patients in refractory CS who required MCS and those who, because of their age and absence of comorbidities, were candidates for advanced therapies. The primary endpoint was survival to discharge. ResultsA total of 130 patients were included (69 local and 61 transferred patients). The mean age was 52±15 years (72% men). The most frequent causes of CS were acute decompensated heart failure (29%), acute myocardial infarction (26%), and postcardiotomy CS (25%). MCS was used in 105 patients (81%), mostly extracorporeal membrane oxygenation (58%). Survival to discharge was 57% (74 of 130 patients). The most frequent destinations were myocardial recovery and heart transplant. Independent predictors of in-hospital mortality were SAPS II score, lactate level, acute myocardial infarction etiology, and vasoactive-inotropic score. ConclusionsThe creation of multidisciplinary teams for patients with mainly refractory CS and a regional network is feasible and allows survival to discharge in more than a half of attended patients with CS.

Resultados iniciales de un programa multidisciplinario de atención a pacientes en shock cardiogénico en red

Introduction and objectivesMortality remains high in cardiogenic shock (CS), especially in refractory CS involving the use of mechanical circulatory support (MCS) devices. The aim of this study was to analyze the results of a care program for patients in CS after the creation of a multidisciplinary team in our center and a regional network of hospitals in our area. MethodsObservational and retrospective study of patients attended in this program from September 2014 to January 2019. We included patients in refractory CS who required MCS and those who, because of their age and absence of comorbidities, were candidates for advanced therapies. The primary endpoint was survival to discharge. ResultsA total of 130 patients were included (69 local and 61 transferred patients). The mean age was 52±15 years (72% men). The most frequent causes of CS were acute decompensated heart failure (29%), acute myocardial infarction (26%), and postcardiotomy CS (25%). MCS was used in 105 patients (81%), mostly extracorporeal membrane oxygenation (58%). Survival to discharge was 57% (74 of 130 patients). The most frequent destinations were myocardial recovery and heart transplant. Independent predictors of in-hospital mortality were SAPS II score, lactate level, acute myocardial infarction etiology, and vasoactive-inotropic score. ConclusionsThe creation of multidisciplinary teams for patients with mainly refractory CS and a regional network is feasible and allows survival to discharge in more than a half of attended patients with CS.

Early Escalation of Mechanical Circulatory Support Stabilizes and Potentially Rescues Patients in Refractory Cardiogenic Shock.

Limited progress has been made in the management of cardiogenic shock (CS). Morbidity and mortality of refractory CS remain high. The effects of mechanical circulatory support (MCS) are promising, although many aspects are elusive. We evaluated efficacy and safety of early combined MCS (Impella microaxial pump + venoarterial extracorporeal membrane oxygenation [VA-ECMO]) in refractory CS and aimed to determine factors for decision-making in combined MCS. We analyzed 69 consecutive patients with refractory CS from our registry requiring combined MCS. In 12 cases, therapy was actively withdrawn according to patient's will. Patients were severely sick (Survival After Venoarterial ECMO score mean±SD, -8.9±4.4) predicting 30% in-hospital survival; ventilation 94%, dialysis 56%. Impella pumps and VA-ECMO were combined early (duration of combined MCS: median 94 hours; interquartile range, 49-150 hours). Early MCS escalation stabilized patients rapidly, reducing number and doses of catecholamines (P<0.05 versus baseline) while hemodynamics improved. Reflecting an improved microcirculation, lactate levels normalized within 24 hours (P<0.05 versus baseline). Despite refractory CS and disease severity, survival was favorable (on MCS 61%, 30 days 49%, 6 months 40%). In multivariate Cox-regression, duration of shock-to-first device (hours, hazard ratio, 1.05 [95% CI, 1.01-1.08]; P=0.007) and lactate levels after 12 hours of MCS (hazard ratio, 1.28 [95% CI, 1.09-1.51]; P=0.002) independently predicted survival. Additional right ventricular failure predisposed to futility (hazard ratio, 8.48 [95% CI, 1.85-38.91]; P=0.006). The early and consequent combination of MCS by Impella microaxial pumps and VA-ECMO enables stabilization and may rescue high-risk patients with refractory CS at low overall risk. Independent predictors of survival may guide prognostication, decision-making, and allocation of medical resources.

Bridging INTERMACS 1 patients from VA-ECMO to LVAD via Impella 5.0: De-escalate and ambulate

PurposeVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) stabilizes patients in refractory cardiogenic shock. However, ECMO-related complications strongly affect the outcome, especially if a long-term LVAD is needed. Methods and materialsWe describe a new strategy in management of INTERMACS 1 patients consisting in early weaning from VA-ECMO with axillary Impella 5.0 as a bridge to LVAD implantation. Nine patients in two European centres are described. ResultsAll patients were implanted with VA-ECMO for initial hemodynamic and metabolic stabilization. After a median time of 8 days, Impella 5.0 was implanted. Impella support allowed in all patients weaning from inotropes and from VA-ECMO (after a median time of 22 h). No patients had right ventricular failure after ECMO-weaning and most patients were mobilized and orally fed (88.9%) during Impella support. All patient underwent LVAD implantation after a median Impella time of 17 days. Only one patient had right-ventricular failure after LVAD implantation. All patients were discharged from hospital after a median time of 40 days. ConclusionEarly weaning from VA-ECMO with Impella 5.0 as a bridge to LVAD is a safe and effective strategy in management of INTERMACS 1 patients. This approach minimizes ECMO-related complications and allows patient mobilization and right ventricular function optimization before LVAD implantation.

Adverse Event Profile Associated with Prolonged Use of CentriMag Ventricular Assist Device for Refractory Cardiogenic Shock.

Several studies have investigated early outcomes with a surgical short-term ventricular assist device (VAD), but little is known about adverse event profile during prolonged support with a surgical short-term VAD. This is a retrospective analysis of 161 patients who received a CentriMag ventricular assist system (Abbott Laboratories, Abbott Park, IL) at our institution between January 2007 and June 2014. Device-related adverse events include major bleeding, infection, and stroke incidents occurring during CentriMag support. Cumulative frequency of adverse events was estimated by Nelson's nonparametric method. One hundred and forty-three (88.8%) patients had biventricular VAD and 18 (11.2%) had isolated left VAD. Median duration of support was 16 days (interquartile range [IQR]: 10-29). Mortality was 24.8% and 1 year overall survival is 51.8% (95% CI: 43.3-59.5%). The most common adverse event during support was major bleeding (n = 121, 75.1%). Ninety-five (59.0%) developed major infections such as pneumonia and urinary tract infection. Sixteen patients (10%) experienced stroke. Cumulative data analysis showed that stroke and reoperation caused by bleeding were rare beyond 30 days, whereas infection and nonsurgical bleeding events were directly related to support time. In conclusion, temporary VAD with CentriMag support is an effective treatment for patients in refractory cardiogenic shock. Despite its side effect, profile including a high rate of blood transfusion early in the immediate postoperative period of CentriMag support, aggressive use of the CentriMag support device has acceptable survival to discharge and 1 year survival.

Impact of Veno-Arterial Membrane Oxygenation on Outcome of “Crash and Burn” Patients Transitioned to Durable Left Ventricular Assist Device

Purpose To investigate the outcome of patients in refractory cardiogenic shock who required VA ECMO as a bridge to durable LVAD Methods This is a retrospective review of all adult INTERMACS profile 1 patients who underwent LVAD implantation at our institution between 01/01/2015 and 12/31/2017. The outcomes of patients who were bridged with VA ECMO (ECMO group) were compared with those without bridging (non-ECMO group). Results Out of 27 patients, 16 were bridged with VA ECMO. Basic characteristics are presented in Table 1. After the LVAD implantation, patients in the ECMO group experienced more right ventricular failure requiring temporary RVAD (75% vs. 27%, P = 0.014) and more postoperative surgical bleeding (75% vs. 36%, P = 0.045). Hospital mortality was 25% in ECMO and 18% in non-ECMO group (P = 0.675). Of the hospital survivors, 8 were transplanted, 4 recovered, one patient underwent pump exchange and three are still on support. One-year survival for ECMO group was 56 ±18% versus 47 ±20% in non-ECMO group (Figure 1A). Freedom from infection (Figure 1B), neurologic dysfunction (Figure 1C) and device malfunction (Figure 1D) was 47 ±13%, 65 ±20% and 79 ±11% in ECMO group and 44 ±18%, 37 ±22% and 78 ±14% in non-ECMO group. Conclusion Patients in refractory cardiogenic shock have acceptable post LVAD outcome when bridged with percutaneous VA ECMO. Despite significantly higher rate of postoperative surgical bleeding and the need for biventricular support, both overall survival and LVAD-associated complications are comparable to non-ECMO bridged INTERMACS profile 1 LVAD recipients.

Impact of levosimendan on weaning from peripheral venoarterial extracorporeal membrane oxygenation in intensive care unit

BackgroundFew data are available on the impact of levosimendan in refractory cardiogenic shock patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate the impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU).MethodsThis retrospective cohort study was conducted in a French university hospital from 2010 to 2017. All patients hospitalized in ICU undergoing VA-ECMO were consecutively evaluated.ResultsA total of 150 patients undergoing VA-ECMO were eligible for the study. Thirty-eight propensity-matched patients were evaluated in the levosimendan group and 65 in the non-levosimendan group. In patients treated with levosimendan, left ventricular ejection fraction had increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P < 0.0001) and aortic velocity–time integral from 8.9 ± 4 cm to 12.5 ± 3.8 cm (P = 0.002) 24 h after drug infusion. After propensity score matching, levosimendan was the only factor associated with a significant reduction in VA-ECMO weaning failure rates (hazard ratio = 0.16; 95% confidence interval 0.04–0.7; P = 0.01). Kaplan–Meier survival curves showed that survival rates at 30 days were 78.4% for the levosimendan group and 49.5% for the non-levosimendan group (P = 0.02). After propensity score matching analysis, the difference in 30-day mortality between the two groups was not significant (hazard ratio = 0.55; 95% confidence interval 0.27–1.10; P = 0.09).ConclusionsOur results suggest that levosimendan was associated with a beneficial effect on VA-ECMO weaning in ICU patients.

Planned Concomitant Left and Right Ventricular Assist Device Insertion to Avoid Long-term Biventricular Mechanical Support: Bridge to Right Ventricular Recovery

The planned use of a temporary right ventricular assist device (RVAD) at the time of left ventricular assist device (LVAD) implantation may prevent the need for a permanent biventricular assist device (BiVAD). Herein we describe our RVAD weaning protocol that was effectively employed in 4 patients to prevent the need for permanent BiVAD. Four patients in refractory cardiogenic shock underwent planned RVAD insertion during LVAD implantation due to severely depressed right ventricular function with dilation preoperatively. A standardized RVAD weaning protocol was employed in these 4 patients in preparation for decannulation. Temporary RVADs were successfully placed in all 4 patients at the time of LVAD implantation. All patients survived to RVAD decannulation and discharge and were alive at the time of most recent follow-up (range, 528-742 days post-RVAD decannulation). Planned implantation of a temporary RVAD in high risk patients may avoid the need for biventricular mechanical support in the future.

Temporary Right Heart Support Following LVAD Implantation in High Risk Patients with Dual Mechanical Support Combining Veno-arterial ECLS and Impella Microaxial Pump

Objectives: Dual mechanical support combining veno-arterial (VA) ECLS and Impella microaxial pump rescues high-risk patients in refractory cardiogenic shock and biventricular failure. An implantation of a permanent ventricular assist device (VAD) is a life-saving procedure for these patients if cardiac function does not recover under biventricular unloading. However, many questions centering on perioperative right heart failure (RHF) and stabilization of right ventricular function remain elusive. Here, we compared continuation of common VA ECLS via femoral access with a transvenous implantation technique of a temporary right heart bypass (RHB) for patients undergoing LVAD implantation after dual mechanical support.

Selective implantation of durable left ventricular assist devices as primary therapy for refractory cardiogenic shock

ObjectiveSurgical therapy for refractory primary cardiogenic shock is largely based on emergent placement of extracorporeal membrane oxygenation or short-term ventricular assist devices. We have adopted a strategy of routine implantation of durable left ventricular assist devices (LVAD) as initial therapy for refractory cardiogenic shock, in patients who are potential candidates for heart transplantation, and report our experience. MethodsRetrospective review of 43 consecutive patients with refractory shock caused by acute myocardial infarction (n = 21) or acute decompensated heart failure (n = 22) who were treated with primary implantation of a durable LVAD in a single institution. ResultsAll patients received durable LVAD (axial flow, n = 37; centrifugal, n = 4; pulsatile, n = 2), with concurrent placement of right ventricular assist device (RVAD) in 5 patients (12%). One patient had delayed RVAD implantation. Mean operative time was 362 minutes and mean cardiopulmonary bypass time was 94 minutes. Twenty patients underwent concurrent cardiac procedures. Major early adverse events included operative mortality 14% (6/43), reoperation for bleeding 7% (3/43), and stroke 4.7% (2/43). Median time on mechanical ventilation was 3.5 days, ICU stay 9 days, and hospital stay 25 days. Kaplan-Meier survival was 82.7 ± 6.0% at 6 months and 73.9 ± 8.0% at 12 months. Using competing analysis, the cumulative incidence of transplantation was 10.3 ± 5.0% at 6 months and 30.8 ± 7.9% at 1 year. ConclusionsOur data challenge the notion that patients in refractory cardiogenic shock are best served by an initial period of stabilization with temporary devices. Primary implantation of durable LVADs in cardiogenic shock can yield good midterm outcomes and may have potential benefits.

Lactate and lactate clearance as valuable tool to evaluate ECMO therapy in cardiogenic shock

PurposeECMO support is an ultimate ratio therapy for patients in refractory cardiogenic shock and is linked to high mortality. We assessed the dynamic characteristics of lactate during ECMO therapy and its predictive role on 30-day mortality. Materials and methodsData were retrospectively collected in all patients receiving ECMO support longer than 48h for cardiogenic shock from 01/2008 to 12/2016. Blood lactate was recorded before ECMO implantation, at prespecified timepoints during ECMO support, 1h and 6h post-ECMO as well as peak lactate during ECMO and peak within 24h after ECMO support. Statistical analysis included t-test and ROC-curves to identify cut-off levels for lactate levels to predict 30-day mortality. Results139 patients underwent ECMO therapy longer than 48h for refractory cardiogenic shock resulting in a 30-day mortality of 68%. Lactate before ECMO and peak lactate level during ECMO support showed no significant connection to mortality, while lactate and lactate clearance at 24h were predictive for 30-day mortality with cut-off values of 2.15mmol/l and 0.687 respectively. ConclusionsDynamic course of lactate during ECMO therapy is a valuable tool to assess effective circulatory support and is superior to single lactate measurements as a predictive marker for 30-day mortality.