Revascularization In Cardiogenic Shock Research Articles

Complete Revascularization in Cardiogenic Shock and Myocardial Infarction: The Grail Quest

Complete Revascularization in Cardiogenic Shock and Myocardial Infarction: The Grail Quest

Mechanical Assist Device-Assisted Percutaneous Coronary Intervention: The Use of Impella Versus Extracorporeal Membrane Oxygenation as an Emerging Frontier in Revascularization in Cardiogenic Shock.

The extracorporeal membrane oxygenation (ECMO) procedure aids in the provision of prolonged cardiopulmonary support, whereas the Impella device (Abiomed, Danvers, MA) is a ventricular assist device that maintains circulation by pumping blood into the aorta from the left ventricle. Blood is circulated in parallel with the heart by Impella. It draws blood straight into the aorta from the left ventricle, hence preserving the physiological flow. ECMO bypasses the left atrium and the left ventricle, and the end consequence is a non-physiological flow. In this article, we conducted a detailed analysis of various publications in the literatureand examined various modalities pertaining to the use ofECMO and Impella for cardiogenic shocks, such as efficacy, clinical outcomes, cost-effectiveness, device-related complications, and limitations. The Impella completely unloads the left ventricle, thereby significantly reducing the effort of the heart. Comparatively, ECMO only stabilizes a patient with cardiogenic shock for a short stretch of time and does not lessen the efforts of the left ventricle ("unload" it). In the acute setting, both devices reduced left ventricular end-diastolic pressure and provided adequate hemodynamic support. By comparing patients on Impella to those receiving ECMO, it was found that patients on Impella were associated with better clinical results, quicker recovery, limited complications, and reduced healthcare costs; however, there is a lack of conclusive studies performed demonstrating the reduction in long-term mortality rates. Considering the effectiveness of given modalities and taking into account the various studies described in the literature, Impella has reported better clinical outcomes although more clinical trials are needed for establishing the effectiveness of these interventional approaches in revascularization in cardiogenic shock.

Revascularization in Cardiogenic Shock: Residual Syntax Score and Chronic Total Occlusions

The residual syntax score (rSS) is strongly associated with outcomes in patients with stable coronary artery disease. In patients with acute myocardial infarction-associated cardiogenic shock (AMI-CS), the correlation or association of the rSS, mortality risk, and revascularization strategy has not yet been elucidated and needs more investigation. The SHOCK trial demonstrated that patients with left main and severe triple-vessel disease, who underwent coronary artery bypass grafts, had improved outcomes and higher 1-year survival rates than those with initial medical stabilization. However, it is unclear which is the superior technique for achieving complete revascularization. In contrast to the SHOCK trial’s results, the CULPRIT-MI trial indicated that multivessel intervention had no impact on patient outcomes. Patients with AMI-CS usually have high rSSs due to their complex multivessel disease. Thus, the rSS may be more of a surrogate for the kind of disease than the strategy employed. We, therefore, hypothesize that lowering the rSS might lead to better outcomes. In addition, as there is currently no data confirming an effective targeted strategy, reintroduction of the bypass surgery should be considered.

P11‐12: A tale of ice and fire: Dexmedetomidine‐induced hyperthermia after complex coronary artery revascularization for cardiogenic shock

P11‐12: A tale of ice and fire: Dexmedetomidine‐induced hyperthermia after complex coronary artery revascularization for cardiogenic shock

Revascularization in cardiogenic shock.

Approximately 10% of patients with acute myocardial infarction develop cardiogenic shock. Randomized studies have shown asignificant improvement in survival with early revascularization, which now represents the most important cornerstone in the treatment of infarct-related cardiogenic shock. In the vast majority of cases, this is achieved by percutaneous coronary intervention (PCI). In cases of complex coronary anatomy or mechanical complications, the Heart Team should be consulted promptly. The randomized CULPRIT-SHOCK study showed asurvival advantage for patients with multivessel coronary artery disease and apercutaneous revascularization strategy who were treated by culprit-lesion-only PCI compared with immediate multivessel PCI. There are currently few data on anticoagulation and antiplatelet therapy in cardiogenic shock as well as on active mechanical circulatory support in this setting.

Trends, Outcomes, and Predictors of Revascularization in Cardiogenic Shock

Cardiogenic shock (CS) carries high mortality and morbidity. Early revascularization is an important strategy in management of these patients. We sought to determine the outcomes and predictors of revascularization among patients with CS. Patients with CS and acute myocardial infarction were identified using the National Inpatient Sample (NIS) data from January 2002 to December 2014 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Subsequently, patients who underwent revascularization were then selected. A total of 118,618 patients with CS were identified. Out of these, about 55,735 (47%) patients underwent revascularization. Mean age of patients who underwent revascularization was lower when compared with patients not who underwent revascularization (66.40 vs 72.24 years, p < 0.01). Patients who underwent revascularization had lower mortality when compared with patients not who underwent revascularization (25.1% vs 52.2%, p < 0.01). Extracorporeal membrane oxygenation and mechanical circulatory support devices were often utilized more in patients who underwent revascularization. Overall, we found modest increased trend of revascularization over our study years with decline in mortality. Female gender, weekend admission, drug abuse, pulmonary hypertension, anemia, renal failure, neurological disorders, malignancy were associated with lower odds of revascularization. In conclusion, in this large nationally represented US population sample of CS patients, we found revascularization rate of about 47% with improvement in overall mortality over our study years.

Revascularization in Cardiogenic Shock and Advanced Heart Failure.

Ischemic heart disease is the most common cause of heart failure with systolic dysfunction. The progressive course of heart failure characterized by increasing levels of care and worsening quality of life often indicates an advanced stage. Similarly, cardiogenic shock remains a major clinical problem with prohibitively high mortality rates despite major advances in clinical care. Here, we review the current treatment options and available data for revascularization in patients with ischemic cardiomyopathy, advanced heart failure, and cardiogenic shock. We also explore the emerging role of Interventional Heart Failure specialist within the Heart Team. Although guideline-directed medical therapy remains the cornerstone treatment strategy for patients with advanced heart failure, coronary revascularization is sometimes indicated. There is a relatively paucity of evidence regarding different revascularization strategies and the use of acute mechanical circulatory support in patients with advanced heart failure and in those presenting with cardiogenic shock. A deep understating of the physiologic and hemodynamic effects of different acute mechanical support platforms is of paramount importance in preparation for revascularization in these patients. The decision regarding revascularization in patients with coronary artery disease in the setting of left ventricular dysfunction remains challenging. Clinical decision-making in these cases requires interdisciplinary discussion and assessment of the potential long-term survival derived from surgical revascularization against its higher perioperative risk.

ショック，心不全を伴う急性心筋梗塞に対する冠血行再建術

ショック，心不全を伴う急性心筋梗塞に対する冠血行再建術

Coronary Revascularization in Cardiogenic Shock.

Early revascularization in acute myocardial infarction (MI) complicated by cardiogenic shock (CS) reduces mortality with a life saved for every eight patients treated. Percutaneous coronary intervention (PCI) has become the mainstay of treatment for CS, particularly for ST-segment elevation MI, due to the ability to achieve rapid reperfusion; with coronary artery bypass graft (CABG) operations reserved for patients with mechanical complications or anatomy that poses challenges for timely PCI. Mortality remains high even in patients with successful revascularization, and interventional cardiologists must consider additional treatment options. Recent data supports the performance of multi-vessel PCI to achieve complete revascularization in this setting. In addition, early implementation of a percutaneous hemodynamic support device is recommended in patients in whom shock is profound and unlikely to reverse with culprit lesion PCI.

Integration of medical therapy and mechanical circulatory support in the management of acute heart failure.

Acute heart failure is still characterized by poor prognosis with high mortality. Diagnosis is based on clinical symptoms and hemodynamic measurements. Early coronary revascularization in cardiogenic shock complicating myocardial infarction improves outcome. The further contemporary therapeutic options in the management of acute heart failure are limited to a merely symptomatic effect with relief of dyspnea, reduction of volume overload and improvement of hemodynamic parameters by vasodilators (in hypertension) or inotropic and vasopressor agents (in hypotension). However, so far no medical therapy has been shown to positively affect clinical outcomes of patients with acute heart failure. Early identification of impending circulatory collapse coupled with rapid implementation of mechanical circulatory support may contribute to mortality reduction as a combined concept of the management of acute heart failure.

OUTCOMES FOLLOWING MULTIVESSEL OR CULPRIT VESSEL REVASCULARIZATIONS AT THE TIME OF PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN ST-ELEVATION MYOCARDIAL INFARCTION PATIENTS WITH CARDIOGENIC SHOCK AND MULTIVESSEL DISEASE

Evidence for multivessel (MV) revascularization in cardiogenic shock (CS) and multivessel disease (MVD) is still not enough. We compared outcomes following MV or culprit vessel (CV) revascularizations performed at the time of primary percutaneous coronary intervention (PCI) in ST-elevation

Cardiac power index, mean arterial pressure, and Simplified Acute Physiology Score II are strong predictors of survival and response to revascularization in cardiogenic shock.

Short-term prognostic factors in patients with cardiogenic shock (CS) have previously been established using only hemodynamic parameters without taking into account classic intensive care unit (ICU) severity score or organ failure/support. The aim of this study was to assess early predictors of in-hospital mortality of a monocentric cohort of patients with ST-elevation myocardial infarction complicated by early CS. We retrospectively studied 85 consecutive patients with CS complicating acute myocardial infarction and Thrombolysis in Myocardial Infarction flow grade 3 after percutaneous coronary revascularization. All patients were managed according to the following algorithm: initial resuscitation by a mobile medical unit or in-hospital critical care physician unit followed by percutaneous coronary revascularization and CS management in the ICU. Prehospital CS was diagnosed in 69% of cases, initially complicated by an out-of-hospital cardiac arrest in 64% of cases. All patients were treated with vasopressors, 82% were ventilated, and 22% underwent extrarenal epuration. The 28-day mortality rate was 39%. Under multivariate analysis, initial cardiac power index, mean arterial pressure of less than 75 mmHg at hour 6 of ICU management, and Simplified Acute Physiology Score II were independent predictive factors of in-hospital mortality. In conclusion, parameters directly related to cardiac performance and vascular response to vasopressors and admission Simplified Acute Physiology Score II are strong predictors of in-hospital mortality.

Abstract P367: Temporal Trends in Cardiogenic Shock and Disparities in Use of PCI Among Patients With Cardiogenic Shock by Race/Ethnicity and Gender, Florida 2001-2007

Background: In current ACC/AHA guidelines, early revascularization for cardiogenic shock (CS) complicating acute myocardial infarction (AMI) is a class 1 recommendation in patients aged &lt; 75 years. However, whether the current focus on prompt revascularization during AMI has modified the prevalence of CS is unknown. Therefore, we examined state-wide temporal trends in the prevalence of CS and the use of percutaneous coronary intervention (PCI) by patient age, gender, and race/ethnicity. Methods: Using comprehensive inpatient surveillance for Florida hospitals, we examined all AMI patients (ICD-9-CM 410) discharged between 2001-2007. Data on age, gender, race/ethnicity, AMI type (ST-elevation (STEMI), non-ST-elevation (NSTEMI), and site unspecified), cardiogenic shock (ICD-9-CM 785.50, 785.51) and use of PCI were abstracted for each patient. Temporal trends in the prevalence of CS complicating AMI were examined. Logistic regression analysis was used to examine sociodemographic predictors of the use of PCI among patients with CS. Results: There were 316,285 hospitalizations for AMI in Florida from 2001-2007. Overall 4.1% were complicated by CS. Shock was present in 2.1% of NSTEMI patients, 7.5% of STEMI patients, and 6.0% of unspecified AMI patients. Over time, the prevalence of CS increased from 2001 to 2007 for all AMI patients (3.8% to 4.3%), with the greatest increase among STEMI patients (6.6% to 8.3%). The use of PCI for all AMI patients with CS increased from 28.8% in 2001 to 44.1% in 2007. STEMI patients &lt; 75 years with CS were most likely to receive PCI (49.9% in 2001 increasing to 65.1% in 2007). Logistic regression adjusted for patient age, AMI type, and year revealed that the likelihood of receiving PCI among CS patients was significantly lower for black women (OR 0.68, 95%CI 0.54-0.87, p=0.002) and Hispanic women (OR 0.76, 95% CI 0.64-0.91, p=0.003) compared with white men. Younger CS patients were more likely to receive PCI. Conclusions: The prevalence of cardiogenic shock complicating AMI did not decline in Florida from 2001-2007. However use of PCI among shock patients increased, with the highest use among STEMI patients. Black and Hispanic women with CS were significantly less likely to receive PCI than other race-gender groups.

Long-Term Benefits of Early Revascularization for Cardiogenic Shock

Cardiogenic shock is the leading cause of death in patients hospitalized with acute myocardial infarction (AMI). In the international, randomized

Early Revascularization for Cardiogenic Shock: Long-Term Benefit

In the trial known as SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock), conducted from 1993 to 1998, researchers

Effect of gender on strategies for revascularization for cardiogenic shock

Effect of gender on strategies for revascularization for cardiogenic shock

Early revascularization improved 1-year survival after myocardial infarction with cardiogenic shock

Source Citation Hochman JS, Sleeper LA, White HD, et al., for the SHOCK Investigators. One-year survival following early revascularization for cardiogenic shock. JAMA. 2001 Jan 10;285:190-2. 11176812

One-year survival following early revascularization for cardiogenic shock

One-year survival following early revascularization for cardiogenic shock

Revascularization for cardiogenic shock.

Despite the availability of invasive circulatory monitoring, inotropes and thrombolysis, mortality from cardiogenic shock remains in excess of 50%, and continues to account for the deaths of between 7% and 11% of patients admitted with myocardial infarction.1–,3 In the majority of these patients, the problem is one of overwhelming left ventricular damage and, intuitively, revascularization should be the primary therapeutic strategy. However, attempts to prove this have been fraught with difficulty, and the randomized trial paradigm that revolutionized our approach to acute cardiology appears to have faltered. This review examines the features of cardiogenic shock that have hindered attempts to improve its outcome, discusses whether current evidence is sufficient to support a policy of revascularization and explores the potential value of approaches aimed at minimizing reperfusion damage. The development of cardiogenic shock is rarely unexpected, most patients who develop shock do so within 48 hours of admission, with only 10% shocked on arrival.2 As would be expected, shock is associated with larger infarcts, prior infarction, diabetes and infarct extension.4,,5 The diagnosis itself is straightforward, with a systolic blood pressure <90 mmHg for more than 30 min in the absence of hypovolaemia or other potential causes of hypotension. Additional features such as oliguria and impaired peripheral perfusion identify those at particularly high risk of death.6 The widespread availability of bedside echocardiography has rendered the use of invasive haemodynamics, and in particular a requirement for a cardiac index of less than 2.2 l/min/m2, virtually obsolete in the decision‐making process. Echocardiography readily identifies the mechanism of shock and those patients that might benefit from surgery for intra‐ or extra‐myocardial rupture (Figure 1).4,7,,8 Figure 1. Apical four‐chamber echo view with relative incidence of the mechanisms responsible for cardiogenic shock in the SHOCK 8 and MILIS 4 …

Immediate revascularization for cardiogenic shock after MI reduced 6-month mortality

Source Citation Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascular...