Role Of Mechanical Circulatory Support Research Articles

(1136) - Fulminant Lymphocytic Myocarditis with Acute Biventricular Failure: The Role of Mechanical Circulatory Support

(1136) - Fulminant Lymphocytic Myocarditis with Acute Biventricular Failure: The Role of Mechanical Circulatory Support

Acute Triple Coronary Artery Occlusion Leading to Cardiogenic Shock and Cardiac Arrest Emphasizing the Role of Mechanical Circulatory Support (Escalate before It’s Too Late)

We report a case of cardiac arrest in a 38-year-old male with no past medical history who presented as a case of ST-segment elevation myocardial infarction, and coronary angiography showed triple coronary artery thrombosis complicated with cardiogenic shock (CS) that warrants starting on inotropic support and insertion of intra-aortic balloon pump. CS diagnosis with a high likelihood of deterioration was established based on hemodynamics assessment; hence, an early prompt decision for escalation of mechanical circulatory support to Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was made, which helped to prevent the patient’s further deterioration and organ damage. The patient had uneventful VA-ECMO decannulation and was transferred to the ward and discharged after 28 days in stable condition on oral medical therapy and was following up regularly in the cardiology clinic. Therefore, early hemodynamics assessment in acute myocardial infarction CS cases will help predict rapid worsening, which may require prompt escalation of mechanical circulatory support and perhaps improve the outcome.

Role of Mechanical Circulatory Support in Acute MI Management

Cardiogenic shock complicating acute MI carries high mortality and morbidity in many cases. Mechanical circulatory support devices are often used in these cases, aimed at improving patient-centered outcomes, although there is a lack of large randomized clinical trial-based evidence for many of such devices. Various circulatory support devices are available with their associated risks and benefits. Ideal circulatory support device intends to unload the myocardium, halt the spiral of ischemia, provide support for revascularization, and/or allow time for myocardial recovery. In this review paper, the commonly used mechanical circulatory support devices available for use in acute myocardial infarction settings are discussed, and the pros and cons of these devices are examined, considering the contemporary data for each. While this is an evolving field, the authors believe this paper can be helpful to review the current status of the use of mechanical support devices in the setting of acute MI and highlight some of the unmet needs in this field.

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.

Mechanical Circulatory Support in Cardiovascular Surgical Patients: Single Center Practice and Experience

Background: In view of the role of mechanical circulatory support in patients with severe cardiac insufficiency during perioperative period, we searched the relevant articles on mechanical circulatory support at Fuwai Hospital, and analyzed the indications and complications of different mechanical circulatory support methods. Methods: Relevant studies were identified by computerized searches of PubMed, Ovid, Embase, Cochrane Library, Wanfang Data, VIP Data, Chinese BioMedical Literature & Retrieval System (SinoMed), and China National Knowledge Infrastructure (CNKI), using search words (“intra-aortic balloon counter pulsation” OR “IABP” OR “extracorporeal membrane oxygenation” OR “ECMO” OR “ventricular assist device” OR “VAD”) AND (“Fuwai” OR “fuwai”). All studies concerning the application of IABP, ECMO, and VAD at Fuwai Hospital were included, exclusion criteria included: (1) studies published as review, case report or abstract; (2) animal or cell studies; (3) duplicate publications; (4) studies lacking information about outcomes of interest. Results: A total of 36 literatures were selected for analysis. The specific mechanical circulatory support methods of ECMO and VAD retrieved from the studies were VA-ECMO and LVAD. The number of cases using IABP, ECMO, LVAD was 1968, 972, 67; and the survival rate was 80.4%, 54.9%, 56.7%, respectively. The major complications of IABP, ECMO and LVAD were hemorrhage (1.2%, 35.9% and 14.5%), infection (3.7%, 12.7% and 9.7%), acute kidney injury (9.1%, 29.6% and 6.5%), the secondary complications were limb ischemia, neurological events, cardiovascular events and thrombosis. Conclusions: The present study suggested that, IABP, ECMO and VAD, either alone or in combination, were effective and safe mechanical circulation support when managing cardiovascular surgical patients with severe hemodynamic instability at Fuwai Hospital.

Acute Coronary Syndrome in Pregnancy and the Post-Partum Period.

Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.

Characteristics and Outcomes of COVID-19 Patients Supported by Venoarterial or Veno-Arterial-Venous Extracorporeal Membrane Oxygenation

ObjectivesCardiac injury has been reported in up to 20%-to-30% of patients with COVID-19, and severe disease can lead to cardiopulmonary failure. The role of mechanical circulatory support in these patients remains undetermined. The authors here aimed to determine the characteristics and outcomes of patients with COVID-19 requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) or veno-arterial-venous (VAV) ECMO support.Design and SettingA multicenter, retrospective case series.ParticipantsThe cohort consisted of adult patients (18 years of age and older) with confirmed COVID-19 requiring VA ECMO or VAV ECMO support in the period from March 1, 2020, to April 30, 2021. Outcomes were recorded until July 31, 2021.Measurements and Main ResultsTo show factors related to death during hospitalization, patients were grouped as survivors and nonsurvivors. Kaplan-Meier analysis was used to estimate 90-day in-hospital mortality. Overall, 37 patients from 12 centers comprised the study cohort. The median patient age was 44 years old (interquartile range [IQR], 35-52), and 12 (32%) were female patients. The duration of ECMO support ranged from 2-to-132 days. At the end of the follow-up period, 13 patients (35%) were discharged or transferred alive, and 24 patients (65%) died during the hospitalization. The cumulative in-hospital mortality at 90 days was 64% (95% confidence interval: 47-81). During the time from intubation to VA ECMO or VAV ECMO initiation (1 day [IQR 0-7.5] v 6 days [IQR 2.5-14], p = 0.0383), body mass index (32 [IQR 26-36] v 37 [IQR 33-40], p = 0.009), and baseline C-reactive protein (7.15 v 38.9 mg/dL, p = 0.009) were higher in those who expired.ConclusionOnly one-third of the patients with COVID-19 requiring VA ECMO or VAV ECMO survived to discharge. Close monitoring of at-risk patients with early initiation of ECMO with circulatory support may further improve outcomes.

Abstract 11451: Use of Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights from the PROGRESS-CTO Registry

Introduction: The use of mechanical circulatory support (MCS) in complex percutaneous coronary intervention (PCI) is the subject of ongoing investigation, but the role of MCS in chronic total occlusion (CTO) PCI is not well studied. Methods: We analyzed the patient and angiographic characteristics and procedural outcomes of 7,171 CTO PCIs performed between 2012 and June 2021 at 35 international centers. Results: Mean patient age was 64.5±10 years, mean left ventricular ejection fraction was 50 ± 13 % and 82% were men. MCS was used in 4.5% of the overall cases, MCS use was elective in 78.7% and urgent in 21.3%. The most common type of MCS was Impella CP (55.5%) followed by intra-aortic balloon pump (14.8%), Tandem Heart (10.0%) and Impella 2.5 (8.7%). Diabetes mellitus (51.0% vs. 42.4%, p=0.003), prior congestive heart failure (60.6% vs. 27.9%, p<0.001) and prior myocardial infarction (52.3% vs. 45.3%, p=0.020) were more common in MCS patients. Left ventricular ejection fraction was lower in the patients with MCS use compared to patients without (Mean±standard deviation, 51.0 ± 12 vs. 34.0 ± 15 %, p<0.001). Cases in which MCS was used were more complex with higher J-CTO score compared with cases without MCS (2.94 ± 1.19 vs. 2.39 ± 1.27, p<0.001). Cases performed with MCS had lower technical (81.6% vs. 86.7%, p=0.011) and procedural (71.3% vs. 85.6%, p<0.001) success rates with higher rates of periprocedural major cardiac adverse events compared to no MCS use (12.6% vs. 1.68%, p<0.001). Conclusions: In a contemporary, multicenter registry MCS was used in 4.5% of CTO PCI. Cases where MCS was used were associated with lower technical and procedural success with higher periprocedural major complication rates. Further investigation is required to see if elective use of MCS can improve outcomes in patients with increased comorbidities and higher lesion complexity.

Mechanical Circulatory Support Following Out-of-Hospital Cardiac Arrest: Insights From the National Cardiogenic Shock Initiative

BackgroundEvidence is limited regarding the role of mechanical circulatory support (MCS) in patients with acute coronary syndromes (ACS) complicated by cardiogenic shock (CGS). In particular, the role of MCS in patients with out-of-hospital cardiac arrest (OHCA) is unknown. MethodsThe National Cardiogenic Shock Initiative (NCSI) is a multicenter United States registry of patients with ACS complicated by CGS treated with MCS. We compared the rate of survival to hospital discharge among patients with OHCA, in-hospital cardiac arrest (IHCA), or no cardiac arrest. We subsequently used multivariable analyses to determine independent predictors of OHCA survival. ResultsSurvival to hospital discharge occurred in 85.7% (42/49) of OHCA, 72.4% (50/69) of IHCA, and 74.5% (111/149) of non-cardiac arrest patients. By multivariable analysis, pre-procedural predictors of survival included younger age, female sex, fewer diseased vessels, left anterior descending coronary artery culprit, lower troponin, higher lactate, and delayed initiation of MCS. Procedural and post-procedural predictors of survival included fewer vessels treated, complete revascularization, higher post-MCS cardiac power output, and fewer inotropic medications required. ConclusionsThis study demonstrates that excellent outcomes may be achieved following OHCA when MCS is employed for patients appropriately selected by prognostic demographic, anatomic, and health status characteristics. A larger study population, currently being enrolled, is needed to validate the observation further.

Outcomes of Mechanical Circulatory Support for Giant Cell Myocarditis: A Systematic Review.

Treatment of giant cell myocarditis (GCM) can require bridging to orthotopic heart transplantation (OHT) or recovery with mechanical circulatory support (MCS). Since the roles of MCS and immunotherapy are not well-defined in GCM, we sought to analyze outcomes of patients with GCM who required MCS. A systematic search was performed in June 2019 to identify all studies of biopsy-proven GCM requiring MCS after 2009. We identified 27 studies with 43 patients. Patient-level data were extracted for analysis. Median patient age was 45 (interquartile range (IQR): 32–57) years. 42.1% (16/38) were female. 34.9% (15/43) presented in acute heart failure. 20.9% (9/43) presented in cardiogenic shock. Biventricular (BiVAD) MCS was required in 76.7% (33/43) of cases. Of the 62.8% (27/43) of patients who received immunotherapy, 81.5% (22/27) used steroids combined with at least one other immunosuppressant. Cyclosporine was the most common non-steroidal agent, used in 40.7% (11/27) of regimens. Immunosuppression was initiated before MCS in 59.3% (16/27) of cases, after MCS in 29.6% (8/27), and not specified in 11.1% (3/27). Immunosuppression started prior to MCS was associated with significantly better survival than MCS alone (p = 0.006); 60.5% (26/43) of patients received bridge-to-transplant MCS; 39.5% (17/43) received bridge-to-recovery MCS; 58.5% (24/41) underwent OHT a median of 104 (58–255) days from diagnosis. GCM recurrence after OHT was reported in 8.3% (2/24) of transplanted cases. BiVAD predominates in mechanically supported patients with GCM. Survival and bridge to recovery appear better in patients on immunosuppression, especially if initiated before MCS.

Outcomes of Mechanical Circulatory Support after Giant Cell Myocarditis: A Systematic Review

Giant cell myocarditis (GCM) is a rare, serious form of myocarditis that can require bridging to orthotopic heart transplant (OHT) with mechanical circulatory support (MCS). Given that the roles of MCS and immunosuppressive therapy have not been well defined in this patient population, we sought to analyze the outcomes of patients with GCM who required MCS. A systematic search was performed in June 2019 to identify all studies of biopsy-proven GCM requiring MCS in the English literature after 2009. 27 studies were identified consisting of 43 patients. Patient-level data were extracted for statistical analysis. Median patient age was 45 [IQR: 32 - 57] years, and 42.1% (16/38) of patients were female. 34.9% (15/43) of patients presented with symptoms of acute heart failure, and 20.9% (9/43) presented in cardiogenic shock. Biventricular (BiVAD) MCS was required in 76.7% (33/43) of cases. The final diagnosis of GCM was made using endomyocardial biopsy in 72.1% (31/43) of cases, left ventricular apical core biopsy in 23.3% (10/43) of cases, and biopsy of the explanted heart in 2.3% (1/43) of cases. An immunosuppressive regimen was used in 62.8% (27/43) of cases. Of these patients, 81.5% (22/27) received steroids in combination with at least one other immunosuppressant, of which cyclosporine was the most common, administered to 40.7% (11/27) of patients. Immunosuppression was initiated before MCS in 59.3% (16/27) of cases, after MCS in 29.6% (8/27) of cases, and not specified in 11.1% (3/27) of cases. Survival stratified by immunosuppression (Panel A) and mode of MCS (Panel B) is shown. 58.5% (24/41) underwent OHT with a median time to transplant of 104 [58 - 255] days from diagnosis, and 46 [18 - 201] days from the initiation of MCS. Recurrence of GCM after OHT was reported in 8.3% (2/24) of cases. Non-dischargeable BiVAD predominates in mechanically supported patients with GCM. Survival appears to be better in patients on immunosuppression, especially if initiated before MCS.

Outcomes of Mechanical Circulatory Support Therapy for Cardiogenic Shock Associated with Late Allograft Failure after Heart Transplantation

Treatment of cardiogenic shock associated with late allograft failure after heart transplant (HT) is poorly characterized and infrequently reported. In this study, we examined the role of mechanical circulatory support (MCS) as a method to treat patients with severe late graft failure. From 2000 - 2018, there were 1275 adult HT at our institution. Of those, 26 patients (2.0%) were identified who required MCS for cardiogenic shock due to late allograft failure. Patient demographics and outcomes were retrospectively reviewed. Median age of the cohort was 37.3 years (IQR: 17.3) and 69% were male. Median time from initial transplant to MCS was 2.9 years. At the time of shock, median hemodynamic values were as follows: CVP 18 mmHg, mean PA pressure 29 mmHg, PCWP 25 mmHg, and CI 1.87 L/min/m2. On echocardiogram, median LVEF was 25% and 77% of patients had moderate or severe right ventricular dysfunction. Seven patients (27%) had severe allograft coronary disease, while all remaining patients had chronic or acute worsening rejection. Initial MCS used included veno-arterial extracorporeal membrane oxygenation in 15 patients (58%), biventricular assist device in 10 patients (38%), and total artificial heart in 1 patient (4%). 8 patients underwent revision of MCS during the same hospitalization, on average 18 days after initial placement. While on MCS, the most common treatments for rejection were pulse dose steroids (69%), thymoglobulin (54%), and plasmapheresis (31%), with nearly all patients receiving combination therapy. Six patients (23%) weaned from MCS following medical therapy. Median duration of MCS was 33 days (IQR 55). Major morbidities included bleeding events in 39%, new renal replacement therapy in 23%, major infection in 27%, and stroke in 23%. Eight patients (31%) underwent re-heart transplant, all within one year of MCS, and survival for this cohort was 100% at 1 year. However, for those patients who were not offered re-transplant or who died while awaiting re-transplant, 1 year survival was only 22%, with 61% of deaths occurring in the hospital. Late graft failure resulting in cardiogenic shock carries significant morbidity and mortality, despite use of contemporary MCS.

Surgical outcomes in complex adult congenital heart disease: a brief review.

Life expectancy of patients with congenital heart disease (CHD) continues to increase dramatically over the last few decades, primarily due to significant medical and surgical advancements in the field. Adult congenital heart disease (ACHD) patients are now living longer but continue to face morbidity and reduced long-term survival when compared to the general population. We briefly describe the growth of ACHD with a focus on surgical procedures and outcomes in the more complex lesions including Tetralogy of Fallot, Ebsteins Anomaly of the tricuspid valve, Coarctation of the Aorta, Transposition of the Great Arteries and single ventricle lesions. The advancing role of mechanical circulatory support and cardiac transplantation in ACHD patients is also highlighted. Cardiac surgery in these patients continues to improve with low surgical mortality rate and outstanding long-term outcomes and efficacy.

Complete left bundle branch block as predictor of cardiogenic shock in patient with acute myocardial infarction on the background of diabetes mellitus type 2

Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction, with high hospital mortality rates ∼80 %. The incidence of cardiogenic shock among myocardial infarction patients is approximately 7 %. Cardiogenic shock patients are found that pre-existing diabetes is associated with an increased risk of cardiogenic shock and it worsens outcomes, with a longer hospital stay. Cardiogenic shock develops approximately twice as often among diabetics as among nondiabetic patients with acute myocardial infarction. Diabetes mellitus and left bundle branch block are predictors of cardiogenic shock complicating acute myocardial infarction. Except for bad prognosis, left bundle branch block can be a marker of a slowly progressing, degenerative, ischemic or non-ischemic cardiac disease, affecting not only the muscle but also the heart conduction system. Immediate diagnosis and management are required. In this article, a clinical case of acute posterior myocardial infarction complicated by complete left bundle branch block and cardiogenic shock in the patient with concomitant diabetes mellitus type 2 is demonstrated. This article emphasizes the priority of referring patients with left bundle branch block to primary percutaneous coronary intervention, usage of more specific ECG criteria for acute coronary syndrome, the role of myocardial infarction biomarker including sensitive assays for cardiac troponins, and bedside echocardiography which may improve diagnostic accuracy and result in timely intervention in such patients. This article also underlines the role of mechanical circulatory support, urgent reperfusion therapy, and strict control of glycemia in the acute phase of myocardial infarction which may contribute to clinical stability of patients with diabetes mellitus and myocardial infarction complicated by cardiogenic shock.

The Evolving Landscape of Impella Use in the United States Among Patients Undergoing Percutaneous Coronary Intervention With Mechanical Circulatory Support.

Impella was approved for mechanical circulatory support (MCS) in 2008, but large-scale, real-world data on its use are lacking. Our objective was to describe trends and variations in Impella use, clinical outcomes, and costs across US hospitals in patients undergoing percutaneous coronary intervention (PCI) treated with MCS (Impella or intra-aortic balloon pump). From the Premier Healthcare Database, we analyzed 48 306 patients undergoing PCI with MCS at 432 hospitals between January 2004 and December 2016. Association analyses were performed at 3 levels: time period, hospital, and patient. Hierarchical models with propensity adjustment were used for association analyses. We examined trends and variations in the proportion of Impella use, and associated clinical outcomes (in-hospital mortality, bleeding requiring transfusion, acute kidney injury, stroke, length of stay, and hospital costs). Among patients undergoing PCI treated with MCS, 4782 (9.9%) received Impella; its use increased over time, reaching 31.9% of MCS in 2016. There was wide variation in Impella use across hospitals (>5-fold variation). Specifically, among patients receiving Impella, there was a wide variation in outcomes of bleeding (>2.5-fold variation), and death, acute kidney injury, and stroke (all ≈1.5-fold variation). Adverse outcomes and costs were higher in the Impella era (years 2008-2016) versus the pre-Impella era (years 2004-2007). Hospitals with higher Impella use had higher rates of adverse outcomes and costs. After adjustment for the propensity score, and accounting for clustering of patients by hospitals, Impella use was associated with death: odds ratio, 1.24 (95% CI, 1.13-1.36); bleeding: odds ratio, 1.10 (95% CI, 1.00-1.21); and stroke: odds ratio, 1.34 (95% CI, 1.18-1.53), although a similar, nonsignificant result was observed for acute kidney injury: odds ratio, 1.08 (95% CI, 1.00-1.17). Impella use is rapidly increasing among patients undergoing PCI treated with MCS, with marked variability in its use and associated outcomes. Although unmeasured confounding cannot be ruled out, when analyzed by time periods, or at the hospital level or the patient level, Impella use was associated with higher rates of adverse events and costs. More data are needed to define the appropriate role of MCS in patients undergoing PCI.

Invasive Management of Out of Hospital Cardiac Arrest.

Out of hospital cardiac arrest (OHCA) is a major cause of morbidity and mortality worldwide. Clinical decision making is extremely difficult in this understudied patient population with high prevalence of neurological injury and inexorable shock states. As such, there are uncertain benefits from therapies available in the cardiac catheterization laboratory. Fear of futility and public reporting often affects decision making and can result in risk aversion. This review focuses on invasive management in OHCA care, with particular focus on coronary angiography, coronary revascularization, and mechanical support. Guidelines recommend emergency coronary angiography in patients with ST-segment elevations on ECG after OHCA, while the role of coronary angiography in patients without ST-segment elevations is less clear. Similar uncertainty remains in the appropriate revascularization strategy in these patients. As in other areas of cardiology, there is a growing interest in the role of mechanical circulatory support after OHCA, though the available literature shows mixed results. The many uncertainties associated with treating the patient with OHCA highlight the importance of clinical decision support tools and treatment algorithms in the care of this population. This review focuses on invasive management in OHCA care, with particular focus on coronary angiography, coronary revascularization, and mechanical support.

Mechanical circulatory support for cardiac amyloidosis.

Cardiac amyloidosis, typically from abnormal deposition of AL or ATTR amyloid protein, can result in heart failure requiring transplantation (HTx). The role of mechanical circulatory support (MCS) is not well-established. The purpose of this study was to present our experience with MCS in patients with cardiac amyloidosis. Consecutive patients with cardiac amyloidosis who received MCS at Cedars-Sinai Medical Center between 2010 and 2018 were reviewed. Clinical characteristics and outcomes were compared to a control group of MCS patients without amyloid matched 2:1 for age and INTERMACS Profile. 11 amyloid patients underwent durable MCS, two with paracorporeal biventricular assist devices and 9 with total artificial hearts. No patients received isolated left ventricular assist device support. By 1year, 9 (82%) of patients in the MCS-Amyloid group had been transplanted and 2 (18%) had died. In the MCS-No Amyloid group, by 1year, 8 (36%) of patients had been transplanted, 10 (46%) had died, and 4 (18%) were still living with MCS. Over a 9-year period, patients with amyloid cardiomyopathy who required MCS at our institution all received durable biventricular MCS. For carefully selected patients, this approach is feasible with acceptable outcomes as bridge to transplantation.

Severe heart failure and the need for mechanical circulatory support and heart transplantation in pediatric patients with myocarditis: Results from the prospective multicenter registry "MYKKE".

Myocarditis represents an important cause for acute heart failure. MYKKE, a prospective multicenter registry of pediatric patients with myocarditis, aims to gain knowledge on courses, diagnostics, and therapy of pediatric myocarditis. The role of mechanical circulatory support (MCS) in children with severe heart failure and myocarditis is unclear. The aim of this study was to determine characteristics and outcome of patients with severe heart failure requiring MCS and/or heart transplantation. The MYKKE cohort between September 2013 and 2016 was analyzed. A total of 195 patients were prospectively enrolled by 17 German hospitals. Twenty-eight patients (14%) received MCS (median 1.5years), more frequently in the youngest age group (0-2years) than in the older groups (P<0.001; 2-12 and 13-18years). In the MCS group, 50% received a VAD, 36% ECMO, and 14% both, with a survival rate of 79%. The weaning rate was 43% (12/28). Nine (32%) patients were transplanted, one had ongoing support, and six (21%) died. Histology was positive for myocarditis in 63% of the MCS group. Patients within the whole cohort with age <2years and/or ejection fraction <30% had a significantly worse survival with high risk for MCS, transplantation, and death (P<0.001). Myocarditis represents a life-threatening disease with an overall mortality of 4.6% in this cohort. The fulminant form more often affected the youngest, leading to significantly higher rate of MCS, transplantation, and mortality. MCS represents an important and life-saving therapeutic option in children with myocarditis with a weaning rate of 43%.

Decision-making in advanced heart failure patients requiring LVAD insertion: Can preoperative simulation become the way forward? A case study

Clinical practice heavily relies on results from randomized controlled trials, which may not reflect completely individual patients. Patient-specific modelling has received increasing attention in recent years. Although still far from clinical application on a daily basis, the potential of this approach is significant. The treatment of advanced heart failure may benefit from a modelling framework to guide device treatment and predict outcome. The role of mechanical circulatory support as a long-term solution is increasing in view of the evolving technology and worsening heart failure patient population. Therefore, a preoperative strategy with the ability to predict the course of events in a simulation setting may be justified. Here we present a heart failure patient discussed at a multidisciplinary team meeting whose outcome was compared with simulations carried out with CARDIOSIM$^{©}$ software to investigate the role of this approach as a planning strategy to guide intervention and predict outcome. The clinical decision process is complex and many factors are involved. Patient-specific modelling may have a role to play as part of a preoperative planning strategy with more quantitative evaluation to smooth decision-making.

Ten-year Experience With CentriMag Ventricular Assist Device Use in Acute Myocardial Infarction and Cardiogenic Shock

The role of mechanical circulatory support has dramatically increased for patients with acute myocardial infarction (AMI) and cardiogenic shock. We analyzed our ten-year experience with CentriMag (St. Jude Medical Inc., St. Paul, Minnesota) ventricular assist devices (VAD) in patients for the treatment of AMI and cardiogenic shock.