Short-term Mechanical Circulatory Support Devices Research Articles

Short-Term Mechanical Circulatory Support Devices: Uses and Outcomes

Short-Term Mechanical Circulatory Support Devices: Uses and Outcomes

Abstract P1057: Outcomes Of Impella Versus ECMO In Multivessel Percutaneous Coronary Intervention

Background: Impella is a mechanical circulatory support device indicated in severe cardiogenic shock and high-risk percutaneous coronary intervention. ECMO is also used during the percutaneous coronary intervention (PCI) in an acute coronary syndrome that is complicated by refractory cardiogenic shock. There have been few studies examining short-term mechanical circulatory support devices for patients that undergo PCI, so the choice between Impella and ECMO is still a matter of debate. We investigated the in-hospital outcomes of Impella and ECMO in patients who underwent multi-vessel PCI (MVPCI). Methods: In a retrospective cohort study of National Inpatient Sample 2017 data, we used ICD-10 codes to identify patients who underwent MVPCI and received Impella or ECMO support. Multivariate logistic regression was used to adjust for patient demographics, hospital demographics, and relevant comorbidities. Primary outcomes (inpatient mortality, length of stay (LOS), and total hospital charges. Secondary outcomes, such as respiratory failure (RF), gastrointestinal hemorrhage, cerebrovascular accident (CVA)/transient ischemic attack (TIA), intracerebral hemorrhage (ICH), acute kidney injury (AKI), ventricular tachycardia (VT), and atrial fibrillation, were also analyzed. Results: Among 64,489 patients who had MVPCI, 102 (%) received ECMO support, and 927 (%) received Impella support. Both Impella and ECMO use was associated with high in-hospital mortality (Impella 21.8% vs ECMO (49.5%), high hospital LOS (ECMO 19.9 days vs Impella 9.28 days), and total hospital charges (Impella $3,200,000 vs ECMO $7,500,00). Mortality (OR 4.27, p<0.0001), hospital LOS (OR 5.9, p<0.0001), and total hospital charges (OR 7.52, p<0.0001) for patients undergoing MVPCI. There was no statistically significant difference in complications such as RF, gastrointestinal hemorrhage, CVA/TIA, ICH, AKI, VT, and atrial fibrillation. Hispanic patients had higher mortality with ECMO (OR 2.28, p <0.024) than all other ethnicities and races. Conclusions: Both patients with Impella support and ECMO support had significant inpatient mortality. Our analysis suggests that Impella patients had better outcomes than patients on ECMO for MVPCI.

Ambulatory short-term mechanical circulatory support: facilitates recovery and prepares patients for definitive therapy.

Short-term mechanical circulatory support (ST-MCS) devices have been traditionally deployed in patients with cardiogenic shock, advanced heart failure, cardiovascular collapse, and cardiorespiratory failure. Limitations of the mechanical support devices are typically related to mobility of the patient since the access is frequently through femoral vasculature. This limits the time the patient can be supported by mechanical circulatory support (MCS). We describe deployment of ST-MCS using alternate access such as the subclavian/axillary artery that facilitates ambulation of the patient. These include the deployment of intra-aortic balloon pump (IABP) through the subclavian artery, Impella pump through the axillary/subclavian artery, and extracorporeal membrane oxygenation (ECMO) using the subclavian artery and jugular vein.

Mechanical Thrombectomy for Ischemic Stroke Secondary to Large Vessel Occlusions in Patients on Extracorporeal Membrane Oxygenation

Introduction: The use of short-term mechanical circulatory support (MCS) devices and procedures for function- and life-sustaining therapy is becoming a routine practice at many centers. Concomitant with the increasing use of MCS is the increasing recognition of acute brain injuries, including acute ischemic stroke, which may be caused by a myriad of MCS-driven factors. The aim of this case series was to document our experience with mechanical thrombectomy (MT) for ischemic stroke in extracorporeal membrane oxygenation (ECMO) patients. Methods: We retrospectively reviewed a prospectively maintained database of patients undergoing endovascular thrombectomy for large vessel occlusion at our institution. We identified patients that were on ECMO and underwent thrombectomy. Baseline demographics and procedural and functional outcomes were collected. Results: Three patients on ECMO were identified to have a large vessel occlusion and underwent thrombectomy. Two patients had an internal carotid artery terminus occlusion and one had a basilar artery occlusion. An mTICI 3 recanalization was achieved in all patients without postoperative hemorrhagic complications. Two patients achieved a 3-month mRS of 1, while one had mRS 4. Conclusion: Ischemic stroke can be associated with significant morbidity in MCS patients. We demonstrate that MT can be safely performed in this patient population with good outcomes.

Trends in contemporary advanced heart failure management: an in-depth review over 30 years of heart transplant service in Hong Kong.

The year 2022 marks the 30th anniversary of heart transplant service in Hong Kong (HK). In this study, we describe prevailing trends and outcomes of advanced heart failure (AHF), including heart transplantations (HTx), in HK over the past 30 years. Trends in heart failure prevalence in HK from 1993 to 2021 were analyzed based on data from the Hospital Authority Clinical Data and Reporting System. All AHF patients referred for HTx consideration between 1992 and 2021 were reviewed. The bridge-to-transplant (BTT) utilization of short-term mechanical circulatory support (ST-MCS) devices, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and durable left ventricular assist devices (LVADs), from 2010 to 2021 was reviewed. Overall, 237 heart transplants were performed in HK, with 10-year posttransplant and median survival of 68.1% and 18.7 years, respectively. An increase in AHF clinic referrals was correlated with increasing heart failure prevalence (R2=0.635, P<0.001). In total, 146 referrals were made for ST-MCS, and an observed increase in ST-MCS referrals was correlated with increasing VA-ECMO utilization (R2=0.849, P<0.001). Among 62 patients accepted for AHF therapy, those with durable LVAD implementation had better 1-year survival (71.5%) than those receiving an extracorporeal CentriMag (Levitronix) device as BTT (40%, P=0.008). In total, 143 LVADs were implanted, with 130 as BTT or bridge-to-candidacy (BTC) methods. The survival rate among the 130 BTT/BTC LVAD patients resembled that of HTx recipients (73.8% vs. 69.8% at 9 years, P=0.296). The burden of AHF management has increased and gained complexity over the past 30 years in Hong Kong.

Abstract 14482: Clinical Impact of Advances of Short-Term Mechanical Circulatory Support Devices and Therapeutic Strategies in Patients With Cardiogenic Shock

Introduction: Although revised US adult heart allocation system has provided the opportunity of urgent heart transplantation and improved clinical outcomes in urgent patients, it may not offer select temporary mechanical circulatory support (MCS) patients the opportunity and adequate time to recover to the point of waitlist removal. Severe donor shortages have increased the need for assessment of reversibility of cardiac function. Advances of MCS devices may provide the longer time to assess the appropriate therapeutic strategy. Hypothesis: The aim of this study was to evaluate the impact of bridge-to-decision (BTD) strategies which used recently developed short-term MCS devices strategies. Methods: We retrospectively reviewed the medical records of 108 patients who received BTD strategies from January 2017 to February 2022. Results: Etiology of cardiogenic shock were myocarditis (35.2 %), idiopathic cardiomyopathy (26.0 %) and ischemic cardiomyopathy (30.5 %). Ninety-three (86.1%) had been used any temporary MCS prior to BTD strategy using short-term MCS devices, including intra-aortic balloon pumping, peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) and low-flow percutaneous VAD. Sixty-five (60.2 %) had been inserted extracorporeal centrifugal-flow pump VAD (CF-VAD group), twenty-eight (25.9 %) had high-flow percutaneous VAD (P-VAD group) including with ECMO (ECPELLA) (50 %), and fifteen (13.9 %) had extracorporeal pulsatile-flow pump VAD (PF-VAD group). Duration of short-term MCS support was 42.5±44.1 days. Twenty-five (23.1 %) needed the conversion to other pumps. Forty-eight (40.7%) were withdrawn for recovery of cardiac function (mean duration to decision; 27.7±23.8 days), other forty-eight (40.7 %) were implanted durable implantable VAD for no-recovery of cardiac function (mean duration to decision; 48.4±40.7 days). Twenty patients (18.5 %) died. Clinical prognosis was comparable in three groups (P=0.943). Conclusions: BTD strategies using recently developed short-term MCS devices provided relatively long-term support duration to decision for definitive therapy, and showed favorable clinical outcomes. However, conversion or exchange to other pumps was needed for long-term support.

Minimally invasive apical cannulation and cannula design for short-term mechanical circulatory support devices

BackgroundRefractory cardiogenic shock is still a major clinical challenge with high mortality rates, although several devices can be used to conquer this event. These devices have different advantages and disadvantages originating from their insertion or cannulation method, therefore many complications can occur during their use. The aim of our study was to develop and create prototypes of a novel minimal invasively insertable, transapical cannula for surgical ventricular assist devices, which uniquely incorporates the inflow and outflow routes for the blood of the patient in itself, therefore it enables the use for only one cannula for patients in cardiogenic shock.MethodsTo define the available space for the planned cannula in the left ventricle and ascending aorta, we analyzed computed tomography scans of 24 heart failure patients, who were indicated to left ventricular assist device therapy. Parallel to these measurements, hydrodynamical calculations were performed to determine the sizes of the cannulas, which were necessary to provide effective cardiac output.ResultsAfter the designing steps, we produced prototypes of double-lumened, tube-in-tube apically insertable devices for three different patient groups, which included a separated venous and an arterial part using 3D modelling and printing technology. All the created cannulas are able to provide 5 l/min circulatory support.ConclusionAs a result of our research we created a sizing method based on the specific analysis of computed tomography pictures of end stage heart failure patients and a cannula concept, which can provide effective antegrade flow for patients in cardiogenic shock. We believe the improved version of our tool could have a significant therapeutic role in the future after further development based on animal and in vivo tests.

National Trends In The Utilization Of Short-term Mechanical Circulatory Support Devices During Ventricular Tachycardia Ablation Related Hospitalizations

Background : Sparse data exists describing the characteristics of patients utilizing short term mechanical circulatory support (MCS) devices (intra-aortic balloon pumps, percutaneous ventricular assist devices, extracorporeal membrane oxygenation devices) during ventricular tachycardia (VT) ablation related hospitalizations. The purpose of this study was to characterize the demographics, in-hospital mortality, length of stay and hospital charges for MCS use. Methods : In this serial cross-sectional study, we analyzed all VT ablation related hospitalizations who received short-term MCS in the United States from 2010 to 2017 by using the Nationwide Readmission Database. Results : Among 384,742 hospitalizations with primary diagnosis of VT, 41,075 (10.7%) underwent ablation procedures (4,919 in 2010 to 5,349 in 2017). For those undergoing VT ablation procedures: mean age was 63.1 years, 22.5% were females, 56.9% Medicare insured, 31.0% private insured, 27.0% were elective admissions, unadjusted in-hospital mortality was 2.4%, mean length of stay was 6.6 days and mean hospitalization charge was $147,837. Among 41, 075 VT ablation hospitalizations, 2,479 (6.0%) required use of short term MCS and the utilization increased from 211 (4.3%) in 2010 to 364 (6.8%) in 2017, p<.05 (Figure 1). For these MCS requiring hospitalizations: mean age was 64.9 years, 9.7% were females, 67.1% Medicare insured, 22.1% private insured, 35.0% were elective admissions, unadjusted in-hospital mortality was 15.1%, mean length of stay was 12.9 days and mean hospitalization charge was $335,456. From 2010 to 2017, MCS group had following trends: mean age increased (63.4 years to 64.7 years), proportion of females decreased (14.7% to 6.6%), Medicare insured increased (64.9% to 69.0%), private insured decreased (28.6% to 22.9%) and proportion with elective admission status decreased (38.4% to 38.0%). From 2010 to 2017, unadjusted in-hospital mortality increased from 10.5% to 12.6% (p<.05), mean length of stay changed from 16.8 days to 11.2 days (p<0.05) and mean hospital charges increased from $251,637 to $386,952 (p<.05). Conclusions : Use of short-term MCS during VT ablation related hospitalizations in the United States increased rapidly and in-hospital mortality has remained high. Systematic and longitudinal collection of data in this high-risk group of patients is warranted to ensure improved outcomes in the future. : Sparse data exists describing the characteristics of patients utilizing short term mechanical circulatory support (MCS) devices (intra-aortic balloon pumps, percutaneous ventricular assist devices, extracorporeal membrane oxygenation devices) during ventricular tachycardia (VT) ablation related hospitalizations. The purpose of this study was to characterize the demographics, in-hospital mortality, length of stay and hospital charges for MCS use. : In this serial cross-sectional study, we analyzed all VT ablation related hospitalizations who received short-term MCS in the United States from 2010 to 2017 by using the Nationwide Readmission Database. : Among 384,742 hospitalizations with primary diagnosis of VT, 41,075 (10.7%) underwent ablation procedures (4,919 in 2010 to 5,349 in 2017). For those undergoing VT ablation procedures: mean age was 63.1 years, 22.5% were females, 56.9% Medicare insured, 31.0% private insured, 27.0% were elective admissions, unadjusted in-hospital mortality was 2.4%, mean length of stay was 6.6 days and mean hospitalization charge was $147,837. Among 41, 075 VT ablation hospitalizations, 2,479 (6.0%) required use of short term MCS and the utilization increased from 211 (4.3%) in 2010 to 364 (6.8%) in 2017, p<.05 (Figure 1). For these MCS requiring hospitalizations: mean age was 64.9 years, 9.7% were females, 67.1% Medicare insured, 22.1% private insured, 35.0% were elective admissions, unadjusted in-hospital mortality was 15.1%, mean length of stay was 12.9 days and mean hospitalization charge was $335,456. From 2010 to 2017, MCS group had following trends: mean age increased (63.4 years to 64.7 years), proportion of females decreased (14.7% to 6.6%), Medicare insured increased (64.9% to 69.0%), private insured decreased (28.6% to 22.9%) and proportion with elective admission status decreased (38.4% to 38.0%). From 2010 to 2017, unadjusted in-hospital mortality increased from 10.5% to 12.6% (p<.05), mean length of stay changed from 16.8 days to 11.2 days (p<0.05) and mean hospital charges increased from $251,637 to $386,952 (p<.05). : Use of short-term MCS during VT ablation related hospitalizations in the United States increased rapidly and in-hospital mortality has remained high. Systematic and longitudinal collection of data in this high-risk group of patients is warranted to ensure improved outcomes in the future.

‘Long-Term’ Use of Impella - Safe to Do?

<h3>Purpose</h3> Impella CP, 5.0 and RP belong to the group of short-term mechanical circulatory support (MCS) devices used for patients with severe heart failure and cardiogenic shock. The Impella is designed for short-term support up to 10 days, but our patients frequently require a longer duration of support. As our patients are often bridged to transplant and long waiting lists often result in long waiting times, we are frequently forced to prolong the use of the Impella. Therefore, we aimed to assess the safety of prolonged device duration past 10 days. <h3>Methods</h3> We present our single center data of 69 patients who underwent Impella placement between May 2017 and May 2021. We divided the patients into two groups, Group A (39 patients) with device duration <10 days and Group B (30 patients) with device duration >10 days and compared the occurrence of complications and mortality in the two groups. <h3>Results</h3> Median device duration for Group A was 6.08 (± 2.2) and 21.6 (± 11.8) days in Group B (p .001). Group A contained 6 Impella 5.0, 27 Impella CP and 6 Impella RP vs. Group B with 18 Impella 5.0, 10 Impella CP and 2 Impella RP (p 0.001). There were no significant differences between Group A and Group B regarding: haemolysis 52.4% vs. 42.6% (p 0.36), access site bleeding 24.3% vs. 30% (p 0.4), thrombocytopenia 27% vs. 23.3% (p 0.47), vascular complications 8.1% vs. 6.7% (p 0.6), device migration 5.6% vs. 6.7% (p 0.6), pump thrombosis 10.8% vs. 17.9% (p 0.3), device malfunction 0% vs. 3.3% (p 0.4), ventricular arrhythmias 29.7% vs. 23.3% (p 0.38), access site infection 0% vs. 3.3% (p 0.44), sepsis 32.4% vs. 46.7% (p 0.17), ischemic cerebrovascular accident (CVA) 0% vs. 3.3% and haemorrhagic CVA 0% vs 6.8%. (p 0.13). There were no significant differences regarding pre-implant and pre-explant bilirubin levels in both groups (p 0.35 and p 0.19) and creatinine levels (p 0.2 and 0.06). The platelet count pre-implant showed no significant difference (p 0.07). However, the pre-explant level was significantly lower in Group A (p 0.005). The mortality rate on Impella in Group A and Group B was 28.2% and 13.3% (p 0.1), respectively. <h3>Conclusion</h3> Prolonged device duration has no significant impact on the short-term outcome except on platelet levels. In cases where longer MCS is mandatory careful monitoring might allow longer Impella support.

Oxygen Management in Heart Failure Patients

Symptoms of heart failure (HF) should be alleviated as quickly as feasible. Apart from standard pharmacological therapy, supplementation of oxygen is lifesaving in hypoxemic (SpO2 &lt;90% or PaO2 &lt;60 mmHg) HF patients. For sick patients with SpO2 &lt;85%, respiratory distress (respiratory rate &gt;25 breaths per min) and pulmonary edema, along with oxygen administration, noninvasive positive pressure ventilation (NIPPV) methods, including BiPAP/CPAP or humidified high-flow nasal oxygen, should be tried to optimize oxygenation, reduce work of breathing and to reduce the venous return. If these noninvasive ventilatory support methods fail to improve hypoxemia, endotracheal intubation and mechanical ventilation should be instituted. Short-term mechanical circulatory support (extracorporeal membrane oxygenation) devices are reserved for cardiogenic shock patients due to advanced HF associated with reversible end-organ failure and hypoxia. These temporary mechanical circulatory support devices are also useful as a bridge to long-term mechanical circulatory support or heart transplant in end-stage HF with refractory cardiogenic shock. Even though the use of additional oxygen is a standard practice for hypoxemic patients, routine use of high concentrations of oxygen via inhalational therapy or NIPPV for normoxemic HF patients may result in hyperoxemia. Hyperoxemia has been shown to have negative hemodynamic effects like increased systemic vascular resistance, reduced cardiac index, and decreased coronary blood flow. Detailed prescription by the treating physician, careful monitoring, and meticulous titration of oxygen is essential for safe oxygen treatment for HF patients.

Determination of Brain Death in Patients Undergoing Short-Term Mechanical Circulatory Support Devices

To describe apnoea test (AT) and ancillary study performance for brain death (BD) determination among patients undergoing short-term mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP). We retrospectively analysed data regarding use of AT and ancillary study in consecutive adult patients who were diagnosed with BD while on MCS devices (including ECMO and IABP) over a 10-year period. Out of 140 patients, eight were on MCS devices at the time of BD (four ECMO, two ECMO and IABP, two IABP). The most common aetiology of BD was hypoxic ischaemic brain injury (6/8, 75%). In four patients (50%), the AT was not attempted because of haemodynamic instability and ECMO; in the remaining four (50%), both AT and ancillary studies were used. In three patients on ECMO, AT was performed by reducing the ECMO sweep flow rate to a range 0.5-2.7 L/min in order to achieve hypercarbia. One patient underwent AT while on IABP which was complicated by hypotension. All patients underwent ancillary tests, most commonly transcranial Doppler ultrasonography (TCD) (7/8, 88%); among those, cerebral circulatory arrest was confirmed in six of seven patients (86%), all of whom had left ventricular ejection fracture (LVEF) ≥20% and/or were supported with IABP. There are multiple uncertainties regarding BD diagnosis while on MCS, prompting the need for ancillary studies in most patients. Our study shows that TCD can be used to support BD diagnosis in patients on ECMO who have sufficient cardiac contractility and/or IABP to produce pulsatile flow. TCD use in ECMO patients low LVEF needs further study.

Temporary mechanical circulatory support devices: updates from recent studies.

Over the past several years, the role of short-term mechanical circulatory support (MCS) devices has become the dominant focus in efforts to improve outcomes in patients with cardiogenic shock (CS). Alongside these efforts, temporary MCS devices have been increasingly used to support patients prior to cardiac surgery, during high-risk percutaneous coronary intervention, awaiting cardiac transplantation, and in the setting of refractory cardiac arrest. The present review aims to provide an update on the recent literature evaluating the evolving role of temporary MCS devices, and to provide insights into the current challenges and future directions of MCS research. Recent observational data have demonstrated potential roles for intra-aortic balloon pump preoperatively in high-risk patients awaiting coronary artery bypass grafting, and advanced heart failure patients awaiting transplantation. Impella continues to demonstrate promising results as part of an early MCS strategy in CS, as a temporary bridge to transplantation, and as a mechanism for left ventricular unloading in patients on venoarterial extracorporeal membrane oxygenation (ECMO). Finally, the first randomized trial of ECMO facilitated resuscitation in the United States demonstrated improved survival in patients with refractory out of hospital cardiac arrest. Though randomized data remains limited, observational data continue to support the role of temporary MCS devices in a variety of clinical settings.

Percutaneous Axillary Access for Placement of Microaxial Ventricular Support Devices

Background: There has been increasing utilization of short-term mechanical circulatory support devices for a variety of clinical indications. Many patients have suboptimal iliofemoral access options or reasons why early mobilization is desirable. Axillary artery access is an option for these patients, but little is known about the utility of this approach to facilitate short-term use for circulatory support with microaxial pump devices. Methods: The Axillary Access Registry to Monitor Safety (ARMS) was a prospective, observational multicenter registry to study the feasibility and acute safety of mechanical circulatory support via percutaneous upper-extremity access. Results: One hundred and two patients were collected from 10 participating centers. Successful device implantation was 98% (100 of 102). Devices were implanted for a median of 2 days (interquartile range, 0–5 days; range, 0–35 days). Procedural complications included 10 bleeding events and 1 stroke. There were 3 patients with brachial plexus–related symptoms all consisting of C8 tingling and all arising after multiple days of support. Postprocedural access site hematoma or bleeding was noted in 9 patients. Device explantation utilized closure devices alone in 61%, stent grafts in 17%, balloon tamponade facilitated closure in 15%, and planned surgical explant in 5%. Duration of support appeared to be independently associated with a 1.1% increased odds of vascular complication per day ([95% CI, 0.0%–2.3%] P =0.05). Conclusions: Percutaneous axillary access for use with microaxial support pumps appears feasible with acceptable rates of bleeding despite early experience. Larger studies are necessary to confirm the pilot data presented here.

Experiencia de 5 años en soporte circulatorio mecánico de corta duración en pacientes post infarto de miocardio: Un reporte del registro INCORMACS

Objetivo. Determinar las características clínicas y epidemiológicas de los pacientes con dispositivos de soporte mecánico circulatorio (DSMC) de corta duración, posinfarto de miocardio (IAM) en un hospital de referencia nacional.&#x0D; Materiales y métodos. Estudio descriptivo, retrospectivo, de pacientes post IAM en los que se implantó dispositivos de soporte mecánico circulatorio de corta duración desde el año 2015 al 2020.&#x0D; Resultados. Se implantaron nueve dispositivos de asistencia en igual número de pacientes debido a choque cardiogénico post-IAM. Todos los pacientes fueron varones con IAM con elevación del segmento ST (IAMCEST). Se implantaron ocho dispositivos de oxigenación por membrana extracorpórea (ECMO) y una bomba de flujo centrífugo (en configuración LVAD). La mediana de tiempo de uso del dispositivo fue de ocho días. Las complicaciones más frecuentes fueron la hemorragia no fatal (55,6%), injuria renal aguda (44,4%) y la sepsis (44,4%). La mortalidad intrahospitalaria fue de 55,6%.&#x0D; Conclusiones. El uso de DSMC de corta duración posinfarto de miocardio es aún limitado en nuestra institución y tiene como principal representante al ECMO post-IAMCEST complicado con choque cardiogénico. A pesar del uso de estos dispositivos la mortalidad intrahospitalaria es elevada.

Short-term mechanical circulatory support devices as bridge to heart transplantation: A prospective single-center experience in Argentina.

Patients with cardiogenic shock may require hemodynamic stabilization with short-term mechanical circulatory support devices (ST-MCS) such as extracorporeal membrane oxygenation (ECMO) and centrifugal pump (CP) as bridge to transplantion (BTT). This study aimed to describe ECMO and CP during BTT and after heart transplant. A cohort of patients on ECMO or CP as BTT between April 2006 and April 2018 in a single hospital. Thirty-seven consecutive patients with ECMO (n=14) or CP (n=23) were included. Acute kidney injury was more prevalent during CP (28.6% vs 69.6%, P=.02). There were no differences in stroke, thrombosis, sepsis, or vasoplegia. Bleeding (0% vs 56.5%, P=.0003) and reoperation (0% vs 47.8%, P=.002) were more frequent in CP group as well as mortality (0 vs 7 [30.4%], P=.03). The remaining 30 patients (81.1%) underwent heart transplantation, without differences in primary graft dysfunction, vasoplegia, reoperation for bleeding, or hospital stay. Mortality was 23.3% at 30days, similar in both groups, with no further deaths at median follow-up of 44.2months. In patients with cardiogenic shock, ST-MCS with ECMO or CP as BTT are a lifesaving approach allowing successful transplantation in the majority of cases, with good short- and long-term survival.

Has Short-Term Mechanical Circulatory Support an Impact on Post-Heart Transplant Vasoplegia?

To assess the impact of short-term mechanical circulatory support as bridge-to-urgent transplant on post-transplant vasoplegia. Single-center, retrospective review of all patients who underwent orthotopic heart transplantation between January 2012 and December 2018 (n=135). Patients with postoperative mechanical circulatory (n=9) support were excluded. Patients (n=126) were divided in two groups according to the preoperative use of short-term mechanical circulatory support (26 vs.100). Postoperative vasoplegia was defined as systemic vascular resistance (SVR) <800dynes/m2 with a CI above 3l/min/m2 and/or the use of methylene blue and/or cardiac index above 3l/min/m2 with >0,07mcgrs/kg/min of epinephrine or >0,5mcgrs/kg/min of norepinephrine. Postoperative SVR were calculated with a Swan-Ganz catheter at the arrival at the ICU. Patients mechanically supported showed higher preoperative use of inotropes (96,2% vs.22%, p<0,001), orotracheal intubation (88,46% vs.4% p <0,001) and renal dysfunction (30,8% vs.4%, p<0,001). Pre-transplant use of pulmonary vasodilators (7,7% vs.30%; p=0,02) and ACEIs was higher in the non-supported group (3,8%vs.49%, p<0,001). There was no difference in the incidence of post-transplant vasoplegia (26,9% vs.27%, p=0,99). Perioperative mortality (at discharge) was higher in the supported group (12% vs. 1% p=0,196) but it was not different regarding the incidence of vasoplegia (3,3% vs. 2,8% p= 1,0) CONCLUSION: Post-transplant vasoplegia was not influenced by the preoperative use of short-term mechanical circulatory support devices and was not associated with increased mortality in our series.

Hemolysis associated with Impella heart pump positioning: In vitro hemolysis testing and computational fluid dynamics modeling.

Short-term mechanical circulatory support devices provide temporary hemodynamic support in heart failure and are increasingly used to enable recovery or as a bridge to decision. Blood damage with mechanical circulatory support devices is influenced by many factors, including the magnitude and duration of shear stress and obstruction to blood flow. This study aimed to evaluate the effects of the Impella CP® heart pump positioning on hemolysis using in vitro hemolysis testing and computational fluid dynamics modeling. The in vitro hemolysis testing was conducted per the recommended Food and Drug Administration and American Society for Testing and Materials guidelines. The bench hemolysis testing and computational fluid dynamics simulation analysis were performed for both normal operating (outlet unobstructed) and outlet-obstructed condition of Impella CP (mimicking outlet on the aortic valve due to improper positioning). The modified index of hemolysis was 2.78 ± 0.69 at normal operating conditions compared to 18.7 ± 7.8 when the Impella CP outlet was obstructed (p = 0.002). Computational fluid dynamics modeling showed about three times increase in exposure time to regions of high shear stress when the Impella CP outlet was obstructed compared to unobstructed condition, thus supporting the experimental observations. Based on these results, it is recommended to ensure proper placement of Impella CP via regular monitoring using echocardiographic guidance or other methods to minimize the risk of hemolysis associated with an obstructed outflow.

Mechanical circulatory support devices in cardiogenic shock and acute heart failure: current evidence.

The main purpose of this review is to highlight and summarize recently published studies on the usage of short-term mechanical circulatory support devices for treatment of cardiogenic shock. Importantly, this review will focus on percutaneously implanted devices. In recent years, usage of active mechanical circulatory support devices, such as catheter-based left ventricular-assist devices and veno-arterial extracorporeal membrane oxygenation devices, has been widely adopted. Several device-specific strategies have been proposed to improve outcome of treated patients with cardiogenic shock, ranging from early identification and treatment of patients via dedicated shock protocols to combinatory usage of these devices. However, this is not supported by prospective, randomized trials but by retrospective analysis, which are significantly impacted by bias. Randomized, controlled trials are utterly needed to guide treatment with mechanical circulatory support for patients with cardiogenic shock. Importantly, such trials should focus patient selection criteria.

Abstract TP409: Prevalence and Predictors of Stroke in Patients With Short-Term Mechanical Circulatory Support Devices: A Single-Center Study

Introduction: Short-term mechanical circulatory support devices (ST-MCS) include intra-aortic balloon-pump (IABP), extracorporeal membrane oxygenation (ECMO) and the CentriMag® and Impella® ventricular assist systems (VAS). Despite an exponential increase in their use, data regarding stroke prevalence and predictors are lacking. Objective: To identify the prevalence and predictors of stroke in ST-MCS. Methods: Data was collected prospectively into a database from January 2016 to June 2018 and retrospectively extracted and analyzed. Primary analysis was performed between acute-stroke vs. non-stroke diagnoses. Dichotomous and continuous variables were analyzed using Chi-Square test of proportions and Wilcoxon Ranked Sum test respectively. Results: Out of 203 ST-MCS-patients [IABP 31.5% (n=64), Impella 24.6% (n=50), ECMO 31% (n=63) and CentriMag®VAS 12.8% (n=26)], 8.4% (n=17) had an acute stroke. Among them 6.4% (n=13) had ischemic stroke and 1% (n=2) had hemorrhagic stroke, with 1% (n=2) having both. CentriMag®VAS had a higher stroke rate than the other devices (23.1% [n=6] vs. 6.2% [n=11]; p=0.011, OR 4.53). Predictors of stroke in all patients were central cannulation (p=0.044, OR 3.08), duration &gt;4 days (p=0.025, OR 3.21) and use of another ST-MCS device before primary device (p=0.043, OR 1.45). Flow-rate (p=0.86) and catheter size (p=0.15) did not predict stroke. Only 1 patient was eligible for thrombolytic therapy and received IV tPA, with the most common reasons to hold treatment being unknown last-seen-normal (n=8), coagulopathy (n=2) and established infarct on head CT (n=2). A large vessel occlusion was present in 20% (n=3), but none underwent a mechanical thrombectomy due of established infarction. All hemorrhagic strokes and 47% (n=7) ischemic strokes led to withdrawal of care. Conclusion: About 1 in 12 patients placed on a ST-MCS device may have an acute stroke, but this can be as high as 1 in 5 with the use of the CentriMag®VAS. Factors such as central cannulation, duration &gt;4 days and use of another ST-MCS device before the primary device may be predictive of acute stroke in these patients. Further research in the identification of such predictors, in conjunction with early symptom recognition could help improve treatment rates.

Mechanical circulatory devices in acute heart failure.

Temporary circulatory support (TCS) with short-term mechanical circulatory support (MCS) devices is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of current devices, their indications and management, and discusses results of recent case series and trials. Percutaneous active MCS devices (Impella, TandemHeart…) and venoarterial extracorporeal membrane oxygenation (VA-ECMO) are utilized as a bridge to 'decision' that includes weaning after cardiac function recovery, transplantation, long-term MCS and withdrawal in case of futility. VA-ECMO is considered the first-line TCS since it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella or intra-aortic balloon pump support with ECMO might decrease left ventricular pressure and improve outcomes. Sepsis-associated cardiomyopathy, massive pulmonary embolism, arrhythmic storm and Takotsubo-like cardiomyopathy are among emerging indications for TCS. TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the respective place of different MCS devices in cardiogenic shock treatment strategies.