Short-term Mechanical Circulatory Support Research Articles

Comparison between acute and chronic refractory cardiogenic shock: is prognosis different?

Abstract Funding Acknowledgements None. Background Short-term mechanical circulatory support (ST-MCS) is essential to reverse refractory cardiogenic shock (RCS). Since compensatory mechanisms are differently activated depending on whether the cause of CS is acute injury or decompensation of advanced chronic heart failure, hypothetically, the prognosis could also be different. Purposes The aim of our study was to compare the prognosis of patients with RCS supported with ST-MCS (venoarterial-extracorporeal membrane oxygenation (VA-ECMO), Centrimag, Impella CP and Impella 5.0) according to whether the cause of cardiogenic shock was an acute myocardial injury (acute myocardial infarction, myocarditis...) or a worsening of advanced cardiomyopathy. Methods Consecutive patients ≥ 18 years with RCS requiring ST-MCS at a tertiary center from January 2020 to August 2023 were prospectively included. They were stratified according to whether the cause of shock was acute or chronic. Demographic, clinical characteristics before insertion, and outcomes were included in the analysis. Results A total of 86 patients with RCS were supported with ST-MCS in that period, 55 of them (64%) for acute injury and the rest (n=31; 36%) as decompensation of chronic heart failure, with a significantly higher Charlson Comorbidity Index in the chronic group (2(0-3) vs 3(2-4); p=0.01). Acute shock was predominantly supported with VA-ECMO (49.1%) and Impella CP (41.8%), while Impella 5.0 was the most commonly used device in chronic patients (32.2%). The severity of CS was significantly higher in the acute shock group, assessed by SCAI (p=0.005), VIS Score (55.1 (26.19-90.5) vs 8 (3.1-30); p=0.005) and lactate level (5.3 (3-10.3) vs 1.2 (1-2.2) mmol/l; p<0.005) and a higher but non-significant SOFA score (8 (6-10) vs 6 (4-9); p=0,06). However, no differences were found in prognosis, both in-hospital mortality, mortality during support and 30-day and 1-year mortality (Figure 1). Most patients with chronic shock were referred to cardiac transplantation (54.8%) while most patients with acute shock were weaned by myocardial recovery(30.9%), but there were no differences in the final destination of these patients (p=0.089). There were no differences in systemic and local complications between the three groups, except for the rate of device-related ischemia (21.8% vs. 6.4%, p=0.015). Conclusions In our center, most patients in CS who required short-term mechanical circulatory support debut after an acute cardiac injury. Percutaneous ST-MCS is preferentially selected in the acute group, probably because of its easy accessibility in emergency situations. Although patients with acute CS present a more severe overall situation than patients worsening due to advanced heart failure, there were no differences in the short- and long-term prognosis or in the destination treatment of these patients.Table of resultsFigure 1.Mortality in RCS

SCAI SHOCK stage classification: valid for all indications and devices in patients with short-term mechanical circulatory support?

Abstract Funding Acknowledgements None. Background The Society for Cardiovascular Angiography and Intervention (SCAI) SHOCK stage has demonstrated prognostic value in patients with cardiogenic shock (CS), including patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. It has also been validated in different scenarios as acute coronary syndrome -ACS- or out-of-hospital cardiac arrest. Purpose Our objective was to study the prognostic value of SCAI SHOCK stage in different indications and etiologies requiring different types of short-term mechanical circulatory support (MCS). Methods Retrospective analysis of consecutive patients supported with VA-ECMO or Impella CP® in a referral center. We studied the SCAI SHOCK stage at MCS implantation according different devices, indication and etiology, and its relationship with in-hospital and follow-up survival. Results 263 patients were included between 2014-March 2023 (Table). The SCAI SHOCK stage was less advanced in complex high risk percutaneous coronary intervention (CHIP-PCI) indication and more advanced in postcardiotomy shock, myocarditis, pulmonary embolism (PE), refractory cardiac arrest or electric storm (Figure A). In-hospital survival was 41.1% and it was significantly lower as SCAI SHOCK stage increased (A 83.9%, B 100%, C 66.7%, D 39.2%, E 24.5%; p=0.000), as well as in follow-up for a median time of 24.5 [47] months (figure B). This association was maintained with both types of devices separately: VA-ECMO (A 80%, B 100%, C 33.3%, D 38.9%, E 24.5%, p=0.001) and Impella (A 84%, B 100%, C 75%, D 42.9%, E 25%, p=0.005). Regarding the indication and etiology for MCS, SCAI SHOCK classification was significantly related with survival in CS indication, as well as in ACS and heart failure (HF) etiology (Figure B). However, no relationship between SCAI and survival was observed in indications as CHIP-PCI (A 83.9%, B 100%, C 50%; p=0.386), electrical storm (C 0%, D 100%, E 70%; p=0.075) and postcardiotomy shock (D 35.6%, E 20%; p=0.470), neither in etiologies as PE (D 0%, E 28.6%; p=1), infective endocarditis (D 28.6%, E 0%; p=1), myocarditis (D 100%, E 0%; p=0.250),and other causes of cardiac arrest (D 0%, E 25%; p=1), nor in patients admitted for elective cardiac surgery. Conclusions SCAI SHOCK stage classification showed prognostic value in patients with short-term MCS indicated by diverse etiologies, including both VA-ECMO and Impella CP devices. The prognostic value was maintained for the indication of CS, and in ACS and HF etiologies, but not in electrical storm, CHIP-PCI, PE, myocarditis or postcardiotomy shock. Studies are needed to validate this classification in other settings.TableFigure

(567) - Short-Term Mechanical Circulatory Support Over 65 Years. Is It Worth the Effort?

(567) - Short-Term Mechanical Circulatory Support Over 65 Years. Is It Worth the Effort?

Development and Validation of a Risk Score Predicting Death Without Transplant in Adult Heart Transplant Candidates

The US heart allocation system prioritizes medically urgent candidates with a high risk of dying without transplant. The current therapy-based 6-status system is susceptible to manipulation and has limited rank ordering ability. To develop and validate a candidate risk score that incorporates current clinical, laboratory, and hemodynamic data. A registry-based observational study of adult heart transplant candidates (aged ≥18 years) from the US heart allocation system listed between January 1, 2019, and December 31, 2022, split by center into training (70%) and test (30%) datasets. Adult candidates were listed between January 1, 2019, and December 31, 2022. A US candidate risk score (US-CRS) model was developed by adding a predefined set of predictors to the current French Candidate Risk Score (French-CRS) model. Sensitivity analyses were performed, which included intra-aortic balloon pumps (IABP) and percutaneous ventricular assist devices (VAD) in the definition of short-term mechanical circulatory support (MCS) for the US-CRS. Performance of the US-CRS model, French-CRS model, and 6-status model in the test dataset was evaluated by time-dependent area under the receiver operating characteristic curve (AUC) for death without transplant within 6 weeks and overall survival concordance (c-index) with integrated AUC. A total of 16 905 adult heart transplant candidates were listed (mean [SD] age, 53 [13] years; 73% male; 58% White); 796 patients (4.7%) died without a transplant. The final US-CRS contained time-varying short-term MCS (ventricular assist-extracorporeal membrane oxygenation or temporary surgical VAD), the log of bilirubin, estimated glomerular filtration rate, the log of B-type natriuretic peptide, albumin, sodium, and durable left ventricular assist device. In the test dataset, the AUC for death within 6 weeks of listing for the US-CRS model was 0.79 (95% CI, 0.75-0.83), for the French-CRS model was 0.72 (95% CI, 0.67-0.76), and 6-status model was 0.68 (95% CI, 0.62-0.73). Overall c-index for the US-CRS model was 0.76 (95% CI, 0.73-0.80), for the French-CRS model was 0.69 (95% CI, 0.65-0.73), and 6-status model was 0.67 (95% CI, 0.63-0.71). Classifying IABP and percutaneous VAD as short-term MCS reduced the effect size by 54%. In this registry-based study of US heart transplant candidates, a continuous multivariable allocation score outperformed the 6-status system in rank ordering heart transplant candidates by medical urgency and may be useful for the medical urgency component of heart allocation.

Short-Term Mechanical Circulatory Support Devices: Uses and Outcomes

Short-Term Mechanical Circulatory Support Devices: Uses and Outcomes

СЕРИЯ КЛИНИЧЕСКИХ СЛУЧАЕВ ПРИМЕНЕНИЯ ЭКСТРАКОРПОРАЛЬНОЙ МЕМБРАННОЙ ОКСИГЕНАЦИИ ПРИ ВЫПОЛНЕНИИ ЧКВ ВЫСОКОГО РИСКА

Introduction. Percutaneous coronary interventions (PCI) have become increasingly intricate, particularly considering patient comorbidities. The simultaneous or staged coronary artery stenting in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease during the index hospitalization has garnered considerable interest. The utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in PCI has notably increased, serving both as an emergency intervention in acute myocardial infarction (AMI) and in planned PCI to maintain hemodynamics and organ perfusion. The term "high-risk PCI" has been introduced to denote interventions performed using short-term mechanical circulatory support, necessitating a multidisciplinary approach for patient management. Aim. This study aims to investigate the management approaches for high-risk PCI patients using mechanical circulatory support methods. Materials and Methods. A comprehensive literature review on the management of high-risk PCI patients was conducted. Patients with STEMI who underwent LCA trunk stenting at the bifurcation site using ECMO were selected based on the Barnaul ACCD. Results. Data on ECMO use in high-risk PCI are primarily limited to single-center observational studies or individual clinical cases. In the presented cases, ECMO facilitated successful implementation of complex PCI in patients with STEMI and critical stenoses of large coronary arteries. Indications for routine use of mechanical devices during PCI procedures should be individualized, considering potential benefits and complications. In the cases presented, ECMO use during XRD enabled complete revascularization despite acute heart failure and cardiogenic shock, leading to rapid patient stabilization and discharge in satisfactory condition. Conclusions. Managing high-risk PCI patients necessitates a multidisciplinary approach, requiring collaboration among endovascular surgeons, clinical cardiologists, and cardiac surgeons. Critical aspects in the intensive care unit for these patients are not yet fully understood, emphasizing the need to optimize patient condition pre-procedure, manage concurrent diseases, and ensure adequate postoperative care. The synergy between intensive care specialists and cardiologists can significantly impact treatment outcomes in this clinical context.

Veno-arterial extracorporeal membrane oxygenation as direct bridge to heart transplantation in a low and middle income country

Abstract Introduction The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) as a direct bridge to heart transplantation (BTT) is not common in adults worldwide. BTT with ECMO is associated with increased early/mid-term mortality compared with other interventions. In low- and middle-income countries (LMIC), where no other type of short-term mechanical circulatory support is available, its use is widespread and increasingly used as rescue therapy in patients with cardiogenic shock (CS) as a direct bridge to heart transplantation (HT). Objective To assess the outcomes of adult patients using VA ECMO as a direct bridge to heart transplantation in a LMIC and compare them with international registries. Methods We conducted a single-center study analyzing consecutive adult patients requiring VA-ECMO as BTT due to refractory CS or cardiac arrest (CA) in a cardiovascular center in Argentina between January 2014 and December 2022. Survival and adverse clinical events after VA-ECMO implantation were evaluated. Results Of 86 VA-ECMO, 22 (25.5%) were implanted as initial BTT strategy and 52.1% finally underwent HT. Mean age was 46 years (SD 12); 59% were male. ECMO was indicated in all cases for CS and the most common underlying condition was coronary artery disease (30%), followed by idiopathic dilated cardiomyopathy (15%). Patient outcomes are described in Figure 1. Overall in-hospital mortality for VA ECMO as BTT was 50%. Survival to discharge was 83% in those who achieved HT and 10% in those who did not, p<0.001. In those who did not achieve HT, the main cause of death was haemorrhagic complications (44%), followed by thrombotic complications (33%). The median duration of VA ECMO was 6 days (IQR 3-16). There were no differences in the number of days on ECMO between those who received a transplant and those who did not. In the Spanish registry (Barge Caballero et al 2018), in-hospital survival after HT was 66.7%, the United Network of Organ Sharing registry (Fukuhara et al 2018) estimated post-transplant survival at 73.1% ± 4.4%, and in the French national registry (Jasserson et al 2016), 1-year post-transplant survival was 70% in the VA ECMO group. Conclusions In adult patients with cardiogenic shock, VA-ECMO as a direct BTT allowed successful HT in half of the patients. HT provided a survival benefit in listed patients on VA-ECMO. VA-ECMO can be used to bridge critically ill candidates directly to HT in a setting where no other circulatory support is available, as a salvage strategy with acceptable mortality in a high-volume specialized center. We present a single center experience with results comparable to registries in Spain, France and the United States.

The impact of hospital volume on the prognosis of patients with cardiogenic shock requiring mechanical circulatory support

Abstract Background Short-term mechanical circulatory support (MCS) is indicated in refractory cardiogenic shock (CS). Each hospital's volume of MCS relates to the many factors including population served, clinician experience and availability of MCS. To establish regional integrated Hub-and-spoke care CS systems for improving the prognosis of patients with CS, detailed data on relationship between the volume of MCS and prognosis are required but are lacking. We evaluated the relationship between outcomes, including in-hospital mortality and case volume, and explored whether there is an upper limit to this relationship. Methods We used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients receiving short-term MCS, three sub-cohorts were created based on the MCS type used; the intra-aortic balloon pump (IABP) alone (n=48,643), the extracorporeal membrane oxygenation (ECMO) (n=16,871), and the Impella cohorts (n=696). Results The median volume of annual cases in each hospital was 13.5 (7.4–22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0–10.7) in the Impella cohort. In the IABP alone and ECMO cohorts, the group with the higher case volume had less acute myocardial infarctions and received right heart catheterization more frequently. The highest quintile for the volume of cases in the IABP alone and ECMO cohorts had the lowest in-hospital mortality (IABP alone cohort, 25.1% in quintile 1 vs. 15.2% in quintile 5; ECMO cohort, 73.7% in quintile 1 in 67.4% in quintile 5), while it had the highest cost. Adjusted odds ratios for in-hospital mortality increased as case volume increased (IABP alone cohort, 0.63 [0.58–0.68] in quintile 5; ECMO cohort, 0.73 [0.65–0.82] in quintile 5, with the lowest quintile as reference) but did not increase significantly in the Impella cohort (0.90 [0.58–1.39] in tertile 3, with the lowest tertile as reference) (Figure 1). In continuous models, in-hospital mortality decreased to 28 cases/year in the IABP alone cohort and 12 cases/year in the ECMO cohort, and the mortality became almost flat above that (Figure 2). Hospitals with 28 or more cases/year in the IABP cohort were 3.6 % including 15.5 % of patients, and hospitals with 12 or more cases/year in the ECMO cohort were 4.7% including 20.9% of patients. Conclusions Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline, above which in-hospital mortality remains constant or increases slightly. Centralizing patients with refractory cardiogenic shock in a particular hospital might improve patient outcomes in each region.

Abstract 15087: First Clinical Trial in China to Evaluate the Efficacy and Safety of Moyoassist® Extra-VAD System

Cardiogenic shock(CS)is associated with significant morbidity and mortality. For patients unresponsive to medicinal treatment, an alternative is a mechanical circulatory support (MCS) system. In China, common treatments using short-term MCS include IABP and VA-ECMO, both methods found their limitations. Therefore, a better strategy must be proposed to improve prognosis in CS patients, such as extracorporeal VAD (Extra VAD). Here, we reported 40 patients' data collected from a prospective, multicenter, single group clinical trial conducted from July 2021 to Feb 2023, which aims to evaluate the efficacy and safety of MoyoAssist® Extra-VAD system. MoyoAssist® is developed based on fully magnetically levitated pump technology to temporarily support the left, right, or biventricular circulation of patients with acute heart failure and cardiogenic shock of all causes. Patients were recruited for various indications, with PCCS (50%) and BTT (32.5%) being the top two causes. A combination of median sternotomy (22.5%), peripheral venous cannulation (52.5%) and mini-incision (25%) were employed to implant the device. Especially, jugular vein cannulation was a pioneering approach proposed to enable patients’ early ambulation and recovery. MoyoAssist® Extra-VAD has demonstrated stable and sufficient circulation support without severe device associated adverse events. The mean support duration was 7d16hrs, and overall survival rate at 30-day follow up was 62.5%. Hemodynamics indicated improvement with increased MAP and reduced CVP in all sub-groups. Lactate has shown a significant decrease in the PCCS-survival group (3.95 vs. 1.05, p<0.05), indicating improved reperfusion of organ tissues. While AST has shown a significant drop in the BTT-survival group (67.10 vs. 56.17, p<0.05), indicating improved liver function. During the support, 3 patients with peripheral cannulation and 2 patients with mini-incision were able to ambulate early. The types of complication seen were similar to those reported with CentriMag, but the rates of bleeding (15%) and hemolysis (0%) were much lower. In conclusion, MoyoAssist® Extra-VAD has demonstrated its safety and efficacy for short-to-mid-term support of patients with acute heart failure and cardiogenic shock.

Multidisciplinary cardiogenic shock team approach improves the long-term outcomes of patients suffering from refractory cardiogenic shock treated with short-term mechanical circulatory support.

Short-term mechanical circulatory support (STMCS) may be used as an intentional escalation strategy to treat refractory cardiogenic shock (rCS). However, with growing technical possibilities, making the right choice at the right time can be challenging. We established a shock team in January 2013 comprising a cardiac anaesthetist-intensivist, an interventional cardiologist, and a cardiac surgeon. Since then, a diagnosis of rCS has triggered a multidisciplinary team meeting based on a common algorithm. This study aimed to compare the decision-making process for STMCS for rCS before (2007-2013) and after (2013-2019) the creation of the shock team. This before-and-after cohort study was conducted over a 156-month period. Post-cardiotomy rCS were excluded. The primary outcome was a 1-year survival rate. In total, 250 consecutive adult patients were included in the analysis (84 in the control group and 166 in the shock team group). At baseline, the CardShock score was not different between the two groups (5[3-5] vs. 5[4-6], P = 0.323). The 1-year survival rate was significantly higher in the shock team group compared with the control group (59% vs. 45%, P = 0.043). After a Cox regression analysis, the shock team intervention was independently associated with a significantly improved 1-year survival rate (HR: 0.592, 95% CI: 0.398-0.880, P = 0.010). A multidisciplinary shock team-based decision for STMCS device implantation in rCS is associated with better 1-year survival rates.

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.

Aortic Thrombosis in Patients on Mechanical Circulatory Support: ASystematic Literature Review.

Aortic valve (AV) thrombosis is an uncommon but ominous complication in patients managed with mechanical circulatory support (MCS) devices. In this systematic review, we summarised the data on clinical presentations and outcomes in such patients. We searched articles on PubMed and Google Scholar, reporting at least one adult patient with aortic thrombosis on MCS support and where the individual patient data could be extracted. We grouped the patients by the type of MCS (temporary or durable), and the type of the AV (prosthetic, surgically modified, or native) RESULTS: We identified reports on six patients with aortic thrombus on short-term MCS, and on 41 patients on durable left ventricular assist devices (LVADs). On temporary MCS, AV thrombus typically causes no symptoms and is found incidentally pre- or intra-operatively. For those with durable MCS, the occurrence of aortic thrombus forming on prosthetic or surgically modified valves appears to be more related to the intervention on the valve, rather than from the presence of LVAD. The mortality in this group was 18%. In patients with native AV on durable LVAD support, 60% of patients presented with acute myocardial infarction, acute stroke, or acute heart failure, and mortality in this cohort was 45%. In terms of management, heart transplantation was most successful. While the outcomes of aortic thrombosis were good in patients where temporary MCS was used in the setting of aortic valve surgery, patients with native AV who develop this complication on durable LVAD have high morbidity and mortality. Cardiac transplantation should be strongly considered in eligible candidates because other therapies provide inconsistent results.

Percutaneous left ventricular assist device as a short-term mechanical circulatory support before heart transplantation in patients with high pre-transplant pulmonary hypertension (series of clinical cases)

Federation In certain categories of patients with end-stage heart failure (HF), short-term mechanical circulatory support (MSC) is successfully used as a mechanical «bridge» to heart transplantation (HTx). In predominantly left-ventricular (LV) dysfunction, the use of isolated coronary artery bypass, especially amidst high pulmonary hypertension (PH), seems to be a more physiological method of short-term MSC.Objective: to present the results of a series of clinical cases of the use of percutaneous left ventricular assist device (pLVAD) before HTx in potential recipients with predominantly LV dysfunction and concomitant high PH.Materials and methods. Three potential heart recipients with predominantly left-sided HF and high pre-transplant PH (pulmonary vascular resistance, PVR, 4.7–6.6 Wood units) who required MSC due to progression of hemodynamic disorders were included in the study. A standard venous extracorporeal membrane oxygenation (ECMO) cannula (26 F) was used for percutaneous left atrial-femoral artery (LA–FA) bypass. The cannula was passed from the transfemoral route through the interatrial septum into the left atrial cavity. A paracorporeal centrifugal pump provided blood injection through a standard arterial ECMO cannula (15 F).Results. pLVAD unloaded the left ventricle effectively (PCWP reduced from 27–32 to 15–20 mmHg), reduced pre-transplant PH (mean pulmonary artery pressure (mPAP) reduced from 45–53 to 28–33 mmHg) and improved systemic hemodynamics (cardiac index (CI) increased from 1.8–1.9 to 2.1–2.6 l/min/m2 and mean arterial pressure (mAP) from 56–59 to 70–75 mmHg). All these created the prerequisites for subsequent successful HTx. Against the background of pLVAD, transpulmonary pressure gradient (TPG) decreased from 15–25 to 13–15 mmHg, and PVR decreased from 4.7–6.6 to 2.7–3.4 Wood units. pLVAD flow rate was 2.9–3.8 L/min or 1.38–1.83 L/min/m2 at 4700–7100 rpm. pLVAD duration ranged from 4 (n = 1) to 7 (n = 2) days. All patients underwent successful HTx.Conclusion. pLVAD is a highly effective method of short-term MSC in potential recipients with predominantly LV dysfunction and concomitant high PH, leading to rapid regression of the dysfunction against the background of left ventricular unloading. This short-term MSC technique can be successfully realized using standard ECMO cannulas and centrifugal pumps of any modification, without requiring additional special equipment.

Short-term mechanical support with the Impella 5.x for mitral valve surgery in advanced heart failure-protected cardiac surgery.

Surgical treatment of patients with mitral valve regurgitation and advanced heart failure remains challenging. In order to avoid peri-operative low cardiac output, Impella 5.0 or 5.5 (5.x), implanted electively in a one-stage procedure, may serve as a peri-operative short-term mechanical circulatory support system (st-MCS) in patients undergoing mitral valve surgery. Between July 2017 and April 2022, 11 consecutive patients underwent high-risk mitral valve surgery for mitral regurgitation supported with an Impella 5.x system (Abiomed, Inc. Danvers, MA). All patients were discussed in the heart team and were either not eligible for transcatheter edge-to-edge repair (TEER) or surgery was considered favorable. In all cases, the indication for Impella 5.x implantation was made during the preoperative planning phase. The mean age at the time of surgery was 61.6 ± 7.7 years. All patients presented with mitral regurgitation due to either ischemic (n = 5) or dilatative (n = 6) cardiomyopathy with a mean ejection fraction of 21 ± 4% (EuroScore II 6.1 ± 2.5). Uneventful mitral valve repair (n = 8) or replacement (n = 3) was performed via median sternotomy (n = 8) or right lateral mini thoracotomy (n = 3). In six patients, concomitant procedures, either tricuspid valve repair, aortic valve replacement or CABG were necessary. The mean duration on Impella support was 8 ± 5 days. All, but one patient, were successfully weaned from st-MCS, with no Impella-related complications. 30-day survival was 90.9%. Protected cardiac surgery with st-MCS using the Impella 5.x is safe and feasible when applied in high-risk mitral valve surgery without st-MCS-related complications, resulting in excellent outcomes. This strategy might offer an alternative and comprehensive approach for the treatment of patients with mitral regurgitation in advanced heart failure, deemed ineligible for TEER or with need of concomitant surgery.

Clinical outcomes and predictors of success with Impella weaning in cardiogenic shock: a single-center experience.

Cardiogenic shock (CS) is a severe syndrome with poor prognosis. Short-term mechanical circulatory support with Impella devices has emerged as an increasingly therapeutic option, unloading the failing left ventricle (LV) and improving hemodynamic status of affected patients. Impella devices should be used for the shortest time necessary to allow LV recovery because of time-dependent device-related adverse events. The weaning from Impella, however, is mostly performed in the absence of established guidelines, mainly based on the experience of the individual centres. The aim of this single center study was to retrospectively evaluate whether a multiparametrical assessment before and during Impella weaning could predict successful weaning. The primary study outcome was death occurring during Impella weaning and secondary endpoints included assessment of in-hospital outcomes. Of a total of 45 patients (median age, 60 [51-66] years, 73% male) treated with an Impella device, 37 patients underwent impella weaning/removal and 9 patients (20%) died after the weaning. Non-survivors patients after impella weaning more commonly had a previous history of known heart failure (p = 0.054) and an implanted ICD-CRT (p = 0.01), and were more frequently treated with continuous renal replacement therapy (p = 0.02). In univariable logistic regression analysis, lactates variation (%) during the first 12-24 h of weaning, lactate value after 24 h of weaning, left ventricular ejection fraction (LVEF) at the beginning of weaning, and inotropic score after 24 h from weaning beginning were associated with death. Stepwise multivariable logistic regression identified LVEF at the beginning of weaning and lactates variation (%) in the first 12-24 h from weaning beginning as the most accurate predictors of death after weaning. The ROC analysis indicated 80% accuracy (95% confidence interval = 64%-96%) using the two variables in combination to predict death after weaning from Impella. This single-center experience on Impella weaning in CS showed that two easily accessible parameters as LVEF at the beginning of weaning and lactates variation (%) in the first 12-24 h from weaning begin were the most accurate predictors of death after weaning.

Roadmap towards an institutional Impella programme for high-risk coronary interventions.

Coronary artery disease (CAD) and its complications remain the main cause of morbidity and mortality worldwide. Patients with extensive CAD and multiple comorbidities who require complex, high-risk percutaneous coronary intervention (HR-PCI) are at risk of haemodynamic instability and may require short-term mechanical circulatory support (MCS) during the procedure to maintain sufficient perfusion and prevent ischaemia. Impella is a microaxial continuous blood flow pump used for percutaneous support of the left ventricle in patients undergoing HR-PCI. Data from randomized controlled trials and registries suggested an advantage for Impella devices in patients undergoing HR-PCI, compared with other types of MCS. As a thorough understanding of the benefits and drawbacks of the Impella technology is crucial for patient outcomes, we provide a technological overview of Impella and share our experiences gathered during the implementation of institutional Impella programmes in Poland as a roadmap of selection and periprocedural care for patients treated with Impella in the setting of HR-PCI. We propose 10 steps for implementation of an institutional Impella programme for HR-PCI, including (i) dedicated staff training; (ii) standard operating procedure and troubleshooting algorithms prior to the first intervention; (iii) patient selection by the multidisciplinary Heart Team; (iv) patient preparation using multimodality imaging; (v) procedure planning in terms of large-bore access, equipment, and complete revascularization; (vi) starting with HR-PCI support; (vii) starting with femoral artery access in a patient without extensive peripheral artery disease; (viii) multidisciplinary care after the procedure; (ix) haemodynamic and laboratory monitoring to ensure immediate diagnosis of access-site complications, bleeding, haemolysis, acute kidney injury, and infections; and (x) careful revision of every HR-PCI case with the team.

The North American perspective on short-term mechanical circulatory support for cardiogenic shock: could differences in policy be driving differences in temporary mechanical circulatory support use?

Journal Article Accepted manuscript The North American Perspective on Short-term Mechanical Circulatory Support for Cardiogenic Shock: – Could Differences in Policy be Driving Differences in Temporary Mechanical Circulatory Support Use? Get access Sean van Diepen, MD, MSc, Sean van Diepen, MD, MSc Department of Critical Care Medicine, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada Address for Correspondence: Sean van Diepen, MD, MSc, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-11 St. Edmonton, AB, Canada, T6G 2B7, Tel: 780-407-6948, Email: sv9@ualberta.ca https://orcid.org/0000-0002-6688-828X Search for other works by this author on: Oxford Academic Google Scholar Alexandra Arias-Mendoza, MD, MSc, Alexandra Arias-Mendoza, MD, MSc Coronary Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, México City, México https://orcid.org/0000-0002-5942-4102 Search for other works by this author on: Oxford Academic Google Scholar Shashank S Sinha, MD, MSc Shashank S Sinha, MD, MSc Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA Search for other works by this author on: Oxford Academic Google Scholar European Heart Journal. Acute Cardiovascular Care, zuad065, https://doi.org/10.1093/ehjacc/zuad065 Published: 15 June 2023 Article history Received: 09 June 2023 Accepted: 13 June 2023 Published: 15 June 2023

Step by step daily management of short-term mechanical circulatory support for cardiogenic shock in adults in the intensive cardiac care unit: a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology SC, the European Society of Intensive Care Medicine, the European branch of the Extracorporeal Life Support Organization, and the European Association for

The use of mechanical circulatory support using percutaneous ventricular assist devices (pVAD) has increased rapidly during the last decade without substantial new evidence for their effect on outcome. In addition, many gaps in knowledge still exist such as timing and duration of support, haemodynamic monitoring, management of complications, concomitant medical therapy, and weaning protocols. This clinical consensus statement summarizes the consensus of an expert panel of the Association for Acute CardioVascular Care, European Society of Intensive Care Medicine, European Extracorporeal Life Support Organization, and European Association for Cardio-Thoracic Surgery. It provides practical advice regarding the management of patients managed with pVAD in the intensive care unit based on existing evidence and consensus on best current practice.

P87: Fracture Of A Dual Lumen Protekduo Cannula With Ventricular Perforation And Tamponade In A Recovery COVID-19 Patient

Background: In the absence of formal registry data anecdotal reports of cannula complications provide the only mechanism of risk assessment in the extended use of short term mechanical circulatory support devices. We report an unrecognized cannula fracture with perforation of the right ventricular apex and subsequent tamponade at the time of de-cannulation. Methods and Results: Patient is a 38 yo AAF with a history of asthma diagnosed with COVID 19 (nasal PCR) and admitted to an OSH with hypoxia (O2 sat 70%) and progressive dyspnea on exertion requiring HFNC and subsequent deployment of a right internal jugular 29 Fr Protek-DUO double lumen cannula with in-line oxygenator for venovenous ECMO respiratory support. After 36 days of VV ECMO support and mechanical ventilation, the patient was transferred with a diagnosis of COVID ARDS for transplant evaluation. Fourteen days post-transfer the patient was ambulatory and no longer required mechanical ventilation. No flow related issues were noted during the entire period of ECMO support (flow 2.8 to 3.4 L/min, delta P 20 mmHg or less, single oxygenator exchange on ECMO day 38). On ECMO day 67 the patients CxR was clear (Figure 1) and the RIJ cannula was removed without complication. Approximately two minutes after cannula removal the patient became unresponsive with tachycardia and hypotension (SBP 60 mmHg) which initially responded to volume resuscitation. With progressive loss of systolic blood pressure chest compressions were started with complete hemodynamic collapse. A transthoracic ECHO suggested tamponade and the chest was opened at the bedside demonstrating a chronic appearing hematoma with blood extravasation at the apex of the right ventricle (Figure 2). Bleeding was controlled with a single prolene stitch. Subsequent examination of the cannula demonstrated a fracture in the wire reinforced cannula at the point where the catheter transitioned from the apical RV into the RVOT (Figure 3). Conclusion: Given the progressive pulmonary hypertension frequently seen with prolonged COVID ECMO support, the RA to PA dual-lumen cannula has proven an effective MCS strategy (1) with survival advantage when compared to standard VV ECMO support (2). The Protek-DUO cannula was not designed for prolonged ambulatory MCS (> 60 days). Given the recent report of a seemingly identical cannula fracture event (3), clinicians should be aware of the potential for cannula fracture over time. Literature Cited (1) Mustafa AK, et al. (2020) ECMO for patients with COVID-19 in severe respiratory failure. JAMA Surg 155(10):990-992. (2) Saeed O, et al (2022) Outcomes by cannulation method for venovenous ECMO during COVID-19: a multicenter retrospective study. 46(8):1659-1668. doi: 10.1111/aor.14213. (3) Odish MF, et al (2022) Fracture right atrial-pulmonary artery cannula (Protek-DUO) in a 164-day extracorporeal membrane oxygenation bridge to lung transplant. doi: 10.1097/MAT.0000000000001879. Online ahead of print.

Outcomes of a modified, low-cost, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for elective, periprocedural support of high-risk percutaneous cardiac interventions: An experience from a latinamerican center.

High-risk procedures in interventional cardiology include a wide spectrum of clinical and anatomical scenarios related to a higher periprocedural morbidity and mortality. The prophylactic use of short-term mechanical circulatory support (ST-MCS) may improve both the safety and efficacy of the intervention by leading to more stable procedural hemodynamics. However, the significant costs may limit its use in resource constrained settings. To overcome this limitation, we ideated a modified, low-cost, veno-arterial extracorporeal membrane oxygenator (V-A ECMO) setup. We conducted an observational prospective study including all patients undergoing a high-risk interventional cardiology procedure at our institution under prophylactic ST-MCS using a modified, low-cost version of V-A ECMO, where some components of the standard V-A ECMO circuit were replaced by supplies used for cardiac surgical cardiopulmonary bypass, achieving a cost reduction of 72%. We assessed in-hospital and mid-term outcomes, including procedural success, post-procedure complications and mortality. Between March 2016 and December 2021, ten patients underwent high-risk IC procedures with prophylactic use of V-A ECMO. Isolated percutaneous intervention (PCI) was performed in six patients, isolated transcatheter aortic valve replacement (TAVR) in two, and a combined procedure (PCI + TAVR) in two. Mean ejection fraction was 34% (range 20-64%). Mean STS PROM was 16.2% (range 9.5-35.8%) and mean EuroScore was 23.7% (range 1.5-60%). The planned intervention was successfully performed in all cases. There were no reports of V-A ECMO malfunction. In nine patients the VA-ECMO was withdrawn immediately after the procedure but one patient required extended - 24h - support with no significant issues. One patient experienced a periprocedural myocardial infarction and another developed a femoral pseudoaneurysm. In-hospital and 30-day survival were 100%, and 1-year survival was 80%. High-risk procedures in interventional cardiology can be successfully performed under prophylactic ST-MCS using a modified, low-cost V-A ECMO, suitable for limited-resource settings.