Short-term Mechanical Support Research Articles

Circulating biomarkers of the CS4P and CLIP scores are not altered in a pig model of acute cardiogenic shock and additional short-term circulatory support

BackgroundCardiogenic shock (CS) is the leading cause of death in patients with myocardial infarction with a mortality rate greater than 50%. Recently, the CS 4 Proteins (CS4P) and CLIP scores have been developed to predict survival in CS patients. However, their impact in acute CS and additional short-term left ventricular (LV) circulatory support as prognostic markers is currently not known. Methods and resultsCS was induced in a porcine model by injecting microsphere particles into the left main coronary artery. Mechanical circulatory support was performed by additional percutaneous LV unloading using an Impella microaxial flow-pump for 30 minutes. Serum samples were collected at baseline, following the onset of CS, and additional LV unloading. Serum levels of biomarkers of the CS4P (beta-2-microglobulin, ALDOB, L-FABP, SerpinG1) and the CLIP scores (Cystatin C, Lactate, Interleukin-6, NT-proBNP) were neither different at any time point investigated nor did they correlate with cardiac output. ConclusionThe CS4P and CLIP scores do not reflect immediate whole-body dysregulation in acute CS and have not been able to predict the potential reversal following additional short-term mechanical support by LV unloading in our experimental model. The impact of both scores as prognostic markers after the immediate onset of CS and following additional short-term LV unloading to identify patients at greatest risk remains to be determined.

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.

(934) Short-Term Mechanical Support with the Impella 5.x for Mitral Valve Surgery in Advanced Heart Failure

(934) Short-Term Mechanical Support with the Impella 5.x for Mitral Valve Surgery in Advanced Heart Failure

Short-Term Mechanical Support Devices During High-Risk Percutaneous Coronary Interventions: In-Hospital Outcomes and Predictors of Major Adverse Cardiac and Cerebrovascular Events

Short-Term Mechanical Support Devices During High-Risk Percutaneous Coronary Interventions: In-Hospital Outcomes and Predictors of Major Adverse Cardiac and Cerebrovascular Events

Intra-aortic balloon pump in patients with acute advanced heart failure. Results from a single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with advanced heart failure are frequently referred to cardiac intensive care unit (CICU) for hemodynamic support. Despite optimum pharmacological therapy many of these patients persist in critical condition, demanding short term circulatory support until recovery or heart transplantation. Intra-aortic balloon pump is commonly used in patients with advanced heart failure in order to stabilize hemodynamically compromised patients as bridge to decision for further therapies. Purpose To investigate the outcomes of patients with acute advanced heart failure referred to cardiac intensive care unit and supported with short term mechanical support. To explore the hemodynamic effects of the Intra-aortic balloon pump therapy in these patients. Material & Method We retrospectively analyzed the data from 104 patients with acute advanced heart failure (either as worsening of existing symptoms of chronic HF or as first onset of HF). All patients had severe left ventricular dysfunction, which was frequently associated with right ventricular dysfunction and increased NT pro BNP levels. Demographic data were collected including co-morbidities. Laboratory data included NT-pro BNP, total bilirubin, serum creatinine, urea and baseline e GFR (MDRD Formula). All patients received IABP support and underwent right heart catheterization. Measurements were made before and after the insertion of the IABP. The study has been approved by the Scientific Committee and the Ethics Committee of the Hospital. Results The mean age of the sample was 44 ± 12 years. 76 patients (73, 08%) were male. 20 patients (19, 23%) were of ischemic etiology. The median time on IABP support for the entire cohort was 13 days (3 – 41, 25). There was statistically significant decrease in the NT-pro BNP levels (p<0, 0001). There was improvement in renal function (e GFR (p<0, 0001) and urea levels (p< 0,001)). There was statistically significant improvement in the right heart catheterization measurements (decrease of the right atrium pressure (p <0, 0001), of the PA pressure (p<0,001), and of the pulmonary capillary wedge pressure (p<0,001)). IABP provided clinical stabilization in 88 patients (87, 62%), that is completed pre-transplant evaluation and proceeded in surgery with permanent mechanical support or heart transplantation or transfer to regular ward, while 16 patients (15, 38%) ended up in CICU while being on IABP. Conclusions In this single center study the use of IABP improved the laboratory findings and the hemodynamic status of patients admitted in the cardiac intensive care unit with acute advanced heart failure. It was an effective method of managing patients as bridge to decision for further therapies.

Effect of Donor Age on Posttransplant Mortality in Pediatric Heart Transplant Recipients: A 10-Year Nationwide Cohort Study

<h3>Purpose</h3> The French heart allocation system prioritizes pediatric over adult candidates. This policy seeks to address the shortage of pediatric donor hearts. Consequently, pediatric candidates frequently receive organ from adult donors. An association between donor age and posttransplant mortality has been shown in adult heart recipients. This study aimed to evaluate the effect of donor age on posttransplant mortality in pediatric heart recipients. <h3>Methods</h3> All candidates registered on the national waiting list before 18 years old between January, 1^st 2010 and December 31^st 2020 who underwent transplantation were included in this cohort study using the national registry Cristal. Recipient characteristics at transplant in addition to donor characteristics were analyzed. The main outcome was 1-year posttransplant survival estimated with Kaplan-Meier method. Relationship between donor age and 1 year mortality was assessed with a Cox proportional hazard model with donor age as a continuous variable transformed with restricted cubic splines. <h3>Results</h3> Of the 274 transplant recipients (148 males, <6 years n=69, 6-10 years n=47, 11+ years n=158, cardiomyopathy n=174, congenital heart disease n=46, retransplantation n=13, other n=41) 115 were on inotropic infusion, 32 on short-term mechanical support (MCS) and 45 on long-term MCS at transplant. Among donors, 129 were female, head trauma was the cause of death in 132, 101 had cardiopulmonary resuscitation and 159 (58%) were >17 years old. One-year posttransplant survival was 93%. Congenital heart disease and retransplantation were associated with posttransplant mortality. Donor age was not associated with hazard ratio for 1-year mortality (Figure). <h3>Conclusion</h3> Allocation of adult donor hearts to elective and urgent pediatric candidates through pediatric priority statutes can address the shortage of pediatric donor organs without affecting posttransplant outcomes.

Heart Transplantation Utilizing Organs Following Donation After Circulatory Death (DCD)

<h3>Purpose</h3> Donation after circulatory death (DCD) is gaining momentum for heart transplantation worldwide. Central to the process is a detailed assessment of the donor heart following the circulatory arrest and unpredictable warm ischemia time. Our team used the Organ Care System as the principal means of assessment and preservation of the DCD hearts. Here we describe our single centre experience with DCD heart transplantation. <h3>Methods</h3> Between 2015 and 2021, 36 donor hearts were procured via the DCD pathway. Donor management involved the withdrawal of treatment (WoT) in the donor, stand-down time of 5 minutes following circulatory arrest (asystole), transfer of the patient to the operating theatre, collection of 1.2L donor blood from right atrium for Organ Care System (OCS) prime, delivery of cardioplegia and its procurement. The organs were assessed utilizing OCS and 25 suitable hearts that met the criteria of suitability were transplanted. <h3>Results</h3> The mean age of donors was 30.6±10.7 years (12% females) with intracranial haemorrhage and hypoxic brain damage as main causes of WoT. 52% of the donors suffered cardiac arrest before hospital admission, 25% had a history of cocaine abuse and 48% were current smokers. Mean WoT to asystole time was 11.8±4.1 min, mean WoT to cardioplegia time was 23.1±4.6 min and a mean functional warm ischemia time was 16.3±3.5 min. The mean OCS perfusion time was 245 ±81min.The mean recipient age was 42.6±13.2 years (12% females) with dilated (64%) and ischemic (24%) cardiomyopathy as an aetiology of heart failure in the majority. 6 (24%) patients had long term LVAD while 2(8%) were supported on short-term mechanical support per-operatively.9 (36%) patients required mechanical circulatory support postoperatively with ECMO and IABP and 20 (80%) required continuous renal replacement therapy. The mean ICU stay was 17.8±16.5 days and the mean hospital stay was 45±40 days. Postoperative survival at 30-days was 88%. <h3>Conclusion</h3> Donor hearts procured following donation after circulatory death were transplanted with acceptable short-term survival especially given the high proportion of preoperative mechanical circulatory support and urgency of transplantation in our cohort. ‘Direct procurement and perfusion' method of procurement in DCD offers an opportunity to assess the donor heart for the suitability of transplantation.

CRT-100.17 Short-Term Mechanical Support Devices During High-Risk Percutaneous Coronary Interventions: In-Hospital Outcomes and Predictors of Major Adverse Cardiac and Cerebrovascular Events

CRT-100.17 Short-Term Mechanical Support Devices During High-Risk Percutaneous Coronary Interventions: In-Hospital Outcomes and Predictors of Major Adverse Cardiac and Cerebrovascular Events

Extension of cardiopulmonary bypass outside the operating room as a short-term bridge to recovery "the poor man's ECMO".

This report describes the use of conventional cardiopulmonary bypass (CPB) circuit beyond the operating room to the critical care unit to provide cardiopulmonary support for patients requiring emergent resuscitation as well as short-term support for rest and recovery of the heart. We modified the CPB circuit and created a closed extra corporeal membrane oxygenation (ECMO) circuit using a conventional oxygenator excluding the venous reservoir. We believe that this technique provides a short-term mechanical support and also acts as a bridge to recovery, or a bridge to decision, in very limited resource settings.

Independent risk factors for ICU mortality after left ventricular assist device implantation.

Left ventricular assist devices (LVADs) are used as an alternative therapy for heart transplantation in patients with advanced heart failure. However, the mortality rate of these patients remains relatively high. A large proportion of deaths after LVAD implantation occur during intensive care unit (ICU) stay. We conducted a retrospective study to identify the risk factors for all-cause ICU mortality in patients with an implanted LVAD. Between January 1, 2008 and December 31, 2016, 70 consecutive patients who had received an LVAD were analyzed. The median ICU length of stay was 14days (IQR: 8-31) and 16 patients (22.9% [95%CI: 13.1-32.7]) died in the ICU. The 90-day mortality rate was 25.7% (95%CI: 15.5-35.9). The main causes of ICU mortality were: multiple organ failure, stroke, and hemorrhagic events. The univariate analysis identified the following perioperative risk factors for all-cause ICU mortality: hypertension, preoperative platelet count, preoperative white cell count, inotropic support before LVAD implantation, mechanical ventilation before LVAD implantation, renal replacement therapy before LVAD implantation, short-term mechanical support before LVAD implantation, INTERMACS class 1 to 2, low intraoperative platelet count, low early postoperative hemoglobin level, low early postoperative platelet count, low early postoperative pH, and massive perioperative blood transfusion. In the multivariate logistic regression analysis, only mechanical ventilation before LVAD implantation was retained as an independent risk factor for ICU mortality (OR=11.96 [95%CI: 2.67-53.45], P<.01). These findings confirm that most deaths after LVAD implantation occur in the ICU. Patients that receive mechanical ventilation preoperatively have the highest risk of death. This confirms the need to actively treat respiratory failure and to wean patients from respiratory support before LVAD implantation. Such a strategy offers the best opportunity to initiate active rehabilitation.

Racial Discrepancies between Caucasians and African-Americans in Peripartum Cardiomyopathy Requiring Mechanical Circulatory Support

Background Peripartum Cardiomyopathy (PPCM) is a rare form of cardiomyopathy diagnosed in the last month of pregnancy or up to five months postpartum in the absence of other underlying etiology. PPCM can result in cardiogenic shock or end-stage heart failure requiring mechanical circulatory support (MCS). It is unclear if there are any racial discrepancies in outcomes of patients requiring MCS. Method We queried the data from the National Inpatient Sample database from 2003-2014 to identify patients with the diagnosis of PPCM using the International Classification of Disease (ICD-9) codes 674.5x. Among the patients with PPCM we then identified those requiring short term mechanical support devices (Intra-aortic balloon pump, Impella, Centrimag, Extracorporeal membrane oxygenation), Ventricular assist devices (VAD) and Orthotopic Heart Transplant (OHT) using the corresponding (ICD-9) codes 33.6, 37.5, 37.51, 37.60 37.61, 37.62 37.65, 37.66, 37.68, 39.65. Using ANOVA and Chi-Square analysis, we compared the differences in outcomes in Caucasian and African American (AA) races with PPCM requiring MCS. Results We identified 16,014 Caucasians and 15,537 AA patients with PPCM. Baseline characteristics including mean age, income quartile was similar except for a difference in average income quartile between Caucasian and AA with PPCM requiring VAD (2.49 vs 1.75, p = 0.02). In Caucasians, 2.03% (325/16,104) required MCS and in AA patients, 1.91% (297/15,537) required MCS, showing no difference between the two races. However, increased in-hospital mortality was noted in AA compared to Caucasians requiring short term MCS (20.9% vs 11.94%, p = 0.02) or requiring OHT (6.95% vs 0% p =0.02). There was a trend towards an increase in mortality in AA requiring VAD (16.51% vs 8.27%, p = 0.066) although it wasn't statistically significant. There was no significant difference in average total charges and average length of stay between Caucasian and AA in all three subgroups. We also noted an uptrend in the use of MCS in PPCM over the years as noted in the graph. Conclusion AA group had higher mortality rates in patients requiring MCS when compared to Caucasians. The reasons for these disparities remain unclear and further investigation is much needed given an uptrend use of MCS in patients with PPCM over the years.

Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is an established method of short-term mechanical support for patients in cardiogenic shock, but can create left ventricular (LV) distension. This paper analyzes the physiologic basis of this phenomenon and treatment methods. This is a retrospective review of the existing literature on VA ECMO and LV distension. We undertook a PubMed review of all peer-reviewed papers focusing on VA ECMO, LV distension, and LV venting. We reviewed these papers and synthesized our findings. We also will discuss the various methods of LV venting and venting strategies we use at Columbia. LV distension is becoming an increasingly appreciated aspect of caring for patients on VA ECMO support. The literature demonstrates that the consequences of failing to anticipate, recognize, and treat LV distension are grave, and will worsen an already distended and hypocontractile LV. Myocardial recovery will be hindered, and LV thrombus formation more likely. Early recognition and aggressive management of LV distension is paramount in helping care for this critically ill patient population.

Outcomes in Cardiogenic Shock from Acute Coronary Syndrome Depending on Severity of Obesity

We reviewed 54,044 adult cases of cardiogenic shock (CS) accompanying acute coronary syndrome from the 2005 to 2014 Nationwide Inpatient Sample. We evaluated outcomes among patients who were nonobese, obese (body mass index 30.0 to 39.9 kg/m2) and extremely-obese (body mass index ≥40 kg/m2). A multivariate analysis was performed to assess their impact on in-hospital mortality. There were 3,602 (6.6%) and 1,610 (2.9%) admissions among patients who were obese and extremely-obese. Those obese and extremely-obese were younger compared with the nonobese (62.7 vs 61.2 vs 68.8 years, respectively; p <0.01) but had significantly greater comorbidity burden. CS patients who were not-obese were most likely to have an associated ST elevation myocardial infarction, compared with the obese and extremely-obese (67.7% vs 65.9% vs 60.7%; p <0.01). Compared to the nonobese, patients who were obese had higher rates of percutaneous coronary intervention (55.8% vs 51.5%; p <0.01) and coronary artery bypass grafting (24.0% vs 16.0%; p <0.01) whereas those extremely-obese had higher coronary artery bypass grafting rates (23.9% vs 16.0%; p <0.01) but similar percutaneous coronary intervention rates (51.1% vs 51.5%; p = 0.74). Short-term mechanical support use was lowest among the nonobese followed by the extremely-obese and obese. Adjusted analysis revealed that obesity predicted less (adjusted odd ratio 0.82, 95% confidence interval 0.76 to 0.90) and extreme-obesity predicted higher in-hospital mortality (adjusted odds ratio 1.17, 95% confidence interval 1.05 to 1.32) compared with the nonobese. In conclusion, obesity and extreme-obesity are associated with greater comorbidity burden among ACS related CS admissions. Obesity predicted less in-hospital mortality, whereas extreme obesity was associated with elevated in-hospital mortality.

Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions.

Short-term mechanical support by veno-arterial extracorporeal membrane oxygenation (VA ECMO) is more and more applied in patients with severe cardiogenic shock. A major shortcoming of VA ECMO is its variable, but inherent increase of left ventricular (LV) mechanical load, which may aggravate pulmonary edema and hamper cardiac recovery. In order to mitigate these negative sequelae of VA ECMO, different adjunct LV unloading interventions have gained a broad interest in recent years. Here, we review the whole spectrum of percutaneous and surgical techniques combined with VA ECMO reported to date.

Increased Short-Term and Mid-Term Major Complications Were Observed in Elderly Patients with Renal Dysfunction after Surgical Ventricular Restoration.

This study was conducted to explore the impact of renal dysfunction on short-term and mid-term outcomes in elderly patients. Patients over 65 years of age receiving surgical ventricular restoration (SVR) were included in the study. They were stratified through estimated glomerular filtration rate (eGFR), with a cutoff point of 60 mL/min/1.73m2. Risk-adjusted analysis, including propensity score matching, was carried out to compare short-term and mid-term outcomes between the two groups of patients. From January 1999 to December 2015, a total of 280 elderly patients underwent SVR. Of the patients, 79 had eGFR lower than 60 mL/min/1.73m2 and were considered to have renal dysfunction. Mortality was higher in the renal dysfunction group than the normal renal function group, with marginal significance (adjusted P value = .06). The need for mechanical supports (adjusted P value = .04) was higher in the renal dysfunction group. Hemofiltration (adjusted P value < .01) and requirements for transfusion (adjusted P value = .03) were significantly higher in the renal dysfunction group than in the group with normal renal function. The presence of renal dysfunction was associated with higher risk of major adverse cerebro-cardiovascular events (MACCE) than normal renal function (HR = 2.34, 95% CI = 1.34 - 4.08, P = .003). Compared to patients with normal renal function, elderly SVR patients with renal failure have a higher incidence of short-term mechanical support, mid-term mortality, and MACCE events.

Corrigendum to: Percutaneous short-term active mechanical support devices in cardiogenic shock: a systematic review and collaborative meta-analysis of randomized trials.

Corrigendum to: Percutaneous short-term active mechanical support devices in cardiogenic shock: a systematic review and collaborative meta-analysis of randomized trials.

TCT-588 Percutaneous Short-Term Active Mechanical Support Devices in Cardiogenic Shock: A Systematic Review and Collaborative Meta-Analysis of Randomized Trials

The impact on clinical outcome of active mechanical circulatory support (MCS) devices in cardiogenic shock (CS) has not been fully elucidated yet. This collaborative meta-analysis of randomized trials thus aimed to investigate the efficacy and safety of percutaneous active MCS versus control in CS

P1500Percutaneous short-term active mechanical support devices in cardiogenic shock: a collaborative meta-analysis of randomised trials

P1500Percutaneous short-term active mechanical support devices in cardiogenic shock: a collaborative meta-analysis of randomised trials

Long-Term Outcomes of Pediatric Cardiac Patients Supported by Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation is an important form of short-term mechanical support in children with cardiac disease, but information on long-term outcomes and quality of life is limited. The primary objective of this study was to determine the long-term outcomes of children previously supported by extracorporeal membrane oxygenation for cardiac etiologies. A retrospective analysis was performed on patients with cardiac disease managed with extracorporeal membrane oxygenation between January 1, 1995, and December 31, 2012, at the Children's Hospital of Philadelphia. Survivors completed patient- and parent-reported verbal and written surveys, and univariate analyses assessed risk factors for long-term outcomes. Tertiary-care children's hospital. Patients with cardiac disease managed with extracorporeal membrane oxygenation. None. Over 18 years, 396 patients were managed with extracorporeal membrane oxygenation with 43% survival to discharge. The median age at cannulation was 78 days. The majority had congenital heart disease (86%), surgery prior to extracorporeal membrane oxygenation (71%), and cardiopulmonary arrest as the primary extracorporeal membrane oxygenation indication (53%). With 6-year median follow-up, 66% are known to be deceased, including 38 deaths after hospital discharge. Among survivors at discharge, 65 (38%) completed the phone survey, and 33 (19%) completed the written survey. Negative clinical outcomes, defined as having at least significant physical limitations or "fair" or "poor" health, were present in 18% of patients. No patient- or extracorporeal membrane oxygenation-related variables were associated with negative outcomes in univariate analyses. There were significantly lower self-reported and parent-reported written Pediatric Quality of Life Inventory quality of life scores in children compared with healthy individual normative data but no differences in adolescents. In this series of pediatric cardiac patients supported by extracorporeal membrane oxygenation, mortality was 66% with 6-year median follow-up. The majority reported positive outcomes with respect to health and physical limitations, but children reported lower quality of life compared with healthy individuals.

The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology.

Extracorporeal membrane oxygenation (ECMO) is a technology capable of providing short-term mechanical support to the heart, lungs or both. Over the last decade, the number of centres offering ECMO has grown rapidly. At the same time, the indications for its use have also been broadened. In part, this trend has been supported by advances in circuit design and in cannulation techniques. Despite the widespread adoption of extracorporeal life support techniques, the use of ECMO remains associated with significant morbidity and mortality. A complication witnessed during ECMO is the inflammatory response to extracorporeal circulation. This reaction shares similarities with the systemic inflammatory response syndrome (SIRS) and has been well-documented in relation to cardiopulmonary bypass. The exposure of a patient’s blood to the non-endothelialised surface of the ECMO circuit results in the widespread activation of the innate immune system; if unchecked this may result in inflammation and organ injury. Here, we review the pathophysiology of the inflammatory response to ECMO, highlighting the complex interactions between arms of the innate immune response, the endothelium and coagulation. An understanding of the processes involved may guide the design of therapies and strategies aimed at ameliorating inflammation during ECMO. Likewise, an appreciation of the potentially deleterious inflammatory effects of ECMO may assist those weighing the risks and benefits of therapy.