Survival In Cardiogenic Shock Research Articles

Why left atrial venting fails to influence extracorporeal life support survival in cardiogenic shock: Unravelling the intricate reality of unloading.

Why left atrial venting fails to influence extracorporeal life support survival in cardiogenic shock: Unravelling the intricate reality of unloading.

Timing of Initiation of Extracorporeal Membrane Oxygenation Support and Outcomes Among Patients With Cardiogenic Shock.

Venoarterial extracorporeal membrane oxygenation (ECMO) provides full hemodynamic support for patients with cardiogenic shock, but optimal timing of ECMO initiation remains uncertain. We sought to determine whether earlier initiation of ECMO is associated with improved survival in cardiogenic shock. We analyzed adult patients with cardiogenic shock who received venoarterial ECMO from the international Extracorporeal Life Support Organization (ELSO) registry from 2009 to 2019, excluding those cannulated following an operation. Multivariable logistic regression evaluated the association between time from admission to ECMO initiation and in-hospital death. Among 8619 patients (median, 56.7 [range, 44.8-65.6] years; 33.5% women), the median duration from admission to ECMO initiation was 14 (5-32) hours. Patients who had ECMO initiated within 24 hours (n=5882 [68.2%]) differed from those who had ECMO initiated after 24 hours, with younger age, more preceding cardiac arrest, and worse acidosis. After multivariable adjustment, patients with ECMO initiated >24 hours after admission had higher risk of in-hospital death (adjusted odds ratio, 1.20 [95% CI, 1.06-1.36]; P=0.004). Each 12-hour increase in the time from admission to ECMO initiation was incrementally associated with higher adjusted in-hospital mortality rate (adjusted odds ratio, 1.06 [95% CI, 1.03-1.10]; P<0.001). The association between longer time to ECMO and worse outcomes appeared stronger in patients with lower shock severity. Longer delays from admission to ECMO initiation were associated with higher a mortality rate in a large-scale, international registry. Our analysis supports optimization of door-to-support time and the avoidance of inappropriately delayed ECMO initiation.

(723) Impact of an Institutional Allocation Protocol to Short Term Mechanical Circulatory Support to Improve Survival in Cardiogenic Shock - A Propensity Score Matched Analysis

(723) Impact of an Institutional Allocation Protocol to Short Term Mechanical Circulatory Support to Improve Survival in Cardiogenic Shock - A Propensity Score Matched Analysis

Improving Survival in Cardiogenic Shock-A Propensity Score-Matched Analysis of the Impact of an Institutional Allocation Protocol to Short-Term Mechanical Circulatory Support.

Temporary mechanical circulatory support (tMCS) is a life-saving treatment option for patients in cardiogenic shock (CS), but many aspects such as patient selection, initiation threshold and optimal modality selection remain unclear. This study describes a standard operating procedure (SOP) for tMCS allocation for CS patients and presents outcome data before and after implementation. Data from 421 patients treated for CS with tMCS between 2018 and 2021 were analyzed. In 2019, we implemented a new SOP for allocating CS patients to tMCS modalities. The association between the time of SOP implementation and the 30-day and 1-year survival as well as hospital discharge was evaluated. Of the 421 patients included, 189 were treated before (pre-SOP group) and 232 after implementation of the new SOP (SOP group). Causes of CS included acute myocardial infarction (n = 80, 19.0%), acute-on-chronic heart failure in patients with dilated or chronic ischemic heart failure (n = 139, 33.0%), valvular cardiomyopathy (n = 14, 3.3%) and myocarditis (n = 5, 1.2%); 102 patients suffered from postcardiotomy CS (24.2%). The SOP group was further divided into an SOP-adherent (SOP-A) and a non-SOP-adherent group (SOP-NA). The hospital discharge rate was higher in the SOP group (41.7% vs. 29.7%), and treating patients according to the SOP was associated with an improved 30-day survival (56.9% vs. 38.9%, OR 2.21, 95% CI 1.01-4.80, p = 0.044). Patient allocation according to the presented SOP significantly improved 30-day survival.

How Does a Protocolized Therapeutic Framework Improve Survival in Cardiogenic Shock Due to End-Stage Heart Failure?

<h3>Purpose</h3> We hypothesized that a team-based protocolized treatment framework improve survival from mechanical circulatory support (MCS) bridging to heart transplantation (HT) or left ventricular assist device (LVAD) in patients with cardiogenic shock (CS) from end-stage heart failure (ESHF) by minimizing and reversing multi-organ dysfunction (MOD) before HT or LVAD. <h3>Methods</h3> We introduced a team-based protocolized Recognize/rescue-Optimization-Stabilization-Exit/de-Escalation (ROSE) framework for CS due to ESHF in 2018. We compared 6-month survival before (G1) and after (G2) adoption of this framework. The Sequential Organ Failure Assessment (SOFA) score was used as a measure of MOD. <h3>Results</h3> We included 101 consecutive patients with CS due to ESHF. Adoption of ROSE led to earlier MCS in G2 before severe MOD (INTERMACS 2, lower lactate and SOFA score - TABLE). Ecpella was more common in G2 (32% vs 3%, p<0.001) . MCS lowered SOFA score in both groups; achieving lower SOFA scores prior to HT/LVAD in G2 (4 (2-7) vs 2 (1-5), p=0.012 FIGURE). The duration of MCS bridging were comparable (p=0.417). In G1 and G2 - 44% vs 55% (p=0.292) were bridged to HT, 13% vs 13% (p=0.947) to LVAD; and 2% vs 3% to recovery. 6-month survival was higher in G2 (FIGURE p=0.001) due to lower pre-HT/LVAD SOFA score and lactate on Cox model. Pre-HT/LVAD SOFA score of ≥9 was 73% sensitive and 100% specific (AUC 0.932) for mortality post-HT/LVAD. <h3>Conclusion</h3> Our ROSE protocol improved 6-month survival in patients with CS due to ESHF by minimizing and reducing MOD prior to HT/LVAD therapy. Pre-HT/LVAD SOFA score of ≥9 is specific for mortality post-HT/LVAD.

Lactate Clearance Is Associated With Improved Survival in Cardiogenic Shock: A Systematic Review and Meta-Analysis of Prognostic Factor Studies

ObjectiveElevated blood lactate levels are strongly associated with mortality in patients with cardiogenic shock. Recent evidence suggests that the degree and rate at which blood lactate levels decrease after the initiation of treatment may be equally important in patient prognosis. We performed a systematic review and meta-analysis to evaluate the usefulness of lactate clearance as a prognostic factor in cardiogenic shock. Methods and ResultsWe performed searches of Ovid MEDLINE, Elsevier EMBASE, EBM Reviews–Cochrane Central Register of Controlled Trials, and Web of Science to identify studies comparing lactate clearance between survivors and nonsurvivors at one or more timepoints. Both prospective and retrospective studies were eligible for inclusion. Two study investigators independently screened, extracted data, and assessed the quality of all included studies. Twelve studies were included in the meta-analysis. The median lactate clearance at 6–8 hours was 21.9% (interquartile range [IQR] 14.6%–42.1%) in survivors and 0.6% (IQR –3.7% to 14.6%) in nonsurvivors. At 24 hours, the median lactate clearance was 60.7% (IQR 58.1%–76.3%) and 40.3% (IQR 30.2%–55.8%) in survivors and nonsurvivors, respectively. Accordingly, the pooled mean difference in lactate clearance between survivors and nonsurvivors at 6–8 hours was 17.3% (95% CI 11.6%–23.1%, P < .001) at 6–8 hours and 27.9% (95% CI 14.1%–41.7%, P < .001) at 24 hours. ConclusionsSurvivors had significantly greater lactate clearance at 6–8 hours and at 24 hours compared with nonsurvivors, suggesting that lactate clearance is an important prognostic marker in cardiogenic shock.

Elevated Plasma Bioactive Adrenomedullin and Mortality in Cardiogenic Shock: Results from the OptimaCC Trial.

Aims: Bioactive adrenomedullin (bio-ADM) was recently shown to be a prognostic marker in patients with acute circulatory failure. We investigate the association of bio-ADM with organ injury, functional impairment, and survival in cardiogenic shock (CS). Methods: OptimaCC was a multicenter and randomized trial in 57 patients with CS. In this post-hoc analysis, the primary endpoint was to assess the association between bio-ADM and 30-day all-cause mortality. Secondary endpoints included adverse events and parameters of organ injury or functional impairment. Results: Bio-ADM values were higher in 30-day non-survivors than 30-day survivors at inclusion (median (interquartile range) 67.0 (54.6–142.9) pg/mL vs. 38.7 (23.8–63.6) pg/mL, p = 0.010), at 24 h (p = 0.012), and up to 48 h (p = 0.027). Using a bio-ADM cutoff of 53.8 pg/mL, patients with increased bio-ADM had a HR of 3.90 (95% confidence interval 1.43–10.68, p = 0.008) for 30-day all-cause mortality, and similar results were observed even after adjustment for severity scores. Patients with the occurrence of refractory CS had higher bio-ADM value at inclusion (90.7 (59.9–147.7) pg/mL vs. 40.7 (23.0–64.7) pg/mL p = 0.005). Bio-ADM values at inclusion were correlated with pulmonary vascular resistance index, estimated glomerular filtration rate, and N-terminal pro-B-type natriuretic peptide (r = 0.49, r = –0.47, and r = 0.64, respectively; p < 0.001). Conclusions: In CS patients, the values of bio-ADM are associated with some parameters of organ injury and functional impairment and are prognostic for the occurrence of refractory CS and 30-day mortality.

VA-ECMO improves survival in cardiogenic shock.

VA-ECMO improves survival in cardiogenic shock.

An outlook on biomarkers in cardiogenic shock.

Cardiogenic shock is a severe complication with mortality rates of ∼50% that requires a rapid and complex management to aid and identify the highest and lowest risk patients. To that end, novel cardiogenic shock biomarkers are needed to improve risk stratification and to personalize therapy. Established biomarkers such as BNP, NT-proBNP, ST2, and troponins provide insufficient predictive value in cardiogenic shock. More recent biomarkers, including DPP3, adrenomedullin, angiopoietin 2, and the CS4P score are gaining momentum. DPP3 showed early prediction of refractory status and survival in cardiogenic shock. The CS4P score is based on the levels of liver fatty acid-binding protein (L-FABP), beta-2-microglobulin (B2M), fructose-bisphosphate aldolase B (ALDOB), and SerpinG1 (IC1). These proteins are not cardiac-specific but reflect multiorgan dysfunction, systemic inflammation, and immune activation. The CS4P improved reclassification of 32% of patients compared with the CardShock risk score. A new wave of research focused on novel proteomic and molecular techniques, is providing new candidates that promise to aid clinical decision-making and patient stratification in cardiogenic shock. The CS4P score is emerging as the most robust, yet it requires prospective validation in cardiogenic shock patients managed with circulatory and ventricular assist devices.

MANAGEMENT AND OUTCOMES OF CARDIOGENIC SHOCK IN CARDIAC ICUS WITH AND WITHOUT SHOCK TEAMS: DATA FROM THE CRITICAL CARE CARDIOLOGY TRIALS NETWORK (CCCTN) REGISTRY

Single-center studies suggest that multi-disciplinary shock teams facilitating early use of invasive hemodynamics and mechanical circulatory support (MCS) devices are associated with better survival in cardiogenic shock (CS). The goal of this analysis was to characterize outcomes and practice

Incidence and Outcomes of Acute Kidney Injury Requiring Renal Replacement Therapy in Patients on Percutaneous Mechanical Circulatory Support with Impella-CP for Cardiogenic Shock.

Background: Acute kidney injury (AKI) complicating cardiogenic shock is associated with increased mortality. We hypothesize that renal replacement therapy (RRT) improves survival in cardiogenic shock supported by Impella-CP (Abiomed, Danvers, MA) complicated by AKI.Methods: A retrospective chart review identified 34 patients on Impella-CP for cardiogenic shock between January 2015 and December 2017. AKI was defined as an increase in serum creatinine≥0.3 mg/dL from baseline. Three groups were analyzed: AKI plus RRT, AKI minus RRT, and no AKI. Pre-existing dialysis patients were excluded. The only indication for RRT was AKI not responding to diuretics. Thirty-day mortality was analyzed.Results: There were 13 patients with no AKI, 9 with AKI plus RRT groups, and 12 with AKI minus RRT. Thirty-day mortality was similar between no AKI and AKI plus RRT groups [30.8% (4/13) vs.22.2% (2/9), p=0.48; relative risk [RR] 2.25 (95% confidence interval [CI] 0.22-22.1)]. Thirty-day mortality was higher in AKI minus RRT group compared to the no AKI group [75.0% (9/12) vs. 30.8% (4/13); p=0.03; RR 6.75 (95% CI 1.16-39.2)].Conclusion: In cardiogenic shock patients on Impella-CP, AKI minus RRT is associated with a higher 30-day mortality compared to patients without AKI and/or patients with AKI plus RRT. Short-term mortality may improve in cardiogenic shock patients with AKI who are treated with RRT.

Usefulness of Intra-aortic Balloon Pump in Patients With Cardiogenic Shock

Predictors of survival in cardiogenic shock (CS) treated with intra-aortic balloon pump (IABP) are not clearly understood. In this retrospective study, we sought to evaluate patient characteristics and impact of timing of IABP in treatment of CS. Patients presenting to the Yale New Haven Hospital in CS who received IABP between February 2013 and April 2017 were included in the study. We assessed baseline characteristics and clinical predictors of 30-day mortality. Hundred ninety-three (n = 193) patients were included in this study. Mean age was 68.8 ± 14.5 years. Thirty percent (30%) were women, 38% had cardiac arrest, and left ventricular ejection fraction was 33.7 ± 14.9%. Overall 30-day mortality was 36%. Thirty-day mortality was 24% when IABP was placed within less than 1 hour of onset of CS versus 49% when implanted ≥1 hour after recognition of CS (p = 0.001). Mortality was 18%, 21%, 36%, and 74% for patient requiring 0, 1, 2, and 3 or more inotropes after IABP placement (p < 0.001). In multivariate analysis, advancing age, cardiac arrest on presentation, time to IABP implantation, and number of inotropes needed after IABP implantation predicted 30-day mortality. In the 193 patients, 134 (69.4%) presented with CS from ACS and 59 (30.6%) with CS from non-ACS-related causes. No difference in mortality was noted between the ACS and non-ACS groups 34.3% versus 40.7% (p = 0.39). In conclusion, early use of IABP in CS was associated with significant improvement in 30-day mortality regardless of the etiology of CS. Continued need for significant inotropic support after IABP is associated with worse prognosis and maybe used as an indicator for need to escalate to higher levels of support.

Correction to: Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients.

Because of a technical error, the code corresponding to the outcome for the Basir et al. cohort was mis-implemented in the original version of our article. Characteristics of the cohort are in fact the followings.

ECMO and Short-term Support for Cardiogenic Shock in Heart Failure.

This review aims to discuss the role of ECMO in the treatment of cardiogenic shock in heart failure. Trials done previously have shown that IABP does not improve survival in cardiogenic shock compared to medical treatment, and that neither Impella 2.5 nor TandemHeart improves survival compared to IABP. The "IMPRESS in severe shock" trial compared Impella CP with IABP and found no difference in survival. A meta-analysis of cohort studies comparing ECMO with IABP showed 33% improved 30-day survival with ECMO (risk difference 33%; 95% CI 14-52%; p= 0.0008; NNT 3). ECMO is indicated in medically refractory cardiogenic shock. ECMO can be considered in cardiogenic shock patients with estimated mortality of more than 50%. ECMO is probably the MCS of choice in cardiogenic shock with; biventricular failure, respiratory failure, life-threatening arrhythmias and cardiac arrest.

Epinephrine and short-term survival in cardiogenic shock: an individual data meta-analysis of 2583 patients.

Catecholamines have been the mainstay of pharmacological treatment of cardiogenic shock (CS). Recently, use of epinephrine has been associated with detrimental outcomes. In the present study we aimed to evaluate the association between epinephrine use and short-term mortality in all-cause CS patients. We performed a meta-analysis of individual data with prespecified inclusion criteria: (1) patients in non-surgical CS treated with inotropes and/or vasopressors and (2) at least 15% of patients treated with epinephrine administrated alone or in association with other inotropes/vasopressors. The primary outcome was short-term mortality. Fourteen published cohorts and two unpublished data sets were included. We studied 2583 patients. Across all cohorts of patients, the incidence of epinephrine use was 37% (17-76%) and short-term mortality rate was 49% (21-69%). A positive correlation was found between percentages of epinephrine use and short-term mortality in the CS cohort. The risk of death was higher in epinephrine-treated CS patients (OR [CI] = 3.3 [2.8-3.9]) compared to patients treated with other drug regimens. Adjusted mortality risk remained striking in epinephrine-treated patients (n = 1227) (adjusted OR = 4.7 [3.4-6.4]). After propensity score matching, two sets of 338 matched patients were identified and epinephrine use remained associated with a strong detrimental impact on short-term mortality (OR = 4.2 [3.0-6.0]). In this very large cohort, epinephrine use for hemodynamic management of CS patients is associated with a threefold increase of risk of death.

TCT-551 Lactate Clearance is a Prognostic Marker for Survival in Cardiogenic Shock Receiving Early Percutaneous Mechanical Circulatory Support

The survival of patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) remains low despite early revascularization. The evolving percutaneous mechanical circulatory support (MCS) device options provide the possibility of a brighter future, however markers are needed to

Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock

The role and timing of percutaneous mechanical circulatory support (MCS) devices in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS) are not well understood. We sought to evaluate patient characteristics and predictors of outcomes in patients presenting with AMICS supported with an axial flow percutaneous MCS device; 287 consecutive unselected patients enrolled in the catheter-based ventricular assist device registry presenting with AMICS who underwent percutaneous coronary intervention (PCI) were included in this analysis. All patients were supported with either the Impella 2.5 or Impella CP. Mean patient age was 66 ± 12.5years, 76% were men, and mean left ventricular ejection fraction was 25 ± 12%. Before receiving MCS, 80% of patients required inotropes or vasopressors and 40% were supported with intra-aortic balloon pump; 9% of patients were under active cardiopulmonary resuscitation at the time of MCS implantation. Survival to discharge was 44%. In a multivariate analysis, early implantation of a MCS device before PCI (p= 0.04) and before requiring inotropes and vasopressors (p= 0.05) was associated with increased survival. Survival was 66% when MCS was initiated <1.25hours from shock onset, 37% when initiated within 1.25 to 4.25hours, and 26% when initiated after 4.25hours (p= 0.017). Survival was 68%, 46%, 35%, 35%, and 26% for patients requiring 0, 1, 2, 3, and ≥4 inotropes before MCS support, respectively (p<0.001). In conclusion, MCS implantation early after shock onset, before initiation of inotropes or vasopressors and before PCI, is independently associated with improved survival in patients presenting with AMICS.

(127) - A Shock Team Improves Survival in Cardiogenic Shock by Decreasing Time to Intervention

(127) - A Shock Team Improves Survival in Cardiogenic Shock by Decreasing Time to Intervention

TCT-446 Effect of Intra-Aortic Balloon Counterpulsation on Short-Term Survival in Cardiogenic Shock due to Acute Coronary Syndromes

To compare the outcome of percutaneous coronary intervention (PCI) treatment with intra-aortic balloon counterpulsation (IABP) versus PCI without IABP on 30-days survival in patients with cardiogenic shock (CS) due to acute coronary syndromes (STEMI and non-STEMI). We extracted data for all

Role of receptor for advanced glycation end products in cardiogenic shock*

Activation of the receptor for advanced glycation end products by its ligands promotes inflammatory processes and tissue injury. The available evidence suggests that soluble forms of receptor for advanced glycation end products circulating in the plasma may neutralize the ligand-mediated damage by acting as a decoy. Thus, it is hypothesized that receptor for advanced glycation end products expression might be deleterious, whereas soluble receptor for advanced glycation end products might be beneficial in cardiogenic shock. However, until now, no data exist regarding the role of soluble receptor for advanced glycation end products and receptor for advanced glycation end products in humans with cardiogenic shock complicating myocardial infarction. Prospective observational cohort study. Intensive critical care unit of a university hospital. Forty patients with cardiogenic shock complicating acute myocardial infarction, 20 age-matched patients with acute uncomplicated myocardial infarction and, 20 age-matched healthy volunteers. None. Monocytic receptor for advanced glycation end products expression assessed by flow cytometry was significantly increased in cardiogenic shock nonsurvivors (137.02±7.48 mean fluorescence intensity; n=13) compared to survivors (67.80±8.33 mean fluorescence intensity; n=17; p<.001). Conversely, nonsurvivors had significantly decreased plasma soluble receptor for advanced glycation end products levels (79.87±10.62 arbitrary units; n=13; p=.004) compared to survivors (127.65±10.52 arbitrary units; n=17) as assessed by Western blotting. Receptor for advanced glycation end products expression and soluble receptor for advanced glycation end products levels were determined as independent predictors for 28-day mortality in cardiogenic shock confirmed by receiver-operator characteristics and multivariate analysis (receptor for advanced glycation end products: area under the curve, 0.943±0.05; p<.001; soluble receptor for advanced glycation end products: area under the curve, 0.815±0.08; p<.01). Both receptor for advanced glycation end products>103.6 mean fluorescence intensity or soluble receptor for advanced glycation end products<76.88 arbitrary units independently predicted a 27.87-fold (p<.001) and a 3.97-fold (p=.019) increase in 28-day mortality in cardiogenic shock. Enhanced monocytic receptor for advanced glycation end products expression and decreased plasma soluble receptor for advanced glycation end products levels play a central role in patients with cardiogenic shock associated with proinflammatory and destroying pathways, resulting in an enhanced 28-day mortality-rate. Receptor for advanced glycation end products and soluble receptor for advanced glycation end products may be prognostic biomarkers for survival in cardiogenic shock and might represent a novel therapeutic target in cardiogenic shock.