Temporary Circulatory Support Research Articles

Durable left ventricular assist devices following temporary circulatory support on a microaxial flow pump with and without extracorporeal life support

ObjectiveCirculatory support with a catheter-based microaxial flow pump (mAFP) plays a major role in the treatment of severe cardiogenic shock. In most patients who fail to recover while on temporary mechanical circulatory support (tMCS) and who are not eligible for heart transplantation, durable left ventricular assist device (dLVAD) implantation is usually considered a reliable option.The aim of this study was to describe the outcome of dLVAD therapy following mAFP support and identify mortality predictors. MethodsRetrospective analysis of data from a multicenter registry on patients who underwent dLVAD implantation following tMCS with a mAFP between 01/2017 and 10/2022 (n=332) from 19 European centers. ResultsPatients were supported with an Impella 5.5 (92), 5.0 (153) or CP (87) and transitioned to a HeartWare HVAD (128) or Heartmate 3 (204) during the same period. One hundred and twenty-five (39.2%) patients additionally required extracorporeal life support before and or during mAFP therapy. The 30-day and 1-year survival were 87.8% and 71.1%, respectively. The following risk factors for 1-year mortality were identified: age (OR 1.02), specifically age over 55 years (OR 1.09), BMI >30 kg/m2 (OR 2.2), female sex (OR for male sex 0.43), as well as elevated total bilirubin (OR 1.12) and low platelet counts (OR 0.996). ConclusionsBased on the identified risk factors, a risk score to estimate 1 year mortality was calculated to optimize patient selection for LVAD implantation.

Feasibility of standby ECMO with preset femoral vascular sheaths for high-risk transcatheter aortic valve replacement

Objective Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary circulatory and respiratory support allowing hemodynamic stabilization during high-risk transcatheter aortic valve replacement (TAVR). However, the optimal timing of VA-ECMO use in high-risk TAVR remains controversial. We aimed to report our experience using a novel standby ECMO strategy during high-risk TAVR. Methods We retrospectively evaluated consecutive patients who received high-risk TAVR with standby ECMO between March 1,2023 and March 1,2024 at the Beijing Anzhen Hospital. Small, 5F or 6F sheaths were placed in ipsilateral femoral vein and artery before TAVR procedures. The primary outcome of this study was survival to hospital discharge with good neurological recovery defined as cerebral performance category (CPC) 1-2. Results A total of 24 patients undergoing high-risk TAVR with standby ECMO were included. Six (25.0%) of the 24 patients with standby ECMO suffered from cardiogenic shock or cardiac arrest and required emergency VA-ECMO institution. The median (IQR) cannulation time was 8 (6–11) minutes, and the median (IQR) ECMO duration was 35 (24–48) hours. All of the 24 patients underwent successful TAVR procedures and survival to hospital discharge with CPC1-2. Conclusions Standby ECMO with preset femoral vascular sheaths was feasible and effective for refractory cardiogenic shock and cardiac arrest during high-risk TAVR.

The physiology of venoarterial extracorporeal membrane oxygenation - A comprehensive clinical perspective.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become a standard of care for severe cardiogenic shock, refractory cardiac arrest and related impending multiorgan failure. The widespread clinical use of this complex temporary circulatory support modality is still contrasted by a lack of formal scientific evidence in the current literature. This might at least in part be attributable to VA ECMO related complications, which may significantly impact on clinical outcome. In order to limit adverse effects of VA ECMO as much as possible an indepth understanding of the complex physiology during extracorporeally supported cardiogenic shock states is critically important. This review covers all relevant physiological aspects of VA ECMO interacting with the human body in detail. This, to provide a solid basis for health care professionals involved in the daily management of patients supported with VA ECMO and suffering from cardiogenic shock or cardiac arrest and impending multiorgan failure for the best possible care.

Extended and Safe Support with the CentriMag® Temporary Ventricular Assist Device Implanted with Skirted-Cannula Technique.

CentriMag® (Abbott, Pleasanton, CA, USA) is indicated for temporary circulatory support for up to 30 days. Extended support is not uncommon, and the results vary considerably. Herein, we review our experience on extended support. We retrospectively analyzed 19 patients supported with CentriMag as a bridge to recovery, long-term ventricular assist device or transplantation from September 2011 to October 2021. Nineteen patients (16 men and 3 women; mean age 51.7 ± 9.2 years) had CentriMag left ventricular assist device (LVAD) implantation with the skirted-cannula technique. Twelve (63.2%), 6 (31.6%), and 1 (5.3%) patient were in INTERMACS 1, 2, and 3, respectively. The aims of support were bridge-to-decision in 3 patients (15.8%), and bridge-to-transplantation in 16 patients (84.2%). Fourteen patients were supported for longer than 30 days, while 5 patients had their CentriMag removed before 30 days. Of the 5 patients supported for less than 30 days, 3 died early after implantation due to complications of prolonged shock. The other 2 patients were successfully transplanted. Among the 14 patients supported for longer than 30 days, 1 patient died after transplantation and 13 patients survived either after transplantation or weaning off CentriMag. The overall 1-year survival rate was 73.7%. The duration of support for all patients ranged from 6 to 191 days (64 ± 61 days; median 41 days). The skirted cannula technique for apical cannulation in implantation of CentriMag LVAD is an easy, safe and durable technique. Immediate post-operative and long-term complications are not common. Its use over 30 days is associated with acceptable survival.

Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery

ObjectivesPatients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle. MethodsPreoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed. ResultsA total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation. ConclusionsThe combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.

P5: Red Blood Cell Distribution Width in Patients with Cardiogenic Shock Supported with Impella 5.5 Temporary Percutaneous Microaxial Left Ventricular Assist Device

Background: Severe cardiogenic shock with metabolic derangement can preclude candidacy to durable left ventricular assist device (LVAD) or cardiac transplant, but may be reversed with temporary mechanical circulatory support. Our primary aim was to determine if red cell distribution width- coefficient of variation (RDW-CV) differed among survivors and non-survivors during their admission with temporary circulatory support. Methods: A series of 27 consecutive patients supported with Impella 5.5 percutaneous microaxial LVAD were reviewed retrospectively. All implants were performed via a tunneled vascular graft anastomosed to the right subclavian artery to allow ambulation. RDW-CV was recorded at admission and at the end of circulatory support. The series was divided into survivors and non-survivors. Groups were compared using Student’s t-test. Results: Surviving patients had a lower percentage of males (79% vs 88%), their cardiomyopathy was more likely to be non-ischemic (58% vs 25%), and were slightly younger (62 vs 69.5 years old) than non-survivors. RDW-CV at the end of Impella support was significantly different between those that survived [median RDW-CV 16.8], and those that did not [median RDW-CV 19.98] (p=0.04). Conclusion: In patients supported with temporary circulatory support with Impella 5.5, RDW-CV is significantly lower among patients that survive to discharge when compared to non-survivors.

Total outflow graft thrombosis: From permanent circulatory support to temporary circulatory support by deactivating HeartMate 3™ and implanting Impella 5.5® in a high urgent bridge to transplant concept

X-ray shows a male patient with two left ventricular assist devices. Initial presentation was with intermittent low-flow-alarms.

Heart Allocation Change and Multiple Temporary Circulatory Support as Bridge-to-Bridge

IntroductionWe investigated how the 2018 Organ Procurement and Transplantation Network heart allocation policy change was associated with changes in characteristics and outcomes of candidates receiving multiple temporary mechanical circulatory support (mtMCS) devices. Materials and methodsWe included adult heart transplant candidates listed October 2014-January 2018 and October 2018-January 2022 in the United Network of Organ Sharing dataset. Prepolicy and postpolicy mtMCS recipients were compared at listing, transplant, 90-days, and 1-year post-transplant. Time between first and second devices and time between first device and transplant were modeled via multivariable linear regression. Transplantation likelihood was modeled using competing risks analysis. ResultsPostpolicy, a higher proportion of transplant candidates received mtMCS (4% versus 1%, P < 0.001), and received their second device an adjusted 49 d sooner versus prepolicy (P = 0.001). Time to transplant was also an adjusted 35 d shorter postpolicy, with an 80% increased transplantation likelihood versus prepolicy (95% confidence interval: 1.6-1.9, P < 0.001). Postpolicy patients experienced reduced waitlist mortality (8% versus 14%, P = 0.04) with marked improvements in 90-day (93% versus 85%, P < 0.001) and 1-year (88% versus 70%, P = 0.01) post-transplant survival. ConclusionsPostpolicy mtMCS recipients are more likely to progress to transplantation sooner on the waitlist and their shorter waitlist course together with earlier change to a secondary device was associated with improved post-transplant survival versus prepolicy.

Abstract 11629: Multicenter Development and Validation of a Machine Learning Risk Model to Predict Right Ventricular Failure Following Mechanical Circulatory Support: The STOP-RVF Score

Introduction: Existing models predicting right ventricular failure (RVF) after durable left ventricular assist device (LVAD) support are limited due to lack of multicenter validation, absence of intraoperative characteristics, and marginal predictive power. We sought to derive and validate a risk model to predict post-LVAD RVF. Methods: Advanced heart failure (HF) patients (N=798) requiring continuous-flow LVAD were enrolled at the Utah Transplant Affiliated Hospitals (n=477), Inova Heart &amp; Vascular Institute (n=183), and Henry Ford Medical Center (n=138). Baseline clinical and intraoperative characteristics were recorded. The primary outcome was RVF incidence, defined as the need for right VAD (RVAD) or intravenous inotropes for &gt;14 days. Bootstrap imputation and lasso variable selection were used to derive a predictive model which was then validated. A risk calculator was developed classifying patients into risk groups, and survival was compared. Results: Patients were predominantly white (72%), males (84%), aged 56±13 years. Patients in the RVF and non-RVF groups were comparable in terms of sex, age, and LVAD indication, while RVF patients more commonly had a history of systemic hypertension, non-ischemic cardiomyopathy, lower INTERMACS profiles, and more commonly required inotropic or temporary circulatory support pre-LVAD. Overall, 193 (24.2%) patients developed RVF with 109 (56.5%) requiring inotropes and 84 (43.5%) an RVAD. Multivariable predictors for RVF are shown in the Figure and achieved a c-statistic of 0.74 (95% CI: 0.70-0.78). Inclusion of intraoperative characteristics did not improve model performance. Cumulative survival was higher in the minimal risk group compared to low, moderate, and high. Conclusions: The STOP-RVF calculator effectively stratifies the risk for RVF after LVAD support by implementing routinely collected clinical data. It could impact patient selection and peri-operative management of advanced HF patients.

Impact of Pre-Operative Right Ventricular Response to Hemodynamic Optimization on Outcomes in Patients with LVADs.

Background: Right ventricular failure (RVF) continues to affect patients supported with durable left ventricular assist devices (LVAD) and results in increased morbidity and mortality. Information regarding the impact of right ventricular response to pre-operative optimization on outcomes is scarce. Methods: Single-center retrospective analysis of consecutive patients who underwent first continuous flow LVAD implantation between 2006 and 2020. Patients with bi-ventricular support before LVAD or without hemodynamic data were excluded. Invasive hemodynamics at baseline and after pre-operative medical and/or temporary circulatory support were recorded. Patients were grouped in the following categories: A: No Hemodynamic RV dysfunction (RVD) at baseline; B: RVD with achievement of RV hemodynamic optimization goals; C: RVD without achievement of RV optimization goals. The main outcomes were right ventricular failure defined as inotropes >14 days after implantation, or postoperative right ventricular mechanical support, and all-cause mortality. Results: Overall, 128 patients were included in the study. The mean age was 58 ± 12.5 years, 74.2% were males and, 68.7% had non-ischemic cardiomyopathy. Hemodynamic RVD was present in 70 (54.7%) of the patients at baseline. RV hemodynamic goals were achieved in 46 (79.31%) patients with RVD and in all the patients without RVD at baseline. Failure to achieve hemodynamic optimization goals was associated with a significantly higher risk of RVF after LVAD implantation (adjusted OR 4.37, 95% CI 1.14–16.76, p = 0.031) compared with no RVD at baseline and increased 1-year mortality compared with no RVD (adjusted HR 4.1, 95% CI 1.24–13.2, p = 0.02) and optimized RVD (adjusted HR 6.4, 95% CI 1.6–25.2, p = 0.008).Conclusion: Among patients with RVD, the inability to achieve hemodynamic optimization goals was associated with higher rates of RV failure and increased 1-year all-cause mortality post LVAD implantation.

Mechanical Circulatory Support Devices for the Treatment of Cardiogenic Shock Complicating Acute Myocardial Infarction-A Review.

Cardiogenic shock complicating acute myocardial infarction is a complex clinical condition associated with dismal prognosis. Routine early target vessel revascularization remains the most effective treatment to substantially improve outcomes, but mortality remains high. Temporary circulatory support devices have emerged with the aim to enhance cardiac unloading and improve end-organ perfusion. However, quality evidence to guide device selection, optimal installation timing, and post-implantation management are scarce, stressing the importance of multidisciplinary expert care. This review focuses on the contemporary use of short-term support devices in the setting of cardiogenic shock following acute myocardial infarction, including the common challenges associated this practice.

P42: Institutional Review of Temporary Circulatory Support Configurations for Cardiogenic Shock

Patients experiencing cardiogenic shock continue to suffer a high mortality risk despite advances and innovation in temporary mechanical circulatory support (MCS). Providers now have many tools in the armamentarium to support patients in varied etiologies of cardiogenic shock ranging from acute coronary syndrome, non-ischemic cardiomyopathy (nICM) with end-stage heart failure and postoperative-cardiotomy biventricular dysfunction. Although instituting VA-ECMO rapidly restores circulation and perfusion in cardiopulmonary failure, alternative MCS configurations may be preferred depending on the unique etiology for cardiac decompensation. A retrospective observational review was performed on our institutional data for patients in cardiogenic shock requiring MCS stratifying into those receiving ECMO only versus VA ECMO and Impella (Ecpella) support. An analysis was conducted to evaluate whether metrics including ICU length of stay, days on CRRT ECMO and mechanical ventilation are affected by the MCS configuration in specific etiologies of cardiogenic shock. Charts were reviewed from present time to 2017 with inclusion criteria of patients having documentation of VA ECMO support. Patients who had ECMO for non-cardiac intraoperative arrests, septic shock or ARDS respiratory failure were excluded. 202 patient chart were included into the analysis in which patients received VA ECMO only or Ecpella support. Figure 1 delineates grouping into cohorts: ischemic cardiomyopathy (ICM) including acute coronary syndrome, non-ischemic cardiomyopathy (nICM), and postoperative cardiogenic shock. Data analyzed included duration of days on ECMO, CRRT and mechanical ventilation as well as ICU length of stay (LOS). Statistical analysis was performed using independent t-test to report significance between sample groups. The composite and stratified averages for the metrics in patients who survived are shown in tables 1 and 2. Although not statistically significant, the patients supported by Ecpella in the nICM cohort had reduced days on devices as well as ICU LOS. In contrast, patients receiving ECMO only in the ICM cohort had shorter days on devices and ICU LOS. The postoperative cardiogenic shock cohort did not appear to have any significant trends in the analyzed metrics. Composite mortality rate was 0.63 vs 0.72 in the ECMO only vs Ecpella group. nICM patients appear to benefit from ventricular unloading with impella support during MCS that allows for improved end-organ recovery as evident by shorter days on supportive devices while awaiting myocardial recovery versus bridge to durable therapy. In contrast, prompt restoration of perfusion in ICM patients with ECMO alone may facilitate and expedite myocardial recovery, obviating the need for a left ventricular decompression device. Further studies are necessary to confirm whether pathophysiologic differences of cardiogenic shock in nICM vs ICM cause recovery to be more receptive to particular MCS configurations.

Pre- and post-operative mechanical circulatory support in surgical repair of post-acute myocardial infarction mechanical complications.

The outcomes of patients with acute myocardial infarctions (AMI) have significantly improved with advances in early reperfusion strategies; however, patients with massive infarcts or those who do not receive timely revascularization may develop mechanical complications of AMI. The most common mechanical complications are ventricular septal rupture (VSR), acute mitral regurgitation (MR) due to papillary muscle rupture, and free-wall rupture. Each complication is associated with a high risk of morbidity and mortality, and requires a multidisciplinary approach for prompt diagnosis and hemodynamic stabilization. Surgery is the mainstay of therapy but is associated with poor outcomes if performed too early during the treatment course for VSR or if performed too late with MR and free wall rupture. Optimal timing for surgery in combination with temporary circulatory support may be a feasible strategy for better results.

Results of Temporary Right Heart Assist Device Implantation Following Right Heart Failure

<h3>Purpose</h3> Temporary circulatory support (TCS) is often needed in right heart failure (RHF). The aim of this study was to conduct a peri- and postoperative analysis of patients with the ProtekDuo® dual lumen canula temporary right ventricular assist device (t-RVAD). <h3>Methods</h3> From 2/2015 to 2/2021, 60 patients (53 male, 88,3%) underwent t-RVAD implantation at our center. In a retrospective single center analysis, we evaluated pre-, intra-, and postoperative data. <h3>Results</h3> Mean age at the time of admission was 56 years ± 13. 87% were male patients. Causes of RHF were: ICMP (32%), DCMP (27%), myocarditis (10%), lung embolism (2%), right ventricular infarction (15%), primary graft failure (3%), secondary RHF after LVAD implantation (8%), Danon disease (2%), not identifiable (2%).Concomitant left ventricular assist device (LVAD) implantations were: HVAD (12%), HM3 (32%), Impella® (12%). T-RVAD implantation secondary to permanent LVAD implantation was performed in 3 patients and 6 patients with ongoing Impella® support were upgraded to temporary BIVAD with an additional t-RVAD. Weaning was performed in 42 patients (70%). After t-RVAD, 3 patients were bridged to durable RVAD and 1 was bridged to heart transplantation. In-hospital mortality was 38%, with 18 patients dying on t-RVAD support. Causes of in-hospital death were low cardiac output (74%), bleeding (13%), hemorrhagic stroke (8,7%) and necrotic pancreatitis (4%). Mean ventilation time was 126 hours ± 128 hours. An oxygenator was added to the circuit in 28%. Mean t-RVAD support time was 15 days ± 10 days with a decrease in central venous pressure from 18 ± 6 vs. 12 ± 5 mmHg, p < 0.01, and an increase in central venous saturation 62 ± 15 vs. 76 ± 7 %, p< 0.01. Overall, 33 patients (55%) could be successfully weaned from t-RVAD and discharged home. Mean hospital stay was 62 days, with 27 days on ICU. Full mobilization was possible in 50% of patients, with all patients being at least mobilized to the edge of the bed. Exchange of the ProtekDuo® was performed in 2 cases for canula thrombosis and dislocation, respectively. All female patients died during their initial hospital stay. <h3>Conclusion</h3> Right heart failure affects a heterogenous patient cohort as demonstrated by our analysis. Groin-free percutaneous implantation of the ProtekDuo® dual lumen cannula allows full mobilization, non-surgical explantation and easy addition of an oxygenator in a clinical setting.

Outcome of Temporary Circulatory Support As a Bridge-to-Left Ventricular Assist Device Strategy in Cardiogenic Shock Patients.

Temporary circulatory support (TCS) as a bridge-to-left ventricular assist device (BTL) in cardiogenic shock patients has been increasing, but limited data exists on this BTL strategy. We aimed at analyzing the outcome of BTL patients in a population of cardiogenic shock patients compared with those without TCS at the time of the left ventricular assist device (LVAD) surgery and identify predictors of postoperative mortality in this specific population. A multicenter retrospective observational study conducted in 19 centers from 2006 to 2016. Nineteen French centers. A total of 329 cardiogenic shock patients at the time of LVAD implantation were analyzed. Patients were divided in three groups: those under TCS at the time of LVAD implantation (n = 173), those with TCS removal before LVAD surgery (n = 24), and those who did not undergo a bridging strategy (n = 152). Primary endpoint was 30-day mortality. None. Among the BTL group, 68 (39.3%), 18 (10.4%), and 15 (8.7%) patients were under venoarterial extracorporeal membrane oxygenation, Impella, and IABP support alone, and 72 patients (20.6%) were under multiple TCS support. BTL patients presented similar 30 days survival compared with the TCS removal and non-BTL groups. However, BTL group had a significantly longer ICU duration stay, with two-fold duration of mechanical ventilation time, but the three groups experienced similar postoperative complications. Multivariate analysis identified three independent predictors of mortality in the BTL group: combined surgery with LVAD, body mass index (BMI), and heart failure (HF) duration. BTL strategy was not an independent predictor of mortality in cardiogenic shock patients who underwent LVAD. BTL strategy is not associated with a lower survival among cardiogenic shock patients with LVAD implantation. Predictors of mortality are combined surgery with LVAD, higher BMI, and HF duration.

Current applications and outcomes of venoarterial extracorporeal membrane oxygenation based on 6 years of experience: risk factors for in‑hospital mortality.

Data regarding venoarterial extracorporeal membrane oxygenation (VA ECMO) as a temporary circulatory support in cardiogenic shock (CS) for Central Europe are scarce. The aim of the study was to disclose indications, in-hospital, and long-term (1-year) mortality along with risk factors. The study is a retrospective investigation of patients who underwent VA ECMO for CS at a cardiosurgical tertiary center, from January 2013 to June 2018. A broad spectrum of pre- and postimplantation factors was tested using univariable analysis. A total of 198 patients met the inclusion criteria. The median (interquartile range) duration of support was 207 (91–339) hours, with no significant disparity among hospital survivors and nonsurvivors (P = 0.09). A total of 40.4% of patients died during ECMO support, while the joined in-hospital and 6-month mortality progressed to 65.2%, and 1-year mortality to 67.2%; 9% underwent a subsequent heart transplantation. Main adverse events were bleeding (76%), infection (56%), neurologic injury (15%), and limb ischemia (15%). Multiorgan failure was the most decisive risk factor of in-hospital mortality (odds ratio, 4.45; P <⁠0.001). Patients with postcardiotomy CS had a significantly lower out-of-hospital survival rate than the nonsurgical group (32.3% vs 45%; log-rank P = 0.037). The study showed survival benefit, despite frequent complications. The protocol focusing on proper candidate selection and timing can positively impact patient survival. Additional risk reduction can be achieved with a further increase of the team experience with ECMO.

Current applications and outcomes of venoarterial extracorporeal membrane oxygenation based on six years of experience. Risk factors for in-hospital mortality

Abstract Introduction The data about use of venoarterial ECMO as a temporary circulatory support system in cardiogenic shock (CS) for Central Europe are scarce. Objectives The aim was to disclose the indications, in-hospital and long-term (1 year) mortality along with risk factors. Patients and methods The study is a retrospective investigation of patients who underwent VA ECMO support for the CS in the cardiac and cardiosurgical tertiary centre, from January 2013 to June 2018. We tested a broad spectrum of pre– and post-implantation factors along with their impact on mortality using univariate logistic regression analysis. Results 198 patients met the inclusion criteria. The median duration of support was 207 (IQR 91–339) hours, with no significant disparity in the length of support among hospital survivors and nonsurvivors (p=0.09). 40,4% of all patients deceased during ECMO support, while the joined in-hospital and six-month mortality progressed to 65,2% and one-year mortality to 67,2%. 9% underwent subsequent heart transplantation. The most frequent adverse events were bleeding (76%), infection (56%), neurologic injury (15%) and limb ischemia (15%). Multi-organ failure was identified as the most decisive risk factor of in-hospital mortality (OR 4,45, p&amp;lt;0,001). Patients with postcardiotomy cardiogenic shock had a significantly lower out-of-hospital survival rate than those with decompensated heart failure (32,3% vs 45%, log-rank p=0,037). The learning curve of our centre is noted with the lowest survival in the first two years of ECMO employment in comparison to the following 6-year period. Conclusion The outcomes of the study reinforce the clear survival benefit, despite frequent complications. The protocol focusing on proper candidate selection and timing can positively impact patients survival. The additional risk reduction can be achieved with the further increase of the team experience with ECMO. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Cardiology in Warsaw, Poland - research grant. Figure 1Figure 2

Association between lowering heart rate during IMPELLA support and favorable short-term outcome in patients with cardiogenic shock

Abstract Background Impella has been increasingly used in patients with cardiogenic shock (CGS). Target values for clinical indices for appropriate management of Impella have not yet been established. Purpose We aimed to elucidate the association between heat rate (HR) during Impella treatment in patients with CGS and clinical outcomes. Methods and results We retrospectively evaluated 62 patients (68±14 years; male 77%) with CGS receiving temporary circulatory support with the Impella between February 1, 2019, and February 31, 2021. The primary end point was 30-day mortality. Clinical characteristics, laboratory and hemodynamic markers at implantation of Impella (baseline), 12, 24 hr after implantation, and removal of Impella were assessed. There were 28 patients with concomitant use of extracorporeal membrane oxygenation (ECMO). Treatment periods using Impella were 8±6 days. After excluding 11 patients who died during Impella support, the relationship between clinical indicators at each time points and 30-day mortality was evaluated. There were 22 patients (43%) with 30-day mortality. Factors associated with 30-day mortality were: female, ECMO, higher 24-hr lactate level, lower 24-hr cardiac power output, and higher HR at removal. Lower HR of ≤81 bpm at removal was found to most accurately predict lower 30-day mortality (Figure 1). Higher increases in dose of beta-blockers during Impella support and lower absolute doses of norepinephrine at removal were correlated with decreases in HR during Impella support. Conclusions In patients with CGS treated with Impella, lower HR at removal was associated with lower incidence of 30-day mortality. Lowering HR during Impella treatment was recognized as a simple indicator for favorable clinical outcomes in patients with CGS. It was suggested that chronotropic interventions during Impella treatment may be novel therapeutic options in patients with CGS. Funding Acknowledgement Type of funding sources: None. Figure 1

Systems of Care in Cardiogenic Shock.

Outcomes for cardiogenic shock (CS) patients remain relatively poor despite significant advancements in primary percutaneous coronary interventions (PCI) and temporary circulatory support (TCS) technologies. Mortality from CS shows great disparities that seem to reflect large variations in access to care and physician practice patterns. Recent reports of different models to standardize care in CS have shown considerable potential at improving outcomes. The creation of regional, integrated, 3-tiered systems, would facilitate standardized interventions and equitable access to care. Multidisciplinary CS teams at Level I centers would direct care in a hub-and-spoke model through jointly developed protocols and real-time shared decision making. Levels II and III centers would provide early access to life-saving therapies and safe transfer to designated hub centers. In regions with large geographical distances, the implementation of telemedicine-cardiac intensive care unit (CICU) care can be an important resource for the creation of effective systems of care.

New challenges in cardiac intensive care units.

Critical care cardiology is a steadily and rapidly developing sub-specialization within cardiovascular medicine, since the first emergence of a coronary care unit in the early 1960s. Today, modern cardiac intensive care units (CICU) serve a complex patient population with a high burden of cardiovascular and non-cardiovascular critical illnesses. Treatment of these patients requires a multidisciplinary approach, with a combination of highly specialized knowledge and skills in cardiovascular diseases, as well as emergency, critical-care and internal medicine. The CICU has always posed special challenges to both experienced intensivists as well as fellows-in-training (FIT) and is certainly one of the most demanding training phases. In recent years, these challenges have grown significantly owing to technological innovations, with new and steadily rising numbers of complex interventional procedures and new options for temporary circulatory support for critically ill patients, such as venoarterial extracorporeal membrane oxygenation (VA-ECMO). Herein, we focus on the successful CICU management of these special patient cohorts, which must become an integral part of critical-care training.