Temporary Mechanical Circulatory Support Devices Research Articles

Discordance between aPTT and anti-Xa in monitoring heparin anticoagulation in mechanical circulatory support.

It is unclear whether activated partial thromboplastin time (aPTT) or anti-Xa is more accurate for monitoring heparin anticoagulation in mechanical circulatory support (MCS) patients. This study investigates the relationship between aPTT and anti-Xa in MCS patients and identifies predictors of discordance. aPTT and anti-Xa were simultaneously measured in a prospective cohort of MCS patients receiving unfractionated heparin at a tertiary academic medical centre. Therapeutic aPTT and anti-Xa levels were 60-100s and 0.3-0.7IU/mL, respectively, and concordance was defined as both levels being subtherapeutic, therapeutic, or supratherapeutic. To identify predictors of discordance, both a machine learning random forest model and a multivariate regression model were applied to patient demographics, device type, and 14 laboratory variables; 23001 pairs of simultaneously measured aPTT/anti-Xa were collected from 699 MCS patients. aPTT and anti-Xa were concordant in 35.5% of paired observations and discordant in 64.5% (aPTT>antiXa 61.5%; aPTT<antiXa 3.0%). Discordance with a high aPTT relative to anti-Xa (aPTT>antiXa) was associated with high INR, eGFR, and total bilirubin, as well as low platelets, haemoglobin, pre-albumin, white blood cell count, and haptoglobin. Total artificial heart and durable ventricular assist devices were more likely to be associated with aPTT>anti-Xa than temporary MCS devices. aPTT and anti-Xa were frequently discordant in MCS patients receiving heparin anticoagulation. Clinical conditions common in MCS patients such as concurrent warfarin use, malnutrition, haemolysis, and thrombocytopenia, as well as durable type of MCS devices were associated with a high aPTT relative to anti-Xa.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational multicentric prospective study

Abstract Funding Acknowledgements None. Background Although temporary mechanical circulatory support devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process from VA-ECMO although there are no standardized protocols. Purpose We sought to evaluate the accuracy of echocardiographic indices in predicting successful weaning from VA-ECMO in CS patients. We tested total isovolumic time (tIVT), an index of ventricular performance(1,2), and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; E/e’ at mitral valve; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Multicentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Waning trials were performed daily starting from 48 hours after VA-ECMO institution. A stepwise decrease of VA-ECMO blood flow was applied, until reaching 1 or 1.5 L/min. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died in hospital for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (Figure 1-A): stroke volume (SV) &amp;gt;13.2 ml (HR 4.12 [1.71-9.95], p 0.002), tIVT &amp;gt;23.6 min/sec (HR 0.14 [0.02-1.03], p 0.053), LV VTI &amp;gt;6.6 cm (HR 4.99 [1.94-12.87], p&amp;lt;0.001), MAPSE &amp;gt;6.15 mm (HR 4.42 [1.90-10.24], p 0.001), TAPSE &amp;gt;11 mm (HR 10.13 [1.37-7.02], p 0.023), RV S’ &amp;gt;7 cm (HR 5.40 [1.45-20.12], p 0.012). LVEF, E/e’ and S’ at mitral valve did not reach the statistical significance. Figure 1-B shows Kaplan-Meier analysis on echocardiographic indices collected during the last weaning trial; figure 2 details HR of all these parameters. Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Parameters reflecting ventricular activation and systo-diastolic interaction already demonstrated superiority in defining ventricular performance. Considering the known limitations of LVEF (HR, loading and LV dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation in the acute setting.

Complications and Outcomes in 39,864 Patients Receiving Standard Care Plus Mechanical Circulatory Support or Standard Care Alone for Infarct-Associated Cardiogenic Shock.

Temporary mechanical circulatory support devices (tMCS) are increasingly being used in patients with infarct-associated cardiogenic shock (AMICS). Evidence on patient selection, complications and long-term outcomes is lacking. We aim to investigate differences in clinical characteristics, complications and outcomes between patients receiving no tMCS or either intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (V-A ECMO) or Impella® for AMICS, with a particular focus on long-term outcomes. Using health claim data from AOK-Die Gesundheitskasse (local health care funds), we retrospectively analysed complications and outcomes of all insured patients with AMICS between 1 January 2010 and 31 December 2017. A total of 39,864 patients were included (IABP 5451; Impella 776; V-A ECMO 833; no tMCS 32,804). In-hospital complications, including renal failure requiring dialysis (50.3% V-A ECMO vs. 30.5% Impella vs. 29.2 IABP vs. 12.1% no tMCS), major bleeding (38.1% vs. 20.9% vs. 18.0% vs. 9.3%) and sepsis (22.5% vs. 15.9% vs. 13.9% vs. 9.3%) were more common in V-A ECMO patients. In a multivariate analysis, the use of both V-A ECMO (HR 1.57, p < 0.001) and Impella (HR 1.25, p < 0.001) were independently associated with long-term mortality, whereas use of IABP was not (HR 0.89, p < 0.001). Kaplan-Meier estimates showed better survival for patients on IABP compared with Impella, V-A ECMO and no-tMCS. Short- and long-term mortality was high across all groups. Our data show noticeably more in-hospital complications in patients on tMCS and higher mortality with V-A ECMO and Impella. The use of both devices is an independent risk factor for mortality, whereas the use of IABP is associated with a survival benefit.

Contemporary approach to cardiogenic shock care: a state-of-the-art review.

Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.

Impact of high-profile transvalvular pumps in heasrt failure related cardiogenic shock

Abstract Background Heart failure-related cardiogenic shock (HF-CS) not related to acute MI is a leading cause of CS.(1) Congestion is a major predictor of mortality among patients with HF-CS, for whom in-hospital mortality remains between 25-40%.(2,3) Both low-profile (Impella CP) and high-profile (Impella 5.0/5.5) transvalvular pumps are used to manage these patients. In the last few years, use of Impella 5.0/5.5 pumps in these patients is increasing, although it is often used as an escalation strategy from other temporary mechanical circulatory support (tMCS) devices. Purpose To assess the impact of LV unloading using high profile transvalvular pump (Impella 5.0/5.5) compared to a low-profile pump (Impella CP) on outcomes in HF-CS. Methods The Cardiogenic Shock Working Group (CSWG) is a large, multi-center international prospective registry of CS patients.(1) For this analysis, we retrospectively reviewed patients with HF-CS who underwent Impella 5.0/5.5 therapy for HF-CS and compared them to patients who underwent an Impella CP. Patients who received an Impella device as part of their escalation strategy from another device (IABP) or concomitant or de-escalation strategy with ECMO were excluded. Results Of the 2,755 patients with HF-CS, 125 patients received an Impella 5.0/5.5 while 152 patients received an Impella CP alone; 13 patients were escalated from an Impella CP to 5.0/5.5 pump. Of these 292 patients who either received an Impella CP or 5.0/5.5 or a combination of the two, 228(78%) were male, 208(71%) were white with a mean LVEF at presentation of 19%. About a third (n=78, 27%) presented with de-novo HF-CS while 214(73%) were acute on chronic HF-CS. In-hospital mortality in the entire HF-CS cohort was 717(26%). Unadjusted mortality was higher in those who underwent Impella CP alone (n= 57; 38%) compared to patients with Impella 5.0/5.5 (n=27, 23%; p=0.01). This improvement in mortality was seen in acute on chronic HF-CS with Impella 5.5/5.0 vs CP (41% vs 26%, p=0.02), and as a trend in de-novo HF-CS (30% vs 14%, p=0.13). More patients on Impella 5.0/5.5 went on to receive heart replacement therapies (durable LVAD or heart transplantation) compared to Impella CP (56% vs 9%, p&amp;lt;0.001). Conclusion(s) Use of a high-profile transvalvular pump (Impella 5.0/5.5) was associated with improved mortality compared to a low-profile transvalvular pump (Impella CP) in HF-CS.

Abstract 14879: Stroll in Style: Rocking the MCS Catwalk!

Introduction: Patients who present with cardiogenic shock may require temporary mechanical circulatory support (tMCS) devices in the ICU. Hypothesis: Physical therapy (PT) and rehabilitation is associated with improved outcomes. But literature investigating the feasibility and safety of mobilization in patients on tMCS is limited. Methods: In this survey-based study, we examined various practice patterns in ambulating patients supported on tMCS globally. We received 93 responses of which 73 (80.22%) were from United States. Results: 82 programs believed that mobilization improved outcomes in these patients. Of these 81 programs (87.1%) ambulate patients supported on tMCS, but only 61 programs (65.59%) have an MCS trained physical therapist ambulating patients on tMCS. 72 programs (77.42%) reported staffing issues as a limiting factor in mobilizing these patients. (Figure 1) 82 programs (88.17%) would change the cannulation site for more convenient patient mobilization. 59 (63.44%) programs reported complications associated with mobilization which included device/cannula dislodgement, pump malfunction, bleeding, hemolysis, etc. (Figure 2) Only 41 programs (44.1%) have a guideline or protocol to ambulate these patients. Conclusions: We conclude that current state of PT in patients on tMCS is suboptimal and needs a uniform standardized protocol. Most programs need an experienced physical therapist to facilitate mobilization of these patients. We also outlined various patient and device related factors which can improve mobilization and outcomes in these patients. More studies are needed to assess impact of mobilization on outcomes and length of stay.

Abstract 16305: Closing the Disparities Gap for Heart Transplant Patients Bridged to Transplant With Temporary Mechanical Circulatory Support

Background: There are known disparities in waitlist outcomes by race and sex among patients bridged to heart transplant (BTT) with durable mechanical circulatory support (MCS). With the increasing use of temporary MCS devices (tMCS), we examined waitlist and post-transplant outcomes of patients who had BTT with tMCS. Methods: Data from the United Network for Organ Sharing (UNOS) database was used to identify patients BTT with tMCS between 2008 and 2018. Patients were stratified by race and sex. Primary outcomes were waitlist mortality within 1 year of listing and 1 year post-transplant mortality among those who successfully reached transplant. Survival was examined with the Kaplan Meier method and Cox proportional hazard modeling. Results: A total of 997 patients received tMCS as BTT, including 606 white, 203 Black, 119 Hispanic, 56 Asian, 13 other race, and 302 (30%) female patients. Baseline hemodynamics were comparable among groups. Waitlist mortality within 1 year of listing was 35.8% overall and similar for all races (p=0.418) and both sexes (p=0.617). Among those who successfully reached transplant, there were no differences in 1 year post-transplant survival by race (p=0.722) or sex (p= 0.475). On multivariable Cox proportional hazard modeling, neither race nor sex was associated with waitlist or post-transplant mortality (p=NS). Level of education (&lt;high school) was independently associated with 1 year waitlist mortality (HR 1.49, 95% CI 1.06 - 2.06). History of diabetes (HR 1.38, 95% CI 1.07-1.74) and post-transplant dialysis (HR 1.66, 95% CI 1.18-2.29) were associated with 1 year post transplant mortality. Conclusions: Unlike in BTT with durable MCS, we did not find differences in outcomes associated with race and sex among patients BTT with tMCS. Given the sharp increase in tMCS use after the 2018 U.S. allocation change, it will be important to closely monitor that access to transplantation and outcomes of BTT with tMCS patients continue to be equitable.

Network meta-analysis of temporary mechanical circulatory support in acute myocardial infarction cardiogenic shock

We performed a network meta-analysis of 11 published randomized clinical trials examining the use of temporary mechanical circulatory support (MCS) devices in adults with acute myocardial infarction cardiogenic shock (AMICS), including 1053 total patients with an observed in-hospital or 30-day mortality of 40.4%. None of the temporary MCS devices was associated with lower in-hospital or 30-day mortality compared with initial medical therapy or any other MCS device, either individually or in combination. These data do not support the routine use of temporary MCS devices for the purpose of reducing short-term mortality in unselected patients with AMICS.

Anticoagulation Management in Temporary Mechanical Circulatory Support Devices.

Anticoagulation Management in Temporary Mechanical Circulatory Support Devices.

Temporary Mechanical Circulatory Support Use and Clinical Outcomes of Simultaneous Heart/Kidney Transplant Recipients in the Pre- and Post-heart Allocation Policy Change Eras.

The use of temporary mechanical circulatory support (tMCS) devices (intra-aortic balloon pump; Impella 2.5, CP, 5.0; venoarterial extracorporeal membrane oxygenation) increased significantly across the United States for heart transplant candidates after the allocation policy change. Whether this practice change also affected simultaneous heart-kidney (SHK) candidates and recipient survival is understudied. We used the Scientific Registry of Transplant Recipients database to identify adult SHK recipients between January 2010 and March 2022. The population was stratified into pre- and post-heart allocation change cohorts. Kaplan-Meier curves were generated to compare 1-y survival rates. A Cox proportional hazards model was used to investigate the effect of allocation period on patient survival. Recipient outcomes bridged with eligible tMCS devices were compared in the post-heart allocation era. In a separate analysis, SHK waitlist mortality was evaluated between the allocation eras. A total of 1548 SHK recipients were identified, and 1102 were included in the final cohort (534 pre-allocation and 568 post-allocation change). tMCS utilization increased from 17.9% to 51.6% after the allocation change, with venoarterial extracorporeal membrane oxygenation use rising most significantly. However, 1-y post-SHK survival remained unchanged in the full cohort (log-rank P  = 0.154) and those supported with any of the eligible tMCS devices. In a separate analysis (using a larger cohort of all SHK listings), SHK waitlist mortality at 1 y was significantly lower in the current allocation era ( P  = 0.002). Despite the remarkable increase in tMCS use in SHK candidates after the heart allocation change, 1 y posttransplant survival remained unchanged. Further studies with larger cohorts and longer follow-ups are needed to confirm these findings.

SHOCK2: Single-center Experience and Outcomes with Impella 5.0 and 5.5 in Patients with Cardiogenic Shock

Background: Over the past decade, there have been significant technological advancements in managing patients with cardiogenic shock (CS). Temporary mechanical circulatory support devices are increasingly being employed. In this study, we present the largest single-center experience with Impella 5.0 and 5.5. Methods: Adults with severe CS who were supported with Impella 5.0 or 5.5 between 2010 to 2022 at a single institution were included. Patients were stratified into 3 groups according to their CS etiology: 1) acute myocardial infarction (AMI), 2) acute heart failure (AHF), and 3) post-cardiotomy (PC). The primary outcome was survival, and secondary outcomes included complications during Impella support. Multivariable logistic regression was performed to identify risk factors of mortality prior to discharge. Results: A total of 126 patients were included in this study with CS secondary to AMI (n=37), AHF (n=79), and PC (n=10). The AMI group tended to have older patients with a higher rate of hypertension. Patients in the PC group had a higher rate of preoperative atrial fibrillation and elevated total bilirubin. Among all the groups, the AHF group had a longer hospital length of stay and Impella support duration. Intra-aortic balloon pump and coronary revascularization were more commonly employed in the AMI group. Impella with extracorporeal membrane oxygenation (ECPella) support was utilized in 32 patients (25.4%) from the entire study cohort (Table 1). Impella bridge to transplant was most common in the AHF group, and native cardiac recovery was the most common destination in the AMI and PC groups (Table 1). Rates of survival on discharge, 30-day, 90-day, and 180-day were comparable among the 3 groups (Table 2). Acute kidney injury was the most common complication during Impella support followed by infection requiring antibiotics in all 3 groups (Table 2). An increased rate of limb ischemia was observed in the PC group, and the AMI group experienced a higher incidence of bleeding requiring transfusion. Multivariable analysis demonstrated diabetes mellitus (OR 4.90, CI 1.89-12.72, p=0.001), elevated pre-insertion serum lactate (OR 1.24, CI 1.06-1.44, p=0.008), and acute kidney injury (OR 4.81, CI 1.31-17.62, p=<0.001) were independent predictors of mortality prior to discharge, but etiology of CS did not impact mortality prior to discharge (all, p>0.05). Conclusions: The present study is the largest single-center experience with Impella 5.0 and 5.5 to date. This study demonstrates that Impella 5.0 and 5.5 provide appropriate therapeutic support for patients with profound CS with more than half of patients being alive at 180 days. Etiology of CS did not significantly impact survival. Additional ECMO support was required in more than a quarter of the cohort. Diabetes mellitus, elevated pre-insertion serum lactate, and acute kidney injury were strong risk factors for mortality prior to discharge.

Sex-Specific Outcomes of Candidates Listed as the Highest Priority Status for Heart Transplantation.

While sex differences in heart transplantation (HT) waitlist mortality have been previously described, waitlist and HT outcomes by sex of patients in the highest urgency strata (Status 1) since implementation of the 2018 allocation system change in the United States are unknown. We hypothesized that women listed as Status 1 may have worse outcomes due to adverse events on temporary mechanical circulatory support. The analysis included adult, single-organ HT waitlist candidates listed as Status 1 at any time while listed, after the HT allocation system change (from October 18, 2018 through March 31, 2022). The primary outcome was the rate of HT by sex, assessed using multivariable competing risk analysis where waitlist removal for death or clinical deterioration was the competing event. Post-HT survival by sex of waitlist candidates transplanted as a Status 1 was also compared. Of 1120 Status 1 waitlist candidates (23.8% women), women had a lower rate of HT compared to men (adjusted hazard ratio, 0.74 [95% CI, 0.62-0.88]; P<0.001) and a higher rate of delisting for death or medical unsuitability (adjusted hazard ratio, 1.48 [95% CI, 1.05-2.09]; P=0.026). Calculated panel reactive antibody did not account for all the harm observed. Post-HT survival of Status 1 candidates by sex was similar (adjusted hazard ratio, 1.13 [95% CI, 0.62-2.06]; P=0.70). Women have a lower rate of HT and higher rate of delisting for death or clinical deterioration at the highest urgent status, which appears to be mediated but not fully explained by calculated panel reactive antibody levels. Further investigation into the safety profile of temporary mechanical circulatory support devices in women is needed.

Management of temporary mechanical circulatory support devices in cath-lab and cardiac intensive care unit

AbstractDifferent temporary mechanical circulatory support (tMCS) devices are available and can be used to maintain end-organ perfusion while reducing cardiac work and myocardial oxygen demand. tMCS can provide support to the right ventricle, left ventricle, or both, and its use can be considered in emergency situations such as cardiogenic shock or in elective procedures such as high-risk percutaneous coronary intervention to prevent haemodynamic deterioration. Invasive and, most importantly, non-invasive haemodynamic parameters should be taken into account when choosing the type of tMCS device and its initiation and weaning timing, determining the need for a device upgrade, and screening for complications. In this context, ultrasound tools, specifically echocardiography, can provide important data. This review aims to provide a description of the different tMCS devices, the invasive and non-invasive tools and parameters to guide their management, and their advantages and drawbacks.

Treatment Intensity for the Management of Cardiogenic Shock: Comparison Between STEMI and Non-STEMI

BackgroundCardiogenic shock is a leading cause of mortality in patients with acute myocardial infarction. ObjectivesThe authors sought to compare clinical characteristics, hospital trajectory, and drug and device use between patients with ST-segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) and those without (non-ST-segment elevation myocardial infarction complicated by cardiogenic shock [NSTEMI-CS]). MethodsWe analyzed data from 1,110 adult admissions with cardiogenic shock complicating acute myocardial infarction (AMI-CS) across 17 centers within Cardiogenic Shock Working Group. The primary end point was in-hospital mortality. ResultsOur study included 1,110 patients with AMI-CS, of which 731 (65.8%) had STEMI-CS and 379 (34.2%) had NSTEMI-CS. Most patients were male (STEMI-CS: 71.6%, NSTEMI-CS: 66.5%) and White (STEMI-CS: 53.8%, NSTEMI-CS: 64.1%). In-hospital mortality was 41% and was similar among patients with STEMI-CS and NSTEMI-CS (43% vs 39%, P = 0.23). Patients with out-of-hospital cardiac arrest had higher in-hospital mortality in patients with NSTEMI-CS (63% vs 36%, P = 0.006) as compared to patients with STEMI-CS (52% vs 41%, P = 0.16). Similar results were observed for in-hospital cardiac arrest in patients with STEMI-CS (63% vs 33%, P < 0.001) and NSTEMI-CS (60% vs 32%, P < 0.001). Only 27% of patients with STEMI-CS and 12% of NSTEMI-CS received both a drug and temporary mechanical circulatory support device during the first 24 hours, which increased to 78% and 61%, respectively, throughout the course of the hospitalization (P < 0.001 for both). ConclusionsDespite increasing use of inotropic and vasoactive support and mechanical circulatory support throughout the hospitalization, both patients with STEMI-CS and NSTEMI-CS remain at increased risk for in-hospital mortality. Randomized controls trials are needed to elucidate whether timing and sequence of escalation of support improves outcomes in patients with AMI-CS.

[The Role of the Percutaneous Impella Pump in Anesthesia and Intensive Care].

The use of temporary mechanical circulatory support (tMCS) devices and in particular the increasing use of the Impella device family has gained significant interest over the last two decades. Nowadays, its use plays a well-established key role in both the treatment of cardiogenic shock, and as a preventive and protective therapeutic option during high-risk procedures in both cardiac surgery and cardiology, such as complex percutaneous interventions (protected PCI). Thus, it is not surprising that the Impella device is more and more present in the perioperative setting and especially in patients on intensive care units. Despite the numerous advantages such as cardiac resting and hemodynamic stabilization, potential adverse events exist, which may lead to severe, but preventable complications, so that adequate education, early recognition of such events and a subsequent adequate management are crucial in patients with tMCS. This article provides an overview especially for anesthesiologists and intensivists focusing on technical basics, indications and contraindications for its use with special focus on the intra- and postoperative management. Furthermore, troubleshooting for most common complications for patients on Impella support is provided.

Mechanical circulatory support device selection for bridging to cardiac transplantation: a clinical guide

ABSTRACT Introduction Many patients listed for transplant require temporary or durable mechanical circulatory support (MCS) devices for bridging to cardiac transplantation. The choice of device for bridging to heart depends on a number of factors including level of support desired and patient-device hemocompatibility. Areas covered The authors summarize the current heart transplant landscape including the new UNOS listing criteria as well as indications for bridging to transplant with MCS devices. The authors also review the characteristics of commonly used MCS devices and discuss the limited evidence supporting their use in cardiogenic shock and specifically as a bridge to heart transplant. Expert Opinion The new UNOS heart organ allocation policy has resulted in a growth in the use of temporary MCS devices as bridge to transplantation for patients with cardiogenic shock, while bridging with durable MCS devices have become more challenging. Patients supported on temporary MCS devices should be routinely assessed for potential of myocardial recovery prior to urgent transplantation. Emerging machine learning algorithms may help better identify individuals who are likely to recover on temporary or durable MCS therapy. Modifications to the current heart allocation policy may facilitate bridging of patients with durable left ventricular assist devices.

Hemodynamic Predictors of Stabilization When Using Temporary Mechanical Support for Cardiogenic Shock from Acute on Chronic Heart Failure

Cardiogenic shock from acute on chronic heart failure is a lethal condition that frequently requires temporary mechanical circulatory support devices (tMCS) as a bridge to stabilization, durable support, or heart transplantation. However, there are limited data on methods to optimize use of tMCS in this population. We identified patients who received tMCS devices for cardiogenic shock from acute on chronic heart failure at a single center from August 2016 to July 2020. All the patients had invasive hemodynamic data before and immediately after tMCS placement. We classified patients according to whether they showed stabilization or decompensation with tMCS. We then evaluated hemodynamics pre-tMCS, post-tMCS, and the change in hemodynamics with tMCS (∆-tMCS) and assessed their relationship with clinical outcomes. Among 111 patients who received tMCS, 71 stabilized, and 40 decompensated. Post-tMCS hemodynamics were more likely than were pre-tMCS or ∆-tMCS to predict stabilization. Post-tMCS cardiac index >2.1 (area under the curve: 92.2) and cardiac power index >0.3 (area under the curve: 89.6) were the best predictors of stabilization. Patients who decompensated had increased in-hospital all-cause mortality (hazard ratio 3.06 [1.29 to 7.24], p=0.011), cardiovascular mortality, and increased hospital and intensive care unit length of stay and were less likely to receive left ventricular assist device or heart transplant (hazard ratio 0.56 [0.36 to 0.88], p=0.01). In conclusion, among patients with cardiogenic shock from acute on chronic heart failure who received tMCS, post-tMCS cardiac index and cardiac power index were highly predictive of stabilization. Those who decompensated had increased mortality, hospital length of stay, and intensive care unit length of stay and were less likely to receive heart replacement therapy.

Emerging Modalities for Temporary Mechanical Circulatory Support in Cardiogenic Shock.

Cardiogenic shock (CS) is a life-threatening medical condition that requires prompt recognition and treatment. The use of standardized CS criteria, such as the Society for Cardiovascular Angiography and Interventions criteria, can categorize patients and guide therapeutic strategies. Temporary mechanical circulatory support (MCS) devices have become valuable tools in the treatment of CS, as they can provide cardiovascular support as a bridge to recovery, cardiac surgery, or advanced therapies such as cardiac transplant or durable ventricular assist devices. The use of MCS should be tailored to each individual patient, focused on a stepwise escalation of circulatory support to support both end-organ perfusion and myocardial recovery. As newer MCS devices reduce myocardial oxygen demand without increasing ischemia, the possibility of recovery is optimized. In this review, we discuss the different modalities of MCS focusing on the mechanism of support and the advantages and disadvantages of each device.

Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction.

Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.

Review of Pathophysiology of Cardiogenic Shock and Escalation of Mechanical Circulatory Support Devices.

Cardiogenic shock (CS) is a complex clinical entity that continues to carry a high risk of mortality. The landscape of CS management has changed with the advent of several temporary mechanical circulatory support (MCS) devices designed to provide hemodynamic support. It remains challenging to understand the role of different temporary MCS devices in patients with CS, as many of these patients are critically ill, requiring complex care with multiple MCS device options. Each temporary MCS device can provide different types and levels of hemodynamic support. It is important to understand the risk/benefit profile of each one of them for appropriate device selection in patients with CS. MCS may be beneficial in CS patients through augmentation of cardiac output with subsequent improvement of systemic perfusion. Selecting the optimal MCS device depends on several variables including the underlying etiology of CS, clinical strategy of MCS use (bridge to recovery, bridge to transplant or durable MCS, or abridge to decision), amount of hemodynamic support needed, associated respiratory failure, and institutional preference. Furthermore, it is even more challenging to determine the appropriate time to escalate from one MCS device to another or combine different MCS devices. In this review, we discuss the current available data published in the literature on the management of CS and propose a standardized approach for escalation of MCS devices in patients with CS. Shock teams can play an important role to help in hemodynamic-guided management and algorithm-based step-by-step approach in early initiation and escalation of temporary MCS devices at different stages of CS. It is important to define the etiology of CS, and stage of shock and recognize univentricular vs biventricular shock for appropriate device selection and escalation of therapy.