Use Of Intra-aortic Balloon Pump Research Articles

Effectiveness of VA-ECMO plus intra-aortic balloon pump for cardiac shock in patients with type A aortic dissection: a case series

Limited reports exist on the utilization of venoarterial extracorporeal membrane oxygenation (VA-ECMO) following aortic dissection surgery, possibly due to concerns regarding complications. This case series aimed to evaluate the effectiveness and safety of using VA-ECMO in combination with intra-aortic balloon pump (IABP) for managing postoperative cardiogenic shock in patients with type A aortic dissection (AAD). The study included nine patients with an average age of 57.0 ± 9.5 years. The patients underwent various surgical procedures, including coronary artery bypass grafting (CABG) and aortic root reconstruction. The results showed that the combined use of VA-ECMO and IABP was feasible and effective in managing postoperative cardiogenic shock in AAD patients. However, the in-hospital mortality rate was high, with six out of nine patients succumbing to the condition. Among the patients who received VA-ECMO plus IABP in the operating room, four were successfully weaned from VA-ECMO, and three survived with a mean follow-up of 20 months. The study also highlighted the potential risks of renal complications associated with VA-ECMO and IABP. The findings suggest that the combined therapy of VA-ECMO and IABP may be beneficial for patients who have difficulty weaning from cardiopulmonary bypass (CPB) after AAD surgery.

Beneficial Effects of IABP in Anterior Myocardial Infarction Complicated by Cardiogenic Shock.

Background and Objectives. Recent guidelines have downgraded the routine use of the intra-aortic balloon pump (IABP) in patients with cardiogenic shock (CS) due to ST-elevation myocardial infarction (STEMI). Despite this, its use in clinical practice remains high. The aim of this study was to evaluate the prognostic impact of the IABP in patients with STEMI complicated by CS undergoing primary PCI (pPCI), focusing on patients with anterior MI in whom a major benefit has been previously hypothesized. Materials and Methods. We enrolled 2958 consecutive patients undergoing pPCI for STEMI in our department from 2005 to 2018. Propensity score matching and mortality analysis were performed. Results. CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. In the propensity-matched analysis, the use of the IABP was associated with a lower 30-day mortality (39.3% vs. 60.9%, p = 0.032) in the subgroup of patients with anterior STEMI. Conversely, in the whole group of CS patients and in the subgroup of patients with non-anterior STEMI, IABP use did not have a significant impact on mortality. Conclusions. The use of the IABP in cases of STEMI complicated by CS was found to improve survival in patients with anterior infarction. Prospective studies are needed before abandoning or markedly limiting the use of the IABP in this clinical setting.

Left Ventricular Unloading With Impella Versus IABP in Patients With VA-ECMO: A Systematic Review and Meta-Analysis

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2=71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2=82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2=66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.

Redo aortic surgery: Does one versus multiple affect outcomes?

ObjectiveRedo aortic surgery has a higher risk of morbidity and mortality because it is technically complex due to mediastinal adhesions, infection, and previously implanted prostheses. In this study, we sought to benchmark our single-center experience comparing outcomes in patients undergoing aortic surgery after 1 versus multiple previous cardiac operations. MethodsBetween 2004 and 2019, 429 patients underwent redo aortic surgery. They were classified as aortic surgery after 1 previous surgery (first redo surgery, n = 360) and aortic surgery after 2 or more (multiple) previous surgeries (multiple redo surgery, n = 69). Postoperative outcomes and long-term survival were compared, and risk factors for mortality were identified. ResultsThirty-day mortality was lower in first redo surgery compared with multiple redo surgery (12.3% vs 21.7%, P = .03). Age, cardiopulmonary bypass time, intra-aortic balloon pump use, postoperative cerebrovascular accident, absence of postoperative atrial fibrillation, intra-aortic balloon pump, and multiple redo surgery were independent predictors of 30-day mortality. Long-term survival was similar at 15 years. Patients who received first redo surgery were older (57.9 ± 14.0 years vs 50.3 ± 15.8 years, P = .0001) and had a higher incidence of hypertension (84.7% vs 73.9%, P = .02), whereas patients who received multiple redo surgery had a higher incidence of cerebrovascular disease (31.9% vs 20.3%, P = .03). Aortic valve replacement was the most common previous operation with higher incidence in multiple redo surgery. Incidence of previous aortic surgery was similar. Cardiopulmonary bypass (246 ± 67.3 minutes vs 219.9 ± 57.5 minutes, P = .009) and crossclamp times (208.2 ± 51.8 vs 181.9 ± 50.8 minutes, P = .004) were longer in multiple redo surgery. Incidence of reentry injury and balloon pump insertion were similar. Extracorporeal membrane oxygenation use was higher in multiple redo surgery. Postoperative complications occurred at similar rates, except for higher incidence of dialysis in multiple redo surgery (14.5% vs 7.2%, P = .04). ConclusionsMultiple redo aortic procedures have a higher morbidity and mortality compared with first redo aortic procedures, with linearly increasing short-term mortality risk but similar long-term survival with the number of redo procedures.

Percutaneous coronary intervention for ST-elevation myocardial infarction complicated by cardiogenic shock in a super-aging society.

ST-segment elevation myocardial infarction complicated by cardiogenic shock (STEMICS) is associated with substantial mortality. As life expectancy increases, percutaneous coronary intervention (PCI) is being performed more frequently, even in elderly patients with acute myocardial infarction (AMI). This study sought to investigate the characteristics and impact of PCI on in-hospital mortality in patients with STEMICS. The Japan AMI Registry (JAMIR) is a retrospective, nationwide, real-world database. Among 46 242 patients with AMI hospitalized in 2011-2016, 2760 patients with STEMICS (median age, 72 years) were studied. We compared 2396 (86.8%) patients who underwent PCI with 364 (13.2%) patients who did not. The percentage of mechanical circulatory support use in patients with STEMICS was 69.3% and in-hospital mortality was 34.6%. Compared with patients who did not undergo PCI, patients undergoing PCI were younger and had a higher rate of intra-aortic balloon pump use. A higher proportion was male or current smokers. In-hospital mortality was significantly lower in the PCI group than in the no-PCI group (31.3% vs. 56.0%, P < 0.001). Percutaneous coronary intervention was independently associated with lower in-hospital mortality [adjusted odds ratio (OR), 0.508; 95% confidence interval (CI), 0.347-0.744]. In 789 (28.6%) patients aged ≥80 years, PCI was associated with fewer in-hospital cardiac deaths (adjusted OR, 0.524; 95% CI, 0.281-0.975), but was not associated with in-hospital mortality (adjusted OR, 0.564; 95% CI, 0.300-1.050). In Japan, PCI was effective in reducing in-hospital cardiac death in elderly patients with STEMICS. Age alone should not preclude potentially beneficial invasive therapy.

Intra-Aortic Balloon Pump among Shockable Out-of-Hospital Cardiac Arrest Patients: A Propensity-Weighted Analysis in a Multicenter, Nationwide Observational Study in Japan (The JAAM-OHCA Registry).

The effectiveness of IABP for shockable out-of-hospital cardiac arrest (OHCA) has not been extensively investigated. This study aimed to investigate whether the use of an intra-aortic balloon pump (IABP) for non-traumatic shockable OHCA patients was associated with favorable neurological outcomes. From the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest registry, a nationwide multicenter prospective registry, we enrolled adult patients with non-traumatic and shockable OHCA for whom resuscitation was attempted, and who were transported to participating hospitals between 2014 and 2019. The primary outcome was 1-month survival with favorable neurological outcomes after OHCA. After adopting the propensity score (PS) inverse probability of weighting (IPW), we evaluated the association between IABP and favorable neurological outcomes. Of 57,754 patients in the database, we included a total of 2738 adult non-traumatic shockable patients. In the original cohort, the primary outcome was lower in the IABP group (OR with 95% confidence intervals (CIs)), 0.57 (0.48-0.68), whereas, in the IPW cohort, it was not different between patients with and without IABP (OR, 1.18; 95% CI, 0.91-1.53). In adult patients with non-traumatic shockable OHCA, IABP use was not associated with 1-month survival with favorable neurological outcomes.

Intra-aortic balloon pump reduces 30-day mortality in early stage cardiogenic shock complicating acute myocardial infarction according to SCAI classification.

Cardiogenic shock complicating acute myocardial infarction (AMICS) remains a high 30-day mortality. Mechanical circulatory support devices are increasingly used in AMICS, but their effects on mortality vary partly due to shock severity. This study aimed to evaluate the association between intra-aortic balloon pump (IABP) and 30-day mortality in patients with early stage AMICS. We retrospectively analyzed patients with ST-segment elevation myocardial infarction (STEMI) based on a multicenter clinical trial (NCT04996901). Patients were stratified by IABP use and shock severity was classified according to the Society for Cardiovascular Angiography and Interventions (SCAI) SHOCK stages. The primary outcome was 30-day all-cause mortality. The association between IABP and 30-day mortality was evaluated across shock stages using propensity score matching, weighting, and logistic regression. 5343 patients were included and 299 received IABP. SCAI SHOCK stage was associated with 30-day mortality (OR 20.19, 95%CI 13.60-29.97, P < 0.001). In the 580 matched patients, a significant interaction between IABP and 30-day mortality at different shock stages was observed (P = 0.005). IABP was associated with lower 30-day mortality among patients with shock stage A/B (5.8% vs. 1.2%, OR 0.19, 95%CI 0.03-0.73, P = 0.034) but not stage C/D/E (29.3% vs. 38.1%, OR 1.49, 95%CI 0.84-2.65, P = 0.172). These results were confirmed by sensitivity analyses of the weighted cohort. IABP reduced 30-day mortality in patients with early stage AMICS. The SCAI SHOCK stage provides risk stratification for patients with STEMI and helps identify those who may respond well to IABP.

Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting.

Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined. A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates. Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028). Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Predicting Hemodynamic Changes During Intra-Aortic Balloon Pump Support With a Longitudinal Evaluation.

The use of intra-aortic balloon pump (IABP) has decreased in recent years due to negative outcome studies in cardiogenic shock complicating acute myocardial infarction, despite its favorable adverse-event profile. Acute hemodynamic response studies have identified potential super-responders with immediate improvements in cardiac index (CI) in heart failure patients. This single-center retrospective study aimed to predict CI and mean arterial pressure (MAP) changes throughout the entire duration of IABP support. The study analyzed 336 patients who received IABP between 2016 and 2022. Linear mixed-effect regression models were used to predict CI and MAP improvement during IABP support. The results showed that CI and MAP increases during the first days of support, and changes during IABP support varied with time and were associated with baseline parameters. Longitudinal CI change was associated with body surface area, baseline CI, baseline pulmonary artery pulsatility index, baseline need for pressors, and diabetes. Longitudinal MAP change was associated with baseline MAP, baseline heart rate, need for pressors, or inotropes. The study recommends considering these parameters when deciding if IABP is the most appropriate form of support for a specific patient. Further prospective studies are needed to validate the findings.

Trends in Mechanical Circulatory Support Use and Outcomes of Patients With Cardiogenic Shock in Japan, 2010 to 2020 (from a Nationwide Inpatient Database Study)

Little is known about the impact of the downgrade of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella in Japan, where IABPs have been predominantly used. This study aimed to describe the annual trends in the mechanical circulatory support (MCS) use and outcomes in patients with cardiogenic shock (CS) requiring MCS. Using the Japanese Diagnosis Procedure Combination database from July 2010 to March 2021, we identified inpatients with CS requiring MCS. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella alone, and (3) extracorporeal membrane oxygenation (ECMO), regardless of IABP or Impella use. The patient characteristics and outcomes were reported by the fiscal year. Of the 160,559 eligible patients, 117,599 (73.2%) used IABP alone, 1,465 (0.9%) Impella alone, and 41,495 (25.8%) ECMO. The prevalence of the use of an IABP alone significantly decreased from 80.5% in 2010 to 65.3% in 2020 (p for trend <0.001), whereas the prevalence of the use of an Impella alone significantly increased from 0.0% to 5.0% and ECMO from 19.5% to 29.6% (p for trend <0.001 for both). In-hospital mortality significantly increased from 29.3% in 2010 to 32.6% in 2020 in the overall patients with CS requiring MCS but significantly decreased in those requiring ECMO from 73.7% to 64.1% (p for trend <0.001 for both). In conclusion, there were significant annual changes in the patterns of MCS use and clinical outcomes in patients with CS requiring MCS.

Posterior pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: a systematic review and meta-analysis of 25 randomised controlled trials.

Atrial fibrillation (AF) associated with postoperative pericardial effusion is the most commonly reported adverse event after cardiac surgery. We aimed to determine the role of posterior pericardiotomy in preventing postoperative AF (POAF). We searched PubMed, Scopus, Web of Science, Ovid, and EBSCO from inception until 30 June 2022. We included randomised clinical trials (RCTs) that compared posterior pericardiotomy (PP) versus control (no PP) in patients undergoing cardiac surgery. The primary endpoint was the incidence of POAF after cardiac surgery. The secondary endpoints were supraventricular arrhythmias, early/late pericardial effusion, pericardial tamponade, pleural effusion, length of hospital/intensive care unit stay, intra-aortic balloon pump use, revision surgery for bleeding, and mortality. Twenty-five RCTs comprising 4,467 patients were included in this systematic review and meta-analysis. The overall incidence rate of POAF was 11.7% in the PP group compared with 23.67% in the no PP or control group, with a significant decrease in the risk of POAF following PP (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.38-0.61). Compared with the control group, the risk of supraventricular tachycardia (OR 0.66, 95% CI: 0.43-0.89), early pericardial effusion (OR 0.32, 95% CI: 0.22-0.46), late pericardial effusion (OR 0.15, 95% CI: 0.09-0.25), and pericardiac tamponade (OR 0.18, 95% CI: 0.10-0.33) were lower in the PP group. PP is an effective intervention for reducing the risk of POAF after cardiac surgery. Also, PP is economically efficient in terms of decreasing the length of hospital stay.

Pressure-strain loops unveil haemodynamics behind mechanical circulatory support systems.

Mechanical circulatory support (MCS) systems are increasingly employed in cardiogenic shock and advanced heart failure. A thorough understanding of the complex interactions occurring among heart, vasculature, and device is essential to optimize patient's management. The aim of this study is to explore non-invasive haemodynamic profiling of patients undergoing MCS based on pressure-strain (PS) analysis. Clinical and echocardiographic data from consecutive patients undergoing different MCS systems positioning/implantation admitted to the third level cardiological intensive care unit of Siena Hospital from August 2021 to November 2021 were retrospectively reviewed. Patients without a useful echocardiographic exam or without arterial blood pressure recording at the time of echocardiography were excluded. Myocardial work analysis was performed in the included patients. We reviewed 18 patients, of which nine were excluded. Included patients were three patients with intra-aortic balloon pump (IABP), two patients with durable left ventricular assist device (dLVAD), two patients with Impella®, one patient with extracorporeal membrane oxygenation (ECMO), and one patient with ECMO and IABP. Myocardial work analysis was feasible in each included patient. The use of IABP shifted the PS curve rightward and downward. Global work index (GWI) and global wasted work (GWW) decreased after IABP positioning, whereas global work efficiency (GWE) increased. The use of continuous-flow pumps, whether temporaneous (Impella®) or long term (dLVAD), induced a change in the PS loop morphology, with a shift towards a triangular shape. ECMO positioning alone resulted in a narrowing of the PS loop, with a decrease in GWI and GWE and an increase in GWW and mean arterial pressure. The combined used of IABP with ECMO widened the PS loop and improved GWI and GWE. PS loops analysis in patients undergoing MCS seems to be feasible and may unveil MCS-induced haemodynamic variations. Myocardial work could be used to monitor ventricular-arterial-device coupling and guide tailored MCS management.

The Use of Angio-Seal for Intra-Aortic Balloon Pump Removal in the ICU

The use of intra-aortic balloon pump (IABP) to support the heart during cardiac surgery is a well-established technique. The removal of this device is generally performed in the intensive care unit (ICU) by applying manual pressure. This then requires the patient to lie flat for 4 hours; the Angio-Seal reduces this to 30 minutes. This unit now routinely uses this device to remove IABPs in the ICU. While the use of the Angio-Seal for this purpose has previously been described, no protocol of how to do this has been published. This article provides a protocol for the use of this device in the removal of IABP.

CARC20: Intra-operative Use of Intra-aortic Balloon Pump to Generate Pulsatile Flow During Heart Transplantation

Introduction: The physiologic impact of pulsatile flow (PF) on end-organ perfusion during cardiopulmonary bypass (CPB) is controversial. One method of generating PF during CPB is to use an intra-aortic balloon pump (IABP). Maintaining the IABP during CPB to produce a state of PF for patients undergoing heart transplantation (HT) may impact end-organ perfusion, with implications for short-term graft function and immediate post-operative outcomes. Methods: A single-center retrospective cohort study of adult patients bridged to HT with IABP was conducted between January 2018 and December 2022. Patients were excluded if they were <18 years old, not bridged to HT with IABP, or underwent simultaneous multi-organ transplant. For patients bridged to HT with IABP, beginning in May 2022 the IABP was allowed to continue inflating and deflating during CPB. Upon initiation of CPB, the IABP was set on an internal rate of 80 beats per minute. Patients who underwent HT with IABP turned off while on CPB (IABP-Off) and patients maintained on IABP during HT (IABP-On) were propensity matched according to age, organ ischemia time, and intraoperative dobutamine dose (mcg/kg/min). Results: A total of 70 patients bridged to HT with IABP were propensity matched into IABP-Off (n=12) versus IABP-On (n=12) groups. IABP-Off and IABP-On groups were similar with respect to age (p=0.93), sex (p=0.54), race (p=0.68), BMI (p=0.37), previous sternotomy (p=0.27), and waitlist time (p=0.31). IABP-Off and IABP-On groups had similar organ ischemia times (166.9±40.3 vs. 165.8±55.0 minutes, p=0.96), similar CPB times (109.3±20.6 vs. 111.3±29.7 minutes, p=0.43), and similar case lengths (449.5±108.7 vs. 449.4±115.3 minutes, p=0.50). The groups received similar amounts of intraoperative products and fluids. IABP-Off and IABP-On groups were matched on intraoperative dobutamine dose (2.85±1.73 vs. 3.09±1.76, p=0.74) and received similar doses of other intraoperative inotropes, with the IABP-Off group trending towards a higher norepinephrine dose that did not reach statistical significance. There was no difference in the first measured post-operative lactate between groups, although patients in the IABP-On group had significantly lower peak lactates in the first 24 hours post-transplant (2.39±1.17 vs. 4.31±2.95, p=0.02). There was no difference between groups with respect to post-operative creatinine or length of stay or mortality. Conclusion: Patients maintained on IABP had lower peak lactates in the first 24 hours post-transplant compared to patients in whom IABP was turned off and trended to require less norepinephrine. This limited preliminary data suggests that maintaining pulsatility during CPB may result in improved end-organ perfusion. Table 1. Characteristics of the IABP-Off and IABP-On Cohorts

Coronary Artery Bypass Grafting in the Elderly: Are We Doing the Right Thing? Should These Patients Be Left Alone?

Coronary artery bypass grafting (CABG) in the ageing population is always a debatable topic in most heart centres. Are we doing the right thing by intervening and performing isolated CABG in patients aged ≥75 years? This study aimed to investigate the predictive ability of EUROSCORE II, the revascularisation success of CABG with the survival outcomes of these patients. A retrospective analysis was performed of all patients aged ≥75 years who underwent CABG plus concomitant procedures in this single large tertiary institution during the last 8 years from 2015 to present. Predictive risk ability using EuroSCORE II, revascularisation success, and survival outcomes were analysed. The mean age, gender predominance, nature of surgery, elective vs emergency, duration of cardiopulmonary bypass, length of intensive care unit (ICU) stay, inotropic support, use of intra-aortic balloon pump, ventilation period in ICU, blood products transfusion rate, in-patient mortality rate with survival ratio, and overall 30-day mortality were calculated. EuroSCORE II predictive ability risk was calculated. Patient selection is the key. It is reasonable and rational to perform CABG in the elderly population, bearing in mind that they will have longer ICU and hospital stays, with a longer postoperative recovery period. Frailty risk models may establish a prediction of true operative risk.

Intraaortic Ballon-pump: Physiology, Indication, Management

The intraaortic ballon-pump (IABP) is a percutaneous mechanical circulatory support device, which is used in patients either with insufficient cardiac output or in patients with high-risk situation before cardiac intervention, like surgical revascularisation or percutaneous coronary intervention (PCI). Due to electrocardiographic or arterial pressure pulse the IABP augments diastolic coronary perfusion pressure and reduces systolic afterload. Thereby, myocardial oxygen supply-demand ratio is improved and cardiac output is increased. Many national and international cardiology, cardiothoracic and intensive care medicine societies and associations worked together in order to develop evidence-based recommendations and guidelines for the preoperative, intraoperative and postoperative management of the IABP. This manuscript is mainly based on the S3 guideline "Use of intraaortic balloon-pump in cardiac surgery" from the German Society for Thoracic and Cardiovascular Surgery (DGTHG).

C-6 | Comparative Healthcare Resource Utilization of Impella versus Intra-Aortic Balloon Pump Use for Patients With Acute Coronary Syndrome and Cardiogenic Shock Undergoing Percutaneous Coronary Interventions: Insights from National Inpatient Sample

The use of percutaneous mechanical circulatory support (MCS) devices, including Impella and Intra-aortic balloon pump (IABP), in patients with cardiogenic shock (CS) has increased in recent times. We aimed to evaluate the impact of the choice of MCS device on healthcare resource utilization. We queried the National Inpatient Sample registry between October 2016 to December 2018 to identify adults admitted for ACS related CS and received percutaneous coronary intervention (PCI). The study population was segregated into Impella and IABP groups using ICD 10 diagnosis codes. Primary endpoint was high healthcare resource utilization (HRU), while secondary outcomes included peri procedural complications. Propensity scoring modelling was used to identify matched pair of Impella and IABP patients, adjusting for severity index, comorbidities. During the study period, 439,610 patients received MCS using, Impella or IABP on account of ACS related CS. Median age (years) of the Impella and IABP patients were similar (64.1 vs. 65.1, P=0.08). Gender distribution of the Impella CS patients were like IABP patients with female majorities in both groups, (71.9% vs. 67.9%, P=0.05). Impella patients had a higher comorbidity burden. 1:1 Propensity score matching identified 2,620 Impella patients comparable severity index with IABP patients. Impella patients had higher HRU, surrogate of length of stay (LOS) >7 or non-home disposition at discharge, compared to IABP patients (94.2% vs. 87.3%, P<0.001). Impella patients had higher in-hospital mortality compared to IABP patients (42.8% vs 26.9%, P<0.001). Impella patients also developed more periprocedural complications, including vascular injury (4.6% vs. 1.9%, P=0.004), acute kidney injury (61.5% vs. 51.9%, P<0.001), acute kidney injury requiring dialysis (5.5% vs. 2.9%, P=0.01) when compared to IABP patients. Among patients with ACS undergoing PCI and receiving MCS devices, those receiving Impella demonstrated greater high healthcare resource utilization, had higher LOS >7 days, and more non-home disposition at discharge compared to patients receiving IABP. Further investigation is warranted to elucidate factors associated with these findings.

Pulse pressure loss after extracorporeal cardiopulmonary resuscitation is an independent predictor of ECMO weaning failure

To analyze the predictors of successful weaning off extracorporeal membrane oxygenation (ECMO) after extracorporeal cardiopulmonary resuscitation (ECPR). The clinical data of 56 patients with cardiac arrest who underwent ECPR in Hunan Provincial People's Hospital (the First Affiliated Hospital of Hunan Normal University) from July 2018 to September 2022 were retrospectively analyzed. According to whether ECMO was successfully weaning off, patients were divided into the successful weaning off group and the failed weaning off group. The basic data, duration of conventional cardiopulmonary resuscitation (CCPR, the time from cardiopulmonary resuscitation to ECMO), duration of ECMO, pulse pressure loss, complications, and the use of distal perfusion tube and intra-aortic balloon pump (IABP) were compared between the two groups. Univariate and multivariate Logistic regression analyses were performed to identify the risk factors for weaning failure of ECMO. Twenty-three patients (41.07%) were successfully weaned from ECMO. Compared with the successful weaning off group, patients in the failed weaning off group were older (years old: 46.7±15.6 vs. 37.8±16.8, P < 0.05), higher incidence of pulse pressure loss and ECMO complications [81.8% (27/33) vs. 21.7% (5/23), 84.8% (28/33) vs. 39.1% (9/23), both P < 0.01], and longer CCPR time (minutes: 72.3±19.5 vs. 54.4±24.6, P < 0.01), shorter duration of ECMO support (hours: 87.3±81.1 vs. 147.7±50.8, P < 0.01), and worse improvement in arterial blood pH and lactic acid (Lac) levels after ECPR support [pH: 7.1±0.1 vs. 7.3±0.1, Lac (mmol/L): 12.6±2.4 vs. 8.9±2.1, both P < 0.01]. There were no significant differences in the utilization rate of distal perfusion tube and IABP between the two groups. Univariate Logistic regression analysis showed that the factors affecting the weaning off ECMO of ECPR patients were pulse pressure loss, ECMO complications, arterial blood pH and Lac after installation [pulse pressure loss: odds ratio (OR) = 3.37, 95% confidence interval (95%CI) was 1.39-8.17, P = 0.007; ECMO complications: OR = 2.88, 95%CI was 1.11-7.45, P = 0.030; pH after installation: OR = 0.01, 95%CI was 0.00-0.16, P = 0.002; Lac after installation: OR = 1.21, 95%CI was 1.06-1.37, P = 0.003]. After adjusting for the effects of age, gender, ECMO complications, arterial blood pH and Lac after installation, and CCPR time, showed that pulse pressure loss was an independent predictor of weaning failure in ECPR patients (OR = 1.27, 95%CI was 1.01-1.61, P = 0.049). Early loss of pulse pressure after ECPR is an independent predictor of failed weaning off ECMO in ECPR patients. Strengthening hemodynamic monitoring and management after ECPR is very important for the successful weaning off ECMO in ECPR.

Rotablation for Octogenarians in a Modern Cathlab: Short- and Intermediate-Term Results.

There are limited reports on the treatment of complex calcified lesions using rotational atherectomy (RA) in octogenarians, particularly in high-risk patients. To evaluate procedural and clinical outcomes of RA in octogenarians. Consecutive RA patients from 2010 to 2018 were selected from our catheterization laboratory database, stratified into two groups (≥ or < 80 years old), and analyzed. A total of 411 patients (269 males and 142 females) with a mean age of 73.8 ± 11.3 years were enrolled, of whom 153 were ≥ 80 years old and 258 were < 80 years old. Most of the patients displayed high-risk features. The baseline Syntax scores were high in both groups, and most lesions were heavily calcified (96.1% vs. 97.3%, p = 0.969, respectively). The use of hemodynamic support intra-aortic balloon pump was more frequent in the octogenarians (21.6% vs. 11.6%, p = 0.007), but the RA completion rate was similarly high (95.9% vs. 99.1%, p = 0.842). There was no difference in acute complications. The total/cardiovascular (CV) death rate within one year was higher in the octogenarians, along with higher major adverse cardiovascular event (MACE)/CV MACE rates in the first month. Cox regression analysis showed that age ≥ 80 years, acute coronary syndrome, ischemic cardiomyopathy/shock, multi-vessel disease and serum creatinine were all predictors of MACE, and that these factors plus peripheral artery disease were predictors of all-cause mortality in these patients. RA is feasible with a very high success rate in high-risk octogenarians with complex anatomies, and with equal safety and no increase in complications. The higher rates of all-cause death and MACE were attributed to an older age and other traditional risk factors.

Organ Donation and Transplantation among Non-US Citizens: Opportunities to Improve Global Equity in Heart Transplantation

BackgroundNon-US citizens/non-US residents (NCNR) are a unique and growing population. Patterns of heart donation and heart transplantation (HT) within this subgroup have not been described fully. The purpose of this study was to evaluate the use of organs from NCNR donors and the characteristics and outcomes of NCNR HT recipients. MethodsAll adult donors whose hearts were recovered for HT and all primary adult HT recipients from 2013 to 2020 were identified using the United Network for Organ Sharing. Donors and recipients were categorized as citizens, residents, or NCNR. NCNR were further categorized by reason for travel to the United States. Outcomes included mortality, infection, and rejection at 1-year after transplantation. ResultsNCNR accounted for 0.4% (n = 77) of heart donors. Most NCNR donors identified as Hispanic (61%), were predominately recovered from the South and Southwest United States, and were less likely to express written documentation to be a donor compared with citizens and residents. NCNR accounted for 0.7% (n = 147) of all HT recipients. The majority identified as non-Hispanic White individuals (57.1%). Compared with citizens and residents, NCNR recipients seemed to be sicker, as evidenced by higher intra-aortic balloon pump use before HT and higher priority United Network for Organ Sharing status. Of NCNR recipients, 63% traveled to the United States for HT, predominately from Kuwait (29.9%) and Saudi Arabia (20%). At 1-year after transplant, there were no differences in mortality, infection, or rejection between the groups. ConclusionsA growing subgroup of NCNR travel from countries with low HT rates to the United States for HT. This finding highlights the need for strategies to improve equitable access to HT domestically and abroad.