RESUMO
BACKGROUND: Acute myocardial infarction (AMI) is a major scenario for the use of an intra-aortic balloon pump (IABP), particularly when complicated by cardiogenic shock, although the utilization of mechanical circulatory support devices varies widely per hospital. We evaluated the relationship, at the hospital level, between the volume of IABP use and mortality in AMI. METHODSâANDâRESULTS: Using a Japanese nationwide administrative database, 26,490 patients with AMI undergoing primary percutaneous coronary intervention (PCI) from 154 hospitals were included in this study. The primary endpoint was the observed-to-predicted in-hospital mortality ratio. Predicted mortality per patient was calculated using baseline variables and averaged for each hospital. The associations among PCI volume for AMI, observed and predicted in-hospital mortality, and observed and predicted IABP use were assessed per hospital. Of 26,490 patients, 2,959 (11.2%) were treated with IABP and 1,283 (4.8%) died during hospitalization. The annualized number of uses of IABP per hospital in AMI was 4.5. In lower-volume primary PCI centers, IABP was more likely to be underused than expected, and the observed-to-predicted in-hospital mortality ratio was higher than in higher-volume centers. CONCLUSIONS: A lower annual number of IABP use was associated with an increased mortality risk at the hospital level, suggesting that IABP use can be an institutional quality indicator in the setting of AMI.
Assuntos
Mortalidade Hospitalar , Balão Intra-Aórtico , Infarto do Miocárdio , Intervenção Coronária Percutânea , Humanos , Balão Intra-Aórtico/mortalidade , Balão Intra-Aórtico/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Idoso , Masculino , Feminino , Intervenção Coronária Percutânea/mortalidade , Pessoa de Meia-Idade , Japão/epidemiologia , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Resultado do Tratamento , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricosRESUMO
BACKGROUND: Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited. METHODS AND RESULTS: We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89). CONCLUSIONS: Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.
Assuntos
Coração Auxiliar , Balão Intra-Aórtico , Infarto do Miocárdio , Choque Cardiogênico , Humanos , Choque Cardiogênico/terapia , Choque Cardiogênico/mortalidade , Balão Intra-Aórtico/mortalidade , Masculino , Idoso , Feminino , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Idoso de 80 Anos ou mais , Estados Unidos/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento , MedicareRESUMO
BACKGROUND: Prior studies have found that patients with chronic kidney disease (CKD) have worse outcomes following percutaneous coronary intervention (PCI). There are no data about patients with advanced CKD undergoing Impella-supported high-risk PCI. We, therefore, aimed to evaluate angiographic characteristics and clinical outcomes in patients with CKD who received Impella-supported high-risk PCI as part of the catheter-based ventricular assist device PROTECT III study (A Prospective, Multi-Center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump [IABP] in Patients Undergoing Non Emergent High Risk PCI). METHODS: Patients enrolled in the PROTECT III study were analyzed according to their baseline estimated glomerular filtration rate (eGFR). The primary outcome was 90-day major adverse cardiovascular and cerebrovascular events (the composite of all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization). RESULTS: Of 1237 enrolled patients, 1052 patients with complete eGFR baseline assessment were evaluated: 586 with eGFR ≥60 mL/min per 1.73 m2, 190 with eGFR ≥45 to <60, 105 with eGFR ≥30 to <45, and 171 with eGFR <30 or on dialysis. Patients with lower eGFR (all groups with eGFR <60) were more frequently females and had a higher prevalence of hypertension, diabetes, anemia, and peripheral artery disease. The baseline Synergy Between PCI With Taxus and Cardiac Surgery score was similar between groups (28.2±12.6 for all groups). Patients with lower eGFR were more likely to have severe coronary calcifications and higher usage of atherectomy. There were no differences in individual PCI-related coronary complications between groups, but the rates of overall PCI complications were less frequent among patients with lower eGFR. Major adverse cardiovascular and cerebrovascular events at 90 days and 1-year mortality were significantly higher among patients with eGFR <30 mL/min per 1.73 m2 or on dialysis. CONCLUSIONS: Patients with advanced CKD undergoing Impella-assisted high-risk PCI tend to have higher baseline comorbidities, severe coronary calcification, and higher atherectomy usage, yet CKD was not associated with a higher rate of immediate PCI-related complications. However, 90-day major adverse cardiovascular and cerebrovascular events and 1-year mortality were significantly higher among patients with eGFR<30 mL/min per 1.73 m2 or on dialysis. Future studies of strategies to improve intermediate and long-term outcomes of these high-risk patients are warranted. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04136392.
Assuntos
Angiografia Coronária , Doença da Artéria Coronariana , Taxa de Filtração Glomerular , Coração Auxiliar , Intervenção Coronária Percutânea , Insuficiência Renal Crônica , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Masculino , Feminino , Idoso , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/terapia , Estudos Prospectivos , Resultado do Tratamento , Pessoa de Meia-Idade , Fatores de Risco , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/fisiopatologia , Medição de Risco , Fatores de Tempo , Valor Preditivo dos Testes , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Rim/fisiopatologia , Estados Unidos , Desenho de PróteseRESUMO
BACKGROUND: There is limited real-world data highlighting recent temporal in-hospital morbidity and mortality trends for cases of acute myocardial infarction complicated by cardiogenic shock. The role of mechanical circulatory support within this patient population remains unclear. METHODS: The US National Inpatient Sample database was sampled from 2011 to 2018 identifying 206,396 hospitalizations with a primary admission diagnosis of ST- or Non-ST elevation myocardial infarction complicated by cardiogenic shock. The primary outcomes included trends of all-cause in-hospital mortality, mechanical circulatory support use, and sex-specific trends for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) over the study period. RESULTS: The annual number of AMI-CS hospitalizations increased from 22,851 in 2011 to 30,015 in 2018 and in-hospital mortality trends remained similar (42.9 % to 43.7 %, ptrend < 0.001). The proportion of patients receiving any temporary MCS device decreased (46.4 % to 44.4 %). The use of intra-aortic balloon pump (IABP) decreased (44.9 % to 32.9 %) and the use of any other non-IABP MCS device increased (2.5 % to 15.6 %), ptrend<0.001. Sex-specific mortality indicate female in-hospital mortality remained similar (50.3 % to 51 %, ptrend<0.001), but higher than male in-hospital mortality, which increased non-significantly (38.8 % to 40.2 %, ptrend = 0.372). CONCLUSIONS: From 2011 to 2018, hospitalizations for AMI-CS patients have increased in number. However, there has been no recent appreciable change in AMI-CS mortality despite a changing treatment landscape with decreasing use of IABPs and increasing use of non-IABP MCS devices. Further research is necessary to examine the appropriate use of MCS devices within this population.
Assuntos
Bases de Dados Factuais , Mortalidade Hospitalar , Balão Intra-Aórtico , Choque Cardiogênico , Humanos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Choque Cardiogênico/diagnóstico , Masculino , Feminino , Mortalidade Hospitalar/tendências , Estados Unidos/epidemiologia , Idoso , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Balão Intra-Aórtico/tendências , Balão Intra-Aórtico/mortalidade , Idoso de 80 Anos ou mais , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio sem Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico , Estudos Retrospectivos , Coração Auxiliar/tendências , Medição de Risco , Pacientes Internados , Fatores SexuaisRESUMO
BACKGROUND: Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking. METHODSâANDâRESULTS: Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018-March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0-20.8] vs. 9.0 [4.0-16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0-59.0] vs. 23.0 [6.3-43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20-12.20] vs. 5.23 [3.41-7.00] million Japanese yen; P<0.001). CONCLUSIONS: Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.
Assuntos
Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Mortalidade Hospitalar , Balão Intra-Aórtico , Choque Cardiogênico , Humanos , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Balão Intra-Aórtico/mortalidade , Balão Intra-Aórtico/estatística & dados numéricos , Oxigenação por Membrana Extracorpórea/mortalidade , Masculino , Feminino , Japão/epidemiologia , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Coração Auxiliar/estatística & dados numéricos , Resultado do Tratamento , Adulto , Tempo de Internação , População do Leste AsiáticoRESUMO
To evaluate outcomes of patients undergoing heart transplants (HTs) using an intra-aortic balloon pump (IABP) under exception status. Adult patients supported by an IABP who underwent HT between November 18, 2018, and December 31, 2020, as documented in the United Network for Organ Sharing, were included. Patients were stratified according to requests for exception status. Kaplan-Meier methodology was used to look for differences in survival between groups. A total of 1284 patients were included; 492 (38.3%) were transplanted with an IABP under exception status. Exception status patients had higher body mass index, were more likely to be Black, and had longer waitlist times. Exception status patients received organs from younger donors, had a shorter ischemic time, and had a higher frequency of sex mismatch. The 1-year posttransplant survival was 93% for the nonexception and 88% for the exception IABP patients (hazard ratio: 1.85 [95% confidence interval: 1.12-2.86, P = .006]). The most common reason for requesting an exception status was inability to meet blood pressure criteria for extension (37% of patients). The most common reason for an extension request for an exception status was right ventricular dysfunction (24%). IABP patients transplanted under exception status have an increased 1-year mortality rate posttransplant compared with those without exception status.
Assuntos
Sobrevivência de Enxerto , Transplante de Coração , Balão Intra-Aórtico , Obtenção de Tecidos e Órgãos , Listas de Espera , Humanos , Transplante de Coração/mortalidade , Balão Intra-Aórtico/mortalidade , Masculino , Feminino , Pessoa de Meia-Idade , Listas de Espera/mortalidade , Taxa de Sobrevida , Seguimentos , Fatores de Risco , Adulto , Prognóstico , Estudos Retrospectivos , Doadores de Tecidos/provisão & distribuição , Insuficiência Cardíaca/cirurgia , Insuficiência Cardíaca/mortalidade , Coração Auxiliar , Complicações Pós-Operatórias/mortalidadeRESUMO
OBJECTIVE: Mechanical circulatory support (MCS) devices are widely used for cardiogenic shock (CS). This network meta-analysis aims to evaluate which MCS strategy offers advantages. METHODS: A systemic search of PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was performed. Studies included double-blind, randomized controlled, and observational trials, with 30-day follow-ups. Paired independent researchers conducted the screening, data extraction, quality assessment, and consistency and heterogeneity assessment. RESULTS: We included 39 studies (1 report). No significant difference in 30-day mortality was noted between venoarterial extracorporeal membrane oxygenation (VA-ECMO) and VA-ECMO plus Impella, Impella, and medical therapy. According to the surface under the cumulative ranking curve, the optimal ranking of the interventions was surgical venting plus VA-ECMO, medical therapy, VA-ECMO plus Impella, intra-aortic balloon pump (IABP), Impella, Tandem Heart, VA-ECMO, and Impella plus IABP. Regarding in-hospital mortality and 30-day mortality, the forest plot showed low heterogeneity. The results of the node-splitting approach showed that direct and indirect comparisons had a relatively high consistency. CONCLUSIONS: IABP more effectively reduce the incidence of 30-day mortality compared with VA-ECMO and Impella for the treatment of CS.
Assuntos
Oxigenação por Membrana Extracorpórea/mortalidade , Coração Artificial , Balão Intra-Aórtico/mortalidade , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Coração Auxiliar , Mortalidade Hospitalar , Humanos , Balão Intra-Aórtico/efeitos adversos , Metanálise em Rede , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Left ventricular assist devices (LVAD) are increasingly being used as destination therapy in patients with Stage D heart failure. It has been reported that a majority of patients who receive a durable LVAD (dLVAD) present in cardiogenic shock due to decompensated heart failure (ADHF-CS). As it stands, there is no consensus on the optimal management strategy for patients presenting with ADHF. Bridging with intra-aortic balloon pumps (IABPs) continues to be a therapeutic option in patients with hemodynamic instability due to cardiogenic shock. The majority of data regarding the use of IABP in cardiogenic shock come from studies in patients presenting with acute myocardial infarction with cardiogenic shock and demonstrates that there is no benefit of routine IABP use in this patient population. However, the role of IABPs as a bridge to dLVAD in ADHF-CS has yet to be determined. The hemodynamic changes seen in acute myocardial infarction with cardiogenic shock are known to be different and more acutely impaired than those presenting with ADHF-CS as evidenced by differences in pressure/volume loops. Thus, data should not be extrapolated across these 2 very different disease processes. The aim of this review is to describe results from contemporary studies examining the use of IABPs as a bridge to dLVAD in patients with ADHF-CS. Retrospective evidence from large registries suggests that the use of IABP as a bridge to dLVAD is feasible and safe when compared with other platforms of temporary mechanical circulatory support. However, there is currently a paucity of high-quality evidence examining this increasingly important clinical question.
Assuntos
Insuficiência Cardíaca/terapia , Coração Auxiliar , Balão Intra-Aórtico/instrumentação , Implantação de Prótese/instrumentação , Choque Cardiogênico/terapia , Função Ventricular Esquerda , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Hemodinâmica , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Implantação de Prótese/efeitos adversos , Implantação de Prótese/mortalidade , Recuperação de Função Fisiológica , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Resultado do TratamentoRESUMO
BACKGROUND: The 2018 heart allocation change has resulted in greater frequency of high-risk bridging to orthotopic heart transplantation (OHT). Although survival has been studied in these patients, functional status outcomes are less established. This study evaluated changes in functional status of OHT survivors based on bridging strategy. METHODS: Adults (≥18 y) undergoing OHT between January 2015 and March 2020 were stratified by bridging modality: no bridging, inotropes only, intra-aortic balloon pump (IABP), temporary ventricular assist device (VAD), durable VAD, and extracorporeal membrane oxygenation (ECMO). Using paired analysis, the Karnofsky performance scale (0-100) was utilized to compare differences in function at listing, transplant, and follow-up. RESULTS: In total, 13 142 patients underwent OHT. At the time of both listing and transplant, patients requiring IABP, temporary VAD, and ECMO displayed the lowest functional status (each median 20) compared with other groups (P < 0.001). Among survivors, the median performance status at follow-up was ≥80 for all groups, indicating total functional independence with no assistance required. Substantial improvement in Karnofsky score occurred from transplant to follow-up in survivors bridged with IABP (40), temporary VADs (60), and ECMO (50) (each P < 0.001). Among survivors with at least 90-day follow-up, the median Karnofsky score was 90 regardless of bridging modality. CONCLUSIONS: Despite a higher mortality risk, critically ill patients who survive OHT after bridging with high-risk modalities experience acceptable functional status outcomes. These findings are important to place in the context of the impact that the 2018 allocation change has had on the landscape of OHT in the United States.
Assuntos
Cardiotônicos/uso terapêutico , Oxigenação por Membrana Extracorpórea , Estado Funcional , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Balão Intra-Aórtico , Implantação de Prótese , Adulto , Cardiotônicos/efeitos adversos , Estado Terminal , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Transplante de Coração/mortalidade , Coração Auxiliar , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/mortalidade , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Cardiogenic shock occurring in the setting of advanced heart failure (HF-CS) is increasingly common. However, recent studies have focused almost exclusively on acute myocardial infarction-related CS. We sought to define clinical, hemodynamic, metabolic, and treatment parameters associated with clinical outcomes among patients with HF-CS, using data from the Cardiogenic Shock Working Group registry. METHODS: Patients with HF-CS were identified from the multicenter Cardiogenic Shock Working Group registry and divided into 3 outcome categories assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable ventricular assist device or orthotopic heart transplant), or native heart survival. Clinical characteristics, hemodynamic, laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention stages were compared across the 3 outcome cohorts. RESULTS: Of the 712 patients with HF-CS identified, 180 (25.3%) died during their index admission, 277 (38.9%) underwent HRT (durable ventricular assist device or orthotopic heart transplant), and 255 (35.8%) experienced native heart survival without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups (P<0.01 for all). Biventricular and isolated left ventricular congestion were common among patients who died or underwent HRT, respectively. Lactate, blood urea nitrogen, serum creatinine, and aspartate aminotransferase were highest in patients with HF-CS experiencing in-hospital death. Intraaortic balloon pump was the most commonly used AMCS device in the overall cohort and among patients receiving HRT. Patients receiving >1 AMCS device had the highest in-hospital mortality rate irrespective of the number of vasoactive drugs used. Mortality increased with deteriorating Society of Cardiovascular Angiography and Intervention stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, 1-way ANOVA=<0.001). CONCLUSIONS: Patients with HF-CS experiencing in-hospital mortality had a high prevalence of biventricular congestion and markers of end-organ hypoperfusion. Substantial heterogeneity exists with use of AMCS in HF-CS with intraaortic balloon pump being the most common device used and high rates of in-hospital mortality after exposure to >1 AMCS device.
Assuntos
Insuficiência Cardíaca/terapia , Balão Intra-Aórtico/mortalidade , Infarto do Miocárdio/mortalidade , Choque Cardiogênico/terapia , Resultado do Tratamento , Adulto , Idoso , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Transplante de Coração/métodos , Hemodinâmica/fisiologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de RegistrosRESUMO
BACKGROUND: Although scoring systems are widely used to predict outcomes in postcardiac arrest cardiogenic shock (CS) after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI), data concerning the accuracy of these scores to predict mortality of patients treated with Impella in this setting are lacking. Thus, we aimed to evaluate as well as to compare the prognostic accuracy of acute physiology and chronic health II (APACHE II), simplified acute physiology score II (SAPS II), sepsis-related organ failure assessment (SOFA), the intra-aortic balloon pump (IABP), CardShock, the prediction of cardiogenic shock outcome for AMI patients salvaged by VA-ECMO (ENCOURAGE), and the survival after venoarterial extracorporeal membrane oxygenation (SAVE) score in patients with OHCA refractory CS due to an AMI treated with Impella 2.5 or CP. METHODS: Retrospective study of 65 consecutive Impella 2.5 and 32 CP patients treated in our cardiac arrest center from September 2015 until June 2020. RESULTS: Overall survival to discharge was 44.3%. The expected mortality according to scores was SOFA 70%, SAPS II 90%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 50%, and SAVE score 70% in the 2.5 group; SOFA 70%, SAPS II 85%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 75%, and SAVE score 70% in the CP group. The ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under the curve (AUC) of 0.79, followed by the CardShock, APACHE II, IABP, and SAPS score. These derived an AUC between 0.71 and 0.78. The SOFA and the SAVE scores failed to predict the outcome in this particular setting of refractory CS after OHCA due to an AMI. CONCLUSION: The available intensive care and newly developed CS scores offered only a moderate prognostic accuracy for outcomes in OHCA patients with refractory CS due to an AMI treated with Impella. A new score is needed in order to guide the therapy in these patients.
Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca Extra-Hospitalar , Medição de Risco/métodos , Choque Cardiogênico , Idoso , Cuidados Críticos/métodos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/terapia , Prognóstico , Estudos Retrospectivos , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Análise de SobrevidaRESUMO
BACKGROUND: Temporary mechanical circulatory support (MCS) devices are generally used short term to maintain adequate organ perfusion in patients with advanced heart failure and cardiogenic shock. Unacceptably high waitlist mortality in this cohort motivated changes to heart allocation policy, which recognized the severity of illness by prioritization for temporary MCS and broader sharing in the new U.S. donor heart allocation policy. We evaluated the post-heart transplant outcomes for patients bridged with temporary MCS, a control population not bridged with MCS, and a cohort bridged with durable MCS. METHODS: The heart transplant research database was queried to identify patients bridged with temporary MCS and bridged with durable MCS who went directly to heart transplant in our center. Temporary MCS included Impella, intra-aortic balloon pump, and extracorporeal membrane oxygenation. Post-transplant endpoints were assessed at 30 days, 6 months, and 1 year. RESULTS: From 2010 to 2017, a total of 23 patients were bridged to heart transplant with temporary MCS and 548 were transplanted without MCS bridge. Patients bridged with temporary MCS had younger age, lower body mass index, and higher frequencies of prior blood transfusion and Status 1 (1A/1B) listing at transplant compared to patients not bridged with MCS (all P < .001). Despite the severity of illness in patients bridged with temporary MCS, post-transplant outcomes were indistinguishable from those in patients transplanted without MCS bridge, with no difference in 30-day, 6-month, or 1-year survival or 1-year freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any-treated rejection, acute cellular rejection, or antibody-mediated rejection (P = .23-.97). Similarly, compared to 157 patients bridged with durable MCS, no differences in post-transplant outcomes were identified for the temporary MCS cohort (P = .15-.94). CONCLUSION: Temporary MCS as a bridge to transplant achieves similar post-transplant outcomes at 1 year compared to no MCS and durable MCS. These encouraging findings support recent changes in the Organ Procurement and Transplantation Network | United Network Organ Sharing (OPTN|UNOS) adult heart allocation policy.
Assuntos
Transplante de Coração , Seleção de Pacientes , Políticas , Obtenção de Tecidos e Órgãos , Adulto , Estudos de Coortes , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Transplante de Coração/mortalidade , Coração Auxiliar , Humanos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Listas de Espera/mortalidadeRESUMO
BACKGROUND: The present study aimed to compare the effectiveness and safety of low molecular-weight-heparin (LMWH) and unfractionated heparin (UFH) in acute myocardial infarction (AMI) patients receiving intra-aortic balloon counterpulsation (IABP). MATERIALS AND METHODS: We retrospectively analyzed a total of 344 patients receiving IABP for cardiogenic shock, severe heart failure, ventricular septal rupture, or mitral valve prolapse due to AMI. A total of 161 patients received UFH (a bolus injection 70 U/kg immediately after IABP, followed by infusion at a rate of 15 U/kg/hour and titration to for 50 to 70 seconds of activated partial thromboplastin time. A total of 183 patients received LMWH (subcutaneous injection of 1.0 mg/kg every 12 hours for 5 to 7 days and 1.0 mg/kg every 24 hours thereafter). Events of ischemia, arterial thrombosis or embolism, and bleeding during IABP were evaluated. Major bleeding was defined as a hemoglobin decrease by >50 g/L (vs. prior to IABP) or bleeding that caused hemodynamic shock or life-threatening or requiring blood transfusion. RESULTS: Subjects receiving UFH and LMWH did not differ in baseline characteristics. Ischemia was noted in five (3.1%) and two (1.1%) subjects in UFH and LMWH groups, respectively. Arterial thromboembolism occurred in three (1.9%) subjects in the UFH group, but not in the LMWH group. Logistic regression analysis failed to reveal an association between ischemia or bleeding with heparin type. Major bleeding occurred in 16 (9.9%) and six (3.3%) patients in the UFH and LWMH groups, respectively (p = 0.014). Regression analysis indicated that LMWH is associated with less major bleeding. CONCLUSION: LMWH could reduce the risk of major bleeding in patients receiving IABP. Whether LMWH could reduce arterial thromboembolism needs further investigation.
Assuntos
Anticoagulantes/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , Heparina/administração & dosagem , Balão Intra-Aórtico , Isquemia/prevenção & controle , Infarto do Miocárdio/terapia , Tromboembolia/prevenção & controle , Idoso , Anticoagulantes/efeitos adversos , Pesquisa Comparativa da Efetividade , Feminino , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Isquemia/diagnóstico por imagem , Isquemia/etiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tromboembolia/diagnóstico por imagem , Tromboembolia/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to investigate the impact of acute left ventricular unloading by percutaneous left ventricular assist device on pulmonary congestion and pneumonia in patients with cardiogenic shock (CS). METHODS: In this retrospective study, we analysed patients with CS who received the Impella percutaneous left ventricular assist device (n=50) compared with those who received intra-aortic balloon pump (IABP) support (n=50). Pulmonary congestion was longitudinally assessed while on support by calculating characteristic findings on the chest X-ray using the Halperin score. The rate of pneumonia and early mortality were assessed as a secondary endpoint. RESULTS: The groups (Impella vs IABP) did not differ in terms of age, Sequential Organ Failure Assessment (SOFA) score, Acute Physiology, Chronic Health Evaluation (APACHE) II score or serum lactate levels. Pulmonary congestion decreased in patient treated with Impella at each time point postimplantation. No change in congestion status was observed in patients supported with IABP. Multivariate analysis indicated Impella support as an independent predictor for pulmonary decongestion (OR 4.06, 95% CI 1.15 to 14.35, p=0.030). The rate of early pneumonia was lower in the Impella group compared with the IABP group (54% vs 74%, p=0.037). Failure of pulmonary decongestion during mechanical circulatory support independently predicted early pneumonia (OR 0.28, 95% CI 0.12 to 0.70, p=0.006). CONCLUSION: Pulmonary decongestion may facilitate treatment of pneumonia in patients with CS. Left ventricular unloading by Impella device might support pulmonary decongestion, although a larger prospective trial in this patient population is required.
Assuntos
Coração Auxiliar , Balão Intra-Aórtico , Pneumonia/prevenção & controle , Implantação de Prótese/instrumentação , Edema Pulmonar/prevenção & controle , Choque Cardiogênico/terapia , Função Ventricular Esquerda , Idoso , Feminino , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Pneumonia/diagnóstico , Pneumonia/mortalidade , Pneumonia/fisiopatologia , Implantação de Prótese/efeitos adversos , Implantação de Prótese/mortalidade , Edema Pulmonar/diagnóstico , Edema Pulmonar/mortalidade , Edema Pulmonar/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Fatores de Tempo , Resultado do TratamentoRESUMO
Substantial progress in the field of mechanical circulatory support (MCS) has expanded the treatment options for patients with advanced-stage heart failure (HF). Currently available MCS devices can be implanted percutaneously or surgically. They can also be configured to support the left, right, or both ventricles, offering varying levels of circulatory support. Short-term temporary MCS devices are primarily used in high-risk percutaneous coronary intervention, cardiogenic shock, and post-cardiac arrest, while durable left ventricular assist systems (LVAS) are increasingly utilized either as a bridge-to-transplant, bridge to decision, or as a destination therapy. The evolution from older pulsatile devices to continuous-flow LVAS and the incorporation of smaller pumps, with no valves, fewer moving parts, and improved hemocompatibility has translated into improved clinical outcomes, greater durability, fewer adverse events, and reduced overall cost of care. However, despite marked advances in device design and clinical management, determining MCS candidacy is often difficult and requires the integration of clinical, biomarker, imaging, exercise, and hemodynamic data. This review aims to provide a summary of the current use of short-term and durable MCS devices in the treatment of advanced-stage HF, highlighting several aspects of LVAS support and the challenges that remain.
Assuntos
Oxigenação por Membrana Extracorpórea/instrumentação , Insuficiência Cardíaca/terapia , Coração Auxiliar , Balão Intra-Aórtico/instrumentação , Oxigenadores de Membrana , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração , Hemodinâmica , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Desenho de Prótese , Falha de Prótese , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
Despite early reperfusion and coordinated systems of care, cardiogenic shock (CS) remains the number one cause of morbidity and in-hospital mortality following acute myocardial infarction (AMI). CS is a complex clinical syndrome that begins with hemodynamic instability and can progress to multi-organ failure and profound hemo-metabolic compromise. To improve outcomes, a clear understanding of the treatment objectives in CS and developing time-sensitive management strategies aimed at stabilizing hemodynamics and restoring myocardial perfusion are critical. Left ventricular (LV) load has been identified as an independent predictor of heart failure and mortality following AMI. Decades of preclinical and clinical research have identified several effective LV unloading strategies. Recent initiatives from single and multi-center registries and more recently the Door to Unload (DTU)-STEMI pilot study have provided valuable insight to developing a standardized treatment approach to AMI, based on early invasive hemodynamics and tailored circulatory support to unload the LV. To follow is a review of the pathophysiology and prevalence of shock, limitations of current therapies, and the pre-clinical and translational basis for incorporating LV unloading into contemporary AMI and shock care.
Assuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Hemodinâmica , Balão Intra-Aórtico , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Choque Cardiogênico/terapia , Função Ventricular Esquerda , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Mortalidade Hospitalar , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Recuperação de Função Fisiológica , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Resultado do TratamentoRESUMO
Intraaortic balloon pump (IABP) counterpulsation, introduced more than 50 years ago, remains the most commonly utilized mechanical circulatory support device for patients with cardiogenic shock and myocardial ischemia, despite lack of definitive proof regarding its outcome in these patients. Part I of this review focused on the history of counterpulsation, physiologic principles, technical considerations, and evidence for its use in cardiogenic shock; Part II will discuss periprocedural uses for IABP counterpulsation and review advances in technology, including the emergence of alternative mechanical circulatory support devices that have influenced IABP utilization.
Assuntos
Coração Auxiliar/tendências , Hemodinâmica , Balão Intra-Aórtico/tendências , Isquemia Miocárdica/terapia , Revascularização Miocárdica , Choque Cardiogênico/terapia , Difusão de Inovações , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/instrumentação , Balão Intra-Aórtico/mortalidade , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/fisiopatologia , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Recuperação de Função Fisiológica , Fatores de Risco , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Função VentricularRESUMO
The intra-aortic balloon pump (IABP) has been in routine use for various cardiovascular indications for 5 decades. However, its regular use has been increasingly questioned. The aim of IABP counterpulsation is to enhance coronary blood flow and to reduce afterload of the left ventricle. In-vivo studies, however, provided insight into how physiological responses might counteract the desired effects of the device. Large randomized trials did not show benefit of IABP in the main indications such as infarct-related cardiogenic shock, high-risk myocardial infarction without shock and elective high-risk percutaneous coronary intervention. As these results are reflected differently in international guidelines and the interpretation of the evidence is heterogeneous, the frequency of IABP use differs considerably by region. Current research efforts predominantly focus on other active mechanical circulatory support devices making evidence-based approaches for possible final IABP niches more difficult.
Assuntos
Ponte de Artéria Coronária , Balão Intra-Aórtico , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Choque Cardiogênico/terapia , Animais , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Circulação Coronária , Hemodinâmica , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
Intraaortic balloon pump counterpulsation is the most common form of mechanical circulatory support used in patients with myocardial ischemia and cardiogenic shock. The physiologic principles of counterpulsation include diastolic augmentation of aortic pressure and systolic reduction of left ventricular afterload, resulting in hemodynamic benefits through increased coronary perfusion pressure and improved myocardial oxygen balance in patients with myocardial ischemia. Major trials have failed to conclusively demonstrate improvements in morbidity and mortality with counterpulsation therapy for patients with acute myocardial infarction (MI), cardiogenic shock, and/or severe coronary artery disease undergoing revascularization therapy, and the debate over its applications continues. Part I of this review focuses on the history of the development of counterpulsation, technical considerations, and complications associated with its use, its physiologic effects, and evidence for its use in myocardial ischemia and cardiogenic shock.
Assuntos
Doença da Artéria Coronariana/terapia , Balão Intra-Aórtico , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Choque Cardiogênico/terapia , Animais , Contraindicações de Procedimentos , Doença da Artéria Coronariana/história , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Hemodinâmica , História do Século XX , História do Século XXI , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/história , Balão Intra-Aórtico/mortalidade , Infarto do Miocárdio/história , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Revascularização Miocárdica/efeitos adversos , Revascularização Miocárdica/mortalidade , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Choque Cardiogênico/história , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Função VentricularRESUMO
BACKGROUND: Preventive intra-aortic balloon pump (IABP) for high-risk patients with stable hemodynamics is controversial, and its definition of high-risk is still unclear. This study aimed to investigate the effect of prophylactic IABP on the early outcome of left main disease (LMD) patients receiving off-pump coronary artery bypass grafting (OPCABG) with stable hemodynamics. METHODS: From January 2013 to April 2020, 257 consecutive patients who underwent OPCABG through sternotomy were enrolled in this study. All LMD patients (greater than 70%) had stable hemodynamics (BP>100 mmHg without vasoconstrictor substance infusion). Early outcomes of 125 patients with prophylactic IABP (IABP group) and 132 patients without IABP (Control group) were compared in this study. RESULTS: IABP did not show favorable effect on the conversion to CPB (RR 0.63, 95%CI 0.05-7.89, P = 0.7211), perioperative MI (RR 0.69, 95%CI 0.22-2.12, P = 0.5163), mortality (RR 0.65, 95%CI 0.04-10.25, P = 0.7608) or the composite end of the conversion, MI and mortality (RR 0.63, 95%CI 0.23-1.74, P = 0.3747). There was greater incidence of prolonged ventilation in IABP after adjustment (RR2.16, 95%CI 1.12-4.18, P = 0.0221). There was no IABP-related mortality or limb ischemia. CONCLUSION: No significant difference in early outcomes was observed in hemodynamically stable patients with LMD between prophylactic IABP group and control group. Prophylactic IABP may be unnecessary in patients with LMD undergoing OPCABG.