Management of cardiogenic shock: state-of-the-art.

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock.

Ventriculo-arterial uncoupling with an impella assisted HVAD: The p-D LVAD.

This paper presents the novel use of a temporary percutaneous ventricular assist device (pVAD) in a 51-year-old man with an implanted durable left ventricular assist device (d-LVAD). The pre-existing left ventricular assist device was unable to successfully unload the left ventricle, and the addition of the temporary pVAD achieved successful unloading as well as a decrease in pulmonary artery pressures without compromising the function of the right ventricle allowing safe UNOS listing for orthotopic heart transplantation.

Coronary flow capacity and survival prediction after revascularization: physiological basis and clinical implications.

BACKGROUND AND AIMS: Coronary flow capacity (CFC) is associated with an observed 10-year survival probability for individual patients before and after actual revascularization for comparison to virtual hypothetical ideal complete revascularization. METHODS: Stress myocardial perfusion (mL/min/g) and coronary flow reserve (CFR) per pixel were quantified in 6979 coronary artery disease (CAD) subjects using Rb-82 positron emission tomography (PET) for CFC maps of artery-specific size-severity abnormalities expressed as percent left ventricle with prospective follow-up to define survival probability per-decade as fraction of 1.0. RESULTS: Severely reduced CFC in 6979 subjects predicted low survival probability that improved by 42% after revascularization compared with no revascularization for comparable severity (P = .0015). For 283 pre-and-post-procedure PET pairs, severely reduced regional CFC-associated survival probability improved heterogeneously after revascularization (P < .001), more so after bypass surgery than percutaneous coronary interventions (P < .001) but normalized in only 5.7%; non-severe baseline CFC or survival probability did not improve compared with severe CFC (P = .00001). Observed CFC-associated survival probability after actual revascularization was lower than virtual ideal hypothetical complete post-revascularization survival probability due to residual CAD or failed revascularization (P < .001) unrelated to gender or microvascular dysfunction. Severely reduced CFC in 2552 post-revascularization subjects associated with low survival probability also improved after repeat revascularization compared with no repeat procedures (P = .025). CONCLUSIONS: Severely reduced CFC and associated observed survival probability improved after first and repeat revascularization compared with no revascularization for comparable CFC severity. Non-severe CFC showed no benefit. Discordance between observed actual and virtual hypothetical post-revascularization survival probability revealed residual CAD or failed revascularization.

Comparison of survival by vasoactive-inotropic score in patients receiving veno-arterial extracorporeal life support.

After the initiation of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for hemodynamic support, patients often require vasopressor and inotropic medications to support their blood pressure and cardiac contractility. The vasoactive-inotropic score (VIS) is a standardized calculation of vasopressor and inotrope equivalence, which uses coefficients for each medication to calculate a total value. This study evaluated the association between the 30-day survival of patients receiving V-A ECMO support and the VIS calculated 24 h after ECMO cannulation (VIS24). This was a single-center, retrospective, observational cohort study. The median VIS24 of the entire cohort was 6.0, and was determined as a cutoff for comparison. Patients with a VIS24 < 6.0 were assigned to a group, and those with a VIS24 ≥ 6.0 were assigned to a second group. Patients with a VIS24 < 6.0 had higher 30-day survival than those with a VIS24 ≥ 6.0 (54.5% vs 41.4%; p = 0.03). The group with a VIS24 < 6.0 also had significantly improved survival to decannulation of ECMO support; however, there was no difference in the survival to hospital discharge. We conducted a secondary analysis of quartiles and determined that individuals with a VIS24 > 11.4 had the lowest survival in the cohort. This finding may help identify patients with the lowest probability of 30-day survival in those receiving V-A ECMO for hemodynamic support.

Evaluation of Vasoactive-Inotropic Score and Survival to Decannulation in Adult Patients on Venoarterial Extracorporeal Life Support: An Observational Cohort Study.

Extracorporeal life support with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to assist circulation in patients with severe cardiogenic shock or cardiac arrest. The vasoactive-inotropic score (VIS) is a standardized calculation of vasoactive medication support which uses coefficients for each medication that converts them to an equivalent value. The purpose of this study was to assess the VIS as an early prognostication tool for survival to decannulation patients on adult VA-ECMO support. This was a single-center, observational cohort study of adult patients who received VA-ECMO support compared based on their survival to decannulation. The primary endpoint was the VIS at hour 24 postcannulation. Among the 265 patients included in this study, 140 patients (52.8%) survived to decannulation of VA-ECMO. At 24 hours postcannulation, a lower VIS was observed in the group that survived decannulation (6.5 ± 7.5 vs. 12.3 ± 16.9; p < 0.001). Multivariate analysis performed also demonstrates an association between 24-hour VIS and survival to decannulation (odds ratio 0.95; 95% confidence interval, 0.91-0.95). This study suggests that the 24-hour VIS may be an early prognostic indicator in patients on VA-ECMO patients. http://links.lww.com/ASAIO/B39.

Implantation of a vagus nerve stimulator for patients with heart failure with reduced ejection fraction: An educational video.

Objectives: Implantation and use of vagus nerve stimulation (VNS) systems is a proven treatment strategy for epilepsy and depression, and extensive research regarding vagal control of the heart has led to the idea of VNS as a potential adjunct treatment for heart failure with reduced ejection fraction (HFrEF). We describe our experience with the implantation of an investigational VNS system to manage patients living with HFrEF. Methods: As part of the ongoing ANTHEM-HFrEF (Autonomic Regulation Therapy to Enhance Myocardial Function and Reduce Progression of Heart Failure with Reduced Ejection Fraction) Pivotal Study, a 67-year-old male patient with a history of ischemic cardiomyopathy was randomized to implantation of the VITARIA System (LivaNova Inc). The electrical lead requires no mapping for placement around the vagus nerve. The surgical procedure was completed uneventfully under general anesthesia, and the device was activated in the operating room after surgery. Results: Following successful implantation and activation of the VNS system, the patient was discharged to home on the same day. Conclusions: Current, ongoing studies, such as the ANTHEM-HFrEF Pivotal Study, are designed to determine the long-term effects of VNS on heart failure symptoms, hospitalization rates, and survival. The VNS-implantation procedure was straightforward.

Gender Differences in the Outcomes of Cardiogenic Shock Requiring Percutaneous Mechanical Circulatory Support.

There is evidence for the lower use of percutaneous mechanical circulatory support (pMCS) in women. We aimed to determine (1) whether gender differences exist regarding in-hospital mortality, hospital course, and procedures; (2) whether socio-demographic and treatment-related factors were associated with these differences. Using the National Inpatient Sample, we collected the International Classification of Diseases, Ninth Revision, Clinical Modification codes for cardiogenic shock (CS) because of acute myocardial infarction AMI or acutely decompensated advanced heart failure and included intra-aortic balloon pump, Impella or Tandem Heart percutaneous ventricular assist devices (pVADs), extracorporeal membrane oxygenation. Demographics, co-morbidities, in-hospital course and procedures were recorded, and the Charlson Co-morbidity Index was calculated. Multivariable hierarchical logistic regression analysis and additional sensitivity analyses were performed. We identified 376,116 cases of CS because of acute myocardial infarction or acutely decompensated advanced heart failure, of which 113,305 required pMCS. Women were more likely to be older, non-White, insured by Medicare, and have a higher burden of co-morbidities and higher Charlson Co-morbidity Index. pMCS devices were inserted in 35,516 women (24.9%) and 77,789 men (33.3%). Women were less likely to receive pVAD or pulmonary artery (PA) catheters. Blood transfusions and acute respiratory failure were more common in women than men. Women had 15% higher in-hospital mortality and in a multivariate analysis, women, older age, having no insurance, diabetes mellitus, chronic kidney disease, cerebrovascular disease, peripheral arterial disease, longer time to pMCS insertion, receiving PA catheter, pVAD or extracorporeal membrane oxygenation and having cardiac arrest were associated with higher in-hospital mortality. In conclusion, women requiring pMCS support had a higher co-morbidity load, in-hospital mortality, acute respiratory failure, blood transfusions, and lower PA catheter use. Studies addressing early gender-specific interventions in CS are needed to reduce these differences.

Left Ventricular Assist Device Support and Longitudinal Sleeve Gastrectomy Combined With Diet in Bridge to Heart Transplant.

Combining left ventricular assist device (LVAD) implantation and longitudinal sleeve gastrectomy may enable patients with morbid obesity to lose enough weight for heart transplant eligibility. In a retrospective study, we evaluated long-term outcomes of patients with body mass indexes ≥35 who underwent LVAD implantation and longitudinal sleeve gastrectomy during the same hospitalization (from January 2013 through July 2018) and then adhered to a dietary protocol. We included 22 patients (mean age, 49.9 ± 12.5 yr; mean preoperative body mass index, 43.3 ± 6.2). Eighteen months after gastrectomy, all 22 patients were alive, and 16 (73%) achieved a body mass index of less than 35. Myocardial recovery in 2 patients enabled LVAD removal. As of October 2020, 10 patients (45.5%) had undergone heart transplantation, 5 (22.3%) were waitlisted, 5 (22.3%) still had a body mass index ≥35, and 2 (9%) had died. With LVAD support, longitudinal sleeve gastrectomy, and dietary protocols, most of our patients with morbid obesity and advanced heart failure lost enough weight for transplant eligibility. Support from physicians and dietitians can maximize positive results in these patients.

Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support.

BACKGROUND: Respiratory failure (RF) is a common cause of death and morbid complication in trauma patients. Extracorporeal membrane oxygenation (ECMO) is increasingly used in adults with RF refractory to invasive mechanical ventilation. However, use of ECMO remains limited for this patient population as they often have contraindications for anticoagulation. STUDY DESIGN: Medical records were retroactively searched for all adult patients who were admitted to the trauma service and received veno-venous ECMO (VV ECMO) support between June 2015 and August 2018. Survival to discharge and ECMO-related complications were collected and analyzed. RESULTS: Fifteen patients from a large Level I trauma center met the criteria. The median PaO2/FiO2 ratio was 53.0 (IQR, 27.0-76.0), median injury severity score was 34.0 (IQR, 27.0-43.0), and the median duration of ECMO support was 11 days (IQR, 7.5-20.0). For this cohort, the survival-to-discharge rate was 87% (13/15). The incidence of neurologic complications was 13%, and deep vein thrombosis was reported in two cases (13%). CONCLUSIONS: Survival rates of trauma patients in this study are equivalent to, or may exceed, those of non-trauma patients who receive ECMO support for other types of RF. With the employment of a multidisciplinary team assessment and proper patient selection, early cannulation, traumatic RF may be safely supported with VV ECMO in experienced centers.

Transcatheter Mitral Valve Repair for Severe,Symptomatic Mitral Regurgitation in Patients with Left Ventricular Assist Devices.

Patients with symptomatic stage D heart failure who require left ventricular assist device (LVAD) support and suffer concomitant severe mitral regurgitation are often difficult to manage. One reason is due to cardiac anatomic constraints that limit optimization of the mechanical assist device. Typically, these patients are not candidates for repeat sternotomy with surgical mitral valve repair, and heart transplantation may not be feasible or timely. This case describes two patients with LVAD support who received transcatheter edge-to-edge mitral valve repair for severe, symptomatic mitral regurgitation. We believe this procedure may be a therapeutic option in stable patients with severe mitral regurgitation who require mechanical support.

Inter-hospital COVID ECMO air transportation.

The Coronavirus Disease 2019 (COVID-19) pandemic has required rapid and effective protocol adjustments at every level of healthcare. The use of extracorporeal membrane oxygenation (ECMO) is pivotal to COVID-19 treatment in cases of refractory hypoxemic hypercapnic respiratory failure. As such, our large, metropolitan air ambulance system in conjunction with our experts in advanced cardiopulmonary therapies modified protocols to assist peripheral hospitals in evaluation, cannulation and initiation of ECMO for rescue and air transportation of patients with COVID-19 to our quaternary center. The detailed protocol is described alongside initial data of its use. To date, 14 patients have been placed on ECMO support at an outside facility and successfully transported via helicopter to our hub hospital using this protocol.

Extracorporeal Membrane Oxygenation Utility in Postpartum Patients.

Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.

Risk of pump thrombosis and stroke in patients with continuous-flow left ventricular assist devices and gastrointestinal bleeding.

Gastrointestinal (GI) bleeding is a common complication following the placement of continuous-flow left ventricular assist devices (LVADs) in patients with advanced heart failure. Secondary events arising as a result of GI bleeding have not been well-described. Furthermore, attribution of these events to bleeding is complicated by the interruption or de-intensification of antithrombotic therapy, while bleeding is controlled. The purpose of this study was to assess the incidence of pump thrombosis and ischemic stroke in patients with LVADs who experience GI bleeding, while on support. This was a single-center, retrospective, observational cohort study of consecutive patients with LVADs implanted from January 2012 to June 2018. Patients were assigned to comparator groups based on whether they experienced GI bleeding while on LVAD support. The primary endpoint assessed was the composite of pump thrombosis or ischemic stroke. Secondary endpoints assessed included incidence of pump thrombosis or ischemic stroke. A total of 250 patients were included after screening for exclusion criteria, 101 (40.4%) in the GI bleeding group, and 149 (59.6%) in the non-bleeding group. The incidence of pump thrombosis or ischemic stroke was not significantly greater in patients experiencing GI bleeding [23 (22.8%) vs. 21 (14.1%); P = .09]; however, the incidence of ischemic stroke alone was significantly greater [17 (16.8%) vs. 10 (6.7%); P = .01]. We conclude that GI bleeding in LVAD patients may be associated with a greater risk of ischemic stroke.

The use of a sentinel cerebral protection system during Impella CP removal in a patient with left ventricular thrombus.

Percutaneous mechanical circulatory support (pMCS) devices are commonly being utilized for hemodynamic support in patients undergoing high-risk percutaneous coronary interventions or stabilization for those in cardiogenic shock. Left ventricular (LV) to ascending aorta (Ao) rotodynamic pumps such as the Impella devices allow for rapid hemodynamic stabilization or support in such instances. The use of such devices is contraindicated in patients with known LV thrombus. However, it remains unclear on how to manage patients who develop an LV thrombus while on prolonged Impella support. While there are currently no cerebral embolic protection devices (CEPDs) approved for use in conjunction with LV to Ao pMCS devices or other short-term mechanical support devices, there is a theoretical benefit for the use of such technology in the right circumstances. We present a case describing the use of the sentinel cerebral protection system (SCPS) in a patient who developed LV thrombus while on Impella CP support. The use of the SCPS in this patient suggests a potential role for CEPD in prevention of thromboembolism while on Impella support.

Management of Aortic Insufficiency Using Transcatheter Aortic Valve Replacement in Patients with Left Ventricular Assist Device Support.

Left ventricular assist devices (LVADs) increase survival of patients with heart failure. However, long-term LVAD usage can result in aortic insufficiency (AI), thereby compromising LVAD efficiency. Transcatheter aortic valve replacement (TAVR) is an alternative for patients with high risk for surgical valve replacement. We present three cases that developed moderate to severe AI while on HeartMate II (Abbott Laboratories, Chicago, IL) LVAD support; hence, TAVR procedure was performed. Patients A and B (74 year old and 38 year old) developed severe AI and patient C (67 year old) developed moderate AI with cardiogenic shock, after 368, 1,288, and 342 days on LVAD support, respectively. Their aortic valve annulus sizes were 24.2, 24.6, and 23.3 mm, respectively. Oversized Edwards SAPIEN 3 valves (Edwards, Lifesciences, Irvine, CA) were implanted via a transfemoral approach. The patients were hemodynamically stable after the procedure with mild AI in patient A and no AI in patients B and C. Patients were all discharged to home. Follow-up in patients A and C have resulted in long-term (> 2 years) survival and patient B died 616 days after the procedure due to unrelated complications. Transcatheter aortic valve replacement may be an alternative way to manage AI in LVAD patients. Larger studies are needed to evaluate the long-term efficacy of this approach.

Left Ventricular Assist Device Outflow Graft Obstruction: A Case Series.

Dysfunction of different components within continuous-flow (CF) left ventricular assist device (LVAD) systems may cause adverse cardiovascular and end-organ sequelae. Outflow graft obstruction is a recognized type of LVAD component dysfunction. Ten patients were admitted and treated for LVAD outflow graft obstruction. Two of these patients subsequently developed recurrent outflow graft obstruction requiring reintervention; however, each reoccurrence was at a different site than the original obstruction. Thus, a total of 12 cases of obstruction were analyzed. The most common reasons for hospital admission were low flow LVAD alarms or decompensated heart failure. Presentation with outflow graft obstruction occurred an average of 3.0 years after LVAD implantation. Patients underwent echocardiographic evaluation at the time of admission. Left ventricular assist device component dysfunction was suspected based on echocardiographic findings, and follow-up contrast studies were used to establish the specific diagnosis of outflow graft stenosis. The majority of stenotic lesions (10/12) were treated percutaneously with balloon angioplasty and stenting with balloon-expandable endovascular prostheses. Postintervention, all patients had significant improvement in LVAD flow rates.

Axillary Impella insertion under regional nerve block: A case report.

Percutaneous coronary interventions with the Impella (Abiomed, MA) catheter-based, micro-axial mechanical left ventricular assist device is a safe option for patients undergoing higher risk interventions. However, severe peripheral arterial disease limits vascular access for Impella insertion. Upper extremity arterial access has been traditionally obtained under general anesthesia. We present the first case, to our knowledge, of using peripheral nerve blocks for Impella 3.5 CP insertion into the axillary artery.