Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative.

BACKGROUND: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures. METHODS AND RESULTS: The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively. CONCLUSIONS: Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.

Impact of transcatheter aortic valve replacement on left ventricular hypertrophy, diastolic dysfunction and quality of life in patients with preserved left ventricular function.

Severe aortic stenosis (AS) is associated with left ventricular (LV) hypertrophy and diastolic dysfunction (LVDD). Due to positive impact on transvalvular hemodynamics, transcatheter aortic valve replacement (TAVR) is expected to improve LV remodeling, LVDD and heart failure (HF)-related quality-of-life (QoL). We identified patients with severe AS and LV ejection fraction (LVEF) ≥ 50% who underwent TAVR. We reviewed pre-procedure, 1-month and 1-year post-TAVR transthoracic echocardiograms to assess LV volumetric changes and diastolic function. QoL was assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ). In 171 patients studied, we found significant improvement in LV mass index (LVMI), LV end-systolic diameter and LV end-diastolic diameter from baseline to 1-month to 1-year post-TAVR. Predictors of LVMI regression included greater change from baseline in mean aortic valve (AV) gradient, peak AV velocity, and improvements in septal and lateral e' velocities and E/e' post-TAVR. The percentage of patients with ≥ grade 2 LVDD decreased from 65% to 53% at 1-month and 49% at 1-year. A significant improvement in symptomatology, as reported by KCCQ score was also noted. There is conceivable reverse LV remodeling post-TAVR, impacted by improvements in mean AV gradient, peak AV velocity, E/e', medial and lateral e' velocities, which occurs immediately post-TAVR and persists up to 1-year post-operatively. This is associated with concomitant improvement in LVDD and HF-related QoL as demonstrated by KCCQ scores.

Successful treatment of acute left ventricular assist device thrombosis and cardiogenic shock with intraventricular thrombolysis and a tandem heart.

Management for continuous flow left ventricular assist device (LVAD) thrombosis often relies on speculation of individual clinical risk factors and integration of indirect evidence for device dysfunction. There are no comprehensive guidelines for treatment of this serious complication, and most of our current knowledge comes from anecdotal experience or observational study. More data on effective treatment, both with aggressive pharmacologic and device-based interventions, are needed for improving our understanding of mechanisms driving device thrombosis and for preventing future events. We present a case of LVAD thrombosis with emphasis on recognition and treatment of acute pump thrombosis, and discuss a potentially novel strategy using percutaneous mechanical circulatory support for pump salvage.

Acute myocardial infarction associated with dietary supplements containing 1,3-dimethylamylamine and Citrus aurantium.

We describe the case of a previously healthy 22-year-old man who presented with anginal chest pain and was diagnosed with a non-ST-elevation myocardial infarction. For 3 weeks, he had been ingesting the dietary supplements Jack3d® (principal ingredient, 1,3-dimethylamylamine) and Phenorex™ (principal ingredient, Citrus aurantium) daily, before undertaking physical activity. Coronary angiograms revealed a proximal left anterior descending coronary artery thrombus with distal embolization. A combined medical regimen led to resolution of the thrombus. Three months later, the patient was asymptomatic with no evidence of ischemia. The primary ingredients in the sympathomimetic supplements taken by our patient are controversial in the medical community and have been individually associated with adverse cardiac events. There are no safety data on their simultaneous use. We discuss other reports of adverse effects associated with these supplements and recommend that the relevant safety guidelines be revised.

Percutaneous closure of perivalvular mitral regurgitation with an Amplatzer occluder device in a patient with both prosthetic mitral and aortic valves.

Percutaneous mitral valve closure is a novel technique in evolution as an alternative therapy for nonsurgical candidates with significant mitral regurgitation. Current use has been limited to patients with single prosthetic valves and discrete perivalvular defects. We describe a case of successful percutaneous repair of a mitral perivalvular leak with an Amplatzer ductal occluder in a patient with both prosthetic mitral and aortic valves. In this case, a left ventricle apical approach for access was utilized.