Data for validation and adjustment of APACHE II score in cardiogenic shock patients treated with a percutaneous left ventricular assist device.

A precise prognosis is of imminent importance in intensive care medicine. This article provides data showing the overestimation of intrahospital mortality by APACHE II score in various subgroups of cardiogenic shock patients treated with a percutaneous left ventricular assist device. The data set includes additional baseline characteristics regarding age, pre-existing diseases, characteristics of coronary artery disease, characteristics of cardiopulmonary resuscitation, and hemodynamic parameter not included in the APACHE II score. Further data were provided which characterize derivation and validation group. Both groups were used for adjustment of the APACHE II approach. The data are supplemental to our original research article titled "Predictive value of the APACHE II score in cardiogenic shock patients treated with a percutaneous left ventricular assist device" (Mierke et al., IJC Heart & Vasculature. 40 (2022) 101013. https://doi.org/10.1016/j.ijcha.2022.101013).

Predictive value of the APACHE II score in cardiogenic shock patients treated with a percutaneous left ventricular assist device.

Background: The APACHE II score assesses patient prognosis in intensive care units. Different disease entities are predictable by using a specific factor called Diagnostic Category Weight (DCW). We aimed to validate the prognostic value of the APACHE II score in patients treated with a percutaneous left ventricular assist device because of refractory cardiogenic shock (CS). Methods: From the Dresden Impella Registry, we analyzed 180 patients receiving an Impella CP®. The main outcome was the observed intrahospital mortality ( S ^ ( t h o s p ) ), which was compared to the predicted mortality estimated by the APACHE II score. Results: The APACHE II score, which was 33.5 ± 0.6, significantly overestimated intrahospital mortality ( S ^ ( t h o s p ) 54.4 ± 3.7% vs. APACHE II 74.6 ± 1.6%; p < 0.001). Nevertheless, the APACHE II score showed an acceptable accuracy to predict intrahospital mortality (ROC AUC 0.70; 95% CI 0.62-0.78). Thus, we adapted the formula for calculation of predicted mortality by adjusting DCW. The total registry cohort was randomly divided into derivation group for calculation of adjusted DCW and validation group for testing. Intrahospital mortality was much more precisely predicted using the adjusted DCW compared to the conventional DCW (difference of predicted and observed mortality: -4.7 ± 2.4% vs. -23.2 ± 2.3%; p < 0.001). The new calculated DCW was -1.183 for the total cohort. Conclusion: The APACHE II score has an acceptable accuracy for the prediction of intrahospital mortality but overestimates its total amount in CS patients. Adjustment of the DCW can lead to a much more precise prediction of prognosis.

Percutaneous Left Ventricular Assist Device Leads to Heart Rhythm Stabilisation in Cardiogenic Shock: Results from the Dresden Impella Registry.

BACKGROUND: Severe heart rhythm disturbances (SHRDs) occur regularly in cardiogenic shock (CS). Percutaneous left ventricular assist devices (pLVADs) can actively unload the left ventricle (LV), decreasing left ventricular end-diastolic pressure and wall tension, which are suspected parameters for the induction and maintenance of arrhythmias. The aim of this study was to describe effects of LV unloading on SHRD. METHOD: In the Dresden Impella Registry, 97 patients received an Impella CP in refractory CS. Of them, 19 had SHRDs, which were not stopped by common therapeutic strategies such as electrical defibrillation or antiarrhythmic drugs. They were only stopped after implantation of a micro-axial heart pump. This phenomenon was referred to as heart rhythm stabilisation (HRS). Clinical outcome and laboratory parameters were assessed and risk factors for the occurrence of HRS were identified. RESULTS: All 19 patients with refractory SHRD terminated immediately into a stable heart rhythm after insertion of the micro-axial heart pump. In 37% no additional defibrillation was needed. Of the patients with HRS, CS was mostly caused by myocardial infarction (68%). Resuscitation before pLVAD was performed in 89% for more than 30 minutes. Patients with HRS were resuscitated more frequently and for a longer duration than patients without HRS. After HRS, the serum lactate and norepinephrine dosage decreased in the first 12 hours, whereas left ventricular ejection fraction increased by 95%. CONCLUSIONS: Left ventricular unloading in patients with CS seems to be an option for treating patients with sustained life-threatening tachycardia, who are refractory to common treatment.

Long term survival after early unloading with Impella CP® in acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: The use of percutaneous left ventricular assist devices in patients with acute myocardial infarction complicated by cardiogenic shock (AMICS) is evolving. The aim of the study was to assess the long-term outcome of patients with AMICS depending on early initiation of Impella CP® support prior to a percutaneous coronary intervention (PCI). METHODS: We retrospectively reviewed all patients who underwent PCI and Impella CP® support between 2014 and 2016 for AMICS at our institution. We compared survival to discharge between those with support initiation before (pre-PCI) and after (post-PCI) PCI. RESULTS: A total of 73 consecutive patients (69±12 years old, 27.4% female) were supported with Impella CP® and underwent PCI for AMICS (34 pre-PCI vs. 39 post-PCI). All patients were admitted with cardiogenic shock, and 58.9% sustained cardiac arrest. Survival at discharge was 35.6%. Compared with the post-PCI group, patients in the pre-PCI group had more lesions treated (p=0.03), a higher device weaning rate (p=0.005) and higher survival to discharge as well as to 30 and 90 days after device implantation, respectively (50.0% vs. 23.1%, 48.5% vs. 23.1%, 46.9 vs. 20.5%, p < 0.05). Kaplan-Meier analysis showed a higher survival at one year (31.3% vs. 17.6%, log-rank p-value=0.03) in the pre-PCI group. Impella support initiation before PCI was an independent predictor of survival up to 180 days after device implantation. CONCLUSIONS: In this small, single-centre, non-randomized study Impella CP® initiation prior to PCI was associated with higher survival rates at discharge and up to one year in AMICS patients presenting with high risk for in-hospital mortality.

Influence of the plasminogen activator system on necrosis in acute myocardial infarction: analysis of urokinase- and urokinase receptor-knockout mouse models.

Serine proteases and G-protein-coupled receptors have been studied extensively as effectors of cell death. However, their roles in myocardial infarction have not been determined. In this study, we investigated the influence of the plasminogen activator system involving urokinase and urokinase receptor on necrosis after acute myocardial infarction. Myocardial infarction and reperfusion were induced in mouse hearts using the in vitro Langendorff model. DNA fragmentation and cleaved caspase-3 activity in urokinase- (uPA-/-) and urokinase receptor-knockout mice (uPAR-/-) were determined and compared with those in wild-type mice using in situ nick-end DNA labeling (TUNEL) and enzyme-linked immunosorbent assays, respectively. Infarct sizes were determined using propidium iodide and fluorescent microspheres. Following regional ischemia and reperfusion, a significant increase in the number of TUNEL-positive nuclei was observed in the ischemic zone in mouse hearts and to a lesser degree in regions remote from the ischemic area in wild-type, uPAR-/-, and uPA-/- groups compared with those in directly removed hearts. No significant differences were observed between uPAR-/- and wild-type mice. Conversely, a significant reduction in DNA fragmentation was observed in ischemic and nonischemic regions after acute myocardial infarction in uPA-/- mice when compared with that in wild-type and uPAR-/- groups. The resulting infarct sizes were significantly smaller in uPA-/- mice than in uPAR-/- and wild-type mice. These data demonstrated the involvement of uPA, but not uPAR, in protecting against necrosis during acute myocardial infarction.

Reverse takotsubo cardiomyopathy- life-threatening symptom of an incidental pheochromocytoma: a case report.

BACKGROUND: Cardiogenic shock (CS) due to takotsubo cardiomyopathy (TTC) is a life-threatening condition. Therapy is challenging because of the ambivalent effects of catecholamines. Catecholamines are required to stabilize blood pressure but might aggravate TTC. Cardiac assist devices could be a suitable solution for conserving catecholamines and the prevention of TTC perpetuation. CASE SUMMARY: We report the case of a male patient with refractory CS and severe respiratory insufficiency as a result of a reverse TTC, which involved both ventricles. Simultaneous circulatory support with an Impella CP® and veno-arterial extracorporeal membrane oxygenation was initiated for cardiopulmonary stabilization and catecholamine weaning. A giant, incidental pheochromocytoma was diagnosed as the cause of TTC. After drug treatment and resection of the tumour, biventricular function completely recovered within 7 weeks. DISCUSSION: A rare and challenging situation is the coincidence of a nor/epinephrine-secreting tumour, such as a pheochromocytoma, and severe CS complicating TTC. Although percutaneous left ventricular assist devices (pLVAD) are highly complicated and have shown conflicting results in terms of clinical efficacy for CS, its use may prevent the perpetuation of TTC due to reduced catecholamines requirement.

Impella Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock.

BACKGROUND: Percutaneous mechanical circulatory support devices are increasingly used in acute myocardial infarction complicated by cardiogenic shock (AMI-CS), despite limited evidence for their effectiveness. The aim of this study was to evaluate outcomes associated with use of the Impella device compared with intra-aortic balloon pump (IABP) and medical treatment in patients with AMI-CS. METHODS: Data of patients with AMI-CS treated with the Impella device at European tertiary care hospitals were collected retrospectively. All patients underwent early revascularization and received optimal medical treatment. Using IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial inclusion and exclusion criteria, 372 patients were identified and included in this analysis. These patients were matched to 600 patients from the IABP-SHOCK II trial. The following baseline criteria were used as matching parameters: age, sex, mechanical ventilation, ejection fraction, prior cardiopulmonary resuscitation, and lactate. Primary end point was 30-day all-cause mortality. RESULTS: In total, 237 patients treated with an Impella could be matched to 237 patients from the IABP-SHOCK II trial. Baseline parameters were similarly distributed after matching. There was no significant difference in 30-day all-cause mortality (48.5% versus 46.4%, P=0.64). Severe or life-threatening bleeding (8.5% versus 3.0%, P<0.01) and peripheral vascular complications (9.8% versus 3.8%, P=0.01) occurred significantly more often in the Impella group. Limiting the analysis to IABP-treated patients as a control group did not change the results. CONCLUSIONS: In this retrospective analysis of patients with AMI-CS, the use of an Impella device was not associated with lower 30-day mortality compared with matched patients from the IABP-SHOCK II trial treated with an IABP or medical therapy. To further evaluate this, a large randomized trial is warranted to determine the effect of the Impella device on outcome in patients with AMI-CS. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03313687.

Reversal of the platelet inhibitory effect of the P2Y12 inhibitors clopidogrel, prasugrel, and ticagrelor in vitro: a new approach to an old issue.

AIM: Platelet transfusion is an effective option to reverse platelet inhibition in thienopyridine-treated patients suffering from bleedings or requiring urgent surgery. However, in ticagrelor-treated patients, the previous studies revealed significant clinical effects to platelet rich plasma (PRP) but poor response to pooled platelets (PP) as used in clinical routine. The aim of this study was to elucidate a potential pathomechanism to explain the poor response of ticagrelor to PP. METHODS AND RESULTS: From 79 whole blood samples of patients treated with ticagrelor, prasugrel, or clopidogrel, the PRI-VASP was determined before and after in vitro platelet supplementation of PP or PRP at increasing concentrations. Compared to prasugrel- and clopidogrel-treated patients, the PRI-VASP of ticagrelor-treated patients showed no significant increase after in vitro administration of PP. PRI-VASP was performed in ticagrelor-treated samples after in vitro addition of 1: centrifuged PRP platelets resuspended in PP buffer, 2: PP with human serum, 3: human serum alone. Surprisingly, PP with human serum or human serum alone were able to significantly increase PRI-VASP in samples of ticagrelor-treated patients (11.7 ± 10.9 â†’ 61.3 ± 10.9%, p = 0.006; 11.7 ± 10.9 â†’ 54.1 ± 2.7%, p < 0.001). This effect could also be shown using human albumin (18.9 ± 5.1% â†’ 80 g/l human albumin: 48.1 ± 8.3%, p < 0.001). CONCLUSION: The present study demonstrates that addition of human serum and human albumin alone is able to reverse the ticagrelor effects in vitro and supports our novel hypothesis of the importance of proteins in reversing the effects of ticagrelor by binding active ticagrelor.

Troubleshooter in electrical storm: Mechanical unloading leads to heart rhythm stabilization.

The electrical storm is a life-threatening situation which causes a complex antiarrhythmic treatment. We firstly report a rhythmological stabilization through mechanical unloading of the left ventricle in a health patient who developed electrical storm after endo- and epicardiac re-ablation and who previously underwent 27 unsuccessful defibrillations. No evidence for a specific etiology of the rhythm disturbances was found. After implantation of a percutaneous left ventricular assist device (pLVAD) a single additional defibrillation was needed to terminate ventricular fibrillation. This unique application of pLVAD might be an unprecedented escape strategy for patients who have exhausted all other commonly recommended therapy options.

A novel interventional method for treating femoral pseudoaneurysms: results from a monocentric experience.

AIMS: Iatrogenic pseudoaneurysms of the femoral artery lead to increased morbidity and mortality, especially when surgical treatment is necessary. Manual compression and thrombin injection are commonly used to occlude the pseudoaneurysms. However, in some cases these treatment options are inapplicable or unsuccessful. The aim of the present study was to examine the feasibility, effectiveness and safety of a novel approach with the use of suture-based closure devices to treat pseudoaneurysms. METHODS AND RESULTS: Between January 2014 and May 2016, a total of eight iatrogenic pseudoaneurysms of the femoral artery were treated by the interventional closure technique after at least one ineffective attempt at manual compression. After puncture of the cavity, a PTCA guidewire was used to pass the neck of the pseudoaneurysm and a sheath was inserted in the femoral artery. Afterwards, a suture-based closure system (ProGlide) was used to occlude the neck. All eight pseudoaneurysms were successfully obliterated. No complications occurred during the procedure. CONCLUSIONS: The new interventional technique presented in this study fills the gap in successfully treating pseudoaneurysms that cannot be obturated with conventional techniques. By implementing this new technique in clinical practice, a significant number of open surgical repairs could be prevented.