Characterizing Adaptive Changes and Patient Survival After 2018 Donor Allocation Restructuring: A UNOS Database Analysis.

PURPOSE: We sought to characterize adaptive changes to the revised United Network for Organ Sharing donor heart allocation policy and estimate long-term survival trends for heart transplant (HTx) recipients. METHODS: Patients listed for HTx between October 17, 2013 and September 30, 2021 were identified from the United Network for Organ Sharing database, and stratified into pre- and postpolicy revision groups. Subanalyses were performed to examine trends in device utilization for extracorporeal membranous oxygenation (ECMO), durable left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), microaxial support (Impella), and no mechanical circulatory support (non-MCS). Survival data post-HTx were fitted to parametric distributions and extrapolated to 5 years. RESULTS: We identified 27,523 HTx waitlist candidates during the study period, most of whom (n = 16,376) were waitlisted in the prepolicy change period. Overall, 19,554 patients underwent HTx during the study period (pre: 12,037 and post: 7517). Listings increased after the policy change for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients. Listings for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients decreased. HTx increased for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients after the policy change and decreased for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients. Waitlist survival increased for the overall ( P < 0.01), ECMO ( P < 0.01), IABP ( P < 0.01), and non-MCS ( P < 0.01) groups. Waitlist survival did not differ for the LVAD ( P = 0.8) and Impella ( P = 0.1) groups. Post-transplant survival decreased for the overall ( P < 0.01), LVAD ( P < 0.01), and non-MCS ( P < 0.01) populations. CONCLUSIONS: Allocation policy revisions have contributed to greater utilization of ECMO, Impella, and IABP, decreased utilization of LVADs and non-MCS, increased waitlist survival, and decreased post-HTx survival.

Protocolo assistencial multidisciplinar: relato de caso de 225 dias de balão intra aórtico / Multidisciplinary care protocol: case report of 225 days of intra-aortic balloon pump

Este estudo aborda um caso extremamente raro de um paciente que passou 225 dias com um balão intra aórtico antes de receber um transplante cardíaco. Essa situação extraordinária destaca a importância da abordagem multiprofissional no cuidado de pacientes com desafios clínicos complexos. Além disso, oferece insights valiosos para a comunidade médica e científica, contribuindo para o aprimoramento das estratégias clínicas em um contexto desafiador. A insuficiência cardíaca (IC), uma condição em que o coração não consegue bombear sangue suficiente para atender às necessidades do corpo, afetando mais de 23 milhões de pessoas em todo o mundo, incluindo cerca de 2 milhões no Brasil. A IC é frequentemente causada por condições como doença arterial coronariana (DAC), hipertensão e diabetes, com influência adicional da doença de Chagas na América Latina. Pacientes com IC enfrentam desafios significativos que resultam frequentemente em hospitalizações recorrentes. Uma abordagem multiprofissional é essencial para o tratamento e gerenciamento eficaz da doença, dada a complexidade da patologia e suas comorbidades. Uma equipe multiprofissional reúne especialistas em saúde para fornecer uma abordagem abrangente e personalizada, auxiliando os pacientes na transição até o transplante cardíaco e na gestão contínua da condição, prevenindo complicações. A análise deste caso incomum, no qual o paciente encontrado por um longo período com um balão intraaórtico, destaca a importância crucial da abordagem multiprofissional no cuidado de pacientes com insuficiência cardíaca. Os resultados deste estudo têm o potencial de oferecer novas perspectivas e contribuições benéficas para a comunidade médica, promovendo o avanço das estratégias de tratamento em um contexto clínico notável.

The Effects of Exercise on Cardiogenic Shock with an Intra-Aortic Balloon Pump: A Case Report. / Efeitos do Exercício em Choque Cardiogênico e Balão Intra-Aórtico: Um Relato de Caso.

This case report describes the exercise program on a hospitalized 54-year-old male patient with cardiogenic shock waiting for a heart transplant assisted by an intra-aortic balloon pump, a temporary mechanical circulatory support device. The temporary mechanical circulatory support device, an intra-aortic balloon pump, was placed in the left subclavian artery, enabling the exercise protocol. Measurements and values from Swan-Ganz catheter, blood sample, brain natriuretic peptide (NT-proBNP), and high-sensitivity C-reactive protein (hs-CRP), as well as the six-minute walk test (6MWT) and venous oxygen saturation (SvO2) were obtained before and after an exercise protocol. The exercise training protocol involved the use of an unloaded bed cycle ergometer once a day, for a maximum of 30 minutes, to the tolerance limit. No adverse events or events related to the dislocation of the intra-aortic balloon pump were observed during the exercise protocol. The exercise program resulted in higher SvO2 levels, with an increased 6MWT with lower Borg dyspnea scores (312 meters vs. 488 meters and five points vs. three points, respectively). After completing the ten-day exercise protocol, the patient underwent a non-complicated heart transplant surgery and a full recovery in the ICU. This study showed that exercise is a feasible option for patients with cardiogenic shock who are using an intra-aortic balloon pump and that it is well-tolerated with no reported adverse events.

O presente relato de caso descreve o programa de exercícios aplicado a um paciente do sexo masculino, de 54 anos, internado com choque cardiogênico, aguardando transplante cardíaco e assistido por balão intra-aórtico, um dispositivo de suporte circulatório mecânico temporário. O dispositivo de suporte circulatório mecânico temporário, um balão intra-aórtico, foi colocado na artéria subclávia esquerda, possibilitando o protocolo de exercícios. Antes e após um protocolo de exercícios, foram obtidos dados a partir de cateter de Swan-Ganz, amostra de sangue, peptídeo natriurético cerebral (NT-proBNP), proteína C reativa de alta sensibilidade (PCR-as), teste de caminhada de seis minutos (TC6min) e medição da saturação venosa de oxigênio (SvO2). O protocolo de treinamento físico envolveu a utilização de um cicloergômetro adaptado ao leito, sem carga, uma vez ao dia, por no máximo 30 minutos, até o limite da tolerância. Não foram observados eventos adversos tampouco relacionados ao deslocamento do balão intra-aórtico durante o protocolo de exercícios. O programa de exercícios resultou em maior SvO2 com aumento do TC6min e menores escores de dispneia de Borg (312 metros vs. 488 metros e cinco pontos vs. três pontos, respectivamente). Após completar o protocolo de exercícios de dez dias, o paciente foi submetido a uma cirurgia de transplante cardíaco sem complicações e recuperação total na UTI. O presente estudo demonstrou que o exercício é uma opção viável para pacientes com choque cardiogênico em uso de balão intra-aórtico e que é bem tolerado, além de não haver relatos de eventos adversos.

Efeitos do exercício em choque cardiogênico e balão intra-aórtico: um relato de caso / The Effects of Exercise on Cardiogenic Shock with an Intra-Aortic Balloon Pump: A Case Report

O presente relato de caso descreve o programa de exercícios aplicado a um paciente do sexo masculino, de 54 anos, internado com choque cardiogênico, aguardando transplante cardíaco e assistido por balão intra-aórtico, um dispositivo de suporte circulatório mecânico temporário. O dispositivo de suporte circulatório mecânico temporário, um balão intra-aórtico, foi colocado na artéria subclávia esquerda, possibilitando o protocolo de exercícios. Antes e após um protocolo de exercícios, foram obtidos dados a partir de cateter de Swan-Ganz, amostra de sangue, peptídeo natriurético cerebral (NT-proBNP), proteína C reativa de alta sensibilidade (PCR-as), teste de caminhada de seis minutos (TC6min) e medição da saturação venosa de oxigênio (SvO2). O protocolo de treinamento físico envolveu a utilização de um cicloergômetro adaptado ao leito, sem carga, uma vez ao dia, por no máximo 30 minutos, até o limite da tolerância. Não foram observados eventos adversos tampouco relacionados ao deslocamento do balão intra-aórtico durante o protocolo de exercícios. O programa de exercícios resultou em maior SvO2 com aumento do TC6min e menores escores de dispneia de Borg (312 metros vs. 488 metros e cinco pontos vs. três pontos, respectivamente). Após completar o protocolo de exercícios de dez dias, o paciente foi submetido a uma cirurgia de transplante cardíaco sem complicações e recuperação total na UTI. O presente estudo demonstrou que o exercício é uma opção viável para pacientes com choque cardiogênico em uso de balão intra-aórtico e que é bem tolerado, além de não haver relatos de eventos adversos.

Dispositivos percutáneos temporales de asistencia circulatoria mecánica para el tratamiento y prevención del shock cardiogénico: análisis de eficacia, efectividad y seguridad / Temporary percutaneous mechanical circulatory support devices for the treatment and prevention of cardiogenic shock: efficacy, effectiveness, and safety analysis

INTRODUCCIÓN Los/as pacientes en shock cardiogénico (SC) refractario presentan mal pronóstico y el tratamiento farmacológico no reduce sustancialmente la alta mortalidad. La implantación, en el momento oportuno, de un dispositivo percutáneo temporal de asistencia circulatoria mecánica (DPTACM) puede dar lugar a una rápida estabilización y a una mejoría hemodinámica, disminuyendo la necesidad de fármacos inotrópicos, vasopresores y diuréticos y el riesgo de fallo multiorgánico progresivo. Además, permiten descargar el ventrículo disfuncionante, reduciendo así el consumo de oxígeno y promoviendo un remodelado favorable. Es por ello, que los DPTACM han revolucionado el manejo del SC en las últimas dos décadas y ofrecen una alternativa terapéu tica esperanzadora para estos pacientes. Sin embargo, existen dudas sobre los dispositivos que aportan mejores resultados en el tratamiento y prevención del SC refractario. Es por ello de interés analizar la evidencia científica disponible, de forma que respalde la toma de decisiones en el manejo clínico del SC. OBJETIVOS a) Objetivo general Conocer y comparar la eficacia, efectividad y seguridad de los DPTACM utilizados más habitualmente en nuestro contexto sanitario para el tratamiento y prevención del SC. b) Objetivos específicos • Comparar los efectos clínicos de los DPTACM en el tratamiento de los pacientes con SC refractario. • Comparar los efectos clínicos de los DPTACM en intervenciones coronarias percutáneas (ICP) de alto riesgo. METODOLOGÍA Se ha realizado una revisión sistemática (RS) de la evidencia científica que compara los siguientes DPTACM: dispositivos Impella®, Balón de Contrapulsación intraaórtica (BCPIA) y el Oxigenador extracorpóreo de membrana (ECMO). RESULTADOS Se ha ejecutado una búsqueda sistemática en bases de biomédicas que ha identificado 973 referencias potencialmente relevantes. Tras la selección en base al título y resumen de los artículos se han identificado 92 estudios potencialmente elegibles, que fueron revisados posteriormente a texto com pleto. Finalmente, 31 estudios han sido elegidos para su análisis. La calidad/confianza de la evidencia disponible es mayoritariamente baja o muy baja. Sólo los estudios que comparan el BCPIA frente al trata miento médico convencional y el BCPIA frente a Impella® en ICP de alto riesgo proporcionan evidencia de calidad/confianza alta. • Dispositivos Impella® a) Eficacia y seguridad de los dispositivos Impella® comparados con el BCPIA en ICP de alto riesgo En ICP de alto riesgo los dispositivos Impella® 2.5 producen menos Efectos Adversos Mayores (MAE) como muerte, infarto agudo de miocardio, ictus, accidente isquémico transitorio, repetición de revascularización, necesi dad de cirugía cardíaca o vascular, insuficiencia renal aguda, hipotensión grave, reanimación cardiopulmonar o taquicardia ventricular, insuficiencia aórtica o fallo angiográfico de la ICP que el BCPIA a los 90 días de seguimiento. En pacientes con enfermedad de 3 vasos y baja fracción de eyección ventricular el soporte circulatorio con dispositivos Impella® 2.5 durante la ICP producen menos MAE irreversibles (muerte/ictus/infarto agudo de miocardio) que el BCPIA. No se han demostrado diferencias entre los dispositivos Impella® 2.5 y el BCPIA en la mortalidad hospitalaria, a medio y largo plazo. En cuanto a los resultados de seguridad, el riesgo de complicaciones es semejante para ambos dispositivos percutáneos. b) Eficacia de la implantación precoz vs tardía de dispositivos Impella® 2.5 en ICP de alto riesgo La implantación de dispositivos Impella® 2.5 previa a la ICP se asocia con una mayor supervivencia al alta hospitalaria, a los 30 y a los 90 días que la implantación tras la intervención coronaria. c) Eficacia y seguridad de los dispositivos Impella® 2.5/CP comparados con el BCPIA en el tratamiento del SC No se observan diferencias significativas en la mortalidad a 1 mes ni a los 6 meses en pacientes con SC tratados con dispositivos Impella® 2.5/CP o con BCPIA. Los dispositivos Impella® presentan mayor riesgo de complicaciones vasculares, de hemorragias y de hemólisis severa que el BCPIA en el trata miento del SC. d) Eficacia de los dispositivos Impella® 2.5/CP comparados con el tratamiento médico convencional del SC Los/as pacientes con SC tratados/as con dispositivos Impella® 2.5/CP presentan una mayor supervivencia al alta y a los 6 meses que los/as tratados/as con tratamiento médico convencional. e) Eficacia y seguridad de los dispositivos Impella® comparados con ECMO-VA en el tratamiento del SC No se han demostrado diferencias significativas en la mortalidad hos pitalaria, a los 30 días y a 1 año entre los dispositivos Impella® y el ECMO VA en pacientes con SC. Tampoco se han demostrado diferencias significativas entre ambos dispo sitivos en la incidencia de hemorragias severas en el punto de inserción, com plicaciones relacionadas con el dispositivo o episodios de isquemia periférica. • ECMO-VA a) Eficacia y seguridad del ECMO-VA comparado con BCPIA en el tratamiento del SC En pacientes con SC la supervivencia a los 30 días es significativamente mejor en los/as pacientes en tratamiento con ECMO-VA que con BCPIA. DISPOSITIVOS PERCUTÁNEOS TEMPORALES DE ASISTENCIA CIRCULATORIA MECÁNICA PARA EL No obstante, el soporte con ECMO-VA se asocia con mayor número de complicaciones asociadas con el dispositivo. b) Eficacia y seguridad del ECMO-VA comparado con su combinación con Impella® en el tratamiento del SC No se evidencian diferencias en la mortalidad hospitalaria ni a los 30 días en los/as pacientes con SC tratados con ECMO-VA más Impella® fren te a ECMO-VA. En cambio, la mortalidad a 1 año es significativamente menor con un soporte circulatorio mediante ambos dispositivos. No se han demostrado diferencias significativas en cuanto la aparición de complicaciones vasculares o de hemorragia severa en el punto de inserción. Sin embargo, el uso combinado de ECMO-VA más Impella® se asocia con un mayor riesgo de hemólisis severa. c) Eficacia y seguridad del ECMO-VA comparado con su combinación con BCPIA en el tratamiento del SC En pacientes con SC la combinación de ECMO-VA más BCPIA dis minuye de forma significativa la mortalidad hospitalaria con respecto al so porte con ECMO-VA aislado. La combinación de ECMO-VA más BCPIA no ha demostrado mayor número de complicaciones que la ECMO-VA. • BCPIA a) Eficacia y seguridad del BCPIA comparado con el tratamiento mé dico convencional en el tratamiento del SC No se han demostrado diferencias significativas en la mortalidad a los 30 días en pacientes con SC tratados con BCPIA o con tratamiento médico convencional. b) Eficacia y seguridad del BCPIA comparado con su combinación con ECMO-VA En pacientes con SC se evidencia una mayor supervivencia en los pa cientes tratados con ECMO-VA combinado con BCPIA frente aquellos a los que se aplicó únicamente BCPIA. No se han encontrado diferencias relevantes en cuanto a la aparición de complicaciones o de efectos adversos entre ambas estrategias terapéuticas.

INTRODUCTION Patients with refractory cardiogenic shock (CS) have a poor prognosis, and the associated high mortality is not significantly reduced by medical treatments. The timely placement of a temporary percutaneous mechanical circulatory support device (MCSD) can achieve rapid stabilisation and haemodynamic improvement, reducing the need for inotropes, vasopressors and diuretics and the risk of progressive multiorgan failure. Further, it enables ventricular unloading, thereby reducing oxygen consumption and promoting favourable remodelling. For these reasons, such devices have revolutionised the management of cardiogenic shock in recent decades and represent a promising treatment option for this population. Nonetheless, it remains unclear which of these types of devices provide the best results in the treatment and prevention of refractory CS. Given this, it was deemed interesting to analyse the available scientific evidence, to guide decision making regarding the clinical management of CS. OBJECTIVE a) General objective To assess and compare the efficacy, effectiveness and safety of the MCSDs most commonly used in our healthcare setting in the treatment and prevention of CS. b) Specific objectives • To compare the clinical effects of different MCSDs in the treatment of patients with refractory CS • To compare the clinical effects of different MCSDs in high-risk per cutaneous coronary interventions (PCIs). METHODS A systematic review (SR) of the scientific literature was conducted to identify studies comparing the following MCSDs: Impella® ventricular assist devices, intra-aortic balloon pumps (IABPs) and extracorporeal membrane oxygenation (ECMO) devices. RESULTS A systematic search in biomedical databases identified 973 potentially relevant publications. Title and abstract screening yielded 92 potentially el igible studies and these subsequently underwent full-text review. Finally, 31 studies were included in the analysis. The quality/reliability of the available evidence was mainly low or very low. Only the studies comparing IABPs with usual care alone or with Impel la® devices in high-risk PCI cases were of high quality and reliability. • Impella® devices a) Efficacy and safety of Impella® devices compared with IABPs in high-risk PCI After 90 days of follow-up, in high-risk PCIs, Impella 2.5® devices are associated with lower rates of major adverse effects (MAEs) such as death, acute myocardial infarction, stroke, transient ischemic attack, repeat revas cularisation, need for heart or vascular surgery, acute kidney failure, severe hypertension, cardiopulmonary resuscitation or ventricular tachycardia, aortic insufficiency or angiographic failure of PCI, than IABPs. In patients with three-vessel disease and low ventricular ejection frac tion, the rate of irreversible adverse effects (death, stroke, or acute myocar dial infarction) is lower with circulatory support using an Impella 2.5® device during PCI than with an IABP. No differences have been shown in in-hospital mortality, in the medium or long-term, between Impella 2.5® devices and IAMPs. Regarding results on safety, the risk of complications is similar with both percutaneous devices. b) Efficacy of early vs late placement of Impella 2.5® devices in high-risk PCIs The use of Impella 2.5® devices before PCI is associated with greater survival to discharge, as well as to 30 and 90 days, than its use after this type of coronary intervention. c) Efficacy and safety of Impella 2.5/CP® devices vs IABPs in CS There are no significant differences in mortality at 1 or 6 months in patients with CS treated with Impella 2.5/CP® devices vs IABPs. d) Efficacy of Impella 2.5/CP® devices vs standard medical care in CS Rates of survival to hospital discharge and 6 months are higher in pa tients with CS treated with Impella 2.5/CP® devices than those receiving standard medical care. e) Efficacy and safety of Impella® devices vs venoarterial ECMO in CS No significant differences have been found in in-hospital, 30-day or 1-year mortality using Impella® devices or venoarterial ECMO (VA-ECMO) in patients with CS. Further, no significant differences have been found in rates of severe bleeding at the insertion site, device-related complications or episodes of peripheral ischaemia associated with these two types of devices. • Venoarterial ECMO devices a) Efficacy and safety of venoarterial ECMO vs IABP in CS In patients with CS, 30-day survival is significantly greater in patients receiving VA-ECMO than those treated with IABPs. Nonetheless, VA-EC MO is associated with a higher rate of device-associated complications. b) Efficacy and safety of venoarterial ECMO alone vs in combination with Impella® devices in CS There are no differences in in-hospital or 30-day mortality between patients with CS treated with VA-ECMO plus an Impella® device and those treated with VA-ECMO alone. Nonetheless, 1-year mortality is significantly lower with circulatory support based on both devices. There are no significant differences in vascular complications or severe bleeding at the insertion site; however, the combination of VA-ECMO and an Impella® device is associated with a greater risk of severe haemolysis. c) Efficacy and safety of VA-ECMO alone vs in combination with IABPs in CS In patients with CS, in-hospital mortality is significantly lower with the combination of VA-ECMO and an IABP than with VA-ECMO alone. The combination of VA-ECMO and an IABP is not associated with a higher rate of complications compared to VA-ECMO alone. • IABPs a) Efficacy and safety of IABPs vs standard medical care in CS There are no significant differences in 30-day mortality between CS patients treated with an IABP and those receiving standard medical care. b) Efficacy and safety of IABPs vs the combination of IABPs and VA-ECMO Survival is greater in patients treated with VA-ECMO combined with an IABP than those treated with an IABP alone. No significant differences in safety, in terms of complications or adverse effects, have been found between these two strategies.

Instalación ecoguiada del balón de contrapulsación intraaórtico (BCPIA) vía arteria axilar por abordaje extratorácico en pacientes en espera de trasplante cardíaco / Echo-guided installation of Inta aortic balloon counterpulsation via the extra thoracic axillary artery

Resumen El balón de contrapulsación intraaórtico (BCPIA) es el dispositivo más frecuentemente utilizado para otorgar soporte mecánico en pacientes con insuficiencia cardíaca terminal y compromiso hemodinámico refractario al soporte inotrópico. Se han utilizado diferentes tipos de abordajes para la instalación del BCPIA a través de las extremidades superiores, ya sea vía arteria subclavia o últimamente vía arteria axilar. Con el objetivo de evitar la inmovilidad física asociada al BCPIA instalado vía arteria femoral, aumentar la comodidad del paciente, simplificar la técnica de instalación del catéter y facilitar los cuidados de enfermería necesarios para su mantención, hemos diseñado y utilizado un abordaje simple y seguro para su inserción. Bajo técnica ecoguiada y utilizando un set de micro punción, se realizó la canulación de la arteria axilar en su porción externa (lateral al borde externo del músculo pectoral menor). Con la ayuda de fluoroscopía, el BCPIA fue avanzado hasta posicionarlo en la aorta descendente bajo la emergencia de la arteria subclavia izquierda. En dos pacientes con insuficiencia cardíaca terminal INTERMACS 2, con deambulación restringida debido a la necesidad permanente de soporte inotrópico y BCPIA femoral, bajo visión ecoguiada se realizó la reinstalación de este catéter a través de la arteria axilar izquierda, utilizando anestesia local y fluoroscopía en el laboratorio de hemodinamia. La rehabilitación fue posible rápidamente en ambos pacientes, realizándose el transplante cardíaco ortotópico después de 10 y 69 días de soporte mecánico con BCPIA, sin mayores efectos adversos.

Abstract Intra aortic balloon counterpulsation (IABP) is the most frequently used procedure to give mechanic support in patients with terminal heart failure and hemodynamic compromise refractory to inotropic support. Different approaches have been utilized to install upper extremity IABP, via either the axillary or subclavian arteries. In order to circumvent the limitations associated to long lasting femoral IABP support, simplify the technique, increase patient comfort and facilitate nursing care, we designed a simplified approach. Using echo guidance, the axillary artery was accessed with a micropuncture set just outside the external margin of the pectoral minor muscle. With the help of fluoroscopy the IABP catheter was advanced and its correct position in the descending aorta was confirmed. Two patients in INTERMACS 2 end stage heart failure, bedridden due to permanent inotropic support and femoral IABP, underwent echo guided axillary IABP placement under local anesthesia and fluoroscopy in the catheterization laboratory. Both patients gained rapid access to rehabilitation and received orthotopic heart transplantation after 10 and 69 days of uneventful IABP support.

[Ischemic cardiogenic shock and short-term mechanical circulatory support as bridge to transplantation]. / Shock cardiogénico en infarto agudo de miocardio y soporte circulatorio puente al trasplante.

Cardiogenic shock (CS) has a high mortality rate and often requires advanced therapies such as mechanical circulatory support (MCS) and heart transplantation (HT). Those patients who presented an acute myocardial infarction (AMI) with CS and required support through MCS as bridge to HT were retrospectively analyzed in a single Center. Between January 1997 and June 2020, 524 patients received HT, 203 for ischemic-cardiomyopathy, 103 were in emergency waiting list. Eleven patients met the inclusion criteria (mean age 53 ± 11 years old; men 73%). Five primary angioplasties and 2 emergency myocardial revascularization surgeries were performed. Four patients had coronary anatomy not subject to revascularization. All received inotropic and vasopressor treatment and required intra-aortic balloon pump (IABP). Subsequently, two required support with a left univentricular centrifugal pump (BioMedicus®, Medtronic) and two with peripheral veno-arterial extracorporeal membrane oxygenator (VA-ECMO) (Maquet®, Getinge Group). The median between AMI and HT was 15 days (range 7-21) and the mean age of the donors 28 ± 11 years. All had extensive AMI (necrotic amount 35 ± 5%) with histopathological signs of transmural necrosis and reperfusion injury. The median follow-up was 9 years (range 1-15). None died in hospitalization or during the first year after transplantation. Survival at 5 and 10 years was 73% and 55%. Emergency HT may be the best option for selected patients with acute myocardial infarction and cardiogenic shock refractory to conventional therapy.

El shock cardiogénico (SC) presenta una elevada mortalidad y puede requerir de terapéuticas avanzadas como la asistencia circulatoria mecánica (ACM) y el trasplante cardíaco (TC). Se analizaron en forma retrospectiva, en un único centro, aquellos pacientes que presentaron un infarto agudo de miocardio (IAM), SC y requirieron ACM puente al TC. Entre enero 1997 y junio 2020, 524 pacientes recibieron un TC, 203 por cardiopatía isquémica, 103 en lista de emergencia. Se incluyeron once pacientes con los criterios mencionados (edad media 53 ± 11 años; hombres 73%). Se realizaron 5 angioplastias primarias y 2 cirugías de revascularización miocárdica de urgencia. Cuatro pacientes presentaban anatomía coronaria no pasible de revascularización. Todos recibieron tratamiento inotrópico y vasopresor y requirieron soporte con balón de contrapulsación intra aórtico (BCIA). Dos requirieron el implante de bomba centrífuga univentricular izquierda (BioMedicus®, Medtronic) y 2 de oxigenador de membrana extracorpóreo veno-arterial (ECMO-VA) periférico (Maquet®, Getinge Group). La mediana entre IAM y TC fue 15 días (rango 7-21) y la edad de los donantes 28 ± 11 años. Todos presentaron un IAM extenso (monto necrótico 35 ± 5%) con signos histopatológicos de necrosis transmural e injuria de reperfusión. La mediana de seguimiento fue 9 años (rango 1-15). Ninguno falleció en la internación ni durante el primer año post trasplante. La supervivencia a los 5 y 10 años fue 73% y 55%. El TC en situación de emergencia ha demostrado ser, en nuestro medio, la mejor opción en aquellos pacientes con IAM y SC refractario a la terapia convencional.

Shock cardiogénico en infarto agudo de miocardio y soporte circulatorio puente al trasplante / Ischemic cardiogenic shock and short-term mechanical circulatory support as bridge to Transplantation

Resumen El shock cardiogénico (SC) presenta una elevada mortalidad y puede requerir de terapéuticas avanzadas como la asistencia circulatoria mecánica (ACM) y el trasplante cardíaco (TC). Se analizaron en forma retrospectiva, en un único centro, aquellos pacientes que presentaron un infarto agudo de miocardio (IAM), SC y requirieron ACM puente al TC. Entre enero 1997 y junio 2020, 524 pacientes recibieron un TC, 203 por cardiopatía isquémica, 103 en lista de emergencia. Se incluyeron once pacientes con los criterios mencionados (edad media 53 ± 11 años; hombres 73%). Se realizaron 5 angioplastias primarias y 2 cirugías de revascularización miocárdica de urgencia. Cuatro pacientes presentaban anatomía coronaria no pasible de revascularización. Todos recibieron tratamiento inotrópico y vasopresor y requirieron soporte con balón de contrapulsación intra aórtico (BCIA). Dos requirieron el implante de bomba centrífuga univentricular izquierda (BioMedicus®, Medtronic) y 2 de oxigenador de membrana extracorpóreo veno-arterial (ECMO-VA) periférico (Maquet®, Getinge Group). La mediana entre IAM y TC fue 15 días (rango 7-21) y la edad de los donantes 28 ± 11 años. Todos presentaron un IAM extenso (monto necrótico 35 ± 5%) con signos histopatológicos de necrosis transmural e injuria de reperfusión. La mediana de seguimiento fue 9 años (rango 1-15). Ninguno falleció en la internación ni durante el primer año post trasplante. La supervivencia a los 5 y 10 años fue 73% y 55%. El TC en situación de emergencia ha demostrado ser, en nuestro medio, la mejor opción en aquellos pacientes con IAM y SC refractario a la terapia convencional.

Abstract Cardiogenic shock (CS) has a high mortality rate and often requires advanced therapies such as mechanical circulatory support (MCS) and heart transplantation (HT). Those patients who presented an acute myocardial infarction (AMI) with CS and required support through MCS as bridge to HT were retrospectively analyzed in a single Center. Between January 1997 and June 2020, 524 patients received HT, 203 for ischemic-cardiomyopathy, 103 were in emergency waiting list. Eleven patients met the inclusion criteria (mean age 53 ± 11 years old; men 73%). Five primary angioplasties and 2 emergency myocardial revasculariza tion surgeries were performed. Four patients had coronary anatomy not subject to revascularization. All received inotropic and vasopressor treatment and required intra-aortic balloon pump (IABP). Subsequently, two required support with a left univentricular centrifugal pump (BioMedicus®, Medtronic) and two with peripheral veno-arterial extracorporeal membrane oxygenator (VA-ECMO) (Maquet®, Getinge Group). The median between AMI and HT was 15 days (range 7-21) and the mean age of the donors 28 ± 11 years. All had extensive AMI (necrotic amount 35 ± 5%) with histopathological signs of transmural necrosis and reperfusion injury. The median follow-up was 9 years (range 1-15). None died in hospitalization or during the first year after transplantation. Survival at 5 and 10 years was 73% and 55%. Emergency HT may be the best option for selected patients with acute myocardial infarction and cardiogenic shock refractory to conventional therapy.

Improvements in Functional Status Among Survivors of Orthotopic Heart Transplantation Following High-risk Bridging Modalities.

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.

Increased number of ventricular septal rupture cases after acute myocardial infarction in 2020.

INTRODUCTION: Ventricular septal rupture (VSR) is a serious mechanical complication after acute coronary syndrome and is related to high mortality. Even with advances in the management of acute myocardial infarction (AMI) such as reperfusion therapies, complication rates are still high. During quarantine, patients presenting mechanical complications after AMI have increased in our institution. METHODS: From a retrospective database analysis in our institution between the years 2004 and 2020, we identified 37 cases of VSR after AMI. Four chronic cases were excluded from our analysis. The primary endpoint was to identify baseline characteristics that increased 30-day mortality. RESULTS: Among 33 acute cases of VSR, 24 cases were submitted to surgery. The 30-day mortality of the operated patients was 45.8%. From 2004 to 2019 our average number of operations of VSR was 1.9 cases/year with an increase to 4 cases/year in 2020. Diabetes mellitus, age, cardiogenic shock, and use of intra-aortic balloon pump were associated with significantly increased mortality using logistic regression. CONCLUSION: We reported an increased number of mechanical complication cases from April to September 2020, compared to our historical records. Despite therapeutic advances, mortality rates remain high. Although the number of cases is small to conclude that the pandemic was responsible for this augmentation, we believe that it is related to the decreased number of patients seeking medical assistance.

Desfechos após inserção de balão intra-aórtico em pacientes de cirurgia cardíaca / Outcomes after intra-aortic balloon pump insertion in cardiac surgery patients

RESUMO Objetivo: Avaliar se o momento de inserção de um balão intra-aórtico pré-operatório em comparação com o intraoperatório se associa com menor mortalidade em 30 dias ou diminuição do tempo de permanência no hospital entre pacientes que passaram por inserção de um balão intra-aórtico para cirurgia cardíaca. Métodos: Este foi um estudo observacional de pacientes submetidos à inserção de um balão intra-aórtico no período pré-operatório ou intraoperatório de cirurgia cardíaca em nosso departamento entre 2000 e 2012. Avaliamos a associação entre a inserção pré-operatória em comparação com a intraoperatória de um balão intra-aórtico e a mortalidade em 30 dias em uma análise de regressão logística multivariada, incluindo a classificação pré-operatória segundo a New York Heart Association, a presença de fibrilação atrial pós-operatória, a reoperação, a creatinina pós-operatória e a cirurgia de revascularização do miocárdio isolada como cofatores. Utilizamos um modelo linear multivariado para avaliar se a inserção pré-operatória do balão intra-aórtico, em comparação com a intraoperatória, associou-se com o tempo de permanência no hospital após a cirurgia, com ajuste para reoperação, cirurgia de revascularização do miocárdio isolada, cirurgia valvar, sexo, idade, tempo de bypass cardiopulmonar, tempo de oclusão aórtica, condição pré-operatória do paciente (cirurgia eletiva, de urgência ou emergência) e infarto do miocárdio pré-operatório. Resultados: Foram submetidos à cirurgia cardíaca aberta em nosso departamento 7.540 pacientes consecutivos, tendo sido inserido um balão intra-aórtico em momento pré-operatório ou intraoperatório em 322 (4,2%) pacientes. A média de idade foi 67 ± 10,2 anos, e a mortalidade em 30 dias foi de 12,7%. O tempo mediano de permanência no hospital foi de 9 dias (7 - 13). A inserção pré-operatória de balão intra-aórtico, em comparação com a intraoperatória, não afetou a incidência de mortalidade em 30 dias (RC ajustada = 0,69; IC95% 0,15 - 3,12; p = 0,63) e nem o tempo de permanência no hospital após a cirurgia (β = 5,3; IC95% 1,6 - 12,8; p = 0,13). Conclusão: Em comparação com a inserção intraoperatória, a inserção pré-operatória de um balão intra-aórtico não se associou com menor mortalidade em 30 dias nem reduziu o tempo de permanência no hospital.

ABSTRACT Objective: To assess whether preoperative versus intraoperative insertion of an intra-aortic balloon pump is associated with lower 30-day mortality or reduced length of hospital stay among patients who had an intra-aortic balloon pump inserted for cardiac surgery. Methods: This was an observational study of patients who had an intra-aortic balloon pump inserted in the preoperative or intraoperative period of cardiac surgery in our department between 2000 and 2012. We assessed the association between preoperative versus intraoperative insertion of an intra-aortic balloon pump and 30-day mortality in a multivariable logistic regression analysis, including preoperative New York Heart Association class, postoperative atrial fibrillation, reoperation, postoperative creatinine and isolated coronary bypass grafting as cofactors. We used a multivariate linear model to assess whether a preoperative versus intraoperative intra-aortic balloon pump was associated with length of postoperative hospital stay, adjusting for reoperation, isolated coronary bypass grafting, heart valve surgery, sex, age, cardiopulmonary bypass time, aortic cross-clamp time, preoperative patients' status (elective, urgency or emergency surgery) and preoperative myocardial infarction. Results: Overall, 7,540 consecutive patients underwent open heart surgery in our department, and an intra-aortic balloon pump was inserted pre- or intraoperatively in 322 (4.2%) patients. The mean age was 67 ± 10.2 years old, the 30-day mortality was 12.7%, and the median length of hospital stay was 9 days (7 - 13). Preoperative versus intraoperative intra-aortic balloon pump insertion did not affect the incidence of 30-day mortality (adjusted OR = 0.69; 95% CI, 0.15 - 3.12; p = 0.63) and length of postoperative hospital stay (β = 5.3; 95%CI, -1.6 to 12.8; p = 0.13). Conclusion: Preoperative insertion of an intra-aortic balloon pump was not associated with a lower 30-day mortality or reduced length of postoperative hospital stay compared to intraoperative insertion.

Intra-Aortic Balloon Pump Bridging to Heart Transplantation: Impact of the 2018 Allocation Change.

BACKGROUND: This study evaluates the impact of the 2018 allocation policy change on outcomes of orthotopic heart transplantation (OHT) in patients bridged with intra-aortic balloon pumps (IABPs). METHODS: Adult (≥18 years) patients undergoing OHT between 2013 and 2019 who were bridged with an IABP were stratified based on temporal relation to the policy change. Univariate analysis was used to compare baseline characteristics and postoperative outcomes. Multivariate Cox regression analysis was used to estimate risk-adjusted predictors of post-transplant mortality. RESULTS: A total of 1342 (8.6%) OHT patients were bridged with an IABP during the study period. Rates of bridging with IABP to OHT increased significantly after the policy change (7.0% versus 24.9%, P<0.001). The mean recipient age was 54.1±12.1 years with 981 (73.1%) patients being male. Baseline characteristics were similar between the 2 groups whereas post-policy change patients spent fewer days on the waitlist (15 versus 35 days, P<0.001), had longer ischemic times (3.5 versus 3.0 hours, P<0.001), and received organs from a greater distance (301 versus 105 miles, P<0.001). By multivariable analysis, days on the waitlist (for every 30 days; odds ratio, 1.01 [95% CI, 1.00-1.02], P=0.031) and diabetes mellitus (odds ratio, 1.87 [95% CI, 1.16-3.02], P=0.011) emerged as significant predictors of post-transplant mortality. After the policy change, waitlisted patients requiring IABP support were more likely to survive to transplant (76.4 versus 89.8%, P<0.001). CONCLUSIONS: IABP utilization has increased over 3-fold since the 2018 policy change with improved waitlist outcomes and comparable post-OHT survival. Thus, bridging patients to OHT with IABPs appears to be an effective strategy in the current era.

Preoperative Use of Intra-Aortic Balloon Pump Support Reduced 30-Day Mortality in a Population with LVEF >35% and High Surgical Risk after Coronary Artery Bypass Graft Surgery.

INTRODUCTION: The intra-aortic balloon pump (IABP) is used to prevent complications after coronary artery bypass grafting (CABG) surgery, although some results are controversial and basal ventricular function may play a role. This study assessed the benefit of preoperative use of IABP, as stratified by the ventricular function, in a population submitted to high-surgical-risk CABG. METHODS: Patients >18 years old, with multiple coronary artery disease and thus candidates for CABG, were included. Cardiogenic shock, acute myocardial infarction (AMI), acute ventricle mechanical dysfunction, severe aortic regurgitation, tachyarrhythmia, massive pulmonary embolism, coagulopathy, or low life expectancy were exclusion criteria. RESULTS: One hundred and twenty-nine patients aged 65 years old with hypertension, dyslipidemia, type 2 diabetes mellitus, and mean left ventricular ejection fraction (LVEF) 46% constituted the study population. No difference was observed at 30-day mortality endpoint (IABP vs. no IABP, 17 vs. 24%, OR 0.63, p = 0.20; AMI 25 vs. 31%, OR 0.75, p = 0.29). After LVEF stratification, the subgroup of 48 (75%) patients under IABP support and LVEF >35% had a reduced 30-day mortality risk (LVEF ≤35% vs. LVEF >35%, 37.5 vs. 10.4%, OR 0.3, p = 0.03), independently from potential confounders and showing an interaction with European System for Cardiac Operative Risk Evaluation-II (EuroSCORE-II). At secondary endpoints, IABP use was associated with a lower prevalence of acute renal failure and renal replacement therapy, but with a longer stay in the intensive care unit and longer hospitalization time. CONCLUSION: The preoperative use of IABP was associated with an independent reduction of 30-day mortality risk in cases with LVEF >35% in a population submitted to high-surgical-risk CABG. Likewise, the use of IABP was associated with a lower risk of postoperative renal complications.

Outcomes after intra-aortic balloon pump insertion in cardiac surgery patients. / Desfechos após inserção de balão intra-aórtico em pacientes de cirurgia cardíaca.

OBJECTIVE: To assess whether preoperative versus intraoperative insertion of an intra-aortic balloon pump is associated with lower 30-day mortality or reduced length of hospital stay among patients who had an intra-aortic balloon pump inserted for cardiac surgery. METHODS: This was an observational study of patients who had an intra-aortic balloon pump inserted in the preoperative or intraoperative period of cardiac surgery in our department between 2000 and 2012. We assessed the association between preoperative versus intraoperative insertion of an intra-aortic balloon pump and 30-day mortality in a multivariable logistic regression analysis, including preoperative New York Heart Association class, postoperative atrial fibrillation, reoperation, postoperative creatinine and isolated coronary bypass grafting as cofactors. We used a multivariate linear model to assess whether a preoperative versus intraoperative intra-aortic balloon pump was associated with length of postoperative hospital stay, adjusting for reoperation, isolated coronary bypass grafting, heart valve surgery, sex, age, cardiopulmonary bypass time, aortic cross-clamp time, preoperative patients' status (elective, urgency or emergency surgery) and preoperative myocardial infarction. RESULTS: Overall, 7,540 consecutive patients underwent open heart surgery in our department, and an intra-aortic balloon pump was inserted pre- or intraoperatively in 322 (4.2%) patients. The mean age was 67 ± 10.2 years old, the 30-day mortality was 12.7%, and the median length of hospital stay was 9 days (7 - 13). Preoperative versus intraoperative intra-aortic balloon pump insertion did not affect the incidence of 30-day mortality (adjusted OR = 0.69; 95% CI, 0.15 - 3.12; p = 0.63) and length of postoperative hospital stay (ß = 5.3; 95%CI, -1.6 to 12.8; p = 0.13). CONCLUSION: Preoperative insertion of an intra-aortic balloon pump was not associated with a lower 30-day mortality or reduced length of postoperative hospital stay compared to intraoperative insertion.

OBJETIVO: Avaliar se o momento de inserção de um balão intra-aórtico pré-operatório em comparação com o intraoperatório se associa com menor mortalidade em 30 dias ou diminuição do tempo de permanência no hospital entre pacientes que passaram por inserção de um balão intra-aórtico para cirurgia cardíaca. MÉTODOS: Este foi um estudo observacional de pacientes submetidos à inserção de um balão intra-aórtico no período pré-operatório ou intraoperatório de cirurgia cardíaca em nosso departamento entre 2000 e 2012. Avaliamos a associação entre a inserção pré-operatória em comparação com a intraoperatória de um balão intra-aórtico e a mortalidade em 30 dias em uma análise de regressão logística multivariada, incluindo a classificação pré-operatória segundo a New York Heart Association, a presença de fibrilação atrial pós-operatória, a reoperação, a creatinina pós-operatória e a cirurgia de revascularização do miocárdio isolada como cofatores. Utilizamos um modelo linear multivariado para avaliar se a inserção pré-operatória do balão intra-aórtico, em comparação com a intraoperatória, associou-se com o tempo de permanência no hospital após a cirurgia, com ajuste para reoperação, cirurgia de revascularização do miocárdio isolada, cirurgia valvar, sexo, idade, tempo de bypass cardiopulmonar, tempo de oclusão aórtica, condição pré-operatória do paciente (cirurgia eletiva, de urgência ou emergência) e infarto do miocárdio pré-operatório. RESULTADOS: Foram submetidos à cirurgia cardíaca aberta em nosso departamento 7.540 pacientes consecutivos, tendo sido inserido um balão intra-aórtico em momento pré-operatório ou intraoperatório em 322 (4,2%) pacientes. A média de idade foi 67 ± 10,2 anos, e a mortalidade em 30 dias foi de 12,7%. O tempo mediano de permanência no hospital foi de 9 dias (7 - 13). A inserção pré-operatória de balão intra-aórtico, em comparação com a intraoperatória, não afetou a incidência de mortalidade em 30 dias (RC ajustada = 0,69; IC95% 0,15 - 3,12; p = 0,63) e nem o tempo de permanência no hospital após a cirurgia (ß = 5,3; IC95% 1,6 - 12,8; p = 0,13). CONCLUSÃO: Em comparação com a inserção intraoperatória, a inserção pré-operatória de um balão intra-aórtico não se associou com menor mortalidade em 30 dias nem reduziu o tempo de permanência no hospital.