Home inotrope therapy in chronic stimulant-induced cardiomyopathy: a case series.

Background: Patients with chronic stimulant-induced cardiomyopathy presenting with cardiogenic shock can be stabilized with conventional measures. However, their management post-stabilization has not been well described and poses unique challenges: (i) less chance of myocardial recovery compared to acute stimulant-induced cardiomyopathy, (ii) psychosocial barriers to left ventricular assist device (LVAD) and heart transplantation, and (iii) concern for use of peripherally inserted central catheter for home inotrope in those with a history of substance abuse. Case summary: Three patients with chronic stimulant-induced cardiomyopathy were admitted with cardiogenic shock progressing to Society for Cardiovascular Angiography & Interventions stage D or E. They were stabilized with inotrope and/or biventricular mechanical circulatory support. Long-term home inotrope was used as either a bridge to LVAD, reverse remodelling, or stabilization. Discussion: Home inotrope should be viewed as an option in chronic stimulant-induced cardiomyopathy on a case-by-case basis. It can buy time to allow for myocardial stabilization or recovery through goal-directed medical therapy and stimulant cessation. It can also serve as a 'psychosocial stress test' for future consideration of advanced heart failure therapies.

The impact of group II pulmonary hypertension on congestive heart failure patients admitted with ST elevation myocardial infarction, a nationwide study.

Background: Pulmonary hypertension (PH) is a condition where the blood pressure increases in the pulmonary arteries, leading to reduced oxygen delivery to the body's tissues due to increased blood flow resistance. This condition can result in right ventricular hypertrophy, low cardiac output, and ischemia. In this study, the authors aim to investigate the impact of group II PH (GIIPH) on patients with congestive heart failure who were admitted with ST elevation myocardial infarction (STEMI) through a retrospective cohort study. Methods: Using the National Inpatient Sample (NIS) database from 2017 to 2020, a retrospective cross-sectional study of adult patients with a principal diagnosis of STEMI with a secondary diagnosis with or without GIIPH according to ICD-10 (International Classification of Disease, 10th edition) codes. Several demographics, including age, race, and gender, were analyzed. The primary endpoint was mortality, while the secondary endpoints included cardiogenic shock, mechanical intubation, length of stay in days, and patient charge in dollars. Multivariate logistic regression model analysis was used to adjust for confounders, with a P value less than 0.05 considered statistically significant. Results: The study included 26,925 patients admitted with a STEMI, 95 of whom had GIIPH. The mean age for patients with and without PH was 66.6 and 67.5 years, respectively. In the PH group, 37% were females compared to 34% in the non-PH group. The in-hospital mortality rate was higher in the PH group (31.6% vs. 9.6%, P<0.001, adjusted odds ratio (aOR) =3.33, P=0.02). The rates and adjusted odds of cardiogenic shock and mechanical ventilation were higher in the PH groups (aOR =1.15 and 2.14, respectively) but not statistically significant. Patients with PH had a longer length of stay and a higher total charge. Conclusions: GIIPH was associated with worse clinical and economic outcomes in heart failure patients admitted with STEMI.

A novel predictive score model for successful weaning from mechanical circulatory support in patients with cardiogenic shock.

BACKGROUND: Clinical evidence regarding predictors of successful weaning from mechanical circulatory support (MCS) is lacking. This study aimed to create a simple risk score to predict successful weaning from MCS in patients with cardiogenic shock. METHODS: This retrospective single-center cohort study included 114 consecutive patients with cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation or IMPELLA between January 2013 and June 2023. Patients with out-of-hospital cardiac arrest were excluded. The primary endpoint was successful weaning from MCS defined as successful decannulation without the need for MCS re-implantation and survival to discharge. Multivariable logistic regression with a stepwise variable selection was performed to generate the prediction model. We first developed a general weaning score model, and then created a simple version of the score model using the same variables. RESULTS: Fifty-five patients were successfully weaned from MCS. The following variables measured during weaning evaluation were selected as the components of the weaning score model: acute myocardial infarction (AMI), mean blood pressure, left ventricular ejection fraction (LVEF), lactate level, and QRS duration. According to the results, we conducted a novel weaning score model to predict successful weaning from MCS: 1.774-2.090×(AMI)+0.062×[mean blood pressure (mmHg)]+0.139×[LVEF (%)]-0.322×[Lactate (mg/dl)]-0.066×[QRS (msec)]. The following variables were selected as the components of the simple version of the weaning score model: AMI, mean blood pressure ≥80 mmHg, lactate <10 mg/dL, QRS duration ≤95 msec, and LVEF >35%. CONCLUSIONS: We developed a simple model to predict successful weaning from MCS in patients with cardiogenic shock.

Cardiogenic shock secondary to immune checkpoint inhibitor associated myocarditis.

Immune checkpoint inhibitors have transformed the treatment for multiple cancers and are increasingly used in recent years, but they can cause potentially life-threatening cardiac toxicity. We report a case of a 64-year-old gentleman who presented to the Emergency Department with symptoms of fatigue and breathlessness whilst receiving treatment with an immune checkpoint inhibitor, pembrolizumab, for cholangiocarcinoma. He was found to be in cardiogenic shock with an abnormal electrocardiogram and elevated cardiac troponin at presentation. Echocardiogram demonstrated severely impaired right and left ventricular function. Computed tomography pulmonary angiography and invasive coronary angiography excluded pulmonary embolism and acute myocardial infarction, respectively, and he was diagnosed with immune checkpoint inhibitor associated myocarditis. He was treated with high-dose methylprednisolone and a dobutamine infusion. Within days, his troponin and C-reactive protein levels decreased, and his left ventricular function improved. He was established on heart failure therapies and discharged from hospital 12 days later.

Sex difference in outcomes and management of cardiogenic shock: A systematic review and meta-analysis.

BACKGROUND: Cardiogenic shock (CS) is associated with significant morbidity and mortality. Sex differences in the outcomes and management of cardiogenic shock are not well established. The primary objective of this study is to investigate the differences inik cardiogenic shock outcomes between males and females. METHODS: A systematic review and meta-analysis were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Studies were searched via the MEDLINE/PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to December 2022. RESULTS: The analysis included 24 studies comprising 1,567,660 patients. Compared to females, males with CS had a significantly lower risk of in-hospital all-cause mortality (risk ratio [RR] 0.88, 95 % confidence interval [CI] 0.85-0.90, p < 0.001) and 1-year mortality (RR 0.90, 95 % CI 0.89-0.92, p < 0.001). Males were more likely to undergo percutaneous coronary intervention (RR 1.21, 95 % CI 1.13-1.31, p < 0.0001) and intra-aortic balloon pump placement (RR 1.21, 95 % CI 1.11-1.32, p < 0.0001), with no significant sex differences in the use of extracorporeal membrane oxygenation or Impella. During the index hospitalization, males were at higher risk of arrhythmias (RR 1.18, 95 % CI 1.05-1.34, p = 0.003) and less likely to develop acute kidney injury (RR 0.86, 95 % CI 0.79-0.94, p < 0.001). CONCLUSION: Men have a lower all-cause mortality risk in cardiogenic shock. Addressing disparities in management is crucial for improving CS outcomes, especially for women.

Echocardiographic image quality deteriorates with the severity of cardiogenic shock.

BACKGROUND: Transthoracic echocardiography (TTE) is the primary tool for assessing left ventricular (LV) function in cardiogenic shock (CS). However, inadequate image quality often hinders it. In this retrospective study, we investigated factors associated with LV image quality in patients admitted to the intensive care unit (ICU) with ischemic CS. RESULTS: Two critical care physicians accredited in echocardiography independently reviewed the TTEs of 100 patients admitted to our tertiary cardiac ICU with ST-elevation myocardial infarction complicated by CS between October 2016 and September 2019. Endocardial border definition (EBD) was graded for each myocardial segment of the apical 4-chamber and 2-chamber views using a conventional scoring system (1 = good, 2 = suboptimal, 3 = poor, and 4 = not possible). The biplane EBD index (EBDi) was calculated by averaging all segments from both views. An average EBDi of both observers was correlated with clinical and echocardiographic parameters. The median age was 62 years [54, 73], and 78% were males. LV ejection fraction and cardiac index (CI) medians were 29% [20, 35] and 1.93 l/min/m2 [1.40, 2.51], respectively. The median biplane EBDi was nearly suboptimal (1.833 [1.542, 2.083]). There was no correlation between EBDi and age, sex, or body mass index. However, biplane EBDi demonstrated statistically significant correlations with PaO2 (r2 = 0.066, p = 0.01), mean arterial pressure (MAP, r2 = 0.055, p = 0.03), CI (r2 = 0.105, p < 0.01), tricuspid annulus systolic velocity (RV S', r2 = 0.092, p = 0.01), and tricuspid regurge maximum velocity (TR Vmax, r2 = 0.067, p = 0.01). In a multivariate model, only CI correlated independently with EBDi (r2 = 0.105, p < 0.01). The biplane EBDi predicted CI (area under the curve (AUC) 0.70, p = 0.001) with good sensitivity (71%) and reasonable specificity (61%). CONCLUSIONS: The study suggests that in patients admitted to the ICU with ischemic CS, LV image quality by TTE deteriorates with the severity of shock, as indicated by CI.

[Ethical aspects in the context of extracorporeal life support systems (ECLS): consensus paper of the DGK, DGTHG and DGAI]. / Ethische Aspekte im Rahmen von extrakorporalen Herz-Kreislauf-Unterstützungssystemen (ECLS): Konsensuspapier der DGK, DGTHG und DGAI.

Extracorporeal life support systems (ECLS) are life-sustaining measures for severe cardiovascular diseases, serving as bridging treatment either until cardiovascular function is restored or alternative treatment, such as heart transplantation or the implantation of permanent ventricular assist devices is performed. Given the insufficient evidence and frequent urgency of implantation without initial patient consent, the ethical challenges and psychological burden for patients, relatives and the interprofessional intensive care team are significant. As with any treatment, an appropriate therapeutic goal for ECLS treatment based on the indications and patient informed consent is mandatory. In order to integrate the necessary ethical considerations into everyday clinical practice, a structured algorithm for handling ECLS is proposed here, which takes ethical aspects into due account.

Shark fin sign: A rare EKG finding in a patient with Takotsubo cardiomyopathy from influenza A infection.

This case demonstrated the rare "shark fin" ECG pattern, an ST-segment elevation typically seen in acute myocardial infarction. We reported a case of takotsubo cardiomyopathy secondary to influenza A infection with multiple organ failure, showing the shark fin sign and resulting in in-patient mortality and various complication.

Benefit of prehospital electrocardiogram on door-to-device time in ST-segment elevation myocardial infarction with cardiogenic shock: Data from the Kanagawa Acute Cardiovascular Registry.

BACKGROUND: The benefit of prehospital 12­lead electrocardiogram (PH-ECG) performed by emergency medical service personnel at the site of first medical contact (FMC) in patients with ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock (CS-STEMI) remains unclear. This study aimed to investigate the effect of PH-ECG on door-to-device time in patients with CS-STEMI. METHODS: This study enrolled CS-STEMI (Killip class IV) patients who were transferred directly to hospitals by ambulance (n = 517) from the Kanagawa Acute Cardiovascular Registry database. Patients were divided into PH-ECG (+) (n = 270) and PH-ECG (-) (n = 247) groups. Patients who experienced out-of-hospital cardiac arrest, who did not undergo emergent coronary intervention, or whose data were missing were excluded. Patient characteristics, FMC-to-door time, door-to-device time, and in-hospital mortality were compared between the groups. RESULTS: The patient backgrounds of the PH-ECG (+) and PH-ECG (-) groups were comparable. The peak creatinine kinase level was greater in the PH-ECG (+) group than in the PH-ECG (-) group [2756 (1292-6009) IU/ml vs. 2270 (957-5258) IU/ml, p = 0.048]. The FMC-to-door time was similar between the two groups [25 (20-33) min vs. 27 (20-35) min, p = 0.530], while the door-to-device time was significantly shorter in the PH-ECG group [74 (52-103) min vs. 83 (62-111) min, p = 0.007]. In-hospital mortality did not differ between the two groups (18 % vs. 21 %, p = 0.405). Multivariable logistic regression analyses revealed that PH-ECG (+) was independently associated with a door-to-device time < 60 min [odds ratio (95 % confidence intervals): 1.88 (1.24-2.83), p = 0.003]. CONCLUSIONS: PH-ECG was significantly associated with shorter door-to-device times in patients with CS-STEMI. Further studies with larger populations and more defined protocols are required to evaluate the utility of PH-ECG in patients with CS-STEMI.

NLRP3 inflammasome-induced pyroptosis and serum ASC specks are increased in patients with cardiogenic shock.

BACKGROUND: Cardiogenic shock (CS) is characterized by impaired cardiac function, very high mortality, and limited treatment options. The pro-inflammatory signalling during different phases of CS is incompletely understood. METHODS: We collected serum and plasma (N=44) as well as freshly isolated peripheral blood mononuclear cells (PBMC, N=7) of patients with CS complicating acute myocardial infarction on admission and after revascularization (24h, 48h, 72h) and of healthy controls (serum and plasma N=75; PBMC N=12). RESULTS: PBMC of CS patients had increased gene expression of NLRP3, CASP1, PYCARD, IL1B, and IL18 and showed increased rates of pyroptosis (control: 4.7±0.3% vs. 9.9±1.7% in CS patients, p=0.02). Serum interleukin (IL)-1ß levels were increased after revascularization. IL-18 and IL-6 were higher in patients with CS than in healthy controls but comparable before and after revascularization. Pro-inflammatory apoptosis-associated speck-like proteins containing CARD (ASC) specks were elevated in the serum of CS patients on admission and increased after revascularization (admission: 11.1±4.4 specks/µl, after 24h: 19.0±3.9, p=0.02). ASC specks showed a significant association with 30-day mortality in patients with CS (p<0.05). The estimated regression coefficients and odds ratios indicated a positive relationship between ASC specks and mortality (Odds ratio 1.029, 95% CI, 1.000 to 1.072; p=0.02). CONCLUSIONS: Pyroptosis and circulating ASC specks are increased in patients with CS and are particularly induced after reperfusion This underscores their potential role as a biomarker for poor outcomes in CS patients. ASC specks represent promising new therapeutic targets for CS patients with high inflammatory burden.

Feasibility of veno-arterial extracorporeal life support in awake patients with cardiogenic shock.

OBJECTIVES: This study sought to demonstrate outcomes of veno-arterial extracorporeal life support (VA-ECLS) in non-intubated ("awake") patients with cardiogenic shock, as very few studies have investigated safety and feasibility in this population. METHODS: This was a retrospective review of 394 consecutive VA-ECLS patients at our institution from 2017 to 2021. We excluded patients cannulated for indications definitively associated with intubation. Patients were stratified by intubation status at time of cannulation and baseline differences were balanced by inverse probability of treatment weighting. The primary outcome was in-hospital mortality while secondary outcomes included adverse events during ECLS and destination at discharge. RESULTS: Out of 135 patients in the final cohort, 79 were intubated and 56 were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation with technical success of 100% without intubation. Indications for VA-ECLS in awake patients included acute decompensated heart failure (64.3%), pulmonary hypertension or massive pulmonary embolism (12.5%), myocarditis (8.9%), and acute myocardial infarction (5.4%). After adjustment, awake and intubated patients had similar ECLS duration (7 vs 6 days, p = 0.19), in-hospital mortality (39.6% vs 51.7%, p = 0.28), and rates of various adverse events. Intubation status was not a significant risk factor for 90-day mortality (HR [95% CI]: 1.26 [0.64, 2.45], p = 0.51) in multivariable analysis. Heart transplantation (15.1% vs 4.9%) and ventricular assist device (17.4% vs 2.2%) were more common destinations at discharge in awake patients than intubated patients (p = 0.02). CONCLUSIONS: Awake VA-ECLS is safe and feasible with comparable outcomes as intubated counterparts in select cardiogenic shock patients.

Ten-year trends in characteristics, management and outcomes of patients admitted with cardiogenic shock in the ACTION-SHOCK cohort.

BACKGROUND: The ACTION-SHOCK registry offers a decade-long perspective on patients admitted with cardiogenic shock (CS). AIMS: To assess trends in the management and outcomes of patients with CS over 10 years. METHODS: Trends in the characteristics, management and outcomes of patients with CS admitted into the cardiac intensive care unit of Pitié-Salpêtrière hospital from 2011 to 2020 were analysed. Short-term outcomes included in-hospital mortality, heart transplantation or ventricular assist device. Long-term outcomes were all-cause death or readmission for acute heart failure at 1 year. RESULTS: Over a 10-year period, data from 700 patients with CS (median [interquartile range] age 61 [50-72] years; 73% of men) were analysed. The proportion of CS related to acute myocardial infarction decreased (from 45% in 2011-2012 to 27% in 2019-2020) while the proportions related to chronic coronary syndrome (18% to 23%) and non-ischaemic cardiomyopathies (37 to 51%) increased (P<0.01). The use of rescue extracorporeal membrane oxygenation remained stable (19 to 14%) and intra-aortic balloon pump use decreased (22% to 7%) (P<0.01). In-hospital mortality remained stable (27 to 29%) as did the proportions of patients discharged after transplantation (17 to 14%) or with a durable ventricular assist device (2 to 4%). Among patients discharged alive, death or readmission for acute heart failure at 1 year remained high (37 to 47%). CONCLUSION: CS remained associated with a poor prognosis over the last decade. There are significant unmet needs in the management strategies of patients with CS.

Unsupervised machine learning to identify subphenotypes among cardiac intensive care unit patients with heart failure.

AIMS: Hospitalized patients with heart failure (HF) are a heterogeneous population, with multiple phenotypes proposed. Prior studies have not examined the biological phenotypes of critically ill patients with HF admitted to the contemporary cardiac intensive care unit (CICU). We aimed to leverage unsupervised machine learning to identify previously unknown HF phenotypes in a large and diverse cohort of patients with HF admitted to the CICU. METHODS: We screened 6008 Mayo Clinic CICU patients with an admission diagnosis of HF from 2007 to 2018 and included those without missing values for common laboratory tests. Consensus k-means clustering was performed based on 10 common admission laboratory values (potassium, chloride, anion gap, blood urea nitrogen, haemoglobin, red blood cell distribution width, mean corpuscular volume, platelet count, white blood cell count and neutrophil-to-lymphocyte ratio). In-hospital mortality was evaluated using logistic regression, and 1 year mortality was evaluated using Cox proportional hazard models after multivariable adjustment. RESULTS: Among 4877 CICU patients with HF who had complete admission laboratory data (mean age 69.4 years, 38.4% females), we identified five clusters with divergent demographics, comorbidities, laboratory values, admission diagnoses and use of critical care therapies. We labelled these clusters based on the characteristic laboratory profile of each group: uncomplicated (25.7%), iron-deficient (14.5%), cardiorenal (18.4%), inflamed (22.3%) and hypoperfused (19.2%). In-hospital mortality occurred in 10.7% and differed between the phenotypes: uncomplicated, 2.7% (reference); iron-deficient, 8.1% [adjusted odds ratio (OR) 2.18 (1.38-3.48), P < 0.001]; cardiorenal, 10.3% [adjusted OR 2.11 (1.37-3.32), P < 0.001]; inflamed, 12.5% [adjusted OR 1.79 (1.18-2.76), P = 0.007]; and hypoperfused, 21.9% [adjusted OR 4.32 (2.89-6.62), P < 0.001]. These differences in mortality between phenotypes were consistent when patients were stratified based on demographics, aetiology, admission diagnoses, mortality risk scores, shock severity and systolic function. One-year mortality occurred in 31.5% and differed between the phenotypes: uncomplicated, 11.9% (reference); inflamed, 26.8% [adjusted hazard ratio (HR) 1.56 (1.27-1.92), P < 0.001]; iron-deficient, 33.8% [adjusted HR 2.47 (2.00-3.04), P < 0.001]; cardiorenal, 41.2% [adjusted HR 2.41 (1.97-2.95), P < 0.001]; and hypoperfused, 52.3% [adjusted HR 3.43 (2.82-4.18), P < 0.001]. Similar findings were observed for post-discharge 1 year mortality. CONCLUSIONS: Unsupervised machine learning clustering can identify multiple distinct clinical HF phenotypes within the CICU population that display differing mortality profiles both in-hospital and at 1 year. Mortality was lowest for the uncomplicated HF phenotype and highest for the hypoperfused phenotype. The inflamed phenotype had comparatively higher in-hospital mortality yet lower post-discharge mortality, suggesting divergent short-term and long-term prognosis.

Clinical predictors and outcomes of ST-elevation myocardial infarction related cardiogenic shock in the Asian population.

Background: Cardiogenic shock (CS) complicating myocardial infarction is associated with poor outcomes. Data among Asian populations are scarce. We aimed to investigate the long-term outcomes, prognostic factors, and predictors of CS among Asian ST elevation myocardial infarction (STEMI) patients. Methods: This was a retrospective cohort study of consecutive patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI within our regional STEMI network between 2015 and 2019. The long-term outcomes of those with and without CS were compared. Clinical predictors of outcomes and development of CS were investigated. Results: A total of 1791 patients who underwent PPCI were included. Patients completed at least 2 years' follow-up with a median follow-up period of 2.6 years (IQR 1.0, 3,9). Overall, 208/1791 (11.6 %) STEMI patients developed CS. These patients were older (61.1 ± 12.5 vs 57.8 ± 12.2, P < 0.001) and mostly men (87.0 %). All-cause mortality (59.9 % vs 4.7 % P < 0.001), cardiac mortality (43.8 % vs 2.2 %, P < 0.001) and major adverse cardiovascular events (MACE) was significantly higher in the CS group (59.1 % vs 14.0 %, P < 0.001). Independent predictors of survival were higher index LVEF (adjusted hazards ratio [aHR] 0.967, 95 %CI 0.951-0.984, p < 0.001) and higher arterial pH at onset of shock (aHR 0.750, 0.626-0.897, p = 0.002). Increased serum lactate concentration independently predicts poor prognosis (aHR 1.084, 95 % CI 1.046-1.124, p < 0.001). Conclusion: In Asian STEMI patients who underwent PPCI, CS was associated with poor outcomes. Higher LVEF on index admission was associated with better outcomes; while lactic acidosis independently predicted mortality.

Assessing aortic flow with doppler echocardiography in cardiogenic shock: A crucial diagnostic tool.

PURPOSE: Cardiogenic shock still has a high mortality. In order to correctly manage these patients, it is useful to have available haemodynamic parameters, invasive and non-invasive. The aim of this review is to show the current evidence on the use of echocardiographic aortic flow assessment by left ventricular outflow tract - velocity time integral. METHODS: Publications relevant to the discussion of echocardiographic aortic flow assessment by left ventricular outflow tract - velocity time integral and cardiogenic shock, were retrieved from PubMed®. RESULTS: Left ventricular outflow tract - velocity time integral is an easily sampled and reproducible parameter that has already been shown to have prognostic value in various cardiovascular pathologies, including myocardial infarction and heart failure. Although there are still few data available in the literature, the LVOT-VTI also seems to have an important role in CS from prognosis to guidance in the escalation/de-escalation of vasoactive therapy and to support devices by allowing an estimate of patient's probability of response to fluid administration. CONCLUSION: Aortic flow assessment can become a very useful invasive parameter in the management of cardiogenic shock.

Utility of Adjunctive Impella Support to Venoarterial Extracorporeal Membrane Oxygenation for a Refractory Electrical Storm.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) stabilizes hemodynamics in an electrical storm leading to cardiogenic shock. However, adverse effects of VA-ECMO are increased left ventricular (LV) afterload and LV end-diastolic pressure due to retrograde blood return. These adverse effects could be ameliorated by LV unloading with Impella insertion. This case illustrates the possible efficacy of adjunctive Impella insertion for a refractory electrical storm that is resistant to defibrillation under mechanical support with VA-ECMO for cardiogenic shock.

Outcomes of Patients With Cancer With Myocardial Infarction-Associated Cardiogenic Shock Managed With Mechanical Circulatory Support.

Background: Cardiogenic shock (CS) is the leading cause of death among patients with acute myocardial infarction (AMI) and is managed with temporary mechanical circulatory support (tMCS) in advanced cases. Patients with cancer are at high risk of AMI and CS. However, outcomes of patients with cancer and AMI-CS managed with tMCS have not been rigorously studied. Methods: Adult patients with AMI-CS managed with tMCS from 2006 to 2018 with and without cancer were identified using the National Inpatient Sample. Propensity score matching (PSM) was performed for variables associated with cancer. Primary outcome was in-hospital death, and secondary outcomes were major bleeding and thrombotic complications. Results: After PSM, 1287 patients with cancer were matched with 12,870 patients without cancer. There was an increasing temporal trend for prevalence of cancer among patients admitted with AMI-CS managed with tMCS (P trend < .001). After PSM, there was no difference in in-hospital death (odds ratio [OR], 1.00; 95% CI, 0.88-1.13) or thrombotic complications (OR, 1.10; 95% CI, 0.91-1.34) between patients with and without cancer. Patients with cancer had a higher risk of major bleeding (OR, 1.29; 95% CI, 1.15-1.46). Conclusions: Among patients with AMI-CS managed with tMCS, cancer is becoming increasingly frequent and associated with increased risk of major bleeding, although there was no difference in in-hospital death. Further studies are needed to further characterize outcomes, and inclusion of patients with cancer in trials of tMCS is needed.

Sex Disparities in the Management, Outcomes, and Transfer of Patients Hospitalized for Cardiogenic Shock.

Background: Previous studies have shown that women have worse outcomes for cardiogenic shock (CS) than men. Patients who receive care in CS "hubs" have also been shown to have improved outcomes when compared to those treated at "spokes." This study aimed to examine the presence of sex disparities in the outcomes of CS in relation to hospital type. Methods: Hospitalizations of adults with a diagnosis of CS were identified using data from the 2016-2019 Nationwide Readmissions Database. CS "hubs" were defined as any centers receiving at least 1 interhospital transfer with CS, while those without such transfers were classified as "spokes." Data were combined across years and multivariable logistic regression modeling was used to evaluate the association of sex with in-hospital mortality, invasive procedures, and transfer to hubs. Results: There were a total of 618,411 CS hospitalizations (62.2% men) with CS related to acute myocardial infarction comprising 15.3 to 17.3% of women hospitalizations and 17.8 to 20.3% of men hospitalizations. In-hospital mortality was lower at hubs (34.5% for direct admissions, 31.6% for transfers) than at spokes (40.3%, all P < .01). Women underwent fewer invasive procedures (right heart catheterization, percutaneous coronary intervention, mechanical circulatory support) and had higher mortality than men. Female sex was independently associated with decreased transfers to hubs (odds ratio, 0.93; 95% CI, 0.89-0.96) and increased mortality (odds ratio, 1.09; 95% CI, 1.05-1.12). Conclusions: Women with CS were less likely to be treated at a hub or transferred to a hub, had higher in-hospital mortality, and had a lower likelihood of receiving CS-related procedures than men. Further research is needed to understand sex-specific gaps in CS outcomes.

Treatment of Cardiogenic Shock and Refractory Ventricular Fibrillation: Pulling Out All the Stops.

We report the case of a 62-year-old woman who presented with an acute inferior wall myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation. Following prolonged resuscitation in the emergency room, she was transferred to the cardiac catheterization laboratory where, as a first step, mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (ECMO) was established. Next, a right heart catheterization study was performed, followed by coronary angiography and angioplasty of the infarct-related artery. Promptly on transfer to the intensive care unit, a hypothermia protocol was initiated. By postprocedure day 1, the patient's ventricular fibrillation had resolved, mean arterial pressure was >65 mm Hg, and pulmonary artery diastolic pressure was 10 mm Hg. Echocardiography demonstrated complete recovery of left ventricular systolic function. Lactate levels had fallen from 11.0 mmol/L (pre-ECMO) to 1.2 mmol/L. The patient was successfully weaned off pressor and ECMO support within 24 hours of the percutaneous coronary intervention procedure. She was extubated on postprocedure day 2 and discharged home on day 6. At 26-month follow-up, she remains well, angina free, neurologically intact, and without evidence of heart failure. The treatment algorithm used in this case should be considered favorably in the management of patients presenting with acute myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation.