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1.
Curr Opin Crit Care ; 30(4): 379-384, 2024 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-38841993

RESUMO

PURPOSE OF REVIEW: Discussing the rationale and current evidence for left ventricular unloading in cardiogenic shock. RECENT FINDINGS: Microaxial flow pumps (MFP) and intra-aortic balloon pumps (IABP) augment cardiac output while simultaneously unloading the left ventricle (e.g. reducing left ventricular pressure), thereby targeting a key mechanism of cardiogenic shock. A recent randomized trial has shown a mortality reduction with MFP in selected patients with cardiogenic shock, strengthening the rationale for this strategy, although the evidence for the IABP is so far neutral. MFP/IABP can also be used concomitantly with veno-arterial extracorporeal membrane oxygenation (va-ECMO) to alleviate the va-ECMO-related increase in left ventricular afterload, to facilitate weaning and ultimately to improve myocardial recovery and prognosis of affected patients. However, the use of MFP/IABP in this indication solely relies on retrospective data, which need to be interpreted with caution, especially as these strategies are associated with more complications. Currently ongoing randomized trials will help to further clarify the role of left ventricular unloading in patients on va-ECMO. SUMMARY: Left ventricular unloading addresses a key mechanism of cardiogenic shock, with strong evidence to support MFP use in selected patients, but further randomized controlled trials are required to clarify the role of different devices/strategies for the overall shock population.


Assuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Balão Intra-Aórtico , Choque Cardiogênico , Choque Cardiogênico/terapia , Choque Cardiogênico/fisiopatologia , Humanos , Balão Intra-Aórtico/métodos , Oxigenação por Membrana Extracorpórea/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto
2.
Perfusion ; 39(3): 506-513, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-36749309

RESUMO

INTRODUCTION: The intra-aortic balloon pump (IABP) is one of the most utilized cardiac assist devices. Patients receiving IABP therapy are typically managed in high acuity clinical care areas with limited bed space and high demand. Our center instituted a certified clinical perfusionist (CCP) led initiative to remove IABP catheters in order to reduce IABP therapy time, hasten removal and improve efficiency. METHODS: The purpose of the study is to compare outcomes for IABP removal by a certified clinical perfusionist to a physician. The primary outcome measures were site hematoma score and limb related complications. A survey was submitted to bedside nurses, managers/patient care coordinators, CCP's and physicians. The IABP quality assurance database was interrogated for the study. RESULTS: There were 350 patients eligible for inclusion. The cohort was well balanced between CCP (n = 284) and physician (n = 66) groups for patient demographics, indication, insertion specifics and type of medical intervention. The majority of patients had no bruise or hematoma with perfusionist (n = 246, 87%) or physician (n = 58, 88%) (p = 0.78) removal. The physician group demonstrated a higher rate of grade 3 hematomas (p = 0.03). There was no statistically significant difference between CCP and physician groups for limb complications and mortality. Survey results showed an improved efficiency in bed space allocation, physician workload and a decreased IABP support time. CONCLUSION: There is no difference in limb complications between perfusionist and physician removal of IABP catheters. The survey demonstrate an improvement in resource allocation and efficiency. A perfusionist led IABP removal program can be done safely and may help improve program efficiency.


Assuntos
Catéteres , Balão Intra-Aórtico , Humanos , Resultado do Tratamento , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos , Hematoma , Estudos Retrospectivos
3.
Heart Lung Circ ; 33(7): 975-982, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38575436

RESUMO

BACKGROUND: Evidence supporting anticoagulation with unfractionated heparin (UFH) in patients with an intra-aortic balloon pump (IABP) to prevent limb ischaemia remains limited, while bleeding risks remain high. Monitoring heparin in this setting with anti-factor Xa (anti-Xa) is not previously described. OBJECTIVES: The study objective is to describe the incidence of thromboembolic and bleeding events with the use of UFH in patients with an IABP utilising monitoring with both anti-Xa and activated partial thromboplastin time (aPTT). METHODS: This is a retrospective study of adults who received an IABP and UFH for ≥24 hours. Electronic medical records were reviewed for pertinent data. The primary outcome was the incidence of limb ischaemia during IABP. Secondary outcomes included myocardial infarction, thrombus on IABP, or stroke. Exploratory outcomes included any venous thromboembolism and bleeding events. RESULTS: Of 159 patients, 88% received an IABP for cardiogenic shock and median duration of IABP support was 118 hours (interquartile range, 67-196). Limb ischaemia occurred in four of 159 patients (2.5%). Strokes occurred in 3.8% of the cohort, and bleeding events occurred in 33%. Despite anticoagulation use in all patients, 11% experienced a venous thromboembolism, with most identified upon asymptomatic screening with concern for heparin-induced thrombocytopenia. We found no differences in outcomes that occurred with a hybrid anti-Xa and aPTT versus aPTT monitoring alone. CONCLUSIONS: We observed a high rate of thrombotic and bleeding complications with the use of UFH in patients with an IABP. Use of anti-Xa versus aPTT for monitoring was not associated with complications. These data suggest safer anticoagulation strategies are needed in this setting.


Assuntos
Heparina , Balão Intra-Aórtico , Humanos , Heparina/efeitos adversos , Heparina/administração & dosagem , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/efeitos adversos , Estudos Retrospectivos , Feminino , Masculino , Idoso , Pessoa de Meia-Idade , Choque Cardiogênico , Incidência , Anticoagulantes/efeitos adversos , Anticoagulantes/administração & dosagem , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia
4.
Artif Organs ; 47(1): 198-204, 2023 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-35943826

RESUMO

BACKGROUND: Use of prolonged femoral intra-aortic balloon pump support limits the mobility of patients awaiting heart transplant. We assessed the safety and outcomes of a structured, tilting physical therapy protocol in patients supported by intra-aortic balloon pumps while awaiting transplant. METHODS: We retrospectively reviewed five years of transplant patients. Eighteen patients received femoral intra-aortic balloon support, a heart transplant, and met all eligibility criteria. We compared complications and outcomes between patients who received the structured, tilting physical therapy (Protocol Group) and those that received standard of care (Control Group). RESULTS: Complications were not significantly different between groups. The majority of the Protocol Group were discharged to home (10/12), while half (3/6) of the Control Group were discharged to a rehabilitation facility. Post-transplant length of stay was significantly less in the Protocol Group (median 16 vs. 28 days, p = 0.03). CONCLUSION: Despite the small number analyzed, the data indicates that the structured, tilting physical therapy protocol led to a significantly reduced length of stay post-transplantation. Importantly, use of the protocol did not result in access site complications, thrombosis, or arrhythmias in the majority of the patients.


Assuntos
Insuficiência Cardíaca , Transplante de Coração , Coração Auxiliar , Humanos , Insuficiência Cardíaca/terapia , Estudos Retrospectivos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos
5.
Perfusion ; 38(1): 142-149, 2023 01.
Artigo em Inglês | MEDLINE | ID: mdl-34479456

RESUMO

OBJECTIVE: Intra-aortic balloon pump (IABP) is currently recommended as a strategy to address the increased afterload in patients who received venoarterial extracorporeal membrane oxygenation (VA-ECMO). The benefit of VA-ECMO with IABP in postcardiotomy cardiogenic shock is inconclusive. A systematic review and meta-analysis was conducted to assess the influence of VA-ECMO with IABP for postcardiotomy cardiogenic shock (PCS). METHODS: The Cochrane Library, PubMed, and Embase were searched for all articles published from 1 January, 1964 to July 11, 2020. Retrospective cohort studies targeting the comparison of VA-ECMO with IABP and isolated VA-ECMO were included in this study. RESULTS: We included 2251 patients in the present study (917 patients in the VA-ECMO with IABP group and 1334 patients in the isolated VA-ECMO group). Deaths occurred in 589 of 917 patients (64.2%) in the VA-ECMO with IABP group and occurred in 885 of 1334 patients (66.3%) in isolated VA-ECMO group. Pooling the results of all studies showed that VA-ECMO with IABP was not related to a reduced in-hospital mortality in patients who received VA-ECMO for PCS (RR, 0.95; 95% CI, 0.86-1.04; p = 0.231). In addition, VA-ECMO with IABP was not related to an increased rate of VA-ECMO weaning in patients who received VA-ECMO for PCS (RR, 1.28; 95% CI, 0.99-1.66; p = 0.058). CONCLUSIONS: This study indicates that VA-ECMO with IABP did not improve either in-hospital survival or weaning for VA-ECMO in postcardiotomy cardiogenic shock patients.


Assuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Humanos , Choque Cardiogênico/etiologia , Choque Cardiogênico/cirurgia , Oxigenação por Membrana Extracorpórea/métodos , Estudos Retrospectivos , Balão Intra-Aórtico/métodos
6.
Perfusion ; 38(1): 51-57, 2023 01.
Artigo em Inglês | MEDLINE | ID: mdl-34318736

RESUMO

INTRODUCTION: The intra-aortic balloon pump (IABP) and Impella are left ventricular unloading devices with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) in place and later serve as bridging therapy when VA-ECMO is terminated. We aimed to determine the potential differences in clinical outcomes and rate of complications between the two combinations of mechanical circulatory support. METHODS: This was a retrospective, single institutional cohort study conducted in the intensive care unit (ICU) of Queen Elizabeth Hospital, Hong Kong. Inclusion criteria included all patients aged ⩾18 years, who had VA-ECMO support, and who had left ventricular unloading by either IABP or Impella between January 1, 2018 and October 31, 2020. Patients <18 years old, with central VA-ECMO, who did not require left ventricular unloading, or who underwent surgical venting procedures were excluded. The primary outcome was ECMO duration. Secondary outcomes included length of stay (LOS) in the ICU, hospital LOS, mortality, and complication rate. RESULTS: Fifty-two patients with ECMO + IABP and 14 patients with ECMO + Impella were recruited. No statistically significant difference was observed in terms of ECMO duration (2.5 vs 4.6 days, p = 0.147), ICU LOS (7.7 vs 10.8 days, p = 0.367), and hospital LOS (14.8 vs 16.5 days, p = 0.556) between the two groups. No statistically significant difference was observed in the ECMO, ICU, and hospital mortalities between the two groups. Specific complications related to the ECMO and Impella combination were also noted. CONCLUSIONS: Impella was not shown to offer a statistically significant clinical benefit compared with IABP in conjunction with ECMO. Clinicians should be aware of the specific complications of using Impella.


Assuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Humanos , Idoso , Adolescente , Choque Cardiogênico , Oxigenação por Membrana Extracorpórea/métodos , Estudos Retrospectivos , Estudos de Coortes , Coração Auxiliar/efeitos adversos , Balão Intra-Aórtico/métodos
7.
Zhonghua Yi Xue Za Zhi ; 103(10): 752-756, 2023 Mar 14.
Artigo em Zh | MEDLINE | ID: mdl-36889689

RESUMO

The study aimed to evaluate whether an intra-aortic balloon pump (IABP) could improve the prognosis of patients with cardiogenic shock (CS) of Stage C (Classic), Stage D (Deteriorating), and Stage E (Extremis) based on Society for Cardiovascular Angiography and Interventions (SCAI) classification. The hospital information database was searched, and the patients who met the diagnostic criteria of CS were included and treated following the same protocol. The association between IABP and the survival of patients at 1 month and 6 months were analyzed separately in SCAI stage C of CS, and stages D and E of CS. The multiple logistic regression models were used to separately evaluate whether IABP was independently associated with increased survival in stage C of CS, and stages D and E of CS. A total of 141 patients with stage C of CS and 267 patients with stages D and E of CS were included. In stage C of CS, IABP was significantly associated with improved survival of patients at 1 month [adjusted OR (95%CI)=0.372 (0.171-0.809), P=0.013] and survival at 6 months [adjusted OR (95%CI)=0.401 (0.190-0.850), P=0.017]. However, when percutaneous coronary intervention or coronary artery bypass grafting (PCI/CABG) was introduced as an adjusted factor, there was a significant association between survival rates and PCI/CABG rather than IABP. In stages D and E of CS, IABP was significantly associated with an improved survival at 1 month [adjusted OR (95%CI)=0.053 (0.012-0.236), P=0.001]. Therefore, IABP could assist patients with stage C of CS in the perioperative period of PCI/CABG and improve survival rates, and IABP might prolong short-term prognosis of patients with stages D and E of CS.


Assuntos
Intervenção Coronária Percutânea , Choque Cardiogênico , Humanos , Choque Cardiogênico/terapia , Resultado do Tratamento , Prognóstico , Angiografia , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos
8.
Medicina (Kaunas) ; 59(10)2023 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-37893524

RESUMO

Background and Objectives. Recent guidelines have downgraded the routine use of the intra-aortic balloon pump (IABP) in patients with cardiogenic shock (CS) due to ST-elevation myocardial infarction (STEMI). Despite this, its use in clinical practice remains high. The aim of this study was to evaluate the prognostic impact of the IABP in patients with STEMI complicated by CS undergoing primary PCI (pPCI), focusing on patients with anterior MI in whom a major benefit has been previously hypothesized. Materials and Methods. We enrolled 2958 consecutive patients undergoing pPCI for STEMI in our department from 2005 to 2018. Propensity score matching and mortality analysis were performed. Results. CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. In the propensity-matched analysis, the use of the IABP was associated with a lower 30-day mortality (39.3% vs. 60.9%, p = 0.032) in the subgroup of patients with anterior STEMI. Conversely, in the whole group of CS patients and in the subgroup of patients with non-anterior STEMI, IABP use did not have a significant impact on mortality. Conclusions. The use of the IABP in cases of STEMI complicated by CS was found to improve survival in patients with anterior infarction. Prospective studies are needed before abandoning or markedly limiting the use of the IABP in this clinical setting.


Assuntos
Infarto do Miocárdio , Infarto do Miocárdio sem Supradesnível do Segmento ST , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Choque Cardiogênico/cirurgia , Choque Cardiogênico/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Intervenção Coronária Percutânea/métodos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Resultado do Tratamento
9.
Zhonghua Xin Xue Guan Bing Za Zhi ; 51(8): 851-858, 2023 Aug 24.
Artigo em Zh | MEDLINE | ID: mdl-37583334

RESUMO

Objective: To investigate the impact of combined use and timing of arterial-venous extracorporeal membrane oxygenation (VA-ECMO) with intra-aortic balloon pump (IABP) on the prognosis of patients with acute myocardial infarction complicated with cardiogenic shock (AMICS). Methods: This was a prospective cohort study, patients with acute myocardial infarction and cardiogenic shock who received VA-ECMO support from the Heart Center of Lanzhou University First Hospital from March 2019 to March 2022 in the registration database of the Chinese Society for Extracorporeal Life Support were enrolled. According to combination with IABP and time point, patients were divided into VA-ECMO alone group, VA-ECMO+IABP concurrent group and VA-ECMO+IABP non-concurrent group. Data from 3 groups of patients were collected, including the demographic characteristics, risk factors, ECG and echocardiographic examination results, critical illness characteristics, coronary intervention results, VA-ECMO related parameters and complications were compared among the three groups. The primary clinical endpoint was all-cause death, and the safety indicators of mechanical circulatory support included a decrease in hemoglobin greater than 50 g/L, gastrointestinal bleeding, bacteremia, lower extremity ischemia, lower extremity thrombosis, acute kidney injury, pulmonary edema and stroke. Kaplan-Meier survival curves were used to analyze the survival outcomes of patients within 30 days of follow-up. Using VA-ECMO+IABP concurrent group as reference, multivariate Cox regression model was used to evaluate the effect of the combination of VA-ECMO+IABP at different time points on the prognosis of AMICS patients within 30 days. Results: The study included 68 AMICS patients who were supported by VA-ECMO, average age was (59.8±10.8) years, there were 12 female patients (17.6%), 19 cases were in VA-ECMO alone group, 34 cases in VA-ECMO+IABP concurrent group and 15 cases in VA-ECMO+IABP non-concurrent group. The success rate of ECMO weaning in the VA-ECMO+IABP concurrent group was significantly higher than that in the VA-ECMO alone group and the VA-ECMO+IABP non-concurrent group (all P<0.05). Compared with the ECMO+IABP non-concurrent group, the other two groups had shorter ECMO support time, lower rates of acute kidney injury complications (all P<0.05), and lower rates of pulmonary edema complications in the ECMO alone group (P<0.05). In-hospital survival rate was significantly higher in the VA-ECMO+IABP concurrent group (28 patients (82.4%)) than in the VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (7 patients) (all P<0.05). The survival rate up to 30 days of follow-up was also significantly higher surviving patients within were in the ECMO+IABP concurrent group (26 cases) than in VA-ECMO alone group (9 patients) and VA-ECMO+IABP non-concurrent group (4 patients) (all P<0.05). Multivariate Cox regression analysis showed that compared with the concurrent use of VA-ECMO+IABP, the use of VA-ECMO alone and non-concurrent use of VA-ECMO+IABP were associated with increased 30-day mortality in AMICS patients (HR=2.801, P=0.036; HR=2.985, P=0.033, respectively). Conclusions: When VA-ECMO is indicated for AMICS patients, combined use with IABP at the same time can improve the ECMO weaning rate, in-hospital survival and survival at 30 days post discharge, and which does not increase additional complications.


Assuntos
Oxigenação por Membrana Extracorpórea , Infarto do Miocárdio , Edema Pulmonar , Humanos , Feminino , Pessoa de Meia-Idade , Idoso , Choque Cardiogênico/terapia , Choque Cardiogênico/complicações , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Edema Pulmonar/complicações , Assistência ao Convalescente , Estudos Prospectivos , Alta do Paciente , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos , Resultado do Tratamento , Estudos Retrospectivos
10.
J Card Fail ; 28(7): 1202-1216, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-34774745

RESUMO

The intra-aortic balloon pump (IABP) is widely implanted as temporary mechanical circulatory support for cardiogenic shock (CS). However, its use is declining following the results of the IABP-SHOCK II trial, which failed to show a clinical benefit of the IABP in acute coronary syndrome (ACS)-related CS. Acute-on-chronic heart failure has become an increasingly recognized, distinct cause of CS (HF-CS). The pathophysiology of HF-CS differs from that of ACS-CS because it typically represents the progression from a state of congestion (with relatively preserved cardiac output) to a low-output state with hypoperfusion. The IABP is a volume-displacement pump that promotes forward flow from a high-capacitance reservoir to low-capacitance vessels, improving peripheral perfusion and decreasing left ventricular afterload in the setting of high filling pressures. The IABP can improve ventricular-vascular coupling and, therefore, myocardial energetics. Additionally, many patients with HF-CS are candidates for cardiac replacement therapies (left ventricular assist device or heart transplantation) and, therefore, may benefit from a bridge strategy that stabilizes the hemodynamics and end-organ function in preparation for more durable therapies. Notably, the new United Network for Organ Sharing donor heart allocation system has recently prioritized patients on IABP support. This review describes the role of IABP in the treatment of HF-CS. It also briefly discusses new strategies for vascular access as well as fully implantable versions for longer duration of support.


Assuntos
Insuficiência Cardíaca , Transplante de Coração , Coração Auxiliar , Infarto do Miocárdio , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/terapia , Transplante de Coração/efeitos adversos , Coração Auxiliar/efeitos adversos , Humanos , Balão Intra-Aórtico/métodos , Infarto do Miocárdio/terapia , Choque Cardiogênico/etiologia , Choque Cardiogênico/cirurgia , Doadores de Tecidos , Resultado do Tratamento
11.
Catheter Cardiovasc Interv ; 99(7): 1976-1983, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35419933

RESUMO

BACKGROUND: In contemporary Cardiac Intensive Care Unit (CICU), bedside intra-aortic balloon pump (IABP) insertion under echocardiographic guidance may be an attractive option for selected patients with cardiogenic shock (CS). Currently available data on this approach are limited. AIM: This study aimed to assess the feasibility and safety of bedside IABP insertion, as compared to fluoroscopic-guided insertion in the Catheterization Laboratory (CathLab), and to describe the clinical features of patients receiving bedside IABP insertion using a standardized technique in real-world CICU practice. METHODS: We prospectively evaluated all patients admitted the CICU who received transfemoral IABP between June 2020 and October 2021. The overall study cohort was divided according to implant strategy in bedside and CathLab groups. The primary outcome was correct radiographic IABP positioning at the first bedside chest X-ray obtained after insertion. Secondary outcomes included IABP-related complications. RESULTS: Among 115 patients, bedside IABP insertion was performed in 35 (30.4%) cases, mainly presenting with CS-related to acute decompensated heart failure (ADHF) (68.6 vs 33.8%; p < 0.001), with lower LVEF, higher proportion of right ventricular involvement and higher need of inotropes/vasopressors, compared to those receiving CathLab insertion. Bedside IABP insertion resulted feasible and safe, with similar rates of correct IABP positioning (82.9 vs. 82.5%; p = 0.963) and IABP-related major vascular complications (5.7 vs. 5.0%; p = 0.874), as compared to CathLab positioning. CONCLUSION: This study suggests the feasibility and safety of bedside IABP insertion, which could be of relevant interest in patients with ADHF-related CS who may not need coronary angiography or other urgent CathLab procedures.


Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Insuficiência Cardíaca/etiologia , Coração Auxiliar/efeitos adversos , Humanos , Unidades de Terapia Intensiva , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos , Estudos Retrospectivos , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Resultado do Tratamento
12.
Can J Anaesth ; 69(12): 1537-1553, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-36195825

RESUMO

PURPOSE: To compare the relative efficacy of supportive therapies (inotropes, vasopressors, and mechanical circulatory support [MCS]) for adult patients with cardiogenic shock complicating acute myocardial infarction. SOURCE: We conducted a systematic review and network meta-analysis and searched six databases from inception to December 2021 for randomized clinical trials (RCTs). We evaluated inotropes, vasopressors, and MCS in separate networks. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to rate the certainty in findings. The critical outcome of interest was 30-day all-cause mortality. PRINCIPAL FINDINGS: We included 17 RCTs. Among inotropes (seven RCTs, 1,145 patients), levosimendan probably reduces mortality compared with placebo (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33 to 0.87; moderate certainty), but primarily in lower severity shock. Milrinone (OR, 0.52; 95% CI, 0.19 to 1.39; low certainty) and dobutamine (OR, 0.67, 95% CI, 0.30 to 1.49; low certainty) may have no effect on mortality compared with placebo. With regard to MCS (eight RCTs, 856 patients), there may be no effect on mortality with an intra-aortic balloon pump (IABP) (OR, 0.94; 95% CI, 0.69 to 1.28; low certainty) or percutaneous MCS (pMCS) (OR, 0.96; 95% CI, 0.47 to 1.98; low certainty), compared with a strategy involving no MCS. Intra-aortic balloon pump use was associated with less major bleeding compared with pMCS. We found only two RCTs evaluating vasopressors, yielding insufficient data for meta-analysis. CONCLUSION: The results of this systematic review and network meta-analysis indicate that levosimendan reduces mortality compared with placebo among patients with low severity cardiogenic shock. Intra-aortic balloon pump and pMCS had no effect on mortality compared with a strategy of no MCS, but pMCS was associated with higher rates of major bleeding. STUDY REGISTRATION: Center for Open Science ( https://osf.io/ky2gr ); registered 10 November 2020.


RéSUMé: OBJECTIF: Comparer l'efficacité relative des thérapies de soutien (inotropes, vasopresseurs et assistance circulatoire mécanique [ACM]) chez les patients adultes atteints d'un choc cardiogénique compliquant un infarctus aigu du myocarde. SOURCES: Nous avons réalisé une revue systématique et une méta-analyse en réseau et effectué des recherches dans six bases de données depuis leur création jusqu'à décembre 2021 pour en tirer les études randomisées contrôlées (ERC). Nous avons évalué les inotropes, les vasopresseurs et les ACM dans des réseaux distincts. Deux réviseurs ont effectué la recherche, l'évaluation du texte intégral et l'extraction. Nous avons utilisé le système de notation GRADE (Grading of Recommendations Assessment, Development, and Evaluation) pour évaluer la certitude des résultats. Le critère d'évaluation d'intérêt était la mortalité toutes causes confondues à 30 jours. CONSTATATIONS PRINCIPALES: Nous avons inclus 17 ERC. Parmi les inotropes (sept ERC, 1145 patients), le lévosimendan a probablement réduit la mortalité par rapport au placebo (rapport de cotes [RC], 0,53; intervalle de confiance [IC] à 95 %, 0,33 à 0,87; certitude modérée), mais principalement en cas de choc de sévérité moindre. La milrinone (RC, 0,52; IC 95 %, 0,19 à 1,39; certitude faible) et la dobutamine (RC, 0,67, IC 95 %, 0,30 à 1,49; certitude faible) pourraient n'avoir aucun effet sur la mortalité par rapport au placebo. En ce qui concerne l'ACM (huit ERC, 856 patients), il pourrait n'y avoir aucun effet sur la mortalité avec un ballon intra-aortique (IABP) (RC, 0,94; IC 95 %, 0,69 à 1,28; certitude faible) ou un ACM percutané (ACMp) (RC, 0,96; IC 95 %, 0,47 à 1,98; certitude faible), par rapport à une stratégie sans ACM. L'utilisation d'un ballon intra-aortique était associée à moins de saignements majeurs par rapport à une ACMp. Nous n'avons trouvé que deux ERC évaluant les vasopresseurs, ce qui n'a pas fourni suffisamment de données pour la méta-analyse. CONCLUSION: Les résultats de cette revue systématique et de la méta-analyse en réseau indiquent que le lévosimendan réduit la mortalité par rapport au placebo chez les patients présentant un choc cardiogénique de faible gravité. Le ballon intra-aortique et l'ACMp n'ont eu aucun effet sur la mortalité par rapport à une stratégie sans ACM, mais l'ACMp était associée à des taux plus élevés de saignements majeurs. ENREGISTREMENT DE L'éTUDE: Center for Open Science ( https://osf.io/ky2gr ); enregistrée le 10 novembre 2020.


Assuntos
Infarto do Miocárdio , Choque Cardiogênico , Adulto , Humanos , Choque Cardiogênico/tratamento farmacológico , Choque Cardiogênico/etiologia , Metanálise em Rede , Simendana/uso terapêutico , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Hemorragia/etiologia , Resultado do Tratamento
13.
J Cardiothorac Vasc Anesth ; 36(8 Pt B): 2876-2883, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35304046

RESUMO

OBJECTIVES: To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). DESIGN: A retrospective multicenter registry study. SETTING: At 19 cardiac surgery units. PARTICIPANTS: A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). MEASUREMENTS AND MAIN RESULTS: The overall series mean age was 63 ± 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMO-IABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, in-hospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). CONCLUSIONS: This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Choque , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Balão Intra-Aórtico/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque/etiologia , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia
14.
Perfusion ; 37(1): 69-77, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33325335

RESUMO

INTRODUCTION: This study aimed to test a computer-driven cardiovascular model for the evaluation of the visceral flow during intra-aortic balloon pump (IABP) assistance. METHODS: The model includes a systemic and pulmonary circulation as well as a heart contraction model. The straight polyurethane tube aorta had a single visceral while four windkessel components mimicked resistance compliance of the brachiocephalic, renal and sub-mesenteric, pulmonary, and systemic circulation. Twelve flow probes were placed in the circuit to measure pressures and flows with the IABP on and off. RESULTS: With the balloon off, the meantime to reach the steady state was 48 ± 16 s; with the balloon on, this figure was 178 ± 20 s. The stability of pressure and flow signals was obtained after 72 ± 11 min. The number of cycles of stability of the system was 93 [86-103]. Measurements were reliable either with samples of 10 or 20 beats. Bland Altman method demonstrated the reliability of measurements. Finally, all measurements were comparable to published in vivo data. CONCLUSION: The presented mock circulation was reliable and gave values with high accuracy both at baseline and during mechanical assistance. This system allows evaluation of the mesenteric flow during IABP, under different clinical/hemodynamic conditions. Nonetheless, its translational potential needs to be further evaluated.


Assuntos
Contrapulsação , Coração Auxiliar , Aorta , Circulação Coronária , Hemodinâmica , Humanos , Balão Intra-Aórtico/métodos , Reprodutibilidade dos Testes
15.
Ter Arkh ; 94(9): 1094-1098, 2022 Oct 24.
Artigo em Russo | MEDLINE | ID: mdl-36286761

RESUMO

Cardiogenic shock (CS) is one of the main causes of death in patients with acute myocardial infarction (AMI). Mortality from CS remains high, despite the introduction of myocardial revascularization and the use of modern medication. The use of mechanical circulatory support (MCS) is promising, it could reduce mortality in patients with AMI and CS. AIM: To define effectiveness and safety of MCS in patients with AMI and CS. MATERIALS AND METHODS: Our study includes 47 patients with AMI and refractory CS, who were treated at the University Clinic of Cardiology of the Yevdokimov Moscow State University of Medicine and Dentistry from 2019 to 2022. Mortality and various complications were analyzed in patients with refractory CS, patients who received and did not receive mechanical circulatory support (intra-aortic balloon pump IABP, extracorporeal membrane oxygenation ECMO). RESULTS: Mortality among patients with refractory CS was significantly lower in the subgroup of patients who received mechanical circulatory support devices (59% vs 93%; p=0.02). Moreover, reliability is achieved mainly due to patients in whom were VA-ECMO implanted (p=0.02), not IABP (p=0.16). CONCLUSION: VA-ECMO associated with reduced mortality and should be considered in patients with AMI and refractory CS. Further research is needed to select the optimal method of mechanical circulatory support in patients with CS.


Assuntos
Infarto do Miocárdio , Choque Cardiogênico , Humanos , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Estudos Retrospectivos , Reprodutibilidade dos Testes , Resultado do Tratamento , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/métodos , Infarto do Miocárdio/complicações
16.
Lancet ; 396(10245): 199-212, 2020 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-32682486

RESUMO

Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Balão Intra-Aórtico/métodos , Choque Cardiogênico/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Coração Auxiliar/efeitos adversos , Humanos , Balão Intra-Aórtico/efeitos adversos
17.
Am Heart J ; 236: 87-96, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33359779

RESUMO

BACKGROUND: Temporary mechanical circulatory support (MCS) devices are increasingly used in cardiogenic shock, but whether sociodemographic differences by sex, race and/or ethnicity, insurance status, and neighborhood poverty exist in the utilization of these devices is unknown. METHODS: Retrospective cross-sectional study using the National Inpatient Sample for 2012-2017. Logistic regression models were used to examine predictors of use of temporary MCS devices and for in-hospital mortality, clustering by hospital-year. RESULTS: Our study population included 109,327 admissions for cardiogenic shock. Overall, 14.3% of admissions received an intra-aortic balloon pump, 4.2% a percutaneous ventricular assist device, and 1.8% extracorporeal membranous oxygenation (ECMO). After adjusting for age, comorbidities, and hospital characteristics, use of temporary MCS was lower in women compared to men (adjusted odds ratio [aOR] = 0.76, P < .001), Black patients compared to white ones (aOR = 0.73, P < .001), those insured by Medicare (aOR = 0.75, P < .001), Medicaid (aOR = 0.74, P < .001), or uninsured (aOR = 0.90, P = .015) compared to privately insured, and those in the lowest income neighborhoods (aOR = 0.94, P = .003) versus other neighborhoods. Women, admissions covered by Medicare, Medicaid, or uninsured, and those from low-income neighborhoods also had higher mortality rates even after adjustment for MCS implantation. CONCLUSIONS: There are differences in the use of temporary MCS in the setting of cardiogenic shock among specific populations within the United States. The growing use of MCS for treating cardiogenic shock highlights the need to better understand its impact on outcomes.


Assuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar/estatística & dados numéricos , Balão Intra-Aórtico , Choque Cardiogênico , Estudos Transversais , Demografia , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde , Mortalidade Hospitalar , Humanos , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Fatores Socioeconômicos , Estados Unidos/epidemiologia
18.
J Interv Cardiol ; 2021: 8843935, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33536855

RESUMO

BACKGROUND: Although scoring systems are widely used to predict outcomes in postcardiac arrest cardiogenic shock (CS) after out-of-hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI), data concerning the accuracy of these scores to predict mortality of patients treated with Impella in this setting are lacking. Thus, we aimed to evaluate as well as to compare the prognostic accuracy of acute physiology and chronic health II (APACHE II), simplified acute physiology score II (SAPS II), sepsis-related organ failure assessment (SOFA), the intra-aortic balloon pump (IABP), CardShock, the prediction of cardiogenic shock outcome for AMI patients salvaged by VA-ECMO (ENCOURAGE), and the survival after venoarterial extracorporeal membrane oxygenation (SAVE) score in patients with OHCA refractory CS due to an AMI treated with Impella 2.5 or CP. METHODS: Retrospective study of 65 consecutive Impella 2.5 and 32 CP patients treated in our cardiac arrest center from September 2015 until June 2020. RESULTS: Overall survival to discharge was 44.3%. The expected mortality according to scores was SOFA 70%, SAPS II 90%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 50%, and SAVE score 70% in the 2.5 group; SOFA 70%, SAPS II 85%, IABP shock 55%, CardShock 80%, APACHE II 85%, ENCOURAGE 75%, and SAVE score 70% in the CP group. The ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under the curve (AUC) of 0.79, followed by the CardShock, APACHE II, IABP, and SAPS score. These derived an AUC between 0.71 and 0.78. The SOFA and the SAVE scores failed to predict the outcome in this particular setting of refractory CS after OHCA due to an AMI. CONCLUSION: The available intensive care and newly developed CS scores offered only a moderate prognostic accuracy for outcomes in OHCA patients with refractory CS due to an AMI treated with Impella. A new score is needed in order to guide the therapy in these patients.


Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca Extra-Hospitalar , Medição de Risco/métodos , Choque Cardiogênico , Idoso , Cuidados Críticos/métodos , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Parada Cardíaca Extra-Hospitalar/complicações , Parada Cardíaca Extra-Hospitalar/terapia , Prognóstico , Estudos Retrospectivos , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Análise de Sobrevida
19.
Int Heart J ; 62(5): 1182-1185, 2021 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-34544989

RESUMO

A 20-year-old man with arrhythmogenic right ventricular cardiomyopathy (ARVC) was resuscitated from ventricular fibrillation. He was transferred to our hospital because of progressive multiorgan dysfunction despite mechanical circulatory support with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP). At admission to our hospital, chest X-ray showed bilateral complete lung opacification, and echocardiography revealed a massive thrombus occupying the left atrium (LA) and left ventricle (LV). Conversion to central ECMO with transapical LV venting and thrombectomy were performed. The huge LA thrombus occluded all pulmonary veins (PVs). Despite the surgery and intensive care, complete lung opacity remained, and he died of multiorgan failure associated with sepsis. Autopsy demonstrated bilateral pulmonary multiple red infarctions, and histopathology showed alveolar wall necrosis with extensive hemorrhage, confirming a diagnosis of pulmonary hemorrhagic infarction. Extensive pulmonary infarction was attributable to PV occlusion due to massive LA thrombus. PV thrombosis should be considered when refractory lung opacities are encountered during VA-ECMO and necessitates early intervention.


Assuntos
Displasia Arritmogênica Ventricular Direita/complicações , Oxigenação por Membrana Extracorpórea/métodos , Insuficiência de Múltiplos Órgãos/complicações , Trombose/diagnóstico , Fibrilação Ventricular/etiologia , Autopsia/métodos , Ecocardiografia/métodos , Evolução Fatal , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/patologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/patologia , Hemorragia/complicações , Hemorragia/diagnóstico , Humanos , Balão Intra-Aórtico/métodos , Masculino , Infarto Pulmonar/diagnóstico , Veias Pulmonares/diagnóstico por imagem , Veias Pulmonares/patologia , Pneumopatia Veno-Oclusiva/complicações , Pneumopatia Veno-Oclusiva/diagnóstico , Ressuscitação/métodos , Sepse/complicações , Trombectomia/métodos , Trombose/patologia , Trombose/cirurgia , Fibrilação Ventricular/terapia , Adulto Jovem
20.
Am Heart J ; 229: 127-137, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32861678

RESUMO

BACKGROUND: Cardiogenic shock remains the leading cause of in-hospital death in acute myocardial infarction (AMI). Because of temporary changes in management of cardiogenic shock with widespread implementation of early revascularization along with increasing attention to the use of mechanical circulatory devices, complete and longitudinal data are important in this subject. The objective of this study was to examine temporal trends of first-time hospitalization, management, and short-term mortality for patients with AMI-related cardiogenic shock (AMICS). METHODS: Using nationwide medical registries, we identified patients hospitalized with first-time AMI and cardiogenic shock from January 1, 2005, through December 31, 2017. We calculated annual incidence proportions of AMICS. Thirty-day mortality was estimated with use of Kaplan-Meier estimator comparing AMICS and AMI-only patients. Multivariable Cox regression models were used to assess mortality rate ratios. RESULTS: We included 101,834 AMI patients of whom 7,040 (7%) had AMICS. The median age was 72 (interquartile range: 62-80) for AMICS and 69 (interquartile range: 58-79) for AMI-only patients. The gender composition was similar between AMICS and AMI-only patients (male: 64% vs 63%). The annual incidence proportion of AMICS decreased slightly over time (2005: 7.0% vs 2017: 6.1%, P for trend < .0001). In AMICS, use of coronary angiography increased between 2005 and 2017 from 48% to 71%, as did use of left ventricular assist device (1% vs 10%) and norepinephrine (30% to 70%). In contrast, use of intra-aortic balloon pump (14% vs 1%) and dopamine (34% vs 20%) decreased. Thirty-day mortality for AMICS patients was 60% (95% CI: 59-61) and substantially higher than the 8% (95% CI: 7.8-8.2) for AMI-only patients (mortality rate ratio: 11.4, 95% CI: 10.9-11.8). Over time, the mortality decreased after AMICS (2005: 68% to 2017: 57%, P for temporal change in adjusted analysis < .0001). CONCLUSIONS: We observed a slight decrease in AMICS hospitalization over time with changing practice patterns. Thirty-day mortality was markedly higher for patients with AMICS compared with AMI only, yet our results suggest improved 30-day survival over time after AMICS.


Assuntos
Cardiotônicos/uso terapêutico , Mortalidade Hospitalar/tendências , Balão Intra-Aórtico , Infarto do Miocárdio/complicações , Intervenção Coronária Percutânea , Padrões de Prática Médica , Choque Cardiogênico , Idoso , Angiografia Coronária/estatística & dados numéricos , Dinamarca , Intervenção Médica Precoce/métodos , Intervenção Médica Precoce/estatística & dados numéricos , Feminino , Coração Auxiliar , Humanos , Balão Intra-Aórtico/instrumentação , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/estatística & dados numéricos , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Padrões de Prática Médica/normas , Padrões de Prática Médica/tendências , Sistema de Registros/estatística & dados numéricos , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Tempo para o Tratamento
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