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Pubblicazioni recenti - cardiogenic
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Intra-aortic Balloon Pump vs Peripheral Ventricular Assist Device Utilization in the US.
Ann Thorac Surg2020 May;():. doi: S0003-4975(20)30752-9.
Sanaiha Yas, Ziaeian Boback, Antonios James W, Kavianpour Behdad, Anousheh Ramtin, Benharash Peyman,
Abstract
BACKGROUND:
The objective of the present study was to characterize practical utilization trends and outcomes for intra-aortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) in cardiogenic shock at a national level.
METHODS:
An analysis of all adult patients admitted non-electively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample (NIS). Trends of inpatient IABP and pVAD use were analyzed using survey weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights (IPTW) were used to perform risk-adjusted analyses of pVAD mortality a composite of adverse events (AE), and resource utilization, with IABP as reference.
RESULTS:
Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051received a device: IABP= 127,792 (16.5%) or pVAD=15,259 (2.0%). The usage of IABP decreased (23.8 to 12.7%, p-for-trend<0.001), while pVAD implantation increased significantly during the study period (0.2 to 4.5%, p-for-trend<0.001). IPTW demonstrated significantly higher odds of mortality with pVAD (OR 1.9, 95% CI 1.7-2.2), but not AE (OR 1.1 95% CI 0.96-1.27) compared to IABP. After risk-adjustment, pVAD use was associated with an additional $15,202 (P<0.001) for survivors and $29,643 for non-survivors (P<0.001).
CONCLUSIONS:
Over the study period, the rate of pVAD utilization for cardiogenic shock has significantly increased. Compared to IABP, pVAD use was associated with increased mortality, costs and several adverse events. Multi-institutional clinical trials with rigorous inclusion criteria are warranted to evaluate the clinical utility of pVADs in the modern era.
Copyright © 2020. Published by Elsevier Inc.
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An outlook on biomarkers in cardiogenic shock.
Curr Opin Crit Care2020 May;():. doi: 10.1097/MCC.0000000000000739.
Iborra-Egea Oriol, Montero Santi, Bayes-Genis Antoni,
Abstract
PURPOSE OF REVIEW:
Cardiogenic shock is a severe complication with mortality rates of ?50% that requires a rapid and complex management to aid and identify the highest and lowest risk patients. To that end, novel cardiogenic shock biomarkers are needed to improve risk stratification and to personalize therapy.
RECENT FINDINGS:
Established biomarkers such as BNP, NT-proBNP, ST2, and troponins provide insufficient predictive value in cardiogenic shock. More recent biomarkers, including DPP3, adrenomedullin, angiopoietin 2, and the CS4P score are gaining momentum. DPP3 showed early prediction of refractory status and survival in cardiogenic shock. The CS4P score is based on the levels of liver fatty acid-binding protein (L-FABP), beta-2-microglobulin (B2M), fructose-bisphosphate aldolase B (ALDOB), and SerpinG1 (IC1). These proteins are not cardiac-specific but reflect multiorgan dysfunction, systemic inflammation, and immune activation. The CS4P improved reclassification of 32% of patients compared with the CardShock risk score.
SUMMARY:
A new wave of research focused on novel proteomic and molecular techniques, is providing new candidates that promise to aid clinical decision-making and patient stratification in cardiogenic shock. The CS4P score is emerging as the most robust, yet it requires prospective validation in cardiogenic shock patients managed with circulatory and ventricular assist devices.
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Cardiogenic shock: role of invasive cardiology.
Curr Opin Crit Care2020 May;():. doi: 10.1097/MCC.0000000000000738.
Feistritzer Hans-Josef, Thiele Holger, Desch Steffen,
Abstract
PURPOSE OF REVIEW:
Early revascularization significantly improved the outcome of patients with cardiogenic shock following acute myocardial infarction (AMI). Nevertheless, the mortality remains substantial, ranging between 40 and 50% after 30 days. The present review summarizes the current evidence regarding revascularization strategies, vascular access site and concomitant antiplatelet and antithrombotic treatment in infarct-related cardiogenic shock.
RECENT FINDINGS:
On the basis of the SHOCK trial, early revascularization is the most relevant procedure to improve the outcome of patients with infarct-related cardiogenic shock. The majority of these patients present with multivessel coronary disease. The randomized CULPRIT-SHOCK trial showed that in the emergency setting, percutaneous coronary intervention (PCI) should be confined to the culprit lesion. Regarding vascular access site, no data derived from randomized controlled trials in cardiogenic shock are available. Emergency coronary artery bypass grafting (CABG) is nowadays rarely performed in cardiogenic shock with rates less than 5% but is still a treatment option if coronary anatomy is not amenable to PCI. Regarding antiplatelet treatment, a randomized trial testing the intravenous P2Y12 inhibitor cangrelor versus an oral P2Y12 inhibitor in infarct-related cardiogenic shock is currently being performed.
SUMMARY:
Early revascularization is the cornerstone of treatment of infarct-related cardiogenic shock and should be confined to the culprit lesion in the emergency setting.
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The association of diabetes and admission blood glucose with 30-day mortality in patients with acute myocardial infarction complicated by cardiogenic shock.
Eur Heart J Acute Cardiovasc Care2020 May;():2048872620925265. doi: 10.1177/2048872620925265.
Thoegersen Michael, Josiassen Jakob, Helgestad Ole Kl, Berg Ravn Hanne, Schmidt Henrik, Holmvang Lene, Jensen Lisette Okkels, Møller Jacob Eller, Hassager Christian,
Abstract
BACKGROUND:
Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction, with short-term mortality of approximately 50%. Whether diabetes mellitus and high blood glucose levels are associated with mortality in contemporary patients with acute myocardial infarction complicated by cardiogenic shock is inadequately described.
PURPOSE:
To investigate if diabetes mellitus and high admission blood glucose were associated with 30-day mortality in a large, contemporary population with acute myocardial infarction complicated by cardiogenic shock.
METHODS:
Patients with acute myocardial infarction complicated by cardiogenic shock admitted at two tertiary centres in Denmark from 2010 to 2017 were individually identified through patient charts, resulting in the inclusion of 1716 cardiogenic shock patients. Glucose level at admission to the intensive care unit was available in 1302 patients.
RESULTS:
There was no significant difference in 30-day mortality between diabetes mellitus types I and II (63% vs. 62%, NS). Thirty-day mortality was significantly higher in diabetes patients compared to non-diabetes patients (62% vs. 50%, ?16?mmol/L, 67%; ?=?0.028) and non-diabetes patients (4-8?mmol/L, 32%; 8-12?mmol/L, 43%; 12-16?mmol/L, 57%; >16?mmol/l; 68%; ?
CONCLUSION:
Patients with acute myocardial infarction complicated by cardiogenic shock and concomitant diabetes mellitus type I or II had a significantly higher 30-day mortality in comparison to patients without diabetes mellitus, whereas no difference was found between diabetes mellitus types I and II. High glucose levels on admission to the intensive care unit were associated with increased 30-day mortality in diabetes mellitus and non-diabetes mellitus patients.
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Effects of levosimendan on weaning and survival in adult cardiogenic shock patients with veno-arterial extracorporeal membrane oxygenation: systematic review and meta-analysis.
Perfusion2020 May;():267659120918473. doi: 10.1177/0267659120918473.
Burgos Lucrecia María, Seoane Leonardo, Furmento Juan Francisco, Costabel Juan Pablo, Diez Mirta, Vrancic Mariano, Aissaoui Nadia, Benzadón Mariano Noel, Navia Daniel,
Abstract
INTRODUCTION:
Veno-arterial extracorporeal membrane oxygenation may be used to support patients with refractory cardiogenic shock. Many patients can be successfully weaned, the ability of some medications to facilitate weaning from veno-arterial extracorporeal membrane oxygenation were reported. To date, there are limited studies investigating the impact of levosimendan on veno-arterial extracorporeal membrane oxygenation weaning. The objective of this systematic review and meta-analysis was to assess the effects of levosimendan on successful weaning from veno-arterial extracorporeal membrane oxygenation and survival in adult patients with cardiogenic shock.
METHODS:
We performed a systematic review and meta-analysis (PubMed, the Cochrane Library, and the International Clinical Trials Registry Platform published from the year 2000 onwards) investigating whether levosimendan offers advantages compared to standard therapy or placebo, in cardiogenic shock adult patients treated with veno-arterial extracorporeal membrane oxygenation. The primary outcome was veno-arterial extracorporeal membrane oxygenation successful weaning, whereas secondary outcome was all-cause mortality at the longest follow-up available. We pooled risk ratio and 95% confidence interval using fixed and random effects models according to the heterogeneity.
RESULTS:
A total of five non-randomized clinical trials comprising 557 patients were included, 299 patients for levosimendan and 258 patients for control groups. The pooled prevalence of veno-arterial extracorporeal membrane oxygenation successful weaning was 61.4% (95% confidence interval 39.8-82.9%), and all-cause mortality was 36% (95% confidence interval 29.6-48.8%). There was a significant increase in veno-arterial extracorporeal membrane oxygenation successful weaning with levosimendan compared to the controls (risk ratio?=?1.42 (95% confidence interval 1.12-1.8), p for effect?=?0.004, I?=?71%). A decrease risk of all-cause mortality in the levosimendan group was also observed, risk ratio?=?0.62 (95% confidence interval 0.44-0.88), p for effect?=?0.007, I?=?36%.
CONCLUSION:
The use of levosimendan on adult patients with cardiogenic shock may facilitate the veno-arterial extracorporeal membrane oxygenation weaning and reduce all-cause mortality. Few articles of this topic are available, and prospective, randomized multi-center trials are warranted to conclude decisively on the benefits of levosimendan in this setting.
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Acute neurological complications in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation support.
Egypt Heart J2020 May;72(1):26. doi: 10.1186/s43044-020-00053-5.
Laimoud Mohamed, Ahmed Walid,
Abstract
BACKGROUND:
Extracorporeal life support has markedly progressed over the recent years to support patients with severe cardiac and pulmonary dysfunction refractory to conventional management. Many patients developed acute neurological complications while being supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to study the frequencies and outcomes of CNS complications in adult patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and to study the risk factors of these CNS complications. We conducted a retrospective study including adult patients admitted to the cardiac critical care unit with cardiopulmonary instability and supported with VA-ECMO from January 2016 until December 2018 in a tertiary care hospital.
RESULTS:
After reviewing 231 patients with ECMO, 67 patients with cardiogenic shock supported with VA-ECMO were included. About 65.7% of the studied patients were supported after cardiothoracic surgeries. About 56.7% of the patients developed acute CNS events. According to brain CT imaging, ischaemic stroke was diagnosed in 14.9% and intracerebral haemorrhage (ICH) was diagnosed in 11.9% of patients while 16.4% of patients with CNS events had negative brain CT imaging. The SOFA score was significantly higher in the group with CNS events at ICU admission and after 48?hours . As compared to patients with ischaemic strokes, patients with ICH were younger with lesser BMI, had higher SOFA scores at admission and at 48?hours of ICU admission, had longer cardiopulmonary bypass and aortic cross clamping times and had more support with central than peripheral VA-ECMO. AF was more frequent in the group with CNS events especially in the ischaemic stroke subgroup. Presence of intracardiac thrombi was more frequent in the ischaemic stroke subgroup. There was no statistically significant difference between both groups regarding ECMO circuit thrombi. The use of IABP and presence of DM were more frequent in the ischaemic stroke subgroup. Patients with neurological events had hypoalbuminaemia and higher blood glucose and serum creatinine levels compared to those without CNS events. The peak lactate level and lactate after 24?hours of ECMO support were significantly higher in those with CNS events. Patients with ICH had significant thrombocytopenia and higher INR with more prolonged aPTT and PTT ratio than those with ischaemic stroke. Patients with neurological events had significant hospital mortality, more mechanical ventilation days and tracheostomy, AKI and haemodialysis compared to those without CNS events, but there were no significant differences between both groups regarding ECMO duration, ICU or post ICU stays nor 1?year mortality.
CONCLUSION:
Acute neurological events are frequent in patients supported with VA-ECMO and associated with significant morbidity and hospital mortality. As compared to ischaemic stroke, ICH is more frequent in younger patients with lesser BMI, central VA-ECMO after cardiothoracic surgeries, thrombocytopenia, and coagulopathy. Our findings may have major implications for the care of patients requiring VA-ECMO.
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Factors associated with the use of bare metal stents in patients with ST elevation myocardial infarction.
Cardiovasc Revasc Med2020 May;():. doi: S1553-8389(20)30255-4.
Raj Leah, Upadyhay Rani, Clavijo Leonardo C, Tun Han, Mehra Anilkumar, Hindoyan Antotreas, Matthews Ray V, Shavelle David M,
Abstract
BACKGROUND:
Drug eluting stents (DES) are used in the majority of patients undergoing percutaneous coronary intervention (PCI). Factors associated with the use of bare metal stents (BMS) for patients undergoing primary PCI for ST elevation myocardial infarction (STEMI) have not been adequately explored. The objective of this study was to evaluate factors associated with BMS use in STEMI patients undergoing primary PCI.
METHODS:
Patients undergoing primary PCI for STEMI between January 2008 and February 2015 were retrospectively identified. Patients who received both a DES and BMS were included in the DES group and patients receiving balloon angioplasty only were excluded. Baseline demographics, angiographic variables, procedure related variables and in-hospital events were collected. Multivariate analysis was performed to identify factors associated with BMS use.
RESULTS:
Eight hundred and sixty-five patients underwent primary PCI for STEMI during the study period. Seventy-two patients (8.3%) received balloon angioplasty only and were excluded, yielding 793 patients for the study cohort. Three hundred fifty-two patients (44%) received BMS and 441 patients (56%) received DES. Patients receiving DES had a higher prevalence of diabetes mellitus, prior myocardial infarction, prior PCI, left anterior descending artery culprit location and Medicaid Insurance compared to those receiving BMS. Patients receiving BMS had a higher prevalence of cardiogenic shock and right coronary artery culprit location. Unadjusted in-hospital mortality was significantly higher for patients receiving BMS compared to patients receiving DES, 11.1% vs 3.2%, respectively, p < 0.0001. Multivariate predictors of BMS use were cardiogenic shock (OR 30.3; 95% CI 11.25 to 81.73) and diabetes mellitus (OR 2.99; 95% CI 1.04 to 8.64).
CONCLUSION:
In a contemporary series of patients undergoing primary PCI for STEMI, BMS were used in 44% of patients and independent factors associated with BMS use were cardiogenic shock and diabetes mellitus.
Copyright © 2020 Elsevier Inc. All rights reserved.
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Initial outcomes of a multidisciplinary network for the care of patients with cardiogenic shock.
Rev Esp Cardiol (Engl Ed)2020 May;():. doi: S1885-5857(20)30127-4.
Hernández-Pérez Francisco José, Álvarez-Avelló José Manuel, Forteza Alberto, Gómez-Bueno Manuel, González Ana, López-Ibor Jorge V, Silva-Melchor Lorenzo, Goicolea Javier, Martín Carlos Esteban, Iranzo Reyes, Goirigolzarri-Artaza Josebe, Escudier-Villa Juan Manuel, Ortega-Marcos Javier, Oteo-Domínguez Juan Francisco, Herrero-Cano Ángela, Moñivas Vanessa, Mingo-Santos Susana, Villar Susana, Jiménez-Blanco Marta, Coscia Claudia, Serrano-Fiz Santiago, Alonso-Pulpón Luis, Segovia-Cubero Javier,
Abstract
INTRODUCTION AND OBJECTIVES:
Mortality remains high in cardiogenic shock (CS), especially in refractory CS involving the use of mechanical circulatory support (MCS) devices. The aim of this study was to analyze the results of a care program for patients in CS after the creation of a multidisciplinary team in our center and a regional network of hospitals in our area.
METHODS:
Observational and retrospective study of patients attended in this program from September 2014 to January 2019. We included patients in refractory CS who required MCS and those who, because of their age and absence of comorbidities, were candidates for advanced therapies. The primary endpoint was survival to discharge.
RESULTS:
A total of 130 patients were included (69 local and 61 transferred patients). The mean age was 52±15 years (72% men). The most frequent causes of CS were acute decompensated heart failure (29%), acute myocardial infarction (26%), and postcardiotomy CS (25%). MCS was used in 105 patients (81%), mostly extracorporeal membrane oxygenation (58%). Survival to discharge was 57% (74 of 130 patients). The most frequent destinations were myocardial recovery and heart transplant. Independent predictors of in-hospital mortality were SAPS II score, lactate level, acute myocardial infarction etiology, and vasoactive-inotropic score.
CONCLUSIONS:
The creation of multidisciplinary teams for patients with mainly refractory CS and a regional network is feasible and allows survival to discharge in more than a half of attended patients with CS.
Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.
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Safe Ambulation of Critically Ill Cardiac Patients with Femoral Balloon Pumps: A Case Cohort Study.
J Card Fail2020 May;():. doi: S1071-9164(19)31870-6.
Ramsey Stephen C, Lucas Jason, Barrett Peter, Ballard William L, Kaul Prashant, Klein Andrew J,
Abstract
OBJECTIVE:
To demonstrate the safety of ambulation of patients with intra-aortic balloon pumps (IABP) inserted via the femoral approach.
SETTING:
One cardiovascular surgical intensive care unit and one cardiac care unit PATIENTS: 70 patients who received a femoral IABP at our institution between December 2015 and June 2019 who met a standardized criterion for ambulation.
INTERVENTIONS:
These patients underwent initial standing trials with a specialty standing bed/tilt table and progressed to standing exercises and ultimately ambulation (defined as covering a distance of at least 10 ft.) with the physical therapist.
MEASUREMENTS AND MAIN RESULTS:
A total of 323 sessions of ambulation were successfully performed in 70 patients with IABP inserted via the femoral approach for an average of 4.61 sessions per patient. The average ambulation session time was 45 minutes (3-62 minutes, covering a median distance of 420 ft [805 IQR]. Complications were defined as major or minor and were monitored for during and post ambulation. Major complications included limb ischemia, arterial dissection, aortic aneurysm, balloon rupture, significant hemodynamic compromise or death. Minor complications included balloon migration, infection, paresthesia, changes in balloon augmentation, or hematoma at insertion site. There were no major complications associated with ambulation and only 11 minor complications observed with a total complication rate of 3.40% over all ambulation sessions.
CONCLUSION:
Ambulation of select patients with femoral IABPs appears to be a safe activity using the enclosed protocol and selection process. Future studies to show these activities decrease muscle deconditioning in these patients and enhance recovery are required.
Copyright © 2020. Published by Elsevier Inc.
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SCAI cardiogenic shock classification after out of hospital cardiac arrest and association with outcome??
Catheter Cardiovasc Interv2020 May;():. doi: 10.1002/ccd.28984.
Pareek Nilesh, Dworakowski Rafal, Webb Ian, Barash Jemma, Emezu Gift, Melikian Narbeh, Hill Jonathan, Shah Ajay, MacCarthy Philip, Byrne Jonathan,
Abstract
OBJECTIVES:
We aimed to validate the Society for Cardiovascular Angiography and Interventions (SCAI) classification to evaluate association with outcome in a real-world population and effect of invasive therapies.
BACKGROUND:
Cardiogenic shock is common after Out of Hospital Cardiac Arrest (OOHCA) but is often multifactorial and challenging to stratify.
METHODS:
The SCAI shock grade was applied to an observational registry of OOHCA patients on admission to our center between 2012 and 2017. The primary end-point was 30-day mortality and secondary end-points were mode of death and 12-month mortality. Provision of early CAG and mechanical circulatory support (MCS) was evaluated by SCAI shock grade using logistic regression.
RESULTS:
Three hundred and ninety-three patients (median age 64.3?years (24.9% females) were included. One hundred and seven patients (27.2%) were in Grade A, 94 (23.9%) in Grade B, 66 (16.8%) in Grade C, 91 (23.2%) in Grade D, and 35 (8.9%) in Grade E. There was a step-wise significant increase in 30-day mortality with increasing shock grade (A 28.9% vs. B 33.0% vs. C 54.5% vs. D 59.3% vs. E 82.9%; p?
CONCLUSIONS:
Increasing SCAI shock grade after OOHCA is associated with 30-day mortality, requirement for renal replacement therapy and mortality attributed to multiorgan dysfunction syndrome and cardiac etiology death.
© 2020 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.
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Clinical Characteristics and Outcomes of STEMI Patients With Cardiogenic Shock and Cardiac Arrest.
JACC Cardiovasc Interv2020 May;13(10):1211-1219. doi: S1936-8798(20)30877-3.
Omer Mohamed A, Tyler Jeffrey M, Henry Timothy D, Garberich Ross, Sharkey Scott W, Schmidt Christian W, Henry Jason T, Eckman Peter, Megaly Michael, Brilakis Emmanouil S, Chavez Ivan, Burke Nicholas, Gössl Mario, Mooney Michael, Sorajja Paul, Traverse Jay H, Wang Yale, Hryniewicz Katarzyna, Garcia Santiago,
Abstract
OBJECTIVES:
This study sought to compare the clinical characteristics and long-term outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with and without cardiogenic shock (CS) or cardiac arrest (CA) before percutaneous coronary intervention (PCI).
BACKGROUND:
Patients with STEMI complicated by CS or CA are underrepresented in STEMI registries.
METHODS:
Consecutive patients with STEMI or new left bundle branch block within 24 h of symptom onset were included in a regional STEMI program comprising a PCI center (Minneapolis Heart Institute at Abbott Northwestern Hospital), 11 hospitals <60 miles from PCI center (zone 1), and 19 hospitals 60 to 210 miles from PCI center (zone 2). No patients were excluded. Patients were stratified based on the presence (+) or absence (-) of CS or CA before PCI. Patients with CA were further classified based on initial rhythm. Primary outcomes were in-hospital and 5-year mortality.
RESULTS:
Between March 2003 and December 2014, 4,511 STEMI patients were included in the regional program, including 398 (9%) with CS and 499 (11%) with CA. Hospital mortality was: CS+ and CA+, 44%; CS+ and CA-, 23%; CS- and CA+, 19%; and CS- and CA-, 2% (p < 0.001). The 5-year survival probability for CS+ and CA+ patients was 0.69 (95% confidence interval: 0.61 to 0.76) and 0.89 (95% confidence interval: 0.84 to 0.93), respectively (p < 0.01). Compared with patients with shockable rhythms, CA patients with nonshockable rhythms had significantly lower odds of survival at hospital discharge and at 5 years (both p?
CONCLUSIONS:
The combination of CS and CA significantly increases short-term mortality in patients with STEMI. After 5 years of follow-up, CS patients remained at high risk of fatal events, whereas the prognosis of CA patients was determined by initial rhythm at presentation.
Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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Did the SYNTAX Score Pass the Test of Time?
JACC Cardiovasc Interv2020 May;13(10):1207-1210. doi: S1936-8798(20)30857-8.
Serruys Patrick W, Hara Hironori, Onuma Yoshinobu,
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Prognostic Value of SYNTAX Score in Patients With Infarct-Related Cardiogenic Shock: Insights From the CULPRIT-SHOCK Trial.
JACC Cardiovasc Interv2020 May;13(10):1198-1206. doi: S1936-8798(20)30876-1.
Guedeney Paul, Barthélémy Olivier, Zeitouni Michel, Hauguel-Moreau Marie, Hage Georges, Kerneis Mathieu, Lattuca Benoit, Overtchouk Pavel, Rouanet Stéphanie, Fuernau Georg, de Waha-Thiele Suzanne, Zeymer Uwe, Sandri Marcus, Akin Ibrahim, Desch Steffen, Thiele Holger, Montalescot Gilles,
Abstract
OBJECTIVES:
This study sought to evaluate the prognostic value of the SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) scores in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary disease with infarct-related cardiogenic shock (CS).
BACKGROUND:
The prognostic value of the SYNTAX score in this high-risk setting remains unclear.
METHODS:
The CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock) trial was an international, open-label trial, where patients presenting with infarct-related CS and multivessel disease were randomized to a culprit-lesion-only or an immediate multivessel PCI strategy. Baseline SYNTAX score was assessed by a central core laboratory and categorized as low SYNTAX score (SS ?22), intermediate SYNTAX score (22
RESULTS:
Pre-PCI SYNTAX score was available in 624 patients, of whom 263 (42.1%), 207 (33.2%) and 154 (24.7%) presented with low, intermediate and high SYNTAX score, respectively. A stepwise increase in the incidence of adverse events was observed from low to intermediate and high SYNTAX score for the 30-day risk of death or RRT and the 1-year risk of death (p < 0.001, for all). After multiple adjustments, intermediate and high SYNTAX score remained strongly associated with 30-day risk of death or renal replacement therapy and 1-year risk of all-cause death. There was no significant interaction between SYNTAX score and the coronary revascularization strategy for any outcomes.
CONCLUSIONS:
In patients presenting with multivessel disease and infarct-related CS, the SYNTAX score was strongly associated with 30-day death or RRT and 1-year mortality.
Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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Two Sides of a Coin With Disparate Effects: Mechanical Circulatory Support and Bleeding.
JACC Cardiovasc Interv2020 May;13(10):1194-1197. doi: S1936-8798(20)30812-8.
Cigarroa Joaquin E, Divanji Punag,
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Frequency and Impact of Bleeding on Outcome in Patients With Cardiogenic Shock.
JACC Cardiovasc Interv2020 May;13(10):1182-1193. doi: S1936-8798(20)30742-1.
Freund Anne, Jobs Alexander, Lurz Philipp, Feistritzer Hans-Josef, de Waha-Thiele Suzanne, Meyer-Saraei Roza, Montalescot Gilles, Huber Kurt, Noc Marko, Windecker Stephan, Zeymer Uwe, Ouarrak Taoufik, Schneider Steffen, Thiele Holger, Desch Steffen,
Abstract
OBJECTIVES:
This study sought to determine frequency, associated factors, and impact of bleeding in infarct-related cardiogenic shock.
BACKGROUND:
Early revascularization is associated with improved survival in patients with acute myocardial infarction complicated by cardiogenic shock. On the downside, invasive treatment and accompanying antithrombotic therapies are associated with an increased bleeding risk. Prospective data assessing the incidence, severity, risk factors, and prognostic implication of bleeding in patients with cardiogenic shock are scarce.
METHODS:
As a pre-defined subanalysis of the CULPRIT-SHOCK (PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock) randomized trial, we examined distribution of bleeding events in 684 patients with infarct-related cardiogenic shock and compared patients with any bleeding to those without.
RESULTS:
A total of 21.5% patients experienced at least 1 bleeding event until 30 days after randomization. The vast majority of bleeding (57%) occurred within the first 2 days of hospitalization. Patients with bleeding had prolonged catecholamine treatment and mechanical ventilation and there was a significant association with sepsis, peripheral ischemic complications, new atrial fibrillation, and ventricular fibrillation. In multivariable analysis, bleeding was associated with a significantly higher mortality (hazard ratio: 2.11; 95% confidence interval: 1.63 to 2.75; p < 0.0001). Treatment with active mechanical support by extracorporeal membrane oxygenation or Impella emerged as the major risk factor for bleeding.
CONCLUSIONS:
Risk of bleeding in infarct-related cardiogenic shock is high and associated with increased mortality.
Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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Use of Administrative Claims to Assess Outcomes and Treatment Effect in Randomized Clinical Trials for Transcatheter Aortic Valve Replacement: Findings from the Extending Trial-Based Evaluations of Medical Therapies Using Novel Sources of Data (EXTEND) Study.
Circulation2020 May;():. doi: 10.1161/CIRCULATIONAHA.120.046159.
Strom Jordan B, Faridi Kamil F, Butala Neel M, Zhao Yuansong, Tamez Hector, Valsdottir Linda R, Brennan J Matthew, Shen Changyu, Popma Jeffrey J, Kazi Dhruv S, Yeh Robert W,
Abstract
Whether passively collected data can substitute for adjudicated outcomes to reproduce the magnitude and direction of treatment effect observed in cardiovascular clinical trials is not well known. We linked adults aged ?65 in the US CoreValve Pivotal High Risk (HiR) and Surgical or Transcatheter Aortic Valve Replacement in Intermediate-Risk Patients (SURTAVI) Trials to 100% Medicare inpatient claims, 1/1/2003-12/31/2016. Primary (e.g. death and stroke) and secondary trial endpoints, were compared across treatment arms (e.g. TAVR vs. SAVR) using trial-adjudicated outcomes versus outcomes derived from claims at 1-year (HiR) or 2-years (SURTAVI). Among 600 linked CoreValve HiR participants (linkage rate 80.0%), the rate of the trial's primary endpoint of all-cause mortality occurred in 13.7% of patients receiving TAVR and 16.4% of patients receiving SAVR at 1-year using both trial data (HR 0.84, 95% CI 0.65-1.09; p= 0.33) and claims data (HR 0.86, 95% CI 0.66-1.11; p = 0.34; interaction p-value = 0.80). Noninferiority of TAVR relative to SAVR was seen using both trial and claims-based outcomes (p < 0.001 for both). Among 1005 linked SURTAVI trial participants (linkage rate 60.5%), the trial's primary endpoint was 12.9% for TAVR and 13.1% for SAVR using trial data (HR 1.08, 95% CI 0.79-1.48, p = 0.90), and 11.3% for TAVR and 12.5% for SAVR patients using claims data (HR 1.02, 95% CI 0.73-1.41, p = 0.58; interaction p-value = 0.89). TAVR was noninferior to SAVR when compared using both trial and claims (p < 0.001 for both). Rates of procedural secondary outcomes (e.g. aortic valve reintervention, pacemaker rates) were more closely concordant between trial and claims data than non-procedural outcomes (e.g., stroke, bleeding, cardiogenic shock). In the CoreValve HiR and SURTAVI trials, ascertainment of trial primary endpoints using claims reproduced both the magnitude and direction of treatment effect compared with adjudicated event data, but non-fatal and non-procedural secondary outcomes were not as well reproduced. Use of claims to substitute for adjudicated outcomes in traditional trial treatment comparisons may be valid and feasible for all-cause mortality and certain procedural outcomes, but may be less suitable for other endpoints.
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Correction to: Extracorporeal membrane oxygenation support for postcardiotomy cardiogenic shock in adult patients: predictors of in?hospital mortality and failure to be weaned from extracorporeal membrane oxygenation.
J Artif Organs2020 May;():. doi: 10.1007/s10047-020-01171-2.
Mashiko Yuji, Abe Tomonobu, Tokuda Yoshiyuki, Oshima Hideki, Usui Akihiko,
Abstract
In the original publication of the article, author group affiliation was published incorrectly.
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The Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Undergoing Coronary Revascularization with Percutaneous Ventricular Assist Device Support.
J Atr Fibrillation;12(5):2179. doi: 10.4022/jafib.2179.
Sonu Gupta, Rupak Desai, Bishoy Hanna, Abhishek Deshmukh, Gautam Kumar, Rajesh Sachdeva, Adam E Berman,
Abstract
Background:
Atrial fibrillation (AF) is common in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) requiring percutaneous ventricular assist device (pVAD-Impella®) support during percutaneous coronary interventions (PCI). We evaluated the effects of a coexistent diagnosis of AF on clinical outcomes in patients with AMI-CS undergoing PCI with pVAD support.
Methods:
The National Inpatient Sample (2008-2014) was queried to identify patients with AMICS requiring PCI with pVAD support and had a concomitant diagnosis of AF. Propensity-matched cohorts (AF+ vs AF-) were compared for in-hospital outcomes.
Results:
A total of 840 patients with AMICS requiring PCI with pVAD support (420 AF+ vs 420 AF-) were identified in the matched cohort. Patients with AF were older (mean 69.7±12.0 vs 67.9±11.3 yrs, p=0.030). All-cause in-hospital mortality rates between the two groups were similar (40.5% vs 36.7%, p=0.245); however, higher postprocedural respiratory complications (9.5% vs 4.8%, p=0.007) were seen in AF+ group. In-hospital cardiac arrests were more frequent in the AF- group (32.0% vs 19.2%, p<0.001). We examined the length of stay (LOS), transfer to other facilities, and hospital charges as metrics of health care resource consumption and found that the AF+ cohort experienced fewer routine discharges (13.1% vs 30.2%), more frequent transfers to other facilities including skilled nursing facilities or intermediate care facilities (27.3% vs 17.8%; p<0.001), more frequently required the use of home health care (14.3% vs 7.1%; p<0.001). The mean LOS (11.9±10.1 vs 9.11±6.8, p<0.001) and hospital charges ($308,478 vs $277,982, p=0.008) were higher in the AF+ group.
Conclusions:
In patients suffering AMICS requiring PCI and pVAD support, a coexistent diagnosis of AF was not associated with an increase in all-cause in-hospital mortality as compared to patients without AF. However, healthcare resource consumption as assessed by various metrics was consistently greater in the AF+ group.
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Association Between Delays in Mechanical Ventilation Initiation and Mortality in Patients With Refractory Cardiogenic Shock.
JAMA Cardiol2020 May;():. doi: 10.1001/jamacardio.2020.1274.
van Diepen Sean, Hochman Judith S, Stebbins Amanda, Alviar Carlos L, Alexander John H, Lopes Renato D,
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Endotracheal Surfactant Combined With Budesonide for Neonatal ARDS.
Front Pediatr2020 ;8():210. doi: 10.3389/fped.2020.00210.
Deliloglu Burak, Tuzun Funda, Cengiz Merve Meryem, Ozkan Hasan, Duman Nuray,
Abstract
Acute respiratory distress syndrome (ARDS) is a clinical condition characterized by acute diffuse inflammatory lung injury and severe hypoxemia. In 2017, the Montreux Consensus defined diagnostic criteria for ARDS in the neonatal period. The management of ARDS includes strict adherence to lung-protective ventilation strategies and therapeutic agents to improve gas exchange. We report two similar cases of premature infants with gestational ages of 23 and 24 weeks diagnosed with neonatal ARDS according to the Montreux definition. These patients developed acute worsening of oxygenation on the 30th and 28th day of life, respectively, while they were ventilated on volume-guarantee assist/control mode. Chest X-rays revealed bilateral diffuse opacity, there were no cardiogenic origins for pulmonary edema, and their oxygenation indexes were >8. Both cases fulfilled the neonatal ARDS criteria and the patients' clinical conditions were associated with late onset neonatal sepsis. After lung recruitment maneuver, the infants began HFO volume-guarantee ventilation and received surfactant treatment. Since they showed a poor short-term response, intratracheal surfactant of 100 mg/kg plus budesonide of 0.25 mg/kg were administered and their oxygenation indexes were reduced stepwise. Both patients survived and were discharged home with spontaneous breathing of room air. Neonatal ARDS is generally an underdiagnosed condition associated with sepsis, pneumonia, and meconium aspiration. Impaired surfactant activity and reduced lung compliance play important roles in its pathophysiology. To our knowledge, this is the first case report indicating the possible therapeutic role of budesonide plus surfactant in ARDS treatment. Since ARDS is an entity not recognized in newborns, we want to emphasize neonatal ARDS diagnosis and underline that the combination of budesonide and surfactant may be a novel therapeutic option in the treatment of ARDS.
Copyright © 2020 Deliloglu, Tuzun, Cengiz, Ozkan and Duman.
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