Lucia S.D. Jewbali

Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials

AIMS Studies have compared safety and efficacy of percutaneous left ventricular assist devices (LVADs) with intra-aortic balloon pump (IABP) counterpulsation in patients with cardiogenic shock. We performed a meta-analysis of controlled trials to evaluate potential benefits of percutaneous LVAD on haemodynamics and 30-day survival. METHODS AND RESULTS Two independent investigators searched Medline, Embase, and Cochrane Central Register of Controlled Trials for all controlled trials using percutaneous LVAD in patients with cardiogenic shock, where after data were extracted using standardized forms. Weighted mean differences (MDs) were calculated for cardiac index (CI), mean arterial pressure (MAP), and pulmonary capillary wedge pressure (PCWP). Relative risks (RRs) were calculated for 30-day mortality, leg ischaemia, bleeding, and sepsis. In main analysis, trials were combined using inverse-variance random effects approach. Two trials evaluated the TandemHeart and a recent trial used the Impella device. After device implantation, percutaneous LVAD patients had higher CI (MD 0.35 L/min/m(2), 95% CI 0.09-0.61), higher MAP (MD 12.8 mmHg, 95% CI 3.6-22.0), and lower PCWP (MD -5.3 mm Hg, 95% CI -9.4 to -1.2) compared with IABP patients. Similar 30-day mortality (RR 1.06, 95% CI 0.68-1.66) was observed using percutaneous LVAD compared with IABP. No significant difference was observed in incidence of leg ischaemia (RR 2.59, 95% CI 0.75-8.97) in percutaneous LVAD patients compared with IABP patients. Bleeding (RR 2.35, 95% CI 1.40-3.93) was significantly more observed in TandemHeart patients compared with patients treated with IABP. CONCLUSION Although percutaneous LVAD provides superior haemodynamic support in patients with cardiogenic shock compared with IABP, the use of these more powerful devices did not improve early survival. These results do not yet support percutaneous LVAD as first-choice approach in the mechanical management of cardiogenic shock.

Impaired microcirculation predicts poor outcome of patients with acute myocardial infarction complicated by cardiogenic shock

AIMS we investigated the relationship between sublingual perfused capillary density (PCD) as a measure of tissue perfusion and outcome (i.e. occurrence of organ failure and mortality) in patients with cardiogenic shock from acute myocardial infarction. METHODS AND RESULTS we performed a prospective study in 68 patients. Using Sidestream Dark Field imaging, PCD was measured after hospital admission (T0, baseline) and 24 h later (T1). We compared patients with baseline PCD ≤ median to patients with baseline PCD > median. Sequential organ failure assessment (SOFA) scores were calculated at both time points. The Kaplan-Meier 30-day survival analyses were performed and predictors of 30-day mortality were identified. The baseline PCD was a predictor of the change in the SOFA score between T0 and T1 (ΔSOFA; ρ = -0.25, P = 0.04). Organ failure recovered more frequently in patients with PCD > median (>10.3 mm mm(-2); n = 33) than in patients with PCD ≤ median (n = 35; 52 vs. 29%, P < 0.05). Twenty-two patients (32%) died: 17 patients (49%) with PCD ≤ median vs. 5 patients (15%) with PCD > median (P = 0.004). After adjustment, the cardiac power index [odds ratio (OR): 0.48, 95% CI: 0.24-0.94) and PCD (OR: 0.65, 95% CI: 0.45-0.92) remained significant predictors of 30-day outcome. Patients with baseline sublingual PCD ≤ median that improved at T1 had a considerable better prognosis relative to patients who had a persistently low PCD. CONCLUSION diminished sublingual PCD, at baseline or following treatment, is associated with development of multi-organ failure and is a predictor of poor outcome in patients with acute myocardial infarction complicated by cardiogenic shock.

Low-dose nitroglycerin improves microcirculation in hospitalized patients with acute heart failure

Impaired tissue perfusion is often observed in patients with acute heart failure. We tested whether low‐dose nitroglycerin (NTG) improves microcirculatory perfusion in patients admitted for acute heart failure.

The Effects of Intra-Aortic Balloon Pump Support on Macrocirculation and Tissue Microcirculation in Patients with Cardiogenic Shock

Objectives: It was the aim of this study to evaluate the effects of intra-aortic balloon pump (IABP) counterpulsation on sublingual microcirculation as a model for tissue perfusion. Methods: In 13 patients with cardiogenic shock treated with IABP, the IABP assist ratio was reduced from 1:1 to 1:8 for 15 min. Using sidestream dark field imaging, 117 movie files of the sublingual microcirculation were obtained and quantified at different IABP assist ratios at 3 time points: 1:1 (T0), 1:8 (T1) and 1:1 (T2), respectively. Data are presented as the median and interquartile range. Results: The median age of the patients was 59 years (range 56–73), and 62% were males. Discontinuation of IABP decreased the mean arterial pressure [75 mm Hg (71–84) at T0 vs. 69 mm Hg (64–79) at T1; p < 0.001], cardiac index [2.9 l/min/m2 (1.6–3.3) at T0 vs. 2.4 l/min/m2 (1.5–2.8) at T1; p = 0.005] and cardiac power index [0.46 W/m2 (0.29–0.59) at T0 vs. 0.36 W/m2 (0.24–0.50) at T1; p = 0.006]. However, these modest changes in macrohemodynamics did not significantly influence sublingual perfused capillary density and capillary red blood cell velocity (p = 0.28 and 0.73, respectively). Conclusion: A temporary, modest decrease in microcirculatory driving force, induced by lowering the IABP assist ratio, does not impair sublingual microcirculatory perfusion as measured by a novel 2-dimensional imaging technique.

Mechanical circulatory support devices improve tissue perfusion in patients with end-stage heart failure or cardiogenic shock.

OBJECTIVES This study evaluated the effects of mechanical circulatory support (MCS) on sub-lingual microcirculation as a surrogate for splanchnic microvascular perfusion. METHODS Between May 2008 and April 2009, 10 consecutive patients received an MCS device or extracorporeal membrane oxygenation for end-stage chronic heart failure (n = 6) or cardiogenic shock (n = 4). Microcirculation was investigated using a hand-held Sidestream Dark Field imaging device. Perfused capillary density (PCD) and capillary red blood cell velocity (cRBCv) were assessed before device implantation (T0), immediately after implantation (T1), and 1 day after implantation (T2). RESULTS Median patient age was 45 years (interquartile range [IQR] 38-52 years) and 70% were men. MCS significantly decreased pulmonary capillary wedge pressure (p = 0.04). Median cardiac power index increased (0.29 [IQR, 0.21-0.34] W/m(2) at T0 vs 0.48 [IQR, 0.39-0.54] W/m(2) at T1, p = 0.005) as well as median central venous oxygen saturation (54% [IQR, 46%-61%] at T0 vs 78% [IQR, 67%-85%] at T1, p = 0.007). There was a 3-fold increase in tissue perfusion index (sub-lingual PCD x cRBCv) during mechanical circulatory support (573 [IQR, 407-693] at T0 vs 1909 [IQR, 1771-2835] at T1, p = 0.005). Microcirculatory parameters remained improved at T2. CONCLUSION Mechanical circulatory support for severe heart failure is associated with a consistent, significant, and sustained improvement in tissue perfusion, as measured at the bedside by a 2-dimensional microcirculation imaging technique.

Conventional hemodynamic resuscitation may fail to optimize tissue perfusion: An observational study on the effects of dobutamine, enoximone, and norepinephrine in patients with acute myocardial infarction complicated by cardiogenic shock

Aim To investigate the effects of inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock. Methods and Results Thirty patients with cardiogenic shock were included. Patients received dobutamine, enoximone, or norepinephrine. We performed hemodynamic measurements at baseline and after titration of the inotropic agent until cardiac index (CI) ≥2.5 L.min−1.m−2 or mixed-venous oxygen saturation (SvO2) ≥70% (dobutamine or enoximone), and mean arterial pressure (MAP) ≥70 mmHg (norepinephrine). As parameters of tissue perfusion, we measured central-peripheral temperature gradient (delta-T) and sublingual perfused capillary density (PCD). All patients reached predefined therapeutic targets. The inotropes did not significantly change delta-T. Dobutamine did not change PCD. Enoximone increased PCD (9.1 [8.9–10.2] vs. 11.4 [8.4–13.9] mm.mm−2; p<0.05), and norepinephrine tended to decrease PCD (9.8 [8.5–11.9] vs. 8.8 [8.2–9.6] mm.mm−2, p = 0.08). Fifteen patients (50%) died within 30 days after admission. Patients who had low final PCD (≤10.3 mm.mm−2; 64%) were more likely to die than patients who had preserved PCD (>10.3 mm.mm−2; mortality 72% vs. 17%, p = 0.003). Conclusion This study demonstrates the effects of commonly used inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock. Despite hemodynamic optimization, tissue perfusion was not sufficiently restored in most patients. In these patients, mortality was high. Interventions directed at improving microcirculation may eventually help bridging the gap between improved hemodynamics and dismal patient outcome in cardiogenic shock.

Short-term mechanical circulatory support as a bridge to durable left ventricular assist device implantation in refractory cardiogenic shock: a systematic review and meta-analysis.

Short-term mechanical circulatory support (MCS) is increasingly used as a bridge to decision in patients with refractory cardiogenic shock. Subsequently, these patients might be bridged to durable MCS either as a bridge to candidacy/transplantation, or as destination therapy. The aim of this study was to review support duration and clinical outcome of short-term MCS in cardiogenic shock, and to analyse application of this technology as a bridge to long-term cardiac support (left ventricular assist device, LVAD) from 2006 till June 2016. Using Cochrane Register of Trials, Embase and Medline, a systematic review was performed on patients with cardiogenic shock from acute myocardial infarction, end-stage cardiomyopathy, or acute myocarditis, receiving short-term MCS. Studies on periprocedural, post-cardiotomy and cardiopulmonary resuscitation support were excluded. Thirty-nine studies, mainly registries of heterogeneous patient populations (n = 4151 patients), were identified. Depending on the device used (intra-aortic balloon pump, TandemHeart, Impella 2.5, Impella 5.0, CentriMag and peripheral veno-arterial extracorporeal membrane oxygenation), mean support duration was (range) 1.6-25 days and the mean proportion of short-term MCS patients discharged was (range) 45-66%. The mean proportion of bridge to durable LVAD was (range) 3-30%. Bridge to durable LVAD was most frequently performed in patients with end-stage cardiomyopathy (22 [12-35]%). We conclude that temporary MCS can be used to bridge patients with cardiogenic shock towards durable LVAD. Clinicians are encouraged to share their results in a large multicentre registry in order to investigate optimal device selection and best duration of support.

Preventing LVAD implantation by early short-term mechanical support and prolonged inodilator therapy: A case series with acute refractory cardiogenic shock treated with veno-arterial extracorporeal membrane oxygenation and optimised medical strategy

Cardiogenic shock continues to be a life-threatening condition carrying a high mortality and morbidity, where the prognosis remains poor despite intensive modern treatment modalities. In recent years, mainly technical improvements have led to a more widespread use of short- and long-term mechanical circulatory support, such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and left ventricular assist devices (LVADs). Currently, LVADs are indispensable as ‘bridge’ to cardiac recovery, heart transplantation (HTX), and/or as destination therapy Importantly, both LVADs and HTX put a vast burden on financial resources, besides significant short- and long-term risks of morbidity and mortality. These considerations underscore the importance of optimal timing and appropriate patient selection for LVAD therapy, avoiding as much as possible an unfortunate and costly clinical path. In this report, we present a series of three cases with acute refractory cardiogenic shock (‘crash and burn’, INTERMACS profile 1) successfully treated by ECMO and early optimal medical therapy preventing a certain path towards LVAD and/or HTX, for which they were initially referred. This conservative approach in INTERMACS profile one patients warrants very early introduction of adequate medical heart failure therapy under the umbrella of a combination of short-term mechanical circulatory and inotropic support by phosphodiesterase inhibitors. Therefore, this novel combined medical-mechanical approach could have important clinical implications for this extremely challenging patient category, as it may avoid an unnecessary and costly clinical path towards LVAD and/or heart transplantation.

Coronary angiography after cardiac arrest: Rationale and design of the COACT trial

BACKGROUND Ischemic heart disease is a major cause of out-of-hospital cardiac arrest. The role of immediate coronary angiography (CAG) and percutaneous coronary intervention (PCI) after restoration of spontaneous circulation following cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) remains debated. HYPOTHESIS We hypothesize that immediate CAG and PCI, if indicated, will improve 90-day survival in post-cardiac arrest patients without signs of STEMI. DESIGN In a prospective, multicenter, randomized controlled clinical trial, 552 post-cardiac arrest patients with restoration of spontaneous circulation and without signs of STEMI will be randomized in a 1:1 fashion to immediate CAG and PCI (within 2 hours) versus initial deferral with CAG and PCI after neurological recovery. The primary end point of the study is 90-day survival. The secondary end points will include 90-day survival with good cerebral performance or minor/moderate disability, myocardial injury, duration of inotropic support, occurrence of acute kidney injury, need for renal replacement therapy, time to targeted temperature control, neurological status at intensive care unit discharge, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, and reasons for discontinuation of treatment. SUMMARY The COACT trial is a multicenter, randomized, controlled clinical study that will evaluate the effect of an immediate invasive coronary strategy in post-cardiac arrest patients without STEMI on 90-day survival.

A simple risk chart for initial risk assessment of 30-day mortality in patients with cardiogenic shock from ST-elevation myocardial infarction

Aims: Early risk stratification is important in patients with cardiogenic shock from ST-elevation myocardial infarction (STEMI). We aimed to develop a simple risk chart that includes clinical parameters that are readily available at time of hospital admission to assess risk of 30-day mortality. Methods and results: A series of 544 STEMI patients admitted to undergo primary percutaneous coronary intervention and presenting with cardiogenic shock were included between 2000 and 2012. Overall 30-day mortality was 38.4% and did not change over the years (p-trend=0.64). Baseline variables that were available at time of hospital admission were entered into a logistic regression model in a forward stepwise manner. Only age (odds ratio (OR) per year 1.05, 95% confidence interval (CI) 1.04–1.07, p<0.001), initial serum lactate level (OR per mmol/l 1.17, 95% CI 1.11–1.24, p<0.001) and initial creatinine level above the upper limit of normal (OR 2.89, 95% CI 1.90–4.37, p<0.001) remained independent predictors, and were subsequently used to develop a risk chart that stratifies risk of 30-day mortality into categories ranging from 0–20% to 80–100%. The calibration plot showed a close relationship between expected and observed mortality. The risk chart had a higher discriminative accuracy than the GRACE score (c-index 0.75 vs. 0.66, p=0.009). Adding variables that were obtained from coronary angiography and during clinical course did not significantly improve discriminative accuracy of risk chart (c-index 0.77, p=0.48). Conclusion: Mortality of patients with cardiogenic shock from STEMI undergoing primary percutaneous coronary intervention can be well predicted already at time of hospital admission by a risk chart that uses only three variables, namely, age, initial serum lactate and creatinine level.