The in-hospital outcomes of the use of microaxial left ventricular assist device vs intra-aortic ballon pump in acute myocardial infarction complicated by cardiogenic shock

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
C Jin ◽  
Y Yang ◽  
B Liu
Keyword(s):  
Cardiac Arrest ◽  
Blood Transfusion ◽  
Length Of Stay ◽  
Propensity Score ◽  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Left Ventricular ◽  
Bleeding Complications ◽  
Categorical Variables ◽  
Cardiac Complications

Abstract Purpose To compare the outcomes of patients with AMI underwent percutaneous coronary intervention (PCI) complicated by cardiogenic shock treated with IABP vs MLVAD. Methods The Nationwide Inpatient Sample (NIS) database is the largest inpatient registry in the U.S. We used NIS year 2009–2014 to identify adult patients admitted for AMI, who received PCI and complicated by cardiogenic shock. Based on the use of IABP or MLVAD, the study population was divided into 2 groups. To reduce selection bias, we performed propensity score matching using Kernell method. Patient characteristics, hospital characteristics, and comorbidities were matched. Logistic regression was used for categorical variables including in-hospital mortality, requirement of blood transfusion, sepsis, cardiac arrest and cardiac complications (including iatrogenic complications, hemopericardium, and cardiac tamponade). Poisson regression was used for continuous variables including length of stay and total cost. Results A total of 49837 patients were identified. With propensity score match, 34132 patients in IABP group were matched to 1430 patients in MLVAD group. Compared with MLVAD group, the IABP group had lower in-hospital mortality rates (28.29% vs 40.36%, OR 0.58 (0.42–0.81), p=0.002), lower rate of blood transfusion (9.63% vs 11.50%, OR 0.49 (0.27–0.88), p=0.017), and lower cost (47167 vs 70429 USD, p<0.001). IABP and MLVAD group had similar length of stay (8.9 versus 9.3 days, p=0.882), rates of cardiac complication (6.50% vs 7.24%, OR 0.56 (0.26–1.19), p=0.134), rates of sepsis (9.30% vs 14.98%, OR 0.66 (0.38–1.14), p=0.133), and rates of cardiac arrest (37.84% vs 41.05%, OR 0.70 (0.45–1.10), p=0.123). Conclusion In patients with AMI underwent PCI and complicated by cardiogenic shock, MLAVD compared with IABP was associated with higher risk of in-hospital mortality, requirement of blood transfusion indicating presence of major bleeding complications, and cost, although study interpretation is limited by retrospective observational design. Further research is warranted to elucidate the optimal MCSD in these patients. Funding Acknowledgement Type of funding source: None

scholarly journals Impact of temporary mechanical circulatory support on mortality in cardiogenic shock: an emulated target trial with a prospective, multicenter, French cohort study

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
A Ughetto ◽  
J Eliet ◽  
N Nagot ◽  
H David ◽  
F Bazalgette ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Propensity Score ◽  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Circulatory Support ◽  
Control Group ◽  
Heart Team ◽  
Hospital Survival ◽  
Expert Center

Abstract Background The field of temporary mechanical circulatory support (TMCS) has advanced in last decade justifying that TMCS is increasingly used for treatment of refractory cardiogenic shock (CS). Nevertheless, the efficacy of TMCS (extracorporeal life support (ECLS) and Impella) in CS remains controversial due to the lack of high-quality evidence. The aim of this prospective multicenter observational study simulating a randomized trial was to assess the impact of TMCS on the hospital mortality in patients with CS. Methods This study (ClinicalTrials.gov ID: NCT03528291) was conducted at 3 TMCS centers organized in a cardiac assistance network, one as a level 1 TMCS center (expert center), and 2 as level 2 centers (hub centers). The study was designed and led by the heart team of the expert center with input from the hub centers. All patients admitted to an intensive care unit between July 2017 and May 2020 either directly at the TMCS centers or after transfer from a non-specialized hospital, were screened for TMCS indication provided they were admitted for CS. CS was defined according to the European Society of Cardiology criteria. Were excluded patients younger than 18 years, CS after cardiac surgery, or after cardiac arrest if it was refractory or with a no flow >3 min and/or out-of-hospital cardiac arrest with non-shockable rhythm, or CS in the context of myocardial infarction complications, massive pulmonary embolism, and if TMCS was contraindicated TMCS indication was decided after a multidisciplinary discussion carried out by the “heart team”. Implantation of TMCS resulted from an agreement of the heart team within the first 24 hours after admission mainly based on the initial severity of the CS, or if CS was refractory to the medical treatment. The primary outcome was in-hospital survival. A propensity score-weighted analysis was done for treatment-effect estimation. This method, which weights each patient according to their propensity score, includes all participants in the analysis. Results 246 patients with CS were included in the study: 121 in TMCS group (72% ECLS, 14% Impella, 14% both ECLS and Impella) and 125 in control group. After adjustment by a propensity score, hospital mortality was comparable in the two groups (32% TMCS group vs 27% control group; Odds ratio with TMCS, 1.28; 95% confidence interval, 0.87 to 1.88; p=0.21). Mortality at D180 was also similar in the two group (33% vs 30% respectively; p=0.51). Thromboembolic events were significantly higher in the TCMS group (14% vs 4%; p<0.01) as well as the transfusion rate ((median (IQR); 4.0 (0.0; 9.0) vs 0.0 (0.0; 0.0); p<0.01). Conclusion In our study, the use of TMCS does not seem to improve hospital survival in patients with cardiogenic shock. Thus, TMCS, which are iatrogenic side effects providers, should be reserved for the most severe patient and discussed by a multidisciplinary team. FUNDunding Acknowledgement Type of funding sources: None. Flow chart

scholarly journals Unloading in Refractory Cardiogenic Shock After Out-Of-Hospital Cardiac Arrest Due to Acute Myocardial Infarction—A Propensity Score-Matched Analysis

2021 ◽  
Vol 8 ◽  
Author(s):  
Jan-Thorben Sieweke ◽  
Muharrem Akin ◽  
Julian-Arman Beheshty ◽  
Ulrike Flierl ◽  
Johann Bauersachs ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiac Arrest ◽  
Propensity Score ◽  
Cardiogenic Shock ◽  
Neurological Outcome ◽  
Left Ventricular ◽  
Successful Resuscitation ◽  
Refractory Cardiogenic Shock ◽  
Hospital Cardiac Arrest

Aims: Unclear neurological outcome often precludes severely compromised patients after out-of-hospital cardiac arrest (OHCA) from mechanical circulatory support (MCS), while it may be considered as rescue therapy for patients with refractory cardiogenic shock (rCS) in the absence of OHCA. This analysis sought to investigate the role of left ventricular (LV) unloading in patients with rCS related to acute myocardial infarction (AMI) after OHCA.Methods: Of 273 consecutive patients receiving microaxial pumps in the Hannover Cardiac Unloading Registry between January 2013 and August 2018, 47 presented with AMI–rCS following successful resuscitation. Subsequently, the patients were compared by propensity score matching to patients with OHCA AMI–rCS without MCS. The patient data for OHCA without LV unloading was available from 280 patients of the Hannover Cooling Registry for the same time period. Furthermore, the patients with OHCA without rCS were compared to the patients with OHCA AMI–rCS and LV unloading.Results: In total, 15 OHCA AMI–rCS patients without MCS were matched to patients with AMI–rCS and Impella. Patients without LV support had a higher proportion of a cardiac cause of death (n = 7 vs. n = 3; p = 0.024). LV unloading with Impella counteract rCS status and was associated with a preferable 30-day survival (66.7 vs. 20%, p = 0.01) and a favorable neurological outcome after 30 days (Cerebral Performance Category ≤2, 47 vs. 27%). Impella support is associated with a higher 30-day survival (odds ratio, 2.67; 95% confidence interval, 1.02–13.66).Conclusion: In patients after OHCA with AMI–rCS, Impella support incorporated in a strict standardized treatment algorithm results in a preferable 30-day survival and counteracts severe rCS status.

Cardiovascular outcomes of concurrent TAVR and PCI compared to TAVR alone using the U.S. national inpatient sample: 2011–2014

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Byer ◽  
D Celli ◽  
B Zarrabian ◽  
R Colombo
Keyword(s):  
Cardiac Arrest ◽  
Ischemic Stroke ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Hospital Admission ◽  
Clinical Decision Making ◽  
The United States ◽  
Cardiovascular Outcomes ◽  
National Inpatient Sample

Abstract Introduction The high concurrent prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) inevitably forces experts to face a pressing decision whether to revascularize and replace the aortic valve at the same time. While current recommendations support combined transaortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) for treatment of ostial/proximal lesions, or in unstable patients, less clear indications exist for patients not fulfilling this pattern. The population undergoing concomitant TAVR and PCI can be clinically challenging and thus it is important to further characterize prognosis and major cardiovascular outcomes in this cohort. Purpose To assess the likelihood of major cardiovascular events in patients undergoing TAVR with PCI during the same hospital admission compared to those with TAVR only. As well as to have a better understanding of the risks and possible benefits of a combined procedure and thus aid in clinical decision-making. Methods This study used the National Inpatient Sample (NIS) of patients undergoing a TAVR from 2011 to 2014. The NIS is a stratified systematic random sample of 20% hospital admissions in the United States. Internal Classification of Diseases Ninth Revision-Clinical Modification procedure codes were used to identify all patients that underwent a PCI and/or TAVR during the same admission. Patients aged greater than 50 years were included. Outcomes of interest included all-cause in-hospital mortality, new TIA/ischemic stroke, cardiogenic shock, cardiac arrest, hemopericardium, and length of stay. Multivariate logistic regression was used to adjust for patient and procedural confounders. Results Among the 33,652 patients who underwent TAVR between 2011 and 2014, 1,179 underwent a PCI during the same hospital admission. The adjusted odds of all-cause in-hospital mortality was 3.05 (95% CI 1.95–4.75) in those with a TAVR+PCI compared to TAVR only. The adjusted odds of cardiac arrest and cardiogenic shock was 2.50 (95% CI: 1.48–4.22) and 4.85 (95% CI 3.05–7.7), respectively. Furthermore, the odds of a new TIA/ischemic stroke during the same admission was 0.86 (95% CI 0.35–2.07) and odds of hemopericardium was 3.13 (95% CI: 0.71–13.70). Conclusion Concomitant PCI and TAVR during the same hospitalization was associated with higher all-cause in-hospital mortality, increased length of stay, cardiogenic shock, and cardiac arrest but does not appear to increase the likelihood of stroke/TIA. While this suggest worse outcomes in the cohort undergoing both procedures, the initial indications for these patients to receive a PCI might predispose them to these outcomes. Funding Acknowledgement Type of funding source: None

scholarly journals Cardiac arrest complicating cardiogenic shock: from pathophysiological insights to Impella-assisted cardiopulmonary resuscitation in a pheochromocytoma-induced Takotsubo cardiomyopathy—a case report

2021 ◽  
Vol 5 (3) ◽  
Author(s):  
Filippo Zilio ◽  
Simone Muraglia ◽  
Roberto Bonmassari
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Left Ventricle ◽  
Cardiogenic Shock ◽  
Takotsubo Cardiomyopathy ◽  
Perfusion Pressure ◽  
Coronary Perfusion Pressure ◽  
Left Ventricular ◽  
Coronary Perfusion ◽  
Refractory Cardiac Arrest

Abstract Background A ‘catecholamine storm’ in a case of pheochromocytoma can lead to a transient left ventricular dysfunction similar to Takotsubo cardiomyopathy. A cardiogenic shock can thus develop, with high left ventricular end-diastolic pressure and a reduction in coronary perfusion pressure. This scenario can ultimately lead to a cardiac arrest, in which unloading the left ventricle with a peripheral left ventricular assist device (Impella®) could help in achieving the return of spontaneous circulation (ROSC). Case summary A patient affected by Takotsubo cardiomyopathy caused by a pheochromocytoma presented with cardiogenic shock that finally evolved into refractory cardiac arrest. Cardiopulmonary resuscitation was performed but ROSC was achieved only after Impella® placement. Discussion In the clinical scenario of Takotsubo cardiomyopathy due to pheochromocytoma, when cardiogenic shock develops treatment is difficult because exogenous catecholamines, required to maintain organ perfusion, could exacerbate hypertension and deteriorate the cardiomyopathy. Moreover, as the coronary perfusion pressure is critically reduced, refractory cardiac arrest could develop. Although veno-arterial extra-corporeal membrane oxygenation (va-ECMO) has been advocated as the treatment of choice for in-hospital refractory cardiac arrest, in the presence of left ventricular overload a device like Impella®, which carries fewer complications as compared to ECMO, could be effective in obtaining the ROSC by unloading the left ventricle.

Abstract 12686: In-hospital Outcomes of Left Ventricular Assist Device Implantation and Concomitant Valvular Surgery

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Yujiro Yokoyama ◽  
Toshiki Kuno ◽  
Hiroki Ueyama ◽  
Suchith Shetty ◽  
Aaqib Malik ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Hospital Mortality ◽  
Left Ventricular Assist Device ◽  
Left Ventricular ◽  
Combined Surgery ◽  
Assist Device ◽  
Hospital Outcomes ◽  
Ventricular Assist ◽  
Valvular Surgery ◽  
Left Ventricular Assist

Background: Valvular heart disease is common among Left Ventricular Assist Device (LVAD) recipients. However, its management at the time of LVAD implantation remains controversial. We sought to investigate and compare in-hospital outcomes of concomitant valvular surgery at the time of LVAD implantation. Methods: Patients who underwent LVAD implantation and concomitant aortic (AVR), mitral (MVR) or tricuspid valve (TVR) repair or replacement between 2010 and 2017 were identified using the national inpatient sample (NIS) in the US. Endpoints were in-hospital outcomes, length of stay and cost. Procedure-related complications were identified via ICD-9 and ICD-10 coding and analysis was performed via mixed effect models. Results: A total of 25,171 weighted adults underwent LVAD implantation without valvular surgery, 1,329 had isolated TVR, 1,021 AVR, 377 MVR and 615 had combined valvular surgery (411 had TVR+AVR, 115 TVR+MVR, 62 AVR+MVR, 25 AVR+MVR+TVR). During the study period, rates of AVR decreased and combined valvular surgeries increased. Patients who underwent TVR had overall higher burden of comorbidities than LVAD recipients with or without other valvular procedures. Post-operative bleeding was more frequent among those who underwent AVR whereas acute kidney injury requiring dialysis was higher among those who underwent TVR or combined valvular surgery. In-hospital mortality was higher among those who underwent AVR, MVR or combined surgery without differences in the rates of stroke among groups (Table 1). Length of stay did not differ significantly among groups but cost of hospitalization and non-routine discharge rates were higher for cases of TVR and combined surgery. Conclusion: Approximately one in nine LVAD recipients underwent concomitant valvular surgery and TVR was the most frequently performed procedure. In-hospital mortality and cost were lower among those who did not undergo valvular surgery.

Perianal disease remains an understudied and difficult complication in leukemia patients.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e19016-e19016
Author(s):  
Shreya Gupta ◽  
Nirav Patil ◽  
Emily Steinhagen-Golbig ◽  
Benjamin Kent Tomlinson ◽  
Sharon Stein ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Hospital Mortality ◽  
Hospital Cost ◽  
Hospital Costs ◽  
Perianal Abscess ◽  
Lymphocytic Leukemia ◽  
Operative Intervention ◽  
Perianal Disease ◽  
Categorical Variables ◽  
Continuous Variables

e19016 Background: Perianal infection is a rare and poorly understood complication of patients with acute myeloid/lymphocytic leukemia (AML/ALL). With the advancements in oncology, patients are living longer in an immunocompromised state and thus bearing the inherent problems such as infections that arise with it. Perianal infection and its management impacts patients' quality of life as well as interrupts their ongoing oncologic treatment. The optimal treatment strategy for perianal infections in this highly immunocompromised group remains unclear, as does the selection and outcomes of patients for operative intervention. The aim of this study is to identify patient characteristics associated with perianal infection and to delineate outcomes in patients that undergo operative intervention. Methods: The National Inpatient Sample (NIS) database was used to identify hospitalized patients with diagnoses of perianal abscess and AML/ALL between 2007 and 2015. Patient data were weighted to obtain national estimates. Demographics and clinical characteristics were compared between patients with and without perianal disease using Rao-Scott Chi-square test for categorical variables, and weighted simple linear regression for continuous variables. Characteristics and outcomes were compared between patients who underwent operative or non-operative management. Results: There were 12,626 (0.7%) patients with perianal disease among 1,782,778 AML/ALL patient admissions. Patients with perianal disease were more likely to be younger (43.9 (42.5 – 45.3) years, p < 0.001), male (67.4% vs 32.6%, p < 0.001) and white (65.8% vs 54.8%, p < 0.001). Length of stay (18.4 days vs 9 days, p < 0.001) and hospital cost ($54K vs $25K, p < 0.001) were higher in those with perianal disease, but there was no difference in in-hospital mortality (5.5% in those with perianal diseases vs 6.2% in those without, p = 0.150). Greater proportion of patients without perianal disease were discharged to hospice (12.6% patients without perianal disease vs 5.1% patients with perianal disease, p < 0.001). Receiving a surgical intervention did not improve outcomes with respect to in-hospital mortality (5.9% operative vs 5.4 non-operative, p = 0.596), length of stay (20.2 days vs 18.2 days, p = 0.582) or hospital cost ($67K vs $53K, p = 0.525). Conclusions: Perianal disease is a rare but distressing complication in AML/ALL patients associated with longer hospital stays and higher hospital costs. Operative intervention for perianal disease did not reduce rates of in-hospital mortality, length of stay or hospital cost but it does impact the probability of discharge to hospice. Non-operative and operative intervention both remain equivocal in changing the outcomes these patients. Further studies are required to examine these associations and determine best practices for treatment of this condition in this complex patient population.

Abstract 18294: Left Ventricular Systolic Dysfunction Early After Resuscitation From Cardiac Arrest is Associated With Shockable Arrest Rhythm

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Jacob C Jentzer ◽  
Hussein Abu-Daya ◽  
Asher Shafton ◽  
Meshe Chonde ◽  
Didier Chalhoub ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Hospital Mortality ◽  
Troponin I ◽  
Left Ventricular Systolic Dysfunction ◽  
Systolic Dysfunction ◽  
Mitral Annulus ◽  
Left Ventricular ◽  
Ventricular Systolic Dysfunction ◽  
Mitral Annulus Velocity ◽  
Fractional Shortening

Introduction: Left ventricular systolic dysfunction (LVSD) is common after resuscitation from cardiac arrest (CA). The association of echocardiographic LVSD with cardiac rhythm during CA is not well described. Hypothesis: Patients with a shockable rhythm (VT/VF) will have a greater degree of LVSD by echocardiography after CA. Methods: Prospective registry of patients resuscitated from CA underwent transthoracic echocardiography (TTE) within 24 hours after CA. We determined 2D measurements, LVEF, spectral Doppler of mitral inflow and LV outflow, systolic and diastolic tissue Doppler of the mitral annulus velocity, and tricuspid plane annular excursion (TAPSE). We collected data on in-hospital mortality as well as vasopressor doses and troponin I levels. TTE parameters and clinical characteristics were compared between patients with a shockable (VT/VF) arrest rhythm and a non-shockable (asystole/PEA) arrest rhythm and between survivors and non-survivors using t-tests and ANOVA. Results: Of the 55 patients, the 23 (42%) with shockable CA rhythms had significantly higher LV end-systolic dimension (4.1cm vs. 3.3cm, p = 0.0073), lower LV fractional shortening (0.15 vs. 0.28, p <0.0001), and lower LVEF both by visual estimate (36.2% vs. 52.3%, p = 0.0012) and by Simpson’s biplane method (37.5% vs. 52.3%, p = 0.0506). Other measured TTE parameters did not differ between groups, including TAPSE (shockable 1.53 vs. non-shockable 1.82, p = 0.1731). Admission and peak 24 hour vasopressor requirements did not differ between groups. Peak troponin levels were higher (22.26 vs. 3.88, p = 0.0198) in patients with shockable CA rhythms, but admission troponin levels were no different (0.88 vs. 0.51, p = 0.1527). TTE parameters did not differ between survivors and non-survivors (visual LVEF 47.0% vs. 44.2%, p = 0.5968; LV fractional shortening 0.19 vs. 0.25, p = 0.0916). Conclusions: Patients with shockable CA rhythms have more severe LVSD on 24 hour echocardiography despite similar vasopressor requirements and admission troponin levels. Echocardiographic parameters at 24 hours did not predict in-hospital mortality. Early echocardiography after CA appears more useful for differentiating primary CA rhythm than for predicting mortality.

Abstract 289: Hospital Volume of LVAD Procedures Determines Patient Outcome

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Katherine Feldman ◽  
Rami Doukky ◽  
Tricia Johnson ◽  
David Levine ◽  
Sam Hohmann
Keyword(s):  
Heart Failure ◽  
Hospital Mortality ◽  
The United States ◽  
Left Ventricular ◽  
Policy Implications ◽  
Ventricular Assist Devices ◽  
Categorical Variables ◽  
Procedure Volume ◽  
End Stage Heart Failure ◽  
End Stage

Background: Left ventricular assist devices (LVADs) provide mechanical circulatory support to patients with end-stage heart failure. The use of these devices in the United States has been increasing since the FDA approved the first device in 1994. There are no published studies that have evaluated the relationship between LVAD procedural volume and hospital mortality, despite large variation across hospitals in the volume of LVAD procedures performed. This study sought to explore whether a correlation exists between hospital and surgeon’s procedural volumes and patient outcomes, and also to identify a critical threshold. Methods: We conducted a retrospective cross-sectional analysis of all patient discharges from UHC member hospitals from January 2008 through June 2012 after an insertion of an LVAD during their hospitalization. Patients were identified from UHC’s Clinical Database/Resource Manager (CDB/RM) on the basis of the principal or secondary International Classification of Diseases Ninth Revision, Clinical Modification ( ICD-9-CM) procedure code 37.66. The primary outcome was all cause mortality. Results: There were 87 hospitals that admitted at least 1 patient for an LVAD procedure during the study period (77.5 percent males, mean age 54.3). The mean length of stay was 42.1 days and a mean total cost of $299,067. We identified variation of in-hospital mortality by hospital LVAD procedure volume quartile. Quartile 1 included hospitals performing 1-9 procedures (38.8% mortality), quartile 2 performed 10-46 procedures (18.1% mortality), quartile 3 performed 55-97 procedures (12.8% mortality), and the fourth quartile performed 107-319 procedures (16.1% mortality) during the study period. Categorical variables were compared with the Chi-Square Test, and continuous variables were compared with t-tests. There was significant variation in the mortality for almost all study variables including age, gender, admission severity of illness, and admission risk of mortality, and the variation persisted by volume quartile. Conclusion: Initial results suggest that there is a correlation between hospital LVAD procedure volume and in-hospital mortality. LVADs are becoming an increasingly common treatment method for patients with end-stage heart failure and are either awaiting transplant or will receive the device as the final method of therapy. Identifying critical volume thresholds could improve outcomes and ultimately improve the efficiency and value of care. Implications: Identifying mortality associated with LVAD procedures at these hospitals will provide patients and physicians with more information when seeking treatment options for heart failure. This study may also have health policy implications for cardiac treatment by implementing guidelines that LVAD hospital and surgeon programs must adhere to.

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