P5738Multicenter analysis of left ventricular unloading on top of VA-ECMO for treatment of cardiogenic shock

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
B Schrage ◽  
S Dabboura ◽  
H Bezerra ◽  
J M Sinning ◽  
H Thiele ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiopulmonary Resuscitation ◽  
Cardiogenic Shock ◽  
Primary Endpoint ◽  
Left Ventricular ◽  
Predictors Of Outcome ◽  
Severe Cardiogenic Shock ◽  
All Cause Mortality ◽  
Va Ecmo

Abstract Background Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) is increasingly used for treatment of severe cardiogenic shock, although it causes an increase in left ventricular (LV) afterload and might therefore hamper myocardial recovery. Recently, the addition of catheter-based left ventricular assist device (cLVAD) on top of VA-ECMO has been used to unload the LV and to improve outcome measures. However, there is limited data on predictors of outcome in this high-risk population. Aim The aim of this study was to evaluate predictors of 30-day survival in a multicentre cohort of severe cardiogenic shock patients treated with cLVADon top of VA-ECMO. Material and methods We report on consecutive patients from six tertiary care centers being treated with cLVAD in addition to VA-ECMO for treatment of cardiogenic shock. The primary endpoint is 30-day all-cause mortality. To identify predictors of the primary endpoint, multivariate analysis using an “elastic net” variable selection algorithm was done after imputation of missing variables. Results A total of 220 patients treated with cLVAD on top of VA-ECMO were included in the analysis. Of these, 79.1% were male with a median age of 55.5 (25thpercentile 48.0, 75thpercentile 65.6) years. In 60.5% of the patients, acute myocardial infarction was the underlying cause of cardiogenic shock and in 44.6% VA-ECMO was used for refractory cardiac arrest (eCPR). In the multivariable analysis, the following baseline parameters were significantly associated with the primary endpoint: Age (odds ratio of 1.68 per standard deviation), duration of cardiopulmonary resuscitation (OR 2.08 per SD), lactate (OR 1.04 per SD) and time from onset of shock to VA-ECMO (OR 1.30 per SD). Conclusion and outlook In this large-scale multicentre analysis of severe cardiogenic shock patients treated with VA-ECMO plus additional cLVAD unloading, age, duration of cardiopulmonary resuscitation, lactate and time from onset of shock to VA-ECMO were significantly associated with 30-day all-cause mortality. To further investigate this topic, we will evaluate predictors of outcome in distinct patient populations such as acute myocardial infarction vs. acute heart failure and patients without vs. patients with prior cardiopulmonary association.

scholarly journals Impella versus IABP in acute myocardial infarction complicated by cardiogenic shock

Open Heart ◽  
2019 ◽  
Vol 6 (1) ◽  
pp. e000987 ◽  
Author(s):  
Brunilda Alushi ◽  
Andel Douedari ◽  
Georg Froehlig ◽  
Wulf Knie ◽  
Thomas H Wurster ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiogenic Shock ◽  
Primary Outcome ◽  
Left Ventricular ◽  
Cox Proportional Hazards ◽  
Left Ventricular Ejection ◽  
Bleeding Complications ◽  
Ventricular Ejection Fraction ◽  
All Cause Mortality

ObjectiveWe investigated the benefit of Impella, a modern percutaneous mechanical support (pMCS) device, versus former standard intra-aortic balloon pump (IABP) in acute myocardial infarction complicated by cardiogenic shock (AMICS).MethodsThis single-centre, retrospective study included patients with AMICS receiving pMCS with either Impella or IABP. Disease severity at baseline was assessed with the IABP-SHOCK II score. The primary outcome was all-cause mortality at 30 days. Secondary outcomes were parameters of shock severity at the early postimplantation phase. Adjusted Cox proportional hazards models identified independent predictors of the primary outcome.ResultsOf 116 included patients, 62 (53%) received Impella and 54 (47%) IABP. Despite similar baseline mortality risk (IABP-SHOCK II high-risk score of 18 % vs 20 %; p = 0.76), Impella significantly reduced the inotropic score (p < 0.001), lactate levels (p < 0.001) and SAPS II (p =0.02) and improved left ventricular ejection fraction (p = 0.01). All-cause mortality at 30 days was similar with Impella and IABP (52 % and 67 %, respectively; p = 0.13), but bleeding complications were more frequent in the Impella group (3 vs 4 units of transfused erythrocytes concentrates due to bleeding complications, p = 0.03). Previous cardiopulmonary resuscitation (HR 3.22, 95% CI 1.76 to 5.89; p < 0.01) and an estimated intermediate (HR 2.77, 95% CI 1.42 to 5.40; p < 0.01) and high (HR 4.32 95% CI 2.03 to 9.24; p = 0.01) IABP-SHOCK II score were independent predictors of all-cause mortality.ConclusionsIn patients with AMICS, haemodynamic support with the Impella device had no significant effect on 30-day mortality as compared with IABP. In these patients, large randomised trials are warranted to ascertain the effect of Impella on the outcome.

scholarly journals Veno-Arterial Extracorporeal Membrane Oxygenation for Electrical Injury Induced Cardiogenic Shock Support: A Case Report

2020 ◽  
Author(s):  
Tamer Jamal ◽  
Amjad Shalabi ◽  
Liza Grosman-Rimon ◽  
Diab Ghanim ◽  
Offer Amir ◽  
...  
Keyword(s):  
Cardiopulmonary Resuscitation ◽  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
High Voltage ◽  
Left Ventricular ◽  
Cardiac Massage ◽  
Electrical Injury ◽  
Membrane Oxygenation ◽  
Severe Cardiogenic Shock ◽  
Va Ecmo

Abstract Background High voltage electrical injury (HVEI) of more than 1,000V is a potentially devastating form of a multisystem injury associated with high morbidity and mortality. We present the first case of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a life saving device for treating a patient with severe cardiogenic shock after a high voltage electrical injury.Case Presentation A 26-year-old male sustained HVEI while working with a concrete mixer pump that came in contact with a high voltage cable of 10,000 volts. He was immediately disconnected from the mixer pump, underwent cardiopulmonary resuscitation and was transported to the nearest medical centre with severe cardiogenic shock with an ejection fraction (EF) of < 10%. Upon arrival, he was in critical condition, sedated and mechanically ventilated, haemodynamically unstable and supported by intravenous (IV) inotropes after a few events of ventricular fibrillation, with an electrical entry point on the left hand and an exit point located on his right leg. Blood pH was 6.8, PCO2 53 mmHg, PaO2 of 57 mmHg, lactate 8 mmol/L, and Troponin 38000 ng/dl. The EF was 10% with global severe left ventricular dysfunction. During cardiopulmonary resuscitation (CPR), including cardiac massage and few electrical shocks, he was immediately connected to the VA-ECMO via open right femoral approach with distal arterial leg perfusion.He was treated with IV broad spectrum antibiotics, and high volume fluids to prevent rhabdomyolysis-induced acute kidney injury, total parenteral nutrition, topical silver sulfadiazine cream, and Granuflex for severe electrical burns. He was gradually weaned from inotropes over the next 3 days, during which his clinical condition and bloodwork improved tremendously. His EF gradually increased to 50% and he was weaned from the VA-ECMO, and underwent decannulation 86 hours after initialization. He was discharged on day 27 without any sequelae.Conclusion The VA-ECMO treatment can be a lifesaving device for treating severe cardiogenic shock caused by high voltage electrical injury, and should be considered while treating these “high-mortality risk” patients.

scholarly journals Veno-Arterial Extracorporeal Membrane Oxygenation for Electrical Injury Induced Cardiogenic Shock Support: A Case Report

2020 ◽  
Author(s):  
Tamer Jamal ◽  
Amjad Shalabi ◽  
Liza Grosman-Rimon ◽  
Diab Ghanim ◽  
Offer Amir ◽  
...  
Keyword(s):  
Cardiopulmonary Resuscitation ◽  
Extracorporeal Membrane Oxygenation ◽  
Cardiogenic Shock ◽  
High Voltage ◽  
Left Ventricular ◽  
Cardiac Massage ◽  
Electrical Injury ◽  
Membrane Oxygenation ◽  
Severe Cardiogenic Shock ◽  
Va Ecmo

Abstract BackgroundHigh voltage electrical injury (HVEI) of more than 1,000V is a potentially devastating form of a multisystem injury associated with high morbidity and mortality. We present the first case of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a life saving device for treating a patient with severe cardiogenic shock after a high voltage electrical injury.Case Presentation A 26-year-old male sustained HVEI while working with a concrete mixer pump that came in contact with a high voltage cable of 10,000 volts. He was immediately disconnected from the mixer pump, underwent cardiopulmonary resuscitation and transported to the nearest medical centre with severe cardiogenic shock with ejection fraction (EF) < 10%. Upon arrival he was in critical condition, sedated and mechanically ventilated, haemodynamically unstable and supported by intravenous (IV) inotropes after a few events of ventricular fibrillation, with an electrical entry point on the left hand and an exit point in his right leg. Blood pH was 6.8, PCO2 53 mmHg, PaO2 of 57 mmHg, lactate 8 mmol/L, and Troponin 38000 ng/dl. EF was 10% with a global severe left ventricular dysfunction. During cardiopulmonary resuscitation (CPR) including cardiac massage and few electrical shocks he was immediately connected to the VA-ECMO via open right femoral approach with distal arterial leg perfusion.He was treated with IV broad spectrum antibiotics, and high volume fluids to prevent rhabdomyolysis-induced acute kidney injury, total parenteral nutrition, topical silver sulfadiazine cream, and Granuflex for severe electrical burns. He was gradually weaned from inotropes over the next 3 days, during which his clinical condition and bloodwork improved tremendously. His EF gradually increased to 50% and he was weaned from the VA-ECMO and underwent decannulation 86 hours after initialization. He was discharged on day 27 without any sequelae.Conclusion VA-ECMO treatment can be a lifesaving device for treating severe cardiogenic shock caused by high voltage electrical injury, and should be considered while treating these “high-mortality risk” patients.

scholarly journals Mechanical circulatory support with impella in patients with non-acute myocardial infarction related cardiogenic shock

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J Haurand ◽  
S Bueter ◽  
C Jung ◽  
M Kelm ◽  
R Westenfeld ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Apache Ii Score ◽  
Hemodynamic Parameters ◽  
Clinical Scores ◽  
Lactate Levels

Abstract Background Percutaneous left ventricular assist devices such as the Impella pump, are used to hemodynamically stabilize patients with cardiogenic shock (CS) caused by acute myocardial infarction (AMI) until cardiac function has recovered after revascularization. Whether Impella mechanical circulatory support (MCS) is effective in stabilizing patients with CS not caused by AMI has so far not been thoroughly investigated. Purpose The aim of this study is to analyze whether MCS with Impella is effective to stabilize patients with non-AMI related CS compared to patients with AMI related CS. Method We retrospectively analyzed 106 patients with CS and Impella support in the years from 2011 to 2018. Efficacy to stabilize the patient was assessed by laboratory values such as lactate, hemodynamic parameters and clinical scores. The difference in mortality was calculated with the Log-Rank-Test, comparing Kaplan-Meier curves. Results 36 patients suffered from non-AMI CS and in 70 patients CS was caused by AMI. Regarding the clinical scores and hemodynamic parameters, both groups were severely ill, with no significant difference in APACHE II score, with a mean score of 17.9 in the non-AMI group compared to 20.5 in the AMI-group (p=0.103), the SOFA score (mean score of 6.3 in non-AMI group vs 6.8 in AMI group, p=0.467) and cardiac index (mean CI of 1.9 l/min/m2 in non-AMI group vs 2.2 l/min/m2 in AMI group, p=0.176). There was a comparable mean decrease in lactate levels in both groups 48 hours after initiation of MCS, from initially 4.1 mmol/l to 1.7 mmol/l (p&lt;0.001) in the non-AMI group and from initially 3.6 mmol/l to 2.2 mmol/l (p=0.025) in the AMI group. The non-ACS group exhibited a trend of lower mortality compared to the AMI group, with 47% in the non-AMI group and 57% in the AMI group (p=0.067). In multivariate analysis, age, lactate levels, cardiopulmonary resuscitation, low platelets and higher doses of inotropes and vasopressors were independent predictors for mortality. An upgrade to LVAD was performed for 22% of the non-AMI group and for 6% of the AMI group (p=0.020). Conclusion Impella support is effective to hemodynamically stabilize patients with non-AMI related CS. Therefore, MCS can be used as bridge to recovery or enables further treatment options as upgrade to longterm mechanical support devices. Funding Acknowledgement Type of funding source: None

Abstract 429: First-Line Vasopressor Agent for Cardiogenic Shock Due to Acute Myocardial Infarction: Results From Tokyo CCU Network Registry

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Tadashi Ashida ◽  
Tsukasa Yagi ◽  
Ken Nagao ◽  
Norihiro Kuroki ◽  
Tadateru Takayama ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Renal Function ◽  
Mortality Rate ◽  
Cardiogenic Shock ◽  
First Line ◽  
Poor Renal Function ◽  
Vasopressor Agent ◽  
Significant Difference ◽  
All Cause Mortality

Background: In the guidelines for cardiogenic shock, norepinephrine, as compared with dopamine, was associated with fewer cases of arrhythmia and may be a better first-line vasopressor agent. However, few clinical studies have investigated the effects of optimal first-line vasopressor agents for patients with poor renal function. Methods: From a multicenter, prospective, cohort registry of emergency cardiovascular patients in Tokyo between 2013 and 2016, we identified adult patients with cardiogenic shock due to acute myocardial infarction (AMI) who received either norepinephrine, dopamine or both as a vasopressor agent without mechanical circulatory supports. Study patients were divided into 4 groups according to estimated glomerular filtration rate (eGFR). The primary endpoint was all-cause mortality at 30 days after admission. Results: Of the 4,034 patients with cardiogenic shock due to AMI, 665 were eligible for this study; 419 received norepinephrine (N group), 154 dopamine (D group), and 92 both agents (B group). There was a significant difference in the all-cause mortality rate between the three groups in the whole cohort (16.0% in the N group, 9.7% in the D group and 40.2% in the B group, P<0.001). In addition, there was a significant difference in the all-cause mortality rate between the three groups in the subgroups of patients with eGFR stage 3a and 3b. (Figure). After adjustment of independent factors for mortality, the odds ratio of the D group (reference, the N group) was 0.51 (95%CI 0.26-0.99, p=0.049). Conclusion: Compared with norepinephrine, dopamine was associated with a lower all-cause mortality rate for patients with cardiogenic shock due to AMI, especially patients with poor renal function.

Abstract 20556: Safety and Efficacy of Intracoronary Hypoxia-PrecondItioned Bone Marrow Mononuclear Cells Administration for Acute Myocardial Infarction Patients

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Xin Yang Hu ◽  
Xin Huang ◽  
Qian Yang ◽  
Lihan Wang ◽  
Jianzhong Sun ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Bone Marrow ◽  
Primary Endpoint ◽  
Perfusion Defect ◽  
Mononuclear Cells ◽  
Left Ventricular ◽  
Bone Marrow Mononuclear Cells ◽  
Safety And Efficacy ◽  
Intracoronary Infusion

IMPORTANCE: Cell therapy has been a potential approach for ST-segment elevation acute myocardial infarction (STEMI). To improve the therapeutic oucome, the safety and efficacy of hypoxia-preconditioned (H-) bone marrow mononuclear cells (BMCs) in AMI patients need further evaluation. OBJECTIVE: To investigate the safety and efficacy of H-BMCs therapy in AMI patients. DESIGN: A phase 1, randomized and blinded study (February, 2011~ March, 2012) with one-year of follow-up. SETTING: A single center for hospitalized care. PARTICIPANTS: 22 Patients with an acute ST elevation myocardial infarction were recruited and randomized to two groups: normoxia BMCs (N-, n=11) and H-BMCs (n=11). INTERVENTIONS: Intracoronary infusion of H-BMCs or N-BMCs within 5-7 days after treatment with percutaneous transluminal coronary intervention (PCI). Patients were similarly treated by a stop-flow technique through an over-the-wire balloon catheter. MAIN OUTCOMES AND MEASURES: Primary endpoint was Treatment-emergent 30-day serious adverse event rate defined as a composite of death, MI, sustained ventricular tachycardia, stroke, hospitalization for worsening heart failure and revascularization. Secondary endpoints were change of myocardium perfusion, global left ventricular ejection fraction and left ventricular volumes. RESULTS: The primary endpoint events was none for N-BMCs and 9.1% (95% CI, 0.2%-41.3%) for H-BMCs. There was significant increase in the change of LVEF of H-BMCs group at 6 month. The change of end diastolic volume (EDV) and end systolic volume (ESV) in H-BMCs at 12 month were significantly decreased. Ratio of myocardium perfusion defect by Single-Photon Emission Computed Tomography (SPECT) was significantly reduced in H-BMCs group at 6 months, and score of myocardium perfusion defect by SPECT was significantly reduced than that of baseline in H-BMCs group at 6 and 12 months, unlike N- group. CONCLUSIONS AND RELEVANCE: Intracoronary infusion with H-BMCs appeared to be safe and effective for patients with AMI. Although the sample size precludes a definitive statement about safety and efficacy, these results provide the basis for larger studies to provide definitive evidence about safety and to assess efficacy of this new therapeutic approach.

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