Delayed surgery after mechanical circulatory support for ventricular septal rupture with cardiogenic shock

Abstract OBJECTIVES The effectiveness of delayed surgery for ventricular septal rupture (VSR) following myocardial infarction (MI) in patients with cardiogenic shock remains unknown. We aimed to investigate the outcomes of delayed surgery following mechanical circulatory support for patients in cardiogenic shock after VSR. METHODS We reviewed 8 patients with post-MI VSR and cardiogenic shock who underwent delayed surgery at our institution between July 2015 and November 2017. Surgery was delayed until haemodynamic stabilization and improved organ ischaemia were achieved by initiating intra-aortic balloon pumping with or without veno-arterial extracorporeal membrane oxygenation (ECMO). We investigated the operative mortality, morbidity and late survival. RESULTS All 8 patients had preoperative intra-aortic balloon pump support, and 5 had additional veno-arterial ECMO support. Emergency repair was successfully avoided in all cases. The median time from the onset of MI to operation was 7.1 (3.7–9.9) days, and that from the diagnosis of VSR to operation was 1.9 (1.3–2.3) days. The operative mortality was 12.5%, and complications related to mechanical circulatory support occurred in 1 case (12.5%). The 2-year survival rate was 62.5%. CONCLUSIONS A combination of preoperative mechanical circulatory support and delayed surgery may improve the outcomes of patients with post-MI VSR, which was complicated by cardiogenic shock. The key to a better surgical outcome may be delaying the surgery for improving end-organ perfusion. This requires further investigation, especially for determining the optimal duration of support.

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Faculty Opinions recommendation of Mechanical circulatory support with the Impella® LP5.0 pump and an intra-aortic balloon pump for cardiogenic shock in acute myocardial infarction: The IMPELLA-STIC randomized study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.736961014.793576620 ◽

2020 ◽

Author(s):

Navin Kapur

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Randomized Study ◽

Circulatory Support ◽

Intra Aortic Balloon Pump

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.1231 ◽

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<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

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Association between Public Reporting of Outcomes and the Use of Mechanical Circulatory Support in Patients with Cardiogenic Shock

Journal of Interventional Cardiology ◽

10.1155/2019/3276521 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7

Author(s):

Vikas Singh ◽

Rodrigo Mendirichaga ◽

Parth Bhatt ◽

Ghanshyambhai Savani ◽

Anil K. Jonnalagadda ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Public Reporting ◽

Circulatory Support ◽

High Risk Population ◽

Risk Averse ◽

National Inpatient Sample ◽

Regional Comparison ◽

To Receive

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43–0.57; p<0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06–1.34; p<0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51–0.72; p<0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.

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