Early Enteral Nutrition Tolerance in Patients With Cardiogenic Shock Requiring Mechanical Circulatory Support

Background: Enteral nutrition (EN) is recommended within the first 24–48 h for patients with hemodynamic stability, following admission to an intensive care unit (ICU). However, for patients with approximate stable hemodynamics requiring mechanical circulatory support and vasoactive drugs, the application of early EN remains controversial. We sought to evaluate the tolerance of early EN in patients with cardiogenic shock who required vasoactive drugs and mechanical circulatory support after cardiac surgery.Methods: This single-center, prospective observational study included patients with cardiogenic shock, requiring vasoactive drugs and mechanical circulatory support after cardiac surgery, undergoing EN. The primary endpoint was EN tolerance and secondary endpoints were mortality, length of mechanical ventilation, and length of ICU stay.Results: From February 2019 to December 2020, 59 patients were enrolled, of which 25 (42.37%) developed intolerance within 3 days of starting EN. Patients in the EN intolerant group had a longer median length of mechanical ventilation (380 vs. 128 h, p = 0.006), a longer median ICU stay (20 vs. 11.5 days, p = 0.03), and a higher proportion of bloodstream infections (44 vs. 14.71%, p = 0.018). The median EN calorie levels for all patients in the first 3 days of EN were 4.00, 4.13, and 4.28 kcal/kg/day, respectively. Median protein intake levels of EN in the first 3 days were 0.18, 0.17, and 0.17 g/kg/day, respectively. No significant difference was observed in the median dose of vasoactive drugs between the groups (0.035 vs. 0.05 μg/kg/min, p = 0.306).Conclusions: Patients with cardiogenic shock after cardiac surgery had a high proportion of early EN intolerance, and patients with EN intolerance had a worse prognosis, but no significant correlation was identified between EN tolerance and the dose of vasoactive drugs.

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Effects of Early Enteral Nutrition on Immune Function and Prognosis of Patients With Sepsis on Mechanical Ventilation

Journal of Intensive Care Medicine ◽

10.1177/0885066618809893 ◽

2018 ◽

Vol 35 (10) ◽

pp. 1053-1061 ◽

Cited By ~ 1

Author(s):

Ying Liu ◽

Wei Zhao ◽

Wenxiu Chen ◽

Xiao Shen ◽

Run Fu ◽

...

Keyword(s):

Immune Response ◽

Mechanical Ventilation ◽

Enteral Nutrition ◽

Hospital Stay ◽

Th17 Cells ◽

Treg Cells ◽

Early Enteral Nutrition ◽

Therapeutic Effects ◽

Icu Stay ◽

Significant Difference

Objective: To explore the therapeutic effects of early enteral nutrition (EEN) on patients with sepsis on mechanical ventilation. Methods: Patients with sepsis on mechanical ventilation in the medical intensive care unit (ICU) from January 2013 to March 2016 were treated with enteral nutrition. Patients treated within 48 hours of initiation of mechanical ventilation were assigned to the EEN group, and the rest were assigned to the delayed enteral nutrition (DEN) group. Peripheral blood Th17 cells and Treg cells, endotoxin (ET) level, 28-day mortality, duration of mechanical ventilation, lengths of ICU stay and hospital stay, and incidence of ICU-acquired weakness (ICU-AW) were analyzed between the 2 groups. Results: The proportion of Th17 cells and ET levels in the EEN group were significantly lower than those in the DEN group, whereas the proportion of Treg cells in the EEN group was remarkably higher than that in the DEN group ( P < .05). The duration of mechanical ventilation, lengths of ICU stay and hospital stay, and incidence of ICU-AW were higher in the DEN group than in the EEN group ( P < .05), but there was no significant difference in the 28-day mortality between the 2 groups. Conclusion: Patients with sepsis mainly present with an increased proportion of Th17 cells in the early stage, manifesting as enhanced immune response. Early enteral nutrition can inhibit the excessive immune response, shorten the duration of mechanical ventilation, lengths of ICU stay and hospital stay, and reduce the incidence of ICU-AW, but it has no obvious effect on 28-day mortality.

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Left heart Impella-device to bridge acute mitral regurgitation to MitraClip-procedure: a novel implementation of percutaneous mechanical circulatory support

European Heart Journal ◽

10.1093/ehjci/ehaa946.1849 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

C Vandenbriele ◽

T Balthazar ◽

J Wilson ◽

S Ledot ◽

R Smith ◽

...

Keyword(s):

Mechanical Ventilation ◽

Cardiac Output ◽

Mitral Regurgitation ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Surgical Intervention ◽

Left Ventricular ◽

Inotropic Support ◽

Circulatory Support ◽

Acute Mitral Regurgitation

Abstract Background Acute mitral regurgitation (MR) is an emergency, often requiring urgent surgery. Severe acute MR presenting with hemodynamic collapse is usually caused by papillary muscle rupture or dysfunction after acute myocardial infarction (AMI) or chordal rupture, resulting in flail mitral leaflet(s). Preoperative stabilization is complex due to concomitant hemodynamic collapse and hypoxic respiratory failure. Finding the right balance between both preload and inotropic support is challenging. When patients are too sick for immediate surgical intervention, mechanical circulatory support can be considered because of its ability to both unload and reduce of cardiac work while increasing coronary perfusion and cardiac output. Nevertheless, even after initial stabilization, surgical risk remains high in critically ill acute severe MR patients and transcatheter treatments such as MitraClip are increasingly being explored. Methods Between August 2017 and September 2019, patients presenting with acute severe mitral regurgitation and considered too ill for immediate surgical intervention (EURO-II score >11.2% plus pulmonary oedema necessitating mechanical ventilation and/or hemodynamic instability), were selected for an Impella-assisted LV unloading technique as bridge to MitraClip-procedure. Five patients were selected for the combined left Impella/MitraClip-procedure in two tertiary cardiac ICUs. Results The mean age was 72 years. The cause of MR was ischemic in 20% and all patients presented in cardiogenic shock state, necessitating mechanical ventilation. The overall cardiac operative risk assessment (Euro-II) score predicted a 35% chance of in-hospital mortality. Cardiac output was severely impaired (mean LVOT VTI 8.2 cm). All patients were on inotropic support and supported by an Impella-CP pVAD (mean flow 2.5 Liter per minute; mean 6.3 days of support). In all cases, we managed to reduce the LVEDP below 15 mmHg using the combination of medical therapy (afterload reduction, inotropes), mechanical ventilation and pVAD-therapy. The MR was significantly reduced by a MitraClip-procedure in each Impella supported patient. The overall survival at discharge was 80%. One patient with late referral and multiple organ failure at presentation deceased due to refractory cardiogenic shock. Overall, severe MR was reduced to grade 1+ and all four patients survived 6 months after discharge with only one readmission for decompensated heart failure. Conclusions A combined strategy of Impella and MitraClip appears to be a novel, feasible alternative for patients presenting with acute, severe MR unable to proceed to a corrective surgical procedure at presentation due to severe left ventricular forward flow failure. In these cases, the early initiation of pVAD-support may reduce the risk of development of irreversible end- organ damage and dysfunction. Exploration in a larger, randomised population is warranted to investigate this strategy further. Funding Acknowledgement Type of funding source: None

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Abstract 15717: Impact of Mechanical Circulatory Support on Outcomes and In-hospital Mortality of Peripartum Cardiomyopathy Patients With Cardiogenic Shock: An Analysis of the Nis Database

Circulation ◽

10.1161/circ.142.suppl_3.15717 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Jennifer Maning ◽

Bertrand Ebner ◽

Louis Vincent ◽

Jelani Grant ◽

Sunita Mahabir ◽

...

Keyword(s):

Hospital Mortality ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Peripartum Cardiomyopathy ◽

Circulatory Support ◽

Significant Difference ◽

Baseline Characteristics ◽

Similar Survival ◽

Stage Renal Disease ◽

End Stage

Background: Peripartum cardiomyopathy (PPCM) is an uncommon form of cardiomyopathy that affects young women at the end of pregnancy or in the first few months following delivery, and is associated with increased morbidity and mortality. In selected patients with cardiogenic shock (CS), mechanical circulatory support (MCS) devices improve outcomes. However, data comparing outcomes of patients with PPCM who develop CS and receive mechanical circulatory support (MCS) vs. those treated medically remains limited. Methods: Using the National Inpatient Database (NIS) we identified patients with PPCM who were treated for CS from 2012 to 2017. Primary outcome was in-hospital mortality. Multivariate analysis models were adjusted for statistically significant differences in baseline characteristics between the groups. Results: A total of 4686 patients were admitted with a diagnosis of PPCM, of these 199 patients developed cardiogenic shock. Only 50 (25.1%) patients received MCS. Patients who received MCS were less likely to have a prior ICD in place (6% vs. 23%, p = 0.008), and were more likely to suffer from end-stage renal disease (6% vs. 0.67%, p = 0.020). There were no other major differences in baseline characteristics among the two groups. The incidence of ICD implant prior to discharge (4% vs. 7.4%, p = 0.243, OR 0.39) and cardiac arrest (16% vs. 7.4%, p = 0.173, OR 2.01) was not significantly different between the groups. There was no significant difference in in-hospital mortality between those who received MCS devices and those treated medically (22% vs 10.1%, p = 0.256, OR 1.73). LOS was longer for the MCS group (23.2% vs. 13.4 mean days, p = 0.001). Conclusions: The use of MCS in PPCM patients who developed cardiogenic shock appears to offer similar survival benefit compared to those treated medically, despite being associated with longer length of stay This finding may be related to the complexity and acuity level of patients receiving MCS compared to those treated medically.

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A 20-year multicentre outcome analysis of salvage mechanical circulatory support for refractory cardiogenic shock after cardiac surgery

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-016-0545-5 ◽

2016 ◽

Vol 11 (1) ◽

Cited By ~ 12

Author(s):

Maziar Khorsandi ◽

Scott Dougherty ◽

Andrew Sinclair ◽

Keith Buchan ◽

Fiona MacLennan ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Circulatory Support ◽

Outcome Analysis ◽

Refractory Cardiogenic Shock

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Outcomes of temporary mechanical circulatory support in cardiogenic shock due to end-stage heart failure

Journal of the Intensive Care Society ◽

10.1177/1751143720988706 ◽

2021 ◽

pp. 175114372098870

Author(s):

Hoong Sern Lim ◽

Aaron Ranasinghe ◽

David Quinn ◽

Colin Chue ◽

Jorge Mascaro

Keyword(s):

Heart Failure ◽

Cardiogenic Shock ◽

Organ Dysfunction ◽

Mechanical Circulatory Support ◽

Circulatory Support ◽

Number Of Patients ◽

Significant Difference ◽

End Stage Heart Failure ◽

Baseline Characteristics ◽

End Stage

Background There are few reports of mechanical circulatory support (MCS) in patients with cardiogenic shock (CS) due to end-stage heart failure (ESHF). We evaluated our institutional MCS strategy and compared the outcomes of INTERMACS 1 and 2 patients with CS due to ESHF. Methods Retrospective analysis of prospectively collected data (November 2014 to July 2019) from a single centre. ESHF was defined by a diagnosis of HF prior to presentation with CS. Other causes of CS (eg: acute myocardial infarction) were excluded. We compared the clinical course, complications and 90-day survival of patients with CS due to ESHF in INTERMACS profile 1 and 2. Results We included 60 consecutive patients with CS due to ESHF Differences in baseline characteristics were consistent with the INTERMACS profiles. The duration of MCS was similar between INTERMACS 1 and 2 patients (14 (10–33) vs 15 (7–23) days, p = 0.439). There was no significant difference in the number of patients with complications that required intervention. Compared to INTERMACS 2, INTERMACS 1 patients had more organ dysfunction on support and significant lower 90-day survival (66% vs 34%, p = 0.016). Conclusion Our temporary MCS strategy, including earlier intervention in patients with CS due to ESHF at INTERMACS 2 was associated with less organ dysfunction and better 90-day survival compared to INTERMACS 1 patients.

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Long-term clinical outcome of cardiogenic shock patients undergoing Impella CP treatment vs. standard of care

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.154 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

C Scherer ◽

E Luesebrink ◽

S Massberg ◽

M Orban

Keyword(s):

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Vascular Complications ◽

University Hospital ◽

Circulatory Support ◽

Term Survival ◽

Long Term Outcome ◽

Number Of Patients ◽

Significant Difference

Abstract Funding Acknowledgements Type of funding sources: None. Background The number of patients treated with the mechanical circulatory support device Impella Cardiac Power (CP) for cardiogenic shock is steadily increasing. The aim of this study was to investigate long-term survival and complications related to this modality. Methods Patients undergoing Impella CP treatment for cardiogenic shock were retrospectively enrolled and matched with cardiogenic shock patients not treated with mechanical circulatory support between 2010 and 2020. Data were collected from the cardiogenic shock registry of our university hospital. Results 68 patients with refractory cardiogenic shock without mechanical circulatory support were matched with 68 patients treated with Impella CP. At presentation, the mean age was 67 ± 14 years with 82% being male in the group without support and 68 ± 14 years (p = 0.65) with 77% being male (p = 0.52) in the group with Impella. There was no significant difference in the rate of cardiac arrest (57% vs. 54%, p = 0.86) and myocardial infarction was the predominant cause of cardiogenic shock in both groups (66% vs. 74%, p = 0.34). A total of 46% of patients without cardiocirculatory support and 54% of patients with Impella support died during the first month (p = 0.32). After one year, mortality rates were similar in both groups (53% in conventional vs. 59% in Impella CP group, p = 0.51) as was mortality rate at long-term 5-years follow-up (73% in conventional vs. 72% in Impella CP group, p = 0.50). The rate of clinically significant bleedings during ICU stay was much lower in the conventional group than in the Impella support group (25% vs. 42%, p = 0.03). Conclusion In this small observational and non-randomized analysis no difference in long-term outcome between patients treated with Impella CP vs. guideline directed cardiogenic shock therapy without mechanical circulatory support could be detected. Care must be taken regarding the high rate of bleeding and vascular complications when using Impella CP. Large, adequately powered studies are urgently needed to investigate the efficacy and safety of Impella CP in cardiogenic shock.

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IMPELLA® or Extracorporeal Membrane Oxygenation for Left Ventricular Dominant Refractory Cardiogenic Shock

Journal of Clinical Medicine ◽

10.3390/jcm10040759 ◽

2021 ◽

Vol 10 (4) ◽

pp. 759

Author(s):

Guillaume Schurtz ◽

Natacha Rousse ◽

Ouriel Saura ◽

Vincent Balmette ◽

Flavien Vincent ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Left Ventricular ◽

Circulatory Support ◽

Membrane Oxygenation ◽

Refractory Cardiogenic Shock ◽

Significant Difference ◽

Va Ecmo ◽

Unadjusted Analysis

Mechanical circulatory support (MCS) devices are effective tools in managing refractory cardiogenic shock (CS). Data comparing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and IMPELLA® are however scarce. We aimed to assess outcomes of patients implanted with these two devices and eligible to both systems. From 2004 to 2020, we retrospectively analyzed 128 patients who underwent VA-ECMO or IMPELLA® in our institution for refractory left ventricle (LV) dominant CS. All patients were eligible to both systems: 97 patients were first implanted with VA-ECMO and 31 with IMPELLA®. The primary endpoint was 30-day all-cause death. VA-ECMO patients were younger (52 vs. 59.4, p = 0.006) and had a higher lactate level at baseline than those in the IMPELLA® group (6.84 vs. 3.03 mmol/L, p < 0.001). Duration of MCS was similar between groups (9.4 days vs. 6 days in the VA-ECMO and IMPELLA® groups respectively, p = 0.077). In unadjusted analysis, no significant difference was observed between groups in 30-day mortality: 43.3% vs. 58.1% in the VA-ECMO and IMPELLA® groups, respectively (p = 0.152). After adjustment, VA-ECMO was associated with a significant reduction in 30-day mortality (HR = 0.25, p = 0.004). A higher rate of MCS escalation was observed in the IMPELLA® group: 32.3% vs. 10.3% (p = 0.003). In patients eligible to either VA-ECMO or IMPELLA® for LV dominant refractory CS, VA-ECMO was associated with improved survival rate and a lower need for escalation.

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Long-Term Clinical Outcome of Cardiogenic Shock Patients Undergoing Impella CP Treatment vs. Standard of Care

Journal of Clinical Medicine ◽

10.3390/jcm9123803 ◽

2020 ◽

Vol 9 (12) ◽

pp. 3803

Author(s):

Clemens Scherer ◽

Enzo Lüsebrink ◽

Danny Kupka ◽

Thomas J. Stocker ◽

Konstantin Stark ◽

...

Keyword(s):

Cardiogenic Shock ◽

Mechanical Circulatory Support ◽

Vascular Complications ◽

University Hospital ◽

Circulatory Support ◽

Term Survival ◽

Long Term Outcome ◽

Number Of Patients ◽

Significant Difference

The number of patients treated with the mechanical circulatory support device Impella Cardiac Power (CP) for cardiogenic shock is steadily increasing. The aim of this study was to investigate long-term survival and complications related to this modality. Patients undergoing Impella CP treatment for cardiogenic shock were retrospectively enrolled and matched with cardiogenic shock patients not treated with mechanical circulatory support between 2010 and 2020. Data were collected from the cardiogenic shock registry of the university hospital of Munich (DRKS00015860). 70 patients with refractory cardiogenic shock without mechanical circulatory support were matched with 70 patients treated with Impella CP. At presentation, the mean age was 67 ± 15 years with 80% being male in the group without support and 67 ± 14 years (p = 0.97) with 76% being male (p = 0.68) in the group with Impella. There was no significant difference in the rate of cardiac arrest (47% vs. 51%, p = 0.73) and myocardial infarction was the predominant cause of cardiogenic shock in both groups (70% vs. 77%). A total of 41% of patients without cardiocirculatory support and 54% of patients with Impella support died during the first month (p = 0.17). After one year, mortality rates were similar in both groups (55% in conventional vs. 59% in Impella CP group, p = 0.30) as was mortality rate at long-term 5-years follow-up (64% in conventional vs. 73% in Impella CP group, p = 0.33). The rate of clinically significant bleedings during ICU stay was lower in the conventional group than in the Impella support group (15% vs. 43%, p = 0.002). In this small observational and non-randomized analysis no difference in long-term outcome between patients treated with Impella CP vs. guideline directed cardiogenic shock therapy without mechanical circulatory support could be detected. Care must be taken regarding the high rate of bleeding and vascular complications when using Impella CP. Large, adequately powered studies are urgently needed to investigate the efficacy and safety of Impella CP in cardiogenic shock.

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