Mechanical Circulatory Support in the Cardiac Catheterization Laboratory for Cardiogenic Shock

: Despite advances in early reperfusion and a technologic renaissance in the space of mechanical circulatory support (MCS), cardiogenic shock (CS) remains the leading cause of in-hospital mortality following acute myocardial infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patient without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated in the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trial designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.

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Abstract 16115: The Society of Cardiovascular Angiography and Interventions Cardiogenic Shock Classification Predicts Mortality in Cardiac Arrest Patients Prior to Pci

Circulation ◽

10.1161/circ.142.suppl_3.16115 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Fernando Ortiz ◽

George A Stouffer ◽

Joseph Rossi ◽

Jason N Katz

Keyword(s):

Cardiac Arrest ◽

Hospital Mortality ◽

Cardiogenic Shock ◽

Statistical Significance ◽

Circulatory Support ◽

Catheterization Laboratory ◽

Cardiac Catheterization Laboratory ◽

Coronary Syndrome ◽

Vasopressor Support ◽

Stage D

Introduction: Acute coronary syndrome (ACS) complicated by cardiac arrest (CA) has a heterogeneous presentation, and risk can be challenging to stratify. This study aimed to apply the SCAI cardiogenic shock stages to patients with ACS complicated by CA at early pivotal time intervals when prompt interventions may have a greater impact. Methods: Patients undergoing PCI presenting with CA were stratified according to the SCAI shock classification, retrospectively, on arrival to the cardiac catheterization laboratory (CCL) and on arrival to the intensive care unit (ICU). The primary end-point was in-hospital mortality. Secondary end-points were mortality stratified by the use of mechanical circulatory support or the level of vasopressor support used. Results: Between 01/2014 -08/2018, seventy-nine patients presented with ACS complicated by a CA. The mean age was 70 (SD ± 12) years, and 19 (24%) were females. On arrival to the CCL 17 (22%) were stage A, 6 (8%) were stage B, 31 (40%) were stage C, 19 (24%) were stage D, and 6 (8%) were stage E. In general, there was a stepwise increase in mortality with increasing stage (A 35% vs. B 16% vs. C 48% vs. D 68% vs. E 83%; p=0.05). There was a similar trend when stratified on arrival to the ICU (Figure 1), although of marginal statistical significance (P = 0.07). Presentation with shock stage D or E to the CCL was predictive of mortality (OR 3.7 CI 1.3-10.5; p=0.01) on logistic regression models. The use of mechanical support was not associated with increased mortality. However, the use of an Impella in patients requiring high vasopressor support at arrival to the CCL was associated with a trend towards decreased mortality (25% vs. 61%, p=0.18). Conclusion: Increasing SCAI shock stages on arrival to the CCL and ICU is associated with increased in-hospital mortality among patients who presented after a CA and underwent PCI. The SCAI classification at defined time points has the potential to serve as an important research tool.

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