Early Escalation of Mechanical Circulatory Support Stabilizes and Potentially Rescues Patients in Refractory Cardiogenic Shock

Tongers, Jörn; Sieweke, Jan‐Thorben; Kühn, Christian; Napp, L. Christian; Flierl, Ulrike; Röntgen, Philipp; Schmitto, Jan D.; Sedding, Daniel; Haverich, Axel; Bauersachs, Johann; Schäfer, Andreas

doi:10.1161/circheartfailure.118.005853

Cited by 74 publications

(66 citation statements)

References 42 publications

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“…Written informed consent was obtained from legal guardians during the unconscious period and re-consented by survivors after gaining consciousness. HACORE includes anonymized data from all OHCA patients treated at our cardiac arrest centre with a standardized protocol including therapeutic hypothermia and mechanical circulatory support if required [1,[12][13][14][15]. In the present analysis, all OHCA patients undergoing implantation of V-A ECMO for eCPR between January 2018 and December 2019 were analysed.…”

Section: Methodsmentioning

confidence: 99%

Use of extracorporeal membrane oxygenation for eCPR in the emergency room in patients with refractory out-of-hospital cardiac arrest

et al. 2020

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Background Out-of-hospital cardiac arrest (OHCA) refractory to conventional high-quality cardiopulmonary resuscitation (CPR) may be rescued by extracorporeal CPR (eCPR) using veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Even when trying to identify eCPR candidates based on criteria assumed to be associated with a favourable neurological outcome, reported survival rates are frequently below 10%. Methods All patients undergoing implantation of V-A ECMO for eCPR between January 2018 and December 2019 (N = 40) were analysed (age 53±13 years; 75% male). Patients with refractory OHCA and potentially favourable circumstances (initial shockable rhythm, witnessed arrest, bystander CPR, absence of limiting comorbidities, age <75 years) were transported under mechanical chest compression. Candidates for eCPR should have a pH �6.9, arterial lactate �15 mmol/L and time-to-ECMO should be �60 minutes. Results Overall 30-day survival was 12.5%, with 3 of 5 survivors having a favourable neurological outcome (cerebral performance category (CPC) 1 or 2), representing 7.5% of the total eCPR population. No patient selected for eCPR met all pre-defined criteria (median of unfavourable criteria: 3). Importantly, time-to-ECMO most often (39/40) exceeded 60 minutes (mean 102 ±32 min.), and lactate was >15mmol/L in 30 out of 40 patients. Moreover, 22 out of 40 patients had a non-shockable rhythm on the first ECG.

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Section: Methodsmentioning

confidence: 99%

Use of extracorporeal membrane oxygenation for eCPR in the emergency room in patients with refractory out-of-hospital cardiac arrest

et al. 2020

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“…This may explain inferior survival outcomes in studies using Impella. In a recent study by Tongers et al [2], using Impella with VA ECMO showed 30-day survival rate of 49% and 6-month survival rate of 40%. Another study from Berlin [3] used Impella for left-sided mechanical circulatory support (MCS) and showed 37% in-hospital survival rate.…”

Section: Role Of Impellamentioning

confidence: 96%

Outcome of CentriMag™ extracorporeal mechanical circulatory support use in critical cardiogenic shock (INTERMACS 1) patients

Mehta

Venkateswaran

2020

Indian J Thorac Cardiovasc Surg

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Purpose Prognosis of patients presenting with INTERMACS 1 critical cardiogenic shock is generally poor. The aim of our study was to investigate the results of CentriMag™ extracorporeal short-term mechanical circulatory support as a bridge to decision in patients presenting with critical cardiogenic shock in our unit. Methods We retrospectively analysed 63 consecutive patients from January 2005 to June 2017, who were treated with a CentriMag™ device at our institution as a bridge to decision. Patients requiring extracorporeal support for post-cardiotomy shock and for primary graft dysfunction after heart transplantation were excluded. Results Patients’ median age was 44 years (IQR 31–52, range 15.4–62.0) and 42 (67%) were male. Primary diagnosis at presentation was ischaemic cardiomyopathy (n = 24; 38.1%), viral myocarditis (n = 19; 30.2%), idiopathic dilated cardiomyopathy (n = 8; 12.7%), and others (n = 12; 19%). The median duration of support was 25 (IQR 9.5–56) days. A total of 7 (11%) patients were supported with peripheral veno-arterial (VA) extra corporeal membrane oxygenation (ECMO), 6 (9%) with central VA ECMO, 8 (13%) with left ventricular assist device (LVAD), 17 (27%) with biventricular assist device (BiVAD), and 25 (40%) with ECMO and then converted to BiVAD. Overall, 22 (34.9%) patients died while on CentriMag™ mechanical circulatory support. Complications included bleeding requiring reoperation/intervention in 24 (38%), renal failure requiring dialysis in 29 (46%), bacterial infections in 23 (37%), fungal infections in 15 (24%), critical limb ischaemia in 6 (10%), and stroke in 8 (13%). The overall survival to successful explant from CentriMag™ was 65.1% (n = 41) and survival to hospital discharge was 58.7% (n = 37). Of these, 10 (16%) had cardiac recovery and were successfully explanted, 20 (32%) were bridged to heart transplantation, 11 (17%) were bridged to long-term left ventricular assist device, 3 (4.7%) were later on transplanted, and 1 (1.6%) recovered to decommissioning. The 1-, 5-, and 10-year survival rates were 55%, 46%, and 23% respectively. Conclusion Our results demonstrate an excellent outcome with the use of the CentriMag™ device in this seriously ill population. Despite requiring multiple procedures, over 58% of patients were discharged from hospital with 5-year survival of 46%.

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“…Although the prediction of refractory CS to an individual clinical situation will always remain a challenge, the identification of risk factors of outcome might ease the communication of objective prognostic information to family members and surrogate decision makers, help ICU physicians and interventionists to identify severe CS patients with reasonable chance of survival and reduce of futile healthcare. Lactate is a well-known predictor of mortality in cardiogenic shock and serves as an independent predictor in setting of severe CS treated with Impella or VA-ECMO or both [ 42 , 43 , 44 ], while combined use of lactate and pH demonstrated better prognostic capacity than traditional risk scores in patients treated with VA-ECMO for severe shock [ 45 ]. Similarly, vasoactive score served as predictor of mortality in patients treated with Impella 5.0 and biventricular support [ 20 ].…”

Section: Discussionmentioning

confidence: 99%

Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival

Chatzis¹,

Syntila²,

Markus³

et al. 2021

JCM

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Since mechanical circulatory support (MCS) devices have become integral component in the therapy of refractory cardiogenic shock (RCS), we identified 67 patients in biventricular support with Impella and venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) for RCS between February 2013 and December 2019 and evaluated the risk factors of mortality in this setting. Mean age was 61.07 ± 10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54 ± 16.03 and 12.25 ± 2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p < 0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate > 6 mmol/L, vasoactive score > 100 and pH < 7.26 on initiation of biventricular support, as well as Charlson comorbity index > 3 and prior resuscitation were independent predictors of survival. In conclusion, biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels.

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Early Escalation of Mechanical Circulatory Support Stabilizes and Potentially Rescues Patients in Refractory Cardiogenic Shock

Cited by 74 publications

References 42 publications

Use of extracorporeal membrane oxygenation for eCPR in the emergency room in patients with refractory out-of-hospital cardiac arrest

Use of extracorporeal membrane oxygenation for eCPR in the emergency room in patients with refractory out-of-hospital cardiac arrest

Outcome of CentriMag™ extracorporeal mechanical circulatory support use in critical cardiogenic shock (INTERMACS 1) patients

Biventricular Unloading with Impella and Venoarterial Extracorporeal Membrane Oxygenation in Severe Refractory Cardiogenic Shock: Implications from the Combined Use of the Devices and Prognostic Risk Factors of Survival

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