Prognostic Impact of Active Mechanical Circulatory Support in Cardiogenic Shock Complicating Acute Myocardial Infarction, Results from the Culprit-Shock Trial

Abstract

Objectives: To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). Background: Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. Methods: This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. Results: Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®; n = 95 extracorporeal membrane oxygenation (ECMO); n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p < 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p < 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7–5.9; p < 0.001). Conclusions: In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

Clinical outcomes of hundred large Impella implantations in cardiogenic shock patients based on individual clinical scenarios

“…In a meta‐analysis by the same research team, not only 30‐day mortality but also 6‐month mortality and post‐interventional LV ejection fraction were comparable between the Impella CP and IABP groups 17 . Other authors have supported this result, with an even higher rate of bleeding complications with Impella CP support and comparable clinical outcomes up to 5 years with respect to mortality 16,18–21 . We believe that based on currently available evidence, the indication for Impella CP support in this setting is still controversial.…”

“…17 Other authors have supported this result, with an even higher rate of bleeding complications with Impella CP support and comparable clinical outcomes up to 5 years with respect to mortality. 16,[18][19][20][21] We believe that based on currently available evidence, the indication for Impella CP support in this setting is still controversial. However, studies focusing on the utilization of large Impella in patients with acute CS after AMI are limited.…”

Complicating Acute Myocardial Infarction. Current Status and Unresolved Targets for Subsequent Research

“…The results of the SHOCK trial and its subsequent subanalyses have provided arguments for the class IB recommendation of the European Society of Cardiology on revascularization in MI complicated by acute heart failure [55]. The results of the CULPRIT-SHOCK trial showed that in MI patients with CS and multivessel coronary disease, the 30-day composite of death or severe renal failure leading to renal replacement therapy was lower among those who only underwent PCI of the culprit lesion than it was among those who underwent multivessel PCI [56][57][58]. Despite full epicardial blood flow restoration following primary coronary angioplasty in acute MI, ischemia/reperfusion is associated with cardiac myocyte necrosis, coronary microvasculature damage and interstitial edema [59], leading to a lack of adequate tissue perfusion, referred to as the no-reflow phenomenon [60].…”

Ultrasound Assessment in Cardiogenic Shock Weaning: A Review of the State of the Art

“…The early implantation of mechanical circulatory support devices has increased in recent years as initial vasopressor and inotropic therapies remain insufficient to stabilize the shock status [ 4 ]. A total of 19% of the patients with CS following an acute myocardial infarction in the CULPRIT-SHOCK trial received at least one mechanical circulatory support device [ 5 ]. Although the exact moment of initiation remains controversial and despite the lack of strong evidence in this field [ 1 , 4 , 6 ], there are a wide range of hemodynamic, echocardiographic, and clinical parameters that can be assessed to help the heart team make the decision.…”