Temporary Mechanical Circulatory Support for Refractory Cardiogenic Shock Before Left Ventricular Assist Device Surgery

Abstract

Background There are limited data on the role of temporary mechanical circulatory support ( MCS ) devices for cardiogenic shock before left ventricular assist device ( LVAD ) surgery. This study sought to evaluate the trends of use and outcomes of MCS in cardiogenic shock before LVAD surgery. Methods and Results This was a retrospective cohort study from 2005 to 2014 using the National Inpatient Sample (20% stratified sample of US hospitals). This study identified admissions undergoing LVAD surgery with preoperative cardiogenic shock. Admissions for other cardiac surgery and heart transplant were excluded. Temporary MCS was identified using administrative codes. The primary outcome was hospital mortality and secondary outcomes were hospital costs and lengths of stay in admissions with and without MCS use. In this 10‐year period, 9753 admissions were identified with 40.6% requiring pre‐ LVAD MCS . There was a temporal increase in the frequency of cardiogenic shock associated with an increase in non–intra‐aortic balloon pump MCS devices. The cohort receiving MCS had greater in‐hospital myocardial infarction, ventricular arrhythmias, and use of coronary angiography. On multivariable analysis, older age, myocardial infarction, and need for MCS devices were independently predictive of higher in‐hospital mortality. In 696 propensity‐matched pairs, use of MCS was predictive of higher in‐hospital mortality (odds ratio 1.4 [95% confidence interval 1.1–1.6]; P =0.02) and higher hospital costs, but similar lengths of stay. Conclusions In patients with cardiogenic shock bridged to LVAD therapy, there was a steady increase in preoperative MCS use. Use of MCS identified patients at higher risk for in‐hospital mortality and greater resource utilization.

Complications in Patients with Acute Myocardial Infarction Supported with Extracorporeal Membrane Oxygenation

“…During the period between 1 January 2000 through 31 December 2016, a retrospective cohort of admissions from the HCUP-NIS with a primary diagnosis of AMI (International Classification of Disease-9 Clinical Modification [ICD-9CM] 410.x; International Classification of Disease-10 Clinical Modification [ICD-10CM] I21.x-22.x) receiving ECMO support (ICD-9CM 39.65; ICD-10CM 5A15223) were identified consistent with prior literature [7]. Deyo's modification of Charlson Comorbidity Index was used to identify co-morbid diseases and prior methodology was used to identify cardiac and non-cardiac procedures [2,3,7,8,11,[13][14][15][16][17][18][19][20][21][22][23]. We identified relevant complications and categorized them as (a) vascular complications-arterial injury, acquired arterio-venous fistula, and vascular complications requiring surgery; (b) lower limb amputation; (c) hematologic-post-operative hemorrhage, hemolytic anemia, thrombocytopenia, and blood transfusion; and (d) neurologic-ischemic or hemorrhagic stroke ( Supplementary Table S1).…”

“…In patients with AMI, ECMO is often used to support tenuous hemodynamics during cardiac arrest, cardiopulmonary resuscitation, cardiogenic shock, and high risk coronary intervention [1][2][3][4][5][6][7][8]. However, by virtue of its unique configuration, ECMO is associated with higher left ventricular afterload, greater vascular complications due to large bore access, limb ischemia due to lack of antegrade flow, greater clotting, and thrombocytopenia due to a complex circuit and higher risk of strokes due to variation in anticoagulation [1].…”

“…Extracorporeal membrane oxygenation (ECMO) is increasingly used in acute cardiovascular care for the management of acute myocardial infarction (AMI) complicated by cardiac arrest, cardiogenic shock and complications from cardiac interventional procedures [1][2][3][4][5][6][7][8][9][10]. ECMO provides cardiac output support of nearly 3-5 L, biventricular support and respiratory support, thereby assisting with critical cardiorespiratory support in extreme situations [11].…”

“…ECMO provides cardiac output support of nearly 3-5 L, biventricular support and respiratory support, thereby assisting with critical cardiorespiratory support in extreme situations [11]. Despite limited data and the absence of randomized controlled trials, ECMO has been widely accepted in clinical practice [2][3][4][5][6][7][8]. Despite the stated benefits from ECMO therapy, these acutely ill patients receiving ECMO support for AMI continue to experience high in-hospital mortality [7].…”

Complications from percutaneous-left ventricular assist devices versus intra-aortic balloon pump in acute myocardial infarction-cardiogenic shock

“…However, large-scale randomized trials like IABP-SHOCK II (Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock) have demonstrated no difference in AMI-CS outcomes with or without the IABP [5]. Newer devices including TandemHeart, Impella and extracorporeal membrane oxygenation (ECMO) have been introduced into clinical practice in the last 10-15 years, with Impella being the most commonly used today [6][7][8][9][10][11][12][13][14][15][16][17].…”