Escalation of temporary mechanical circulatory support in the setting of deteriorating cardiogenic shock
Isseh IN, Dagher C, Sharma S, Basir MB, and Parikh S. Escalation of temporary mechanical circulatory support in the setting of deteriorating cardiogenic shock. Catheterization and Cardiovascular Interventions 2020; 95:S178.
Catheterization and cardiovascular interventions
Background: Cardiogenic shock (CS) is a deadly condition and mechanical circulatory support (MCS) is frequently utilized. We evaluated the characteristics of CS patients who required escalation of MCS due to deteriorating shock.
Methods: From 07/2016-07/2018 we identified consecutive CS patients with deteriorating shock requiring escalation of MCS. Deteriorating shock was defined as worsening hypotension, escalating doses of vasopressors or worsening end-organ hypoperfusion. MCS escalation was defined as adding or exchanging a MCS device to existing MCS. All statistical tests were performed with a two-sided P value=.05.
Results: 81 CS patients (61 ±14.2y, 73% men) had deteriorating shock requiring MCS escalation. 23% presented with acute myocardial infarction, 72% with decompensated heart failure (non-ischemic cardiomyopathy 26% and ischemic cardiomyopathy 46%) and 5% undifferentiated. Distribution of CS per SCAI classification was stage C 7%, D 82% and E 11%. Survival to discharge was 32%. Survivors were younger (55 vs 65y, P=0.002) and had lower BMI (29 vs 34, P=0.031). Initial MCS was IABP (n=32), Impella 2.5 (=4), CP (=32), 5.0 (=2), TandemHeart (=3), ProtekDuo (=3), VVECMO (=2), VAECMO (=2) and ProtekDuo+Impella CP (=1). Patients were escalated to Impella 2.5 (n=1), CP (=16), 5.0 (=10), TandemHeart (=6), VAECMO (=8), VAECMO+(IABP, 2.5 or CP) (=20), ProtekDuo+(IABP, CP, 5.0 or TandemHeart) (=13), Impella CP+RP (=2), TandemHeart+Impella RP (=1), central VAECMO (=3) and LVAD (=1). Lactate levels pre and post escalation were lower in survivors compared to non-survivors (3.3 vs 6.9, P=0.02) and (2 vs 4.4, P=0.01). Non-survivor lactate levels did not significantly improve post escalation (6.9 vs 4.4, P=0.06) and mean arterial pressure decreased (77.1 vs 66.8, P=0.002) despite significant improvement in cardiac index (1.9 vs 3.4, P<0.001) and cardiac power output (0.6 vs 1.1, P=0.0001). Utilization of a PA catheter preescalation was associated with improved survival (40% vs 18%, P=0.04).
Conclusions: CS patients requiring escalation of MCS due to deteriorating shock have low hospital survival (32%). Younger age, lower BMI, lower lactate levels and utilization of PA catheter pre-escalation were associated with increased survival.