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Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock

Published:December 17, 2016DOI:https://doi.org/10.1016/j.amjcard.2016.11.037
      The role and timing of percutaneous mechanical circulatory support (MCS) devices in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS) are not well understood. We sought to evaluate patient characteristics and predictors of outcomes in patients presenting with AMICS supported with an axial flow percutaneous MCS device; 287 consecutive unselected patients enrolled in the catheter-based ventricular assist device registry presenting with AMICS who underwent percutaneous coronary intervention (PCI) were included in this analysis. All patients were supported with either the Impella 2.5 or Impella CP. Mean patient age was 66 ± 12.5 years, 76% were men, and mean left ventricular ejection fraction was 25 ± 12%. Before receiving MCS, 80% of patients required inotropes or vasopressors and 40% were supported with intra-aortic balloon pump; 9% of patients were under active cardiopulmonary resuscitation at the time of MCS implantation. Survival to discharge was 44%. In a multivariate analysis, early implantation of a MCS device before PCI (p = 0.04) and before requiring inotropes and vasopressors (p = 0.05) was associated with increased survival. Survival was 66% when MCS was initiated <1.25 hours from shock onset, 37% when initiated within 1.25 to 4.25 hours, and 26% when initiated after 4.25 hours (p = 0.017). Survival was 68%, 46%, 35%, 35%, and 26% for patients requiring 0, 1, 2, 3, and ≥4 inotropes before MCS support, respectively (p <0.001). In conclusion, MCS implantation early after shock onset, before initiation of inotropes or vasopressors and before PCI, is independently associated with improved survival in patients presenting with AMICS.
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      References

        • Seyfarth M.
        • Sibbing D.
        • Bauer I.
        • Fröhlich G.
        • Bott-Flügel L.
        • Byrne R.
        • Dirschinger J.
        • Kastrati A.
        • Schömig A.
        A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction.
        J Am Coll Cardiol. 2008; 52: 1584-1588
        • Sauren L.D.
        • Accord R.E.
        • Hamzeh K.
        • de Jong M.
        • van der Nagel T.
        • van der Veen F.H.
        • Maessen J.G.
        Combined Impella and intra-aortic balloon pump support to improve both ventricular unloading and coronary blood flow for myocardial recovery: an experimental study.
        Artif Organs. 2007; 31: 839-842
        • Meyns B.
        • Stolinski J.
        • Leunens V.
        • Verbeken E.
        • Flameng W.
        Left ventricular support by catheter-mounted axial flow pump reduces infarct size.
        Am Coll Cardiol. 2003; 41: 1087-1095
        • Remmelink M.
        • Sjauw K.D.
        • Henriques J.P.
        • de Winter R.J.
        • Koch K.T.
        • van der Schaaf R.J.
        • Vis M.M.
        • Tijssen J.G.
        • Piek J.J.
        • Baan Jr., J.
        Effects of left ventricular unloading by Impella recover LP2.5 on coronary hemodynamics.
        Catheter Cardiovasc Interv. 2007; 70: 532-537
        • Aqel R.A.
        • Hage F.G.
        • Iskandrian A.E.
        Improvement of myocardial perfusion with a percutaneously inserted left ventricular assist device.
        J Nucl Cardiol. 2010; 17: 158-160
        • Lam K.
        • Sjauw K.D.
        • Henriques J.P.
        • Ince C.
        • de Mol B.A.
        Improved microcirculation in patients with an acute ST-elevation myocardial infarction with the Impella LP2.5 percutaneous left ventricular assist device.
        Clin Res Cardiol. 2009; 98: 311-318
        • O'Neill W.W.
        • Schreiber T.
        • Wohns D.H.
        • Rihal C.
        • Naidu S.S.
        • Civitello A.B.
        • Dixon S.R.
        • Massaro J.M.
        • Maini B.
        • Ohman E.M.
        The current use of Impella 2.5 in acute myocardial infarction complicated by cardiogenic shock: results from the USpella Registry.
        J Interv Cardiol. 2014; 27: 1-11
        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • Casey Jr., D.E.
        • Chung M.K.
        • de Lemos J.A.
        • Ettinger S.M.
        • Fang J.C.
        • Fesmire F.M.
        • Franklin B.A.
        • Granger C.B.
        • Krumholz H.M.
        • Linderbaum J.A.
        • Morrow D.A.
        • Newby L.K.
        • Ornato J.P.
        • Ou N.
        • Radford M.J.
        • Tamis-Holland J.E.
        • Tommaso C.L.
        • Tracy C.M.
        • Woo Y.J.
        • Zhao D.X.
        • American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice guidelines.
        J Am Coll Cardiol. 2013; 61: e78-e140
        • Windecker S.
        • Kolh P.
        • Alfonso F.
        • Collet J.P.
        • Cremer J.
        • Falk V.
        • Filippatos G.
        • Hamm C.
        • Head S.J.
        • Jüni P.
        • Kappetein A.P.
        • Kastrati A.
        • Knuuti J.
        • Landmesser U.
        • Laufer G.
        • Neumann F.J.
        • Richter D.J.
        • Schauerte P.
        • Sousa Uva M.
        • Stefanini G.G.
        • Taggart D.P.
        • Torracca L.
        • Valgimigli M.
        • Wijns W.
        • Witkowski A.
        2014 ESC/EACTS guidelines on myocardial revascularization.
        Eur Heart J. 2014; 35: 2541-2619
        • Hochman J.S.
        • Sleeper L.A.
        • Webb J.G.
        • Sanborn T.A.
        • White H.D.
        • Talley J.D.
        • Buller C.E.
        • Jacobs A.K.
        • Slater J.N.
        • Col J.
        • McKinlay S.M.
        • LeJemtel T.H.
        Early revascularization in acute myocardial infarction complicated by cardiogenic shock.
        N Engl J Med. 1999; 341: 625-634
        • Thiele H.
        • Zeymer U.
        • Neumann F.J.
        • Ferenc M.
        • Olbrich H.G.
        • Hausleiter J.
        • Richardt G.
        • Hennersdorf M.
        • Empen K.
        • Fuernau G.
        • Desch S.
        • Eitel I.
        • Hambrecht R.
        • Fuhrmann J.
        • Böhm M.
        • Ebelt H.
        • Schneider S.
        • Schuler G.
        • Werdan K.
        Intraaortic balloon support for myocardial infarction with cardiogenic shock.
        N Engl J Med. 2012; 367: 1287-1296
        • Hochman J.S.
        • Buller C.E.
        • Sleeper L.A.
        • Boland J.
        • Dzavik V.
        • Sanborn T.A.
        • Godfrey E.
        • White H.D.
        • Lim J.
        • LeJemtel T.
        Cardiogenic shock complicating acute myocardial infarction—etiologies, management and outcome: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?.
        J Am Coll Cardiol. 2000; 36: 1063-1070
        • Lauten A.
        • Engström A.E.
        • Jung C.
        • Empen K.
        • Erne P.
        • Cook S.
        • Windecker S.
        • Bergmann M.W.
        • Klingenberg R.
        • Lüscher T.F.
        • Haude M.
        • Rulands D.
        • Butter C.
        • Ullman B.
        • Hellgren L.
        • Modena M.G.
        • Pedrazzini G.
        • Henriques J.P.
        • Figulla H.R.
        • Ferrari M.
        Percutaneous left-ventricular support with the Impella-2.5-assist device in acute cardiogenic shock: results of the Impella-EUROSHOCK-registry.
        Circ Heart Fail. 2013; 6: 23-30
        • Stamm C.
        • Friehs I.
        • Cowan D.B.
        • Cao-Danh H.
        • Choi Y.H.
        • Duebener L.F.
        • McGowan F.X.
        • del Nido P.J.
        Dopamine treatment of postischemic contractile dysfunction rapidly induces calcium-dependent pro-apoptotic signaling.
        Circulation. 2002; 106: 290-298
        • Lin H.
        • Young D.B.
        Opposing effects of plasma epinephrine and norepinephrine on coronary thrombosis in vivo.
        Circulation. 1995; 91: 1135-1142
        • Jolly S.
        • Newton G.
        • Horlick E.
        • Seidelin P.H.
        • Ross H.J.
        • Husain M.
        • Dzavik V.
        Effect of vasopressin on hemodynamics in patients with refractory cardiogenic shock complicating acute myocardial infarction.
        Am J Cardiol. 2005; 96: 1617-1620
        • Kapur N.K.
        • Qiao X.
        • Paruchuri V.
        • Morine K.J.
        • Syed W.
        • Dow S.
        • Shah N.
        • Pandian N.
        • Karas R.H.
        Mechanical pre-conditioning with acute circulatory support before reperfusion limits infarct size in acute myocardial infarction.
        JACC Heart Fail. 2015; 3: 873-882
        • Tamareille S.
        • Achour H.
        • Amirian J.
        • Felli P.
        • Bick R.J.
        • Poindexter B.
        • Geng Y.J.
        • Barry W.H.
        • Smalling R.W.
        Left ventricular unloading before reperfusion reduces endothelin-1 release and calcium overload in porcine myocardial infarction.
        J Thorac Cardiovasc Surg. 2008; 136: 343-351
        • Achour H.
        • Boccalandro F.
        • Felli P.
        • Amirian J.
        • Uthman M.
        • Buja M.
        • Smalling R.W.
        Mechanical left ventricular unloading prior to reperfusion reduces infarct size in a canine infarction model.
        Catheter Cardiovasc Interv. 2008; 64: 182-192
        • Patel M.R.
        • Smalling R.W.
        • Thiele H.
        • Barnhart H.X.
        • Zhou Y.
        • Chandra P.
        • Chew D.
        • Cohen M.
        • French J.
        • Perera D.
        • Ohman E.M.
        Intra-aortic balloon counterpulsation and infarct size in patients with acute anterior myocardial infarction without shock: the CRISP AMI randomized trial.
        JAMA. 2011; 306: 1329-1337
        • Acharya D.
        • Loyaga-Rendon R.Y.
        • Pamboukian S.V.
        • Tallaj J.A.
        • Holman W.L.
        • Cantor R.S.
        • Naftel D.C.
        • Kirklin J.K.
        Ventricular assist device in acute myocardial infarction.
        J Am Coll Cardiol. 2016; 67: 1871-1880
        • Griese D.P.
        • Reents W.
        • Diegeler A.
        • Kerber S.
        • Babin-Ebell J.
        Simple, effective and safe vascular access site closure with the double-ProGlide preclose technique in 162 patients receiving transfemoral transcatheter aortic valve implantation.
        Catheter Cardiovasc Interv. 2013; 82: E734-E741