Background
The National Cardiogenic Shock Initiative is a single‐arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI).
Methods
Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the “SHOCK” trial with an additional exclusion criteria of intra‐aortic balloon pump counter‐pulsation prior to MCS.
Results
A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in‐hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST‐elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min.
Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12–24 hr reliably predicted overall mortality postindex procedure.
Conclusion
In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.
OTIVATED BY MORBIDITY attributable to cardiopulmonary bypass, 1-3 US surgeons performed approximately 21% of coronary artery bypass operations off-pump in 2002. 4 Nonetheless, concern remains about the technical difficulty of off-pump coronary artery bypass (OPCAB), including the possibility of imprecise anastomoses and incomplete revascularization compromising patient outcomes. 5-9 Two prospective, randomized studies 10,11 and all but a few 12 retrospective comparisons have reported significantly fewer grafts in OPCAB. Retrospective studies among selected patients showing sig
This pivotal multicenter study with a robotic-enhanced coronary intervention system demonstrated the safety and feasibility of the system. The robotic remote-control procedure met the expected technical and clinical performance, with significantly lower radiation exposure to the operator. (Evaluation of the Safety and Effectiveness of the CorPath 200 System in Percutaneous Coronary Interventions [PCI] [PRECISE]; NCT01275092).
An endothelium-dependent vasodilator response to acetylcholine has been described recently in patients with coronary artery disease. Those studies determined responses only of large epicardial arteries. Our study was designed to determine the integrated effects of acetylcholine on epicardial diameter, coronary flow, and vascular resistance. Patients (n=64) with nonstenotic epicardial coronaries underwent coronary angiography with simultaneous recording of coronary flow velocity using a 3F subselective Doppler catheter. Measurements of epicardial arterial cross-sectional area (ECA), velocity, estimated flow (velocity times area), and vascular resistance were made before and after bolus administration of acetylcholine (100 ,ug i.c.). Similar measurements were made after papaverine (12-15 mg i.c.), a nonendothelium-dependent vasodilator. Acetylcholine resulted in a reduction of ECA of 19±3%, whereas papaverine increased ECA by 9±2%. Estimated flow increased 69±12% after acetylcholine and 147±12% after papaverine. Resistance fell after both agents (acetylcholine, -17+13%; papaverine, -61±2%). Transvascular resistance fell after acetylcholine in all but five patients. These patients had dramatic epicardial artery constriction (40±8% decrease in ECA). The effect of acetylcholine on both ECA and resistance was blocked by atropine (1 mg i.c.). Nitroglycerin (300 ,jg i.c.) resulted in epicardial dilatation (7.5±2.8%) in the same patients in whom acetylcholine caused constriction (-11.2+3.1%o). Pretreatment with methylene blue, an inhibitor of endothelium-derived relaxing factor (EDRF), potentiated epicardial artery vasoconstriction with acetylcholine (-25±7%o before versus -47±11% after, p
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