Background
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is being increasingly used to treat cardiogenic shock, however its effect on increasing left ventricular (LV) afterload may slow myocardial recovery and negatively affect survival. Percutaneous mechanical support devices have been utilized for LV unloading by reducing afterload in an attempt to improve outcomes. While the use of LV unloading devices remains debatable, its use has not been specifically studied in patients with non-acute myocardial infarction cardiogenic shock (non-AMICS).
Purpose
To study the outcomes of VA-ECMO with or without LV unloading devices in patients with non-AMICS patients.
Methods
National inpatient sample database from years 2015 to 2018 was queried to select patients admitted with non-AMICS. Patients were included in the study if they underwent VA-ECMO during admission and later categorized into 3 groups i.e. VA-ECMO, VA-ECMO plus Impella and VA-ECMO plus intra-aortic balloon pump (IABP). Baseline demographics and in-hospital outcomes were compared between the 3 pre-specified groups. Statistical significance was assigned at p<0.05.
Results
178,605 patients met criteria for non-AMICS. Of these, 2190 (1.23%) patients received VA-ECMO alone, 965 (0.54%) received VA-ECMO plus IABP and 414 (0.23%) received VA-ECMO plus Impella. On univariate analysis, patients who received VA-ECMO alone had higher rates of inpatient mortality as compared to those who received VA-ECMO plus IABP or VA-ECMO plus Impella (39.04%, 33.72% and 25.81% respectively, p=0.001). On multivariate analysis, the patients who received VA-ECMO plus IABP or VA-ECMO plus Impella had lower odds of mortality when compared to VA-ECMO alone (OR: 0.61 (0.39–0.96), p=0.03), OR: 0.51 (0.23–1.08), p=0.08). The length of stay and cost were significantly higher for patients with VA-ECMO with unloading devices (IABP or Impella) compared with VA-ECMO alone (24.77±2.44 and 27.74±3.55 days vs 23.70±1.25 days respectively. p=0.001, $846,404±71169 and 860,999±121942 vs $740,274±43644 respectively, p=0.001).
Conclusions
Non AMICS patients who received VA-ECMO along with LV unloading devices (esp IABP) had lower in-hospital mortality as compared to those who received VA-ECMO alone despite having longer length of stay and higher cost. Use of LV unloading devices like IABP or Impella may improve outcomes in patients requiring VA-ECMO support for non-myocardial infarction cardiogenic shock. Further studies are needed to identify specific patient subsets that may benefit from this approach.
FUNDunding Acknowledgement
Type of funding sources: None.
Introduction. The last decade has witnessed major evolution and shifts in the use of transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Included among the shifts has been the advent of alternative access sites for TAVR. Consequently, transapical access (TA) has become significantly less common. This study analyzes in detail the trend of TA access for TAVR over the course of 7 years. Methods. The national inpatient sample database was reviewed from 2011–2017 and patients with AS were identified by using validated ICD 9-CM and ICD 10-CM codes. Patients who underwent TAVR through TA access were classified as TA-TAVR, and any procedure other than TA access was classified as non-TA-TAVR. We compared the yearly trends of TA-TAVR to those of non-TA-TAVR as the primary outcome. Results. A total of 3,693,231 patients were identified with a diagnosis of AS. 129,821 patients underwent TAVR, of which 10,158 (7.8%) underwent TA-TAVR and 119,663 (92.2%) underwent non-TA-TAVR. After peaking in 2013 at 27.7%, the volume of TA-TAVR declined to 1.92% in 2017 (
p
<
0.0001
). Non-TA-TAVR started in 2013 at 72.2% and consistently increased to 98.1% in 2017. In-patient mortality decreased from a peak of 5.53% in 2014 to 3.18 in 2017 (
p
=
0.6
) in the TA-TAVR group and from a peak of 4.51% in 2013 to 1.24% in 2017 (
p
=
0.0001
) in the non-TA-TAVR group. Conclusion. This study highlights a steady decline in TA access for TAVR, higher inpatient mortality, increased length of stay, and higher costs compared to non-TA-TAVR.
Background: Large bore access procedures rely on vascular closure devices to minimize access site complications. Suture-based vascular closure devices (S-VCD) such as ProGlide and ProStar XL have been readily used, but recently, newer generation collagen-based vascular closure devices (C-VCD) such as MANTA have been introduced. Data on comparisons of these devices are limited. Methods: PubMed, Scopus and Cochrane were searched for articles on vascular closure devices using keywords, (“Vascular closure devices” OR “MANTA” OR “ProStar XL” OR “ProGlide”) AND (“outcomes”) that resulted in a total of 875 studies. Studies were included if bleeding or vascular complications as defined by Valve Academic Research Consortium-2 were compared between the two types of VCDs. The event level data were pooled across trials to calculate the Odds Ratio (OR) with 95% CI, and analysis was done with Review Manager 5.4 using random effects model. Results: Pooled analyses from these nine studies resulted in a total of 3410 patients, out of which 2855 were available for analysis. A total of 1229 received C-VCD and 1626 received S- VCD. Among the patients who received C-VCD, the bleeding complications (major and minor) were similar to patients who received S-VCD ((OR: 0.70 (0.35–1.39), p = 0.31, I2 = 55%), OR:0.92 (0.53–1.61), p = 0.77, I2 = 65%)). The vascular complications (major and minor) in patients who received C-VCD were also similar to patients who received S-VCD ((OR: 1.01 (0.48–2.12), p = 0.98, I2 = 52%), (OR:0.90 (0.62–1.30), p = 0.56, I2 = 35%)). Conclusions: Bleeding and vascular complications after large bore arteriotomy closure with collagen-based vascular closure devices are similar to suture-based vascular closure devices.
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