Cardiogenic shock treated with temporary mechanical circulatory support in Brazil: The effect of learning curve

Abstract

Aims: Treatment with mechanical circulatory support (MCS) has been proposed to mitigate mortality in cardiogenic shock (CS). However, there is a lack of data on MCS programs implementation and the effect of the learning curve on its outcomes in limited resources countries such as Brazil. Methods: Prospective cohort of patients with CS admitted in four tertiary-care centers treated with Impella CP or veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Clinical outcomes were peri-procedural complications, short-term mortality rate, and the centers’ learning curve. The cohort was divided into two periods: from April 2017 to July 2018 ( n = 24), and from August 2018 to December 2020 ( n = 25). Results: The study enrolled 49 patients [age 59 (43–63) years; 34 (70%) males]. The most common causes for CS were acute myocardial infarction in 22 (45%) and acute decompensation of chronic heart failure in 10 (20%). VA-ECMO was employed in 35 (71%) and Impella CP in 14 (29%) of patients. Overall complications occurred in 37 (76%) of patients, where major bleeding in 19 (38%) was the most common. The overall mortality rate was 61%, but it was lower in the second period (40%) in comparison to the first period (83%), p = 0.002. The learning curve analysis showed a decrease in the mortality rate after 40 consecutive cases. Conclusions: Implementation of a temporary MCS program for refractory CS in a limited resource country is feasible. The learning curve effect might have played a role on survival rate since high morbimortality has decreased within time reaching optimal results by the end of the study.

Shock Teams: A Call to Action for the Brazilian Cardiology Community

“…This study evaluated 49 patients treated with MCS, either ECMO (71%) or Impella (29 %), between 2018 and 2020. 2 The main causes of cardiogenic shock were acute myocardial infarction (45%) and decompensated heart failure (20%), with an overall mortality of 61%. Despite the high rate of deaths and complications, there was a progressive improvement in outcomes over the two years of study (83% vs 40% mortality, p = 0.002), which suggests that improvement in MCS results involves a learning curve.…”

“…Despite the high rate of deaths and complications, there was a progressive improvement in outcomes over the two years of study (83% vs 40% mortality, p = 0.002), which suggests that improvement in MCS results involves a learning curve. 2 Experience with cardiogenic shock teams Key studies have been published recently by centers that implemented shock teams (Table 1). Although none of these were clinical trials, the data demonstrated that working in a team led to better outcomes in patients with cardiogenic shock, regardless of ischemic or non-ischemic etiology.…”

“…1 American hospitals participating in the National Cardiogenic Shock Initiative. 2 American hospitals participating in the Critical Care Cardiology Trials Network.…”

“…Despite advances in diagnosis and treatment over the last 30 years, especially in myocardial reperfusion therapies, mortality from cardiogenic shock remains high worldwide, with 50% of cases resulting in adverse outcomes. 1,2 In particular, there has been an increase in the incidence of nonischemic cardiogenic shock (ie, associated with acute and/or advanced chronic heart failure), which has led to a shift with less patients hospitalized due to acute ischemic syndromes in critical cardiology units.. 3,4 In the last decade, due to persistently high mortality and the complexity of presentation and treatment involved in cardiogenic shock, especially of non-ischemic etiology, some institutions, particularly in the United States, developed process of care to improve outcomes for these patients, resulting in "shock teams", which were based on other successful initiatives to manage critical situations through multidisciplinary teams acting according to systematized protocols, such as rapid response teams, trauma teams, and stroke teams. 5,6 In Brazil, however, data on cardiogenic shock are scarce and there are no reports of initiatives involving shock teams.…”

“…5,6 In Brazil, however, data on cardiogenic shock are scarce and there are no reports of initiatives involving shock teams. 2 The shock team concept which uses a standardized treatment algorithm including team activation criteria and mechanical circulatory support (MCS) based on hemodynamic variables, was studied by Tehrani et al in Virginia, USA. 7 In this study, implementation of this system led to a significant increase in the 30-day survival of cardiogenic shock patients compared to the previous year.…”