Clinical Outcomes Associated With Acute Mechanical Circulatory Support Utilization in Heart Failure Related Cardiogenic Shock

Abstract

Background: Cardiogenic shock occurring in the setting of advanced heart failure (HF-CS) is increasingly common. However, recent studies have focused almost exclusively on acute myocardial infarction-related CS. We sought to define clinical, hemodynamic, metabolic, and treatment parameters associated with clinical outcomes among patients with HF-CS, using data from the Cardiogenic Shock Working Group registry. Methods: Patients with HF-CS were identified from the multicenter Cardiogenic Shock Working Group registry and divided into 3 outcome categories assessed at hospital discharge: mortality, heart replacement therapy (HRT: durable ventricular assist device or orthotopic heart transplant), or native heart survival. Clinical characteristics, hemodynamic, laboratory parameters, drug therapies, acute mechanical circulatory support device (AMCS) utilization, and Society of Cardiovascular Angiography and Intervention stages were compared across the 3 outcome cohorts. Results: Of the 712 patients with HF-CS identified, 180 (25.3%) died during their index admission, 277 (38.9%) underwent HRT (durable ventricular assist device or orthotopic heart transplant), and 255 (35.8%) experienced native heart survival without HRT. Patients who died had the highest right atrial pressure and heart rate and the lowest mean arterial pressure of the 3 outcome groups ( P <0.01 for all). Biventricular and isolated left ventricular congestion were common among patients who died or underwent HRT, respectively. Lactate, blood urea nitrogen, serum creatinine, and aspartate aminotransferase were highest in patients with HF-CS experiencing in-hospital death. Intraaortic balloon pump was the most commonly used AMCS device in the overall cohort and among patients receiving HRT. Patients receiving >1 AMCS device had the highest in-hospital mortality rate irrespective of the number of vasoactive drugs used. Mortality increased with deteriorating Society of Cardiovascular Angiography and Intervention stages (stage B: 0%, stage C: 10.7%, stage D: 29.4%, stage E: 54.5%, 1-way ANOVA=<0.001). Conclusions: Patients with HF-CS experiencing in-hospital mortality had a high prevalence of biventricular congestion and markers of end-organ hypoperfusion. Substantial heterogeneity exists with use of AMCS in HF-CS with intraaortic balloon pump being the most common device used and high rates of in-hospital mortality after exposure to >1 AMCS device.

Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association

“…Although significant heterogeneity was noted with respect to tMCS device use in HF-CS, IABP was the most common device used in the overall cohort and in patients receiving durable LVAD and heart transplantation. 77…”

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery

“…The preferred outcome for any patient managed with tMCS is a bridge to recovery. A recent multicentre HF-CS registry reported overall rates of recovery of 36% [11 ▪▪ ]. The ability to achieve this outcome is highly dependent on the context, as patients with acute events, such as AMI or myocarditis, have a much higher likelihood of recovery than patients with a decompensation of chronic heart failure.…”

“…In severe HF-CS that requires tMCS, successful bridging to recovery remains an unlikely outcome. Among patients in the Cardiogenic Shock Working Group registry who received at least one tMCS device, in-hospital mortality ranged from 23 to 55% [11 ▪▪ ].…”

Heart Failure-Related Cardiogenic Shock: Pathophysiology, Evaluation and Management Considerations

“…23 Whereas NHR is the therapeutic endpoint in most cases of AMI-CS, LVAD or HT are more likely outcomes in HF-CS. 35,36 Of HF-CS patients in the CSWG registry, 39% underwent HRT and 37% experienced NHR. In contrast, among the estimated 70%-80% patients who survive AMI-CS, almost 90% experience NHR.…”