Impella and venoarterial extracorporeal membrane oxygenation in cardiogenic shock complicating acute myocardial infarction

Abstract

AimsThis research aimed to give contemporary insight into the use of Impella and venoarterial extracorporeal membrane oxygenation (VA‐ECMO) in myocardial infarction‐related cardiogenic shock (AMICS) and into associated outcomes, adverse events, and resource demands.Methods and ResultsThis nationwide observational cohort study describes all AMICS patients treated with Impella(ABIOMED, Danvers, USA) and/or VA‐ECMO in 2020–2021. Impella and/or VA‐ECMO were used in 20% of all AMICS cases(n = 4088). Impella patients were older (34% vs 13% >75 years, p < 0.001) and less frequently presented after an out‐of‐hospital cardiac arrest (18% vs. 40%, p < 0.001). In‐hospital mortality was lower in the Impella versus VA‐ECMO cohort (61% vs. 67%, p = 0.001). Adverse events occurred less frequently in Impella‐supported patients: Acute haemorrhagic anaemia (36% vs. 68%, p < 0.001), cerebrovascular accidents (4% vs. 11%, p < 0.001), thromboembolisms of the extremities (5% vs. 8%, p < 0.001), systemic inflammatory response syndrome (21% vs. 25%, p = 0.004), acute kidney injury (44% vs. 53%, p < 0.001), and acute liver failure (7% vs. 12%, p < 0.001). Impella patients were discharged home directly more often (20% vs. 11%, p < 0.001) whereas VA‐ECMO patients were more often discharged to another care facility (22% vs. 19%, p = 0.031). Impella patients had shorter hospital stays and lower hospital costs.ConclusionThis is the largest, most recent European cohort study describing outcomes, adverse events, and resource demands based on claims data in patients with Impella and/or VA‐ECMO. Overall, adverse event rates and resource consumption were high. Given the current lack of beneficial evidence, our study reinforces the need for prospectively established, high‐quality evidence to guide clinical decision making.This article is protected by copyright. All rights reserved.

Persistent high mortality in acute myocardial infarction‐associated cardiogenic shock despite early mechanical circulatory support: Need for stepwise and integrated approach of care

“…Despite today's doctors having access to an extensive array of high-technological heart and lung-supporting devices to acutely support critically ill patients, the mortality among this precarious patient group remains exceedingly high. Here, we discuss the recent large nationwide German database by Bogerd et al 1 which reported that 8% of patients with acute myocardial infarction (AMI) who underwent a percutaneous coronary intervention (n = 256 112) presented with cardiogenic shock (CS) (n = 4088) and that AMI complicated by CS (AMICS) is still associated with a high in-hospital mortality (more than one out of two patients) in line with recent registries 2 and randomized controlled trials. 3 This contemporary real-world experience (2020-2021) is particularly valuable, as opposed to previous studies with similar methodology from the US 4 which evaluated almost 20 years of care, with inherent limitations of major changes introduced in all aspects of care over the study timeline.…”

“…In this large nationwide study, only few patients were bridged to heart replacement therapies (<10) as it was the case in the IABP-SHOCK II study (33/598 patients received a VAD [5.5% of the whole population] and none HTx) and the ECLS-SHOCK trial (no VAD or HTx reported) signing the absence of consideration of the global patient trajectory in case of lack of recovery (>50% of death causes were secondary to refractory CS in the IABP-SHOCK II and ECLS-SHOCK trials). 1,3,7 The pre-determined endpoint of short-term mortality is subject to debate as in-hospital/30-day mortality is probably too short and insufficient to cover and consider potential benefit/harms of each therapeutic strategy. The use of aMCS is associated with frequent and potentially severe complications responsible for acute consequences, high costs and chronic psychological (depression, post-traumatic stress disorders) and physical sequalae (intensive care unit-associated neuropathy, sarcopenia, infections, altered mental state) that are rarely studied and reported.…”

“…Therefore, considering the narrow therapeutic window of aMCS use with its complex benefit-risk ratio, high rates of complications, high resource utilization and costs, and the absence of solid clinical proofs, we need CS expert multidisciplinary centres and specialized networks able to provide up-to-date dedicated and personalized patient-centred care, as suggested by European and US guidelines for advanced heart failure. 10,12,13 In the post-ECLS-SHOCK era, the real-life results of Bogerd et al 1 learn us a few things: (i) not all AMICS receive MCS, but only 20% (Thiele et al 3 Futures studies should consider a standardized step-by-step approach for AMICS integrating (i) CS diagnosis and severity of shock grading using the SCAI classification 14 and other biological, echocardiographic and haemodynamic parameters, (ii) global standardized protocols of care including not only aMCS (type, mode and timing of insertion, management and follow-up, weaning strategy) 15 but also associated medical management considering coronary revascularization, critical care (inotropic agents and dose, ventilation strategy, renal replacement therapy, anticoagulation management, etc. ), and (iii) well-defined patient trajectory (possible HTx or VAD) to improve short-and long-term outcomes of AMICS patients.…”

Contemporary use of temporary mechanical circulatory support in infarct‐related cardiogenic shock: Time to stop and reflect?

“…In this issue of the Journal, Bogerd and colleagues present data on contemporary use of MCS for AMICS in Germany in 2020-2021. 3 MCS was used in 4088 out of 20 399 patients (20%) with AMICS. The most frequently used device was mAFP and least frequent combination of mAFP and VA-ECMO (ECMELLA).…”

“…Observational studies like the study by Bogerd et al 3 will still be important in AMICS to demonstrate real-life standard of care, but retrospective analyses of administrative databases are not suited for assessing efficacy. Even trying to identify patients most likely to benefit or being harmed by MCS from large registries with in-depth knowledge of haemodynamic and metabolic status may be problematic.…”