Improved Survival After Acute Myocardial Infarction Complicated by Cardiogenic Shock With Circulatory Support and Transplantation: Comparing Aggressive Intervention With Conservative Treatment

Tayara, Wakkas; Starling, Randall C.; Yamani, Mohamad H.; Wazni, Oussama; Jubran, Fuad; Smedira, Nicholas G.

doi:10.1016/j.healun.2005.10.011

Cited by 75 publications

(42 citation statements)

References 43 publications

(26 reference statements)

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“…The role of combined treatment is not clear. A nonrandomized comparison of "aggressive" and "conservative" approaches found that early use of circulatory support and heart transplantation was associated with better survival than selection for revascularization, 71 but a study of surgical treatment with LVAD with or without CABG found that mortality was higher in patients who had CABG with LVAD placement early after MI. 72 Two randomized trials of the TandemHeart versus IABP in CS complicating MI have been conducted.…”

Section: Total Circulatory Support: LV Assist Devices and Extracorpormentioning

confidence: 99%

Cardiogenic Shock

2008

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ardiogenic shock (CS) occurs in Ϸ5% to 8% of patients hospitalized with ST-elevation myocardial infarction (STEMI). Recent research has suggested that the peripheral vasculature and neurohormonal and cytokine systems play a role in the pathogenesis and persistence of CS. Early revascularization for CS improves survival substantially. New mechanical approaches to treatment are available, and clinical trials are feasible even in this high-risk population. Most importantly, hospital survivors have an excellent chance for long-term survival with good quality of life. This review will outline the causes, pathophysiology, and treatment of CS with a focus on CS complicating myocardial infarction (MI.) The case will be made for viewing CS as a serious disorder with a high early death rate, but one that is treatable and that, if approached aggressively, can result in full recovery. The diagnosis is usually made with the help of pulmonary artery (PA) catheterization; however, Doppler echocardiography may also be used to confirm elevation of LV filling pressures. 1 Hypoperfusion may be manifest clinically by cool extremities, decreased urine output, and/or alteration in mental status. Hemodynamic abnormalities form a spectrum that ranges from mild hypoperfusion to profound shock, and the short-term outcome is directly related to the severity of hemodynamic derangement. MI with LV failure remains the most common cause of CS. It is critical to exclude complicating factors that may cause shock in MI patients. Chief among these are the mechanical complications: ventricular septal rupture, contained free wall rupture, and papillary muscle rupture. Mechanical complications must be strongly suspected in patients with CS complicating nonanterior MI, particularly a first MI. Echocardiography is the technique of choice to rule out these entities and should be performed early unless the diagnosis is extensive anterior MI and the patient is undergoing prompt percutaneous coronary intervention (PCI). In addition, the detection of valvular disease before angiography may alter the revascularization approach. Diagnosis and CausesHemorrhage, infection, and/or bowel ischemia may contribute to shock in the setting of MI. As with mechanical complications, a high index of suspicion is required to make these diagnoses in MI patients, and survival may depend on timely recognition and treatment.Any cause of acute, severe LV or RV dysfunction may lead to CS. Acute myopericarditis, tako-tsubo cardiomyopathy, and hypertrophic cardiomyopathy may all present with ST elevation, release of cardiac markers, and shock in the absence of significant coronary artery disease. Stress-induced cardiomyopathy, also known as apical ballooning or takotsubo cardiomyopathy, is a syndrome of acute LV dysfunction after emotional or respiratory distress that leads to CS in 4.2% of cases. 2 Acute valvular regurgitation, typically caused by endocarditis or chordal rupture due to trauma or degenerative disease, may also cause CS. Aortic dissection may lead to CS via acute,...

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Section: Total Circulatory Support: LV Assist Devices and Extracorpormentioning

confidence: 99%

Cardiogenic Shock

2008

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“…17 Improving the availability of this technology at centers offering CABG may represent an opportunity to save more lives. 18 Although emergent revascularization has been shown to improve outcomes in patients with cardiogenic shock, 5 the optimal revascularization strategy in patients with cardiogenic shock needs to be determined. The 22% overall mortality (18% versus 31% in those aged Ͻ75 and Ն75 years, respectively) observed for the cohort with cardiogenic shock undergoing CABG may appear to be low but is a stable estimate among a large number of such patients at a national level.…”

Section: Discussionmentioning

confidence: 99%

Clinical Characteristics and In-Hospital Outcomes of Patients With Cardiogenic Shock Undergoing Coronary Artery Bypass Surgery

et al. 2008

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Background-There exist few studies that characterize contemporary clinical features and outcomes or risk factors for operative mortality in cardiogenic shock (CS) patients undergoing coronary artery bypass grafting (CABG). Methods and Results-We evaluated data of 708 593 patients with and without CS undergoing CABG enrolled in the Society of Thoracic Surgeons National Cardiac Database (2002Database ( -2005. Clinical, angiographic, and operative features and in-hospital outcomes were evaluated in patients with and without CS. Logistic regression was used to identify predictors of operative mortality and to estimate weights for an additive risk score. Patients with preoperative CS constituted 14 956 (2.1%) of patients undergoing CABG yet accounted for 14% of all CABG deaths. Operative mortality in CS patients was high and surgery specific, rising from 20% for isolated CABG to 33% for CABG plus valve surgery and 58% for CABG plus ventricular septal repair. Although mortality for CABG surgery overall declined significantly over time (P for trend Ͻ0.0001), mortality for CS patients undergoing CABG did not change significantly during the 4-year study period (Pϭ0.07). Factors associated with higher death risk for CS patients undergoing CABG were identified by multivariable analysis and summarized into a simple bedside risk score (c statisticϭ0.74) that accurately stratified those with low (Ͻ10%) to very high (Ͼ60%) mortality risk. Conclusions-Patients with CS represent a minority of those undergoing CABG yet have persistently high operative risks, accounting for 14% of deaths in CABG patients. Estimation of patient-specific risk of mortality is feasible with the simplified additive risk tool developed in our study with the use of routinely available preprocedural data. (Circulation. 2008;117:876-885.)

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“…This is best summarised in a meta-analysis by Cheng et al, with a conclusion that despite better haemodynamic profile mortality does not decrease significantly [45]. However, these devices may be a bridge to heart transplantation or -if the donor is lacking -to total artificial heart implantation and staged transplantation with an excellent long-term survival [46][47][48].…”

Section: Novel Devices and Areas Of Future Researchmentioning

confidence: 99%

The management of patients with cardiogenic shock

Sadowski¹,

Janion−Sadowska²

2017

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Cardiogenic shock is a life-threatening condition with a very poor prognosis. Many disorders may contribute to the development of shock. Of them, acute myocardial infarction is the main culprit. Despite tremendous progress in the field of interventional cardiology, in-hospital and long-term mortality still exceeds 50%. Data from large controlled trials on cardiogenic shock are scarce due to ethical reasons. Nevertheless, there is a chance for acceptable long-term survival in patients treated aggressively. The aim of this review is to summarise the key points of differential diagnosis and to emphasise that in most cases of shock due to acute myocardial infarction primary coronary intervention is the treatment of choice. StreszczenieWstrząs kardiogenny jest stanem zagrożenia życia o bardzo złym rokowaniu. Wiele sytuacji klinicznych przyczynia się do rozwoju wstrząsu, ale ostry zawał serca stanowi najczęstszą przyczynę. Pomimo olbrzymiego postępu w kardiologii interwencyjnej śmiertelność szpitalna i długoterminowa nadal przekracza 50%. Z powodów etycznych nie dysponujemy danymi z kontrolowanych badań klinicznych. Niemniej agresywne leczenie stwarza szansę na uzyskanie akceptowalnego poziomu śmier-telności w tej grupie chorych. Celem pracy jest próba podsumowania najważniejszych elementów diagnostyki różnicowej oraz wykazanie, że pilna rewaskularyzacja za pomocą angioplastyki wieńcowej jest leczeniem z wyboru w większości przypadków.

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Improved Survival After Acute Myocardial Infarction Complicated by Cardiogenic Shock With Circulatory Support and Transplantation: Comparing Aggressive Intervention With Conservative Treatment

Cited by 75 publications

References 43 publications

Cardiogenic Shock

Cardiogenic Shock

Clinical Characteristics and In-Hospital Outcomes of Patients With Cardiogenic Shock Undergoing Coronary Artery Bypass Surgery

The management of patients with cardiogenic shock

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