Prognostic implications of microcirculatory perfusion versus macrocirculatory perfusion in cardiogenic shock: a CULPRIT-SHOCK substudy

Abstract

Background: After early revascularisation, restoration of macrocirculatory perfusion parameters is the primary objective in the management of cardiogenic shock complicated acute myocardial infarction. Nevertheless, vital organ perfusion may be compromised at the systemic microcirculatory level, even in patients with preserved macrohaemodynamics. Microvascular perfusion was shown to have independent prognostic value for early mortality. The present study aims to compare the prognostic value of microcirculatory versus macrocirculatory perfusion parameters. Methods: This substudy of the culprit lesion-only percutaneous coronary intervention versus multivessel percutaneous coronary intervention in cardiogenic shock (CULPRIT-SHOCK) trial examined the sublingual capillary network using videomicroscopy post-percutaneous coronary intervention to determine the proportion of perfused capillaries (<20 µm) and perfused capillary density. Thirty-day follow-up was performed to obtain the occurrence of a combined clinical endpoint of all-cause death and renal replacement therapy. Results: Videomicroscopy measurements were performed in 66 patients. There was a significant adjusted association between microcirculatory perfusion parameters and the combined clinical endpoint (proportion of perfused capillaries: P=0.020; perfused capillary density: P=0.035), whereas there was no significant adjusted association between macrocirculatory perfusion parameters and the combined clinical endpoint (systolic blood pressure: P=0.205). Normotensive patients with compromised microcirculatory perfusion parameters had a higher risk of the combined clinical endpoint than normotensive patients with preserved microcirculatory perfusion parameters (proportion of perfused capillaries: Breslow P=0.014; perfused capillary density: Breslow P=0.076). Conclusions: There is a significant and independent association between microcirculatory perfusion parameters perfused capillary density and proportion of perfused capillaries and the combined clinical endpoint of all-cause death and renal replacement therapy at 30 days follow-up. In patients with loss of haemodynamic coherence between microcirculatory and macrocirculatory perfusion parameters, microcirculatory perfusion parameters confer dominant prognostic value.

Sublingual microcirculation predicts survival after out‐of‐hospital cardiac arrest

“…Our results go in line with previous investigations which highlighted the important role of the microcirculation in critical ill patients independently of global hemodynamics, 16,21,22 e.g., in septic or cardiogenic shock.…”

Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery

“…Microcirculatory impairment has been associated with organ injury in patients with hemorrhagic, cardiogenic, and septic shock. [47][48][49] The authors observed a progressive decline in PVD that was associated with an increased early SOFA score as well as postoperative lactate levels. Patients with the lowest PVD had both high lactate levels and increased SOFA scores.…”

Update on the management of cardiogenic shock complicating acute myocardial infarction

“…A substudy of the culprit lesion-only percutaneous coronary intervention versus multivessel percutaneous coronary intervention in cardiogenic shock (CULPRIT-SHOCK) trial, used this method for assessing the impact of microcirculatory dysfunction on clinical outcome. 9 Whereas there was no significant association with macrocirculatory hemodynamic parameters, there was a significant association between microcirculatory perfusion parameters and the combined clinical endpoint of all-cause death and renal replacement therapy at 30 days follow-up. The observed incoherence between macro- and microcirculatory perfusion parameters, suggests that clinical monitoring of tissue perfusion may be more crucial than arterial blood pressure in the management of cardiogenic shock.…”