Risk Scores in ST-Segment Elevation Myocardial Infarction Patients with Refractory Cardiogenic Shock and Veno-Arterial Extracorporeal Membrane Oxygenation

Abstract

Although many risk models have been tested in patients implanted by veno-arterial extracorporeal membrane oxygenation (VA-ECMO), few scores assessed patients’ prognosis in the setting of ST-segment elevation myocardial infarction (STEMI) with refractory cardiogenic shock. We aimed at assessing the performance of risk scores, notably the prEdictioN of Cardiogenic shock OUtcome foR AMI patients salvaGed by VA-ECMO (ENCOURAGE) score, for predicting mortality in this particular population. This retrospective observational study included patients admitted to Tours University Hospital for STEMI with cardiogenic shock and requiring hemodynamic support by VA-ECMO. Among the fifty-one patients, the 30-day and 6-month survival rates were 63% and 56% respectively. Thirty days after VA-ECMO therapy, probabilities of mortality were 12, 17, 33, 66, 80% according to the ENCOURAGE score classes 0–12, 13–18, 19–22, 23–27, and ≥28, respectively. The ENCOURAGE score (AUC of the Receiving Operating Characteristic curve = 0.83) was significantly better compared to other risk scores. The hazard ratio for survival at 30 days for each point of the ENCOURAGE score was 1.10 (CI 95% (1.06, 1.15); p < 0.001). Decision curve analysis indicated that the ENCOURAGE score had the best clinical usefulness of the tested risk scores and the Hosmer–Lemeshow test suggested an accurate calibration. Our data suggest that the ENCOURAGE score is valid and the most relevant score to predict 30-day mortality after VA-ECMO therapy in STEMI patients with refractory cardiogenic shock. It may help decision-making teams to better select STEMI patients with shock for VA-ECMO therapy.

Algorithmic management of postcardiotomy shock with mechanical support: Bring a map, a plan, and your parachute—and know how to use all three

“… 3 , 6 , 12 Early use of MCS can significantly improve recovery chances. 9 , 10 The odds of a successful patient recovery are improved through identification of patients at risk, multidisciplinary formulation of a preoperative plan, prompt initiation of support, and vigilant postoperative care. Family support, recognition of patient goals of care, and medical futility are equally essential.…”

“…Myocardial ischemia and ischemic ventricular septal defect are some examples where this practice has been demonstrated with excellent results. 8,9 OPERATIVE DECISION-MAKING "Everyone has a plan until they get punched in the mouth. "…”

“…Myocardial ischemia and ischemic ventricular septal defect are some examples where this practice has been demonstrated with excellent results. 8 , 9 …”

Extracorporeal Membrane Oxygenation in Infarct-Related Cardiogenic Shock

“…Next to general AMI-CS risk models, prediction scores derived from CS cohorts treated with VA-ECMO due to refractory shock were developed [ 23 , 24 ]. With the ENCOURAGE Score, a score is available for VA-ECMO in refractory AMI-CS giving acceptable discrimination between risk groups on first validations [ 25 ]. The PREDICT Score incorporates only three point-of-care biomarkers (arterial lactate, pH and standard bicarbonate concentration) and reveals good discrimination with respect to in-hospital mortality in VA-ECMO therapy for CPR or CS irrespective of the timing of the score assessment (one, six or twelve hours) [ 26 ].…”