Original clinical science
Clinical outcome of mechanical circulatory support for refractory cardiogenic shock in the current era

https://doi.org/10.1016/j.healun.2012.10.005Get rights and content

Background

Mortality for refractory cardiogenic shock (RCS) remains high. However, with improving mechanical circulatory support device (MCSD) technology, the treatment options for RCS patients are expanding. We report on a recent 5-year single-center experience with MCSD for treatment of RCS.

Methods

This study was a retrospective review of adult patients who required an MCSD due to RCS in the past 5 years. We excluded those patients with post-cardiotomy shock and post-transplant cardiac graft dysfunction. In the setting of RCS, a short-term ventricular assist device (VAD) was inserted as a bridge-to-decision device. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) was chosen in cases of unknown neurologic status, complete hemodynamic collapse or severe coagulopathy.

Results

From January 2007 through January 2012, 90 patients received an MCSD for RCS, 21 (23%) of whom had active cardiopulmonary resuscitation (CPR). The etiology of RCS included acute myocardial infarction in 49% and acute decompensated heart failure in 27%. Mean age was 53±14 years, 71% were male, and 60% had an intra-aortic balloon pump. The initial approach utilized was short-term VAD in 49% and VA ECMO in 51%. Median length of support was 8 days (IQR 4 to 18 days). Exchange to implantable VAD was performed in 26% of patients. Other destinations included myocardial recovery in 18% and heart transplantation in 11%. Survival to hospital discharge was 49%. Multivariate analysis showed ongoing CPR to be an independent risk factor for mortality (OR = 5.79, 95% CI 1.285 to 26.08, p = 0.022).

Conclusions

In the current era, roughly half of the patients who need an MCSD for RCS survive, and roughly half of these survivors require an implantable VAD. Ongoing CPR is predictive of in-hospital mortality.

Section snippets

Methods

This study is a retrospective review of the charts of the consecutive patients who received an MCSD for RCS from January 2007 through January 2012. Those patients who received the device for post-cardiotomy shock or post-transplant cardiac graft dysfunction were excluded from the analysis, as their pathophysiology is quite different from those who develop RCS without going through cardiac surgery. Demographics, hemodynamics and biochemical values (all prior to MCS) were collected from patients’

Statistical analysis

Mean values and standard deviations (SDs) were determined for continuous variables. Categorical variables were presented and compared as numbers and percentages. The distribution of all variables was tested for normality, and non-parametric testing was done to analyze the data. All skewed parameters are presented as median and interquartile range (IQR), whereas all non-skewed parameters are presented as mean±SD. Paired t-tests were used for analysis between continuous non-skewed variables and

Results

During the study period, 90 patients received MCS for RCS. The etiology of RCS included acute myocardial infarction in 49%, acute decompensated heart failure in 27%, and myocarditis in 8% (Table 1). Mean age was 53±14 years, 71% were male, 60% had an IABP, and 23% were undergoing active CPR at insertion of the MCSD (Table 2). Hemodynamics data to calculate cardiac power output (watts) (mean arterial pressure×cardiac output/ 451) were available for 38 patients. The mean cardiac power output of

Discussion

In this study we have addressed the outcomes of device therapy in RCS, focusing on experience from the last 5 years. The major findings are that: (1) 49% of patients survived to hospital discharge; (2) 48% of patients who survived to the next destination required device exchange to implantable VAD; and (3) overall 1-year survival was 46%.

It is important to emphasize that, contrary to previous reports describing the outcomes of device therapy in CS, this study has addressed the outcomes of one

Disclosure statement

U.P.J. and Y.N. have received consulting fees from Thoratec Corp. The remaining authors have no conflicts of interest to disclose.

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