PMID- 32164431
OWN - NLM
STAT- MEDLINE
DCOM- 20200817
LR  - 20200817
IS  - 1941-3297 (Electronic)
IS  - 1941-3289 (Linking)
VI  - 13
IP  - 3
DP  - 2020 Mar
TI  - Early Escalation of Mechanical Circulatory Support Stabilizes and Potentially 
      Rescues Patients in Refractory Cardiogenic Shock.
PG  - e005853
LID - 10.1161/CIRCHEARTFAILURE.118.005853 [doi]
AB  - BACKGROUND: Limited progress has been made in the management of cardiogenic shock 
      (CS). Morbidity and mortality of refractory CS remain high. The effects of 
      mechanical circulatory support (MCS) are promising, although many aspects are 
      elusive. We evaluated efficacy and safety of early combined MCS (Impella 
      microaxial pump + venoarterial extracorporeal membrane oxygenation [VA-ECMO]) in 
      refractory CS and aimed to determine factors for decision-making in combined MCS. 
      METHODS AND RESULTS: We analyzed 69 consecutive patients with refractory CS from 
      our registry requiring combined MCS. In 12 cases, therapy was actively withdrawn 
      according to patient's will. Patients were severely sick (Survival After 
      Venoarterial ECMO score mean+/-SD, -8.9+/-4.4) predicting 30% in-hospital survival; 
      ventilation 94%, dialysis 56%. Impella pumps and VA-ECMO were combined early 
      (duration of combined MCS: median 94 hours; interquartile range, 49-150 hours). 
      Early MCS escalation stabilized patients rapidly, reducing number and doses of 
      catecholamines (P<0.05 versus baseline) while hemodynamics improved. Reflecting 
      an improved microcirculation, lactate levels normalized within 24 hours (P<0.05 
      versus baseline). Despite refractory CS and disease severity, survival was 
      favorable (on MCS 61%, 30 days 49%, 6 months 40%). In multivariate 
      Cox-regression, duration of shock-to-first device (hours, hazard ratio, 1.05 [95% 
      CI, 1.01-1.08]; P=0.007) and lactate levels after 12 hours of MCS (hazard ratio, 
      1.28 [95% CI, 1.09-1.51]; P=0.002) independently predicted survival. Additional 
      right ventricular failure predisposed to futility (hazard ratio, 8.48 [95% CI, 
      1.85-38.91]; P=0.006). CONCLUSIONS: The early and consequent combination of MCS 
      by Impella microaxial pumps and VA-ECMO enables stabilization and may rescue 
      high-risk patients with refractory CS at low overall risk. Independent predictors 
      of survival may guide prognostication, decision-making, and allocation of medical 
      resources.
FAU - Tongers, Jorn
AU  - Tongers J
AD  - Departments of Cardiology and Angiology (J.T., J.-T.S., L.C.N., U.F., P.R., J.B., 
      A.S.), Hannover Medical School, Germany.
FAU - Sieweke, Jan-Thorben
AU  - Sieweke JT
AD  - Departments of Cardiology and Angiology (J.T., J.-T.S., L.C.N., U.F., P.R., J.B., 
      A.S.), Hannover Medical School, Germany.
FAU - Kuhn, Christian
AU  - Kuhn C
AD  - Cardiothoracic, Transplantation and Vascular Surgery (C.K., J.D.S., A.H.), 
      Hannover Medical School, Germany.
FAU - Napp, L Christian
AU  - Napp LC
AD  - Departments of Cardiology and Angiology (J.T., J.-T.S., L.C.N., U.F., P.R., J.B., 
      A.S.), Hannover Medical School, Germany.
FAU - Flierl, Ulrike
AU  - Flierl U
AD  - Departments of Cardiology and Angiology (J.T., J.-T.S., L.C.N., U.F., P.R., J.B., 
      A.S.), Hannover Medical School, Germany.
FAU - Rontgen, Philipp
AU  - Rontgen P
AD  - Departments of Cardiology and Angiology (J.T., J.-T.S., L.C.N., U.F., P.R., J.B., 
      A.S.), Hannover Medical School, Germany.
FAU - Schmitto, Jan D
AU  - Schmitto JD
AD  - Cardiothoracic, Transplantation and Vascular Surgery (C.K., J.D.S., A.H.), 
      Hannover Medical School, Germany.
FAU - Sedding, Daniel G
AU  - Sedding DG
AD  - Mid-German Heart Center, Department of Cardiology and Intensive Care Medicine, 
      University Hospital, Martin Luther University Halle-Wittenberg, Halle (Saale), 
      Germany (D.G.S.).
FAU - Haverich, Axel
AU  - Haverich A
AD  - Cardiothoracic, Transplantation and Vascular Surgery (C.K., J.D.S., A.H.), 
      Hannover Medical School, Germany.
FAU - Bauersachs, Johann
AU  - Bauersachs J
AD  - Departments of Cardiology and Angiology (J.T., J.-T.S., L.C.N., U.F., P.R., J.B., 
      A.S.), Hannover Medical School, Germany.
FAU - Schafer, Andreas
AU  - Schafer A
AD  - Departments of Cardiology and Angiology (J.T., J.-T.S., L.C.N., U.F., P.R., J.B., 
      A.S.), Hannover Medical School, Germany.
LA  - eng
PT  - Journal Article
PT  - Observational Study
PT  - Research Support, Non-U.S. Gov't
DEP - 20200313
PL  - United States
TA  - Circ Heart Fail
JT  - Circulation. Heart failure
JID - 101479941
SB  - IM
CIN - Circ Heart Fail. 2020 Mar;13(3):e006846. PMID: 32164437
MH  - Adult
MH  - Aged
MH  - Extracorporeal Membrane Oxygenation/adverse effects/*instrumentation/mortality
MH  - Female
MH  - *Heart-Assist Devices
MH  - *Hemodynamics
MH  - Hospital Mortality
MH  - Humans
MH  - Male
MH  - Middle Aged
MH  - *Oxygenators, Membrane
MH  - Prospective Studies
MH  - Prosthesis Design
MH  - Prosthesis Implantation/adverse effects/*instrumentation/mortality
MH  - Recovery of Function
MH  - Registries
MH  - Risk Factors
MH  - Shock, Cardiogenic/diagnosis/mortality/physiopathology/*therapy
MH  - Time Factors
MH  - Treatment Outcome
MH  - *Ventricular Function, Left
MH  - *Ventricular Function, Right
OTO - NOTNLM
OT  - catecholamine
OT  - decision-making
OT  - extracorporeal membrane oxygenation
OT  - hemodynamics
OT  - shock
EDAT- 2020/03/14 06:00
MHDA- 2020/08/18 06:00
CRDT- 2020/03/14 06:00
PHST- 2020/03/14 06:00 [entrez]
PHST- 2020/03/14 06:00 [pubmed]
PHST- 2020/08/18 06:00 [medline]
AID - 10.1161/CIRCHEARTFAILURE.118.005853 [doi]
PST - ppublish
SO  - Circ Heart Fail. 2020 Mar;13(3):e005853. doi: 
      10.1161/CIRCHEARTFAILURE.118.005853. Epub 2020 Mar 13.