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Background The role of intra-aortic balloon pump (IABP) combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock (CS) remains unclear. This study investigated the effect of applying IABP for left ventricle (LV) unloading after VA-ECMO on reducing mortality in patients with CS. Methods Data from 5,492 consecutive patients with CS treated with VA-ECMO between January 2017 and July 2023 were collected from the CSECLS registry. The primary outcome was in-hospital mortality. The secondary outcomes included 30-day mortality, survival on VA-ECMO, and various complications. The association between the application of IABP after VA-ECMO and in-hospital outcomes was assessed. Results Among 5,492 patients undergoing VA-ECMO (mean age 54.7 ± 15.1 years, 3,917 [71.3%] male), 832 (15.1%) received IABP after VA-ECMO. Before VA-ECMO, a higher incidence of cardiac intervention (13.9% vs. 16.7%) and myocardial infarction (12.0% vs. 14.8%) (all P  < 0.05) was seen in the IABP after VA-ECMO group. In this cohort, the IABP after VA-ECMO group had a lower in-hospital mortality (52.5% vs. 48.0%, P  = 0.017) and a higher survival rate on VA-ECMO (75.4% vs. 79.4%, P  = 0.014). On multivariate modeling, the use of IABP after VA-ECMO was associated with a lower risk of in-hospital mortality (adjusted odds ratio[aOR], 0.823 [95% confidence interval [CI], 0.686–0.987]; P  = 0.035) and on-support mortality (aOR, 0.828 [95% CI, 0.688–0.995]; P  = 0.044). However, the use of IABP after VA-ECMO was also associated with an increased incidence of complications, including mechanical (aOR: 1.905, [95% CI, 1.278–2.839]; P  = 0.002), bleeding (aOR: 1.371, [95% CI, 1.092–1.721]; P  = 0.007), renal (aOR: 1.252, [95% CI, 1.041–1.505]; P  = 0.017), and pulmonary (aOR: 1.768, [95% CI, 1.446–2.163]; P  < 0.001). Conclusion In this multicenter retrospective study, the use of IABP after VA-ECMO was associated with lower in-hospital mortality in patients with CS. These findings suggest that IABP may offer advantages for LV unloading in patients with CS treated with VA-ECMO, but further validation through randomized controlled trials is warranted to better understand the balance of risks and benefits.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

Cardiogenic shock remains the leading cause of in-hospital death in acute myocardial infarction (AMI). Because of temporary changes in management of cardiogenic shock with widespread implementation of early revascularization along with increasing attention to the use of mechanical circulatory devices, complete and longitudinal data are important in this subject. The objective of this study was to examine temporal trends of first-time hospitalization, management, and short-term mortality for patients with AMI-related cardiogenic shock (AMICS). Using nationwide medical registries, we identified patients hospitalized with first-time AMI and cardiogenic shock from January 1, 2005, through December 31, 2017. We calculated annual incidence proportions of AMICS. Thirty-day mortality was estimated with use of Kaplan-Meier estimator comparing AMICS and AMI-only patients. Multivariable Cox regression models were used to assess mortality rate ratios. We included 101,834 AMI patients of whom 7,040 (7%) had AMICS. The median age was 72 (interquartile range: 62-80) for AMICS and 69 (interquartile range: 58-79) for AMI-only patients. The gender composition was similar between AMICS and AMI-only patients (male: 64% vs 63%). The annual incidence proportion of AMICS decreased slightly over time (2005: 7.0% vs 2017: 6.1%, P for trend < .0001). In AMICS, use of coronary angiography increased between 2005 and 2017 from 48% to 71%, as did use of left ventricular assist device (1% vs 10%) and norepinephrine (30% to 70%). In contrast, use of intra-aortic balloon pump (14% vs 1%) and dopamine (34% vs 20%) decreased. Thirty-day mortality for AMICS patients was 60% (95% CI: 59-61) and substantially higher than the 8% (95% CI: 7.8-8.2) for AMI-only patients (mortality rate ratio: 11.4, 95% CI: 10.9-11.8). Over time, the mortality decreased after AMICS (2005: 68% to 2017: 57%, P for temporal change in adjusted analysis < .0001). We observed a slight decrease in AMICS hospitalization over time with changing practice patterns. Thirty-day mortality was markedly higher for patients with AMICS compared with AMI only, yet our results suggest improved 30-day survival over time after AMICS.

Background The use of intraaortic balloon pump (IABP) effectively reduces left ventricular afterload and significantly increases coronary perfusion pressure by raising aortic diastolic pressure. This study examined the short and medium-term outcomes of 22,540 adult cardiac surgical patients requiring an IABP. Methods From 2009 to 2018, 1114 patients (4.94%) undergoing open-heart surgery at a single tertiary cardiac hospital received IABP support and were included in this retrospective study. They were categorized into pre-operative (Group A, n = 577), intra-operative (Group B, n = 475), and post-operative (Group C, n = 62) IABP insertion groups. Results Cardiogenic shock occurred in 11.2% of cases, mainly in Group A. Hemodynamic instability (38.8%) drove IABP use in Groups A and C, while difficulty weaning from CPB was the primary reason in Group C. The overall operative mortality rate was 10.9%, highest at 25.8% postoperatively. Multivariate analysis identified significant predictors of mortality: age (OR: 1.067, 95% CI: 1.041–1.094, p < 0.001), higher BMI (OR: 1.071, 95% CI: 1.017–1.128, p = 0.009), pulmonary hypertension (OR: 2.085, 95% CI: 1.302–3.341, p = 0.002), renal disease (OR: 2.780, 95% CI: 1.556–4.967, p < 0.001), and cardiogenic shock (OR: 3.684, 95% CI: 2.066–6.569, p < 0.001). Complications were more common in Group C, especially with renal disease. Average preoperative and postoperative stays were 4.0 ± 4.8 days and 15.2 ± 20.4 days, respectively, with no significant differences between groups. Conclusion IABP might offer safety for open-heart surgery, with longer hospital stays potentially associated with high-risk patients. Pre-operative IABP prophylaxis could be crucial in high-risk open-heart cases to reduce mortality. Clinical registration number: NHG DSRB Ref No# 2016/01070 and 2019/00397.

Despite the growing use of temporary mechanical circulatory support (tMCS), little data exists to inform management and weaning of these devices. We performed an online survey among cardiac intensive care unit directors in North America to examine current practices in the management of patients treated with intraaortic balloon pump and Impella. We received responses from 84% of surveyed centers (n=37). Our survey focused on three key aspects of daily management: 1. Hemodynamic monitoring; 2. Hemocompatibility; and 3. Weaning and removal. We found substantial variability surrounding all three areas of care. Our findings highlight the need for consensus around practices associated with improved outcomes in patients treated with tMCS.

PurposeTo compare the relative efficacy of supportive therapies (inotropes, vasopressors, and mechanical circulatory support [MCS]) for adult patients with cardiogenic shock complicating acute myocardial infarction.SourceWe conducted a systematic review and network meta-analysis and searched six databases from inception to December 2021 for randomized clinical trials (RCTs). We evaluated inotropes, vasopressors, and MCS in separate networks. Two reviewers performed screening, full-text review, and extraction. We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to rate the certainty in findings. The critical outcome of interest was 30-day all-cause mortality.Principal findingsWe included 17 RCTs. Among inotropes (seven RCTs, 1,145 patients), levosimendan probably reduces mortality compared with placebo (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.33 to 0.87; moderate certainty), but primarily in lower severity shock. Milrinone (OR, 0.52; 95% CI, 0.19 to 1.39; low certainty) and dobutamine (OR, 0.67, 95% CI, 0.30 to 1.49; low certainty) may have no effect on mortality compared with placebo. With regard to MCS (eight RCTs, 856 patients), there may be no effect on mortality with an intra-aortic balloon pump (IABP) (OR, 0.94; 95% CI, 0.69 to 1.28; low certainty) or percutaneous MCS (pMCS) (OR, 0.96; 95% CI, 0.47 to 1.98; low certainty), compared with a strategy involving no MCS. Intra-aortic balloon pump use was associated with less major bleeding compared with pMCS. We found only two RCTs evaluating vasopressors, yielding insufficient data for meta-analysis.ConclusionThe results of this systematic review and network meta-analysis indicate that levosimendan reduces mortality compared with placebo among patients with low severity cardiogenic shock. Intra-aortic balloon pump and pMCS had no effect on mortality compared with a strategy of no MCS, but pMCS was associated with higher rates of major bleeding.Study registrationCenter for Open Science (https://osf.io/ky2gr); registered 10 November 2020

Infections from prolonged use of axillary intra-aortic balloon pumps (IABPs) have not been well studied. Bloodstream infection (BSI) occurred in 13% of our patients; however, no difference in outcome was noted between those with BSI and those without. Further studies regarding protocol developments that minimize BSI risk are needed.

Cardiogenic shock (CS) is associated with high morbidity and mortality despite recent advances in the temporary mechanical circulatory support (MCS) devices. The current utilization and outcomes of these MCS devices with or without vasopressors compared with conventional medical therapy (no-MCS) in CS remain poorly described. The study population was extracted from the 2014 Nationwide Readmissions Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for CS, temporary MCS devices, and vasopressor infusion. Study end points included in-hospital all-cause mortality, length of index hospital stay (LOS), the likelihood of receiving invasive treatment, postprocedural bleeding, vascular complications, total hospitalization charges, and discharge disposition. A total of 59,148 discharges with a diagnosis of CS were identified (age 67 years; 38.5% female). Temporary MCS devices were utilized in 22.7%. The use of these devices was associated with lower in-hospital all-cause mortality (33.0% vs 39.7%, p <0.01), increased likelihood of invasive therapy (75.7% vs 26.3%, p <0.01), and increased likelihood of being discharged home (24.8% vs 20.6%, p <0.01). However, the MCS group had longer LOS (16.9 vs 12.1 days, p <0.01), higher vascular complications (2.6% vs 1.4%, p <0.01), bleeding (31.2% vs 16.8%, p <0.01), and total hospitalization charges ($374,574 vs $182,045, p <0.01). In conclusion, the use of the temporary MCS devices for the treatment of CS was associated with lower mortality, increased the likelihood of receiving invasive treatment and the likelihood of being discharged home. However, it was associated with higher in-hospital complications, LOS, and hospitalization charges.

The use of Extracorporeal Membrane Oxygenation (ECMO) remains associated with high rates of complications, weaning failure and mortality which can be partly explained by a knowledge gap on how to properly manage patients on ECMO support. To address relevant patient management issues, we designed a “Randomized Embedded Multifactorial Adaptive Platform (REMAP)” in the setting of ECMO (REMAP ECMO) and a first embedded randomized controlled trial (RCT) investigating the effects of routine early left ventricular (LV) unloading through intra-aortic balloon pumping (IABP). REMAP ECMO describes a registry-based platform allowing for the embedding of multiple response adaptive RCTs (trial domains) which can perpetually address the effect of relevant patient management issues on ECMO weaning success. A first trial domain studies the effects of LV unloading by means of an IABP as an adjunct to veno-arterial (V-A) ECMO versus V-A ECMO alone on ECMO weaning success at 30 days in adult cardiogenic shock patients admitted to the Intensive Care Unit (ICU). The primary outcome of this trial is “successful weaning from ECMO” being defined as a composite of survival without the need for mechanical circulatory support, heart transplantation, or left ventricular assist device (LVAD) at 30 days after initiation of ECMO. Secondary outcomes include the need for interventional escalation of LV unloading strategy, mechanistic endpoints, survival characteristics until 1 year after ECMO initiation, and quality of life. Trial data will be analysed using a Bayesian statistical framework. The adaptive design allows for a high degree of flexibility, such as response adaptive randomization and early stopping of the trial for efficacy or futility. The REMAP ECMO LV unloading study is approved by the Medical Ethical Committee of the Erasmus Medical Center and is publicly registered. This REMAP ECMO trial platform enables the efficient roll-out of multiple RCTs on relevant patient management issues. A first embedded trial domain will compare routine LV unloading by means of an IABP as an adjunct to V-A ECMO versus V-A ECMO alone. ClinicalTrials.gov, NCT05913622