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Graphical AbstractKey findings for early vs. delayed temporary mechanical circulatory support for patients with acute myocardial infarction complicated by cardiogenic shock. AMI, acute myocardial infarction; IABP, intra-aortic balloon pump; MCS, mechanical circulatory support; V-A ECMO, veno-arterial extracorporeal membrane oxygenation.

There are limited data on in-hospital cardiac arrest (IHCA) complicating non-ST-segment-elevation myocardial infarction (NSTEMI) based on management strategy.

Cardiorenal syndrome (CRS) complicates 33% of acute decompensated heart failure (ADHF) admissions, and patients with persistent congestion at discharge have high 30-day event rates.

We report a case of a 59-year-old male in post-myocardial infarction cardiogenic shock undergoing left atrial venous arterial extracorporeal membrane oxygenation (LAVA-ECMO) as a bridge to transplantation. The unique feature of this ECMO configuration is use of a single trans-septal cannula to provide biventricular unloading and use of a single arterial access.

Cardiogenic shock (CS) is associated with significant morbidity and mortality. Differentiating the etiologic factors driving CS has epidemiological significance and aids in optimization of therapeutic strategies, prognostication, and resource utilization. The aim herein is to investigate the epidemiology and clinical outcomes of CS in those with ischemic and nonischemic CS etiologies. Using International Classification of Diseases codes, we queried the national inpatient sample for CS hospitalization from 2007 to 2018 and divided the study sample into cohorts of ischemic (I-CS) and nonischemic cardiogenic shock (NI-CS). We then compared the primary outcome of in-hospital mortality between these 2 cohorts. Two groups of secondary outcomes (clinical and procedural) were also assessed between the 2 cohorts. CS was present in 557,860 hospitalizations; 84% of these were I-CS and 15.8% NI-CS. Patients with I-CS were older, more commonly males, with more risk factors for coronary artery disease (P< 0.05). NI-CS had higher prevalence of preexisting systolic heart failure and atrial fibrillation. The in-hospital mortality was significantly higher in patients with I-CS (32.2% vs. 29.5%, adjusted odds ratio 1.10, P< 0.001). Frequencies of acute ischemic stroke, mechanical ventilation, ventricular arrhythmias, and vascular complications were higher in I-CS versus NI-CS, while acute kidney injury and acute liver failure were more common in NI-CS (P< 0.05). The use of mechanical circulatory support devices was higher in the I-CS group. In conclusion, patients with I-CS comprise the vast majority of CS and are associated with higher mortality and higher resource utilization. Conversely, patients with NI-CS appear to have higher survival but with a higher prevalence of end-organ dysfunction.

Introduction: Hydroxychloroquine has been used for rheumatological diseases for many decades and is considered a safe medication. With the COVID-19 outbreak, there has been an increase in reports associating cardiotoxicity with hydroxychloroquine. It is unclear if the cardiotoxic profile of hydroxychloroquine is previously underreported in the literature or is it a manifestation of COVID-19 and therapeutic interventions. This manuscript evaluates the incidence of cardiotoxicity associated with hydroxychloroquine prior to the onset of COVID-19. Methods: PubMED, EMBASE, and Cochrane databases were searched for keywords derived from MeSH terms prior to April 9, 2020. Inclusion eligibility was based on appropriate reporting of cardiac conditions and study design. Results: A total of 69 articles were identified (58 case reports, 11 case series). The majority (84%) of patients were female, with a median age of 49.2 (range 16-92) years. 15 of 185 patients with cardiotoxic events were in the setting of acute intentional overdose. In acute overdose, the median ingestion was 17,857 ± 14,873 mg. 2 of 15 patients died after acute intoxication. In patients with long-term hydroxychloroquine use (10.5 ± 8.9 years), new onset systolic heart failure occurred in 54 of 155 patients (35%) with median cumulative ingestion of 1,493,800 ± 995,517 mg. The majority of patients improved with the withdrawal of hydroxychloroquine and standard therapy. Conclusion: Millions of hydroxychloroquine doses are prescribed annually. Prior to the COVID-19 pandemic, cardiac complications attributed to hydroxychloroquine were uncommon. Further studies are needed to understand the impact of COVID-19 on the cardiovascular system to understand the presence or absence of potential medication interactions with hydroxychloroquine in this new pathophysiological state.

Mechanical circulatory support devices are increasingly used for the treatment of acute myocardial infarction complicated by cardiogenic shock. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Institutions require expert teams to safely implant and manage these devices. This article reviews the mechanism of action, physiologic effects, and data as they relate to the utilization of these devices.

ABSTRACTTechnological advancements and the development of shock teams and protocols have led to increasing utilization of mechanical circulatory support (MCS) devices. These large-bore devices are used to provide hemodynamic support in patients undergoing complex cardiovascular procedures and to support end-organ perfusion in those with heart failure or cardiogenic shock. Vascular access complications are common and limit the therapeutic and hemodynamic benefits of such devices. In this review, the authors discuss common techniques used to overcome hostile femoral anatomy and review alternative accesses that can be used for the safe delivery of MCS devices.

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Veno-arterial extracorporeal membrane oxygenation is used in patients requiring biventricular support; however, its use increases the afterload. In patients with severe aortic insufficiency or severe left ventricular disfunction, it will increase left-side filling pressures, hence the need for left ventricle unloading with an additional mechanical circulatory support device. We present a case of a patient with cardiogenic shock and severe aortic insufficiency who underwent left atrial veno-arterial extracorporeal membrane oxygenation and provide a step-by-step explanation of the technique.

Introduction:The coronavirus disease 2019 (COVID-19) pandemic has created challenges in the delivery of acute cardiovascular care. Here, we evaluate the clinical characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) during the COVID-19 pandemic.Hypothesis:COVID-19 time period will associate with longer door to intervention times, and increased all-cause mortality among patients presenting with AMICS.Methods:Using the National Cardiogenic Shock Initiative database, we identified 406 patients who presented with AMICS. This group was divided into those who presented prior to COVID-19 (N=346, 5/9/2016-2/29/20) and those who presented during the pandemic (N=60, 3/1/20-11/10/20). Clinical characteristics, treatment patterns, and outcomes were compared between the two groups.Results:The median age (25th-75thpercentile) of the cohort was 64 (55-72) years, and 23.7% of the group was female. There were no significant differences in age, sex, and medical comorbidities between the two groups. Patients presenting during the pandemic were less likely to be of Black race, and more likely to be of Hispanic and White race than patients presenting prior to COVID-19. Median door to balloon (89.5 vs. 88 mins, p=0.38), door to support (88 vs. 78 mins, p=0.13), and onset of shock to support (73.5 vs. 62 mins, p=0.15) times were not significantly different when comparing those who presented prior to with those who presented during the pandemic. Rates of transfer from another hospital, and cardiac arrest prior to arrival in the cardiac catheterization lab were similar between the two groups. ST-Elevation Myocardial Infarction presentations were increased during the COVID-19 period (95% vs 80%, p=0.01). In adjusted logistic regression models, time period (during vs pre-COVID-19) did not significantly associate with survival to discharge (OR 1.17, 95% CI 0.59-2.35, p=0.65) or with one month survival (OR 0.82, 95% CI 0.42-1.61, p=0.56).Conclusions:Care of patients presenting with AMICS has remained robust among hospitals participating in the National Cardiogenic Shock Initiative during the COVID-19 pandemic.

Acute myocardial infarction and cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Early mechanical revascularization improves survival, and development of STEMI systems of care has increased the utilization of revascularization in AMI-CS from 19% in 2001 to 60% between in 2014. Mechanical circulatory support (MCS) devices are increasingly utilized to support and prevent hemodynamic collapse. These devices provide different levels of uni- and bi-ventricular support, have different mechanisms of actions, and provide different physiological effects. Shock protocols and teams are increasingly utilized to treat patients as we await large scale trials evaluating the use of MCS in AMI-CS. Herein we review the definition, incidence, pathophysiology and treatment of AMI-CS.

Background:There is limited data on the difference in procedural and clinical outcomes between Unites States regions in patients with ST elevation myocardial infarction (STEMI) with cardiogenic shock (CS). We aim to identify disparities in treatment and outcomes in patients with STEMI CS between the 4 US regions.Methods:Using the National Inpatient Sample database, we identified adult patients admitted with STEMI associated with CS between 2006 and 2015 using ICD-9-DM codes. Based on the US regions (Northeast, Midwest, South, and West), we divide patients in 4 cohorts and compared the baseline patient characteristics, clinical outcomes and procedural outcomes.Results:167,501 patients with STEMI CS were included; 29,103 (17.4%) were hospitalized in the Northeast, 39,314 (23.5%) in the Midwest, 62,896 (37.5%) in the South, and 36,188 (21.6%) in the West. In-hospital mortality was higher in Northeast region (37.7%), followed by the South (36.6%), West (35.7%), and Midwest (35.2%). Rates of percutaneous coronary intervention were higher in the Midwest (68.5%) and lower in the Northeast (56%). The use of percutaneous ventricular assist device and ECMO was higher in the Northeast (3.3% and 2.2%) and lower in the West region (2.1% and 0.4%). The median length of stay was similar among all 4 cohorts (6 days) but median hospital costs were higher in the West ($36,614) and lower in the South ($28,795).Conclusion:There are several disparities in the management, outcomes, and hospital costs in patients with STEMI complicated by CS between the 4 US regions.

Background:The National Cardiogenic Shock Initiative (NCSI) is a single-arm, prospective, multicenter study to assess clinical outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI).Methods:From July 2016 to May 2019, patients who presented with AMICS to the 65 participating hospitals were included in the study and were treated using a standard protocol with invasive hemodynamic monitoring, early MCS and PCI. Patients were stratified based on the age and 4 cohorts were generated: <50, 50-59, 60-69, and >=70 years old.Results:A total of 213 patients were included, 28 were <50 years old, 55 were 50 to 59 years old, 58 were 60 to 69 years old, and 73 were >=70 years old. There was significantly difference in mortality among groups; using patients younger than 50 years old as the reference (35.6% mortality), the mortality for patients aged 50 to 59 was 25.5% (OR: 9.22 p=0.037), 34.5% for patients 60 to 69 years old (OR: 14.2, p=0.012), and 42.5% for patients 70 years or older (OR: 19.2, p=0.004). A lactic acid greater than 4 mmol/dl was associated with higher mortality in older cohorts.There was no significant difference in the rates of acute kidney injury among cohorts. Patients in the younger cohorts required additional support and had longer length of stay when compared to the older cohorts. Radial access was less commonly used in patients older than 70 years old (13.7%) and more common in younger than 50 years old (28.6%).Conclusion:The odds of inpatient mortality is proportional to the patient age group, which could be as high as 20 times higher for patients 70 years and older, 14 times higher in patients 60 to 69 years old, and 9 times higher in patients 50 to 59 years old, when compared with patients younger than 50 years old. There is a cumulative risk with age and a lactic acid greater than 4 mmol/dl to predict mortality in AMICS.

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