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Aims: Haemodynamic assessment can be determinant in phenotyping cardiogenic shock (CS) and guiding patient management. Aim of this study was to evaluate the correlation between echocardiographic and invasive assessment of haemodynamics in acute decompensated heart failure-related CS (ADHF-CS)., Methods and Results: All consecutive ADHF-CS patients (SCAI shock stage ≥B) undergoing right heart catheterization (RHC) between 2020 and 2022 were prospectively enrolled. Patients underwent echocardiography 30 min before RHC. The evaluated haemodynamic parameters and their echocardiographic estimates ('e') comprised cardiac index (CI), wedge pressure (WP), pulmonary artery pressures (PAP), cardiac power output (CPO) and pulmonary artery pulsatility index (PAPi). Hundred and one ADHF-CS patients (56 ± 11 years, 64% SCAI shock stage C, left ventricular ejection fraction 29 ± 5%) were included. Good correlation was found for CI, systolic PAP, RAP, and CPO (Pearson r > 0.8 for all), moderate correlation for ePAPi (r = 0.67) and PVR (r = 0.51), while estimation of WP was weak. The sensitivity and specificity of eCI to identify low output state (CI ≤2.2 L/min/m2) were 0.97 and 0.73, respectively, those of eWP for elevated filling pressures (WP >15 mmHg) were 0.84 and 0.55, those of ePAPs for PAPs ≥35 mmHg were 0.87 and 0.63, those of eCPO for CPO <0.6 W were 0.76 and 0.85, those of ePAPi for PAPi <1.85 were 0.89 and 0.92. Echocardiographic phenotyping of CS showed a good agreement with invasive classification (K value 0.457, P < 0.001)., Conclusion: Echocardiographic estimation of haemodynamics and subsequent phenotypization of CS is feasible with good agreement with invasive evaluation., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Aims: We sought to characterize circulating protein biomarkers associated with cardiogenic shock (CS) using highly multiplex proteomic profiling., Methods and Results: This analysis employed a cross-sectional case-control study design using a biorepository of patients admitted to a cardiac intensive care unit between 2017 and 2020. Cases were patients adjudicated to have CS, and controls were those presenting for cardiac critical care without shock, including subsets of patients with isolated hypotension or heart failure (HF). The Olink platform was used to analyse 359 biomarkers with Bonferroni correction. The analysis included 239 patients presenting for cardiac critical care (69 cases with CS, 170 non-shock controls). A total of 63 biomarkers (17.7%) were significantly associated with CS after Bonferroni correction compared with all controls. Of these, nine biomarkers remained significantly associated with CS when separately cross-validated in subsets of controls presenting with isolated hypotension and HF: cathepsin D, fibroblast growth factor (FGF)-21 and -23, growth differentiation factor (GDF)-15, insulin-like growth factor-binding protein-1, N-terminal pro-B-type natriuretic peptide, osteopontin, oncostatin-M-specific receptor subunit beta (OSMR), and soluble ST2 protein (sST2). Four biomarkers were identified as providing complementary information for CS diagnosis with development of a multi-marker model: sST2, FGF-23, CTSD, and GDF-15., Conclusion: In this pilot study of targeted proteomic profiling in CS, we identified nine biomarkers significantly associated with CS when cross-validated against non-shock controls including those with HF or isolated hypotension, illustrating the potential application of a targeted proteomic approach to identify novel candidates that may support the diagnosis of CS., Competing Interests: Conflict of interest: S.M.P., D.A.M., A.B., K.K.B., E.A.B., and D.D.B. are members of the TIMI Study Group that receives institutional research grant support through Brigham and Women’s Hospital from: Abbott, Abiomed, Amgen, Anthos Therapeutics, AstraZeneca, Daiichi-Sankyo, Intarcia, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche Diagnostics, Siemens Healthcare Diagnostics, Inc., and Zora Biosciences. D.A.M. reports consulting fees from Abbott Laboratories, ARCA biopharma, InCarda, Inflammatix, Merck & Co., Novartis, and Roche Diagnostics. J.D., M.D., E.P.M., L.M., and B.O.O are employees and shareholders of Regeneron Pharmaceuticals, Inc. A.S.V. reports consulting fees from Broadview Ventures. E.A.B. reports consulting fees from Novo Nordisk, Esperion, PriMed, Medscape, Amgen, and Servier, and participation on clinical endpoint committees for studies sponsored by Kowa Pharmaceuticals. D.D.B. reports consulting fees from AstraZeneca, Mobility Bio, Inc., and Youngene Therapeutics, honoraria from the Medical Education Speakers Network (MESN) and USV Private Limited, and participation on clinical endpoint committees for studies sponsored by Beckman Coulter, Kowa Pharmaceuticals, and Tosoh Biosciences. The remaining co-authors report no conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Myocardial infarction and heart failure are major cardiovascular diseases that affect millions of people in the USA with morbidity and mortality being highest among patients who develop cardiogenic shock. Early recognition of cardiogenic shock allows prompt implementation of treatment measures. Our objective is to develop a new dynamic risk score, called CShock, to improve early detection of cardiogenic shock in the cardiac intensive care unit (ICU)., Methods and Results: We developed and externally validated a deep learning-based risk stratification tool, called CShock, for patients admitted into the cardiac ICU with acute decompensated heart failure and/or myocardial infarction to predict the onset of cardiogenic shock. We prepared a cardiac ICU dataset using the Medical Information Mart for Intensive Care-III database by annotating with physician-adjudicated outcomes. This dataset which consisted of 1500 patients with 204 having cardiogenic/mixed shock was then used to train CShock. The features used to train the model for CShock included patient demographics, cardiac ICU admission diagnoses, routinely measured laboratory values and vital signs, and relevant features manually extracted from echocardiogram and left heart catheterization reports. We externally validated the risk model on the New York University (NYU) Langone Health cardiac ICU database which was also annotated with physician-adjudicated outcomes. The external validation cohort consisted of 131 patients with 25 patients experiencing cardiogenic/mixed shock. CShock achieved an area under the receiver operator characteristic curve (AUROC) of 0.821 (95% CI 0.792-0.850). CShock was externally validated in the more contemporary NYU cohort and achieved an AUROC of 0.800 (95% CI 0.717-0.884), demonstrating its generalizability in other cardiac ICUs. Having an elevated heart rate is most predictive of cardiogenic shock development based on Shapley values. The other top 10 predictors are having an admission diagnosis of myocardial infarction with ST-segment elevation, having an admission diagnosis of acute decompensated heart failure, Braden Scale, Glasgow Coma Scale, blood urea nitrogen, systolic blood pressure, serum chloride, serum sodium, and arterial blood pH., Conclusion: The novel CShock score has the potential to provide automated detection and early warning for cardiogenic shock and improve the outcomes for millions of patients who suffer from myocardial infarction and heart failure., Competing Interests: Conflict of interest: N.S. reports consulting for Abbott Vascular as a member of an advisory board., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Competing Interests: Conflict of interest: None declared.

Aims: Cardiogenic shock (CS) is associated with high mortality. The purpose of this study was to assess the impact of hospital structure-related variables on mortality in patients with CS treated at percutaneous and surgical revascularization capable centres (psRCC) from a large nationwide registry., Methods and Results: Retrospective observational study including consecutive patients with main or secondary diagnosis of CS and ST elevation myocardial infarction (STEMI). Patients discharged from Spanish National Healthcare System psRCC were included (2016-20). The association between the volume of CS cases attended by each centre, availability of intensive cardiac care unit (ICCU) and heart transplantation (HT) programmes, and in-hospital mortality was assessed by multilevel logistic regression models. The study population consisted of 3074 CS-STEMI episodes, of whom 1759 (57.2%) occurred in 26 centres with ICCU. A total of 17/44 hospitals (38.6%) were high-volume centres, and 19/44 (43%) centres had HT programmes availability. Treatment at HT centres was not associated with a lower mortality (P = 0.121). Both high volume of cases and ICCU showed a trend to an association with lower mortality in the adjusted model [odds ratio (OR): 0.87 and 0.88, respectively]. The interaction between both variables was significantly protective (OR 0.72; P = 0.024). After propensity score matching, mortality was lower in high-volume hospitals with ICCU (OR 0.79; P = 0.007)., Conclusion: Most CS-STEMI patients were attended at psRCC with high volume of cases and ICCU available. The combination of high volume and ICCU availability showed the lowest mortality. These data should be taken into account when designing regional networks for CS management., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: Conflict of interest: P.R.L. is supported by a career award from the Heart and Stroke Foundation of Canada.

Acute valvular emergencies represent an important cause of cardiogenic shock. However, their clinical presentation and initial diagnostic testing are often non-specific, resulting in delayed diagnosis. Moreover, metabolic disarray or haemodynamic instability may result in too great a risk for emergent surgery. This review will focus on the aetiology, clinical presentation, diagnostic findings, and treatment options for patients presenting with native acute left-sided valvular emergencies. In addition to surgery, options for medical therapy, mechanical circulatory support, and novel percutaneous interventions are discussed., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: In patients with cardiogenic shock, delayed surgery after stabilization of haemodynamics and improvement in end-organ function by mechanical circulatory support is known to yield better outcomes than emergency surgery. We aimed to investigate the effectiveness of Impella (Abiomed, Danvers, MA, USA) as a bridge to cardiac surgery in patients with cardiogenic shock., Methods: We reviewed 7 patients with cardiogenic shock who underwent Impella support as a bridge to cardiac surgery using cardiopulmonary bypass at our institution between April 2018 and August 2021., Results: Cardiogenic shock was caused by ventricular septal rupture in 3 patients, papillary muscle rupture in 1 and acute myocardial infarction in 3. Cardiac surgery was delayed by 1-7 (3.9 ± 2.5) days with Impella support after the diagnosis of cardiogenic shock, during which the hepatic and renal function of the patients improved significantly. Device-related or operation-related adverse events included re-exploration for bleeding in 3 patients, acute limb ischaemia due to thromboembolism in 1 and intraoperative aortic dissection in 1. Thirty-day mortality was 14.3%, and the cumulative survival was 71.4% at 1 year. The survival tended to be better than that in historical control group in which extracorporeal membrane oxygenation was used as a bridge to surgery (P = 0.0992)., Conclusions: Impella is an effective tool for bridging patients with cardiogenic shock to surgery. This strategy may improve surgical outcomes in patients with cardiogenic shock. However, prolonged Impella support may increase significant adverse events, and further investigation is required to determine the optimal duration of support before surgery., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Cardiogenic shock mortality rates remain high despite significant advances in cardiovascular medicine and the widespread uptake of mechanical circulatory support systems. Except for early invasive angiography and percutaneous coronary intervention of the infarct-related artery, all other widely used therapeutic measures are based on low-quality evidence. The grim prognosis and lack of high-quality data warrant further action. Within Part 2 of this two-part educational review on basic mechanisms in cardiogenic shock, we aimed to highlight the current status of translating our understanding of the pathophysiology of cardiogenic shock into clinical practice. We summarize the current status of biomarker research in risk stratification and therapy guidance. In addition, we summarized the current status of translating the findings from bench-, bedside, and biomarker studies into treatment options. Several large randomized controlled trials (RCTs) are underway, providing a huge opportunity to study contemporary cardiogenic shock patients. Finally, we call for translational, homogenous, biomarker-based, international RCTs testing novel treatment approaches to improve the outcome of our patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

The current European Society of Cardiology (ESC) Heart Failure Guidelines are the most comprehensive ESC document covering heart failure to date; however, the section focused on acute heart failure remains relatively too concise. Although several topics are more extensively covered than in previous versions, including some specific therapies, monitoring and disposition in the hospital, and the management of cardiogenic shock, the lack of high-quality evidence in acute, emergency, and critical care scenarios, poses a challenge for providing evidence-based recommendations, in particular when by comparison the data for chronic heart failure is so extensive. The paucity of evidence and specific recommendations for the general approach and management of acute heart failure in the emergency department is particularly relevant, because this is the setting where most acute heart failure patients are initially diagnosed and stabilized. The clinical phenotypes proposed are comprehensive, clinically relevant and with minimal overlap, whilst providing additional opportunity for discussion around respiratory failure and hypoperfusion., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.)

Objectives: Patients in cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) may experience severe complications from reduced left ventricular (LV) unloading and increased cardiac afterload. These effects are usually modified by adding a percutaneous direct Impella vent or surgical LV vent on top of VA-ECMO in selected patients. However, direct comparisons between 2 LV unloading strategies in patients with cardiogenic shock due to myocardial infarction are lacking. Therefore, we sought to investigate the impact of these 2 different approaches., Methods: We enrolled 112 patients treated with an Impella or surgical LV vent during VA-ECMO support between January 2014 and February 2020. The primary endpoint was 30-day mortality. Secondary endpoints included rates of myocardial recovery or transition to durable mechanical circulatory support. Additionally, we assessed adverse events such as peripheral ischaemic complications requiring intervention, sepsis and ischaemic stroke., Results: At 30 days, 38 patients in the Impella group (54%) and 26 patients in the surgical LV vent group (63%) had died (relative risk with Impella 0.78, 95% confidence interval 0.47-1.30; P = 0.35). Impella group and the surgical LV vent group differed significantly with respect to the secondary end points including rates of myocardial recovery (24% and 7%, respectively; P = 0.022) and rates of durable mechanical circulatory support (17% and 42%, P = 0.012). Complication rates were not statistically different between the 2 groups., Conclusions: The use of Impella device as therapeutic unloading therapy during VA-ECMO did not significantly reduce 30-day mortality compared to surgical LV vent in patients with cardiogenic shock due to acute myocardial infarction., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Aims: Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce. The objective of the study is to externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course., Methods and Results: The Simplified Acute Physiology Score (SAPS) II Score, the CardShock score, the IABP-SHOCK II score, and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. The primary outcome was 30-day all-cause mortality. Discriminative power was assessed by comparing the area under the curves (AUC) in case of continuous scores. In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination [area under the curve (AUC = 0.74)], followed by the CardShock score (AUC = 0.69) and the SAPS II score, giving only moderate discrimination (AUC = 0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (Stage E) but showed poor discrimination between Stages C and D with respect to short-term-mortality., Conclusion: Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification, or even development of new scores might be necessary to reach higher levels of discrimination., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Objectives: Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h., Methods: Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization., Results: A total of 62 125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2-8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P < 0.001], major bleeding during VA-ECMO (OR 3.76; P = 0.001), prolonged cardiopulmonary bypass time (OR 1.01; P < 0.001) and female gender (OR 4.87; P < 0.001)., Conclusions: Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We describe the case of a peripartum thrombotic thrombocytopenic purpura with fulminant cardiogenic shock treated with extracorporeal life support. Thrombotic thrombocytopenic purpura should be considered in the case of thrombotic microangiopathy with several or severe organ involvement and needs emergent treatment with plasmapheresis (with or without rituximab). In the case of cardiac involvement, aggressive treatment should be considered given the high mortality and the potential complete recovery.

Most of the guideline-recommended treatment strategies for patients with acute coronary syndromes have been tested in large randomised clinical trials. Still, a major challenge is represented by patients with acute myocardial infarction admitted with impending or established cardiogenic shock. Despite early revascularization the mortality of cardiogenic shock remains high and roughly half of patients do not survive until hospital discharge or 30-day follow-up. However, there is only limited evidence-based scientific knowledge in the cardiogenic shock setting. Therefore, recommendations and actual treatments are often based on retrospective or prospective registry data and extrapolations from randomised clinical trials in acute myocardial infarction patients without cardiogenic shock. This position statement will summarise the current consensus of the diagnosis and treatment of patients with acute myocardial infarction complicated by cardiogenic shock based on current evidence and will provide advice for clinical practice.

Aims: Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction with symptoms and electrocardiographic changes mimicking acute myocardial infarction (AMI). The objective of this study was to evaluate in-hospital death and hospital readmission in patients with TTS and to compare outcomes to patients with AMI., Methods and Results: Patients diagnosed with TTS and AMI were identified using the United States Nationwide Readmission Database from 2010 to 2014. In-hospital outcomes for the index admission, and rates and causes of 30 day readmissions were compared between TTS patients and AMI patients without TTS. Sixty-one thousand, four hundred, and twelve patients with TTS and 3 470 011 patients with AMI without TTS were identified. Patients with TTS were younger, more often women (89% vs. 41%), and less likely to have cardiovascular risk factors than AMI patients. Mortality during the index admission was lower in TTS compared with AMI (2.3% vs. 10.2%, P < 0.0001). Cardiogenic shock occurred at the same frequency (5.7%) with TTS or AMI. Among TTS survivors, 7132 patients (11.9%) were readmitted within 30 days, and mortality associated with readmission was 3.5%. The most common reason for readmission after TTS was heart failure (HF; 10.6% of readmissions)., Conclusion: Takotsubo syndrome is associated with substantial morbidity and mortality. Although outcomes are more favourable than AMI, approximately 2% of patients died in hospital and approximately 12% of survivors were readmitted within 30 days; HF was the most frequent indication for rehospitalization. Careful outpatient follow-up of TTS patients may be warranted to avoid readmissions., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.)

Kounis syndrome is defined as the coincidental occurrence of an acute coronary syndrome with hypersensitivity reactions following an allergic event. The three reported variants of Kounis syndrome are vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus. The syndrome is caused by various inflammatory mediators. The pathophysiological characteristics of Kounis syndrome involve coronary artery spasm and/or atheromatous plaque erosion or rupture during an allergic reaction. Several causes have been described to induce Kounis syndrome, and their number is increasing rapidly. The haemodynamic effect of the syndrome complicated by cardiogenic shock seems to combine allergic shock with extensive peripheral vasodilation and myocardial suppression with the characteristics of cardiogenic shock. Treatment of Kounis syndrome is challenging because it needs management of both cardiac and allergic manifestation simultaneously. We present a case report of type I Kounis syndrome, with coronary spasm secondary to cefuroxime injection complicated with cardiogenic shock. A brief review of the literature on the various facets of this condition is also provided.

Aims: Early risk stratification is important in patients with cardiogenic shock from ST-elevation myocardial infarction (STEMI). We aimed to develop a simple risk chart that includes clinical parameters that are readily available at time of hospital admission to assess risk of 30-day mortality., Methods and Results: A series of 544 STEMI patients admitted to undergo primary percutaneous coronary intervention and presenting with cardiogenic shock were included between 2000 and 2012. Overall 30-day mortality was 38.4% and did not change over the years (p-trend=0.64). Baseline variables that were available at time of hospital admission were entered into a logistic regression model in a forward stepwise manner. Only age (odds ratio (OR) per year 1.05, 95% confidence interval (CI) 1.04-1.07, p<0.001), initial serum lactate level (OR per mmol/l 1.17, 95% CI 1.11-1.24, p<0.001) and initial creatinine level above the upper limit of normal (OR 2.89, 95% CI 1.90-4.37, p<0.001) remained independent predictors, and were subsequently used to develop a risk chart that stratifies risk of 30-day mortality into categories ranging from 0-20% to 80-100%. The calibration plot showed a close relationship between expected and observed mortality. The risk chart had a higher discriminative accuracy than the GRACE score (c-index 0.75 vs. 0.66, p=0.009). Adding variables that were obtained from coronary angiography and during clinical course did not significantly improve discriminative accuracy of risk chart (c-index 0.77, p=0.48)., Conclusion: Mortality of patients with cardiogenic shock from STEMI undergoing primary percutaneous coronary intervention can be well predicted already at time of hospital admission by a risk chart that uses only three variables, namely, age, initial serum lactate and creatinine level., (© The European Society of Cardiology 2015.)

Objectives: Short-term ventricular assist devices are more frequently used in patients with acute cardiogenic shock. The aim of this study was to evaluate its effect on haemodynamic parameters, as well as the short- and long-term outcome and complication rate associated with the device., Methods: All patients treated with the Impella® Recover device at our centre from 2003 to 2014 (n = 66) were included in this study, and follow-up time was 2.9 (±0.4) years. Data were obtained through patient records and the population register. Patient-related factors, preimplantation and early postimplantation haemodynamic and biochemical parameters were analysed. Characteristics of survivors and non-survivors were compared., Results: The device was implanted in 66 patients and 58% (38/66) were alive at 30 days post-implantation. The mean duration of support was 7.4 (±0.8) days. Mean time in the intensive care unit was 24 (±4) days. Following device implantation, patients' cardiac index improved from 2.1 l/min/m(2) (±0.20) to 3.8 l/min/m(2) (±0.20) at Day 7, mixed venous saturation increased from 56% (±2.0) to 68% (±1.2) and diuresis increased from 69 ml/h (±9) at device insertion to 105 ml/h (±19) at Day 7 on support. Central venous pressure, lactate levels and inotropic support decreased on support. No difference between survivors and non-survivors was established. No correlation was established between preimplant parameters and 30-day mortality., Conclusions: The Impella® Recover device improved haemodynamics in patients with acute cardiogenic shock. Still, 30-day mortality remains high and future studies must focus on the optimal timing of placement of the device., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Studies on mechanical-medical bridging for decompensated pulmonary hypertension (PH) are limited. We analysed the outcomes for critical PH patients who underwent extracorporeal membrane oxygenation (ECMO) support using a bridge-to-recovery (BTR) strategy. This study aimed to identify prognostic factors of BTR and evaluate the outcomes of survivors., Methods: Between 2009 and 2012, 6 patients who received veno-arterial ECMO due to decompensated PH with cardiogenic shock were retrospectively reviewed. All of the patients were managed with an aggressive titration of PH therapies and the optimization of right ventricular (RV) function to wean them off of ECMO. Three of the patients survived to discharge, and the others suffered in-hospital mortality. The differences between their baseline characteristics, ECMO set-up, haemodynamic change and complications were analysed., Results: The average age was 46.67 ± 14.07 years, with a male-to-female ratio of 1:2. The non-survival group exhibited a higher baseline systolic pulmonary artery pressure (127.67 ± 25.81 vs 67.67 ± 24.83 mmHg, P = 0.044) than the survival group before ECMO. All of the non-survivors underwent cardiopulmonary-cerebral resuscitation prior to ECMO implantation (100 vs 0%, P = 0.100). The survivors tended to have received suboptimal PH therapies before ECMO and had more readily correctable predisposing factors of right ventricular failure. The non-survivors required a longer duration of ECMO and suffered more end-organ failure or sepsis, although those differences were not statistically significant. Pneumonia developed in 3 of the survivors and caused late mortality in 2 after discharge., Conclusions: ECMO provides a therapeutic window for the medical stabilization of critically decompensated PH patients. Prompt ECMO intervention before haemodynamic collapse and careful patient selection are critical for successful BTR outcomes., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Unlabelled: Early identification of higher risk patients presenting with ST-elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI) will allow a more aggressive strategy and approach. The aim of this study was to evaluate the shock index (ratio of heart rate/systolic blood pressure on admission) as a predictor of mortality post PPCI in addition to other parameters., Methods: We analysed prospectively collected data on 3049 STEMI patients treated with PPCI in a large tertiary centre between March 2008-December 2011, out of which 2424 patients were aged up to 75 years (young) and 625 patients were older than 75 years (elderly)., Results: Compared to younger patients, in-hospital mortality rates were four-fold higher in the elderly (11.5% vs 2.8%, odds ratio (OR) 3.5, 95% confidence interval (CI) 2.0-5.9). Cardiogenic shock (OR 8.7 (5.1-14.6)), non-TIMI3 (Thrombosis In Myocardial Infarction) flow post percutaneous coronary intervention (PCI) (OR 5.0 (3.1-7.9)), age over 75 (OR 3.5 (2.3-5.3)) and a positive shock index pre PPCI (OR 3.5 (2.0-5.9)) were the strongest independent predictors of in-hospital mortality. For long-term outcome (median follow-up period 454 days) we excluded 141 (4.6%) patients that died during the initial hospital stay. Previous angina (hazard ratio (HR) 2.9), and previous cerebrovascular events (HR 3.7) were predictors of adverse outcome in the younger patients, while previous myocardial infarction (HR 2.0) and a positive shock index (HR 2.3) were predictors in the elderly. Cardiogenic shock prior to PPCI was not able to predict long-term outcome for in-hospital survivors., Conclusion: Mortality rates following PPCI were higher in elderly patients although remained acceptable. Invasively measured shock index before PPCI is the strongest independent predictor of long-term outcome in elderly patients. In addition, predictors of in-hospital mortality were similar across different age groups but differed significantly in relation to longer-term mortality., (© The European Society of Cardiology 2014.)

Objectives: Traditionally, patients on extracorporeal life support (ECLS) are sedated and mechanically ventilated and therefore prone to complications related to immobility and ventilation. We adopted this 'Awake ECLS' strategy for the patients with refractory cardiogenic shock (RCS) as a bridge to decision., Methods: Sixty-eight patients with RCS were supported by ECLS (All veno-arterial) in years 2010-2014. Patients that could not survive 24 h after ECLS implantation (9 patients) were excluded from the study. Study population constituted 59 patients-'Awake' group (n = 18; maintained awake without intubation) and 'Control' group (n = 41; intubated and required mechanical ventilation)., Results: Nine (50%) patients were awake at implantation, with 5 of them remaining free of sedation and ventilator support through to explantation. Nine patients were ventilated at the time of implantation but subsequently extubated and remained non-intubated and ventilator free. Post-ECLS survival at 1 month was 78 and 42% while the survival to discharge was 78 and 37% in awake and control group, respectively., Conclusions: ECLS as a bridge to decision in RCS is effective in restoring adequate systemic perfusion and recovering end-organ function. ECLS can be initiated in awake patients with RCS and patients can be awakened on ECLS. The 'awake ECLS' strategy may avoid complications related to mechanical ventilation, sedation and immobilization. RCS patients supported on ECLS without severe metabolic acidosis, multiorgan failure, intra-aortic balloon pump or uncertain neurological status are more likely to be weaned from the ventilator. Patients that are awake at the time of ECLS implantation are more likely to remain awake during ECLS., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Current diagnostic criteria for cardiogenic shock (CS) require the use of a pulmonary artery catheter (PAC), which is time-consuming and may cause complications. A set of simple yet accurate noninvasive diagnostic criteria would be of significant utility., Methods: Candidate components for the Noninvasive Parameters for Assessment of Cardiogenic Shock (N-PACS) criteria were required to be objective, readily available, and noninvasive. Variables encompassing hypotension, hypoperfusion, predisposing conditions, and elevated intracardiac filling pressures were optimized versus a PAC-based standard in a retrospective developmental cohort of 122 patients with acute myocardial infarction (AMI). The finalized criteria were validated in a prospective cohort of coronary care unit patients in whom a PAC was placed for clinical indications., Results: According to invasive criteria, CS was present in 32 of 217 consecutive patients undergoing PAC. Compared to the PAC-based standard, the N-PACS criteria had a sensitivity of 96.9% (95% confidence interval (CI) 82.0-99.8), specificity of 90.8% (95% CI 85.5-94.4), positive predictive value of 64.6% (95% CI 49.4-77.4), negative predictive value of 99.4% (95% CI 96.2-100), positive likelihood ratio of 10.5 (95% CI 6.7-16.7), negative likelihood ratio of 0.03 (95% CI 0.00-0.24), and diagnostic odds ratio of 306.4. Results were similar among patients with and without AMI., Conclusion: A simple, echocardiography-based set of noninvasive diagnostic criteria can be used to accurately diagnose CS., (© The European Society of Cardiology 2014.)

Objectives: Therapy refractory cardiogenic shock is associated with dismal outcome. Percutaneous implantation of an extracorporeal life support (ECLS) system achieves immediate cardiopulmonary stabilization, sufficient end-organ perfusion and reduction of subsequent multiorgan failure (MOF)., Methods: Forty-one patients undergoing percutaneous ECLS implantation for cardiogenic shock from February 2012 until August 2013 were retrospectively analysed. Mean age was 52 ± 13 years, 6 (15%) were female. Mean pH values obtained before ECLS implantation were 7.15 ± 0.24, mean lactate concentration was 11.7 ± 6.4 mmol/l. Levels obtained 6 h after ECLS implantation were 7.30 ± 0.14 and 8.7 ± 5.0 mmol/l, respectively. In 23 patients (56%) cardiogenic shock resulted from an acute coronary syndrome in 13 (32%) from cardiomyopathy, in 5 (12%) from other causes. Twenty-seven (66%) had been resuscitated, in 14 (34%) implantation was performed under ongoing cardiopulmonary resuscitation (CPR). Of note, 97% of the acute coronary syndrome patients underwent percutaneous coronary intervention (PCI) either before ECLS implantation or under ECLS support. Extracorporeal life support implantation was performed on scene (Emergency Department, Cath Lab, Intensive Care Unit) by a senior cardiac surgeon and a trained perfusionist, in 8 cases (20%) in the referring hospital., Results: Thirty-day mortality was 51% [21 patients, due to MOF (n = 14), cerebral complications (n = 6) and heart failure (n = 1)]. Logistic regression analysis identified 6-h pH values as an independent risk factor of 30-day mortality (P < 0.001, OR = 0.000, 95% CI 0.000-0.042). Neither CPR nor implantation under ongoing CPR resulted in significant differences. In 26 cases (63%), the ECLS system could be explanted, after mean support of 169 ± 67 h. Seven of these patients received cardiac surgery [ventricular assist device implantation (n = 4), heart transplantation (n = 1), other procedures (n = 2)]., Conclusions: Due to the evolution of transportable ECLS systems and percutaneous techniques implantation on scene is feasible. Extracorporeal life support may serve as a bridge-to-decision and bridge-to-treatment device. Neurological evaluation before ventricular assist device implantation and PCI under stable conditions are possible. Despite substantial mortality, ECLS implantation in selected patients by an experienced team offers additional support to conventional therapy as well as CPR and allows survival in patients that otherwise most likely would have died. This concept has to be implemented in cardiac survival networks in the future.

Aims: Extracorporeal membrane oxygenation (ECMO) is a very effective bridging therapy in patients with cardiogenic shock. To perform coronary angiography in these patients our group developed an unique system to get urgent vascular access with minimal additional vascular complication risk. The 6 Fr coronary catheters are introduced through a standard Y-connector, which is inserted into the arterial cannula of the ECMO-line close to the patient, the blind end of which is then equipped with a haemostatic valve (Check-Flo Performer accessory adapter, Cook Medical, USA). To the best of our knowledge, we here present the first patient, in whom this system had been used to insert an 8 Fr radiofrequency ablation catheter to treat incessant ventricular fibrillation., Methods and Results: A 66-year-old patient had been transferred with electrical storm 5 days after an acute MI. After failed interventional and medical therapies an ECMO system had been inserted (right femoral artery cannula 15 Fr, left femoral vein cannula 21 Fr) and an electrophysiological study had been performed because of incessant ventricular fibrillation episodes, which always were induced by the same ventricular premature beat (VPB). During this first EP study over the left femoral artery the VPB could be targeted and successfully ablated. Unfortunately the VPB recovered again after some days so a second EP study had to be performed. This time the left femoral artery could not be used because of a postinterventional complication so we used the arterial cannula of the ECMO system as the access for the ablation catheter using a Y-connector. Using this way again a successful ablation procedure could be performed, after getting familiar with manipulation the ablation catheter over the ECMO cannula and with the help of different curved ablation catheters. The issue of compromising of the effective lumen of the arterial cannula by the ablation catheter`s cross sectional area could be overcome with increasing the rotational speed of the V-A ECMO., Conclusion: Ablation of ventricular arrhythmias using a Y-connector to insert the ablation catheter into the arterial cannula is feasible in patients with a V-A ECMO system avoiding additional arterial puncture with potentially major vascular complications in critically ill patients. Manipulation of the catheter is not as easy as using a standard sheath but can well be performed after a short habituation.

We report the case of a patient who developed severe cardiogenic shock during the open repair of a ruptured abdominal aortic aneurysm. After controlling the bleeding from the ruptured aneurysm, the electrocardiogram exhibited ST-T elevation and bradycardia. A median sternotomy was performed, and cardiopulmonary bypass was established. Under cardiopulmonary bypass support, the patient successfully underwent a Y-shaped graft replacement. The venous and arterial cannulae were recannulated through the femoral artery and vein. The chest and abdomen were closed in the usual fashion. Five hours after admission to the intensive care unit, cardiopulmonary bypass was weaned successfully, and the patient was extubated 1 day after surgery. Postoperative coronary angiography showed severe vasospastic angina of the right coronary artery, which might have caused cardiogenic shock during the aneurysm repair. The patient had an uneventful recovery period and was discharged on the 14th postoperative day without neurological complications.

The left ventricular apical core biopsy performed during implantation of a left ventricular assist device (VAD) is a well-known diagnostic procedure in confirming cardiomyopathies leading to end-stage heart failure. We describe a patient in whom disseminated malignancy was revealed by means of the apical core biopsy after extracorporeal life support and left ventricular assist device implantation as a bridge to transplantation. This case emphasizes the importance of thorough oncological screening before VAD implantation and the possible consequences of circulating tumour cells in this device-assisted circulation.

Objectives: Although rare, life-threatening complications requiring emergency cardiac surgery do occur after diagnostic and therapeutic cardiac catheterization procedures. The operative mortality has been persistently reported to remain high. The purpose of this observational study was to evaluate and report the outcomes, with particular emphasis on early mortality, of these risky operations that were performed in a single highly specialized cardiac centre., Methods: Between June 1997 and August 2007, 100 consecutive patients, 13 after diagnostic complicated cardiac catheterization (0.038% of 34,193 angiographies) and 87 after crashed percutaneous coronary intervention (PCI; 0.56% of 15,544 PCIs), received emergency operations at the Feiring Heart Center. In the same period, 10,192 other patients underwent open cardiac surgery. Early outcome data were analysed and compared between the cohorts. Follow-up was 100% complete., Results: The preoperative status of the 100 patients was that 4 had ongoing external cardiac massage, 24 were in cardiogenic shock, 32 had frank enduring ST-segment infarction but without shock and 40 had threatened acute myocardial infarction. There was 1% (1 patient) 30-day mortality in the study group, which is equal (0.9%, P=0.60) to that of all other operations. Postoperative myocardial infarction and prolonged ventilator use were significantly higher in the crash group, whereas the rate of stroke, renal failure, reopening for bleeding and mediastinitis were similar between the groups., Conclusions: With rapid transfer to an operation room, minimizing the time of warm myocardial ischaemia, and by performing complete coronary revascularization, it is possible to obtain equally low operative mortality in patients with life-threatening cardiac catheterization-associated complications, as is the case with open cardiac operations in general.

Despite technological advances in a newer generation of ventricular assist devices (VAD), complications, such as pump thromboses, remain a significant cause of morbidity and indeed mortality in these patients. We present the case of a 34-year old patient who underwent HeartAssist 5 (HA5) implantation as a bridge to cardiac transplant. After an initial uneventful recovery, he developed a pump thrombosis that was refractory to medical treatment. We present the surgical technique used to exchange the HA5 with a HeartWare (HVAD), leaving the old inflow-sewing ring in situ.

Non-implantable ventricular assist device plays a major role in emergent or urgent situation where a patient has acutely decompensating hemodynamics. One of its major disadvantages is that the patient needs to be bed-bound after insertion. We have developed a surgical technique that allows ambulatory management of the patients who received non-implantable device with CentriMag.

Aims: A simple management strategy is required for patients with acute pulmonary embolism which allows a rapid and reliable diagnosis in order to start timely and appropriate treatment., Methods and Results: Two hundred and four consecutive patients with suspected pulmonary embolism were managed according to a standardized protocol based on the clinical pretest probability and the initial haemodynamic presentation (shock index=heart rate divided by systolic blood pressure). Patients with a high pretest probability and a positive shock index (> or =1) (n=21) underwent urgent transthoracic echocardiography. Based on the presence or absence of right ventricular dysfunction, reperfusion treatment was initiated immediately. Patients with a negative shock index (<1) (n=183) underwent diagnostic evaluation including pretest probability, D-dimer, and spiral computed tomography (CT) as first-line tests. Echocardiography was performed only when a central pulmonary embolism was found in the spiral CT(n=33). According to our strategy, 98 patients met the diagnostic criteria of pulmonary embolism: 75 patients (all shock index <1) were treated with heparin alone, 16 (seven had a shock index > or =1) with thrombolysis, four (all shock index > or =1) with catheter fragmentation, and three (all shock index > or =1) with surgical embolectomy. The all-cause mortality rate at 30 days was 5%, and at 6 months 11%. Right ventricular dysfunction on baseline echocardiography was not associated with a higher mortality rate at 6 months (logrank 2.4, P=0.12)., Conclusions: The novel management strategy for patients with suspected pulmonary embolism resulted in a rapid diagnosis and treatment with a low 30-day mortality. In patients with pulmonary embolism and a positive shock index, time-consuming imaging tests can be avoided to reduce the risk of sudden death and not to delay reperfusion therapy.

Floating masses in ascending aorta are an uncommon source of embolism. We report the case of a 46-year-old woman, smoker, on synthetic progestagen, with no previous history of thrombotic events, who was admitted to our emergency department for an acute anterior myocardial infarction. Coronary angiogram showed occlusion of left main coronary trunk. Recanalization of the artery was obtained. Ascending aorta angiogram revealed a free floating mass attached to the aortic wall without evidence of aortic dissection. Transesophageal echocardiography confirmed the presence of a pedunculated mobile mass attached to the aortic wall superior to the left coronary ostium. The patient underwent urgent surgery. Intraoperatively a floating thrombus was localized in the posterior wall of ascending aorta. At macroscopical examination aortic wall and leaflets were normal. Post-operative low cardiac output refractory to inotropic drugs and intraaortic balloon counterpulsation required a circulatory assist device. Consequences for the patient were catastrophic in terms of outcome.

A 54-year-old man was treated with weekly 24-h infusion of high-dose 5-fluorouracil (2600 mg/m2) and leucovorin (100 mg/m2) for metastatic colon cancer. At first, he tolerated the treatment well and no significant toxicity was identified. After a total of eight courses of treatment, a stable disease was observed, but mild shortness of breath was found on occasion. The patient had no previous history of cardiac disease and the heart performance assessed by left ventricular ejection fraction before treatment was normal. Unfortunately, acute pulmonary edema with lethal cardiogenic shock occurred during the ninth course of treatment, in spite of intensive medical treatment. The chest X-ray showed extreme cardiomegaly. Repeated assessment of his heart function by echocardiogram and ventricular ejection fraction revealed a very poor cardiac performance. Toxic cardiogenic shock during weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin is extremely rare. To the best of our knowledge, no case has been reported in the English literature. We report a case and the relevant literature about the incidence, clinical picture and possible pathophysiology on 5-fluorouracil-related cardioxicity is reviewed.

Objective: In this paper we describe the preliminary results of a prospective operative protocol designed in order to define the role of emergent myocardial revascularization in extensive acute myocardial infarction and in post-infarction cardiogenic shock., Methods: Entry criteria are: age < 75 years; anterior acute myocardial infarction with ST segment elevation > 4 leads, infero-postero-lateral or inferior and right ventricular within 6 h from onset of chest pain; post-infarction cardiogenic shock within 3 h from onset of shock. From November 1994 to July 1995, after emergency coronary arteriography, 23 patients were treated by coronary artery bypass grafting. Fifteen were operated for extensive acute myocardial infarction (group A, mean age 54.1 +/- 9.4 years) and eight for post-infarction cardiogenic shock (group B mean age 65.0 +/- 8.7 years). Mean time from onset was 4.4 +/- 1.3 h in group A and 2.2 +/- 0.8 h in group B. Mean left ventricular ejection fraction was 39.3 +/- 12.7% in group A and 22.6 +/- 3.5% in group B. Six out of eight group B patients needed intraaortic balloon counterpulsation preoperatively, and 2/8 cardiopulmonary resuscitation., Results: Myocardial revascularization consisted in 3.4 +/- 1.1 grafts in group A (vein grafts, except for 8 patients who also received a left internal thoracic artery graft) and 3.3 +/- 1.1 vein grafts in group B. All patients in group B and 3/15 (20%) in group A underwent intraaortic balloon counterpulsation. In-hospital death occurred in 1/15 (6.7%) patients of group A and in 4/8 (50%) patients of group B. At a mean follow-up of 4.1 +/- 3.4 months for group A and 3.9 +/- 2.2 months for group B left ventricular ejection fraction was 43.4 +/- 9.0% in group A and 35.7 +/- 13.1% in group B., Conclusions: Experience of 9 months with this prospective protocol showed its effectiveness in the management of critically ill patients with acute coronary occlusion leading to low mortality rate in acute myocardial infarction and improved survival rate in post-infarction cardiogenic shock.

The case of a 49-year-old patient is described who presented with cardiogenic shock and electrocardiographic signs of an inferolateral Q-wave infarction, and who received systemic lysis with anisoylated plasminogen streptokinase activator complex (Eminase). After coronary angiography had revealed only peripheral occlusion of a posterolateral branch of the left circumflex coronary artery, a pericardial effusion surrounding both right and left ventricular cavity was identified by echocardiography and was successfully drained via an inferior pericardiotomy with an immediate rise of blood pressure. Upon thoracotomy myocardial rupture was detected in the infarct area and was closed with mattress sutures. A total of 39 cases of successful surgical repair of myocardial free wall rupture reported in the literature is discussed. The mean age of patients was 59.6 +/- 1.3 years. Posterior and anterolateral infarctions were the preferred locations of myocardial rupture. Rupture occurred with a mean delay of 5.0 +/- 1.0 days after the onset of clinical infarct signs. Among patients saved by surgical means were 33 males and 6 females.