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Acute myocardial infarction with refractory cardiogenic shock (AMI-RCS) is associated with poor outcomes. Several percutaneous mechanical circulatory support devices exist; however, limitations exist regarding long-term use. Herein, we describe our experience with the temporary surgical CentriMag VAD. We reviewed 74 patients with AMI-RCS who underwent CentriMag VAD insertion as bridge-to-decision device from 2007 to 2020. Patients were divided into groups based on introduction of the “shock team” model: Era 1 (2007–2014, n = 51) and Era 2 (2015–2020, n = 23). Era 2 had higher proportion of patients with INTERMACS Profile I. The use of percutaneous MCS as bridge to VAD and the use of minimally invasive VAD were higher in Era 2. There were fewer postoperative bleeding events in Era 2 (80% vs 61%, p = .07). Thirty-day mortality was 23% and 1-year survival was 55%, which were no differences between eras. Destinations after CentriMag VAD included myocardial recovery (39%), durable LVAD (27%), and transplantation (5%). CentriMag VAD device represents a viable bridge-to-decision device with acceptable short- and long-term outcomes for patients with AMI-RCS. Stable outcomes in a progressively sicker population may be related to changes in practice patterns as well as introduction of the “shock team” concept.

Objectives To describe hemodynamic efficacy and clinical outcomes of Impella percutaneous left ventricular assist device (pLVAD) in patients with cardiogenic shock (CS). Background Percutaneous LVADs are increasingly used in CS management. However, device-related outcomes and optimal utilization remain active areas of investigation. Methods All CS patients receiving pLVAD as mechanical circulatory support (MCS) between 2011 and 2017 were identified. Clinical characteristics and outcomes were analyzed. A multivariable logistic regression model was created to predict MCS escalation despite pLVAD. Outcomes were compared between early and late implantation. Results A total of 115 CS patients (mean age 63.6 ± 13.8 years; 69.6% male) receiving pLVAD as MCS were identified, the majority with CS secondary to acute myocardial infarction (AMI; 67.0%). Patients experienced significant cardiac output improvement (median 3.39 L/min to 3.90 L/min, p = .002) and pharmacological support reduction (median vasoactive-inotropic score [VIS] 25.4 to 16.4, p = .049). Placement of extracorporeal membrane oxygenation (ECMO) occurred in 48 (41.7%) of patients. Higher pre-pLVAD VIS was associated with subsequent MCS escalation in the entire cohort and AMI subgroup (OR 1.27 [95% CI 1.02-1.58], p = .034 and OR 1.72 [95% CI 1.04-2.86], p = .035, respectively). Complications were predominantly access site related (bleeding [9.6%], vascular injury [5.2%], and limb ischemia [2.6%]). In-hospital mortality was 57.4%, numerically greater survival was noted with earlier device implantation. Conclusions Treatment with pLVAD for CS improved hemodynamic status but did not uniformly obviate MCS escalation. Mortality in CS remains high, though earlier device placement for appropriately selected patients may be beneficial.

Background Late graft failure (LGF) is an unresolved issue after orthotopic heart transplant (OHT). In this study, we report characteristics and outcomes of severe LGF requiring mechanical circulatory support (MCS). Methods All patients undergoing OHT from 2000 to 2018 at our center were reviewed. Patients re-admitted to the hospital for late graft failure (>3 months after initial discharge) and developing cardiogenic shock requiring MCS were identified. Outcomes and mortality were evaluated. Results Twenty-six patients were identified. Median age was 37.3 years (interquartile range: 28.2-47.6) and 69% were male. Median time from initial transplant to MCS was 2.9 years. Etiology of graft failure was rejection in 19 patients (73%), transplant coronary artery disease (tCAD) in 3 (12%), with mixed tCAD or rejection in 4 (15%).

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is used to provide cardiopulmonary support in cardiogenic shock; however, high extracorporeal flow may increase left ventricular (LV) afterload leading to LV distention and intracardiac stasis. It is unclear how ECMO flow affects patient outcomes and complications related to ECMO. Retrospective review of patients at a single institution placed on VA ECMO from 2007 to 2018 was performed. Patients were divided into full flow (flow index > 2.2 L/min/m2) and partial flow (flow index < 2.2 L/min/m2) groups. In-hospital mortality and markers of end-organ perfusion were compared between groups balanced for risk factors using propensity score inverse probability of treatment weighting. ECMO-related complications such as LV distention, limb ischemia, and bleeding were recorded. There were 488 patients included, 405 (83%) in the partial flow group, and 83 (17%) in the full flow group. No major differences in age, gender, or comorbidities were found. There was no difference in in-hospital mortality between groups (51% vs. 55%, p = 0.59). At 72 hours post-ECMO initiation, there was no difference in the change in renal, hepatic function, or lactate from baseline nor in the rates of continuous venoveno hemofiltration initiation (p = 0.41). There was a trend towards the decreased incidence of LV distention requiring LV vent placement in the partial flow group (12% vs. 7%, p = 0.16). Compared with full flow VA ECMO, partial flow VA ECMO in carefully selected patients results in similar in-hospital mortality and provides similar end-organ perfusion for the treatment of refractory cardiogenic shock.

The role of the intra-aortic balloon pump (IABP) in acute decompensated heart failure (HF) with cardiogenic shock (CS) is largely undefined. In this study we sought to assess the hemodynamic and clinical response to IABP in chronic HF patients with CS and identify predictors of response to this device.We retrospectively reviewed all patients undergoing IABP implantation from 2011 to 2016 at our institution to identify chronic HF patients with acute decompensation and CS (cardiac index2.2 liters/min/mWe identified 132 chronic HF patients with IABP placed after decompensation with hemodynamic evidence of CS. Overall 30-day survival was 84.1%, and 78.0% of patients were successfully bridged to HRT or discharge without need for escalation of device support. The complication rate during IABP support was 2.3%. Multivariable analysis identified ischemic cardiomyopathy (odds ratio [OR] 3.24, 95% confidence interval [CI] 1.16 to 9.06; p = 0.03) and pulmonary artery pulsatility index (PAPi)2.0 (OR 5.04, 95% CI 1.86 to 13.63; p = 0.001) as predictors of clinical deterioration on IABP.Overall outcomes with IABP in acute decompensated chronic HF patients are encouraging, and IABP is a reasonable first-line device for chronic HF patients with CS. Baseline right ventricular function, as measured by PAPi, is a major predictor of outcomes with IABP in this population.

Background Interventricular interaction, which refers to the impact of left ventricular (LV) function on right ventricular (RV) function and vice versa, has been implicated in the pathogenesis of RV failure in LV assist device (LVAD) recipients. We sought to understand more about interventricular interaction by quantifying changes in the RV systolic and diastolic function with varying LVAD speeds. Methods and Results Four patients (ages 22–69 years, 75% male, and 25% with ischemic cardiomyopathy) underwent a protocolized hemodynamic ramp test within 12 months of LVAD implantation where RV pressure–volume loops were recorded with a conductance catheter. The end-systolic PV relationship and end-diastolic PV relationship were compared using the V20 and V10 indices (volumes at which end-systolic PV relationship and end-diastolic PV relationship reach a pressure of 20 and 10 mm Hg, respectively). The ∆V20 and ∆V10 refer to the change in V20 and V10 from the minimum to maximum LVAD speeds. RV PV loops demonstrated variable changes in systolic and diastolic function with increasing LVAD speed. The end-systolic PV relationship changed in 1 patient (patient 2, ∆V20 = 23.5 mL), reflecting a decrease in systolic function with increased speed, and was unchanged in 3 patients (average ∆V20 = 7.4 mL). The end-diastolic PV relationship changed with increasing speed in 3 of 4 patients (average ∆V10 = 12.5 mL), indicating an increase in ventricular compliance, and remained unchanged in one participant (patient 1; ∆V10 = 4.0 mL). Conclusions Interventricular interaction can improve RV compliance and impair systolic function, but the overall effect on RV performance in this pilot investigation is heterogeneous. Further research is required to understand which patient characteristics and hemodynamic parameters influence the net impact of interventricular interaction.

The purpose of this study was to compare outcomes between patients on extracorporeal membrane oxygenation (ECMO) bridged to left ventricular assist device (LVAD) versus heart transplantation (HT) using registry data.Patients with heart failure supported with ECMO represent the highest priority in the new HT allocation system. For patients on ECMO, bridging to LVAD may be non-inferior compared with bridging to HT.Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 2006 to 2017 and United Network for Organ Sharing (UNOS) database from 2006 to June 2019 requiring ECMO were included. Cause-specific hazard models were created and cumulative incidence functions were calculated with mortality, transplantation, and re-transplantation as competing events.A total of 906 patients received ECMO as bridge to VAD (n = 587, 64.8%) or as bridge to HT (n = 319, 35.2%). Patients bridged directly to HT were younger (age 46.3 ± 15.4 years vs. 52.1 ± 13.2 years; p 0.001) and more likely to be female (93 [29.2%] vs. 139 [23.7%]; p = 0.022). Patients bridged directly to HT were more likely to have a nonischemic cardiomyopathy, restrictive physiologies, and allograft failure; (p 0.05 for all). ECMO use increased over time in both UNOS and INTERMACS. There was no significant difference in mortality between groups (Gray's p = 0.581). This remained true even when the analysis was restricted to transplant-listed or eligible patients as well as patients with dilated phenotypes (excluding patients with congenital heart disease, restrictive phenotypes, and allograft failure).There was no difference in mortality on pump support compared with posttransplant mortality among those bridged from ECMO to LVAD or HT.

Background: Giant cell myocarditis is a rare etiology of cardiogenic shock, which requires high index of suspicion, rapid immunosuppressive therapy, and sometimes mechanical circulatory supportCase presentation69 year old woman with prior medical history of non-ischemic dilated cardiomyopathy and recovered left ventricular ejection fraction (LVEF) presented with cardiogenic shock complicated by acute renal and liver injury requiring support with Impella 5.5. Suspicion for myocarditis was high and patient underwent endomyocardial biopsy and started on high dose steroids. Biopsy was negative for myocarditis. Despite support, patient had progressive shock and incessant ventricular arrhythmia necessitating IV antiarrhytmics and escalation to VA ECMO in addition to Impella and eventually to central Centrimag BiVAD with drainage cannulas in right atrium and LV apex, and reinfusion catheters in pulmonary artery and ascending aorta. (Figure 1) She was urgently listed for heart transplantation as a status 1 and one day later underwent successful orthotopic heart transplantation. Pathological examination of the explanted heart was consistent with Giant cell Myocarditis (Figure 2) Conclusion: Giant cell myocarditis is a rare etiology of cardiogenic shock. Suggestive features include rapid hemodynamic deterioration and incessant ventricular arrhythmia. Negative initial endomyocardial biopsy is not enough to rule out the disease in high clinical suspicion. Rapid escalation of support is warranted in fulminant cases to preserve end organ function and improve survival.(Figure 1 Created with BioRender.com)

Background COVID-19 has spread worldwide and has caused significant morbidity and mortality. Myocardial injury and thrombo-embolism are known complications for those with severe forms of disease. The incidence and risk factors for these complications for those patients who are asymptomatic or with mild forms of COVID-19 is unknown. Case summary In this report we describe the case of a 35-year-old man with no past cardiac history who presented with chest pain and a high-sensitivity troponin level of 386 ng/L in the context of an unspecified mild viral illness 1 month previously. Diagnostic evaluation revealed a new cardiomyopathy, left ventricular thrombus, and mid right coronary artery thrombosis. The coronary thrombosis was treated with thrombectomy. SARS-CoV-2 antibodies returned positive. He initially did well post-procedure; however, prior to discharge, he developed a second arterial thrombo-embolism event, a middle cerebral artery stroke. He was treated with thrombectomy and remains hospitalized. Discussion Recognition that mild COVID-19 can be complicated by subsequent cardiac injury and/or coagulopathy is important. As more people recover from this viral illness and return to normal activity levels, discussion among cardiac experts has begun regarding screening for occult myocardial injury in those who plan to resume competitive athletic activity. This case highlights the need for investigation regarding (i) the duration of thrombophilia after recovery from illness; (ii) the population that should receive thromboprophylaxis; and (iii) the duration of thromboprophylaxis therapy for COVID-19.

Background: Estimated glomerular filtration rate (eGFR) based on serum creatinine (sCr) improves early after left ventricular assist device (LVAD) implantation but subsequently declines. Although sCr is a commonly accepted clinical standard, cystatin C (CysC) has shown superiority in assessment of renal function in disease states characterized by muscle wasting. Among patients with an LVAD, we aimed to (1) longitudinally compare CysC-eGFR and sCr-eGFR, (2) assess their predictive value for early postoperative outcomes, and (3) investigate mechanisms which might explain potential discrepancies. Methods: A prospective cohort (n=116) with CysC and sCr concurrently measured at serial time points, and a retrospective cohort (n=91) with chest computed tomography performed within 40 days post-LVAD were studied. In the prospective cohort, the primary end point was a composite of in-hospital mortality, renal replacement therapy, or severe right ventricular failure. In the retrospective cohort, muscle mass was estimated using pectoralis muscle area indexed to body surface area (pectoralis muscle index). Results: In the prospective cohort, sCr-eGFR significantly improved early post-LVAD and subsequently declined, whereas CysC-eGFR remained stable. CysC-eGFR but not sCr-eGFR predicted the primary end point: odds ratio per 5 mL/(min·1.73 m 2 ) decrease 1.16 (1.02–1.31) versus 0.99 (0.94–1.05). In retrospective cohort, for every 5 days post-LVAD, a 6% decrease in pectoralis muscle index was observed (95% CI, 2%–9%, P =0.003). After adjusting for time on LVAD, for every 1 cm 2 /m 2 decrease in pectoralis muscle index, there was a 4% decrease in 30-day post-LVAD sCr (95% CI, 1%–6%, P =0.004). Conclusions: Initial improvement in sCr-eGFR is likely due to muscle wasting following LVAD surgery. CysC may improve assessment of renal function and prediction of early postoperative outcomes in patients with an LVAD.

Purpose C-reactive protein (CRP) emerged as a biomarker of inflammation in heart failure patients and associated with increased morbidity and mortality. We hypothesized that higher serum CRP level prior to Heartmate 3 LVAD implantation is associated with increased risk of post-implant adverse events and mortality. Methods 123 patients who underwent Heartmate 3 LVAD implantation at a tertiary care center and had a CRP level measured prior to device implant were included in the analysis. Optimal CRP cut-off was determined used ROC curve and patients were categorized into high vs. low CRP groups accordingly. Study end-points included RVAD use, need for CVVH, in-hospital mortality, and 2-year survival. Results Mean and median pre-implant CRP levels in HM3 patients were 35.5±43.6 mg/L and 15.0 mg/L respectively. Patients with an elevated pre-implant CRP (≥12 mg/L) were more likely to be in INTERMACS Class I or II (78.4% vs. 46.6%), to have temporary MCS (49.2% vs. 27.5%), and elevated WBC count (9.1 vs. 7.5) compared to those with a pre-implant CRP less than 12 mg/L (all p Conclusion Pre-implant CRP is a strong predictor of morbidity and mortality in patients undergoing HM3 implantation. Routine assessment of CRP prior to implant may improve patient selection and outcomes in this population.

Purpose Heartmate II risk score (HMRS) and MELD-Xi score are validated mortality risk predictors in Heartmate II left ventricular assist device (LVAD) patients. Prognostic utility of these risk scores remains unknown in patients considered for Heartmate 3 (HM3) LVAD therapy. Methods HMRS were calculated for 175 consecutive patients who underwent HM3 LVAD implantation at a single academic institution. Receiver operating characteristic (ROC) curve and logistic- and cox-regression models were developed to assess the impact of HMRS and MELD-Xi scores on short- and long-term outcomes in HM3 patients. Results Mean HMRS and MELD-Xi scores in HM3 population was 1.38±0.57 and 14.4±0.28, respectively. Pre-implant HMRS was not predictive of RVAD use (OR 1.25, p=0.392), CVVHD (OR 1.16, p=0.722), in-hospital mortality (OR 1.52, p=0.409), or 90-day mortality (OR 1.44, p=0.457). Pre-implant MELD-Xi score showed trend towards increased RVAD use (OR 1.09, p=0.056) and need for CVVH (OR 1.14, p=0.064), however was not predictive of in-hospital mortality (OR 1.02, p=0.836), or 90-day post-LVAD mortality (OR 0.958, p=0.636). Area under curve (AUC) for in-hospital mortality was 0.531 for HMRS and 0.525 for MELD-Xi score (Figure) . There was no difference in post-implant survival (88.6% vs. 85.7%, log-rank p=0.569), freedom from GI bleeding (73.5% vs. 65.1%, log-rank p =0.257) or freedom from stroke (93.3% vs. 90.8% log-rank p = 0.478) at 2-year follow-up in patients with below average vs. above average HMRS. Similarly, There was no difference in post-implant survival (91.3% vs. 82.3%, log-rank p=0.121), freedom from gastrointestinal bleeding (72.2% vs. 65.2%, log-rank p =0.257) or freedom from stroke (92.0% vs. 92.4% log-rank p = 0.820) at 2-year follow-up in patients with below average vs. above average MELD-Xi score. Conclusion HMRS and MELD-Xi scores do not predict mortality in patients undergoing HM3 implantation. New prediction models are required to optimize patient selection and outcomes in HM3 patients.

Purpose Acute mechanical circulatory support devices (MCSD) are increasingly being used to stabilize and optimize patients for durable left ventricular assist device (LVAD) implantation. The primary objective of our study was to assess the outcomes of patients bridged with acute MCSD to HeartMate 3 (HM3). Methods We retrospectively reviewed 165 consecutive patients implanted with a HM3 at our institution from November 2014 to July 2019. Baseline clinical characteristics, hemodynamic data, and post-operative outcomes were assessed. Patients bridged with intraaortic balloon pumps (IABP), extracorporeal membrane oxygenation (ECMO) and/or Impella percutaneous ventricular assist device (pVAD) were compared to patients that were directly implanted with HM3. Results Of the 165 patients, 69 (41.8%) were bridged to HM 3 LVAD with acute MCSD during the study period. The following device configurations were used: 3 patients with ECMO alone, 6 with ECMO + IABP, 2 ECMO + pVAD, 3 pVAD alone and 55 patients with IABP alone. Patients with acute MCSD were numerically younger (56.8 ±12.9 vs. 60.9 ±13.2, p =0.05) and had lower INTERMACS profile levels (1.71 ± 0.49 vs. 2.67 ± 0.64, p Conclusion A large proportion of patients in the contemporary era are bridged with acute MCSD to HM3 and despite their increased severity of illness have outcomes comparable to patients who are not bridged with acute MCSD.

The intra-aortic balloon pump (IABP) neither benefits nor harms patients with acute myocardial infarction (AMI) with cardiogenic shock (CS) but may stabilize those with chronic heart failure who decompensate into CS. We sought to compare its hemodynamic effects in these 2 populations. We performed a retrospective analysis of the hemodynamic effects of IABP for AMI or acute decompensated heart failure (ADHF) patients with hemodynamic evidence of CS. The primary outcome was cardiac output (CO) change following insertion. In total, 205 patients were treated for CS resulting from AMI (73; 35.6%) or ADHF (132; 64.4%). At baseline, both cohorts had significant hemodynamic compromise with mean arterial pressure 75.6 ± 12.3 mm Hg, CO 3.02 ± 0.84 L/min, and cardiac power index 0.26 ± 0.06 W/m2; these parameters were nearly identical between groups though ADHF-CS patients had a higher pre-IABP mean pulmonary artery (PA) pressure than AMI-CS patients. After IABP insertion, ADHF-CS patients had moderate CO augmentation whereas AMI-CS experienced almost no improvement (0.58 ± 0.79 L/min vs 0.12 ± 1.00 L/min; p = 0.0009). Intracardiac filling pressures were reduced by similar amounts in both cohorts. Systemic vascular resistance was reduced in patients with ADHF-CS but not in those with AMI-CS. In conclusion, following IABP insertion, ADHF-CS patients experience roughly a 5-fold greater CO augmentation compared with AMI-CS patients. Pre-IABP PA pressure differences and differential systemic vascular resistance reduction may explain these results and shed light on recent evidence supporting IABP use in ADHF-CS and curbing it in AMI-CS.

Purpose The Society for Cardiovascular Angiography and Interventions (SCAI) recently introduced a staging schema for cardiogenic shock (CS) based on exam findings, lab markers, and hemodynamics. We applied the SCAI schema to CS patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to assess clinical relevance. Methods We retrospectively reviewed patients receiving VA-ECMO for CS at our institution from January 2015 to December 2019. Patients with post-cardiotomy shock and non-cardiac shock etiologies were excluded. Patients were classified to a SCAI stage A-E based on device and drug initiation, hemodynamics, CPR use, and levels of lactate and creatinine. Outcomes included in-hospital mortality, myocardial recovery, and adverse events during ECMO course. Results A total of 245 patients met the inclusion criteria, with median age of 59 years [IQR: 48-67]. One hundred fifty-nine patients (65%) were male. The number of patients in SCAI stages was 0 (0%) in A, 0 (0%) in B, 34 (14%) in C, 82 (33%) in D, and 129 (53%) in E. Of the E patients, 88 (68%) were undergoing CPR. Underlying CS etiologies of acute decompensated heart failure (C: 53%, D: 43%, E: 17%, p Conclusion In patients treated with VA-ECMO for CS, the SCAI classification provided robust risk stratification.

Purpose The use of temporary mechanical circulatory support (tMCS) as a bridge to advanced heart replacement therapies (HRT) has increased in the context of the new heart transplant allocation system. As such, it is important to assess contemporary outcomes for this patient population. The purpose of this study was to assess outcomes of cardiogenic shock patients that were bridged with tMCS to HRT since the allocation system changes. Methods All adult cardiogenic shock patients that were bridged with tMCS to either heart transplantation (OHT) or durable left ventricular assist device (LVAD) at our center between October 2018 and September 2020 were identified. The tMCS devices included extracorporeal membrane oxygenation (ECMO), Impella, or temporary surgical VAD. Early and late clinical outcomes were assessed. Results A total of 33 cardiogenic shock patients were bridged to HRT using tMCS devices (OHT = 12, LVAD = 21). Most patients were male (84.9%) and the median age for all patients was 53 years. In terms of initial tMCS therapy, ECMO was used most commonly (64%) followed by Impella (24%) and temporary surgical VAD (12%). Ten patients (30%) required a second bridge-to-bridge device prior to HRT. Median duration of tMCS support for OHT and LVAD patients were 15.5 days (IQR 6.25-25) and 8 days (IQR 5-18.5), respectively. There were no in-hospital or 30-day mortality events. There was one late death in the VAD group at 16 months. Kaplan-meier curve (Figure 1) shows overall survival with median follow up of 8 months. Conclusion Cardiogenic shock patients can be bridged to HRT using contemporary tMCS technology and management with excellent early- and mid-term outcomes.

Purpose Venoarterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of cardiogenic shock often requires left ventricular (LV) venting to decrease afterload and prevent LV distention. Percutaneous strategies for LV venting are limited by peripheral complications such as bleeding and lower limb ischemia as well as insufficient LV unloading. A surgical LV vent is an alternative option that may provide hemodynamic and clinical benefits. Methods This is a retrospective review of 33 patients with refractory cardiogenic shock requiring VA ECMO who underwent surgical LV vent placement between July 2015 and March 2020. Surgical LV vent was placed in the LV apex via left anterolateral thoracotomy. Patients were stratified according to the percutaneous vent strategy prior to LV vent placement, which included femoral VA ECMO alone (n = 7), ECMO plus intra-aortic balloon pump (IABP) (n = 10), or ECMO plus Impella (ECPELLA) (n = 16) sub-groups. The outcome of interest was immediate hemodynamic change with surgical LV vent placement as well as clinical outcomes. Results The most cited reasons for conversion to surgical LV vent included inadequate venting with percutaneous strategy, hypoxia, and bleeding from peripheral access site. Across all patients, surgical LV vent was associated with a decrease in diastolic pulmonary artery (PA) pressures (20 vs 16 mmHg, p = 0.01) along with an increase in SVO2 (69% vs 80.5%, p Conclusion The surgical LV vent can provide significant LV unloading in patients supported by VA ECMO for cardiogenic shock. Compared to percutaneous methods of LV unloading, the surgical LV vent can provide substantial unloading of the LV, improved oxygenation, and a greater degree of hemodynamic support with acceptable short-term outcomes.

Purpose Aortic insufficiency (AI) following continuous flow left ventricular assist device (LVAD) implant is a well-established complication associated with poor outcomes. Detailed assessment of aortic valve (AV) prior to LVAD implant may be challenging in critically ill patients supported with extracorporeal membranous oxygenation (ECMO) and/or Impella. This study aimed to investigate the risk of AI in HeartMate3 (HM3) recipients bridged from ECMO and/or Impella. Methods A single center retrospective review was conducted on all INTERMACS Stage 1 and 2 patients who were bridged to HM3 LVAD between 11/2014 and 10/2019 with intra-aortic balloon pump (IABP) alone or with ECMO/Impella. Patients were excluded for both repaired and unrepaired more than trace AI at the time of implant, post-LVAD endocarditis, or death during the index hospitalization. Echocardiograms at 1, 3, 6, and 12 months post-implant were reviewed and assessed for AI severity based on jet width and/or vena contracta. Results 17 patients bridged with ECMO/Impella and 50 patients bridged with IABP alone were enrolled to the study. The ECMO/Impella cohort consisted of 10 patients with ECMO and IABP, 2 with ECMO and Impella, 2 with ECMO alone, and 3 with Impella alone. There was no significant difference in age, sex, body mass index, strategy, and etiology of cardiomyopathy between two groups. Proportion of patients without AV opening at 1-month post implant were not significantly different (ECMO/Impella 47% vs. IABP 64%, p=0.26). Cumulative incidence of greater than mild AI during the first-year follow-up was 44% in Impella/ECMO group, compared to 16% in IABP cohort (p=0.038, Figure 1). Conclusion A higher incidence of AI was observed following HM3 LVAD implant in patients bridged with ECMO or Impella support than those bridged with IABP, potentially owing to difficulty assessing the AV in this critically ill population prior to LVAD implantation.

Purpose Left ventricular (LV) distention is a feared complication in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock. LV unloading could be achieved with concomitant intra-aortic balloon pump (IABP) or Impella. We sought to assess the clinical and hemodynamic effects of IABP and Impella on patients supported with VA-ECMO Methods We conducted a retrospective review of patients who received VA-ECMO at our institution between January 2015 and June 2020. Patients with post-cardiotomy shock were excluded. Patients were categorized as having received either ECMO alone or ECMO+LV unloading. LV unloading was further characterized as either ECMO+IABP, or ECMO+Impella. We recorded baseline characteristics, post-operative complications, and hemodynamic changes associated with device initiation. Results During the study period, 142 patients received ECMO alone, 76 received ECMO+IABP, and 76 received ECMO+Impella. The ECMO+LV unloading group had more male patients compared to ECMO alone (70.4% vs 57.5%, p=0.026). 39.4% of ECMO alone patients survived to discharge, compared to 44.4% of ECMO+LV unloading patients (p=0.12). The ECMO+LV unloading group showed a greater decrease in mean pulmonary diastolic pressures compared to ECMO alone after 24 hours of support (-6.0 ± 8.4 mmHg vs -0.1 ± 10.8 mmHg, p = 0.032). ECMO+Impella patients had a higher incidence of bleeding events compared to ECMO alone or ECMO+IABP (52.6% vs 37.3% vs 20.8%, p = 0.0003). Kaplan Meier analysis revealed that ECMO+IABP had better survival compared to ECMO alone and ECMO+Impella (Figure 1). In a multivariable Cox-hazard analysis, age (HR= 1.02), male sex (HR=0.57), baseline lactate (HR =1.05), baseline creatinine (HR=1.06), need for ECPR (HR=2.21) and presence of IABP (HR=0.48) were independent predictors for mortality. Conclusion Concomitant support with IABP may help to reduce morbidity in patients on VA-ECMO for cardiogenic shock.

Purpose The use of extracorporeal membrane oxygenation (ECMO) for patients in cardiogenic shock has significantly increased over the past decade. However, there is a paucity of data examining gender-associated differences in the current mechanical circulatory support era. We assessed the impact of gender on outcomes in patients on venoarterial ECMO for cardiogenic shock. Methods We retrospectively analyzed 574 adult patients who were placed on venoarterial ECMO for cardiogenic shock at our institution between Jan 2007- Dec 2018. Baseline risk factors and outcomes were assessed to compare male and female patients. Propensity score matching (PSM) was used to compare outcomes. The primary endpoint was in-hospital mortality. Secondary outcomes included limb ischemia (LI) defined as recommendation for distal perfusion cannula (DPC) or other interventions, LI interventions, DPC, stroke, bleeding, and continuous venovenous hemofiltration (CVVH) initiation. Results There were 394 male patients (69%) and 180 female patients (31%). In an unadjusted comparison, male patients were more likely to have coronary artery disease and hyperlipidemia and less likely to have COPD. Etiologies of shock were similar between the two groups. Male patients were also less likely to be be cannulated centrally for ECMO, though this difference was not seen after PSM. PSM compared 176 male patients to 176 female patients. There was no difference seen between men and women in in-hospital mortality (46.0% vs 42.6%, p=.59), LI (41.5% vs. 45.5%, p=0.52), LI surgery (15.3% vs. 12.5%, p=0.54), bleeding (44.3% vs. 48.9%, p=0.46), CVVH initiated (37.5% vs. 33.0%, p=0.44), and stroke (9.1% vs. 9.7%, p=1.00). Conclusion Our data suggests that men who receive ECMO for cardiogenic shock are more likely to have pre-existing coronary artery disease and hyperlipidemia while women are more likely to have COPD. After correcting for such differences, there is no significant difference in outcome between male and female patients.

Purpose Right ventricular failure (RVF) after LVAD is associated with increased morbidity and mortality. “Delayed right ventricular assist device (RVAD)”, as a surgical or percutaneous rescue strategy, carries high complication rates. We recently changed our practice and use “Upfront RVAD” (concurrent with LVAD implant) in selected high-risk pts (INTERMACS 1, severe RVF and renal failure). We sought to investigate the effect of this novel strategy on in-hospital mortality and adverse events. Methods We retrospectively reviewed consecutive pts who received primary LVAD implant between 1/2015 and 8/2019. This cohort was divided into 4 groups (Gs): G1- no evidence of RVF and no RVAD; G2 - RVF treated with inotropes >2 wks; G3 - Delayed RVAD; G4 - Upfront RVAD. Clinical outcomes included in-hospital mortality, renal replacement therapy (RRT), stroke and length of stay (LOS). Results 225 pts were enrolled in the study: G1 (n=117, 52%); G2 (n=48, 21.3%); G3 (n=26, 11.6%); G4 (n=34, 15.1%). Frequency of INTERMACS 1 profile was significantly different among groups: G1 10.3%; G2 8.3%; G3 11.5%; G4 51.4%; p=0.001. G4 had significantly lower albumin and longer bypass time compared to the other groups. RVAD strategy (Delayed (G3) vs. Upfront (G4)) and type (surgical vs. percutaneous) varied by implant year (Fig 1a). Mean time to Delayed RVAD (G3) was 2.54 (1-15) days. In-hospital mortality of pts in G4 was similar to G2 and numerically lower than G3. RRT and stroke were the highest in G3 and were similar in G4 vs.G2 (Fig 1b-d). Median (IQR) ICU LOS was G1 7(6-10); G2 15(10-21); G3 22(14-28); G4 20(14-41) days (p Conclusion In-hospital mortality, RRT and stroke events were markedly lower in pts who received Upfront compared to Delayed RVAD. Notably, despite the majority of Upfront RVAD pts being INTERMACS 1, mortality and adverse events were similar to those of pts treated with prolonged inotropes for RVF without RVAD support (

We examined our institutional experience with mechanical circulatory support (MCS) over nearly a decade in patients with ST-segment elevation myocardial infarction (STEMI) to identify temporal trends and the impact of “door-to-unloading” time on in-hospital mortality. Baseline characteristics

Purpose Accurate estimation of renal function using glomerular filtration rate (eGFR) is key for prediction of adverse events among HF pts undergoing LVAD implant. Changes in muscle mass are frequent among HF pts and represent a known confounder of serum creatinine (sCr) based equations. Cystatin C (CysC) is independent of muscle mass and provides an alternative measure of eGFR. We aimed to prospectively compare the value of CysC vs. sCr based eGFR in the prediction of postoperative outcomes among pts undergoing LVAD implant. Methods sCr and CysC were concurrently measured pre-LVAD in 73 pts (age 61±13, F 16%). CKD stages were defined by sCr-eGFR and CysC-eGFR using MDRD4 and CysC-CKD-EPI equations, respectively. The primary endpoint was a composite of severe right ventricular failure (sRVF) or renal replacement therapy (RRT) on the index admission. Predictive values of sCr-eGFR and CysC-eGFR were compared. The independent effect of sCr and CysC on the primary endpoint was assessed using multivariable models. Results Compared to pre-LVAD sCr-eGFR, CysC-eGFR reclassified 46 (63%) pts: 7 (16%) to earlier stage CKD and 39 (84%) to later stage CKD (Fig A). For every increase in CKD stage, there was a 60% increase in the risk of the primary endpoint using CysC-eGFR (p=.02) while the increase in risk did not reach statistical significance using sCr-eGFR (p=.19) (Fig B). CysC-eGFR outperformed sCr-eGFR as predictor of the primary endpoint (AUC 0.68 vs. 0.59, p=0.04, Fig C). In a model including both CysC and sCr: i) higher CysC was associated with an increased risk for the primary endpoint (OR: 1.60 per 0.5 mg/L increase, p=.01); ii) a trend towards a paradoxical association between higher sCr and lower risk was found (OR: 0.42 per 0.5 mg/dL increase, p=.08). Conclusion CysC-eGFR is a more reliable predictor of sRVF or need for RRT among pts undergoing LVAD implant. Higher sCr in relation to CysC may represent a marker of preserved muscle mass and thus might paradoxically confer improved prognosis.

Purpose The use of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) following acute myocardial infarction (AMI) with cardiogenic shock (CS) is increasing, but the ability to predict favorable clinical response is limited. We investigated predictors of in hospital mortality and ventricular recovery in patients supported with VA-ECMO for AMI-CS. Methods We retrospectively reviewed charts of patients with AMI who were supported with VA-ECMO from 2007-2018. Data collected included AMI characteristics and measures of cardiac function. Logistic regression was used to identify predictors of survival to discharge and recovery which was defined as survival to discharge without heart replacement therapy (HRT, durable LVAD or transplant). Results 137 patients were treated with VA-ECMO for AMI during the study period. Mean cardiac index at implantation in the cohort was 1.82 ±0.53 and 26 patients (18.9%) had VA-ECMO placed during active CPR. 43 patients (31.4%) were supported with IABP either before or during VA-ECMO support; 75 patients (54.7%) were supported with Impella either before or during VA-ECMO support. 30-day survival was 60.6% and 52.6% survived to discharge. Of the 72 patients surviving to discharge, 26 (36.1%) were discharged with HRT and 46 (63.9%) had recovery. In a multivariable analysis including, age, gender, lactate, TIMI 3 flow in culprit artery, and LV ejection fraction, younger age was the only independent predictor of survival to discharge (OR 1.18, p=0.02). Independent predictors of ventricular recovery were presence of TIMI 3 flow in culprit artery (OR 5.45, p=0.03) and residual CAD (OR 0.22, p=0.04, Table). At a median follow-up of 375 days (IQR 112, 959) after discharge, 2/46 (4.3%) patients required HRT. Conclusion In patients supported with VA-ECMO for AMI-CS, younger age was associated with survival to discharge while markers of successful revascularization were associated with ventricular recovery.

Background: Cardiogenic shock following acute myocardial infarction (AMI-CS) portends a poor prognosis. Short-term mechanical circulatory support devices (MCSDs) provide hemodynamic support for patients with cardiogenic shock but predictors of survival and the ability to wean from short-term MCSDs remain largely unknown. Methods: All patients > 18 years old treated at our institution with extra-corporeal membrane oxygenation or short-term surgical ventricular assist device for AMI-CS were studied. We collected acute myocardial infarction details with demographic and hemodynamic variables. Primary outcomes were survival to discharge and recovery from MCSD (i.e. survival without heart replacement therapy including durable ventricular assist device or heart transplant). Results: One hundred and twenty-four patients received extra-corporeal membrane oxygenation or short-term surgical ventricular assist device following acute myocardial infarction from 2007 to 2016; 89 received extra-corporeal membrane oxygenation and 35 short-term ventricular assist device. Fifty-five (44.4%) died in the hospital and 69 (55.6%) survived to discharge. Twenty-six (37.7%) required heart replacement therapy (four transplant, 22 durable ventricular assist device) and 43 (62.3%) were discharged without heart replacement therapy. Age and cardiac index at MCSD implantation were predictors of survival to discharge; patients over 60 years with cardiac index 2 had a low likelihood of survival. The angiographic result after revascularization predicted recovery from MCSD (odds ratio 9.00, 95% confidence interval 2.45–32.99, p=0.001), but 50% of those optimally revascularized still required heart replacement therapy. Cardiac index predicted recovery from MCSD among this group (odds ratio 4.06, 95% confidence interval 1.45–11.55, p=0.009). Conclusion: Among AMI-CS patients requiring short-term MCSDs, age and cardiac index predict survival to discharge. Angiographic result and cardiac index predict ventricular recovery but 50% of those optimally revascularized still required heart replacement therapy.

Changes in left ventricular (LV) contractility during high-risk percutaneous coronary intervention (HR-PCI) may foretell hemodynamic collapse that could be prevented by timely use of mechanical circulatory support (MCS). The purpose of this pilot study was to assess the feasibility and sensitivity

Purpose While intra-aortic balloon pump (IABP) counterpulsation has not been shown to be of benefit in patients with acute myocardial infarction (AMI) with cardiogenic shock (CS), emerging data suggest that patients with acute decompensated heart failure (ADHF) might be more likely to stabilize with this device. Methods Patients with hemodynamic evidence of CS related to either AMI or ADHF who received IABP support were studied retrospectively. Cardiac outputs (CO) and indices (CI) were calculated using the Fick method. Hemodynamics were compared before and after IABP insertion and between the AMI and ADHF cohorts. Results During the study period, 77 patients were supported with IABP for AMI related CS while 132 were supported for ADHF related CS. The mean age was 64.7±13.6 years and 75.1% were men. Mean arterial blood pressure was 75.6±10.6mmHg and 78.4±14.6mmHg among ADHF and AMI patients, respectively (p=0.12). Mean pulmonary artery pressure was higher among those with ADHF (37.9±9.3mmHg vs 33.6±8.9mmHg, p=0.002). Left ventricular ejection fraction was 18.0±8.9% among those with ADHF and 28.9±12.0% among those with AMI (p Conclusion While the degree of hemodynamic compromise was similar between those with CS related to AMI and ADHF, the response to IABP counterpulsation differed significantly between these cohorts suggesting that the device's efficacy may differ between etiologies of CS.

Renal dysfunction is a common, important comorbidity in patients with both chronic and acute heart failure (HF). Chronic kidney disease and worsening renal function (WRF) are associated with worse outcomes, but our understanding of the complex bidirectional interactions between the heart and kidney remains poor. When addressing these interactions, one must consider the impact of intrinsic renal disease resulting from medical comorbidities on HF outcomes. WRF may result from any number of important processes. Understanding the role of each of these factors and their interplay are essential in understanding how to improve outcomes in patients with renal dysfunction and HF.

Autosomal dominant polycystic kidney disease (ADPKD) is associated with a substantial cardiovascular disease burden including early onset hypertension, intracranial aneurysms, and left ventricular hypertrophy (LVH). A 41% prevalence of LVH has been reported in ADPKD, using echocardiographic assessment of LV mass (LVM). The HALT PKD study was designed to assess the effect of intensive angiotensin blockade on progression of total kidney volume and LVM. Measurements of LVM were performed using cardiac magnetic resonance (MR).Five hundred forty-three hypertensive patients with GFR60 ml/min per 1.73 m(2) underwent MR assessment of LVM at baseline. LVM was adjusted for body surface area and expressed as LVM index (LVMI; g/m(2)).Baseline BP was 125.1 ± 14.5/79.3 ± 11.6 mmHg. Average duration of hypertension was 5.79 years. Prior use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was present in 59.5% of patients. The prevalence of LVH assessed using nonindexed LVM (g) was 3.9% (n = 21, eight men and 13 women) and 0.93% (n = 5, one man and four women) using LVMI (g/m(2)). In exploratory analyses, the prevalence of LVH using LVM indexed to H(2.7), and the allometric index ppLVmass(HW), ranged from 0.74% to 2.23% (n = 4 to 12). Multivariate regression showed significant direct associations of LVMI with systolic BP, serum creatinine, and albuminuria; significant inverse associations with LVMI were found with age and female gender.The prevalence of LVH in hypertensive ADPKD patients50 years of age with short duration of hypertension, and prior use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers is low. Early BP intervention in ADPKD may have decreased LVH and may potentially decrease cardiovascular mortality.

Background and objectives: Autosomal dominant polycystic kidney disease (ADPKD) is a progressive hereditary disorder affecting children and young adults. Early intervention may be necessary to significantly affect the long-term consequences of this disease. Design, setting, participants, & measurements: The authors conducted a 5-yr randomized clinical trial to assess the effect of BP control with angiotensin-converting enzyme inhibition (ACEI) on disease progression in 85 children and young adults with ADPKD. Study groups were determined by subject BP, including hypertension (BP ≥ 95th percentile), borderline hypertension (BP 75 to 95th percentile), and severe ADPKD (BP ≤75th percentile with > 10 renal cysts). The primary outcome variable was renal volume by ultrasound, with secondary outcome variables including left ventricular mass index (LVMI) and microalbuminuria. In secondary analysis, the authors compared results between hypertensive and normotensive groups. Results: The authors were not able to demonstrate a significant effect of ACEI on renal growth in young subjects with ADPKD. Hypertensive children were at particular risk for increases in renal volume and LVMI and decreased renal function as compared with the other study groups, and borderline hypertensive children were at high risk to develop hypertension over time. However, ACEI treatment was associated with stable renal function and LVMI in this group of children. Conclusions: Close monitoring of cardiovascular and renal status is indicated in ADPKD children with hypertension or borderline hypertension. In contrast to effects in hypertensive ADPKD children, ACEI treatment in normotensive or borderline hypertensive ADPKD children may prevent the development of increased LVMI and deterioration in renal function.

Autosomal dominant polycystic kidney disease (ADPKD) is the most frequent life- threatening, hereditary disease. ADPKD is more common than sickle cell anemia, cystic fibrosis, muscular dystrophy, hemophilia, Down’s syndrome, and Huntington’s disease combined. ADPKD is a multisystemic disorder characterized by the progressive development of renal cysts and marked renal enlargement. Structural and functional renal deterioration occurs in ADPKD patients and is the fourth leading cause of end-stage renal disease (ESRD) in adults. Aside from the renal manifestations, extrarenal structural abnormalities, such as liver cysts, cardiovascular abnormalities, and intracranial aneurysms may lead to morbidity and mortality. Recent studies have identified prognostic factors for progressive renal impairment including gender, race, age, proteinuria, hematuria, hypertension and increased left ventricular mass index (LVMI). Early diagnosis and better understanding of the pathophysiology of the disease provides the opportunity to aggressivly treat hypertension with renin-angiotensin-aldosterone system inhibitors and thereby potentially reduce LVMI, prevent cardiovascular morbidity and mortality and slow progression of the renal disease.

Despite significant improvements in diagnosis, understanding the pathophysiology and management of the patients with acute decompensated heart failure (ADHF), diuretic resistance, yet to be clearly defined, is a major hurdle. Secondary hyperaldosteronism is a pivotal factor in pathogenesis of sodium retention, refractory congestion in heart failure (HF) as well as diuretic resistance. In patients with decompensated cirrhosis who suffer from ascites, similar pathophysiological complications have been recognized. Administration of natriuretic doses of mineralocorticoid receptor antagonists (MRAs) has been well established in management of cirrhotic patients. However, this strategy in patients with ADHF has not been well studied. This article will discuss the potential use of natriuretic doses of MRAs to overcome the secondary hyperaldosteronism as an alternative diuretic regimen in patients with HF.

Many national registries and epidemiological observations have revealed a strong correlation between morbidity and mortality of patients with cardiovascular disease and kidney dysfunction. In patients with heart failure, renal dysfunction is highly prevalent. Even mild to moderate renal dysfunction in patients with congestive heart failure, i.e., cardiorenal syndrome, leads to significant increase in morbidity and mortality. The mechanisms underlying this complicated syndrome are not well elucidated, but the kidney is known to be responsible for the sodium and water retention in heart failure. Without better understanding the pathophysiology of this complex interaction between the heart and kidney, the outcome for these patients remains poor. Moreover, renal parenchymal disease is a pathogenic factor to cardiovascular disease independent of the role of traditional risk factors. More than 88% of patients with chronic kidney disease never reach end-stage renal disease, as the majority of them die due to cardiovascular disease. Thus, understanding the role of renal parenchymal disease as an independent cardiovascular risk state — i.e., renocardiac syndrome — is very important. In this chapter, we discuss the importance of renal function in the pathophysiology of congestive heart failure. We also elaborate on the novel understanding of chronic kidney disease and its role in cardiovascular disease progression. It should be stated that there may be involvement of both the cardiorenal and renocardiac syndromes associated with a systemic disease, such as with diabetes mellitus.

Renal dysfunction is highly prevalent in patients with heart failure. Furthermore, worsening renal function in patients with acute decompensated heart failure (ADHF), the so-called cardiorenal syndrome, impacts short and long-term morbidity and mortality. In recent years, more evidence has surfaced from clinical trials and heart failure registries that a complex cross-talk between the kidney and heart in patients with ADHF exists. Meanwhile, management of patients presenting with ADHF and concomitant renal dysfunction continues to be challenging. Therefore, understanding the interaction of the heart and kidneys is pivotal in tailoring therapy of these patients. We have extensively reviewed the pathophysiology of ADHF, the role of neurohoromones as well as other biomarkers and predictors of mortality in these patients based on the current evidence. Moreover, we have discussed the current and future pharmacologic and non-pharmacologic therapies for treatment of this deadly disease. The strength of the evidence is limited, however, due to a paucity of randomized controlled trials in this patient population. What is evident from current national statistics; however, are the poor results in treating the congestion of ADHF. In this regard, the role of secondary hyperaldosteronism is discussed in the diuretic section as well as diuretic resistance in ADHF. In conclusion, since renal function is the single most important prognostic factor in the outcome of patients with ADHF, a better understanding of the pathophysiology of the cardiorenal syndrome is needed to target therapy and ultimately improve the mortality of patients with ADHF.

Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary condition that may be diagnosed in utero. Our goal was to evaluate symptoms of ADPKD in children, including left ventricular mass index (LVMI), renal volume, renal function and microalbuminuria in relation to systolic and diastolic blood pressure. Eighty-five children were stratified by blood pressure into three cohorts: hypertensive (95th percentile and over), borderline hypertensive (75-95th percentile) and normotensive (75th percentile and below). There were no differences in gender, age, height, renal function, or microalbuminuria between the groups. Both the hypertensive and borderline hypertensive children had a significantly higher LVMI than normotensive children, with no significant difference between hypertensive and borderline hypertensive groups. There was a significant correlation between renal volume and both systolic and diastolic blood pressures in all subjects. Renal volume in hypertensive children was significantly larger than in the borderline hypertensive group, with no significant difference between normotensive and borderline hypertensive groups. These findings show that an increase in LVMI may be detected earlier than an increase in renal volume in children with ADPKD and borderline hypertension, suggesting that close monitoring of cardiac status is indicated in these children.