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We applied the Society for Cardiovascular Angiography and Interventions (SCAI) schema to cardiogenic shock (CS) patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) to assess performance in this high acuity group of patients. Records of adult patients receiving VA-ECMO for CS at our institution from 01/2015 to 12/2019 were reviewed. Post-cardiotomy and noncardiogenic shock patients were excluded. A total of 245 patients were included, with a median age of 59 years [IQR: 48-67]; 159 (65%) were male. There were 34 (14%) patients in Stage C, 82 (33%) in D, and 129 (53%) in E. Of E patients, 88 (68%) were undergoing cardiopulmonary resuscitation. Median ECMO duration decreased with stage (C:7, D:6, E:4 days, P < 0.001). In-hospital mortality increased (C:35%, D:56%, E:71%, P < 0.001) and myocardial recovery decreased with stage (C:65%, D:35%, E:30%, P < 0.001). Acute kidney injury (C:35%, D:45%, E:54%, P = 0.045), acute liver failure (C:32%, D:66%, E:76%, P < 0.001), and infection (C:35%, D:28%, E:16%, P = 0.004) varied among groups. Multivariable analysis revealed age (HR=1.02), male sex (HR=0.62), and E classification (HR=2.69) as independently associated with 1-year mortality. Competing-risks regression identified D (SHR=0.53) and E classification (SHR=0.45) as inversely associated with myocardial recovery. In patients treated with VA-ECMO for CS, the SCAI classification provided robust risk stratification., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2022.)

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) following acute myocardial infarction with cardiogenic shock (AMI-CS) is increasing, but the ability to predict favorable outcomes with support remains limited. We retrospectively reviewed all patients with AMI-CS supported with VA-ECMO between December 2008 and June 2018. One hundred twenty-six patients received VA-ECMO for AMI-CS during the study period; of these, 39 (31.0%) experienced ventricular recovery and were discharged while 87 (69.0%) did not recover, with 71 (56.3%) dying in the hospital and 16 (12.7%) surviving to discharge with either left ventricular assist device or heart transplant. TIMI 3 flow in culprit artery (OR, 4.01; 95% CI, 1.25-12.77; p = 0.02), serum lactate (OR, 0.89; 95% CI, 0.80-0.99; p = 0.04), and prompt revascularization (OR, 3.39; 95% CI, 1.18-9.81; p = 0.02) were independent predictors of ventricular recovery. Four variables emerged as independent predictors of in-hospital mortality and were used to create the AMI-ECMO Risk Score: age >70 years, creatinine >1.5 mg/dL, serum lactate > 4.0 mmol/L, and lack of TIMI 3 flow in culprit artery. In patients supported with VA-ECMO for AMI-CS, prompt, successful revascularization, and lower serum lactate were associated with ventricular recovery while younger age, lower serum lactate, and creatinine, and successful revascularization were associated with survival to discharge. The AMI-ECMO risk score is a simple tool that can help risk stratify patients with AMI-CS being considered for VA-ECMO support., (Copyright © ASAIO 2021.)

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., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2021.)

Background: Anticoagulation therapy management during venoarterial extracorporeal membrane oxygenation (ECMO) is particularly difficult in postcardiotomy shock patients given a significant bleeding risk. We sought to determine the effect of anticoagulation treatment on bleeding and thrombosis risk for postcardiotomy shock patients on ECMO., Methods: We retrospectively reviewed patients who received ECMO for postcardiotomy shock from July 2007 through July 2019. Characteristics of patients who had bleeding and thrombosis were investigated, and risk factors were assessed by multilevel logistic regression., Results: Of the 152 patients who received ECMO for postcardiotomy shock, 33 (23%) had 40 thrombotic events and 64 (45%) had 86 bleeding events. Predictors of bleeding were intraoperative packed red blood cell transfusion (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.01 to 1.09), platelet transfusion (OR 1.10; 95% CI, 1.05 to 1.16), international normalized ratio (OR 1.18; 95% CI, 1.02 to 1.37), and activated partial thromboplastin time greater than 60 seconds (OR 2.32; 95% CI, 1.14 to 4.73). Predictors of thrombosis were anticoagulant use (OR 0.39; 95% CI, 0.19 to 0.79), surgical venting (OR 3.07; 95% CI, 1.29 to 7.31), hemoglobin (OR 1.38; 95% CI, 1.06 to 1.79), and central cannulation (OR 2.06; 95% CI, 1.03 to 4.11). The daily predicted probability of thrombosis was between 0.075 and 0.038 for patients who did not receive anticoagulation and decreased to between 0.030 and 0.013 for patients who received anticoagulation treatment at activated partial thromboplastin times between 25 and 80 seconds., Conclusions: Anticoagulation therapy can reduce thromboembolic events in postcardiotomy shock patients on ECMO, but bleeding risk may outweigh this benefit at activated partial thromboplastin times greater than 60 seconds., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: This analysis sought to investigate the waitlist and post-transplant outcomes of individuals bridged to transplantation by using temporary percutaneous endovascular mechanical circulatory support (tMCS) through a status 2 designation (cardiogenic shock and exception)., Background: The 2018 donor heart allocation policy change granted a status 2 designation to patients supported with tMCS., Methods: Adult patients in the United Network for Organ Sharing registry after October 18, 2018 who received a status 2 designation for tMCS were included and grouped by their status 2 criteria: cardiogenic shock with hemodynamic criteria (CS-HD), cardiogenic shock without hemodynamic criteria before tMCS (CS-woHD), and exception. Baseline characteristics, waitlist events (death and delisting), and post-transplant outcomes were compared., Results: A total of 2,279 patients met inclusion criteria: 68.6% (n = 1,564) with CS-HD, 3.2% (n = 73) with CS-woHD, and 28.2% (n = 642) with exceptions. A total of 64.2% of patients underwent heart transplantation within 14 days of status 2 listing or upgrade, and 1.9% died or were delisted for worsening clinical condition. Among the 35.8% who did not undergo transplantation following 14 days, only 2.8% went on to receive a left ventricular assist device (LVAD). The 30-day transplantation likelihood was similar among groups: 80.1% for the CS-HD group vs 79.7% for the exception group vs 73.3% for the CS-woHD group; P = 0.31. However, patients who met criteria for CS-woHD had 2.3-fold greater risk of death or delisting (95% CI: 1.10-4.75; P = 0.03) compared with CS-HD patients after multivariable adjustment. Pre-tMCS hemodynamics were not associated with adverse waitlist events., Conclusions: The use of tMCS is an efficient, safe, and effective strategy as a bridge to transplantation; however, patients with CS-woHD may represent a high-risk cohort. Transition to a durable LVAD was a rare event in this group., Competing Interests: Funding Support and Author Disclosures Dr Clerkin is supported by National Heart, Lung and Blood Institute grant K23 HL148528. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: In 2018, the United Network for Organ Sharing (UNOS) introduced new criteria for heart allocation. This study sought to assess the impact of this change on waitlist and posttransplant outcomes in adult congenital heart disease (ACHD) recipients., Methods: Between January 2010 and March 2020, we extracted first heart transplant ACHD patients listed from the UNOS database. We compared waitlist and post-transplant outcomes before and after the policy change., Results: A total of 1206 patients were listed, 951 under the old policy and 255 under the new policy. Prior to transplant, recipients under the new policy era were more likely to be treated with extracorporeal membrane oxygenation (P = .018), and have intra-aortic balloon pumps (P < .001), and less likely to have left ventricular assist devices (P = .027).Compared to patients waitlisted in the pre-policy change era, those waitlisted in the post policy change era were more likely to receive transplants (P = .001) with no significant difference in waiting list mortality (P = .267) or delisting (P = .915). There was no difference in 1-year survival post-transplant between the groups (P = .791)., Conclusion: The new policy altered the heart transplant cohort in the ACHD group, allowing them to receive transplants earlier with no changes in early outcomes after heart transplantation., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: Obesity may complicate the peripheral cannulation and delivery of veno-arterial extracorporeal life support (ECLS). With rising global body mass indices (BMI), obesity is becoming increasingly prevalent in severe cardiogenic shock yet its impact on outcomes is not well described. This study sought to examine the relationship between BMI and veno-arterial ECLS outcomes to better inform clinical decision-making., Methods: All cardiogenic shock patients undergoing peripheral veno-arterial ECLS at our institution from March 2008 to January 2019 were retrospectively analysed (n = 431). Patients were divided into 4 groups, BMI 17.5-24.9, 25-29.9, 30-34.9 and ≥35 kg/m2, and compared on clinical outcomes. Multivariable logistic regression was performed to identify variables associated with survival to discharge, the primary outcome of interest., Results: The median BMI was 28.3 kg/m2 (interquartile range 24.8-32.6) with a range of 17.0-69.1 kg/m2. Obese patients achieved significantly lower percentages of predicted flow rates compared with BMI < 25 kg/m2 patients though did not differ in their lactate clearances. Patients with BMI ≥35 kg/m2 had similar complication rates to the other cohorts but were more likely to require continuous veno-venous haemodialysis (51% vs 25-40% in other cohorts, P = 0.002). Overall survival to discharge was 48% (n = 207/431) with no differences between the cohorts (P = 0.92). Patients with BMI ≥35 kg/m2 had considerably lower survival (10%) in extracorporeal membrane oxygenation cardiopulmonary resuscitation compared with the other groups (P = 0.17). On multivariable logistic regression, BMI was not significantly associated with failure to survive to discharge., Conclusions: In conclusion, with the rising global prevalence of obesity, the results of our study suggest that clinicians need not treat obesity as a negative prognostic factor in cardiogenic shock requiring ECLS., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a temporary mechanical circulatory support device capable of providing robust circulatory support in the setting of emergent hemodynamic collapse. Herein we report the use of VA ECMO as a bridge to recovery after cardiac arrest secondary to suspected overdose of ranolazine. A 25-year-old woman with history of diabetes and depression presented to the emergency department after intentional ingestion of multiple pharmaceuticals, including ranolazine. Initially, physical exam was unremarkable, although she was noted to be drowsy. Initial labs revealed normal creatinine and electrolytes and 12-lead electrocardiogram (ECG) showed sinus rhythm with normal intervals. Five hours after presentation, she developed tonic-clonic seizures and required emergent intubation. Repeat labs showed a lactic acid of 8.7mmol/L with hypokalemia to 2.4 mmol/L. Repeat ECG showed interval development of QRS widening (158msec) and QT prolongation (601msec). Electrolyte repletion was given, and sodium bicarbonate administered for toxic ingestion. Despite these measures, the patient had a PEA arrest and CPR was initiated. ACLS was performed without sustained return of spontaneous circulation and the ECPR team was activated. The patient was cannulated to femoral VA ECMO with a low-flow time of 39 minutes. Initial ECMO settings were 4000 RPM, 4L flow, and 2L/min sweep. Post-arrest transthoracic echocardiogram showed mildly reduced biventricular function and no significant valvular pathology. Continuous renal replacement therapy as started for metabolic acidosis. By hospital day 3, vasopressors were weaned off and ECMO wean began. Despite ECMO wean, the patient developed worsening bilateral infiltrates on chest imaging suggesting ARDS. On hospital day 6, the patient was reconfigured to veno-venous (V-V) ECMO support, to optimize oxygenation. A repeat echocardiogram showed biventricular recovery. On hospital day 10, the patient was decannulated from VV ECMO and successfully extubated on day 16. She was discharged on hospital day 38 to an inpatient psychiatry service. Acute drug intoxication represents a potentially reversible cause of hemodynamic collapse and cardiac arrest. ECMO is this case restored end organ perfusion and clinical stability so that the transient effects of the toxic ingestion could be overcome. [ABSTRACT FROM AUTHOR]

Minimal data exists regarding the impact of extracorporeal life support (ECLS) flow on incidence of acute kidney injury (AKI). This study examines the predictive role of ECLS flow and other risk factors in the development of AKI. We performed a retrospective analysis of 519 patients placed on ECLS at our institution between January 2015 and December 2020 for cardiogenic shock (CS). We calculated ECLS flow index using average flow 72 hours post-cannulation and body surface area. Stages of AKI were determined according to KDIGO guidelines. ECLS flow index, baseline characteristics, and outcomes were compared between patients that did and did not develop AKI. Of the included cohort, 180 (38.1%) patients developed AKI: 41 (22.8%) had Stage 1 AKI, 26 (14.4%) had Stage 2 AKI, and 113 (62.8%) had Stage 3 AKI. Patients who developed AKI had lower rates of survival to hospital discharge (39.4% vs. 61.3%, p<0.001) and 1-year survival (28.8% vs. 50.0%, p<0.001) compared to those who did not. Stage 3 AKI was the only stage of AKI that was predictive of 1-year mortality (HR=1.59, p=0.001). ECLS flow index ranged from 0.71-3.03 lpm/mm2 with a median of 1.61 lpm/mm2. Patients with Stage 3 AKI had a higher median flow index than the other groups of patients (1.69 vs. 1.57 lpm/mm2, p=0.015). There was no association between flow index and Stage 2 AKI or Stage 1 AKI, while flow index was specifically predictive of Stage 3 AKI (OR=2.01, p=0.021). Patients with higher flow index were more likely to experience neurological adverse events (OR=1.92, p=0.022) and infection (OR=1.80, p=0.043) and less likely to undergo myocardial recovery (OR=0.43, p=0.002). Patients newly initiated on renal replacement therapy (RRT) had higher median flow index (1.69 vs 1.58 lpm/mm2, p=0.018) and patients with Stage 3 AKI on RRT had the lowest 1-year survival compared to patients with Stage 3 AKI who did not receive RRT, Stage 2 AKI, and Stage 1 AKI (19.0% vs 35.0% vs 43.5% vs 38.2%, p=0.047). In our cohort, AKI is common and Stage 3 AKI is associated with worse outcomes compared to all other stages of AKI. In this study, higher ELCS flow indices were associated with increased likelihood of Stage 3 AKI and RRT incidence, suggesting that baseline sickness rather than ECLS flow has a significant impact on AKI development. These results indicate that lower flow indices may not pose increased risk of renal injury. [ABSTRACT FROM AUTHOR]

Avoidance of intubation and use of VA ECLS in awake patients may be beneficial. This study sought to demonstrate safety and feasibility of VA ECLS in non-intubated awake patients. This was a retrospective review of VA ECLS patients at our institution from 2017 to 2021 not undergoing ECPR and not cannulated for postcardiotomy shock. Patients were divided into intubated and awake/not ventilated at time of cannulation. Patients' baseline characteristics were analyzed, and propensity score matching was used to compare the complications and outcomes of intubated and awake patients. Of the 140 patients included in the study, 103 (74%) were intubated, whereas 37 (26%) were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation and technical success was 100%. Overall, 45 (32%) were female, average age was 56.2±13.5 years, and average body mass index was 30.0±7.4. In the initial cohort, there were no significant differences between intubated and awake patients with respect to demographics and comorbidities. However, awake cohort was most likely to be in acute decompensated heart failure as etiology of shock (51% vs 19%), to be in SCAI D (70% vs 31%), and to have IABP prior to ECLS (59% vs 24%). In the propensity-matched cohort (37 in each group), there were no significant differences in duration of ECLS, stroke, bleeding, need for renal replacement therapy, need for left ventricular unloading or survival to discharge (73% vs 68%). Most common destination post ECLS in intubated patients was recovery (59% vs 24%), as opposed to ventricular assist device implantation (38% vs 2.7%) or transplantation (24% vs 5.4%) in awake patients (p<0.001). In the largest retrospective series to date of awake VA ECLS, its use is safe, feasible and effective in select cardiogenic shock patients especially as a bridge to heart replacement therapies. [ABSTRACT FROM AUTHOR]

There is a paucity of evidence on cannulation and flow strategy for extracorporeal life support (ECLS). Our center employs a partial flow ECLS strategy for cardiogenic shock (CS) in which patients on peripheral ECLS are managed with partial flow using a 15F-17F arterial cannula regardless of patient body size to minimize cannula-related complications. Here we describe our clinical experience of partial flow ECLS strategy for CS. We retrospectively reviewed 145 cases who developed CS requiring ECLS insertion between January 2019 and June 2021. We excluded 6 cases who were cannulated at outside hospital and 29 cases of central ECLS. Etiology for cardiogenic shock was as follows (including 6 cases of extracorporeal cardiopulmonary resuscitation): Post-cardiotomy shock 15, acute on chronic heart failure 25, acute ischemic cardiogenic shock 20, primary graft dysfunction 6, distributive shock 10, acute myocarditis 7, acute right ventricular failure 4, arrhythmia 5, and other 14. Mean age was 57.3 years and length of ECLS support was 7.2 days. Left ventricular venting strategy was used in 63% (67/106) of cases (IABP 50, Impella 17). Arterial cannula size: 15Fr 92%, 17Fr 7% and distal perfusion catheter was placed in 30% of cases. Average ECLS flow was 1.57L/min/m2 (3.0L/min). 53% (57/106) recovered and were decannulated, 28% (30/106) were bridged to advanced therapy (extracorporeal VAD 11, Impella 7, durable LVAD 6, transplant 6). ECLS related complications were as follows: Vascular injury 1, toe necrosis 1, leg ischemia required fasciotomy 0, bleeding from cannulation site 2, pseudoaneurysm 1, permanent neurodeficit 1, transient neurodeficit 2, Groin complication (dehiscence/infection/lymphocele) 11. The rate of survival to discharge was 61% (65/106). Partial flow strategy is a feasible approach with a low rate of fatal complications and can effectively bridge patients to recovery or other advance therapy. Cannula-related complications complications remain a problem with this strategy. [ABSTRACT FROM AUTHOR]

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 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. 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. Concomitant support with IABP may help to reduce morbidity in patients on VA-ECMO for cardiogenic shock. [ABSTRACT FROM AUTHOR]

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. 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. 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. Cardiogenic shock patients can be bridged to HRT using contemporary tMCS technology and management with excellent early- and mid-term outcomes. [ABSTRACT FROM AUTHOR]

Obesity may complicate the effective cannulation and delivery of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). With rising global body mass indices (BMI), obesity is becoming an increasingly more prevalent comorbidity in severe cardiogenic shock yet its impact on outcomes is not well-described. This study examined the relationship between BMI and VA-ECMO outcomes to better inform clinical decision making. Clinical data from all 574 cardiogenic shock patients who received VA-ECMO at our institution from March 2008 to January 2019 were analyzed. Patients were dichotomized into two groups: BMI ≥35kg/m2 (n=91) and BMI<35kg/m2 (n=483). The primary outcome of interest was survival to hospital discharge. Multiple logistic regression was performed to identify variables associated with survival-to-discharge and Kaplan Meier curves were generated to identify differences in survival between the WHO BMI categories. Median BMI was 28.4 kg/m2 (IQR 24.6-32.5) with a range of 14.0-69.1kg/m2. Patients with BMI≥35kg/m2 were significantly more likely to be younger, less likely to be male, and had a significantly higher rate of type 2 diabetes. Overall cohort survival to discharge was 46% (n=267/574), and was not different between the obese and non-obese cohorts (46% vs. 46% p=1.00). Obese patients were more likely to need CVVH while in-hospital (45% vs. 34%, p=0.046). Controlling for preoperative risk factors, multivariable logistic regression identified being underweight (BMI<18.5kg/m2) as the only negative BMI predictor of failure to survive-to-discharge (OR: 0.228, 95% CI: 0.055-0.950, p=0.042). There was no significant difference in one-year survival between the WHO BMI categories (p=0.51, Figure). Clinicians need not treat obesity as a negative prognostic factor in cardiogenic shock requiring VA-ECMO. The results of this study suggest that being underweight, rather than obese, portends a poorer prognosis for these patients. [ABSTRACT FROM AUTHOR]

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. 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. 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<0.001) and ventricular fibrillation (C: 9%, D: 0%, E: 3%, p<0.001) were greater in C. Median ECMO duration decreased with stage (C: 7 [4-14], D: 6 [3-9], E: 4 [1-8] days, p<0.001). In-hospital mortality increased (C: 35%, D: 56%, E: 71%, p<0.001) and myocardial recovery decreased (C: 68%, D: 37%, E: 30%, p<0.001) with stage. Adverse events varied in terms of acute kidney injury (C: 35%, D: 45%, E: 54%, p=0.045) and infection (C: 35%, D: 28%, E: 16%, p=0.004). Kaplan-Meier analysis revealed E had worse survival than C and D (Figure 1). Outcomes were similar between E,CPR+ and E,CPR- patients (68% vs. 73%, p=0.76). In patients treated with VA-ECMO for CS, the SCAI classification provided robust risk stratification. [ABSTRACT FROM AUTHOR]

Treatment of cardiogenic shock associated with late allograft failure after heart transplant (HT) is poorly characterized and infrequently reported. In this study, we examined the role of mechanical circulatory support (MCS) as a method to treat patients with severe late graft failure. From 2000 - 2018, there were 1275 adult HT at our institution. Of those, 26 patients (2.0%) were identified who required MCS for cardiogenic shock due to late allograft failure. Patient demographics and outcomes were retrospectively reviewed. Median age of the cohort was 37.3 years (IQR: 17.3) and 69% were male. Median time from initial transplant to MCS was 2.9 years. At the time of shock, median hemodynamic values were as follows: CVP 18 mmHg, mean PA pressure 29 mmHg, PCWP 25 mmHg, and CI 1.87 L/min/m2. On echocardiogram, median LVEF was 25% and 77% of patients had moderate or severe right ventricular dysfunction. Seven patients (27%) had severe allograft coronary disease, while all remaining patients had chronic or acute worsening rejection. Initial MCS used included veno-arterial extracorporeal membrane oxygenation in 15 patients (58%), biventricular assist device in 10 patients (38%), and total artificial heart in 1 patient (4%). 8 patients underwent revision of MCS during the same hospitalization, on average 18 days after initial placement. While on MCS, the most common treatments for rejection were pulse dose steroids (69%), thymoglobulin (54%), and plasmapheresis (31%), with nearly all patients receiving combination therapy. Six patients (23%) weaned from MCS following medical therapy. Median duration of MCS was 33 days (IQR 55). Major morbidities included bleeding events in 39%, new renal replacement therapy in 23%, major infection in 27%, and stroke in 23%. Eight patients (31%) underwent re-heart transplant, all within one year of MCS, and survival for this cohort was 100% at 1 year. However, for those patients who were not offered re-transplant or who died while awaiting re-transplant, 1 year survival was only 22%, with 61% of deaths occurring in the hospital. Late graft failure resulting in cardiogenic shock carries significant morbidity and mortality, despite use of contemporary MCS. [ABSTRACT FROM AUTHOR]