Author + information
- Joern Tongers1,
- Jan-Thorben Sieweke1,
- Christian Kühn2,
- L Christian Napp2,
- Johann Bauersachs2 and
- Andreas Schafer2
Little progress has been made in the treatment of cardiogenic shock (CS). Particularly in refractory CS its mortality remains substantial. Although the evolving era of mechanical support comes with great promise, many aspects in the management of mechanical support are uncertain. Amongst others, therapy-guidance of and decision-making in mechanical support are of medical, ethical and economic interest.
We sought to evaluate efficacy and predictors of bi-ventricular support in refractory CS.
In our single-center registry, 69 consecutive patients were analyzed (age 57±2 yrs, 78% male). All patients required dual unloading by means of vaECMO plus Impella CP due to refractory CS. Shock-patients were severely sick (SAPS-II 53±13, SOFA 12±3, 33% out-of-hospital CPR, 94% ventilation, 56% dialysis, 38% resuscitation). Impella microaxial pump and vaECMO were inserted and removed percutaneously via femoral access (range of duration: Impella 55-182, vaECMO 81-259 hrs). Reflecting clinical stabilization in response to mechanical support, number and dosing of catecholamines was rapidly reduced, while systolic arterial pressure increased (for all end/time points, p=significant). As a measure of the microcirculation, lactate levels normalized within 24hrs (for all time points, p<0.05 vs. BL). After censoring patients in whom ICU-therapy was withdrawn because of their living will, 30-days mortality was considerably low (40%). Univariate Cox-regression revealed shock-duration until first device, infection, RV-failure, SAPS-II and SOFA scores and lactate level after 12 hrs as variables determining success of unloading-therapy. Shock-duration until first device, infection, and lactate levels after 12 hrs predicted outcome in a multivariate analysis. In addition, bi-ventricular failure significantly predisposed negative outcome.
In conclusion, early bi-ventricular mechanical support employing Impella microaxial pump and vaECMO enable to stabilize and rescue refractory CS patients. Shock-duration until initiation of support therapy, lactate levels at 12 hrs and infections are multivariate predictors of survival in refractory cardiogenic shock requiring mechanical support.
CORONARY: Hemodynamic Support and Cardiogenic Shock