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Critical Care Medicine Sep 2023To review a contemporary approach to the management of patients with cardiogenic shock (CS). (Review)
Review
OBJECTIVES
To review a contemporary approach to the management of patients with cardiogenic shock (CS).
DATA SOURCES
We reviewed salient medical literature regarding CS.
STUDY SELECTION
We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials.
DATA EXTRACTION
We extracted salient study results and scientific statement recommendations regarding the management of CS.
DATA SYNTHESIS
Professional society recommendations were integrated with evaluated studies.
CONCLUSIONS
CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient's needs based on shock severity, phenotype, and exit strategy.
Topics: Humans; Shock, Cardiogenic; Treatment Outcome; Myocardial Infarction; Heart Failure; Heart-Assist Devices
PubMed: 37184336
DOI: 10.1097/CCM.0000000000005919 -
JACC. Heart Failure Sep 2023Heart failure and cardiomyopathy are significant contributors to pregnancy-related deaths, as maternal morbidity and mortality have been increasing over time. In this... (Review)
Review
Heart failure and cardiomyopathy are significant contributors to pregnancy-related deaths, as maternal morbidity and mortality have been increasing over time. In this setting, the role of the multidisciplinary cardio-obstetrics team is crucial to optimizing maternal, obstetrical and fetal outcomes. Although peripartum cardiomyopathy is the most common cardiomyopathy experienced by pregnant individuals, the hemodynamic changes of pregnancy may unmask a pre-existing cardiomyopathy leading to clinical decompensation. Additionally, there are unique management considerations for women with pre-existing cardiomyopathy as well as for those women with advanced heart failure who may be on left ventricular assist device support or have undergone heart transplantation. The purpose of this review is to discuss: 1) preconception counseling; 2) risk stratification and management strategies for pregnant women extending to the postpartum "fourth trimester" with pre-existing heart failure or "pre-heart failure;" 3) the safety of heart failure medications during pregnancy and lactation; and 4) management of pregnancy for women on left ventricular assist device support or after heart transplantation.
Topics: Pregnancy; Female; Humans; Heart Failure; Obstetrics; Heart; Heart Transplantation; Heart-Assist Devices
PubMed: 37678960
DOI: 10.1016/j.jchf.2023.07.009 -
The Journal of Heart and Lung... Jul 2023
Topics: Humans; Lung Transplantation; Heart Transplantation; Heart; Heart-Assist Devices; Heart Failure
PubMed: 37245143
DOI: 10.1016/j.healun.2022.12.004 -
Artificial Organs Jul 2023The quest to replace the natural heart with an artificial one as a permanent system is among the remaining holy grails in medicine and surgery. Beginning in 1969, when...
The quest to replace the natural heart with an artificial one as a permanent system is among the remaining holy grails in medicine and surgery. Beginning in 1969, when the first total artificial heart (TAH) was implanted into a human, to the present, several types have been developed-the AbioCor was among them. On November 5th, 2001, our team at Hahnemann University Hospital in Philadelphia, Pennsylvania placed the world's fifth AbioCor. Excerpts of that moment in time were recorded and serve as a memorial to the past and a testimony to the present and future quest of this elusive holy grail.
Topics: Humans; Heart, Artificial; Pennsylvania
PubMed: 37366022
DOI: 10.1111/aor.14599 -
Circulation Oct 2023The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies,... (Review)
Review
Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC).
The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.
Topics: Humans; Shock, Cardiogenic; Heart Valve Prosthesis Implantation; Research Design; Heart-Assist Devices
PubMed: 37782695
DOI: 10.1161/CIRCULATIONAHA.123.064527 -
The Annals of Thoracic Surgery Jan 2024The 14th Annual Report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) describes outcomes of...
The 14th Annual Report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) describes outcomes of 27,493 patients with a continuous-flow left ventricular assist device (LVAD) from the past decade (2013-2022). In 2022, 2517 primary LVADs were implanted, of which 2512 (99.8%) were fully magnetically levitated (Mag-Lev) devices. This shift to nearly exclusive use of a Mag-Lev device led us to examine its outcomes compared with contemporary (2018-2022) and historical (2013-2017) non-Mag-Lev cohorts. Patients supported by a Mag-Lev device (n = 10,920) had a higher 1- and 5-year survival of 86% (vs 79% and 81%, P < .0001) and 64% (vs 44% and 44%, P < .0001), respectively, than those receiving non-Mag-Lev devices during the contemporary and historical eras. Over 5 years, freedom from gastrointestinal bleeding (72% vs 60%, P < .0001), stroke (87% vs 67%, P < .0001), and device malfunction/pump thrombus (83% vs 54%, P < .0001), but not device-related infection (61% vs 64%, P = .93), was higher with Mag-Lev devices compared with non-Mag-Lev support during the contemporary era. In this large primacy cohort of real-world patients with advanced heart failure, this report underscores marked improvements in short- and intermediate-term survival and reduction of adverse events with a contemporary Mag-Lev LVAD.
Topics: Humans; Heart Failure; Heart-Assist Devices; Societies, Medical; Thrombosis; Registries; Treatment Outcome
PubMed: 37944655
DOI: 10.1016/j.athoracsur.2023.11.004 -
Journal of the American College of... Oct 2023Despite advances in medical therapy for patients with stage C heart failure (HF), survival for patients with advanced HF is <20% at 5 years. Durable left ventricular... (Review)
Review
Despite advances in medical therapy for patients with stage C heart failure (HF), survival for patients with advanced HF is <20% at 5 years. Durable left ventricular assist device (dLVAD) support is an important treatment option for patients with advanced HF. Innovations in dLVAD technology have reduced the risk of several adverse events, including pump thrombosis, stroke, and bleeding. Average patient survival is now similar to that of heart transplantation at 2 years, with 5-year dLVAD survival now approaching 60%. Unfortunately, greater adoption of dLVAD therapy has not been realized due to delayed referral of patients to advanced HF centers, insufficient clinician knowledge of contemporary dLVAD outcomes (including gains in quality of life), and deprioritization of patients with dLVAD support waiting for heart transplantation. Despite these challenges, novel devices are on the horizon of clinical investigation, offering smaller size, permitting less invasive surgical implantation, and eliminating the percutaneous lead for power supply.
Topics: Humans; Quality of Life; Heart Failure; Heart Transplantation; Heart-Assist Devices; Stroke; Treatment Outcome
PubMed: 37758441
DOI: 10.1016/j.jacc.2023.07.019 -
Deutsches Arzteblatt International Oct 2023In Germany, a total of 38 547 heart valve procedures were performed in 2022. With a growing number of patients undergoing the surgical and interventional implantation of... (Review)
Review
BACKGROUND
In Germany, a total of 38 547 heart valve procedures were performed in 2022. With a growing number of patients undergoing the surgical and interventional implantation of heart valves, the incidence of prosthetic endocarditis is also rising.
METHODS
We summarize the current state of the prophylaxis, diagnosis, and treatment of prosthetic endocarditis in a selective review of the literature.
RESULTS
Prosthetic endocarditis accounts for 10-30% of all cases of endocarditis. As its echocardiographic and microbiologic findings are often less specific than those of native endocarditis, its diagnosis now increasingly relies on alternative imaging modalities such as F-18-FDG PET-CT. Anti-infective and surgical treatment are made more difficult by biofilm formation on the prosthetic valve and the frequent formation of perivalvular abscesses.
CONCLUSION
Increased awareness of this clinical entity in the outpatient setting will promote the earlier initiation of appropriate diagnostic studies. Proper diagnostic evaluation is an essential prerequisite for the early detection and timely treatment of prosthetic endocarditis, with the goal of preventing progressive destruction and thus improving the outcome. Preventive and educative measures should be intensified, and certified, multidisciplinary endocarditis teams should be established. Antibiotic prophylaxis is now given much more restrictively than in earlier years; the risk of infection must be weighed against the potential development of both individual and collective resistance to antibiotic drugs.
Topics: Humans; Positron Emission Tomography Computed Tomography; Fluorodeoxyglucose F18; Heart Valve Prosthesis; Endocarditis; Heart, Artificial
PubMed: 37427994
DOI: 10.3238/arztebl.m2023.0104 -
Transplantation Proceedings Sep 2023We sought to compare heart transplant (HTX) outcomes from patients with a total artificial heart (TAH), biventricular assist device (BiVAD), or left ventricular assist...
BACKGROUND
We sought to compare heart transplant (HTX) outcomes from patients with a total artificial heart (TAH), biventricular assist device (BiVAD), or left ventricular assist device (LVAD) as a bridge to transplant (BTT). Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS)-Scientific Registry of Transplant Recipients (SRTR) created a dataset with TAH or durable mechanical circulatory support (MCS) who reached HTX between 2006 and 2015.
METHODS
The retrospective analysis compared TAH outcomes with those with a BiVAD or LVAD before HTX. The primary outcome was posttransplant survival at 1, 36, and 60 months. Secondary outcomes included simultaneous heart-kidney transplants, donor characteristics, and mortality risk factors. INTERMACS-SRTR cohort had, at the time of HTX, 2762 patients with LVAD; 205 BiVAD (139 durable and 66 temporary RVAD); 176 TAH (6 prior HeartMate II).
RESULTS
Sixty months after HTX, mortality rates were 16.5% in the total group: LVAD 15.2%, BiVAD 22.4%, and TAH 29%. Survival differed between the LVAD, the TAH, and BiVAD but not between the BiVAD and TAH groups. One-year survival and complication rates were similar across groups-there was no difference in survival by donor age in the overall cohort. There was a difference in TTD based on recipient age in the LVAD group but not in BiVAD or TAH groups. Occurrence of HTX-kidney and post-transplant dialysis were higher in the TAH versus LVAD and BiVAD groups.
CONCLUSIONS
The TAH is an efficacious BTT. Refinements in technology and patient selection may improve outcomes.
Topics: Humans; Heart Failure; Retrospective Studies; Renal Dialysis; Heart Transplantation; Heart, Artificial; Heart-Assist Devices; Treatment Outcome
PubMed: 37453855
DOI: 10.1016/j.transproceed.2023.05.020 -
European Heart Journal. Acute... Jul 2023The use of mechanical circulatory support using percutaneous ventricular assist devices (pVAD) has increased rapidly during the last decade without substantial new...
Step by step daily management of short-term mechanical circulatory support for cardiogenic shock in adults in the intensive cardiac care unit: a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology SC, the European Society of Intensive...
The use of mechanical circulatory support using percutaneous ventricular assist devices (pVAD) has increased rapidly during the last decade without substantial new evidence for their effect on outcome. In addition, many gaps in knowledge still exist such as timing and duration of support, haemodynamic monitoring, management of complications, concomitant medical therapy, and weaning protocols. This clinical consensus statement summarizes the consensus of an expert panel of the Association for Acute CardioVascular Care, European Society of Intensive Care Medicine, European Extracorporeal Life Support Organization, and European Association for Cardio-Thoracic Surgery. It provides practical advice regarding the management of patients managed with pVAD in the intensive care unit based on existing evidence and consensus on best current practice.
Topics: Humans; Adult; Shock, Cardiogenic; Thoracic Surgery; Extracorporeal Membrane Oxygenation; Cardiology; Heart-Assist Devices; Intensive Care Units; Critical Care
PubMed: 37315190
DOI: 10.1093/ehjacc/zuad064