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. 2018 Dec;7(8):755-765.
doi: 10.1177/2048872617740834. Epub 2017 Nov 2.

Predictors of survival and ability to wean from short-term mechanical circulatory support device following acute myocardial infarction complicated by cardiogenic shock

A Reshad Garan  1 , Christina Eckhardt  1 , Koji Takeda  2 , Veli K Topkara  1 , Kevin Clerkin  1 , Justin Fried  1 , Amirali Masoumi  1 , Ryan T Demmer  3 , Pauline Trinh  3 , Melana Yuzefpolskaya  1 , Yoshifumi Naka  2 , Dan Burkhoff  1 , Ajay Kirtane  1 , Paolo C Colombo  1 , Hiroo Takayama  2
Affiliations

Predictors of survival and ability to wean from short-term mechanical circulatory support device following acute myocardial infarction complicated by cardiogenic shock

A Reshad Garan et al. Eur Heart J Acute Cardiovasc Care. 2018 Dec.

Abstract

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 <1.5 l/min per m2 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.

Keywords: ECMO; Myocardial infarction; cardiogenic shock; mechanical circulatory support; recovery; ventricular assist device.

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Figures

Figure 1.
Figure 1.
Overview of patient outcomes. AMI; acute myocardial infarction; CS, cardiogenic shock; MCSD, mechanical circulatory support device; HRT, heart replacement therapy; LVAD, left ventricular assist device; OHT, orthotopic heart transplant.
Figure 2.
Figure 2.
Kaplan-Meier survival estimates with stratification by cardiac index at the time of MCSD insertion. MCSD, Mechanical Circulatory Support Device; CI, cardiac Index.
Figure 3.
Figure 3.
Survival to hospital discharge with stratification by age and cardiac index at the time of MCSD insertion. MCSD, Mechanical Circulatory Support Device; CI, cardiac index.
Figure 4.
Figure 4.
Recovery from Short-Term Mechanical Circulatory Support Device Following Acute Myocardial Infarction. A) The differences in probability of recovery based on achievement of TIMI 3 flow in culprit vessel. Among those achieving TIMI 3 flow, the probabilities of recovery by B) cardiac index at device implantation and C) by timing of implantation. MCSD, Mechanical Circulatory Support Device; TIMI, Thrombolysis in Myocardial Infarction; CI, cardiac index
Figure 5.
Figure 5.
Kaplan-Meier estimates of post-discharge survival among patients with and without HRT. HRT, heart replacement therapy.
See this image and copyright information in PMC

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