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Multicenter Study
. 2023 Dec 5;12(23):e031401.
doi: 10.1161/JAHA.123.031401. Epub 2023 Nov 28.

Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative

Mir B Basir  1 , Alejandro Lemor  2 , Sarah Gorgis  1 , Kirit C Patel  3 , Brian C Kolski  4 , Aditya S Bharadwaj  5 , Joshua W Todd  6 , Behnam N Tehrani  7 , Alexander G Truesdell  7 , David M Lasorda  8 , Thomas A Lalonde  9 , Amir Kaki  9 , Theodore L Schrieber  9 , Nainesh C Patel  10 , Shaun R Senter  11 , Joseph L Gelormini  12 , Steven P Marso  13 , Ayaz M Rahman  14 , Robert E Federici  15 , Charles E Wilkins  16 , A Thomas McRae 3rd  17 , Ali Nsair  18 , Christopher P Caputo  19 , Matheen A Khuddus  19 , Juan J Chahin  20 , Allison G Dupont  21 , Andrew M Goldsweig  22 , Michael J Lim  23 , Navin K Kapur  24 , David H W Wohns  25 , Yueren Zhou  1 , Michael J Hacala  1 , William W O'Neill  1
Affiliations
Multicenter Study

Early Utilization of Mechanical Circulatory Support in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The National Cardiogenic Shock Initiative

Mir B Basir et al. J Am Heart Assoc. .

Abstract

Background: Acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is associated with significant morbidity and mortality. Mechanical circulatory support (MCS) devices increase systemic blood pressure and end organ perfusion while reducing cardiac filling pressures.

Methods and results: The National Cardiogenic Shock Initiative (NCT03677180) is a single-arm, multicenter study. The purpose of this study was to assess the feasibility and effectiveness of utilizing early MCS with Impella in patients presenting with AMI-CS. The primary end point was in-hospital mortality. A total of 406 patients were enrolled at 80 sites between 2016 and 2020. Average age was 64±12 years, 24% were female, 17% had a witnessed out-of-hospital cardiac arrest, 27% had in-hospital cardiac arrest, and 9% were under active cardiopulmonary resuscitation during MCS implantation. Patients presented with a mean systolic blood pressure of 77.2±19.2 mm Hg, 85% of patients were on vasopressors or inotropes, mean lactate was 4.8±3.9 mmol/L and cardiac power output was 0.67±0.29 watts. At 24 hours, mean systolic blood pressure improved to 103.9±17.8 mm Hg, lactate to 2.7±2.8 mmol/L, and cardiac power output to 1.0±1.3 watts. Procedural survival, survival to discharge, survival to 30 days, and survival to 1 year were 99%, 71%, 68%, and 53%, respectively.

Conclusions: Early use of MCS in AMI-CS is feasible across varying health care settings and resulted in improvements to early hemodynamics and perfusion. Survival rates to hospital discharge were high. Given the encouraging results from our analysis, randomized clinical trials are warranted to assess the role of utilizing early MCS, using a standardized, multidisciplinary approach.

Keywords: Impella; acute myocardial infarction; cardiogenic shock; mechanical circulatory support; percutaneous coronary intervention; pulmonary artery catheter.

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Figures

Figure 1
Figure 1. Study trial sites, including 32 academic centers and 48 community centers.
NCSI indicates National Cardiogenic Shock Initiative.
Figure 2
Figure 2. Suggested treatment protocol for patients presenting with acute myocardial infarction and cardiogenic shock.
AMICS indicates acute myocardial infarction and cardiogenic shock; CO, cardiac output; CPO, cardiac power output; Cr, creatinine; CTO, chronic total occlusion; dPAP, diastolic pulmonary artery pressure; ECG, electrocardiogram; LVAD, left ventricular assist device; MAP, mean arterial pressure; MCS, mechanical circulatory support; MV, multivessel; NSTEMI, non–ST‐elevation myocardial infarction; PA, pulmonary artery; PAPI, pulmonary artery pulsatility index; PCI, percutaneous coronary intervention; RA, right atrial; RHC, right heart catheterization; RV, right ventricular; SBP, systolic blood pressure; sPAP, systolic pulmonary artery pressure; STEMI, ST‐elevation myocardial infarction; and TIMI, thrombolysis in myocardial infarction.
Figure 3
Figure 3. Cause of death and rates of mechanical circulatory support escalation among patients who died.
Figure 4
Figure 4. Lactate trends.
A, In‐hospital survival according to admission lactate level. B, In‐hospital survival according to lactate clearance at 12 to 24 hours. C, Trends in mean lactate levels (with 95% CIs) among survivors and nonsurvivors.
Figure 5
Figure 5. National Cardiogenic Shock Initiative best practices.
CS indicates cardiogenic shock; CTO, chronic total occlusion; GDMT, guideline‐directed medical therapy; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; and TIMI, thrombolysis in myocardial infarction.
See this image and copyright information in PMC

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