Search

Background: Cardiogenic shock (CS) is associated with high mortality despite advances in early revascularization and acute mechanical circulatory support (AMCS) devices. Optimal risk stratification and management strategies for CS are not known. Methods: We retrospectively analyzed 946 consecutive patients with CS defined as clinical signs of hypoperfusion and a systolic BP<90 mmHg across 4 medical centers between 2012-2017. Results: Among 946 patients, CS was managed with medical therapy alone (19%), IABP alone (32%) or AMCS (49%). AMCS device configurations included Impella (41%), VA-ECMO (35%), VA-ECMO plus Impella (18%), and other (6%). Pulmonary artery catheter data was available in 545 patients. Biventricular congestion, defined as RAP≥14 mmHg and PCWP≥18 mmHg, was the most common hemodynamic presentation. Compared to either non-congested (RAP<14 and PCWP<18 mmHg) or LV-dominant congestion (PCWP>18), RV-dominant (RAP>14 and PCWP<18) and biventricular congestion were associated with higher mortality (13% and 18%, 42% and 44% respectively, p<0.01). Renal insufficiency (sCr≥1.48 mg/dl) or mixed hepatopathy (elevated AST>42 IU/L, ALT>54 IU/L, total bilirubin>1.1 mg/dl or direct bilirubin>0.3 mg/dl) was associated with higher mortality compared to sCr<1.41 mg/dl (55% vs. 38%, p<0.01) and normal liver profile (33% vs. 18%, p<0.01). Irrespective of CS management strategy, venous congestion was associated with increased mortality and renal insufficiency (Figure A-B). Among patients with CS requiring AMCS, venous congestion correlated with increased risk of mortality (54% vs. 30%), renal insufficiency (60% vs. 43%), and hepatopathy (87% vs. 77%). Irrespective of AMCS strategy, concomitant venous congestion and renal insufficiency was associated with higher mortality. In the presence of venous congestion alone, mortality for Impella was lower compared to VA-ECMO (Figure C). Conclusions: We report findings from the largest registry of CS comparing AMCS strategies. Elevated right atrial pressure is a major determinant of morbidity and mortality in CS. The combination of venous congestion and renal insufficiency is associated with the highest mortality irrespective of AMCS strategy. [ABSTRACT FROM AUTHOR]