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Temporary mechanical circulatory support as well as multidisciplinary team approach in a regional care organization might improve survival of cardiogenic shock. No study has evaluated the relative effect of each temporary mechanical circulatory support on mortality in the context of a regional network. Prospective observational data were retrieved from patients consecutively admitted with cardiogenic shock to the intensive care units in 3 centers organized into a regional cardiac assistance network. Temporary mechanical circulatory support indication was decided by a heart team, based on the initial shock severity or if shock was refractory to medical treatment within 24 hours of admission. A propensity score for circulatory support use was used as an adjustment co-variable to emulate a target trial. The primary endpoint was in-hospital mortality. Two hundred and forty-six patients were included in the study (median age: 59.5 years, 71.9% male): 121 received early mechanical assistance. The main etiologies were acute myocardial infraction (46.8%) and decompensated heart failure (27.2%). Patients who received early mechanical assistance had more severe conditions than other patients. Their crude in-hospital mortality was 38% and 22.4% in other patients but adjusted in-hospital mortality was not different (hazard ratio 0.91, 95% CI:0.65–1.26). Patients with mechanical assistance had a higher rate of complications than others with longer Intensive Care Unit and hospital stays. In the conditions of a cardiac assistance regional network, in-hospital mortality was not improved by early mechanical assistance implantation. A high incidence of complications of temporary mechanical circulatory support may have jeopardized its potential benefit. [ABSTRACT FROM AUTHOR]

The article focuses on recent randomized clinical trials (RCTs) investigating therapeutic strategies for managing cardiogenic shock (CS). It discusses the efficacy of different medications and treatment approaches, such as inodilators, early venoarterial extracorporeal membrane oxygenation (VA-ECMO) support, and adrenomedullin antibody adrecizumab, aiming to improve patient outcomes and guide clinical practice in CS management.

Aims: To investigate the impact of intra‐aortic balloon pump (IABP) on the regional haemodynamics of patients with severe cardiogenic shock undergoing femoro‐femoral veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO). Methods and results: From July 2017 to April 2018, a total of 39 adult patients with cardiogenic shock receiving both IABP and ECMO for circulatory support were enrolled consecutively in a university‐affiliated cardiac surgery intensive care unit. The blood flow rates (BFRs) of the bilateral femoral artery (IABP side: iFA, ECMO side: eFA) and carotid artery (left: LCA, right: RCA) and the velocity time integral (VTI) of aortic root were assessed by ultrasonography and compared when IABP was on and off. Seventeen of 39 (43.6%) patients survived to discharge, and 29 (74.4%) survived on ECMO. A total of 172 pairs of data (IABP on and off) were collected in this study, measured on the median of 2.0 (1.0, 4.5) days after patients received VA‐ECMO. The BFR on both sides of FA (iFA: 176.4 ± 104.5 vs. 152.2 ± 139.8 mL/min, P < 0.01; eFA: 299.3 ± 279.9 vs. 242.4 ± 258.8 mL/min, P < 0.01) and the aortic VTI (10.1 ± 4.4 vs. 8.5 ± 4.4 cm, P < 0.01) decreased significantly when turning the IABP off, while the BFR on both sides of CA remained unchanged (LCA: 555.7 ± 326.9 vs. 578.6 ± 328.0 mL/min, P = 0.27; RCA: 550.0 ± 331.1 vs. 533.0 ± 303.5 mL/min, P = 0.30). The LCA BFR dramatically increased after turning the IABP off (296.8 ± 129.7 vs. 401.4 ± 278.1 mL/min, P = 0.02) in patients with cardiac stunning (defined as pulse pressure ≤ 5 mmHg). However, there was no significant difference in LCA BFR between IABP‐On and IABD‐Off (359.6 ± 105.4 mL/min vs. 389.6 ± 139.3 mL/min, P = 0.31) in patients with cardiac stunning receiving a higher ECMO blood flow (> 3.5 L/min). Conclusions: Concomitant IABP used in patients undergoing femoro‐femoral VA‐ECMO was associated with increased aortic VTI and BFR in bilateral FA. The change in CA BFR depended on cardiac function. A decreased LCA BFR was observed in patients with cardiac stunning when IABP was turned on, which might be compensated by a higher ECMO blood flow. Further study is needed to confirm the relationship between BFR and extremities and neurological complications. [ABSTRACT FROM AUTHOR]

Background: Limited data are available on the impact of a specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). This study evaluated whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients undergoing veno-arterial (VA) ECMO. Methods: A total of 255 AMI patients who underwent VA-ECMO were included. In January 2014, a multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into a pre-ECMO team group (n = 131) and a post-ECMO team group (n = 124). The primary outcome was in-hospital mortality. Results: In-hospital mortality (pre-ECMO team vs. post-ECMO team, 54.2% vs. 33.9%; p = 0.002) and cardiac intensive care unit mortality (pre-ECMO team vs. post-ECMO team, 51.9% vs. 30.6%; p = 0.001) were significantly lower after the implementation of a multidisciplinary ECMO team. On multivariable logistic regression model, implementation of the multidisciplinary ECMO team was associated with reduction of in-hospital mortality [odds ratio: 0.37, 95% confidence interval (CI) 0.20–0.67; p = 0.001]. Incidence of all-cause mortality [58.3% vs. 35.2%; hazard ratio (HR): 0.49, 95% CI 0.34–0.72; p < 0.001) and readmission due to heart failure (28.2% vs. 6.4%; HR: 0.21, 95% CI 0.08–0.58; p = 0.003) at 6 months of follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group. Conclusions: Implementation of a multidisciplinary ECMO team was associated with improved clinical outcomes in AMI patients complicated by CS. Our data support that a specialized ECMO team is indispensable for improving outcomes in patients with AMI complicated by CS. [ABSTRACT FROM AUTHOR]

We report the ethnic and geographical distribution of patients undergoing extracorporeal membrane oxygenation (ECMO) at our institution in Honolulu, Hawaii. Some of the unique aspects of utilizing ECMO in the state of Hawaii include the complex geography of the Hawaiian islands separated by up to 400 km of ocean, as well as the transportation of patients from Hawaii to centers on the mainland that offer advanced cardiac therapies, the nearest which are 4000 km away. Patients who underwent venovenous (VV) and venoarterial (VA) ECMO cannulation from 2015-2022 were included in the analysis. Patient characteristics prior to cannulation and survival outcomes were analyzed. Ethnicity was compared to 2021 census data in the state of Hawaii. A total of 46 patients who underwent ECMO (VV =21 and VA = 25) were analyzed. The majority of ECMO patients were of Asian descent (50%), and 9% were of Native Hawai'ian descent. This reflects the ethnic diversity of Hawaii when compared to 2021 census data (37% Asian and 11% Native Hawai'ian). The most common indication for VA ECMO was cardiogenic shock due to advanced heart failure (26%) and for VV ECMO was COVID ARDS (22%). The majority of patients were from the island of Oahu (76%), and the remainder (26%) were from the other islands combined. In addition, 11% were transported to the mainland for advanced therapies on ECMO support. Survival to hospital discharge was 57% (48% for VA ECMO and 67% for VV ECMO). The patient characteristics of the ECMO program in our institution demonstrate the unique challenges and benefits of maintaining an ECMO program in Hawaii. Some potential solutions to mitigate these challenges include developing outreach programs for cardiac and critical care providers from the outer islands regarding the ECMO capabilities of our institution, consideration for mobile ECMO air units to cannulate patients directly in the outer islands, and the ability to offer end-stage therapies for cardiac and pulmonary failure on island. [ABSTRACT FROM AUTHOR]

Introduction: Mechanical circulatory support is becoming a more common therapy for end-stage heart failure in intensive cardiac care unit, and currently there are several types of devices that can be used as bridge therapy to recovery phase or hearth transplantation. Extracorporeal membrane oxygenation (ECMO) replaces heart and lung function using extracorporeal blood flow and it can be used as mechanical support in cardio-circulatory or respiratory failure.1 In a patient on ECMO support there is a strong activation of inflammatory response in a short period of time, usually due to shock before the initiation of support, but also, due to long, non-physiological blood flow through the piping, rotational pump and the oxygenator, where there is higher possibility of development of infection. In this phase patients are hemodynamically unstable, dependent on vasoactive support and substitution of intravenous fluids with a raise in inflammatory markers seen in laboratory results. Adsorbers for extracorporeal blood purification (CytosorbTM) can absorb molecules ranging from 5 to 55 kDa, which is the size where cytokines and some metabolites such as bilirubin, bile acids and ammonium can be absorbed, and it can be used to control inflammatory response which eventually can damage blood vessel walls and lead to target organs damage. Case report: This case report will show a 38-year-old patient who was hospitalized in Department of Cardiac Intensive Care after deterioration of his primary condition (cardiomyopathy) with hemodynamic instability, which lead to placement of both left and right sided mechanical circulatory support with an adsorber. This led to a decrease of inflammatory markers with good clinical and microbiological response. Patients soon underwent heart transplantation without any major complications and fast recovery. Conclusion: Use of adsorber via ECMO machine or dialysis machine is a very complex procedure which needs responsible approach to intervention and the only guarantee of success lays in a multidisciplinary approach. [ABSTRACT FROM AUTHOR]