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Hemolysis is a potential limitation of percutaneously delivered left‐sided mechanical circulatory support pumps, including trans valvular micro‐axial flow pumps (TVP). Hemolytic biomarkers among durable left ventricular assist devices include lactate dehydrogenase (LDH) >2.5 times the upper limit of normal (ULN) and plasma‐free hemoglobin (pf‐Hb) >20 mg/dL. We examined the predictive value of these markers among patients with cardiogenic shock (CS) receiving a TVP. We retrospectively studied records of 116 consecutive patients receiving an Impella TVP at our institution between 2012 and 2017 for CS. Twenty‐three met inclusion/exclusion criteria, and had sufficient pf‐Hb data for analysis. Area under receiver‐operator characteristic (ROC) curve for diagnosing hemolysis were calculated. Mean age was 62 ± 14 years and ejection fraction was 15 ± 5%. Mean duration of support was 5.4 ± 3.5 days. Pre‐device LDH levels were >2.5x ULN in 71% (n = 5/7) of 5.0 and 29% of CP patients, while pre‐device pf‐Hb levels were >20 mg/dL in 14% (n = 1/7) of 5.0 and 25% (n = 4/16) of CP patients. Given elevated baseline LDH and pf‐Hb levels, we defined hemolysis as a pf‐Hb level >40 mg/dL within 72 h post‐implant plus clinical evidence of device‐related hemolysis. We identified that 30% (n = 7/23) had device‐related hemolysis. Using ROC curve‐derived cut‐points, an increase in delta pf‐Hb by >27mg/dL, not delta LDH, within 24 h after TVP implant (delta pf‐Hb: C‐statistic = 0.79, sensitivity: 57%, specificity: 93%, p <0.05) was highly predictive of hemolysis. In conclusion, we identified a change in pf‐Hb, not LDH, levels is highly sensitive and specific for hemolysis in patients treated with a TVP for CS. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. Background: Risk stratifying patients with cardiogenic shock (CS) is a major unmet need. The recently proposed Society for Cardiovascular Angiography and Interventions (SCAI) stages as an approach to identify patients at risk for in-hospital mortality remains under investigation. We studied the utility of the SCAI stages and further explored the impact of hemodynamic congestion on clinical outcomes. Methods: The CS Working Group registry includes patients with CS from 8 medical centers enrolled between 2016 and 2019. Patients were classified by the maximum SCAI stage (B–E) reached during their hospital stay according to drug and device utilization. In-hospital mortality was evaluated for association with SCAI stages and hemodynamic congestion. Results: Of the 1414 patients with CS, the majority were due to decompensated heart failure (50%) or myocardial infarction (MI; 35%). In-hospital mortality was 31% for the total cohort, but higher among patients with MI (41% versus 26%, MI versus heart failure, P <0.0001). Risk for in-hospital mortality was associated with increasing SCAI stage (odds ratio [95% CI], 3.25 [2.63–4.02]) in both MI and heart failure cohorts. Hemodynamic data was available in 1116 (79%) patients. Elevated biventricular filling pressures were common among patients with CS, and right atrial pressure was associated with increased mortality and higher SCAI Stage. Conclusions: Our findings support an association between the proposed SCAI staging system and in-hospital mortality among patient with heart failure and MI. We further identify that venous congestion is common and identifies patients with CS at high risk for in-hospital mortality. These findings provide may inform future management protocols and clinical studies. [ABSTRACT FROM AUTHOR]

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]

Right ventricular (RV) failure remains a major cause of global morbidity and mortality for patients with advanced heart failure, pulmonary hypertension, or acute myocardial infarction and after major cardiac surgery. Over the past 2 decades, percutaneously delivered acute mechanical circulatory support pumps specifically designed to support RV failure have been introduced into clinical practice. RV acute mechanical circulatory support now represents an important step in the management of RV failure and provides an opportunity to rapidly stabilize patients with cardiogenic shock involving the RV. As experience with RV devices grows, their role as mechanical therapies for RV failure will depend less on the technical ability to place the device and more on improved algorithms for identifying RV failure, patient monitoring, and weaning protocols for both isolated RV failure and biventricular failure. In this review, we discuss the pathophysiology of acute RV failure and both the mechanism of action and clinical data exploring the utility of existing RV acute mechanical circulatory support devices. [ABSTRACT FROM AUTHOR]