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Veno-venous extracorporeal membrane oxygenation (VV ECMO) restores gas exchanges in severely hypoxemic patients. The need for adjunctive therapies usually originates either from refractory hypoxemia during ECMO (defined as the persistence of low blood oxygen levels despite extracorporeal support) or from the attempt to give a specific therapy for acute respiratory distress syndrome (ARDS). In this review, therapeutic strategies to treat refractory and persistent hypoxemia during ECMO are evaluated. In the second part, therapies that can be added on top of VV ECMO to address inflammation and altered vascular permeability in ARDS are examined. The therapies currently available often allow for an effective treatment of hypoxemia during ECMO. ARDS is still lacking a specific therapy, with low-grade evidence sustaining the majority of currently used drugs.

Extracorporeal membrane oxygenation is used for acute respiratory distress syndrome, refractory cardiogenic shock, and out-of-hospital cardiac arrest with uncertain neurological status, and, until recently, it was the only minimally invasive option to achieve biventricular support. However, extracorporeal membrane oxygenation increases left ventricular afterload and requires systemic anticoagulation, which is a major contraindication in the context of thrombolytic therapy following an ischaemic stroke. Conversely, the Impella heart pumps by design unload the ventricle and require minimal anticoagulation. We report the first case of mechanical circulatory supported with Impella CP on the left and Impella RP on the right (Abiomed Inc., Danvers, MA) for acute biventricular failure due to suspected acute myocarditis in the context of thrombolytic therapy for ischaemic stroke.

Aims To correlate the dynamics of platelet activation with the development of thromboembolic events in patients with continuous-flow left ventricular assist device (cf-LVAD). Methods and results The platelet activity state (PAS) assay was utilized to evaluate platelet activation in 68 cf-LVAD patients implanted with the HeartMate II (n = 15, 22%), HeartMate 3 (n = 15, 22%), or HeartWare HVAD (n = 38, 56%). PAS was measured preoperatively, early post-implant, and at long-term follow-up (1, 3, 6, 12, 18, and 24 months post-implant). PAS was also measured at the occurrence of adverse events in patients who developed thrombotic complications. Data on patient demographics, medical history, antithrombotic therapy, and coagulation parameters were also analysed. Over a median follow-up of 602 (234-942) days, PAS values did not increase over time in the overall population (P = 0.15). However, PAS measured at event was 15-fold higher in the six patients (9%) who suffered pump thrombosis (n = 2) or ischaemic stroke (n = 4) vs. the rest of the population [6.67% (5.59%-11.98%) vs. 0.45% (0.33%-0.75%); P = 0.012], despite comparable coagulation profile. Pre-implant PAS values were 4.5-fold higher in these patients [1.90% (1.24%-3.17%) vs. 0.42% (0.32%-0.72%); P = 0.006]. Neither preoperative variables nor the type of the pump or the antiplatelet strategy were associated with a higher risk of complications. Conclusions Thrombotic events are associated with altered PAS values. Moreover, baseline elevated PAS values in patients who developed thrombotic events suggest patient-specific tendency to post-implant thromboembolic complications. Prospectively, systematic monitoring of PAS might guide the development of refined patient-tailored antithrombotic strategies and the technological improvement of LVAD design.

BACKGROUND Acute left ventricular dysfunction is a major complication of cardiac surgery and is associated with increased mortality. Meta-analyses of small trials suggest that levosimendan may result in a higher rate of survival among patients undergoing cardiac surgery. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial involving patients in whom perioperative hemodynamic support was indicated after cardiac surgery, according to prespecified criteria. Patients were randomly assigned to receive levosimendan (in a continuous infusion at a dose of 0.025 to 0.2 μg per kilogram of body weight per minute) or placebo, for up to 48 hours or until discharge from the intensive care unit (ICU), in addition to standard care. The primary outcome was 30-day mortality. RESULTS The trial was stopped for futility after 506 patients were enrolled. A total of 248 patients were assigned to receive levosimendan and 258 to receive placebo. There was no significant difference in 30-day mortality between the levosimendan group and the placebo group (32 patients [12.9%] and 33 patients [12.8%], respectively; absolute risk difference, 0.1 percentage points; 95% confidence interval [CI], -5.7 to 5.9; P = 0.97). There were no significant differences between the levosimendan group and the placebo group in the durations of mechanical ventilation (median, 19 hours and 21 hours, respectively; median difference, -2 hours; 95% CI, -5 to 1; P = 0.48), ICU stay (median, 72 hours and 84 hours, respectively; median difference, -12 hours; 95% CI, -21 to 2; P = 0.09), and hospital stay (median, 14 days and 14 days, respectively; median difference, 0 days; 95% CI, -1 to 2; P = 0.39). There was no significant difference between the levosimendan group and the placebo group in rates of hypotension or cardiac arrhythmias. CONCLUSIONS In patients who required perioperative hemodynamic support after cardiac surgery, low-dose levosimendan in addition to standard care did not result in lower 30-day mortality than placebo. (Funded by the Italian Ministry of Health; CHEETAH ClinicalTrials.gov number, NCT00994825.).

Introduction/Aim Veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) support is increasingly used in refractory cardiogenic shock and cardiac arrest, but is characterized by a rise in afterload of the left ventricle (LV) which may ultimately either further impair or delay cardiac contractility improvement. The aim of this study was to provide a comprehensive overview regarding the different LV venting techniques and results currently available in the literature. Methods A systematic literature search was performed in the PubMed database: 207 articles published between 1993 and 2016 were included. Papers dealing with pre‐clinical studies, overlapping series, and association with other assist devices were excluded from the review, with 45 published papers finally selected. Heterogeneous indications for LV unloading were reported. The selected literature was divided into subgroups, according to the location or the performed procedure for LV venting. Results Case reports or case series accounted for 60% of the papers, while retrospective study represented 29% of them. Adult series were present in 67%, paediatric patients in 29%, and a mixed population in 4%. LV unloading was performed percutaneously in 84% of the cases. The most common locations of unloading was the left atrium (31%), followed by indirect unloading (intra‐aortic balloon pump) (27%), trans‐aortic (27%), LV (11%), and pulmonary artery (4%). Percutaneous trans‐septal approach was reported in 22%. Finally, the unloading was conducted surgically in 16%,with open chest surgery in 71%, and minimally invasive surgery in 29% of surgical cases. Conclusion Nowadays, only a few data are available about left heart unloading in V‐A ECMO support. Despite the well‐known controversy, IABP remains widely used in combination with V‐A ECMO. Percutaneous approaches utilizing unloading devices is becoming an increasingly used option. However, further studies are required to establish the optimal LV unloading method.

Objectives To evaluate whether the adoption of a right minithoracotomy operative approach had an impact on the long-term results of edge-to-edge (EE) repair compared to conventional sternotomy in patients with Barlow's disease and bileaflet prolapse. Methods We assessed the long-term results of 104 patients with Barlow's disease treated with a minimally invasive EE technique. An equal number of patients had a conventional median sternotomy EE repair for the same disease and were used as a control group. The inverse probability of treatment weighting was used to create comparable distributions of the covariates that were significantly different at baseline in the two groups. We performed a comparative analysis of the groups. Results No hospital deaths were observed. Follow-up was 99.5% complete (median 11.3 years). The cumulative incidence function (CIF) of cardiac death at 12 years, with noncardiac death as a competing risk, showed no difference between the two groups ( P = 0.87). At 12 years, the CIF of recurrent MR ≥ 3+, with death as the competing risk, was 7% in the sternotomy group and 5% in the minimally invasive group ( P = 0.30), and the CIF of recurrence of MR ≥ 2+ was 15 and 14%, respectively ( P = 0.63). The type of surgical approach was not a predictor of cardiac death, reoperation, recurrent MR ≥ 3+ or recurrent MR ≥ 2+. Conclusions A minimally invasive approach does not have a negative impact on the effectiveness and long-term durability of the EE repair for bileaflet prolapse in Barlow's disease. Long-term outcomes are excellent, and valvular performance remains stable over time with no evidence of mitral stenosis.

Heart failure is characterized by ventriculo-arterial decoupling which decreases myocardial efficiency and is exacerbated by tachycardia and by increased total peripheral resistance that worsen static arterial elastance; unlike aortic pressure by itself, this measure is independent of the function of the ventricle. Therefore, it is an index which describes arterial properties.We investigated the effect of intra-aortic balloon counterpulsation on arterial elastance, a variable which can be obtained non-invasively, in patients with acute decompensated heart failure deteriorated in low output state.17 out of 24 patients admitted for acute decompensated heart failure underwent intra-aortic balloon counterpulsation insertion for hemodynamic worsening condition despite medical therapy.Hemodynamic variables were obtained with a pulmonary artery catheter; arterial elastance and cardiac power index were calculated.Intra-aortic balloon counterpulsation was associated with a decrease of the arterial elastance median value (1.64 vs. 1.28 mmHg/ml- P = 0.04) along withan increase in cardiac power index (0.29, vs 0.40, W/m; P = 0.02 ). Mixed venous saturation (53 mmHg, vs 70 mmHg; P = 0.007) and pulmonary mean arterial pressure (41 vs 30 mmHg; P = 0.005) significantly changed after intraortic balloon counterpulsation insertion. No significant changes in heart rate (median 80, vs 80, bpm; P = 0.809) were observed.Intraortic balloon counterpulsation may effectively improve arterial elastance on top of a conservative use of inotropes/vasopressors, with a significant improvement in hemodynamics.

Left ventricle (LV) unloading during VenoArterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) reduces the risk of LV distention, stagnation and pulmonary congestion resulting from the increased afterload. Lacking direct comparisons between unloading strategies we used network meta-analysis to indirectly compare different unloading approaches.A literature research was performed to include all studies on VA-ECMO reporting data on mechanical LV unloading. The pre-specified outcome was in-hospital death.Literature search identified 389 studies: 16 were included in the analysis (3930 patients). Two strategies of mechanical LV unloading were compared: afterload reduction (IABP) and preload reduction (Impella pump, right upper pulmonary/trans-septal catheters, LV surgical vents). Any LV unloading strategy was associated with mortality reduction with overall OR = 0.54; 95% CI 0.42-0.70; p .001. Targeting afterload was associated with reduced mortality (OR = 0.61 95% CI 0.46-0.81; p .001; IAny unloading strategy in VA-ECMO patients was associated with lower mortality as compared to no-unloading. Preload reduction strategies resulted superior to afterload reduction.

Impella RP has been used to treat right ventricular failure (RVF) developing in various clinical settings that underlay different pathological mechanisms and lead to distinct prognostic implications.This is a single-centre retrospective study including all consecutive patients, from January 2015 to December 2018, with inferior STEMI due to acute thrombotic occlusion of right coronary artery (RCA) and unsuccessful primary percutaneous coronary intervention (PCI) complicated by refractory RVF managed with an Impella RP device.A total of 5 patients have been treated. The mean age was 73 ± 9 years, 80% were males. All patients, except one, were hemodynamically stable at hospital admission. In all patients, PCI resulted unsuccessful (final TIMI flow 3), with subsequent development of refractory RVF and cardiogenic shock in the catheterization laboratory, despite the use of inotropes and intra-aortic balloon pump (IABP). In 80% of the cases, Impella RP was placed immediately after PCI. Hemodynamics improved immediately after initiation of Impella RP support, with an increase in systolic blood pressure from 91 ± 17 to 136 ± 13 mmHg, a decrease in central venous pressure from 16 ± 2.5 to 12 ± 4 mmHg and a resolution in lactates from 4.5 ± 2.5 to 1.6 ± 0.7 mg/dL. Mean duration of IABP and Impella RP support were 4 and 7 days, respectively. RV recovery occurred in 80% of the cases. All patients survived at 30-day.In patients with AMI complicated by unsuccessful revascularization of RCA and refractory RVF, the use of Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favourable survival at 30-day.

Background The Impella () percutaneous mechanical circulatory support device is a catheter-based, impeller-driven, axial-flow pump. It reduces left ventricular (LV) stroke work and myocardial oxygen demand while increasing systemic and coronary perfusion in the setting of cardiogenic shock (CS). Purpose The aim of the study was to evaluate clinical characteristics and outcomes of patients with CS treated with Impella at our center. Methods Our single-center, real-world, observational registry included all consecutive patients with CS treated with Impella 2.5, CP, 5.0, or RP at our center from February 2013 to June 2018. Indication for Impella implantation was CS, defined as hypotension (systolic blood pressure Results A total of 130 patients were included in the registry, mean age was 61±12 years, and 79.2% were males. A history of prior MI, chronic heart failure, and chronic kidney disease was present in 28.9%, 26.1%, and 18.3%, respectively. The etiologies of CS were the following: fulminant myocarditis in 6.1% of the patients, acute coronary syndromes in 59.2%, peri-procedural CS during ventricular tachycardia ablation in 7.7% and acute heart failure in 27%. Out-of-hospital cardiac arrest was present in 30.4% of the patients; 60.2% were in INTERMACS I class at presentation. At admission, mean arterial pressure (MAP) was 65±18 mmHg, serum lactate was 6.7±5.5 mmol/L, mean left ventricular ejection fraction 21.4±11.7%, right ventricular dysfunction was indeed present in 48.6% of the patients. Inotropic drugs support was used in 66.4% of the patients. Impella 2.5, CP, and 5.0 were implanted in 76.1%, 15.4%, and 1.5% of the patients, respectively. Impella RP was also used in 11.5% of patients.The mean duration of support was 135±167 hours. Of note, extra-corporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) were implanted before Impella insertion in 42.8% and 46.7% of the patients, respectively. Escalation to ECMO, ventricular assist device, or heart transplantation was needed in 35.8% of the patients. During hospital stay, acute kidney injury occurred in 56.7% of the patients; need of renal replacement therapy (RRT) 31.7%; access site-related bleeding 14.3%; life-threatening bleeding 31.5%; acute limb ischemia 14.5%; hemolysis 33.3%. The rate of all-cause mortality at 30 day was 39.7%. Need of RRT was the only independent predictor of 30-day mortality (OR 6.56; CI 1.71–25.15; p=0.006). Conclusion Our single-center, real-world, observational experience reports acceptable clinical outcomes after Impella implantation in a particularly complex population of patients with CS (INTERMACS class I in 60.2% of patients, prior use of ECMO in 42.8% of patients). All-cause mortality at 30 days was 39.7%, and need of RRT was the only independent predictor for 30-day mortality.

Background The Impella (Abiomed, Danvers, MA) mechanical circulatory support is a catheter-based axial-flow pump. It reduces left ventricular (LV) stroke work and myocardial oxygen demand while increasing systemic and coronary perfusion in the setting of cardiogenic shock (CS), and it provides hemodynamic support during high-risk percutaneous coronary intervention (PCI). Purpose To evaluate the outcomes of Impella-supported patients in the context of CS and protected-PCI. Methods This single-center registry includes all patients implanted with Impella device at our institution between February 2013 and June 2018. Indications for Impella support were CS (hypotension despite adequate filling status with signs of hypoperfusion) and protected-PCI (prophylactic hemodynamic support during non-emergent high-risk PCI). Results A total of 145 patients were implanted with Impella: 130 (89.7%) for CS and 15 (10.3%) for protected-PCI. Among CS patients, mean age was 61.6±12.9, 79.2% males. The prevalence of chronic heart failure (HF) was 26.1%, prior myocardial infarction (MI) 29% and myocardial revascularization 36.6%, chronic kidney disease (CKD) 18.3%. Among protected PCI patients, mean age was 73.4±8.7 years, 86.7% males. The prevalence of HF was 85.7%, prior MI 42.9%, myocardial revascularization 35.7%, CKD 57.1%. In CS group, the indications for Impella implantation were myocarditis in 8 (6.2%) patients, acute coronary syndromes in 77 (59.2%), periprocedural ventricular tachycardia ablation CS in 10 (7.7%), decompensated heart failure in 26.9%. Out of hospital cardiac arrest occurred in 35 (30.4%) patients, INTERMACS I class in 70 (59.3%), mean arterial pressure was 65.4±18.4 mmHg, serum lactate 6.7±5.5 mmol/l, at least 1 inotropic agent use in 73 (66.4%), mean LV EF 21.4±11,7%, right ventricular dysfunction in 53 (48.6%). The rate of device-related complications was not negligible in CS group: 18 (14.5%) patients had limb ischemia and vascular surgery was required in 14, 17 (14.3%) had access-site bleeding. A total of 42 (33.3%) had haemolysis, and 67 (56.8%) acute kidney injury (AKI), half of whom requiring renal replacement therapy. Escalation to other therapies was necessary in 43 cases. Conversely, in the protected-PCI group a low rate of AKI (n=4, 28.6%) and acute limb ischemia (n=1, 7.1%) was observed, whereas no cases of haemolysis nor need of escalation therapy were recorded. Mean Impella support was 135.5±167.21 days for CS group, 60.6±80 for protected-PCI group. Survival at 30 days was 60.33% for CS group and 92.9% for protected-PCI group. One-year all-cause death was 50% for CS group and 13.3% for protected-PCI group. Conclusion Mechanical circulatory support with Impella is associated with good outcomes and reasonable rates of complications in the protected-PCI group, whereas less favorable results were observed in CS population probably due to the greater severity of clinical presentation.

Background Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) is increasingly used for treatment of severe cardiogenic shock, although it causes an increase in left ventricular (LV) afterload and might therefore hamper myocardial recovery. Recently, the addition of catheter-based left ventricular assist device (cLVAD) on top of VA-ECMO has been used to unload the LV and to improve outcome measures. However, there is limited data on predictors of outcome in this high-risk population. Aim The aim of this study was to evaluate predictors of 30-day survival in a multicentre cohort of severe cardiogenic shock patients treated with cLVADon top of VA-ECMO. Material and methods We report on consecutive patients from six tertiary care centers being treated with cLVAD in addition to VA-ECMO for treatment of cardiogenic shock. The primary endpoint is 30-day all-cause mortality. To identify predictors of the primary endpoint, multivariate analysis using an “elastic net” variable selection algorithm was done after imputation of missing variables. Results A total of 220 patients treated with cLVAD on top of VA-ECMO were included in the analysis. Of these, 79.1% were male with a median age of 55.5 (25thpercentile 48.0, 75thpercentile 65.6) years. In 60.5% of the patients, acute myocardial infarction was the underlying cause of cardiogenic shock and in 44.6% VA-ECMO was used for refractory cardiac arrest (eCPR). In the multivariable analysis, the following baseline parameters were significantly associated with the primary endpoint: Age (odds ratio of 1.68 per standard deviation), duration of cardiopulmonary resuscitation (OR 2.08 per SD), lactate (OR 1.04 per SD) and time from onset of shock to VA-ECMO (OR 1.30 per SD). Conclusion and outlook In this large-scale multicentre analysis of severe cardiogenic shock patients treated with VA-ECMO plus additional cLVAD unloading, age, duration of cardiopulmonary resuscitation, lactate and time from onset of shock to VA-ECMO were significantly associated with 30-day all-cause mortality. To further investigate this topic, we will evaluate predictors of outcome in distinct patient populations such as acute myocardial infarction vs. acute heart failure and patients without vs. patients with prior cardiopulmonary association.

Three-dimensional multiplanar reconstruction was used to diagnose recurrence of mitral regurgitation after MitraClip implantation in a 71-year-old man. Subsequent mitral valve surgery in such a case is high risk, and repeat MitraClip intervention could be feasible but is technically challenging. This imaging series demonstrates that LVAD implantation may be a solution to address MitraClip failure.

OBJECTIVES After mitral repair for degenerative mitral regurgitation (MR), no or mild (≤1+/4+) residual MR should remain. Occasionally patients are left with more than mild residual MR (>1+/4+) for a number of reasons. The aim of this study was to assess the late implications of such a suboptimal repair in a matched cohort study. METHODS From 2006 to 2013, a total of 2158 patients underwent mitral repair for degenerative MR in our institution. Fifty patients (2.3%) with residual MR >1+ at hospital discharge (study group) were matched up to 1:2 with 91 patients operated on during the same period who were discharged with MR ≤1+ (control group). The median follow-up was 8 years (interquartile range 6.3–10.1, longest 12.7 years). A comparative analysis of the outcomes in the 2 groups was performed. RESULTS Overall survival at 8 years was 87 ± 8% in the study group and 92 ± 3% in the control group (P = 0.23). There were 3 late deaths (6.0%) in the study group and 6 deaths (6.6%) in the control group. Freedom from reoperation was similar (P = 1.0). At 8 years the prevalence of MR ≥3+ was significantly higher in the study group (15.6% vs 2.1%, P CONCLUSIONS Residual MR more than mild at hospital discharge is associated with lower durability of mitral repair and the need for more medical therapy in the long term. However, even an initial optimal result does not completely arrest the progression of the degenerative process.

AIMS The aim of this study was to investigate nationwide trends and clinical outcomes of the Impella device for cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). METHODS AND RESULTS The IMP-IT study was a multicentre observational national registry which enrolled all patients treated with Impella 2.5, Impella CP, Impella 5.0 and Impella RP, both for CS and HR-PCI indications, across 17 Italian centres from 2004 to June 2018. A total of 406 patients were included: 229 had CS (56.4%) and 177 underwent HR-PCI (43.6%). The use of Impella increased significantly during the study period (average annual percent change 39.8%, 95% confidence interval: 30.4 to 49.9; p

Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for severe respiratory and circulatory failure. It is best performed in high-volume centers to optimize resource utilization and outcomes. Regionalization of ECMO might require the implementation of therapy before and during transfer to the high-volume center. The aim of this international survey was to describe the manner in which interhospital ECMO transport care is organized at experienced centers. Fifteen mobile ECMO centers from nine countries participated in this survey. Seven (47%) of them operated under the "Hub-and-Spoke" model. Transport team composition varies from three to nine members, with at least one ECMO specialist (i.e., nurse or perfusionist) participating in all centers, although intensivists and surgeons were present in 69% and 50% of the teams, respectively. All centers responded that the final decision to initiate ECMO is multidisciplinary and made bedside at the referring hospital. Most centers (75%) have a quality control system; all teams practice simulation and water drills. Considering the variability in ECMO transport teams among experienced centers, continuous education, training and quality control within each organization itself are necessary to avoid adverse events and maintain a low mortality rate. A specific international ECMO Transport platform to share data, benchmark outcomes, promote standardization, and provide quality control is required.

Background: The Extracorporeal Life Support Organization (ELSO) Maastricht Treaty for Nomenclature in Extracorporeal Life Support (ECLS) established consensus nomenclature and abbreviations for ECLS to ensure accurate, concise communication. Methods: We build on this consensus nomenclature by layering a framework of precise and efficient abbreviations for cannula configuration that describe flow direction, number of cannulae used, any additional ECLS-related catheters, and cannulation sites. This work is a consensus of international representatives of the ELSO, including those from the North American, Latin American, European, South and West Asian, and Asian-Pacific chapters of ELSO. Results: The classification increases in descriptive capability by introducing a third (cannula tip position) and fourth (cannula dimension) level to those provided in the previous consensus on ECLS cannulation configuration nomenclature. This expansion offers the simplest level needed to convey cannulation information yet allows for more details when required. Conclusions: A complete nomenclature for ECLS cannulation configurations accommodating future revisions was developed to facilitate ability to compare practices and results, to promote efficient communication, and to improve quality of registry data., SCOPUS: ar.j, info:eu-repo/semantics/published

Percutaneous coronary intervention (PCI) is establishing as the last remaining revascularization option in an increasing number of patients affected by complex coronary artery disease not suitable for surgery. Over the past decade, percutaneous left ventricular assist device (pLVAD) has increasingly replaced intra-aortic balloon pump to provide hemodynamic support during such non-emergent complex high-risk indicated procedures (CHIP) averting the risk of circulatory collapse and of adverse events in long lasting and/or complicated procedures. This review article aims to report the key factors to define CHIP, to summarize the available pLVAD which have CE mark for temporary mechanical LV support and to discuss the rationale of their use in this subset of patients. Based on the expertise of the Italian Society of Interventional Cardiology working group, with the endorsement from Spanish and Portuguese Society of Interventional Cardiology working groups, it will provide several practical suggestions in regards to the use of pLVAD in different clinical CHIP scenarios.

Objective The aim of this study is to evaluate the open transaxillary placement of the Impella 5.0 with a modified surgical technique. Methods From January to July 2018, nine patients (eight males; mean age 60 years) underwent surgical transaxillary Impella 5.0 (Abiomed Inc., Danvers, MA) implantation. Patient and periprocedural data were recorded in a prospectively maintained institutional database. The primary endpoint was technical success. The secondary endpoints were: neurological complications (peripheral or central), bleeding, and wound infection, duration of Impella support, and device failure requiring device replacement. Results Assisted technical success was 100%. The right axillary artery was used in 8/9 cases. Three patients (all on extracorporeal membrane oxygenation) suffered from access site bleeding which required surgical reintervention. One patient suffered from peripheral neurological dysfunction which recovered in 1 month and one patient had a local hematoma which was managed conservatively. The median length of treatment was 16 days (range 8-35). Five patients had myocardial recovery and the Impella could be explanted; the remaining were transitioned to a durable left ventricular assist device with an uneventful postoperative course. Hospital mortality was 33%. Conclusions Open Impella 5.0 device implantation through the axillary artery is safe and effective; technical success was 100% and low rates of major complications are reported.

Background: Percutaneous mechanical circulatory support devices are increasingly used in acute myocardial infarction complicated by cardiogenic shock (AMI-CS), despite limited evidence for their effectiveness. The aim of this study was to evaluate outcomes associated with use of the Impella device compared with intra-aortic balloon pump (IABP) and medical treatment in patients with AMI-CS. Methods: Data of patients with AMI-CS treated with the Impella device at European tertiary care hospitals were collected retrospectively. All patients underwent early revascularization and received optimal medical treatment. Using IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial inclusion and exclusion criteria, 372 patients were identified and included in this analysis. These patients were matched to 600 patients from the IABP-SHOCK II trial. The following baseline criteria were used as matching parameters: age, sex, mechanical ventilation, ejection fraction, prior cardiopulmonary resuscitation, and lactate. Primary end point was 30-day all-cause mortality. Results: In total, 237 patients treated with an Impella could be matched to 237 patients from the IABP-SHOCK II trial. Baseline parameters were similarly distributed after matching. There was no significant difference in 30-day all-cause mortality (48.5% versus 46.4%, P =0.64). Severe or life-threatening bleeding (8.5% versus 3.0%, P P =0.01) occurred significantly more often in the Impella group. Limiting the analysis to IABP-treated patients as a control group did not change the results. Conclusions: In this retrospective analysis of patients with AMI-CS, the use of an Impella device was not associated with lower 30-day mortality compared with matched patients from the IABP-SHOCK II trial treated with an IABP or medical therapy. To further evaluate this, a large randomized trial is warranted to determine the effect of the Impella device on outcome in patients with AMI-CS. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03313687.

BACKGROUND: We systematically analyzed the synergistic effect of: i) cytokine-mediated inflammatory activation of endothelial cells (ECs), and ii) shear-mediated platelet activation (SMPA) as a potential contributory mechanism to intraventricular thrombus formation in the setting of Left Ventricular Assist Device (LVAD) support. METHODS: Intact and shear-activated human platelets were exposed to nonactivated and cytokine-activated ECs. To modulate the level of LVAD-related shear activation, platelets were exposed to shear stress patterns of varying magnitude (30, 50, 70 dynes/cm(2), 10min) via a Hemodynamic Shearing Device. ECs were activated via exposure to inflammatory Tumor Necrosis Factor-α (TNF-α, 10 and 100 ng/mL, 24h), consistent with inflammatory activation recorded in patients on LVAD circulatory support. RESULTS: Adhesivity of shear-activated platelets to ECs was significantly higher than that of intact/unactivated platelets, regardless of the initial activation level (70 dynes/cm(2) shear-activated platelets vs. intact platelets: +80%, p

For patients with myocardial infarct-related cardiogenic shock (CS), urgent percutaneous coronary intervention is the recommended treatment strategy to limit cardiac and systemic ischemia. However, a specific therapeutic intervention is often missing in non-ischemic CS cases. Though drug treatment with inotropes and/or vasopressors may be required to stabilize the patient initially, their ongoing use is associated with excess mortality. Coronary intervention in unstable patients often leads to further hemodynamic compromise either during or shortly after revascularization. Support devices like the intra-aortic balloon pump failed to improve clinical outcomes in infarct-related CS. Currently, more powerful and active hemodynamic support devices unloading the left ventricle such as transvalvular microaxial pumps are available and are being increasingly used. However, as for other devices large randomized trials are not yet available, and device use is based on registry data and expert consensus. In this article, a multidisciplinary group of experienced users of transvalvular microaxial pumps outlines the pathophysiological background on hemodynamic changes in CS, the available mechanical support devices, and current guideline recommendations. Furthermore, different hemodynamic situations in several case-based scenarios are used to illustrate candidate settings and to provide the theoretic and scientific rationale for left-ventricular unloading in these scenarios. Finally, organization of shock networks, monitoring, weaning, and typical complications and their prevention are discussed.

A 71-year-old woman developed stress-related Takotsubo syndrome (TTS) with cardiogenic shock (CS). The left ventricular (LV) ejection fraction was 30%, with apical ballooning and LV outflow tract obstruction (LVOTO) with a peak gradient of 110 mm Hg and severe mitral regurgitation due to systolic

Adequate extracorporeal membrane oxygenation support in the adult requires cannulae permitting blood flows up to 6-8 L/minute. In accordance with Poiseuille's law, flow is proportional to the fourth power of cannula inner diameter and inversely proportional to its length. Poiseuille's law can be applied to obtain the pressure drop of an incompressible, Newtonian fluid (such as water) flowing in a cylindrical tube. However, as blood is a pseudoplastic non-Newtonian fluid, the validity of Poiseuille's law is questionable for prediction of cannula properties in clinical practice. Pressure-flow charts with non-Newtonian fluids, such as blood, are typically not provided by the manufacturers. A standardized laboratory test of return (arterial) cannulae for extracorporeal membrane oxygenation was performed. The aim was to determine pressure-flow data with human whole blood in addition to manufacturers' water tests to facilitate an appropriate choice of cannula for the desired flow range. In total, 14 cannulae from three manufacturers were tested. Data concerning design, characteristics, and performance were graphically presented for each tested cannula. Measured blood flows were in most cases 3-21% lower than those provided by manufacturers. This was most pronounced in the narrow cannulae (15-17 Fr) where the reduction ranged from 27% to 40% at low flows and 5-15% in the upper flow range. These differences were less apparent with increasing cannula diameter. There was a marked disparity between manufacturers. Based on the measured results, testing of cannulae including whole blood flows in a standardized bench test would be recommended. info:eu-repo/semantics/publishedVersion

Introduction: Despite significant technical advancements in the design and manufacture of Left Ventricular Assist Devices, post-implant thrombotic and thromboembolic complications continue to affect long-term outcomes. Previous efforts, aimed at optimizing pump design as a means of reducing supraphysiologic shear stresses generated within the pump and associated prothrombotic shear-mediated platelet injury, have only partially altered the device hemocompatibility. Methods: We examined hemodynamic mechanisms that synergize with hypershear within the pump to contribute to the thrombogenic potential of the overall Left Ventricular Assist Device system. Results: Numerical simulations of blood flow in differing regions of the Left Ventricular Assist Device system, that is the diseased native left ventricle, the pump inflow cannula, the impeller, the outflow graft and the anastomosed downstream aorta, reveal that prothrombotic hemodynamic conditions might occur at these specific sites. Furthermore, we show that beyond hypershear, additional hemodynamic abnormalities exist within the pump, which may elicit platelet activation, such as recirculation zones and stagnant platelet trajectories. We also provide evidences that particular Left Ventricular Assist Device implantation configurations and specific post-implant patient management strategies, such as those allowing aortic valve opening, are more hemodynamically favorable and reduce the thrombotic risk. Conclusion: We extend the perspective of pump thrombosis secondary to the supraphysiologic shear stress environment of the pump to one of Left Ventricular Assist Device system thrombosis, raising the importance of comprehensive characterization of the different prothrombotic risk factors of the total system as the target to achieve enhanced hemocompatibility and improved clinical outcomes.

Heart failure (HF) remains a leading cause of morbidity, hospitalization, and mortality worldwide. Advancement of mechanical circulatory support technology has led to the use of continuous-flow left ventricular assist devices (LVADs), reducing hospitalizations, and improving quality of life and outcomes in advanced HF. Recent studies have highlighted how metabolic and endocrine dysfunction may be a consequence of, or associated with, HF, and may represent a novel (still neglected) therapeutic target in the treatment of HF. On the other hand, it is not clear whether LVAD support, may impact the outcome by also improving organ perfusion as well as improving the neuro-hormonal state of the patients, reducing the endocrine dysfunction. Moreover, endocrine function is likely a major determinant of human homeostasis, and is a key issue in the recovery from critical illness. Care of the endocrine function may contribute to improving cardiac contractility, immune function, as well as infection control, and rehabilitation during and after a LVAD placement. In this review, data on endocrine challenges in patients carrying an LVAD are gathered to highlight pathophysiological states relevant to this setting of patients, and to summarize the current therapeutic suggestions in the treatment of thyroid dysfunction, and vitamin D, erythropoietin and testosterone administration.

In the setting of HeartWare left ventricular assist device (HVAD, Medtronic) implantation, pre-pump blood flow obstruction has been described due to intraventricular thrombus formation occluding the inflow cannula. This phenomenon often evolves in suboptimal pump performance, and requires prompt management to prevent its progression. However, to date, effective strategies and tools for the diagnosis and management of this complication are poorly described. We report a case of HVAD inflow cannula obstruction that drove later in-pump thrombosis and, eventually, complete cannula occlusion, and discuss gap of knowledge and limitations of currently available diagnostic and therapeutic tools in this scenario. Furthermore, we reinforce the value of time-frequency analysis of the HVAD log files to early identify abnormal pump operation associated with inflow cannula obstruction despite unremarkable trends of pump parameters.

Aims Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support stabilizes patients with cardiogenic shock. Despite improved oxygenation and peripheral circulation, LV unloading may be impeded due to the increased afterload, resulting in a failing static left ventricle and in high mortality. Methods and results We describe for the first time a large series of patients treated with the combination of VA-ECMO and Impella® compared with patients with VA-ECMO only. We retrospectively collected data on patients from two tertiary critical care referral centres. We enrolled 157 patients treated with VA-ECMO from January 2013 to April 2015: 123 received VA-ECMO support and 34 had concomitant treatment with VA-ECMO and Impella. A propensity-matching analysis was performed in a 2:1 ratio, resulting in 42 patients undergoing VA-ECMO alone (control group) compared with 21 patients treated with VA-ECMO and Impella. Patients in the VA-ECMO and Impella group had a significantly lower hospital mortality (47% vs. 80%, P < 0.001) and a higher rate of successful bridging to either recovery or further therapy (68% vs. 28%, P < 0.001) compared with VA-ECMO patients. A higher need for continuous veno-venous haemofiltration (48% vs. 19%, P = 0.02) and increased haemolysis (76% vs. 33%, P = 0.004) were reported in the study group due to higher survival. There was no difference in major bleeding rates between the two groups (VA-ECMO and Impella 38% vs. VA-ECMO 29%, P = 0.6). Conclusions Concomitant treatment with VA-ECMO and Impella may improve outcome in patients with cardiogenic shock compared with VA-ECMO only. Nevertheless, randomized studies are needed to validate these promising results further.

Continuous flow ventricular assist devices (cfVADs) while effective in advanced heart failure, remain plagued by thrombosis related to abnormal flows and elevated shear stress. To limit cfVAD thrombosis, patients utilize complex anti-thrombotic regimens built upon a foundation of aspirin (ASA). While much data exists on ASA as a modulator of biochemically-mediated platelet activation, limited data exists as to the efficacy of ASA as a means of limiting shear-mediated platelet activation, particularly under elevated shear stress common within cfVADs. We investigated the ability of ASA (20, 25 and 125 μM) to limit shear-mediated platelet activation under conditions of: 1) constant shear stress (30 dynes/cm2and 70 dynes/cm2); 2) dynamic shear stress, and 3) initial high shear exposure (70 dynes/cm2) followed by low shear exposure-i.e. a platelet sensitization protocol, utilizing a hemodynamic shearing device providing uniform shear stress in vitro. The efficacy of ASA to limit platelet activation mediated via passage through a clinical cfVAD system (DeBakey Micromed) in vitro was also studied. ASA reduced platelet activation only under conditions of low shear stress (38% reduction compared to control, n = 10, p < 0.004), with minimal protection at higher shear stress and under dynamic conditions (n = 10, p > 0.5) with no limitation of platelet sensitization. ASA had limited ability (25.6% reduction in platelet activation rate) to modulate shear-mediated platelet activation induced via cfVAD passage. These findings, while performed under "deconstructed" non-clinical conditions by utilizing purified platelets alone in vitro, provide a potential contributory mechanistic explanation for the persistent thrombosis rates experienced clinically in cfVAD patients despite ASA therapy. An opportunity exists to develop enhanced pharmacologic strategies to limit shear-mediated platelet activation at elevated shear levels associated with mechanical circulatory support devices.

Aim Italy is a country with high rates of immigration and the knowledge of immigrant health is very fragmentary. We provide a current picture of cardiovascular disease causes and clinical outcomes following heart surgery. Methods A clinical and echocardiographic survey was conducted on 154 consecutive immigrants referred for heart surgery to San Raffaele Hospital in Milan between 2003 and 2011. Results Major causes of heart disease were rheumatic heart disease (RHD) (nU 64, 41%), nonrheumatic valvulopathies (nU 41, 27%), ischemic heart disease (IHD) (nU 25, 16%), congenital heart disease (nU 13, 9%) and miscellaneous (nU 11, 7%). Median age was 49 years [interquartile range (IQR) 7–81]; 55% of patients were male. Among valvulopathies, rheumatic mitral disease was predominant (nU 56, 53%) as both single and multivalvular disease (nU 46, 73%); myxomatous prolapse emerged as the second main pattern of mitral disease (nU 30, 33%). Among patients with IHD, 72% had a high cardiovascular risk. Surgery was scheduled in 138 patients (90%). Clinical follow-up was available in 96 patients (62%) [median time 62 months (IQR 15–123)], among whom 92 (96%) were alive, four patients (4%) had died and 58 (38%) were lost. Conclusion Cardiovascular diseases represent a major health topic among immigrants in developed countries. RHD still is the predominant cause of hospitalization for heart surgery, nonrheumatic valvulopathies and IHD emerging as second and third causes, respectively. Data underline the need of reinforcement of prevention and care strategies in the matter of immigrant health and warrant the urgent attention of the international public health and research communities. J Cardiovasc Med 2014, 15:000‐000

Background The objective of this study was to assess the fate at long term of mild-to-moderate functional tricuspid regurgitation (TR) left untreated at the time of mitral valve repair in patients with dilated cardiomyopathy. Methods We selected from our prospective hospital database 84 patients (age, 64 ± 9.6 years; ejection fraction, 0.31 ± 0.064) who underwent mitral repair for secondary mitral regurgitation in whom concomitant mild-to-moderate TR (nonlinear scale 1 to 4+) was left untreated. Tricuspid regurgitation was classified as mild in 61 patients (72.6%) and moderate in 23 patients (27.3%). Annular dilatation itself was not systematically measured and was not used as a trigger for tricuspid annuloplasty. Most of the patients were in New York Heart Association functional class III or IV (56 of 84; 66.7%). Results At a median follow-up of 7.3 years (interquartile range, 4.5 to 9.3), 17 patients (20.2%) had moderate-to-severe TR and 21 patients (25%) showed a progression of at least two grades of their untreated preoperative TR. Freedom from moderate-to-severe TR or from progression of at least two grades of the baseline TR was 77% ± 5% at 5 years and 56.7% ± 8.4% at 10 years. Multivariate analysis identified preoperative right ventricular dysfunction (hazard ratio, 7.2; 95% confidence interval, 2.8 to 23; p = 0.001) and age (hazard ratio, 1; 95% confidence interval, 1.0 1.1; p = 0.03) as independent predictors of TR worsening. Conclusions A significant number of dilated cardiomyopathy patients with mild-to-moderate TR left untreated at the time of mitral repair show important TR at follow-up. In this setting, a more aggressive policy should be used taking into consideration the degree of annular dilatation and the function of the right ventricle and not simply the grade of TR.

Purpose CytoSorb treatment is a promising tool to treat severe inflammatory status in the acute care setting. Its effect on drugs is, however, poorly documented in vivo, although unselective and unpredictable removal of small molecules might translate into decreased blood levels of potentially life-saving medications. The aim of this study was to assess the impact of Cytosorb treatment on clereance of small drug molecules, measured as dose adjustements need, in a large population of critically ill patients. Methods Single-center analysis of Cytosorb treatments performed between 01-2018 and 03-2019 in patients with cardiogenic shock of several origins. Results 109 Cytosorb treatments were performed in 86 patients. A decrease in LDH (p=0.007), troponin T (p=0.022) and CPK (p=0.013), together with a trend toward lower need of inotropes, was reported during treatment, supporting its clinical efficacy in the study population. Vancomycin dose was significantly changed during the days of treatment (p Conclusion Cytosorb therapy was effective in improving shock parameters in a large population of cardiogenic shock patients, without affecting the dose need of vancomycin and bivalirudin after reaching target concentration. The results of this study further support the role of Cytosorb in the treatment of critically ill.

Purpose Many surgeons prefer to use cardiopulmonary bypass (CPB) machine when durable ventricular assist devices (VAD) is implanted in patients on veno-arterial membrane oxygenation (VA-ECMO). The aim of this study was to investigate if omitting CPB machine at the time of surgery negatively influence the outcome. Methods Data of eleven high volume VA-ECMO/VAD centers are collected and evaluated to identify patients who underwent VAD implantation after ECMO support between January 2010 and July 2018. Preoperative parameters and postoperative outcome are analyzed. Propensity score analysis was performed to identify two identical groups; one who were operated on without CPB (no CPB group) and the other group were operated on using CPB (CPB group) Results A total of 531 patients met the inclusion criteria. Nineteen patients were supported with Cardiowest TAH and are excluded from this analysis. The remaining 512 patients included 306 patients in the CPB group and 206 patients in no CPB group. After 1:1 propensity score matching 207 patients remained in each group and were compared. The total surgery time was significantly longer in the CBP group (288 ± 92 vs. 206 ± 64 min, p= Conclusion This study shows, omitting CPB at the time of durable VAD implantation for patients on VA-ECMO results in shorter surgery time, lower reexploration rate for bleeding and less blood product requirements. A trend toward lower RVAD use was also observed. Survival remains similar between both Groups.

Purpose Patients on veno-arterial membrane oxygenation (VA-ECMO) are high-risk candidates for durable ventricular assist device (VAD) surgery. The aim of this study was to compare the outcome of patients who received durable VAD on VA-ECMO using less invasive (LIS) vs. sternotomy approach. Methods Data of eleven high volume VA-ECMO/VAD centers are collected and evaluated to identify patients who underwent VAD implantation after ECMO support between January 2010 and July 2018. Preoperative parameters and postoperative outcome are analyzed. Results A total of 531 patients met the inclusion criteria. Nineteen patients were supported with Cardiowest TAH and were excluded from this analysis. The remaining 512 patients were 1:3 propensity score matched and resulted in 99 patients remained in LIS group vs. 293 patients in sternotomy group. The total surgery time was significantly longer in the sternotomy group (270±80 vs. 203±61 min; p Conclusion This study shows that LIS approach may be superior to sternotomy approach for patients on VA-ECMO. The postoperative morbidities were comparable. However, a superior short and long term outcome was observed in LIS Group.

Left ventricle (LV) unloading during VA-ECMO reduces the detrimental effect of increased afterload. Lacking direct comparisons between unloading strategies we used network metanalysis to indirectly compare different unloading approaches. A literature research was performed to include all studies on

Objective Extracorporeal cardiopulmonary resuscitation (eCPR) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is gaining importance as a rescue therapy for refractory cardiac arrest. VA-ECMO, especially in the setting of eCPR, is plagued by hemorrhagic and thromboembolic complications. The authors’ aims were to describe the coagulation profile in refractory cardiac arrest and assess its prognostic role. Design Single-center retrospective study. Setting Cardiac surgical intensive care unit of a university hospital. Participants One hundred eighty-eight patients treated with eCPR for intra-hospital and out-of-hospital refractory cardiac arrest, between 2008 and 2017. Interventions The authors retrospectively analyzed data from the first blood sample drawn during cannulation for VA-ECMO to understand the association of coagulation parameters with survival to hospital discharge, number of blood components transfused, anticoagulation therapy, serum lactate levels, no-flow time, and low-flow time. Measurements and Main Results Platelet count was 126 ± 79 × 109/L and in 17% of the population it was lower than 50 × 109/L, prothrombin time was 3.22 ± 4.01, activated partial thromboplastin time was 117 ± 78 seconds, fibrinogen was 186 ± 148 mg/dL, antithrombin was 47 ± 16%, and D-dimer was ≥2-fold the normal upper limit in 95% of patients. Fifty percent of patients had a disseminated intravascular coagulation (DIC) score ≥6 (52% among out-of-hospital cardiac arrest, 33% among in-hospital cardiac arrest), according to the criteria of the Japanese Society on Thrombosis and Hemostasis (2016). The median DIC score was 5.5 points (interquartile range 4-8), significantly different between survivors and nonsurvivors (4 [3-6] v 6 [4-8], p = 0.007). Every DIC score point contributed to the mortality risk (OR 1.34, 95% CI 1.09-1.67, p = 0.006). Patients with overt DIC less frequently received anticoagulants (28.6% v 55.9%, p = 0.002), started anticoagulant therapy later (12 [10-23] v 8.5 [5-12] hours, p = 0.045), and received a larger quantity of blood products (11 [4-23] v 3 [0-8.5] units, p Conclusion Coagulation derangements are frequent in patients with refractory cardiac arrest and have important consequences for eCPR management for anticoagulant therapy and blood product transfusion. The presence of DIC diagnostic criteria should be considered among the prognostic factors in this population of patients.

Objectives: Aim of the study was to assess in-hospital survival rate and the degree of myocardial recovery after MCS treatment (IABP or IMPELLA) at discharge and at 6 months in patients with AMI-CS and planned early percutaneous revascularization. Background: All studies on MCS for acute myocardial infarction related cardiogenic shock (AMI-CS) focused on its impact on in-hospital mortality; however, few data about its role on myocardial recovery are available. Methods: Retrospective study on 64 patients: 36 patients (56%) received IABP and 28 (44%) Impella 2.5/CP. Results: Patients treated with Impella were sicker compared to those treated with IABP as shown by a higher need of catecholamines (93% Impella vs 57% IABP, P = 0.002) and higher inotropic score before procedure: 8 (5-15) versus 4.5 (0-9), P = 0.02. In-hospital survival and MCS-related complications were comparable; hemolysis was more frequent in the Impella group (32% vs 0%, P < 0.0001). Myocardial damage was lower in those patients who were implanted with IMPELLA before PCI: lower troponin peak [3831 ng/dL (1441-8436) vs 16 581 (7802-23 675), P = 0.004] and lower CPK peak [893 UI/L (584-4082) vs 5797 (2483-9292) P = 0.04]. Impella patients had higher LVEF at 6 months [45 (38-52) vs 40 (33-45)%, P = 0.04]. LVEF increase at 6 months was statistically significant in both groups (P < 0.0001), with higher myocardial recovery in patients supported with Impella (absolute delta-LVEF increase 20% vs 10% P = 0.005). Conclusions: Cardiac unloading with IMPELLA in ACS-CS, especially if implanted before PCI, might provide lower myocardial damage and improved myocardial recovery which translates into significantly higher LVEF at 6 months.

Background: Intra-aortic balloon pump (IABP) had a pivotal role in the therapy of cardiogenic shock (CS), but recent studies have questioned its effects on patients' outcome. Aim of this study is the description of a "real world" series of patients in which IABP was used as a primary mechanical circulatory support (MCS). Methods: All patients who received IABP in our institution during 1 year were prospectively enrolled in our study. The outcomes were: ICU mortality, length of ICU stay, factors associated with mortality and complications of IABP. A logistic regression model was developed to estimate the effect of several risk factors on mortality. Results: A total of 119 patients were enrolled, 54 patients underwent IABP placement for CS unrelated to cardiac surgery (medical CS) and 65 after open-heart surgery. There was no significant difference for mortality between medical CS [12/54 (22.2%)] and cardiac surgery [7/65 (10.8%)] (P=0.09). The morbidity rate related to IABP was 11.3%. Multivariable analysis identified AKI (OR =9.3; 95% CI, 2.0-40.0; P=0.004), inotropic score at the time of IABP implantation (OR =1.06; 95% CI, 1.01-1.11; P=0.009) and history of myocardial revascularization (OR =4.7; 95% CI, 1.1-20.2; P=0.036) as independent predictors for early death (P < 0.05). A ROC curve analysis for inotropic score at time of implantation and mortality was performed in the overall population [AUC=0.78 (95% CI, 0.66-0.90)]. A cutoff of 20 has a specificity =72% and sensitivity=74% in this population. Conclusions: Mortality is similar in medical and postcardiotomy CS. The benefits of IABP are limited if the amount of inotropes and the severity of shock are too high.