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Extracorporeal life support (ECLS) has been increasingly used in the treatment of severe infarct-related cardiogenic shock in the last decade. The randomised ECLS-SHOCK trial demonstrated no benefit of early routine use on 30-day all-cause death. We herein present mid-term results. At 1-year follow-up, there were no significant differences in all-cause or cardiovascular mortality, neurologic outcome, recurrent myocardial infarction, repeat revascularisation and rehospitalisations for heart failure between ECLS and usual medical care., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Glucagon-like peptide-1 (GLP-1) is a gut-derived peptide secreted in response to nutritional and inflammatory stimuli. Elevated GLP-1 levels predict adverse outcome in patients with acute myocardial infarction or sepsis. GLP-1 holds cardioprotective effects and GLP-1 receptor agonists reduce cardiovascular events in high-risk patients with diabetes. In this study, we aimed to investigate the capacity of GLP-1 to predict outcome in patients with cardiogenic shock (CS) complicating myocardial infarction., Methods: Circulating GLP-1 levels were serially assessed in 172 individuals during index PCI and day 2 in a prospectively planned biomarker substudy of the IABP-SHOCK II trial. All-cause mortality at short- (30 days), intermediate- (1 year), and long-term (6 years) follow-up was used for outcome assessment., Results: Patients with fatal short-term outcome (n = 70) exhibited higher GLP-1 levels [86 (interquartile range 45-130) pM] at ICU admission in comparison to patients with 30-day survival [48 (interquartile range 33-78) pM; p < 0.001] (n = 102). Repeated measures ANOVA revealed a significant interaction of GLP-1 dynamics from baseline to day 2 between survivors and non-survivors (p = 0.04). GLP-1 levels above vs. below the median proved to be predictive for short- [hazard ratio (HR) 2.43; 95% confidence interval (CI) 1.50-3.94; p < 0.001], intermediate- [HR 2.46; 95% CI 1.62-3.76; p < 0.001] and long-term [HR 2.12; 95% CI 1.44-3.11; p < 0.001] outcome by multivariate Cox-regression analysis., Conclusion: Elevated plasma levels of GLP-1 are an independent predictor for impaired prognosis in patients with myocardial infarction complicated by CS. The functional relevance of GLP-1 in this context is currently unknown and needs further investigations., Trial Registration: www., Clinicaltrials: gov Identifier: NCT00491036., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Importance: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear., Objective: To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up., Design, Setting, and Participants: The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death., Interventions: Early vs delayed or selective coronary angiography and revascularization if indicated., Main Outcomes and Measures: Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year., Results: A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups., Conclusions and Relevance: This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation., Trial Registration: ClinicalTrials.gov Identifier: NCT02750462.

Background: Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). OAC treatment has been proven feasible in mild-to-moderate chronic kidney disease (CKD). In contrast, the optimal antithrombotic management of AF patients with end-stage renal disease (ESRD) is unknown and LAAC has not been proven in these patients in prospective randomized clinical trials., Objectives: The objective of this study is to evaluate safety and efficacy of LAAC in patients with ESRD., Methods: Patients undergoing LAAC were collected in a German multicenter real-world observational registry. A composite endpoint consisting of the occurrence of ischemic stroke/transient ischemic attack, systemic embolism, and/or major clinical bleeding was assessed. Patients with ESRD were compared with propensity score-matched patients without severe CKD. ESRD was defined as a glomerular filtration rate < 15 ml/min/1.73 m 2 or chronic hemodialysis treatment., Results: A total of 604 patients were analyzed, including 57 with ESRD and 57 propensity-matched patients. Overall, 596 endocardial and 8 epicardial LAAC procedures were performed. Frequency of major complications was 7.0% (42/604 patients) in the overall cohort, 8.8% (5/57 patients) in patients with ESRD, and 10.5% (6/57 patients) in matched controls (p = 0.75). The estimated event-free survival of the combined endpoint after 500 days was 90.7 ± 4.5% in patients with ESRD and 90.2 ± 5.5% in matched controls (p = 0.33)., Conclusions: LAAC had comparable procedural safety and clinical efficacy in patients with ESRD and patients without severe CKD., (© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: Galectin-3 (Gal-3) is considered a potential cardiovascular inflammatory marker that may provide additional risk stratification for patients with acute heart failure. It is unknown whether mild therapeutic hypothermia (MTH) impacts Gal-3 levels. Therefore, this biomarker study aimed to investigate the effect of MTH on Gal-3. Methods: In the randomized SHOCK-COOL trial, 40 patients with cardiogenic shock (CS) complicating acute myocardial infraction (AMI) were randomly assigned to the MTH (33 °C) or control group in a 1:1 ratio. Blood samples were collected on the day of admission/day 1, day 2, and day 3. Gal-3 level kinetics throughout these time points were compared between the MTH and control groups. Additionally, potential correlations between Gal-3 and clinical patient characteristics were assessed. Multiple imputations were performed to account for missing data. Results: In the control group, Gal-3 levels were significantly lower on day 3 than on day 1 (day 1 vs. day 3: 3.84 [IQR 2.04−13.3] vs. 1.79 [IQR 1.23−3.50] ng/mL; p = 0.049). Gal-3 levels were not significantly different on any day between the MTH and control groups (p for interaction = 0.242). Spearman’s rank correlation test showed no significant correlation between Gal-3 levels and sex, age, smoking, body mass index (BMI), and levels of creatine kinase-MB, creatine kinase, C-reactive protein, creatinine, and white blood cell counts (all p > 0.05). Patients with lower Gal-3 levels on the first day after admission demonstrated a higher risk of all-cause mortality at 30 days (hazard ratio, 2.67; 95% CI, 1.11−6.42; p = 0.029). In addition, Gal-3 levels on day 1 had a good predictive value for 30-day all-cause mortality with an area under the receiver operating characteristic curve of 0.696 (95% CI: 0.513−0.879), with an optimal cut-off point of less than 3651 pg/mL. Conclusions: MTH has no effect on Gal-3 levels in patients with CS complicating AMI compared to the control group. In addition, Gal-3 is a relatively stable biomarker, independent of age, sex, and BMI, and Gal-3 levels at admission might predict the risk of 30-day all-cause mortality.

Background: There is evidence that monocyte chemoattractant protein-1 (MCP-1) levels reflect the intensity of the inflammatory response in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) and have a predictive value for clinical outcomes. However, little is known about the effect of mild therapeutic hypothermia (MTH) on the inflammatory response in patients with CS complicating AMI. Therefore, we conducted a biomarker study to investigate the effect of MTH on MCP-1 levels in patients with CS complicating AMI., Methods: In the randomized mild hypothermia in cardiogenic shock (SHOCK-COOL) trial, 40 patients with CS complicating AMI were enrolled and assigned to MTH (33 °C) for 24 h or normothermia at a 1:1 ratio. Blood samples were collected at predefined time points at the day of admission/day 1, day 2 and day 3. Differences in MCP-1 levels between and within the MTH and normothermia groups were assessed. Additionally, the association of MCP-1 levels with the risk of all-cause mortality at 30 days was analyzed. Missing data were accounted for by multiple imputation as sensitivity analyses., Results: There were differences in MCP-1 levels over time between patients in MTH and normothermia groups ( P for interaction = 0.013). MCP-1 levels on day 3 were higher than on day 1 in the MTH group (day 1 vs day 3: 21.2 [interquartile range, 0.25-79.9] vs. 125.7 [interquartile range, 87.3-165.4] pg/mL; p = 0.006) and higher than in the normothermia group at day 3 (MTH 125.7 [interquartile range, 87.3-165.4] vs. normothermia 12.3 [interquartile range, 0-63.9] pg/mL; p = 0.011). Irrespective of therapy, patients with higher levels of MCP-1 at hospitalization tended to have a decreased risk of all-cause mortality at 30 days (HR, 2.61; 95% CI 0.997-6.83; p = 0.051)., Conclusions: The cooling phase of MTH had no significant effect on MCP-1 levels in patients with CS complicating AMI compared to normothermic control, whereas MCP-1 levels significantly increased after rewarming., Trial Registration: NCT01890317.

Background: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear., Methods: In this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days., Results: A total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P = 0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups., Conclusions: Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause. (Funded by the German Center for Cardiovascular Research; TOMAHAWK ClinicalTrials.gov number, NCT02750462.)., (Copyright © 2021 Massachusetts Medical Society.)

Aims: Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce. The objective of the study is to externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course., Methods and Results: The Simplified Acute Physiology Score (SAPS) II Score, the CardShock score, the IABP-SHOCK II score, and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. The primary outcome was 30-day all-cause mortality. Discriminative power was assessed by comparing the area under the curves (AUC) in case of continuous scores. In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination [area under the curve (AUC = 0.74)], followed by the CardShock score (AUC = 0.69) and the SAPS II score, giving only moderate discrimination (AUC = 0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (Stage E) but showed poor discrimination between Stages C and D with respect to short-term-mortality., Conclusion: Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification, or even development of new scores might be necessary to reach higher levels of discrimination., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Data reporting a head-to-head comparison between Amulet and Watchman devices are scarce. The aim of this study was to compare the Watchman™ versus Amulet™ left atrial appendage closure (LAAC) devices in a consecutive, industry-independent registry., Methods: Patients who underwent LAAC using Watchman or Amulet devices from January 2014 to December 2019 at the University Heart Center Lübeck, Lübeck, Germany were included in the present analysis. Primary endpoints included periprocedural complications (in-hospital death, pericardial tamponade, device embolization, stroke, major bleeding and vascular access complications), and complications during long-term follow-up (ischemic stroke, hemorrhagic stroke, thromboembolism, device thrombus, bleeding and death)., Results: After matching the patients for age (±5 years), gender, CHA2DS2Vasc score (±1) and HASBLED score (±1), each of the Watchman and the Amulet groups included 113 patients. Patients in the Amulet group had significantly more periprocedural complications (2.7% vs 10.6%, p = 0.029; respectively) and more major bleeding complications (0% vs 5.3%, p = 0.029; respectively). During long-term follow-up, the rate of events was comparable between the Watchman and Amulet groups (18.3% versus 20.8%, p = 0.729; respectively)., Conclusion: Amulet LAAC device was associated with increased periprocedural complications as compared to Watchman LAAC device. On long-term follow-up, both devices showed comparable efficacy and safety., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: RRT: consultant to Boston Scientific, speaker‘s bureau: Boston Scientific, Abbot Medical. MS: proctor in Boston Scientific for Watchman 2.5 and Watchman FLX. All other authors declare no competing financial and/or non-financial interests in relation to the work described., (© 2021 The Author(s).)

Aims: The aim of this pooled sub-analysis of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated either with clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor., Methods and Results: For the current analysis the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. 856 patients were eligible for analysis. Of these, 507 patients (59.2%) received clopidogrel, 178 patients (20.8%) prasugrel and 171 patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ significantly between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60-1.09, p adj  = 0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65-1.15, p adj  = 0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20 -0.69, p adj  = 0.002) and not significantly different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43 -1.24, p adj  = 0.24)., Conclusion: This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that acute therapy with either clopidogrel, prasugrel or ticagrelor is no independent predictor of 1-year mortality. Treatment with ticagrelor seems independently associated with less in-hospital moderate and severe bleeding events compared to clopidogrel. This finding might be due to selection bias and should be interpreted with caution., (© 2021. The Author(s).)

Background: Cardiogenic shock (CS) complicating acute myocardial infarction (AMI) still reaches excessively high mortality rates. This analysis is aimed to develop a new easily applicable biomarker-based risk score., Methods and Results: A biomarker-based risk score for 30-day mortality was developed from 458 patients with CS complicating AMI included in the randomized CULPRIT-SHOCK trial. The selection of relevant predictors and the coefficient estimation for the prognostic model were performed by a penalized multivariate logistic regression analysis. Validation was performed internally, internally externally as well as externally in 163 patients with CS included in the randomized IABP-SHOCK II trial. Blood samples were obtained at randomization. The two trials are registered with ClinicalTrials.gov (NCT01927549 and NCT00491036), are closed to new participants, and follow-up is completed. Out of 58 candidate variables, the four strongest predictors for 30-day mortality were included in the CLIP score (cystatin C, lactate, interleukin-6, and N-terminal pro-B-type natriuretic peptide). The score was well calibrated and yielded high c-statistics of 0.82 [95% confidence interval (CI) 0.78-0.86] in internal validation, 0.82 (95% CI 0.75-0.89) in internal-external (temporal) validation, and 0.73 (95% CI 0.65-0.81) in external validation. Notably, it outperformed the Simplified Acute Physiology Score II and IABP-SHOCK II risk score in prognostication (0.83 vs 0.62; P < 0.001 and 0.83 vs. 0.76; P = 0.03, respectively)., Conclusions: A biomarker-only score for 30-day mortality risk stratification in infarct-related CS was developed, extensively validated and calibrated in a prospective cohort of contemporary patients with CS after AMI. The CLIP score outperformed other clinical scores and may be useful as an early decision tool in CS., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background Intravenous morphine administration can adversely affect platelet inhibition induced by P2Y 12 receptor inhibitors after acute myocardial infarction. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. The aim of this prospective, randomized MonAMI (Impact of Morphine Treatment With and Without Metoclopramide Coadministration on Platelet Inhibition in Acute Myocardial Infarction) trial was, therefore, to investigate the impact of morphine with or without metoclopramide coadministration on myocardial and microvascular injury. Methods and Results Patients with acute myocardial infarction (n=138) were assigned in a 1:1:1 ratio to ticagrelor 180 mg plus: (1) intravenous morphine 5 mg (morphine group); (2) intravenous morphine 5 mg and metoclopramide 10 mg (morphine+metoclopramide group); or (3) intravenous placebo (control group) administered before primary percutaneous coronary intervention. Cardiac magnetic resonance imaging was performed in 104 patients on day 1 to 4 after the index event. Infarct size was significantly smaller in the morphine only group as compared with controls (percentage of left ventricular mass, 15.5 versus 17.9; P =0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (28% versus 54%; P =0.022) and the extent of microvascular obstruction was smaller (percentage of left ventricular mass, 0 versus 0.74; P =0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio, 0.37; 95% CI, 0.14-0.93 [ P =0.035]). There was no significant difference in infarct size ( P =0.491) and extent ( P =0.753) or presence ( P =0.914) of microvascular obstruction when comparing the morphine+metoclopramide group with the control group. Conclusions In this randomized study, intravenous administration of morphine before primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following acute myocardial infarction. This effect was not observed in the morphine plus metoclopramide group. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02627950.

Background: In acute myocardial infarction complicated by cardiogenic shock the use of mechanical circulatory support devices remains controversial and data from randomized clinical trials are very limited. Extracorporeal life support (ECLS) - venoarterial extracorporeal membrane oxygenation - provides the strongest hemodynamic support in addition to oxygenation. However, despite increasing use it has not yet been properly investigated in randomized trials. Therefore, a prospective randomized adequately powered clinical trial is warranted., Study Design: The ECLS-SHOCK trial is a 420-patient controlled, international, multicenter, randomized, open-label trial. It is designed to compare whether treatment with ECLS in addition to early revascularization with percutaneous coronary intervention or alternatively coronary artery bypass grafting and optimal medical treatment is beneficial in comparison to no-ECLS in patients with severe infarct-related cardiogenic shock. Patients will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoint of ECLS-SHOCK is 30-day mortality. Secondary outcome measures such as hemodynamic, laboratory, and clinical parameters will serve as surrogate endpoints for prognosis. Furthermore, a longer follow-up at 6 and 12 months will be performed including quality of life assessment. Safety endpoints include peripheral ischemic vascular complications, bleeding and stroke., Conclusions: The ECLS-SHOCK trial will address essential questions of efficacy and safety of ECLS in addition to early revascularization in acute myocardial infarction complicated by cardiogenic shock., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aims: The mortality in cardiogenic shock (CS) is high. The role of specific mechanical circulatory support (MCS) systems is unclear. We aimed to compare patients receiving Impella versus ECLS (extracorporal life support) with regard to baseline characteristics, feasibility, and outcomes in CS., Methods and Results: This is a retrospective cohort study including CS patients over 18 years with a complete follow-up of the primary endpoint and available baseline lactate level, receiving haemodynamic support either by Impella 2.5 or ECLS from two European registries. The decision for device implementation was made at the discretion of the treating physician. The primary endpoint of this study was all-cause mortality at 30 days. A propensity score for the use of Impella was calculated, and multivariable logistic regression was used to obtain adjusted odds ratios (aOR). In total, 149 patients were included, receiving either Impella (n = 73) or ECLS (n = 76) for CS. The feasibility of device implantation was high (87%) and similar (aOR: 3.14; 95% CI: 0.18-56.50; P = 0.41) with both systems. The rates of vascular injuries (aOR: 0.95; 95% CI: 0.10-3.50; P = 0.56) and bleedings requiring transfusions (aOR: 0.44; 95% CI: 0.09-2.10; P = 0.29) were similar in ECLS patients and Impella patients. The use of Impella or ECLS was not associated with increased odds of mortality (aOR: 4.19; 95% CI: 0.53-33.25; P = 0.17), after correction for propensity score and baseline lactate level. Baseline lactate level was independently associated with increased odds of 30 day mortality (per mmol/L increase; OR: 1.29; 95% CI: 1.14-1.45; P < 0.001)., Conclusions: In CS patients, the adjusted mortality rates of both ECLS and Impella were high and similar. The baseline lactate level was a potent predictor of mortality and could play a role in patient selection for therapy in future studies. In patients with profound CS, the type of device is likely to be less important compared with other parameters including non-cardiac and neurological factors., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: The impact of coronary artery chronic total occlusion (CTO) and its management with percutaneous coronary intervention (PCI) in the setting of myocardial infarction (MI) related cardiogenic shock (CS) remains unclear., Methods: This is a pre-specified analysis from the culprit-lesion-only PCI vs multivessel PCI in CS (CULPRIT-SHOCK) trial which randomized patients presenting with MI and multivessel disease complicated by CS to a culprit-lesion-only or immediate multivessel PCI strategy. CTO was defined by central core-laboratory evaluation. The independent associations between the presence of CTO and adverse outcomes at 30 days and 1 year were assessed using multivariate logistics models., Results: A noninfarct related CTO was present in 157 of 667 (23.5%) analyzed patients. Patients presenting with CTO had more frequent diabetes mellitus or prior PCI but less frequently presented with ST segment elevation MI as index event. The presence of CTO was associated with higher rate of death at 30 days (adjusted Odds ratio 1.63; 95% confidence interval [CI] 1.01-2.60). Rate of death at 1 year was also increased but did not reach statistical significance (adjusted Odds ratio 1.62; 95%CI 0.99-2.66). Compare to immediate multivessel PCI, a strategy of culprit-lesion-only PCI was associated with lower rates of death or renal replacement therapy at 30 days in patients with and without CTO (Odds ratio 0.79 95%CI 0.42-1.49 and Odds ratio 0.67 95%CI 0.48-0.96, respectively), without significant interaction (P = .68)., Conclusions: In patients with MI-related CS and multivessel disease, the presence of CTO is associated with adverse outcomes while a strategy of culprit-lesion-only PCI seems beneficial regardless of the presence of CTO., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Myocardial infarction with a culprit lesion located in the left main or proximal left anterior descending artery compared with other coronary segments is associated with more myocardium at risk and worse clinical outcomes., Objective: To evaluate the association of culprit lesion location with outcomes of culprit-lesion-only percutaneous coronary intervention with optional staged revascularization vs immediate multivessel percutaneous coronary intervention in patients with multivessel disease, myocardial infarction, and cardiogenic shock., Design, Setting, and Participants: Post hoc analysis of the Culprit Lesion Only Coronary Intervention vs Multivessel Coronary Intervention in Cardiogenic Shock (CULPRIT-SHOCK), an investigator-initiated randomized, open-label clinical trial. Patients with multivessel disease, acute myocardial infarction, and cardiogenic shock were enrolled at 83 European centers from April 2013 through April 2017., Interventions: Patients were randomized to culprit-lesion-only percutaneous coronary intervention with optional staged revascularization or immediate multivessel percutaneous coronary intervention (1:1). For this analysis, patients were stratified by culprit lesion location in the left main or proximal left anterior descending artery group and other-culprit-lesion location group., Main Outcomes and Measures: End points included a composite of death or kidney replacement therapy at 30 days and death at 1 year., Results: The median age of the study population was 70 (interquartile range, 60-78 years) and 524 of the study participants were men (76.4%). Of the 685 patients, 33.4% constituted the left main or proximal left anterior descending artery group and 66.6% the other-culprit-lesion location group. The left main or proximal left anterior descending artery group had worse outcomes compared with the other-culprit-lesion location group (56.8% vs 47.5%; P = .02 for the composite end point at 30 days and 59.8% vs 50.1%; P = .02 for death at 1 year). In both groups, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a reduced risk of the composite end point at 30 days (49.1% vs 64.3% and 44.1% vs 50.9%; P for interaction = .27). At 1 year, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a significantly reduced risk of death in the left main or proximal left anterior descending artery but not the other-culprit-lesion location group (50.0% vs 69.6%; P = .003 and 49.8% vs 50.4%; P = .89; P for interaction = 0.02)., Conclusions and Relevance: In patients with multivessel disease with myocardial infarction and cardiogenic shock, a culprit lesion located in the left main or proximal left anterior descending artery vs other coronary segments was associated with worse outcomes. These patients may especially benefit from culprit-lesion-only percutaneous coronary intervention with optional staged revascularization, although further investigation is needed to confirm this finding., Trial Registration: ClinicalTrials.gov Identifier: NCT01927549.

Objectives: This study sought to compare single lactate values at admission (L1) and after 8 h (L2) with lactate clearance (LC) for mortality prediction in cardiogenic shock (CS)., Background: Early estimation of prognosis in CS complicating acute myocardial infarction is crucial for tailored treatment selection. Arterial lactate is the most widely used point-of-care parameter in CS. In septic shock, lactate reduction over time-LC-has been extensively investigated. However, in CS, only limited data exist, and the prognostic value of LC is unknown., Methods: This study is a subanalysis of the IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial and the corresponding registry. Lactate levels were prospectively collected. All-cause mortality at 30 days was assessed as primary endpoint., Results: For 671 of 783 (85.7%) patients, L1 and L2 values were available. The area under the receiver-operating characteristic curve (L1: 0.69; L2: 0.76; LC: 0.59) showed no difference between L1 and LC (p = 0.20). In contrast, L2 was a significantly better predictive parameter than L1 or LC (p < 0.001 for both). In multivariable stepwise Cox regression analysis, L2 ≥3.1 mmol/l (best cutoff value by Youden index) and LC <-3.45%/h remained independently predictive for time to death (p < 0.001 for both), with L2 showing the highest chi-square test score (42.1) and hazard ratio (2.89; 95% confidence interval: 2.10 to 3.97)., Conclusions: Arterial lactate after 8 h is superior in mortality prediction in comparison with baseline lactate and LC. A cutoff value of 3.1 mmol/l for lactate after 8 h showed the best discrimination for assessing early prognosis in CS and may serve as new treatment goal. (Intraaortic Balloon Pump in Cardiogenic Shock II [IABP-SHOCK II]; NCT00491036)., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to evaluate the prognostic value of the SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) scores in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary disease with infarct-related cardiogenic shock (CS)., Background: The prognostic value of the SYNTAX score in this high-risk setting remains unclear., Methods: The CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock) trial was an international, open-label trial, where patients presenting with infarct-related CS and multivessel disease were randomized to a culprit-lesion-only or an immediate multivessel PCI strategy. Baseline SYNTAX score was assessed by a central core laboratory and categorized as low SYNTAX score (SS ≤22), intermediate SYNTAX score (2232). Adjudicated endpoints of interest were the 30-day risk of death or renal replacement therapy (RRT) and 1-year death. Associations between baseline SYNTAX score and outcomes were assessed using multivariate logistic regression., Results: Pre-PCI SYNTAX score was available in 624 patients, of whom 263 (42.1%), 207 (33.2%) and 154 (24.7%) presented with low, intermediate and high SYNTAX score, respectively. A stepwise increase in the incidence of adverse events was observed from low to intermediate and high SYNTAX score for the 30-day risk of death or RRT and the 1-year risk of death (p < 0.001, for all). After multiple adjustments, intermediate and high SYNTAX score remained strongly associated with 30-day risk of death or renal replacement therapy and 1-year risk of all-cause death. There was no significant interaction between SYNTAX score and the coronary revascularization strategy for any outcomes., Conclusions: In patients presenting with multivessel disease and infarct-related CS, the SYNTAX score was strongly associated with 30-day death or RRT and 1-year mortality., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: After early revascularisation, restoration of macrocirculatory perfusion parameters is the primary objective in the management of cardiogenic shock complicated acute myocardial infarction. Nevertheless, vital organ perfusion may be compromised at the systemic microcirculatory level, even in patients with preserved macrohaemodynamics. Microvascular perfusion was shown to have independent prognostic value for early mortality. The present study aims to compare the prognostic value of microcirculatory versus macrocirculatory perfusion parameters., Methods: This substudy of the culprit lesion-only percutaneous coronary intervention versus multivessel percutaneous coronary intervention in cardiogenic shock (CULPRIT-SHOCK) trial examined the sublingual capillary network using videomicroscopy post-percutaneous coronary intervention to determine the proportion of perfused capillaries (<20 µm) and perfused capillary density. Thirty-day follow-up was performed to obtain the occurrence of a combined clinical endpoint of all-cause death and renal replacement therapy., Results: Videomicroscopy measurements were performed in 66 patients. There was a significant adjusted association between microcirculatory perfusion parameters and the combined clinical endpoint (proportion of perfused capillaries: P =0.020; perfused capillary density: P =0.035), whereas there was no significant adjusted association between macrocirculatory perfusion parameters and the combined clinical endpoint (systolic blood pressure: P =0.205). Normotensive patients with compromised microcirculatory perfusion parameters had a higher risk of the combined clinical endpoint than normotensive patients with preserved microcirculatory perfusion parameters (proportion of perfused capillaries: Breslow P =0.014; perfused capillary density: Breslow P =0.076)., Conclusions: There is a significant and independent association between microcirculatory perfusion parameters perfused capillary density and proportion of perfused capillaries and the combined clinical endpoint of all-cause death and renal replacement therapy at 30 days follow-up. In patients with loss of haemodynamic coherence between microcirculatory and macrocirculatory perfusion parameters, microcirculatory perfusion parameters confer dominant prognostic value.

Background: Reperfusion strategies in acute myocardial infarction (AMI) may result in ischemia reperfusion injury characterized by increased oxidative stress, inflammation, and ultimately death of myocardial tissue which may be of particular importance in infarct-related cardiogenic shock (CS). Many anti-oxidative and immune regulatory processes depend on selenium which in large proportions is bound to circulating selenoprotein P (SelP). Individual SelP patterns may therefore be associated with inflammatory response and possibly mortality in patients with CS post AMI., Methods: In the randomized Intra-Aortic Balloon Pump in cardiogenic Shock II (IABP-SHOCK II)-trial, 600 patients with CS complicating AMI were assigned to therapy with or without IABP. In a predefined biomarker substudy of 147 patients, we analyzed SelP levels 1 and 3 days following randomization. Samples were compared with healthy controls and associations with the unspecific inflammatory marker C-reactive protein (CRP) were analyzed., Results: Compared with controls SelP levels in patients with infarct-related CS were markedly higher (2.7-fold at day 1 and 5.7-fold at day 3 following AMI, all P < 0.001). Thirty-day mortality was significantly higher in patients with SelP levels above the 75th percentile at day 3 following AMI (26% vs. 46%, P = 0.045). SelP was significantly proportionally correlated with CRP 1 (R = 0.762, P < 0.0001) and 3 days (R = 0.777 P < 0.0001) following AMI., Conclusion: SelP levels are significantly increased post AMI with CS. Higher SelP levels are associated with increased CRP levels indicative for inflammatory processes. Future studies should focus on the characterization of SelP profiles following AMI and the identification of pathomechanisms affected by SelP.

Background: The concept of percutaneous extracorporeal life support (ECLS) is based on immediate cardiovascular stabilization allowing for sufficient end-organ perfusion, thus improving the outcome in patients with circulatory arrest. Lifebridge ® (Zoll Medical GmbH, Germany) is a portable ECLS device designed for rapid application due to its automated set-up., Methods: A total of 60 tertiary cardiovascular centers were interrogated with regard to application and short-term results after use of Lifebridge ECLS system. Detailed data were collected by standardized case report forms in all centers consented to participate in the study. Demographic and clinical baseline characteristics of the patient population, procedural and follow-up data were recorded and analyzed., Results: In total, 444 patients were analyzed regarding mortality. The detailed study cohort consisted of 112 patients. A total of 80% of the study subjects represented patients post cardiopulmonary resuscitation, 43% were in cardiogenic shock and 50% suffered from acute myocardial infarction. The survival rates were 36% immediately after device implementation and 16% after 30 days. Multivariable analysis revealed that only serum lactate concentration at admission could be proven as independent predictor of patients' outcome. Patients with lactate concentrations above 10 mmol/L exhibited > 95% mortality (p < 0.05 versus below 10 mmol/L)., Conclusion: The present study provides real-world clinical data of patients treated with a transportable automated ECLS system. In conclusion, Lifebridge is a safely applicable cardiorespiratory stabilization tool associated with acceptable complication rates. Nevertheless, mortality rates were high in these critically ill patients, especially in those showing high lactate concentrations at admission.

Purpose of Review: Cardiogenic shock remains beside sudden cardiac death the most outcome relevant complication of acute myocardial infarction. Over the last two decades as confirmation of the benefit of early revascularization no further relevant improvement in outcome could be achieved. Biomarkers are important for diagnosis, monitoring, and management in cardiogenic shock patients., Recent Findings: A bunch of different biomarkers have been associated with prognosis in patients with cardiogenic shock. In routine use standard parameters such as serum lactate or serum creatinine are still most important in monitoring these patients. These established markers outperformed novel markers in prognostic impact in recent trials., Summary: Biomarkers serve as important treatment targets and may help physicians in therapeutic decision-making. Furthermore, the complex pathophysiology of cardiogenic shock may be better understood by investigation of different biomarkers.

Rationale: Remote ischemic conditioning (RIC) or ischemic postconditioning (PostC) may protect the myocardium from ischemia-reperfusion injury in patients with ST-segment-elevation myocardial infarction., Objective: To determine whether combined intrahospital RIC and PostC or PostC alone in addition to primary percutaneous coronary intervention (PCI) reduce long-term clinical events after ST-segment-elevation myocardial infarction., Methods and Results: The present study is a post hoc analysis of a prospective trial which randomized 696 ST-segment-elevation myocardial infarction patients with symptoms <12 hours 1:1:1 to either combined RIC and PostC in addition to primary PCI, PostC alone in addition to primary PCI, or conventional PCI (control). Three cycles of RIC were performed by inflation of an upper arm blood pressure cuff for 5 minutes followed by deflation for 5 minutes. PostC was performed after primary PCI via 4 cycles of 30 seconds balloon occlusions followed by 30 seconds of reperfusion. Major adverse cardiac events consisting of cardiac death, reinfarction, and new congestive heart failure were assessed during long-term follow-up. Follow-up data were obtained in 97% of patients in median 3.6 years after the index event (interquartile range, 2.9-4.2 years). Major adverse cardiac events occurred in 10.2% of patients in the combined RIC and PostC group and in 16.9% in the control group (odds ratio, 0.56; 95% CI, 0.32-0.97; P=0.04). The difference was driven by a significantly reduced rate of new congestive heart failure in the RIC and PostC group (2.7% versus 7.8%; odds ratio, 0.32; 95% CI, 0.13-0.84; P=0.02). In contrast, PostC alone did not reduce major adverse cardiac events compared with controls (14.1% versus 16.9%; odds ratio, 0.81; 95% CI, 0.48-1.35; P=0.41), and the reduction of new congestive heart failure was not statistically significant (3.5% versus 7.8%; odds ratio, 0.43; 95% CI, 0.18-1.03; P=0.05)., Conclusions: Cardioprotection by combined intrahospital RIC and PostC in addition to primary PCI significantly reduced the rate of major adverse cardiac events and new congestive heart failure after ST-segment-elevation myocardial infarction., Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02158468.

Aims: Cangrelor has a potentially favorable pharmacodynamic profile in cardiogenic shock (CS). We aimed to evaluate the clinical course of CS patients undergoing percutaneous coronary intervention (PCI) treated with cangrelor., Methods and Results: We retrospectively identified 136 CS patients treated with cangrelor. Patients were 1:1 matched to CS patients from the IABP-SHOCK II trial not receiving cangrelor by age, sex, cardiac arrest, type of myocardial infarction, culprit lesion, glycoprotein IIb/IIIa inhibitor, and oral P2Y 12 -receptor inhibitor and followed-up for 12 months. The study cohort consisted of 88 matched pairs. Thirty-day and 12-month mortality was 29.5% and 34.1% in cangrelor-treated patients and 36.4% and 47.1% in control group (P = 0.34 and P = 0.08, respectively). The rate of definite acute stent thrombosis was 2.3% in both groups. Moderate and severe bleeding events occurred in 21.6% in the cangrelor and 19.3% in the control group (P = 0.71). Patients treated with cangrelor more frequently experienced ≥1 TIMI flow grade improvement during PCI (92.9% vs. 81.2%, P = 0.02)., Conclusion: Cangrelor treatment was associated with similar bleeding risk and significantly better TIMI flow improvement compared with oral P2Y 12 inhibitors in CS patients undergoing PCI. The use of cangrelor in CS offers a potentially safe and effective antiplatelet option and should be evaluated in randomized trials., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aims: To evaluate the prognostic value of intramyocardial haemorrhage (IMH) depicted by T2* imaging for risk stratification in ST-elevation myocardial infarction (STEMI) patients in comparison with established cardiac magnetic resonance (CMR) prognosis markers., Methods and Results: This multicentre study enrolled 264 patients reperfused within 12 h after symptom onset. CMR was performed within the first week after STEMI to assess left ventricular function and infarct characteristics including IMH. The primary endpoint was a composite of death, reinfarction, and new congestive heart failure (major adverse cardiac events, MACE) at 12 months. MACE occurred in 19 patients (7.2%) showing a higher prevalence of IMH when compared with patients without MACE (47% vs. 21%, P = 0.008). The presence of IMH (n = 60, 23%) was independently associated with MACE after adjusting for clinical risk factors [hazard ratio 2.7, 95% confidence intervals (CIs) 1.1-6.6; P = 0.032] or other CMR prognosis markers (hazard ratio 3.1, 95% CI 1.2-7.7; P = 0.013). The addition of IMH to a model of prognostic CMR parameters (ejection fraction, infarct size, and microvascular obstruction) led to net reclassification improvement of 0.42 (95% CI 0.11-0.73, P = 0.009)., Conclusion: IMH assessed by T2* imaging may provide prognostic information that is incremental to other CMR markers of infarct severity and classical clinical risk factors. IMH could therefore be relevant as an important prognostic measure as well as therapeutic target when caring for patients after STEMI.

Background: The aim of our study was the identification of genetic variants associated with postoperative complications after cardiac surgery., Methods: We conducted a prospective, double-blind, multicenter, randomized trial (RIPHeart). We performed a genome-wide association study (GWAS) in 1170 patients of both genders (871 males, 299 females) from the RIPHeart-Study cohort. Patients undergoing non-emergent cardiac surgery were included. Primary endpoint comprises a binary composite complication rate covering atrial fibrillation, delirium, non-fatal myocardial infarction, acute renal failure and/or any new stroke until hospital discharge with a maximum of fourteen days after surgery., Results: A total of 547,644 genotyped markers were available for analysis. Following quality control and adjustment for clinical covariate, one SNP reached genome-wide significance (PHLPP2, rs78064607, p = 3.77 × 10 - 8 ) and 139 (adjusted for all other outcomes) SNPs showed promising association with p < 1 × 10 - 5 from the GWAS., Conclusions: We identified several potential loci, in particular PHLPP2, BBS9, RyR2, DUSP4 and HSPA8, associated with new-onset of atrial fibrillation, delirium, myocardial infarction, acute kidney injury and stroke after cardiac surgery., Trial Registration: The study was registered with ClinicalTrials.gov NCT01067703, prospectively registered on 11 Feb 2010.

Background: Experimental trials suggest improved outcome by mild therapeutic hypothermia for cardiogenic shock after acute myocardial infarction. The objective of this study was to investigate the hemodynamic effects of mild therapeutic hypothermia in patients with cardiogenic shock complicating acute myocardial infarction., Methods: Patients (n=40) with cardiogenic shock undergoing primary percutaneous coronary intervention without classic indications for mild therapeutic hypothermia underwent randomization in a 1:1 fashion to mild therapeutic hypothermia for 24 hours or control. The primary end point was cardiac power index at 24 hours; secondary end points included other hemodynamic parameters and serial measurements of arterial lactate., Results: No relevant differences were observed for the primary end point of cardiac power index at 24 hours (mild therapeutic hypothermia versus control: 0.41 [interquartile range, 0.31-0.52] versus 0.36 [interquartile range, 0.31-0.48] W/m 2 ; P=0.50; median difference, -0.025 W/m 2 ; 95% CI, -0.12 to 0.06). Similarly, all other hemodynamic measurements were not statistically different. Arterial lactate levels at 6, 8, and 10 hours were significantly higher in patients in the mild therapeutic hypothermia group with a slower decline ( P for interaction=0.03). There were no differences in 30-day mortality (60% versus 50%; hazard ratio, 1.27; 95% CI, 0.55-2.94; P=0.55)., Conclusions: In this randomized trial, mild therapeutic hypothermia failed to show a substantial beneficial effect on cardiac power index at 24 hours in patients with cardiogenic shock after acute myocardial infarction., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01890317.

Background: The role of intraaortic balloon counterpulsation (IABP) in cardiogenic shock is still a subject of intense debate despite the neutral results of the IABP-SHOCK II trial (Intraaortic Balloon Pump in Cardiogenic Shock II) with subsequent downgrading in international guidelines. So far, randomized data on the impact of IABP on long-term clinical outcomes in patients with cardiogenic shock complicating acute myocardial infarction are lacking. Furthermore, only limited evidence is available on general long-term outcomes of patients with cardiogenic shock treated by contemporary practice., Methods: The IABP-SHOCK II trial is a multicenter, randomized, open-label trial. Between 2009 and 2012, 600 patients with cardiogenic shock complicating acute myocardial infarction undergoing early revascularization were randomized to IABP versus control., Results: Long-term follow-up was performed 6.2 years (interquartile range 5.6-6.7) after initial randomization. Follow-up was completed for 591 of 600 patients (98.5%). Mortality was not different between the IABP and the control group (66.3% versus 67.0%; relative risk, 0.99; 95% CI, 0.88-1.11; P =0.98). There were also no differences in recurrent myocardial infarction, stroke, repeat revascularization, or rehospitalization for cardiac reasons (all P >0.05). Survivors' quality of life as assessed by the EuroQol 5D questionnaire and the New York Heart Association class did not differ between groups., Conclusions: IABP has no effect on all-cause mortality at 6-year long-term follow-up. Mortality is still very high, with two thirds of patients with cardiogenic shock dying despite contemporary treatment with revascularization therapy., Clinical Trial Registration: URL: https://www., Clinicaltrials: gov/. Unique identifier: NCT00491036.

Background: Left ventricular hypertrophy (LVH) has been suggested as a determinant of outcome in patients with ST-segment elevation myocardial infarction (STEMI). However, available data are inconclusive and the underlying mechanisms remain unclear. Therefore, the aim of this study was to evaluate the impact of LVH on myocardial injury and clinical outcome in a large multicenter STEMI population., Methods: Cardiovascular magnetic resonance was performed in 795 patients within 10 days after STEMI to assess left ventricular (LV) mass and parameters of myocardial injury. Gender-specific cutoff values of indexed LV mass were used to define LVH (67 g/m 2 for men and 61 g/m 2 for women). Rates of major adverse cardiac events (MACE) were determined at 12-month follow-up., Results: LVH was present in 438 patients (55%) and associated with a significantly larger infarct size [18.3% of LV mass (%LV) versus 14.0%LV; p < 0.01], a lower myocardial salvage index (47.8 versus 54.4; p < 0.01), larger extent of microvascular obstruction (0.4 versus 0%LV; p < 0.01) and lower LV ejection fraction (47.9 versus 53.2%; p < 0.01) compared to STEMI patients without LVH. The effect of LVH on LV ejection fraction, infarct size and myocardial salvage index remained statistically significant after adjustment for baseline characteristics (p < 0.01 for all). MACE rates at 12 months were numerically higher in patients with versus without LVH without reaching statistical significance (7.5 versus 5.6%; p = 0.32)., Conclusion: In STEMI patients, LVH is associated with more pronounced structural and functional alterations in CMR imaging as an indicator for adverse clinical outcomes in STEMI survivors.

Background: Mechanisms underlying increased mortality in patients with chronic total occlusion (CTO) of a non-infarct-related artery (non-IRA) are unknown. Cardiac magnetic resonance (CMR) is uniquely suited to provide important mechanistic and pathophysiological information on myocardial damage and reperfusion injury. Aim of this study was to investigate the association of a CTO in a non-IRA with myocardial damage assessed by CMR in patients with ST-elevation myocardial infarction (STEMI)., Methods: STEMI patients (n = 791) were stratified according to the presence of single-vessel disease (SVD), multivessel disease (MVD) without a CTO and MVD with a concomitant CTO in a non-IRA. CMR parameters of myocardial injury and clinical outcome after 12 months (major adverse cardiac events [MACE]: death, re-infarction, readmission for heart failure) were compared between groups., Results: A CTO in a non-IRA was present in 74 patients (9%), whereas 372 (47%) had MVD without a CTO and 345 (44%) had SVD. Patients with a CTO in a non-IRA had significantly larger infarcts, a lower myocardial salvage index and lower left ventricular ejection fraction as compared to patients with SVD or MVD without a CTO. MACE rates were significantly higher in patients with MVD and concomitant non-IRA CTO (9.7%) versus MVD patients without CTO (6.5%) and SVD patients (4.1%) (p = 0.015). MVD with non-IRA CTO was a significant independent predictor of clinical outcome [hazard ratio 2.06, 95% confidence interval 1.11-3.82, p = 0.021]., Conclusion: In patients with acute reperfused STEMI, the presence of a CTO in a non-IRA was associated with larger myocardial damage and increased MACE rates., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Limited data from observational retrospective studies suggest an association between glucose levels and prognosis of patients with cardiogenic shock (CS). The aim of this study was to investigate the prognostic role of glucose at admission in patients with acute myocardial infarction (AMI) complicated by CS included in the largest CS trial to date, the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial., Methods and Results: In the IABP-SHOCK II-trial, patients with CS complicating AMI undergoing early revascularization were randomized to a therapy with vs. without IABP support. Primary and secondary endpoints were mortality within 30 days and 1 year, respectively. Glucose levels were examined at admission. Glucose levels were available in 513 patients. In total, 33.7% of the patients had known diabetes. Patients with diabetes had higher glucose levels compared to those without diabetes (median [interquartile range (IQR)] 13.1 mmol/L [IQR 9.5-18.3] vs. 10.8 mmol/L [IQR 7.8-15.4], p = 0.0003). Patients with glucose concentrations above the median (11.5 mmol/L) had higher 30-day and 1-year mortality compared to those below the median (47.7 vs. 36.5%, p = 0.004; 57.7 vs. 47.1%, p = 0.011, respectively). This negative prognostic impact of increased glucose levels remained significant in multivariate adjustment and was not influenced even after adjustment for the presence or absence of diabetes mellitus., Conclusions: In patients with CS complicating AMI, increased glucose concentration at admission was an independent predictor for mortality at 30-days and 1-year, independently of the diabetic state.

Aims: The most prominent procedure-related and thus modifiable risk factor for contrast-induced acute kidney injury is contrast media (CM) volume. The DyeVert™ system has been designed to reduce the amount of CM. The primary objective of this randomised controlled trial was thus to examine whether the novel DyeVert™ contrast reduction system (Osprey Medical Inc., Minnetonka, MN, USA) leads to a reduction in CM volume in patients undergoing diagnostic coronary angiography., Methods: Patients scheduled for a diagnostic coronary angiogram were randomised to angiography with or without the DyeVert™ system. The primary efficacy endpoint was mean CM volume. Image quality was evaluated by an independent reviewer blinded to treatment allocation., Results: A total of 96 patients underwent randomisation. Baseline characteristics were well balanced between groups. Use of the DyeVert™ system resulted in a significant 41.0% reduction in CM volume (36.9±10.9mL versus 62.5±12.7mL, p<0.001). Image quality using the DyeVert™ system was non-inferior compared to control (p=0.03). There were no device-related adverse events., Conclusions: The DyeVert™ system leads to significant reduction in CM volume in patients undergoing diagnostic coronary angiography, while maintaining image quality., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: This study assessed the prognostic significance of remote zone native T1 alterations for the prediction of clinical events in a population with ST-segment elevation myocardial infarction (STEMI) who were treated by primary percutaneous coronary intervention (PPCI) and compared it with conventional markers of infarct severity., Background: The exact role and incremental prognostic relevance of remote myocardium native T1 mapping alterations assessed by cardiac magnetic resonance (CMR) after STEMI remains unclear., Methods: We included 255 consecutive patients with STEMI who were reperfused within 12 h after symptom onset. CMR core laboratory analysis was performed to assess left ventricular (LV) function, standard infarct characteristics, and native T1 values of the remote, noninfarcted myocardium. The primary endpoint was a composite of death, reinfarction, and new congestive heart failure within 6 months (major adverse cardiac events [MACE])., Results: Patients with increased remote zone native T1 values (>1,129 ms) had significantly larger infarcts (p = 0.012), less myocardial salvage (p = 0.002), and more pronounced LV dysfunction (p = 0.011). In multivariable analysis, remote zone native T1 was independently associated with MACE after adjusting for clinical risk factors (p = 0.001) or other CMR variables (p = 0.007). In C-statistics, native T1 of remote myocardium provided incremental prognostic information beyond clinical risk factors, LV ejection fraction, and other markers of infarct severity (all p < 0.05). The addition of remote zone native T1 to a model of prognostic CMR parameters (ejection fraction, infarct size, and myocardial salvage index) led to net reclassification improvement of 0.82 (95% confidence interval: 0.46 to 1.17; p < 0.001) and to an integrated discrimination improvement of 0.07 (95% confidence interval: 0.02 to 0.13; p = 0.01)., Conclusions: In STEMI patients treated by PPCI, evaluation of remote zone alterations by quantitative noncontrast T1 mapping provided independent and incremental prognostic information in addition to clinical risk factors and traditional CMR outcome markers. Remote zone alterations may thus represent a novel therapeutic target and a useful parameter for optimized risk stratification. (Effect of Conditioning on Myocardial Damage in STEMI [LIPSIA-COND]; NCT02158468)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Aim of the current study was to analyse the impact of atrial fibrillation (AF) on prognosis in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI), which has never been investigated yet., Methods: The current analysis is a substudy of the IABP-SHOCK II trial. Patients were grouped according to the presence or absence of AF. The primary endpoint was all-cause mortality at 30-day follow-up. Secondary endpoints included all-cause mortality, recurrent myocardial infarction, repeat revascularisation, and stroke at 12 months., Results: AF was documented in 28.2% (n = 169) of all 600 patients initially enrolled in the IABP-SHOCK II trial. There were no significant differences with respect to mortality at 30 days and 12 months between patients with and without AF (p = 0.81, p = 0.74). Similarly, the rates of recurrent myocardial infarction, repeat revascularisation, and stroke did not differ between groups (all p > 0.05). There was no interaction of intraaortic balloon counterpulsation (IABP) and no IABP in patients with or without AF with respect to clinical outcome at 30 days and 12 months (p > 0.05)., Conclusion: AF is not associated with clinical outcome at 30 days and 12 months in CS complicating AMI.

Background: Early revascularisation of the culprit lesion is the therapeutic cornerstone in cardiogenic shock complicating acute myocardial infarction. The optimal management of additional non-culprit lesions is unclear. This systematic review and meta-analysis aims to summarise current evidence on the comparison of immediate multivessel percutaneous coronary intervention (MV-PCI) or culprit lesion only PCI with possible staged revascularisation (C-PCI) in patients with cardiogenic shock complicating acute myocardial infarction., Methods: Medical literature databases were screened to identify analyses comparing MV-PCI with C-PCI in patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease. In absence of randomised trials, 10 cohort studies were included in the current meta-analysis. The primary outcome of short-term mortality was assessed at hospital discharge or 30 days after hospital admission. Secondary outcomes were long-term mortality as well as myocardial re-infarction, stroke, acute renal failure, and bleeding at short-term follow-up., Results: Of 6051 patients, 1194 (19.7%) received MV-PCI and 4857 (80.3%) C-PCI. Short-term mortality was 37.5% in patients undergoing MV-PCI compared with 28.8% in C-PCI patients (risk ratio 1.26, 95% confidence interval 1.12-1.41, p=0.001). Long-term mortality ( p=0.77), myocardial re-infarction ( p=0.77), stroke ( p=0.12), acute renal failure ( p=0.17) and bleeding ( p=0.53) did not differ significantly between the two revascularisation groups., Conclusions: Results of this first meta-analysis on the interventional management of patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease do not support MV-PCI over C-PCI. However, possible treatment selection bias in the individual studies must be taken into account.

Background: In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial., Methods: In this multicenter trial, we randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke., Results: At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P=0.01). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P=0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P=0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ significantly between the two groups., Conclusions: Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI. (Funded by the European Union 7th Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).

Objectives: This study evaluated the usability and contrast volume savings of the novel DyeVert™ System., Background: During coronary diagnostic and interventional procedures, a substantial portion of injected contrast does not contribute to vessel imaging due to reflux into the ascending aorta. Contrast volume is the primary physician modifiable risk factor for prevention of contrast-induced acute kidney injury CI-AKI which is a frequent complication in patients undergoing coronary angiographic procedures and is related to increases in morbidity, mortality, and healthcare costs., Methods: In this pilot trial, 44 patients undergoing coronary diagnostic and/or percutaneous coronary intervention (PCI) procedures were enrolled in two centers. All procedures were conducted using a manual manifold injection setup and the DyeVert System, which facilitates the diversion of excess contrast volume prior to injection into the patient. Direct measurements of both the amount of contrast that was attempted to be injected and the actual volume injected into the patient were taken., Results: The difference between the two amounts indicated the volume saved. Procedure types included 34 diagnostic studies and 10 PCI. The mean percent volume saved by the DyeVert System was 47%, with a corresponding P value of <0.0001 achieving the pre-specified level of greater than 15% of contrast media being saved. Mean volume savings were similar for both diagnostic (47 ± 9%) and PCI (50 ± 9%) procedures. Image quality was good in 43/44 (98%) patients., Conclusions: The DyeVert System substantially decreases contrast delivered to patients during diagnostic or interventional coronary procedures while maintaining adequate image quality. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: A significant portion of patients with ST-elevation myocardial infarction (STEMI) display multivessel coronary artery disease. However, data on the association of multivessel coronary artery disease and reperfusion success are scarce. The aim of the current study was to analyse the impact of multivessel coronary artery disease on myocardial salvage assessed by cardiac magnetic resonance imaging in a large unselected cohort of STEMI patients., Methods: STEMI patients ( n=738) included in the AIDA STEMI trial underwent primary percutaneous coronary intervention within 12 hours after symptom onset. Cardiac magnetic resonance imaging was performed 3 days after the index event (interquartile range (IQR) 2-4). The severity of coronary artery disease was graded as single-vessel disease compared to multivessel disease. The primary endpoint was defined as a composite of death, non-fatal myocardial re-infarction and congestive heart failure (major adverse cardiac events) at 12 months., Results: Multivessel coronary artery disease was present in 46.3% ( n=342) of all patients. Patients with multivessel coronary artery disease were older and more often had diabetes in comparison to those with single-vessel disease ( P<0.001 and P=0.005). Angiographic and electrocardiographic reperfusion success defined as Thrombolysis in Myocardial Infarction flow III post-percutaneous coronary intervention and ST-segment resolution ⩾70% were similar between both groups ( P=0.48 and P=0.21). Patients with multivessel disease displayed no significant difference with respect to myocardial salvage index (49.8 (IQR 31.4-71.6) versus 52.7 (IQR 35.1-67.1), P=0.81) in comparison to patients with single-vessel disease. The presence of multivessel coronary artery disease was identified as an independent predictor for the time-dependent occurrence of major adverse cardiac events (hazard ratio 3.25, 95% confidence interval 1.53-6.91, P=0.002)., Conclusion: Although multivessel coronary artery disease is not associated with impaired reperfusion success assessed by cardiac magnetic resonance imaging, patients with multivessel disease are at a high risk of adverse clinical outcomes., Clinical Trial Registration: Clinicaltrials.gov NCT00712101.

Primary percutaneous coronary intervention (PCI) is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) presenting within 12 h of symptom onset. A benefit in the subacute stage is less clear. The aim of the present analysis was to compare myocardial salvage and infarct size between patients with early and late reperfusion after STEMI. We compared cardiac magnetic resonance (CMR) data from a randomized controlled trial (RCT) in STEMI patients presenting within 12 h (n = 695) and a RCT of subacute STEMI patients presenting between 12 and 48 h (n = 93) after symptom onset. CMR imaging was performed 3.9 ± 6.3 days after myocardial infarction. Analyses were performed for an unmatched cohort comprising all patients (n = 788) and a cohort matched for area at risk (n = 186). In the overall cohort, area at risk was similar in both groups [37.1 ± 16.1% of left ventricular mass (%LV) vs. 38.3 ± 16.2%LV; p = 0.50]. Compared to STEMI patients with early reperfusion, patients with late PCI demonstrated larger infarct size (18.0 ± 12.5%LV vs. 28.9 ± 16.9%LV; p < 0.01) and higher extent of microvascular obstruction (1.5 ± 2.9%LV vs. 2.7 ± 4.1%LV; p = 0.01). Myocardial salvage index was significantly smaller in patients with late reperfusion (52.1 ± 25.9 vs. 27.4 ± 26.0; p < 0.01). Analysis of the matched cohorts confirmed the decreased myocardial salvage (p < 0.01) and increased infarct size (p < 0.01) in case of late reperfusion. Compared to patients with timely primary PCI, late reperfusion after STEMI results in decreased myocardial salvage and increased infarct size. However, salvageable myocardium was also found in subacute stages of STEMI.

Background: The current study presents data from a real-world cohort of patients with refractory cardiogenic shock (CS) undergoing extracorporeal life support (ECLS) focusing on the comparison of elderly versus younger patients., Methods and Results: One hundred consecutive patients with refractory CS underwent percutaneous ECLS implantation performed by interventional cardiologists. Follow-up was performed at hospital discharge as well as at a median of 18 months [interquartile range 15-36]. Patients were grouped according to median age (≤60 versus >60 years). ECLS could be weaned in more than half of the cohort (n = 56, 56%) with no differences between the age groups (p = 1.00). Despite similar rates of initial haemodynamic stabilisation, in-hospital mortality was higher in patients >60 years (82% versus 58%, p = 0.02). At mid-term follow-up, only three patients were alive in the group of patients >60 years. This resulted in a mortality rate of 94% in the elderly in comparison with 68% in patients aged ≤60 years (p = 0.001)., Conclusions: Despite a high rate of initial successful ECLS weaning, mid-term prognosis of patients with CS undergoing ECLS above the age of 60 years is poor with superior results in patients aged ≤60 years.

Background: Despite the improvement of therapeutic options for patients in acute myocardial infarction (AMI), cardiogenic shock (CS) remains a complication with high mortality rates. Organ failure centrally determines the prognosis of these high-risk patients. Aim of the current study was to assess the incidence of hypoxic hepatitis (HH) in CS, its laboratory detection evaluating novel and established biomarkers and to estimate the prognostic relevance of HH in current clinical practice., Methods: In 172 patients with CS complicating AMI, blood samples were collected at admission and after 1 day as prespecified subanalysis of the intra-aortic balloon pumping IABP-SHOCK II trial. Classic parameters of HH were measured in addition to argininosuccinate synthase 1 and sulfotransferase isoform SULT2A1 was determined as new biomarker using standard enzyme-linked immunosorbent assay kits. All-cause mortality at 30 days was used for outcome assessment., Results: The overall mortality rate was 40%. The incidence of HH with an increase of aminotransferase levels to be 20 times above the upper normal level was 18%. Patients with HH had a distinctly higher 30-day mortality rate compared to patients without HH (68 vs. 34%; p < 0.001). After multivariable adjustment aspartate-aminotransferase (ASAT) remained an independent predictor of 30-day mortality together with serum lactate and serum creatinine, while the new biomarkers failed to predict outcome. Comparing different liver markers using receiver operating characteristic analysis, ASAT showed the highest area under the curve for the prediction of outcome., Conclusions: HH occurs frequently in CS and is associated with particular poor outcome. As conventional biomarker, ASAT is the strongest laboratory predictor of outcome. ClinicalTrials.gov Identifier: NCT00491036.

Background: Catalytic iron (CI) is unbound ferric iron with the potential to generate reactive oxygen species with further deleterious vascular effects. In acute coronary syndromes, high levels of CI are linked to all-cause mortality. The prognostic impact of CI and iron metabolism in cardiogenic shock (CS) is currently undetermined. Aims of this study were to investigate the prognostic impact of CI and to identify predictors of high CI levels in patients with CS complicating acute myocardial infarction., Methods: The Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial randomized 600 patients with CS to either therapy with intraaortic balloon pump or control. In 185 of these patients, blood samples were systematically collected at baseline and day 3. CI levels were measured using a modified bleomycin detectable iron assay. Furthermore, levels of free hemoglobin, total serum iron, transferrin, total iron binding capacity, ferritin, hepcidin, and transferrin saturation were assessed., Results: Patients with baseline CI levels in the highest quartile had a worse outcome in comparison to patients with lower CI (day 1: HR 1.91 [1.11-3.31], p=0.005; day 3: HR 2.15 [1.06-4.34], p=0.01). In multivariable Cox-regression analysis baseline CI remained an independent predictor of 30-day mortality (HR per 10LOG 2.08 [1.25-3.47], p=0.005). Predictors of CI levels on day 3 were baseline CI, bleeding events, and baseline troponin T., Conclusions: CI levels were associated with increased short-term mortality in CS complicating acute myocardial infarction. High levels of CI at day 3 were associated with bleeding and high troponin levels., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Aims: There is evidence suggesting a positive effect of cigarette smoking on myocardial tissue reperfusion and clinical outcomes in patients with myocardial infarction ('smoker's paradox'). We aimed to evaluate the relationship of smoking with cardiac magnetic resonance (CMR)-determined myocardial salvage and damage as well as clinical outcomes in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI)., Methods and Results: This multicentre study included 727 consecutive STEMI patients reperfused within 12 h after symptom onset. CMR imaging parameters [area at risk (AAR), infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)] were compared according to admission smoking status. Major adverse cardiac event (MACE) rates at 12 months after infarction were compared between groups. Three hundred and thirty-nine (46.6%) patients were current smokers. There was no difference in the extent of AAR [35 (24-47) vs. 37 (27-49) % of left ventricular volume (LV), P = 0.10], IS [16 (8-25) vs. 17 (10-26) %LV, P = 0.21], MSI [53 (29-70) vs. 52 (34-71), P = 0.47], MVO [0 (0-1.7) vs. 0 (0-1.6) %LV, P = 0.91], or in the frequency of IMH (42 vs. 39%, P = 0.58) between smokers and non-smokers. Smokers had lower MACE (3.8 vs. 8.2%, P = 0.01) rates. However, adjustment for differences in baseline risk factors attenuated the association of smoking with MACE markedly (hazard ratio = 0.71, 95% confidence interval 0.36-1.38, P = 0.31)., Conclusion: Smoking is not associated with PPCI efficacy (myocardial salvage) or irreversible myocardial damage in patients with STEMI. The lower MACE rate of smokers was entirely explained by differences in baseline risk characteristics, thus challenging the existence of a smoker's paradox., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Background: In myocardial infarction without cardiogenic shock (CS), the affected coronary vessel has significant influence on the final infarct size and patient prognosis. CS data on this relation are scarce. The objective of this study was to determine the prognostic relevance of the culprit lesion location in patients with CS complicating acute myocardial infarction., Methods: In the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial patients with CS were randomized to therapy with intraaortic balloon pump or control. Additional CS patients not eligible for the randomized trial were included in a registry. We compared the location of the culprit lesions in these patients with regard to the affected coronary vessel [left main (LM), left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA)] and location within the vessel (proximal, mid or distal) regarding short- and long-term outcome., Results: Of 758 patients, the majority had the culprit lesion in the LAD (44 %) compared to RCA (27 %), LCX (19 %) or LM (10 %). Proximal lesions were more frequent than mid or distal culprit lesions (60 vs. 27 vs. 13 %, p < 0.001). No differences were observed for mortality with respect to either culprit vessel (log-rank p value = 0.54). In contrast, a higher mortality was observed for patients with distal culprit lesions after 1 year (log-rank p value = 0.04). This difference persisted after multivariable adjustment (hazard ratio for distal lesions 1.40; 95 % confidential interval 1.03-1.90; p = 0.03)., Conclusion: For patients with CS complicating myocardial infarction, the culprit vessel seems to be unrelated with mortality whereas distal culprit lesions may have a worse outcome.

Data on the impact of initial Thrombolysis In Myocardial Infarction (TIMI) flow in the culprit coronary artery on myocardial damage after ST-elevation myocardial infarction (STEMI) are limited. Aim of this multicenter study was, therefore, to elucidate the impact of TIMI flow grade before percutaneous coronary intervention (PCI) on infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) assessed by cardiac magnetic resonance (CMR) imaging in patients with STEMI. We enrolled 738 patients with STEMI reperfused by primary PCI within 12 hours after symptom onset at 8 centers. Impaired coronary flow was defined as an initial coronary TIMI flow grade ≤1, whereas preserved coronary flow was defined as an initial coronary TIMI flow grade ≥2. CMR was performed in median 3 days (interquartile range 2 to 4 days) after infarction using a standardized infarction protocol. IS, MVO, and MSI were determined in central core laboratory-masked analyses. The primary clinical end point of the study was the time to major adverse cardiac events defined as death, reinfarction, and new onset of heart failure within 12 months after infarction. TIMI flow ≤1 before PCI was present in 507 patients (68.7%) and was significantly associated with larger IS (19% left ventricular [LV] vs 9% LV; p <0.001), less MSI (0.46 vs 0.65; p <0.001), reduced left ventricular ejection fraction (49% vs 55%; p <0.001), and a higher extent of MVO (0.6% LV vs 0.0% LV; p <0.001). Moreover, TIMI flow before PCI was identified as an independent predictor of IS, MVO, and MSI. However, there were no significant differences in major adverse cardiac event rates between groups (6.1% vs 7.5%; p = 0.48). In conclusion, TIMI flow pre-PCI is reversely associated with myocardial injury and is an independent predictor of myocardial damage assessed by CMR., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Several studies in patients with acute myocardial infarction (AMI) without cardiogenic shock (CS) indicate a better survival in smokers, the so called "smoker's paradox". For CS, this relationship has not been investigated so far in the primary percutaneous coronary intervention (PCI) era., Methods: In a predefined substudy of the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial and its accompanying registry including patients with CS complicating AMI we investigated differences in outcome of smokers compared to non-smokers. All-cause-mortality at 1year was used as primary endpoint., Results: Of 772 patients with available smoking status 263 patients were smokers (34%). Smokers were more often male (79% vs. 65%; p<0.001), of younger age (61 [interquartile range IQR 52-70] vs. 73 [IQR 64-79] years; p<0.001), had less comorbidity including arterial hypertension (62% vs. 71%; p=0.007) and diabetes mellitus (26% vs. 38%; p<0.001) and had lower levels of serum creatinine (13% vs. 25%; p<0.001). There was no significant difference between the 2 groups regarding left ventricular ejection fraction, initial revascularization strategy or use of IABP. Smokers had lower rates of mortality at 12months in univariable analysis (43% vs. 59%; p<0.001) but not after adjustment for important confounders using Cox-regression analysis (hazard ratio 0.77, 95% confidence interval 0.59-1.03; p=0.08)., Conclusion: Smoking is not predictive of outcome in patients with CS complicating AMI. The observed survival benefit in univariable analysis seems to be explained by the younger age and lower risk profile of smokers., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Percutaneous edge-to-edge mitral valve reconstruction (PMVR) has emerged as a treatment option in patients with severe mitral regurgitation not considered suitable candidates for surgery. The majority of PMVR procedures are performed under general anesthesia (GA), although deep sedation (DS) appears to be an attractive alternative. We thus sought to assess the impact on intensive care unit (ICU) length of stay, efficacy, and safety of DS in comparison to GA in patients undergoing PMVR using the MitraClip(®) system., Methods: Sixty consecutive patients underwent PMVR procedures at two centers. The first 30 patients were treated by GA followed by 30 patients undergoing DS under different settings. The primary clinical endpoint was ICU length of stay. The primary efficacy endpoint included procedural success and procedural duration. The safety endpoint was defined as a composite of death, stroke, cardiogenic shock, moderate and severe bleeding as well as pneumonia., Results: The ICU length of stay was significantly shorter in the DS group in comparison to GA patients (p = 0.001). The hospital length of stay did not differ following DS in comparison to GA (p = 0.96). Procedural success was high in both groups (100 versus 96.7 %, p = 0.34) at similar procedural duration time (p = 0.60). No difference between GA and DS was observed with respect to the occurrence of the combined safety endpoint (p = 0.47)., Conclusions: In comparison to GA, DS reduces the ICU length of stay in PMVR without negative effects on safety and efficacy. Prospective randomized trials are needed to confirm these findings.

Objectives: Assessment of aortic regurgitation (AR) immediately after transcatheter aortic valve replacement (TAVR) is essential to guide further intervention in cases of relevant AR. It was the aim of this study to identify a simple and reproducible hemodynamic parameter for the assessment of AR., Background: Relevant AR after TAVR is present in up to 21% of cases and might be associated with adverse long-term outcomes., Methods: Three hundred sixty-two consecutive patients who were treated with TAVR for symptomatic aortic valve stenosis were analyzed. AR was assessed by aortic root angiography according to the Sellers classification. For hemodynamic evaluation, the diastolic pressure-time (DPT) index was calculated after TAVR: the area between the aortic and left ventricular pressure-time curves was measured during diastole and divided by the duration of diastole to calculate the DPT index. The DPT index was finally adjusted for the respective systolic blood pressure: DPT indexadj = (DPT index/systolic blood pressure) × 100., Results: Patients with angiographically nonrelevant AR (grade <2) had higher DPT indexadj (30.7 ± 6.8) compared with those with relevant AR (grade ≥2) (26.2 ± 5.8) (p < 0.05). Patients with DPT indexadj ≤27.9 had significantly higher 1-year mortality risk in comparison with those with DPT indexadj >27.9: 41.4% versus 13.5% (hazard ratio: 3.8; 95% confidence interval: 2.4 to 5.9; p [log rank-test] < 0.001). In multivariate regression analysis, DPT indexadj ≤27.9 was the strongest independent predictor of 1-year mortality (hazard ratio: 2.5; 95% confidence interval: 1.8 to 3.7; p < 0.001)., Conclusions: DPT indexadj is a simple, investigator-independent parameter that should be considered to differentiate between relevant and nonrelevant AR after TAVR., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Cardiac arrest is the major cause of sudden death in developed countries. Extracorporeal cardiopulmonary resuscitation (ECPR) employs extracorporeal membrane oxygenation (ECMO) in patients without return of spontaneous circulation (ROSC) by conventional cardiopulmonary resuscitation (CPR). Aim of the current study was to assess short- and long-term outcome in patients treated with ECPR in our tertiary center and to identify predictors of outcome., Methods: We retrospectively collected data of all patients treated with ECPR at our institution from 2002 to 2013. Outcome was assessed according to patient records; good neurological outcome was defined as cerebral performance category 1 or 2. Quality of life data was collected using EQ-5 questionnaire. Uni- and multivariate analysis was applied to identify predictors of outcome., Results: One-hundred and seventeen patients were included into the study. Weaning from ECMO was successful in 61 (52 %) patients. Thirty-day survival endpoint was achieved by 27 (23 %) patients. Good neurological outcome was present in 17 (15 %) patients. Multivariate analysis revealed baseline serum lactate as the strongest predictor of outcome, whereas age and out-of-hospital CPR did not predict outcome. The optimal lactate cut-off to discriminate outcome was determined at 4.6 mmol/l [HR 3.55 (2.29-5.49), p < 0.001, log-rank test]., Conclusion: ECPR represents a treatment option in patients without ROSC after conventional CPR rescuing 15 % of patients with good neurological outcome. Serum lactate may play a crucial role in patient selection for ECPR.

Background: In acute myocardial infarction complicated by cardiogenic shock (CS), up to 80% of patients present with multivessel coronary artery disease. Currently, the best revascularization strategy is unknown. Therefore, a prospective randomized adequately powered clinical trial is warranted., Study Design: The CULPRIT-SHOCK study is a 706-patient controlled, international, multicenter, randomized, open-label trial. It is designed to compare culprit lesion only percutaneous coronary intervention (PCI) with possible staged non-culprit lesion revascularization versus immediate multivessel PCI in patients with CS complicating acute myocardial infarction. Patients will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoint of CULPRIT-SHOCK is 30-day mortality and severe renal failure requiring renal replacement therapy. Secondary outcome measures such as hemodynamic, laboratory, and clinical parameters will serve as surrogate endpoints for prognosis. Furthermore, an intermediate- and long-term follow-up at 6 and 12 months will be performed. Safety endpoints include the assessment of bleeding and stroke., Conclusions: The CULPRIT-SHOCK trial will address the question of optimal revascularization strategy in patients with multivessel disease and acute myocardial infarction complicated by CS., (Copyright © 2015 Elsevier Inc. All rights reserved.)