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Myocardial recovery is the primary goal of temporary mechanical circulatory support (tMCS) in patients with acute myocardial infarction cardiogenic shock (AMI CS). Recovery is observed in approx 30% of patients treated with high flow transaortic devices, while chances of weaning dramatically decrease after durable LVAD implantation. Early clinical parameters associated with recovery that may be target of medical intervention in CS patients are largely unknown. The aim of the study was to identify simple clinical parameters associated with myocardial recovery in AMI CS patients on tMCS. Observational study on all AMI CS patients treated with Impella 5.0 or 5.5 at a referral center from 01/18 to 09/22. 35 patients with AMI CS (71% of the whole Impella 5.0/5.5 population of the study period) were included: 33 had Impella 5.0 and 2 Impella 5.5. 31 (89%) were male and mean age was 61±11 years. Median Impella support duration was 12 days (min 4 - max 39): 12 patients had myocardial recovery, 9 were bridged to LVAD, 6 to heart transplant and 8 died on tMCS. Hospital survival was 69%. Clinical parameters tested for recovery are shown in table 1: patients who received complete percutaneous revascularization had higher chances of recovery (75% vs 39%, p=0.04), while late revascularization led to a lower recovery rate (16% vs 61%, p=0.02). Longer duration of tMCS before upgrade to Impella 5.0/5.5 was associated with lower recovery rate (p=0.03). LV function improvement within the first 7 days of treatment was present in 75% of patients who experienced recovery compared to 21% of no-recovery group, p=0.01. Patients weaned from MCS following myocardial recovery had no re-hospitalization for heart failure. In patients with AMI CS, prompt and complete revascularization regardless the culprit lesion and early upgrade to full hemodynamic support are key factors to increase myocardial recovery rate. Patients can be evaluated with respect to their recovery chances in the first 7-10 days of support. [ABSTRACT FROM AUTHOR]

To highlight the feasibility of positron emission tomography (PET) imaging for the assessment of myocardial viability (MV) during Impella support, as an alternative to cardiac MRI (CMR), which is precluded for patients on temporary and durable mechanical circulatory support (MCS). We included patients who underwent metabolic myocardial PET while receiving Impella for cardiogenic shock from 2019-2022 in San Raffaele Hospital (Milan, Italy). All patients received PET during support, 60' after 18-fluorodesoxyglucose injection, following oral glucose load and insulin infusion. Ventricular segments were considered viable with uptake >50% of the maximum uptake value. Five patients were included (age 69 [48-76] years; 100% males), in 67% CS was related to AMI treated with primary PCI. LVEF was 15 (15-15)% and NT-proBNP 11061 (5865-22512) pg/L. All were spontaneously breathing and transfer to Nuclear Medicine was uneventful in all cases. PET was acquired 11 (7-22) days after Impella insertion. PET image quality was excellent despite the presence of Impella, the patients' arms position along the flanks and the high baseline blood glucose due to patients' labile metabolic profile and critical state (pre-injection glucose 180 [170-180] mg/mL). PET properly discriminated vital from non-vital segments: we found only 8 (7-9) viable segments out of 17 total segments per patient; LV necrotic area per patient was high at 53 (47-59)%. Impella duration was 22 (14-23) days. In-hospital death was 20%; LVAD implant rate was 60% (2 BTT; 1 DT). Evaluation of MV is useful in the process of myocardial recovery to consider a second step of revascularization, bridging treatments or definitive heart replacement therapies. In our experience, PET imaging was feasible during Impella support, when CMR assessment was not possible. This preliminary single‐center experience suggests the feasibility of PET imaging in patients with tMCS to obtain objective evidence of myocardial viability. [ABSTRACT FROM AUTHOR]

Implantation of durable left ventricular assist device (LVAD) in cardiogenic shock (CS) patients after acute myocardial infarction (AMI) poses specific challenges (small left ventricular size, acute infarct area, need for antithrombotic therapy, status Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 with impaired organ function and derangements in coagulation and inflammatory parameters) which may affect outcomes. We reviewed data of all AMI-CS patients who were implanted LVAD after Impella support at a referral center with the aim to analyze feasibility, timing, and outcomes of durable LVAD implantation after tMCS with Impella due to AMI-CS. Twenty-one patients were treated between 2013 and 2023: all were in Society for Cardiovascular Angiography & Interventions (SCAI) class D-E and INTERMACS 1-2 at presentation, median LV ejection fraction (EF) and LV end-diastolic diameter (EDD) were 15 (10-20)% and 57 (54-60) mm, respectively. Eleven patients (52%) were supported with Impella CP, seven with Impella 5.0 (33%), and three (14%) with Impella 2.5. Axillary cannulation was performed in nine patients (43%). Five patients (24%) had concomitant venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Median duration of Impella support was 12 (8-14) days. Overall, the use of Impella was characterized by low rate of complications and allowed successful bridge to durable LVAD in all patients, with 100% 30 day survival rate., Competing Interests: Disclosure: M.P., S. Alticcio, P.N., A.O., and A.M.S. received speaker fee by Abiomed GmbH. M.P. received consultancy fee by Abiomed GmbH. The other authors have no conflicts of interest to report., (Copyright © ASAIO 2024.)

Aims: Impella malrotation-inlet orientation away from the left ventricular (LV) apex with normal console waveforms and proper device depth-is commonly observed and possibly associated worse haemodynamics. This study aimed to characterize the haemodynamic consequences of Impella malrotation in cardiogenic shock (CS) patients., Methods and Results: We included 100 CS patients (60 ± 12 years; 79.0% males) with available echocardiography during Impella support and pulmonary artery catheter assessment before and during (at 48 h) Impella support. Impella malrotation was identified in 36%. At 48 h, malrotation patients had higher pulmonary artery wedge pressure (PAWP, 16.0 ± 8.2 vs. 13.0 ± 4.6 mmHg; P = 0.033), higher systolic pulmonary artery pressure (PAP, 35.0 ± 11.3 vs. 29.5 ± 9.0 mmHg; P = 0.015), higher diastolic-PAP (19.3 ± 8.1 vs. 15.1 ± 6.1 mmHg; P = 0.007), higher mean-PAP (25.7 ± 9.1 vs. 20.8 ± 6.8 mmHg; P = 0.005), higher right atrial pressure (10.3 ± 4.8 vs. 7.7 ± 4.3 mmHg; P = 0.009), higher pulmonary vascular resistance index (4.78 ± 2.75 vs. 3.49 ± 1.94 WUm 2 ; P = 0.020) and higher pulmonary artery elastance (0.91 ± 0.60 vs. 0.67 ± 0.40 mmHg/mL; P = 0.045). Serum lactate at 48 h was higher in malrotation patients (6.63 ± 6.25 vs. 3.60 ± 4.21 mmol/L; P = 0.004). Malrotation patients presented larger LVEDD during support (52 ± 10 vs. 46 ± 11 mm; P = 0.006), higher rates of aortic regurgitation (AR, 86 vs. 56%; P = 0.004) and higher increase in AR severity (+0.94 ± 0.92 vs. + 0.46 ± 0.95; P = 0.016). No significant differences were found in major adverse outcomes., Conclusions: In CS patients, Impella malrotation is associated with suboptimal unloading of the LV, worse pulmonary haemodynamics and worse indexes of right ventricular afterload., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Aims: The initial bundle of cares strongly affects haemodynamics and outcomes in acute decompensated heart failure cardiogenic shock (ADHF-CS). We sought to characterize whether 24 h haemodynamic profiling provides superior prognostic information as compared with admission assessment and which haemodynamic parameters best predict in-hospital death., Methods and Results: All patients with ADHF-CS and with available admission and 24 h invasive haemodynamic assessment from two academic institutions were considered for this study. The primary endpoint was in-hospital death. Regression analyses were run to identify relevant predictors of study outcome. We included 127 ADHF-CS patients [65 (inter-quartile range 52-72) years, 25.2% female]. Overall, in-hospital mortality occurred in 26.8%. Non-survivors were older, with greater CS severity. Among admission variables, age [odds ratio (OR) = 1.06; 95% confidence interval (CI): 1.02-1.11; P adj  = 0.005] and CPI RAP (OR = 0.62 for 0.1 increment; 95% CI: 0.39-0.95; P adj  = 0.034) were found significantly associated with in-hospital death. Among 24 h haemodynamic univariate predictors of in-hospital death, pulmonary elastance (PaE) was the strongest (area under the curve of 0.77; 95% CI: 0.68-0.86). PaE (OR = 5.98; 95% CI: 2.29-17.48; P adj  < 0.001), pulmonary artery pulsatility index (PAPi, OR = 0.77; 95% CI: 0.62-0.92; P adj  = 0.013) and age (OR = 1.06; 95% CI: 1.02-1.11; P adj  = 0.010) were independently associated with in-hospital death. Best cut-off for PaE was 0.85 mmHg/mL and for PAPi was 2.95; cohort phenotyping based on these PaE and PAPi thresholds further increased in-hospital death risk stratification; patients with 24 h high PaE and low PAPi exhibited the highest in-hospital mortality (56.2%)., Conclusions: Pulmonary artery elastance has been found to be the most powerful 24 h haemodynamic predictor of in-hospital death in patients with ADHF-CS. Age, 24 h PaE, and PAPi are independently associated with hospital mortality. PaE captures ventricular (RV) afterload mismatch and PAPi provides a metric of RV adaptation, thus their combination generates four distinct haemodynamic phenotypes, enhancing in-hospital death risk stratification., (© 2024 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Aims: Artificial intelligence (AI) has emerged as a potential useful tool to support clinical treatment of heart failure, including the setting of mechanical circulatory support (MCS). Modern Impella pumps are equipped with advanced technology (SmartAssist), enabling real-time acquisition and display of data related to both pump performance and the patient's haemodynamic status. These data emerge as an 'ideal' source for data-driven AI applications to predict the clinical course of an ongoing therapeutic protocol. Yet, no evidence of effective application of AI tools in the setting of Impella support is available. On this background, we aimed at identifying possible future applications of AI-based tools in the setting of temporary MCS with an Impella device., Methods: We explored the state of research and development at the intersection of AI and Impella support and derived future potential applications of AI in routine Impella clinical management., Results: We identified different areas where the future implementation of AI tools may contribute to addressing important clinical challenges in the setting of Impella support, including (i) early identification of the best suited pathway of care according to patients' conditions at presentation and intention to treat, (ii) prediction of therapy outcomes according to different possible therapeutic actions, (iii) optimization of device implantation procedures and evaluation of proper pump position over the whole course of support and (iv) prevention and/or rationale management of haemocompatibility-related adverse events. For each of those areas, we discuss the potential advantages, challenges and implications of harnessing AI-driven insights in the setting of MCS with an Impella device., Conclusions: Temporary MCS with an Impella device has great potential to benefit from the integration of AI-based tools. Such tools may indeed translate into groundbreaking innovation supporting clinical decision-making and therapy regulation, in particular in complex scenarios such as the multidevice MCS strategy., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Formal assessment of myocardial viability (MV) is challenging in acute myocardial infarction-related cardiogenic shock (AMI-CS) patients receiving Impella mechanical circulatory support, as the cardiac magnetic resonance gold standard technique is not feasible due to the metallic components of the device. 18-fluorodesoxyglucose metabolic myocardial positron emission tomography ( 18 FDG-PET) may represent a valid and feasible alternative to obtain semi-quantitative and objective evidence of MV during Impella support. We hereby report the first series of sequential AMI-CS patients who received 18 FDG-PET scanning to assess MV during Impella support to demonstrate the safety and feasibility of this approach. In this cohort no adverse events occurred during 18 FDG-PET scans, and all images were of excellent quality. This study provides a pragmatic guidance on how to perform this imaging modality during Impella support and finally confirms the safety and feasibility of this advanced imaging method also in this vulnerable cohort of patients., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Objectives: Hypotension is associated with adverse outcomes in critically ill and perioperative patients. However, these assumptions are supported by observational studies. This meta-analysis of randomized controlled trials aims to compare the impact of lower versus higher blood pressure targets on mortality., Data Sources: We searched PubMed, Cochrane, and Scholar from inception to February 10, 2024., Study Selection: Randomized trials comparing lower versus higher blood pressure targets in the management of critically ill and perioperative settings., Data Extraction: The primary outcome was all-cause mortality at the longest follow-up available. This review was registered in the Prospective International Register of Systematic Reviews, CRD42023452928., Data Synthesis: Of 2940 studies identified by the search string, 28 (12 in critically ill and 16 in perioperative settings) were included totaling 15,672 patients. Patients in the low blood pressure target group had lower mortality (23 studies included: 1019/7679 [13.3%] vs. 1103/7649 [14.4%]; relative risk 0.93; 95% CI, 0.87-0.99; p = 0.03; I2 = 0%). This corresponded to a 97.4% probability of any increase in mortality with a Bayesian approach. These findings were mainly driven by studies performed in the ICU setting and with treatment lasting more than 24 hours; however, the magnitude and direction of the results were similar in the majority of sensitivity analyses including the analysis restricted to low risk of bias studies. We also observed a lower rate of atrial fibrillation and fewer patients requiring transfusion in low-pressure target groups. No differences were found in the other secondary outcomes., Conclusions: Based on pooled randomized trial evidence, a lower compared with a higher blood pressure target results in a reduction of mortality, atrial fibrillation, and transfusion requirements. Lower blood pressure targets may be beneficial but there is ongoing uncertainty. However, the present meta-analysis does not confirm previous findings and recommendations. These results might inform future guidelines and promote the study of the concept of protective hemodynamics., Competing Interests: Dr. Lee’s institution received funding from the Canadian Institutes of Health Research; he received funding from Fonds de Recherche Quebec—Sante. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Introduction: Exogenous haptoglobin administration may enhance plasma-free hemoglobin (pfHb) clearance during hemolysis and reduce its end-organ damage: we systematically reviewed and summarized available evidence on the use of haptoglobin as a treatment for hemolysis of any cause., Methods: We included studies describing haptoglobin administration as treatment or prevention of hemolysis-related complications. Only studies with a control group reporting at least one of the outcomes of interest were included in the quantitative synthesis. Primary outcome was the change in pfHb concentration 1 h after haptoglobin infusion., Results: Among 573 articles, 13 studies were included in the review (677 patients, 52.8% received haptoglobin). Median initial haptoglobin intravenous bolus was 4,000 (2,000, 4,000) IU. Haptoglobin was associated with lower pfHb 1 h (SMD -11.28; 95% CI: -15.80 to -6.75; p &lt; 0.001) and 24 h (SMD -2.65; 95% CI: -4.73 to -0.57; p = 0.001) after infusion. There was no difference in all-cause mortality between haptoglobin-treated patients and control group (OR 1.41; 95% CI: 0.49-4.95; p = 0.520). Haptoglobin was associated with a lower incidence of acute kidney injury (OR 0.64; 95% CI: 0.44-0.93; p = 0.020). No adverse events or side effects associated with haptoglobin use were reported., Conclusions: Haptoglobin administration has been used in patients with hemolysis from any cause to treat or prevent hemolysis-associated adverse events. Haptoglobin may reduce levels of pfHb and preserve kidney function without increase in adverse events., (© 2024 S. Karger AG, Basel.)

Aims: Impella 5.0 and 5.5 are promising low-invasive left ventricle (LV) temporary mechanical circulatory supports (tMCS) for cardiogenic shock due to LV mechanical unloading and are paired with powerful hemodynamic support. This study aimed to analyze data and destinies of patients supported with Impella 5.0/5.5 at a national referral center for cardiogenic shock and to assess the parameters associated with myocardial recovery and successful weaning., Methods: A single-center observational study was conducted on all patients treated with Impella 5.0 or 5.5 from March 2018 to July 2023., Results: A total of 59 patients underwent Impella 5.0/5.5 implantation due to profound cardiogenic shock, with acute myocardial infarction being the most frequent cause of shock (42 patients, 71%). The median duration of Impella support was 13 days (maximum duration of 52 days). Axillary cannulation was feasible in almost all patients, and 36% were mobilized during support. A total of 44 patients (75%) survived to the next therapy/recovery: 21 patients experienced recovery and 15 and 8 were bridged to long-term LVAD and heart transplantation, respectively. The global survival rate was 66%. The predictors of native heart recovery at multivariate analysis were the number of days on tMCS before upgrade to Impella 5.0/5.5 [hazard ratio (HR) 0.68 (0.51-9) p  = 0.0068] and improvement of LVEF within the first 7-10 days of support [HR 4.72 (1.34-16.7), p  = 0.016]., Conclusions: Transcatheter systems such as Impella 5.0/5.5 revolutionized the field of tMCS. Myocardial recovery is the primary clinical target. Its prognostication and promotion are key to ensure the most proficuous course for each patient from cardiogenic shock to long-term event-free survival., Competing Interests: MP, AO, SA, LB, PN, EF, and AS received speaker fees from Abiomed GmbH. MP received consultancy fees from Abiomed GmbH. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Pieri, Ortalda, Altizio, Bertoglio, Nardelli, Fominskiy, Lapenna, Ajello and Scandroglio.)