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Cardiogenic shock is a complex syndrome defined by systemic hypoperfusion and inadequate cardiac output arising from a wide array of underlying causes. Although the understanding of cardiogenic shock epidemiology, specific subphenotypes, haemodynamics, and cardiogenic shock severity staging has evolved, few therapeutic interventions have shown survival benefit. Results from seminal randomised controlled trials support early revascularisation of the culprit vessel in infarct-related cardiogenic shock and provide evidence of improved survival with the use of temporary circulatory support in selected patients. However, numerous questions remain unanswered, including optimal pharmacotherapy regimens, the role of mechanical circulatory support devices, management of secondary organ dysfunction, and best supportive care. This Review summarises current definitions, pathophysiological principles, and management approaches in cardiogenic shock, and highlights key knowledge gaps to advance individualised shock therapy and the evidence-based ethical use of modern technology and resources in cardiogenic shock., Competing Interests: Declaration of interests MA reports speaker honoraria from Abbott Vascular and Edwards Lifesciences, unrelated to the submitted work. RL reports research grants from Medtronic and LivaNova paid to their institution; consulting fees from Medtronic and LivaNova paid to their institution; speaker honoraria from Abiomed; travel support from Medtronic and LivaNova; lab supplies from Medtronic, unrelated to the submitted work; and is an advisory board member for Eurosets and Xenios (fees paid to institution). AM reports research grants from Roche, 4TEEN4, Sphyngotec, Abbott Diagnostics, and Windtree; consulting fees from Roche, Adrenomed, Corteria, and Fire1; speaker honoraria from Merck, Novartis, Roche, and Bayer; and lab supplies by Sphyngotec, unrelated to the submitted work; and is an advisory board member for Secret-HF, S-Form Pharma, and Implicity. DAM reports research grants from Abbott Laboratories, Abiomed, Amgen, Anthos Therapeutics, Arca Biopharma, AstraZeneca, Daiichi Sankyo, Intarcia, Janssen, Merck & Co, Novartis, Pfizer, Poxel, Regeneron, Roche Diagnostics, Siemens, Softcell Medical, and Zora Biosciences (paid to the institution); consulting fees from Abbott Laboratories, Arca Biopharma, Merck & Co, Novartis, Regeneron, and Roche Diagnostics unrelated to the submitted work; and is an advisory board member for InCarda Therapeutics. DB reports a research grant from LivaNova paid to their institution; consulting fees from LivaNova, Xenios, Medtronic, Inspira, Cellenkos, and HBOX Therapies; and payment from UpToDate, unrelated to the submitted work. AC reports speaker honoraria from Getinge, Baxter, and Xenios unrelated to the submitted work. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Cardiogenic shock (CS) is a severe complication of acute myocardial infarction (AMI) with high mortality rates. While mechanical circulatory support devices like intra-aortic balloon pump (IABP) and Impella are used to manage CS, their comparative effectiveness remains unclear. This meta-analysis aims to evaluate the safety and efficacy of Impella in the treatment of AMI-associated CS., Methods: A comprehensive literature search was performed across PubMed, EMBASE, Google Scholar, SCOPUS, and Web of Science. The primary efficacy endpoint was 6-month all-cause mortality. Secondary efficacy endpoints included 30-day mortality, major bleeding, limb ischemia, sepsis, and left ventricular ejection fraction. Pooled odds ratios (OR) and standardized mean difference (SMD) with 95% confidence intervals (CIs) were calculated using the random-effects model via Revman version 5.4. Statistical significance was determined at P < .05., Results: Four RCTs with a total of 442 patients were included in this meta-analysis. The pooled analysis showed that the odds of 6-month all-cause mortality were significantly lower with Impella compared to standard of care (OR: 0.64, 95% CI: 0.43-0.95; P value: .03). However, 30-day mortality reported no statistically significant difference between the 2 groups (OR: 1.03; 95% CI: 0.43-2.48; P = .95). Our analysis found that the use of impella is associated with a statistically significant increase in the odds of major bleeding (OR: 3.61; 95% CI: 1.14-11.40; P = .03), limb ischemia (OR: 4.91; 95% CI: 1.37-17.59; P = .01), and sepsis (OR: 2.75; 95% CI: 1.25-6.08; P = .01). No statistical significance was found in left ventricular ejection fraction at follow-up between the 2 groups (SMD: -0.35; 95% CI: -0.78 to 0.07; P = .11)., Conclusion: Impella significantly reduces 6-month all-cause mortality in patients with CS following AMI compared to standard of care. However, this survival benefit is offset by a substantial increase in major bleeding, limb ischemia, and sepsis risks associated with Impella. Future large scale trials are needed to validate these findings and refine clinical guidelines for the optimal use of Impella in treating CS., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

The prognosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is reported to be as worse as myocardial infarction with obstructive coronary arteries. However, its mechanical complications are still poorly understood. A 71-year-old woman developed MINOCA after ascending aortic replacement surgery. During treatment, the patient experienced cardiogenic shock due to a ventricular septal rupture (VSR). The introduction of Impella devices reduced the left-to-right shunt and improved the patient's hemodynamics. Finally, a scheduled surgical repair was performed under stable conditions. In this report, we focused on the pathophysiology of MINOCA-related VSR and discussed the effectiveness of Impella devices as a bridge to surgical repair and circulatory backup during the perioperative period.

Background and Aims: Cardiogenic shock (CS) remains the primary cause of in-hospital death after acute coronary syndromes (ACS), with its plateauing mortality rates approaching 50%. To test novel interventions, personalized risk prediction is essential. The ORBI (Observatoire Régional Breton sur l'Infarctus) score represents the first-of-its-kind risk score to predict in-hospital CS in ACS patients undergoing percutaneous coronary intervention (PCI). However, its sex-specific performance remains unknown, and refined risk prediction strategies are warranted., Methods: This multinational study included a total of 53 537 ACS patients without CS on admission undergoing PCI. Following sex-specific evaluation of ORBI, regression and machine-learning models were used for variable selection and risk prediction. By combining best-performing models with highest-ranked predictors, SEX-SHOCK was developed, and internally and externally validated., Results: The ORBI score showed lower discriminative performance for the prediction of CS in females than males in Swiss (area under the receiver operating characteristic curve [95% confidence interval]: 0.78 [0.76-0.81] vs. 0.81 [0.79-0.83]; P =.048) and French ACS patients (0.77 [0.74-0.81] vs. 0.84 [0.81-0.86]; P = .002). The newly developed SEX-SHOCK score, now incorporating ST-segment elevation, creatinine, C-reactive protein, and left ventricular ejection fraction, outperformed ORBI in both sexes (females: 0.81 [0.78-0.83]; males: 0.83 [0.82-0.85]; P < .001), which prevailed following internal and external validation in RICO (females: 0.82 [0.79-0.85]; males: 0.88 [0.86-0.89]; P < .001) and SPUM-ACS (females: 0.83 [0.77-0.90], P = .004; males: 0.83 [0.80-0.87], P = .001)., Conclusions: The ORBI score showed modest sex-specific performance. The novel SEX-SHOCK score provides superior performance in females and males across the entire spectrum of ACS, thus providing a basis for future interventional trials and contemporary ACS management., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

BACKGROUND Takotsubo syndrome, or stress-induced cardiomyopathy, is a rare but serious condition that mimics myocardial infarction and can cause temporary cardiac dysfunction in the absence of coronary artery disease. General anesthesia can make diagnosis more challenging. Although it has already been described in a context of solid organ transplantation, takotsubo syndrome remains under-reported in lung transplantation, necessitating awareness to avoid diagnostic and management delays. CASE REPORT We report a case of takotsubo syndrome in a 54-year-old woman undergoing pulmonary transplantation for end-stage chronic obstructive pulmonary disease. Preoperative evaluations showed no cardiac pathology. During surgery, she developed severe left ventricular failure with ST-segment elevations and diffuse hypokinesia, leading to cardiogenic shock and multiorgan dysfunction. Delayed diagnosis of takotsubo syndrome and late initiation of veno-arterial extracorporeal membrane oxygenation worsened her condition. Postoperatively, she developed lung abscesses, broncho-cutaneous fistula, and hemorrhagic shock, resulting in a prolonged intensive care unit stay. Two years after the transplant, left ventricular dysfunction was persistent, significantly affecting her quality of life. CONCLUSIONS This case report highlights the importance of awareness of takotsubo syndrome associated with lung transplantation, particularly in at-risk patients. Indeed, early diagnosis and management of this cardiomyopathy are crucial for improving outcomes. Multimodal monitoring, including transesophageal echocardiography and continuous ST-segment monitoring, is essential for timely diagnosis. Although rare, this complex clinical condition should be considered in lung transplant recipients with sudden heart failure to ensure prompt and effective treatment. Further research is needed to understand this stress cardiomyopathy in this specific setting and to develop effective management strategies.

Extracorporeal membrane oxygenation is increasingly being used to support patients with hypoxemic respiratory failure and cardiogenic shock. During the COVID-19 pandemic, consensus guidance recommended extracorporeal life support for patients with COVID-19-related cardiopulmonary disease refractory to optimal conventional therapy, prompting a substantial expansion in the use of this support modality. Extracorporeal membrane oxygenation was particularly integral to the bridging of COVID-19 patients to heart or lung transplantation. Limited human and physical resources precluded widespread utilization of mechanical support during the COVID-19 pandemic, necessitating careful patient selection and optimal management by expert healthcare teams for judicious extracorporeal membrane oxygenation use. This review outlines the evidence supporting the use of extracorporeal life support in COVID-19, describes the practice and outcomes of extracorporeal membrane oxygenation for COVID-19-related respiratory failure and cardiogenic shock, and proposes lessons learned for the implementation of extracorporeal membrane oxygenation as a bridge to transplantation in future public health emergencies., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Cardiogenic shock remains highly associated with early mortality, with mortality often exceeding 50%. We sought to determine the association between prognostic factors and in-hospital and 30-day mortality in cardiogenic shock., Methods: We performed a systematic review and meta-analysis of prognostic factors in cardiogenic shock, searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for records up to June 5, 2023. English-language studies that investigated prognostic factors and in-hospital and/or 30-day mortality in cardiogenic shock were included. Studies were excluded if they evaluated the pediatric population, were postmortem studies, or included fewer than 100 patients. The primary aim was to identify modifiable and non-modifiable prognostic factors associated with in-hospital and 30-day mortality in cardiogenic shock., Results: We identified 160 studies, including 2,459,703 patients with a median in-hospital mortality of 41.4% (interquartile range, 33.6% to 49.2%). The majority were retrospective cohort studies. Patient factors potentially associated with an increase in early mortality included an age greater than or equal to 75 years of age, peripheral arterial disease, chronic kidney disease, and female sex. Procedural and presentation factors potentially associated with increased mortality included out-of-hospital cardiac arrest, left main culprit artery, left ventricular ejection fraction less than 30%, dialysis, and need for mechanical circulatory support. Revascularization in the form of coronary artery bypass graft and percutaneous coronary intervention were potentially associated with reduced in-hospital mortality., Conclusions: This analysis quantifies the association between patient, presentation, and treatment-related factors and early mortality in cardiogenic shock. Increased certainty in the association of these prognostic factors with cardiogenic shock outcomes can aid in clinical risk assessment, development of risk tools, and analysis of clinical trials.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used in case of potentially reversible cardiac failure and restores systemic hemodynamics. However, whether this is followed by improvement of microcirculatory perfusion is unknown. Moreover, critically ill patients have possible pre-existing microcirculatory perfusion disturbances. Therefore, this review provides an overview of alterations in sublingual microcirculatory perfusion in critically ill adult patients receiving VA-ECMO support. Pubmed, Embase (Ovid), Cochrane Central Register of Controlled Trials, and Web of Science were systematically searched according to PRISMA guidelines. Studies reporting sublingual microcirculatory perfusion measurements in adult patients supported by VA-ECMO were included. Outcome parameters included small vessel density (SVD), perfused vessel density (PVD), perfused small vessel density (PSVD), proportion of perfused vessels (PPV), microvascular flow index (MFI) and the heterogeneity index (HI). The protocol was registered at PROSPERO (CRD42021243930). The search identified 1215 studies of which 11 were included. Cardiogenic shock was the most common indication for VA-ECMO (n=8). Three studies report increased PSVD, PPV, and MFI 24 hours after initiation of ECMO compared to pre-ECMO. Nonetheless, microcirculatory perfusion stabilized thereafter. Four out of four studies showed higher PSVD and PPV in survivors compared to non-survivors. Over time, survivors showed recovery of microcirculatory perfusion within hours of initiation of ECMO, whereas this was absent in non-survivors. Notwithstanding the limited sample, VA-ECMO seems to improve microcirculatory perfusion shortly after initiation of ECMO, especially in survivors. Further research in larger cohorts is needed to clarify the longitudinal effects of ECMO on microcirculatory perfusion., (© 2024 The Author(s). Microcirculation published by John Wiley & Sons Ltd.)

Introduction: Acute Coronary Syndrome (ACS) are one of the main causes of mortality in France. Patients presenting with ACS are typically hospitalized in a specialized cardiology ward. The main objective of this study was to describe, characterize and evaluate the outcome of patients hospitalized for ACS in a generalist intensive care unit (rather than a cardiac care unit)., Methods: This was a retrospective study. Our population consisted of ACS patients admitted to an intensive care unit in a hospital center (Centre Hospitalier de Troyes) between 2012 and 2021. All patients admitted for ACS to the intensive care unit and who underwent coronary angiography were included., Results: In 10 years, 104 patients, or 3.8% of ACS patients who underwent coronary angiography were admitted to intensive care. The majority were admitted after recovered cardiac arrest (72%) and were in cardiogenic shock (68%), accounting for a high in-hospital mortality (45.2%). In-hospital mortality was 45.2%. In multivariate analysis, the GRACE score was associated with in-hospital mortality (OR for each additional point = 1.024, 95% confidence interval 1.006-1.045, p = 0.01). Among the survivors, 88% had good neurological function when leaving the hospital., Discussion: Mortality of ACS patients in intensive care was close to 50%. However, the neurological prognosis of the surviving patients was good. This population is rarely mentioned in the literature, and deserves to be evaluated by multicenter, prospective registries, with a view to improving management and prognosis., Competing Interests: Déclaration de liens d'intérêts Les auteurs déclarent n'avoir aucun lien d'intérêt en relation avec cet article., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

The management of cardiogenic shock is an ongoing challenge. Despite all efforts and tremendous use of resources, mortality remains high. Whilst reversing the underlying cause, restoring/maintaining organ perfusion and function are cornerstones of management. The presence of comorbidities and preexisting organ dysfunction increases management complexity, aiming to integrate the needs of vital organs in each individual patient. This review provides a comprehensive overview of contemporary literature regarding the definition and classification of cardiogenic shock, its pathophysiology, diagnosis, laboratory evaluation, and monitoring. Further, we distill the latest evidence in pharmacologic therapy and the use of mechanical circulatory support including recently published randomized-controlled trials as well as future directions of research, integrating this within an international group of authors to provide a global perspective. Finally, we explore the need for individualization, especially in the face of neutral randomized trials which may be related to a dilution of a potential benefit of an intervention (i.e., average effect) in this heterogeneous clinical syndrome, including the use of novel biomarkers, artificial intelligence, and machine learning approaches to identify specific endotypes of cardiogenic shock (i.e., subclasses with distinct underlying biological/molecular mechanisms) to support a more personalized medicine beyond the syndromic approach of cardiogenic shock., (© 2024. The Author(s).)

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) shunts venous blood to the systemic arterial circulation to provide end-organ perfusion while increasing afterload that may impede left ventricle (LV) ejection and impair cardiac recovery. To maintain flow across the aortic valve and reduce risk of lethal clot formation, secondary mechanical circulatory support (MCS) devices are increasingly used despite limited understanding of their effects on cardiac function. This study sought to quantify the effects of VA-ECMO and combined with either intraaortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) on LV physiologic state and perfusion metrics in a porcine model of acute cardiogenic shock. Shock was induced through serial left anterior descending artery microbead embolization followed by initiation of VA-ECMO support and then placement of either IABP or pVAD. Hemodynamic measurements, LV pressure-volume loops, and carotid artery blood flow were evaluated before and after institution of combined MCS. The IABP decreased LV end-diastolic pressure by a peak of 15% while slightly increasing LV stroke work compared with decreases of more than 60% and 50% with the pVAD, respectively. The pVAD also demonstrated increased coronary perfusion and systemic pressure gradients in comparison to the IABP. Combined support with VA-ECMO and pVAD improves cardiovascular state in comparison to IABP., (Copyright © ASAIO 2024.)

A 63-year-old man presented with delayed inferior ST-elevation myocardial infarction complicated with ventricular septal rupture (VSR). He developed cardiogenic shock and respiratory failure requiring intubation and Impella (Abiomed) support.

The objective was to investigate the outcomes of concomitant venoarterial extracorporeal membrane oxygenation (ECMO) and left ventricular unloading with Impella (ECPELLA) compared with ECMO alone to treat patients affected by cardiogenic shock. Data from patients needing mechanical circulatory support from 4 international centers were analyzed. Of 438 patients included, ECMO alone and ECPELLA were adopted in 319 (72.8%) and 119 (27.2%) patients, respectively. Propensity score matching analysis identified 95 pairs. In the matched cohort, 30-day mortality rates in the ECMO and ECPELLA were 49.5% and 43.2% ( P = 0.467). The incidences of complications did not differ significantly between groups ( P = 0.877, P = 0.629, P = 1.000, respectively). After a median follow-up of 0.18 years (interquartile range 0.02-2.55), the use of ECPELLA was associated with similar mortality compared with ECMO alone (hazard ratio 0.81, 95% confidence interval 0.54-1.20, P = 0.285), with 1-year overall survival rates of 51.3% and 46.6%, for ECPELLA and ECMO alone, respectively. ECMO alone and ECPELLA are both effective strategies in patients needing mechanical circulatory support for cardiogenic shock, showing similar rates of early and mid-term survival., Competing Interests: Disclosure: The authors have no conflicts of interest to disclose., (Copyright © ASAIO 2024.)

Background: Cardiogenic shock (CS) is characterized by high mortality and requires accurate prognostic tools to predict outcomes and guide treatment. The Society for Cardiovascular Angiography and Interventions (SCAI) shock classification indicates shock severity and can be used for outcome prediction., Objective: Here, we compare the prognostic performance of SCAI shock classification determined on admission and during intensive care unit (ICU) stay., Methods: We included all patients with CS or conditions associated with developing CS based on ICD codes. SCAI shock stages were determined on admission and during the first 5 days of ICU stay. Receiver operating curves were used to compare the prognostic performance of SCAI stages on admission, SCAI stages during ICU stay and CS evolution (absent, resolved, persistent and new onset) for in-hospital mortality., Results: Between 01/2018 and 06/2022, 1303 patients were identified and 862 patients were included. On admission, 50.6 % patients had SCAI shock stage A, 3.9 % SCAI shock stage B, 17.7 % SCAI shock stage C, 7.0 % SCAI shock stage D and 20.8 % SCAI shock stage E. Shock stage distribution changed dynamically during ICU stay. Compared to SCAI stage on admission (AUC 0.80; 95 % CI 0.77-0.83), highest achieved SCAI stage during ICU (AUC 0.86, 95 % CI 0.83-0.89, p < 0.0001) and shock evolution (AUC 0.87, 95 % CI 0.85-0.90, p < 0.0001) yielded better prognostic performance., Conclusions: SCAI shock stages changed dynamically during ICU stay, and prognostic performance can be improved by considering highest achieved SCAI shock stage as well as the evolution of CS compared to SCAI shock stage on admission., Competing Interests: Declaration of competing interest All authors are requested to disclose any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within three years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work. If there are no conflicts of interest, the COI should read: “The authors report no relationships that could be construed as a conflict of interest”., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Cardiogenic shock (CS) is associated with significant morbidity and mortality. Sex differences in the outcomes and management of cardiogenic shock are not well established. The primary objective of this study is to investigate the differences inik cardiogenic shock outcomes between males and females., Methods: A systematic review and meta-analysis were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Studies were searched via the MEDLINE/PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to December 2022., Results: The analysis included 24 studies comprising 1,567,660 patients. Compared to females, males with CS had a significantly lower risk of in-hospital all-cause mortality (risk ratio [RR] 0.88, 95 % confidence interval [CI] 0.85-0.90, p < 0.001) and 1-year mortality (RR 0.90, 95 % CI 0.89-0.92, p < 0.001). Males were more likely to undergo percutaneous coronary intervention (RR 1.21, 95 % CI 1.13-1.31, p < 0.0001) and intra-aortic balloon pump placement (RR 1.21, 95 % CI 1.11-1.32, p < 0.0001), with no significant sex differences in the use of extracorporeal membrane oxygenation or Impella. During the index hospitalization, males were at higher risk of arrhythmias (RR 1.18, 95 % CI 1.05-1.34, p = 0.003) and less likely to develop acute kidney injury (RR 0.86, 95 % CI 0.79-0.94, p < 0.001)., Conclusion: Men have a lower all-cause mortality risk in cardiogenic shock. Addressing disparities in management is crucial for improving CS outcomes, especially for women., Competing Interests: Declaration of competing interest Dr. Andrew M. Goldsweig has consulted for Inari Medical and has received speaking fees from Philips and Edwards Lifesciences. The other authors report no disclosures., (Copyright © 2024. Published by Elsevier Inc.)

Background: Cardiogenic Shock (CS) complicating acute myocardial infarction (AMI) poses a significant mortality risk, suggesting the opportunity to implement effective mechanical circulatory support strategies. The comparative efficacy of Intra-Aortic Balloon Pump (IABP) and Impella in managing CS-AMI remains a subject of investigation., Objective: This meta-analysis aims to evaluate the comparative effectiveness of Impella and IABP in managing CS-AMI, exploring mortality and adverse events., Methods: A systematic search of major databases from inception to November 2023 identified eight studies, comprising 10,628 patients, comparing Impella and IABP in CS-AMI. Retrospective studies (preferably Propensity-matched) and Randomized Clinical Trials (RCTs) were included., Results: Impella use exhibited significantly higher mortality (57% vs. 46%; OR: 1.44, 95% CI: 1.29-1.60; p < 0.001) and major bleeding (30% vs 15%; OR: 2.93, 95% CI: 1.67-5.13; p < 0.001)., Conclusions: In unselected CS-AMI patients, Impella usage is associated with significantly higher mortality and major bleeding., Competing Interests: Declaration of competing interest Authors have no conflict of interest to declare., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Cardiogenic shock (CS) occurs infrequently in pregnancy and has a high mortality rate. Medical treatment options are few, with limited evidence of efficacy. Temporary mechanical circulatory supports (tMCS) may play a key role in addressing this therapeutic lacuna. We report successfully managing second-trimester CS using an Impella 5.5 micro-axial pump. Our patient presented in the second-trimester with CS. Hemodynamic parameters indicated biventricular dysfunction (low cardiac index, low pulmonary artery pulsatility index). She received diuresis and inotropic support to optimize her fluid status and cardiac function. However, failure to improve to the point where she would be able to tolerate the hemodynamic stresses of labor despite optimizing medical therapy prompted consideration of tMCS. The Impella 5.5 was chosen for its higher output (to maximize fetal perfusion), relative longevity, and lower hemolysis rates compared to other devices. It was used to support her from gestational weeks 28-30 and through the delivery. Support was continued for 4 weeks postpartum to allow for any potential cardiac recovery. Hope unrealized, a workup for destination therapy was initiated. Patient preference and high panel reactive antibodies informed the decision to pursue destination left ventricular assist device (LVAD) therapy. After a 3 month neonatal intensive care unit (NICU) stay, mother and baby were successfully discharged home., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2024.)

Objectives: Post-cardiotomy extracorporeal life support (ECLS) cannulation might occur in a general post-operative ward due to emergent conditions. Its characteristics have been poorly reported and investigated This study investigates the characteristics and outcomes of adult patients receiving ECLS cannulation in a general post-operative cardiac ward., Methods: The Post-cardiotomy Extracorporeal Life Support (PELS) is a retrospective (2000-2020), multicenter (34 centers), observational study including adult patients who required ECLS for post-cardiotomy shock. This PELS sub-analysis analyzed patients´ characteristics, in-hospital outcomes, and long-term survival in patients cannulated for veno-arterial ECLS in the general ward, and further compared in-hospital survivors and non-survivors., Results: The PELS study included 2058 patients of whom 39 (1.9%) were cannulated in the general ward. Most patients underwent isolated coronary bypass grafting (CABG, n = 15, 38.5%) or isolated non-CABG operations (n = 20, 51.3%). The main indications to initiate ECLS included cardiac arrest (n = 17, 44.7%) and cardiogenic shock (n = 14, 35.9%). ECLS cannulation occurred after a median time of 4 (2-7) days post-operatively. Most patients' courses were complicated by acute kidney injury (n = 23, 59%), arrhythmias (n = 19, 48.7%), and postoperative bleeding (n = 20, 51.3%). In-hospital mortality was 84.6% (n = 33) with persistent heart failure (n = 11, 28.2%) as the most common cause of death. No peculiar differences were observed between in-hospital survivors and nonsurvivors., Conclusions: This study demonstrates that ECLS cannulation due to post-cardiotomy emergent adverse events in the general ward is rare, mainly occurring in preoperative low-risk patients and after a postoperative cardiac arrest. High complication rates and low in-hospital survival require further investigations to identify patients at risk for such a complication, optimize resources, enhance intervention, and improve outcomes., (© 2024 The Author(s). Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Objective: Our study examines the long-term outcomes of patients discharged from the hospital without heart replacement therapy (HRT) after recovery from cardiogenic shock using venoarterial extracorporeal life support (VA-ECLS)., Methods: We retrospectively reviewed 615 cardiogenic shock patients who recovered from VA-ECLS at our institution between January 2015 and July 2021. Of those, 166 patients (27.0%) who recovered from VA-ECLS without HRT were included in this study. Baseline characteristics, discharge labs, vitals, electrocardiograms and echocardiograms were assessed. Patients were contacted to determine vital status. The primary outcome was post-discharge mortality., Results: Of 166 patients, 158 patients (95.2%) had post-discharge follow-up, with a median time of follow-up of 2 years (IQR: [1 year, 4 years]). At discharge, the median ejection fraction (EF) was 52.5% (IQR: [32.5, 57.5]). At discharge, 92 patients (56%) were prescribed β-blockers, 28 (17%) were prescribed an ACE inhibitor, ARB or ARNI, and 50 (30%) were prescribed loop diuretics. Kaplan-Meier analysis showed a 1-year survival rate of 85.6% (95% CI: [80.1%, 91.2%]) and a 5-year survival rate of 60.6% (95% CI: [49.9%, 71.3%]). A Cox regression model demonstrated that a history of congestive heart failure (CHF) was strongly predictive of increased mortality hazard (HR = 1.929; p = 0.036), while neither discharge EF nor etiology of VA-ECLS were associated with increased post-discharge mortality., Conclusions: Patients discharged from the hospital after full myocardial recovery from VA-ECLS support without HRT should have close outpatient follow-up due to the risk of recurrent heart failure and increased mortality in these patients., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acute right ventricular failure (RVF) is prevalent in multiple disease states and is associated with poor clinical outcomes. Right-sided temporary mechanical circulatory support (tMCS) devices are used to unload RV congestion and increase cardiac output in cardiogenic shock (CS) with hemodynamically significant RVF. Several RV-tMCS device platforms are available; however consensus is lacking on patient selection, timing of escalation to RV-tMCS, device management, and device weaning. The purposes of this review are to 1) describe the current state of tMCS device therapies for acute RVF with CS, 2) discuss principles of escalation to RV-tMCS device therapy, 3) examine important aspects of clinical management for patients supported by RV-tMCS devices including volume management, anticoagulation, and positive pressure ventilation, and 4) provide a framework for RV-tMCS weaning., (Copyright © 2024 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: This study examines the role of extracorporeal life support flow in the development of acute kidney injury in cardiogenic shock., Methods: We performed a retrospective analysis of 465 patients placed on extracorporeal life support at our institution between January 2015 and December 2020 for cardiogenic shock. Flow index was calculated by dividing mean flow by body surface. Stages of acute kidney injury were determined according to Kidney Disease: Improving Global Outcomes (KDIGO) organization guidelines., Results: There were 179 (38.5%) patients who developed acute kidney injury, 63.1% of which were classified as Stage 3--the only subgroup associated with 1-year mortality (hazard ratio = 2.03, p < .001). Risk of k idney injury increased up to a flow index of 1.6 L/min/m 2 , and kidney injury was more common among patients with flow index greater than 1.6 L/min/m 2 ( p = .034). Those with kidney injury had higher baseline lactate levels (4.4 vs 3.1, p = .04), and Stage 3 was associated wit higher baseline creatinine ( p < .001)., Conclusions: In our cohort, kidney injury was common and Stage 3 kidney injury was associated with worse outcomes compared to other stages. Low flow was not associated with increased risk of kidney injury. Elevated baseline lactate and creatinine among patients with acute kidney injury suggest underlying illness severity, rather than flow, may influence kidney injury risk., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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.)

Objectives: The use of awake extracorporeal membrane oxygenation (ECMO, without intubation or sedation under ECMO support in patients with cardiogenic shock is growing rapidly because emerging clinical investigations indicates it may reduce morbidity associated with sedation and intubation. We systematically reviewed the efficacy of awake ECMO and provided evidence for clinical practitioners and researchers., Design: Systematic review and trial sequential meta-analysis based on observational studies., Data Sources: Data was retrieved from seven databases (PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database and Cochrane Library) up to 1 March 2024., Eligibility Criteria: We included observational studies that compared the differences in clinical outcomes between awake ECMO and non-awake ECMO in patients with cardiogenic shock., Data Extraction and Synthesis: Two reviewers rigorously conducted literature retrieval, screening and data extraction. The RevMan software was used for data synthesis., Results: Five retrospective observational studies involving 1044 patients with cardiogenic shock were included. Compared with non-awake ECMO, awake ECMO was associated with a lower mortality rate of patients with cardiogenic shock (OR=0.28; 95% CI, (0.15, 0.49); p<0.0001; I 2 =50%). Trial sequential analysis indicated that the sample mortality outcome reached the required information size. No significant differences were observed between the two groups on secondary outcomes such as the occurrence of ventilator-associated pneumonia, weaning from ECMO, tracheostomy, haemorrhage, thrombosis, limb ischaemia and nosocomial infection., Conclusions: Implementing awake ECMO may result in better clinical outcomes in patients with cardiogenic shock. Because of the limited sample sizes and potential bias of the current studies, more rigorously designed large-scale trials are urgently needed to verify the above findings., Prospero Registration Number: CRD42023407607., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The classification of cardiogenic shock (CS) has evolved from a singular cold-and wet-hemodynamic profile. Data from registries and clinical trials have contributed to a broader recognition that although all patients with CS have insufficient cardiac output leading to end organ hypoperfusion, there is considerable variability in CS acuity, underlying etiologies, volume status, and systemic vascular resistance. Mixed CS can be broadly categorized as CS with at least 1 additional shock state . Mixed CS states are now the second leading cause of shock in contemporary coronary intensive care units, but there is little high-quality evidence to guide routine care, and there are no standardized classification frameworks or well-established hemodynamic definitions. This primer summarizes the current epidemiology and proposes a classification framework and invasive hemodynamic parameters to guide categorization that could be applied to help better phenotype patients captured in registries and trials, as well as guide management of mixed CS states., Competing Interests: Dr Morrow is a member of the TIMI Study Group, which has received institutional research grant support through Brigham and Women’s Hospital from Abbott Laboratories, Abiomed, Amgen, Anthos Therapeutics, Arca Biopharma, AstraZeneca, Daiichi‐Sankyo, Intarcia, Janssen, Merck, Novartis, Pfizer, Poxel, Quark Pharmaceuticals, Regeneron, Roche, Siemens, and Zora Biosciences. Dr Morrow has received consulting fees from Abbott Laboratories, Arca Biopharma, InCarda, Inflammatix, Merck, Novartis, and Roche Diagnostics. Dr Gage has received an educational honorarium from Zoll and is a former member of the Abiomed speaker’s bureau. Dr Pöss has received research funding (institutional) from the German Cardiac Society, Dr Rolf M. Schwiete Foundation, German Heart Research Foundation, and Maquet Cardiopulmonary GmbH. The other authors report no conflicts.

Background: Despite the progress made in recent years in the treatment of Acute Heart Failure (AHF), its prognosis remains poor in the developing country. The objective of this study is to analyze the survival and predictors of mortality of patients with acute heart failure in the cardiology department of the Basse Terre Hospital Center in Guadeloupe., Methods: this was a historical cohort study carried out over a period from June 2021 to June 2022, targeting all acute heart failure patients undergoing cardiac monitoring in the cardiology department of the Basse Terre Hospital Center in Guadeloupe. Sociodemographic, clinical, biological characteristics and outcome (recovery or death) were studied. Survival was described using the Kaplan Meier method α = 5%., Results: this study involved 242 acute heart failure patients whose median age was 75 years and the majority were male (sex ratio 2 M/1F). Among these patients, 14.9% died, the most common cause of death was cardiogenic shock (52.8%). After adjustment, tobacco consumption (aHR: 2.90; 95% CI: 1.36-8.09), Chronic Kidney Disease (aHR: 2.52; 95% CI: 1.22-5.20), infection (aHR: 2.14; 95CI %: 1.99-4.58), hyponatremia (aHR: 1.90; 95% CI: 1.10-2.86), mitral regurgitation (aHR: 3.04; 95% CI: 1.98-9.47) and N-terminal pro Brain Natriuretic Peptide > 10000ng/ml (aHR: 2.57; 95% CI: 1.21-5.49) were independently associated with the risk of death in heart failure patients., Conclusion: Acute heart failure leads to high mortality, mainly due to cardiogenic shock and factors of multiple organ failure., (© 2024. The Author(s).)

Aims: The Shock Academic Research Consortium (SHARC) recently proposed pragmatic consensus definitions to standardize classification of cardiogenic shock (CS) in registries and clinical trials. We aimed to describe contemporary CS epidemiology using the SHARC definitions in a cardiac intensive care unit (CICU) population., Methods and Results: The Critical Care Cardiology Trials Network (CCCTN) is a multinational research network of advanced CICUs coordinated by the TIMI Study Group (Boston, MA). Cardiogenic shock was defined as a cardiac disorder resulting in SBP < 90 mmHg for ≥30 min [or the need for vasopressors, inotropes, or mechanical circulatory support (MCS) to maintain SBP ≥ 90 mmHg] with evidence of hypoperfusion. Primary aetiologic categories included acute myocardial infarction-related CS (AMI-CS), heart failure-related CS (HF-CS), and non-myocardial (secondary) CS. Post-cardiotomy CS was not included. Heart failure-related CS was further subcategorized as de novo vs. acute-on-chronic HF-CS. Patients with both cardiogenic and non-cardiogenic components of shock were classified separately as mixed CS. Of 8974 patients meeting shock criteria (2017-23), 65% had isolated CS and 17% had mixed shock. Among patients with CS (n = 5869), 27% had AMI-CS (65% STEMI), 59% HF-CS (72% acute-on-chronic, 28% de novo), and 14% secondary CS. Patients with AMI-CS and de novo HF-CS were most likely to have had concomitant cardiac arrest (P < 0.001). Patients with AMI-CS and mixed CS were most likely to present in more severe shock stages (SCAI D or E; P < 0.001). Temporary MCS use was highest in AMI-CS (59%). In-hospital mortality was highest in mixed CS (48%), followed by AMI-CS (41%), similar in de novo HF-CS (31%) and secondary CS (31%), and lowest in acute-on-chronic HF-CS (25%; P < 0.001)., Conclusion: SHARC consensus definitions for CS classification can be pragmatically applied in contemporary registries and reveal discrete subpopulations of CS with distinct phenotypes and outcomes that may be relevant to clinical practice and future research., Competing Interests: Conflict of interest: D.D.B., E.A.B., S.M.P., V.M.B.-Z., J.-G.P., and D.A.M. are members of the TIMI Study Group, which has received institutional research grant support through Brigham and Women’s Hospital from Abbott, Abiomed, Amgen, Anthos Therapeutics, ARCA Biopharma, Inc., AstraZeneca, Bayer HealthCare Pharmaceuticals, Inc., Daiichi-Sankyo, Eisai, Intarcia, Ionis Pharmaceuticals, Inc., Janssen Research and Development, LLC, MedImmune, Merck, Novartis, Pfizer, Quark Pharmaceuticals, Regeneron Pharmaceuticals, Inc., Roche, Siemens Healthcare Diagnostics, Inc., Softcell Medical Limited, The Medicines Company, and Zora Biosciences. D.D.B. has received consulting fees from AstraZeneca, Pfizer, Mobility Bio, Inc., and Youngene Therapeutics; honoraria from the Metabolic Endocrine Education Foundation, and USV Private Limited; and participates on clinical endpoint committees for studies sponsored by Beckman Coulter, Kowa Pharmaceuticals, Novo Nordisk, and Tosoh Biosciences. L.S. reports speakers bureaus for Abiomed., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by uninhibited platelet production. It can present with vasomotor symptoms, and less commonly, severe thrombotic events such as myocardial infarction. ST-segment elevation myocardial infarction (STEMI) secondary to the hypercoagulable state in ET is a diagnostic challenge as the complication is rare, especially outside the typical demographics affected by ET such as the female and elderly populations., Case Presentation: Here we report a case of a 32-year-old male found to have STEMI and a markedly elevated platelet count. Angiography revealed occlusion of the left anterior descending and left circumflex arteries, requiring percutaneous intervention and Impella support. The patient was later diagnosed with essential thrombocythemia, treated with hydroxyurea and antiplatelet therapy, and discharged with a wearable cardioverter defibrillator., Conclusions: This case illustrates the potential for severe thrombotic complications such as STEMI due to ET. Severe thrombotic complications are less common manifestations of ET in general, particularly in young males. Recognition and diagnosis of ET are critical for the institution of appropriate therapy and prevention of STEMI and cardiogenic shock among other complications., (© 2024. The Author(s).)

Background: The outcomes of patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) and the efficacy and safety of extracorporeal life support (ECLS) may be affected by the timing of hospital admission., Objectives: The present ECLS-SHOCK substudy sought to investigate the prognostic impact of on-hours vs off-hours admission and the efficacy of ELCS according to the timing of hospital admission time in AMI-CS., Methods: Patients with AMI-CS enrolled in the multicenter, randomized ECLS-SHOCK trial from 2019 to 2022 were included. The prognosis of patients admitted during regular hours (ie, on-hours) was compared to patients admitted during off-hours. Thereafter, the prognostic impact of ECLS was investigated stratified by the timing of hospital admission. The primary endpoint was 30-day all-cause mortality. Statistical analyses included Kaplan-Meier, univariable, and multivariable logistic regression analyses., Results: Of 417 patients enrolled in the ECLS-SHOCK trial, 48.4% (n = 202) were admitted during off-hours. Patients admitted during off-hours were younger (median age = 62 years [Q1-Q3: 55-69 years] vs 63 years [Q1-Q3: 58-71 years]; P = 0.036) and more commonly treated using initial femoral access for coronary angiography (79.0% [n = 158/200] vs 67.9% [n = 146/215]; P = 0.011). However, off-hours admission was not associated with an increased risk of 30-day all-cause mortality (off-hours vs on-hours: 46.0% [n = 93/202] vs 50.7% [n = 109/215]; OR: 0.83; 95% CI: 0.56-1.22). Furthermore, ECLS had no prognostic impact on 30-day all-cause mortality in patients with AMI-CS admitted during on-hours (50.5% [n = 52/103] vs 50.9% [n = 57/112]; P = 0.95; OR: 0.98; 95% CI: 0.58-1.68) or in patients admitted during off-hours (45.3% [n = 48/106] vs 46.9% [n = 45/96]; P = 0.82; OR: 0.94; 95% CI: 0.54-1.63). Finally, ECLS was associated with an increased risk of bleeding events, especially in patients admitted during on-hours., Conclusions: The prognosis in AMI-CS was not affected by admission time with a similar effect of ECLS during on- and off-hours., Competing Interests: Funding Support and Author Disclosure Supported by the Else Kröner Fresenius Foundation, the German Heart Research Foundation, and the Helios Health Institute (formerly Leipzig Heart Institute). Dr Rassaf has received honoraria, lecture fees, and grant support from Edwards Lifesciences, AstraZeneca, Bayer, Novartis, Berlin Chemie, Daiicho-Sankyo, Boehringer Ingelheim, Novo Nordisk, Cardiac Dimensions, and Pfizer, all unrelated to this work; and is a cofounder of Bimyo GmbH, a company that develops cardioprotective peptides. Dr Clemmensen has previously or currently been involved in research contracts, consulting, and Speakers Bureau for Abbott, Abiomed, AstraZeneca, Aventis, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CeleCor, CytoSorbent, Daiichi-Sankyo, Eli-Lilly, Evolva, Ferrer, Fibrex, Idorsia, Janssen, Merck, Myogen, Medtronic, Mitsubishi Pharma, The Medicines Company, Nycomed, Organon, Pfizer, Pharmacia, Philips, Regado, Sanofi, Searle, Servier, and ViFor Pharma; and has received research and/or educational grants from Abbott, Abiomed, AstraZeneca, Aventis, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CeleCor, CytoSorbent, Daiichi-Sankyo, Eli-Lilly, Evolva, Ferrer, Fibrex, Idorsia, Janssen, Merck, Myogen, Medtronic, Mitsubishi Pharma, The Medicines Company, Nycomed, Organon, Pfizer, Pharmacia, Philips, Regado, Sanofi, Searle, Servier, and ViFor Pharma. Dr Linke has received grants from Novartis and Edwards Lifesciences; has received personal fees from Abbott, Abiomed, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Edwards Lifesciences, Medtronic, Meril, Novartis, Sanofi Genzyme, and Pfizer; and has received other fees from Picardia, Filterlex, and Transverse Medical outside the submitted work. Dr Pöss has received research grants (institutional) from German Cardiac Society, German Heart Research Foundation, Dr Rolf M. Schwiete Foundation, and Maquet Cardiopulmonary GmbH. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: We report a rare case of new onset autoimmune adrenal insufficiency in childhood, presenting with severe shock requiring mechanical circulatory support. In the current era of readily available imaging, laboratory and other diagnostic investigations, medical history and careful physical exam can often provide valuable diagnostic information for timely therapy., Case Presentation: A 7-year-old boy with a history of mild intermittent asthma, presented with severe cardiogenic shock requiring extracorporeal membrane oxygenation (ECMO). Bronzing of his entire body was noted on physical exam. Stress dose hydrocortisone was given for suspected adrenal insufficiency. After weaning from ECMO and extensive rehabilitation, the patient recovered and was discharged home., Conclusion: Primary adrenal insufficiency (PAI) should be considered in the context of physical exam and laboratory findings, even in the presence of circulatory shock., (© 2024. The Author(s).)

Objective: As the global use of extracorporeal membrane oxygenation (ECMO) treatment increases, survival rates have not correspondingly improved, emphasizing the need for refined patient selection to optimize resource allocation. Currently, prognostic markers at the molecular level are limited., Methods: Thirty-four cardiogenic shock (CS) patients were prospectively enrolled, and peripheral blood mononuclear cells (PBMCs) were collected at the initiation of ECMO (t0), two-hour post-installation (t2), and upon removal of ECMO (tr). The PBMCs were analyzed by comprehensive epigenomic assays. Using the Wilcoxon signed-rank test and least absolute shrinkage and selection operator (LASSO) regression, 485,577 DNA methylation features were analyzed and selected from the t0 and tr datasets. A random forest classifier was developed using the t0 dataset and evaluated on the t2 dataset. Two models based on DNA methylation features were constructed and assessed using receiver operating characteristic (ROC) curves and Kaplan-Meier survival analyses., Results: The ten-feature and four-feature models for predicting in-hospital mortality attained area under the curve (AUC) values of 0.78 and 0.72, respectively, with LASSO alpha values of 0.2 and 0.25. In contrast, clinical evaluation systems, including ICU scoring systems and the survival after venoarterial ECMO (SAVE) score, did not achieve statistical significance. Moreover, our models showed significant associations with in-hospital survival (p < 0.05, log-rank test)., Conclusions: This study identifies DNA methylation features in PBMCs as potent prognostic markers for ECMO-treated CS patients. Demonstrating significant predictive accuracy for in-hospital mortality, these markers offer a substantial advancement in patient stratification and might improve treatment outcomes., (© 2024. The Author(s).)

Background: Right ventricular dysfunction (RVD) complicates 30%-40% of cases in acute myocardial infarction (AMI) and cardiogenic shock (CS). There are sparse data on the effects of RVD on outcomes and the impact of providing early left ventricular (LV) mechanical circulatory support (MCS) on RV function and hemodynamics., Methods and Results: Between July 2016 and December 2020, 80 sites participated in the study. All centers agreed to treat patients with AMI-CS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of LV-MCS. RVD was defined as a right atrial (RA) pressure of >12 mm Hg and a pulmonary artery pulsatility index (PAPI) of <1 within 24 hours of the index procedure. The primary outcome was survival to discharge. In a subgroup analysis, data available from the Automated Impella Controller console was used to analyze diastolic suction alarms from LV placement signal and its relation to RVD. A total of 361 patients were included in the analysis, of whom 28% had RVD. The median age was 64 years (interquartile range 55-72 years), 22.7% were female and 75.7% were White. There was no difference in age, sex, or comorbidities between those with or without RVD. Patients with RVD had a higher probability of active CPR during LV-MCS implant (14.7% vs 6.3%), Society for Cardiovascular Angiography and Interventions stage E shock (39.2% vs 23.2%), and higher admission lactate levels (5.1 mg/dL vs 3.0 mg/dL). Survival to discharge was significantly lower among those with RVD (61.8% vs 73.4%, odds ratio 0.89, 95% confidence interval 0.36-0.95, P = .031). This association remained significant in the multivariate analysis. There was no significant difference in hemodynamic variables within 24 hours of LV-MCS support among those with or without RVD. At 24 hours, patients with a CPO of >0.6 W and a PAPi of >1 had a trend toward better survival to discharge compared with those with a CPO of ≤0.6 W and a PAPi of ≤1 (77.1% vs 54.6%, P = .092). Patients with RVD were significantly more likely to have diastolic suction alarms within 24 hours of LV-MCS initiation., Conclusions: RVD in AMI-CS is common and associated with worse survival to discharge. Early LV-MCS decreases filling pressures rapidly within the first 24 hours and decreases the rate of RVD. Achieving a CPO of >0.6 W and a PAPi of >1 within 24 hours is associated with high survival. Diastolic suction alarms may have usefulness as an early marker of RVD., Competing Interests: Disclosures Dr. Tedford reports no direct conflicts of interest related to this manuscript. He reports general disclosures to include consulting relationships with Abbott, Acorai, Aria CV Inc., Acceleron/Merck, Alleviant, CareDx, Cytokinetics, Edwards LifeSciences, Gradient, Lexicon Pharmaceuticals, Medtronic, and United Therapeutics. Dr. Tedford serves on steering committee for Merck, Edwards, and Abbott, as well as a research advisory board for ​Abiomed. He also does hemodynamic core lab work for Merck. Dr. Cowger is a paid consultant/advisor for Abbott, Inc (HeartMate 3 LVAD; tendyne and cephea valve trials), Medtronic (HVAD study), Bioventrix, CorWave, and Procyrion (Aortix device). She is an unpaid steering committee member for Endotronix (Cordella PA sensor) and Nuwellis. She is on the DSMB for BiVACOR and Berlin Heart Excor device trials. She is a speaker for Zoll, Abbott, and Bioventrix., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cardiogenic shock (CS) is a syndrome of low cardiac output resulting in critical end-organ hypoperfusion and hypoxia. The mainstay of management involves optimizing preload, afterload and contractility. In medically refractory cases, temporary percutaneous mechanical support (MCS) is used as a bridge to recovery, surgical ventricular assist device, or transplant. Anticoagulation is recommended to prevent device-related thromboembolism. However, MCS can be fraught with hemorrhagic complications, compounded by incident multisystem organ failure often complicating CS. Currently, there are limited data on optimal anticoagulation strategies that balance the risk of bleeding and thrombosis, with most centers adopting local antithrombotic stewardship practices. In this review, we detail anticoagulation protocols, including anticoagulation agents, therapeutic monitoring, and complication mitigation in CS requiring MCS. This review is intended to provide an evidence-based framework in this population at high risk for in-hospital bleeding and mortality., Competing Interests: Disclosures JDA receives research funding from Boston Scientific, Shockwave and Med Alliance and serves as a consultant for Abbott, Medtronic, Penumbra, and Recor. All other authors report no relevant conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Sex-based disparities have been demonstrated in care delivery for females with cardiogenic shock (CS), including lower use of coronary angiography (CAG), percutaneous intervention (PCI) and mechanical circulatory support (MCS). We evaluated whether sex-based disparities exist and are associated with worse CS outcomes in females., Methods: We studied a retrospective cohort of 1498 consecutive, unique adult cardiovascular intensive care unit (CICU) admissions with CS from 2007-2018., Results: Compared to males, females (n = 566, 37.1%) were older (71.7 vs 67.8 years; P < 0.001) but had similar burdens of medical comorbidities. Acute myocardial infarction (AMI) was present in 54.1% of females and 59.1% of males (P = 0.06). There were no sex-based differences in the use of CAG and PCI, but females received temporary MCS less commonly. Specifically, females with non-AMI CS received MCS devices less commonly (17.6% vs 24.4%; P = 0.04). There was no difference in in-hospital or 1-year mortality rates between the sexes. Compared to males, females who received PCI had lower risks of 1-year mortality (unadjusted HR 0.72; P = 0.03), whereas females who received CAG without PCI had higher risks of 1-year mortality (unadjusted HR 1.41; P = 0.02)., Conclusions: No sex-based disparities in mortality due to CS were demonstrated in this large, diverse cohort of patients with CICU admissions. Females who underwent PCI demonstrated lower risks of 1-year mortality, whereas females who underwent CAG without PCI demonstrated higher risks of 1-year mortality compared to males. This may reflect underuse of PCI as a mortality-reducing therapy in females., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In those with heart failure-related cardiogenic shock (HF-CS), an intra-aortic balloon pump (IABP) may improve hemodynamics and be useful as a bridge to advanced therapies. We explore whether those with cardiac amyloidosis and HF-CS might experience hemodynamic improvement and describe the hemodynamic response after IABP., Methods and Results: We retrospectively identified consecutive patients with a diagnosis of cardiac amyloid, either light chain or transthyretin, who were admitted to our intensive care unit with HF-CS. Patients were excluded if an IABP was placed during heart transplant or for shock related to acute myocardial infarction. Invasive hemodynamics before and after IABP placement were assessed. We identified 23 patients with cardiac amyloid who had an IABP placed for HF-CS. The 1-year survival rate was 74% and most (65%) were bridged to heart transplant, although 1 patient was bridged to destination left ventricular assist device. After IABP, the mean arterial pressure, cardiac index, and cardiac power index were significantly increased, whereas mean right atrial pressure, mean pulmonary artery pressure, and pulmonary capillary wedge pressure were all significantly decreased. A smaller left ventricular end-diastolic diameter (per cm) was associated with a higher likelihood of a cardiac index of <2.2 L/min/m 2 after IABP (odds ratio 0.16, 95% confidence interval 0.01-0.93, P = .04)., Conclusions: IABP significantly improved cardiac index while decreasing right atrial pressure, mean pulmonary artery pressure, and pulmonary capillary wedge pressure in cardiac amyloidosis patients with HF-CS., Competing Interests: Funding and Disclosures Dr Longinow is supported by a grant from Pfizer. Dr Pieter Martens is supported by a grant from the Belgian American Educational Foundation (BAEF) and by the Frans Van de Werf Fund. Dr Andrew Higgins has received honoraria from Abbott. Dr Edward Soltesz has received honoraria from Abiomed, Abbott, and Atricure. Dr Wilson Tang served as consultant for Sequana Medical, Cardiol Therapeutics, Genomics plc, Zehna Therapeutics, Renovacor, WhiteSwell, Kiniksa, Boston Scientific, and CardiaTec Biosciences, and has received honorarium from Springer Nature and American Board of Internal Medicine. Dr Mazen Hanna is a consultant for Alnylam Pharmaceuticals Inc., Eidos, Akcea Therapeutics, and Pfizer Inc. Dr Lee has received honorarium from Getinge, unrelated to the subject and content of this paper. Dr Estep has served as a consultant and has received honorarium from Abbott, Bioventrix, and Getinge, all unrelated to the subject and contents of this paper. All other authors have no relationships to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Cardiogenic shock (CS) is a hemodynamic syndrome that can progress to systemic metabolic derangements and end-organ dysfunction. Prior studies have reported hemodynamic parameters at the time of admission to be associated with mortality but hemodynamic trajectories in CS have not been well described. We studied the association between hemodynamic profiles and their trajectories and in-hospital mortality in patients with CS due to heart failure (HF-CS) and acute myocardial infarction (MI-CS). Using data from the large multicenter Cardiogenic Shock Working Group (CSWG) registry, we analyzed hemodynamic data obtained at the time of pulmonary artery catheter (PAC) insertion (dataset at baseline) and at PAC removal or death (dataset at final time point). Univariable regression analyses for prediction of in-hospital mortality were conducted for baseline and final hemodynamic values, as well as the interval change (delta-P). Data was further analyzed based on CS etiology and survival status. A total of 2260 patients with PAC data were included (70% male, age 61 ± 14 years, 61% HF-CS, 27% MI-CS). In-hospital mortality was higher in the MI-CS group (40.1%) compared with HF-CS (22.4%, P < .01). In the HF-CS cohort, survivors exhibited lower right atrial pressure (RAP), pulmonary artery pressure (PAP), cardiac output/index (CO/CI), lactate, and higher blood pressure (BP) than nonsurvivors at baseline. In this cohort, during hospitalization, improvement in metabolic (aspartate transaminase, lactate), BP, hemodynamic (RAP, pulmonary artery pulsatility index [PAPi], pulmonary artery compliance for right-sided profile and CO/CI for left-sided profile), had association with survival. In the MI-CS cohort, a lower systolic BP and higher PAP at baseline were associated with odds of death. Improvement in metabolic (lactate), BP, hemodynamic (RAP, PAPi for right-sided profile and CO/CI for left-sided profile) were associated with survival. In a large contemporary CS registry, hemodynamic trajectories had a strong association with short-term outcomes in both cohorts. These findings suggest the clinical importance of timing and monitoring hemodynamic trajectories to tailor management in patients with CS., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Cardiogenic shock is severe circulatory failure that results in significant in-hospital mortality, related morbidity, and economic burden. Patients with cardiogenic shock are at high risk for atrial and ventricular arrhythmias, particularly within the subset of patients with an overlap of cardiogenic shock and cardiac arrest., Areas Covered: This review article will explore the prevalence, definition, management, and outcomes of common arrhythmias in patients with cardiogenic shock. This review will describe the pathophysiology of arrhythmia in cardiogenic shock and the impact of inotropic agents on increased arrhythmogenicity. In addition to medical management, focused assessment of mechanical circulatory support, radiofrequency ablation, deep sedation, and stellate ganglion block will be provided., Expert Opinion: We will navigate the limited data and describe the prognostic impacts of arrhythmia. Finally, we will conclude the review with a discussion of prevention strategies, research limitations, and future research directions.

Purpose of Review: Cardiogenic shock (CS) is associated with high in-hospital and long-term mortality and morbidity that results in significant socio-economic impact. Due to the high costs associated with CS care, it is important to define the short- and long-term burden of this disease state on resources and review strategies to mitigate these., Recent Findings: In recent times, the focus on CS continues to be on improving short-term outcomes, but there has been increasing emphasis on the long-term morbidity. In this review we discuss the long-term outcomes of CS and the role of hospital-level and system-level disparities in perpetuating this. We discuss mitigation strategies including developing evidence-based protocols and systems of care, improvement in risk stratification and evaluation of futility of care, all of which address the economic burden of CS. CS continues to remain the pre-eminent challenge in acute cardiovascular care, and a combination of multi-pronged strategies are needed to improve outcomes in this population., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Cardiogenic shock is a multisystem pathology that carries a high mortality rate, and initial pharmacotherapies include the use of vasopressors and inotropes. These agents can increase myocardial oxygen consumption and decrease tissue perfusion that can oftentimes result in a state of refractory cardiogenic shock for which temporary mechanical circulatory support can be considered. Numerous support devices are available, each with its own hemodynamic blueprint. Defining a patient's hemodynamic profile and understanding the phenotype of cardiogenic shock is important in device selection. Careful patient selection incorporating a multidisciplinary team approach should be utilized., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Use of Intra-Aortic Balloon Pump (IABP) in combination with Impella has been described as an alternative strategy for mechanical circulatory support (MCS) in patients with cardiogenic shock (CS). We provide a systematic review aimed to explore the effectiveness of this paired MCS approach., Methods: We conducted a comprehensive systematic search in MEDLINE, Scopus, and Cochrane databases to identify all studies that investigated dual MCS with IABP and Impella., Results: Our search strategy identified 12 articles, including 1 randomized controlled trial, 1 retrospective study, 1 case series, 7 case report and 2 animal studies. Rationale for this combined MCS strategy stems from an observed reduction in myocardial oxygen demand/supply ratio compared to the use of each device alone, without determining significant variations in left ventricular work. Nonetheless, this combined approach also leads to a 30-40 % decline in Impella flow, increasing the risk of bleeding, Impella displacement, as well as triggering positioning and pressure alarms. Additionally, hemolytic risk data yielded inconclusive results. Importantly, there were no notable disparities in mortality rates when comparing the combined strategy to the use of each device individually., Conclusion: At the current state-of-the-art, there are no conclusive data demonstrating net clinical benefits of combining Impella with IABP. Considering the substantial risks of morbidity associated, we recommend against its use in clinical practice., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jacopo Farina reports administrative support was provided by University Hospital Arcispedale Sant'Anna of Ferrara Department of Cardiology. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Percutaneous ventricular assist devices are increasingly relied on to maintain perfusion for cardiogenic shock patients. Optimal medical management strategies however remain uncertain from limited understanding of interventricular effects. This study analyzed the effects of pharmacologic and left-sided mechanical support on right ventricular function., Methods: A porcine model was developed to assess biventricular function during bolus pharmacologic administration before and after left-sided percutaneous ventricular assist and in cardiogenic shock., Results: The presence of mechanical support increased right ventricular load and stress with respect to the left ventricle. This shifted and exaggerated the relative effects of commonly used vasoactive agents. Furthermore, induction of cardiogenic shock led to differential pulmonary vascular and right ventricular responses., Conclusions: Left ventricular ischemia and mechanical support altered interventricular coupling. Resulting impacts of pharmacologic agents indicate differential right heart responses and sensitivity to treatments and the need for further study to optimize biventricular function in shock patients., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: This study investigated the optimal timing for percutaneous coronary intervention (PCI) in patients with NSTEMI complicated by heart failure (HF)., Methods: In total, 762 patients with NSTEMI and HF in a multicenter, prospective registry in South Korea were classified according to the Killip classification (Killip class 2, n = 414 and Killip class 3, n = 348) and underwent early (within 24 h) and delayed (after 24 h) PCI. The primary outcome was all-cause mortality which was further analyzed with landmark analysis with two months as a cut-off. Secondary outcomes were cardiovascular death, in-hospital cardiogenic shock (CS), readmission due to HF, and acute myocardial infarction during follow-up., Results: Delayed PCI was associated with lower rates of 2-month mortality (6.1 % vs. 15.8 %, p = 0.007) and in-hospital CS (4.3 % vs. 14.1 %, p = 0.003), along with lower risks of 2-month mortality (hazard ratio [HR] = 0.38, 95 % confidence interval [CI] = 0.18-0.83, p = 0.014), in-hospital CS (HR = 0.29, 95 % CI = 0.12-0.71, p = 0.006) in multivariate Cox models of Killip class 3 patients. There was no statistical difference of incidence and risk of all predefined outcomes according to varying timing of PCI in Killip 2 patients., Conclusions: Based on these results, the timing of PCI in patients with NSTEMI complicated by HF should be determined based on HF severity. Delayed PCI should be considered in patients with NSTEMI and more severe HF., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)