Search

BACKGROUND: Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited. METHODS AND RESULTS: We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89). CONCLUSIONS: Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.

Objective To observe and compare in-hospital and 1-year survival and prognosis of patients with 4b acute myocardial infarction (AMI) caused by early and late stent thrombosis (ST). Methods A total of 302 patients with 4b acute myocardial infarction caused by ST were enrolled in this study from January 2015 to February 2018. ST patients were confirmed by coronary angiography. These patients were divided into two groups: the early ST group (n=26) and the late ST group (n=276) according to the time of ST occurrence. Endpoint events during hospitalization and one year of follow up were compared between the two groups of patients. The primary endpoint events included cardiac death and recurrent AMI. The secondary endpoint events included target lesion revascularization (TLR), re-stent thrombosis, heart failure and stroke. The incidence of no endpoint events was compared between two groups of patients by Kaplan and Meier survival analysis. Cox regression analysis was used to analyze risk factors for endpoint events in patients with type 4b AMI. Results There was no significant difference in the incidence of the primary endpoint events during hospitalization between the two groups (7.7% vs. 3.3%，P=0.243). The incidence of heart failure was higher in the early ST group than that of the late ST group (11.5% vs.1.4%, P=0.016). There was no significant difference in the incidence rates of other secondary endpoint events between the two groups (P＞0.05). After a mean follow-up of 1 year, the incidence rates of primary endpoint events and the secondary eendpoint events were higher in the early ST group (20.0% vs. 5.9%，P＜0.05 and 36.0% vs. 11.5%，P＜0.01）than that of the late ST group. Kaplan and Meier survival analysis showed that the 1-year cumulative incidences of non-primary (P= 0.022) and non-secondary events (P＜0.001) were lower in the early ST group than those of the late ST group. Cox regression analysis showed that hypertension and history of coronary artery bypass grafting were independent risk factors for primary endpoint events in patients with 4b AMI, and intraoperative implantation of intraaortic balloon pump (IABP) and shortening the time from stent thrombosis to balloon dilation (ST to B) were independent protective factor. Conclusion Early ST patients have similar in-hospital outcomes and poor long-term prognosis compared with late ST induced 4b type AMI patients. Intraoperative implantation of IABP and shortening of ST to B time may improve the prognosis of 4b type AMI patients. [ABSTRACT FROM AUTHOR]

Background: Early risk stratification is necessary for optimal determination of the treatment strategy in cardiogenic shock (CS) complicating acute coronary syndrome (ACS). Therefore, we evaluated the prognostic impact of an intra-aortic balloon pump on the cardiogenic shock (IABP-SHOCK) II score according to the treatment strategies in ACS complicated by CS using the RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock) registry. Methods: The RESCUE registry contains multicenter observational retrospective and prospective cohorts that include 1247 patients with CS from 12 centers in Korea. A total of 865 patients with ACS complicated by CS were selected and stratified into low-, intermediate- and high-risk categories according to their IABP-SHOCK II scores and then according to treatment: non-mechanical support, IABP, and extracorporeal membrane oxygenators (ECMOs). The primary outcome was all-cause mortality during follow-up. Results: The observed mortality rates for the low-, intermediate-, and high-IABP-SHOCK II score risk categories were 28.8%, 52.4%, and 69.8%, respectively (p < 0.01). Patients in the non-mechanical support and IABP groups showed an increasingly elevated risk of all-cause mortality as their risk scores increased from low to high. In the ECMO group, the risk of all-cause mortality did not differ between the intermediate- and high-risk categories (HR = 1.21, 95% CI: 0.81–1.81, p = 0.33). The IABP-SHOCK II scores for the non-mechanical support and IABP groups showed a better predictive performance (area under curve [AUC] = 0.70, 95% CI: 0.65–0.76) for mortality compared with the EMCO group (AUC = 0.61, 95% CI 0.54–0.67; p-value for comparison = 0.02). Conclusions: Risk stratification using the IABP-SHOCK II score is useful for predicting mortality in ACS complicated by CS when patients are treated with non-mechanical support or IABP. However, its prognostic value may be unsatisfactory in severe cases where patients require ECMOs. [ABSTRACT FROM AUTHOR]

BackgroundAcute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with significant morbidity and mortality.MethodsWe provide an overview of previously conducted studies on the use of mechanical circulatory support (MCS) devices in the treatment of AMI-CS and difficulties which may be encountered in conducting such trials in the United States.ResultsWell powered randomized control trials are difficult to conduct in a critically ill patient population due to physician preferences, perceived lack of equipoise and challenges obtaining informed consent.ConclusionsWith growth in utilization of MCS devices in patients with AMI-CS, efforts to perform well-powered, randomized control trials must be undertaken.

Intra-aortic balloon pumps (IABPs) are used to mechanically temporize a failing heart by decreasing afterload while increasing coronary perfusion pressure of the heart while more definitive treatment is sought. We report a case of a 65-year-old male with nonischemic cardiomyopathy, atrial fibrillation, thyroiditis, and non-Hodgkin lymphoma who presented with worsening heart failure. He underwent a percutaneous placement of a left axillary IABP with seemingly no complications. Approximately 3 weeks post-placement, the patient was taken for a heart transplant when an intraoperative transesophageal echo showed that the IABP was in the aortic arch and ascending aorta, instead of its proper placement in the descending aorta. The patient's arterial line showed waveforms appropriate for an IABP patient, and the patient showed no signs indicative of improper placement. This erroneous placement carried the potential to affect the aortic valve function, injure the aortic intima and/or occlude the aortic arch vessels.. [ABSTRACT FROM AUTHOR]

Background Temporal trends in the management of acute coronary syndrome complicated with cardiogenic shock after the revision of guideline recommendations for intra‐aortic balloon pump (IABP) use and the approval of the Impella require further investigation, because their impact remains uncertain. Methods and Results Using the Japanese Percutaneous Coronary Intervention (J‐PCI) registry database from 2019 to 2021, we identified 12 171 patients undergoing percutaneous coronary intervention for acute coronary syndrome complicated with cardiogenic shock under mechanical circulatory support. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella, and (3) venoarterial extracorporeal membrane oxygenation (VA‐ECMO); the VA‐ECMO group was further stratified into (3a) VA‐ECMO alone, (3b) VA‐ECMO in combination with IABP, and (3c) VA‐ECMO in combination with Impella. The quarterly prevalence and outcomes were reported. The use of IABP alone decreased significantly from 63.5% in the first quarter of 2019 to 58.3% in the fourth quarter of 2021 (P for trend=0.01). Among 4245 patients requiring VA‐ECMO, the use of VA‐ECMO in combination with IABP decreased significantly from 78.7% to 67.3%, whereas the use of VA‐ECMO in combination with Impella increased significantly from 4.2% to 17.0% (P for trend

Background: Lymphocytic myocarditis (LM) is a rare inflammatory disease of the heart. The clinical presentation of LM varies from mild flu-like symptoms to fulminant myocarditis with cardiogenic shock. Fulminant myocarditis has a poor prognosis and the usual treatment is inotropes with or without ventricular assist devices such as intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (V-A ECMO). We report the case of fulminant LM with severe cardiogenic shock that was successfully treated with concomitant use of IABP and V-A ECMO. Case Report: A 32-year-old woman with no medical history presented to the Emergency Department (ED) with chest pain with irradiation to the left upper limb, worse when supine. The electrocardiogram (ECG) on admission showed sinus rhythm with nonspecific ST-T repolarization abnormalities, and laboratory results showed elevated ultrasensitive troponin and C-reactive protein. Transthoracic echocardiography (TTE) showed left ventricular ejection fraction (LVEF) of 25% and diffuse hypokinesis. On the next day, she developed cardiogenic shock requiring vasoactive drugs, IABP, and V-A ECMO. Pulse therapy with methylprednisolone was started. Endomyocardial biopsy (EMB) revealed acute LM, and intravenous human immunoglobulin was administered. The patient evolved with progressive clinical improvement, being discharged 56 days after admission, with an improvement in the LVEF to 55%. Conclusions: Fulminant LM is a rare and potentially fatal condition that requires immediate intervention. The combination of IABP and V-A ECMO among patients with LM-cardiogenic shock may provide survival benefits. [ABSTRACT FROM AUTHOR]

BACKGROUND: Sepsis-induced cardiomyopathy is cardiac dysfunction in sepsis that sometimes results in reduced cardiac output. Inotropic agents are recommended in patients with sepsis and cardiac dysfunction. Here, we present a case of sepsis-induced cardiomyopathy that was resistant to inotropes and was successfully treated with intra-aortic balloon pumping (IABP). We also reviewed the literature on similar cases of sepsis-induced cardiomyopathy treated with IABP. CASE REPORT: A 40-year-old woman with fever and hypotension was admitted to a university hospital. Laboratory test results showed elevated inflammatory markers and cardiac markers, such as creatinine kinase-MB and troponin T. Echocardiography revealed severe left ventricular hypokinesis, and cardiac monitoring revealed a low cardiac output. The patient received antimicrobials, vasopressors, and dobutamine; however, her circulatory status did not respond to these treatments. IABP was introduced 7 h after admission and dramatically increased her blood pressure and cardiac output, resulting in the reduction of vasopressor and dobutamine doses. The patient survived without any IABP-related complications. The literature review of 11 cases of sepsis-induced cardiomyopathy treated with IABP shows consistent results with the presented case in terms of positive effects of IABP on circulatory status and cardiac function, resulting in a reduction of inotropes. CONCLUSIONS: Some sepsis-induced cardiomyopathy cases with reduced left ventricular function may not respond to inotropes. IABP would be a treatment option for these patients because of its positive effects on cardiac and circulatory functions. [ABSTRACT FROM AUTHOR]

BACKGROUND: The objective of this study was to characterize practical use trends and outcomes for intraaortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) use in cardiogenic shock at a national level. METHODS: An analysis of all adult patients admitted nonelectively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample. Trends of inpatient IABP and pVAD use were analyzed using survey-weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights were used to perform risk-adjusted analyses of pVAD mortality, a composite of adverse events (AE), and resource use, with IABP as reference. RESULTS: Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051 received a device: IABP, 127,792 (16.5%); or pVAD, 15,259 (2.0%). IABP use decreased (23.8% to 12.7%; P for trend

Key Clinical Message: Even if cardiac rhythm deteriorated to asystole in the clinical course of fulminant myocarditis, cardiac function may recover, and the patient may be discharged without brain damage, if circulation could be maintained by appropriate mechanical cardiac supports. A 69‐year‐old man was diagnosed with fulminant myocarditis with circulatory collapse. His cardiac rhythm deteriorated to asystole on the second day; however, circulatory status was maintained through extracorporeal membrane oxygenation and intra‐aortic balloon pumping. After 38 h‐lasting asystole, his heart resumed beating. He was discharged without neurological deficits on Day 25. [ABSTRACT FROM AUTHOR]

Key Clinical Message Even if cardiac rhythm deteriorated to asystole in the clinical course of fulminant myocarditis, cardiac function may recover, and the patient may be discharged without brain damage, if circulation could be maintained by appropriate mechanical cardiac supports. Abstract A 69‐year‐old man was diagnosed with fulminant myocarditis with circulatory collapse. His cardiac rhythm deteriorated to asystole on the second day; however, circulatory status was maintained through extracorporeal membrane oxygenation and intra‐aortic balloon pumping. After 38 h‐lasting asystole, his heart resumed beating. He was discharged without neurological deficits on Day 25.

Background: Early risk stratification is necessary for optimal determination of the treatment strategy in cardiogenic shock (CS) complicating acute coronary syndrome (ACS). Therefore, we evaluated the prognostic impact of an intra-aortic balloon pump on the cardiogenic shock (IABP-SHOCK) II score according to the treatment strategies in ACS complicated by CS using the RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock) registry. Methods: The RESCUE registry contains multicenter observational retrospective and prospective cohorts that include 1247 patients with CS from 12 centers in Korea. A total of 865 patients with ACS complicated by CS were selected and stratified into low-, intermediate- and high-risk categories according to their IABP-SHOCK II scores and then according to treatment: non-mechanical support, IABP, and extracorporeal membrane oxygenators (ECMOs). The primary outcome was all-cause mortality during follow-up. Results: The observed mortality rates for the low-, intermediate-, and high-IABP-SHOCK II score risk categories were 28.8%, 52.4%, and 69.8%, respectively (p < 0.01). Patients in the non-mechanical support and IABP groups showed an increasingly elevated risk of all-cause mortality as their risk scores increased from low to high. In the ECMO group, the risk of all-cause mortality did not differ between the intermediate- and high-risk categories (HR = 1.21, 95% CI: 0.81–1.81, p = 0.33). The IABP-SHOCK II scores for the non-mechanical support and IABP groups showed a better predictive performance (area under curve [AUC] = 0.70, 95% CI: 0.65–0.76) for mortality compared with the EMCO group (AUC = 0.61, 95% CI 0.54–0.67; p-value for comparison = 0.02). Conclusions: Risk stratification using the IABP-SHOCK II score is useful for predicting mortality in ACS complicated by CS when patients are treated with non-mechanical support or IABP. However, its prognostic value may be unsatisfactory in severe cases where patients require ECMOs.

The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available. [ABSTRACT FROM AUTHOR]

BACKGROUND: Some patients require intra-aortic balloon pump (IABP) after coronary artery bypass graft (CABG) surgery. IABP can be adjusted to different frequencies such as 1:1, 1:2, or 1:3. In this study, we tried to compare the effect of 1:1 and 1:2 frequencies of IABP on hemodynamic status of the patients after CABG surgery. METHODS: In this experimental study, all patients using IABP after CABG surgery were entered the study as pretest and posttest groups. The study could not be blinded because of the clearness of posttest group for the same echocardiographist. The pretest group included patients using a 1:1 frequency of IABP device. The posttest group included patients in the pretest group who were exposed to a 1:2 frequency for 20 minutes. In both groups, on the moderate dose of inotropic support, hemodynamic parameters of patients including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), cardiac index (CI), stroke volume (SV), and velocity time integral (VTI) in the aorta during systole were measured. Both groups were compared using Wilcoxon signed rank test. SPSS software was used for analysis and P < 0.05 was considered to be statistically significant. RESULTS: Twelve patients were entered into the study. Three patients were excluded because of open chest and instability of vital signs. Nine patients completed the study. 3 patients were men and 6 were women. The mean age was 58.32 ± 13.18 years. MAP in 1:1 frequency was significantly higher than 1:2 (P = 0.043); however, there was no significant difference between 1:1 and 1:2 in other hemodynamic parameters, namely CO, CI, SV, HR, and VTI. CONCLUSION: In patients on moderate dose of inotropes, IABP frequencies of 1:1 and 1:2 have the same effect on hemodynamic parameters such as CI, SBP, DBP, HR, and left ventricular outflow tract (LVOT) VTI; meanwhile, MAP remains higher in 1:1 frequency. [ABSTRACT FROM AUTHOR]

The patient in case 1 was a 50-year-old man who presented to the emergency department of the local hospital with chest pain and syncope for 3 hours due to acute myocardial infarction. He underwent cardiopulmonary resuscitation (CPR) followed by extracorporeal membrane oxygenation (ECMO), and intestinal perforation was detected on day 9. The patient in case 2 was a 58-year-old man who was admitted to the hospital with abdominal pain lasting for 3 days. He also required CPR and ECMO for cardiogenic shock, and intestinal perforation was identified on day 7 of ECMO. We believe that this case report will be important to alert clinicians to the possibility of this complication and to encourage early detection and intervention to improve prognosis. Conventionally, the gastrointestinal tract has received secondary attention in patients receiving ECMO support because the vital organs tend to be considered first. However, this case report illustrates the importance of monitoring gastrointestinal function in patients undergoing ECMO. [ABSTRACT FROM AUTHOR]

Despite the increasing utilization of mechanical circulatory support (MCS) devices, the 4Ts and heparin-induced thrombocytopenia (HIT) Expert Probability (HEP) scores have not been validated in patients with suspected HIT requiring MCS. A retrospective cohort study. At a tertiary university hospital. Adults with suspected HIT requiring any MCS. A diagnostic investigation of HIT. Of the 299 patients included, there were 374 diagnostic investigations of HIT, of which 32 (8.6%) were HIT-probable (heparin PF4 immunoassay optical density ≥1 or positive serotonin release assay). The 4Ts score ≥4 demonstrated a pretest sensitivity of 0.56 (95% confidence interval [CI]: 0.39-0.72) and specificity of 0.8 (95% CI: 0.75-0.83). The HEP score ≥3 demonstrated a pretest sensitivity of 0.31 (95% CI: 0.18-0.49) and specificity of 0.83 (95% CI: 0.79-0.87). The area under the receiver operating characteristic curve for the 4Ts and HEP scores were 0.68 (95% CI: 0.63-0.73) and 0.63 (95% CI: 0.59-0.68), respectively, and were not statistically different (p = 0.21). In patients with an intra-aortic balloon pump, neither the 4Ts nor HEP score had discriminatory ability to differentiate probable HIT. The HEP score had no discriminatory ability in patients with concomitant MCS devices. The 4Ts and HEP scores have a modest predictive performance for probable HIT in patients requiring MCS devices. A low 4Ts or HEP score does not reliably rule out HIT in patients requiring MCS, and clinical suspicion for HIT should be investigated, utilizing laboratory tests in this population. [ABSTRACT FROM AUTHOR]

Data analysis was performed on IABP (intra-aortic balloon pump) patients for the use of anticoagulants, pulse of dorsalis pedis artery, D-dimer data, and coagulation function. According to the differential diagnosis of 52 patients admitted to hospital, data on the use of anticoagulants, dorsalis pedis artery pulsation, D-dimer data, and coagulation function were collected. These data were analyzed by using a nonparametric test, linear regression analysis, adjustment effect analysis, and chi-square test. Some findings of the analysis included: (1) There were differences in the dorsalis pedis artery pulsation of samples from different sexes, all of which were significant. (2) Coagulation function has a significant positive relationship with D-dimer. (3) When the D-dimer affects the prognosis, the regulatory variable (dorsalis pedis artery pulse) is at different levels, and the influence amplitude has significant differences. (4) Samples taken with different anticoagulants all showed significant differences in the dorsalis pedis artery pulsation.

Background Clinical outcomes of acute myocardial infarction complicated by cardiogenic shock remain poor with high in‐hospital mortality. Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) has been widely used for patients with acute myocardial infarction complicated by cardiogenic shock refractory to conservative therapy, which is likely fatal without mechanical circulatory support. However, whether additional intra‐aortic balloon pumping (IABP) use during VA‐ECMO support improves clinical outcomes remains controversial. This study sought to investigate prognostic impact of the combined VA‐ECMO plus IABP treatment compared with VA‐ECMO alone. Methods and Results From the nationwide Japanese administrative case‐mix Diagnostic Procedure Combination (DPC), the JROAD (Japanese Registry of All Cardiac and Vascular Diseases)–DPC, we identified 3815 patients with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention and managed with VA‐ECMO. Of these, 2964 patients (77.7%) were managed with IABP (VA‐ECMO plus IABP), whereas 851 (22.3%) were managed without IABP (VA‐ECMO alone). We compared in‐hospital, 7‐day, and 30‐day mortality between the VA‐ECMO plus IABP versus the VA‐ECMO alone support. Patients managed with VA‐ECMO plus IABP demonstrated significantly lower in‐hospital, 7‐day, and 30‐day mortality than those managed with VA‐ECMO alone (adjusted odds ratios [95% CI] of 0.47 [95% CI, 0.38–0.59], 0.41 [95% CI, 0.33–0.51], and 0.30 [95% CI, 0.25–0.37], respectively). The findings were consistent in the propensity matching and inverse probability of treatment‐weighting models. Conclusions This large‐scale, nationwide study demonstrated that the combination of VA‐ECMO plus IABP support was associated with significantly lower mortality compared with VA‐ECMO support alone in patients presenting with acute myocardial infarction complicated by cardiogenic shock who underwent primary percutaneous coronary intervention.

• Intra-aortic balloon pumping (IABP) was used in 89% of acute myocardial infarction (AMI) cases receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in Japan. • IABP use was associated with a lower risk of 30-day death in AMI cases with VA-ECMO. • The robustness of this association was confirmed with multivariate imputation by chained equations and inverse probability of treatment weighting methods. The prognostic significance of combining intra-aortic balloon pumping (IABP) with extracorporeal membrane oxygenation (ECMO) for acute myocardial infarction (AMI) patients is still unclear. We investigated whether combining IABP with veno-arterial (VA)-ECMO is associated with a lower risk of short-term mortality. Among 12,093 AMI cases enrolled in the Osaka Acute Coronary Insufficiency Study (OACIS), we identified 519 who were administered VA-ECMO during hospitalization. Among these, 459 received IABP support (IABP group) and 60 cases did not (no-IABP group). The primary endpoint was 30-day all-cause death; the secondary endpoint was major bleeding. Logistic regression analysis using original data was conducted. We also established weighted logistic regression models with inverse probability of treatment weighting (IPTW). Logistic regression analysis revealed that IABP use was significantly associated with a reduced risk of 30-day death in the original data [odds ratio (OR) 0.504, 95% confidence interval (CI) 0.282–0.901, p = 0.021]. After IPTW-adjustment for clinically relevant covariates with the use of IABP, patients receiving VA-ECMO with IABP had a lower risk of 30-day death (OR 0.816, 95% CI 0.746–0.892, p < 0.001) compared to those without IABP. The incidence of major bleeding was comparable between the groups (IABP 29.0% vs. non-IABP 21.7%, p =0.302). However, the risk of major bleeding was higher in the IABP group after IPTW-adjustment (OR 1.092, 95% CI 1.008-1.184, p =0.032). IABP support for AMI patients with VA-ECMO was significantly associated with reduced risk of short-term mortality, suggesting that the addition of IABP support might contribute to improved survival in AMI patients requiring VA-ECMO. [Display omitted] [ABSTRACT FROM AUTHOR]

Abstract Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been proposed as a novel approach to managing non‐traumatic cardiac arrest (NTCA). During cardiac arrest, cardiac output ceases and perfusion of vital organs is compromised. Traditional advanced cardiac life support (ACLS) measures and cardiopulmonary resuscitation are often unable to achieve return of spontaneous circulation (ROSC). During insertion of REBOA a balloon‐tipped catheter is placed into the femoral artery and advanced in a retrograde manner into the aorta while the patient is undergoing cardiopulmonary resuscitation (CPR). The balloon is then inflated to fully occlude the aorta. The literature surrounding the use of aortic occlusion in non‐traumatic cardiac arrest is limited to animal studies, case reports and one recent non‐controlled feasibility trial. In both human and animal studies, preliminary data show that REBOA may improve coronary and cerebral perfusion pressures and key physiologic parameters during cardiac arrest resuscitation, and animal data have demonstrated improved rates of ROSC. Multiple questions remain before REBOA can be considered as an adjunct to ACLS. If demonstrated to be effective clinically, REBOA represents a potentially cost‐effective and generalizable intervention that may improve quality of life for patients with non‐traumatic cardiac arrest.

Abstract Objective: To evaluate the mid-term survival rate after tricuspid valve replacement (TVR). Methods: We retrospectively studied 110 consecutive patients who underwent TVR from January 2007 to November 2017. A survival analysis was performed with the Kaplan-Meier method and the log-rank test. Results: The median survival was 65.81 months. Mean age was 50 (range 39 to 59) years. Forty-eight patients (43.6%) were male, and 62 patients (56.4%) were female. Most of the patients (78.5%) were categorized into the New York Heart Association (NYHA) functional classes III/IV. Seventy-two patients (65.5%) had isolated TVR. Six-three patients (57.3%) had previously undergone heart surgery. The Kaplan-Meier survival rates at one year, three years, and five years were 59.0%±5%, 52.0%±6%, and 48.0%±6%, respectively. A Cox regression analysis demonstrated that the risk factors for mid-term mortality were advanced NYHA class (hazard ratio [HR] 2.430, 95% confidence interval [CI] 1.099-5.375, P=0.028), need for continuous renal replacement therapy (CRRT) treatment (HR 3.121, 95% CI 1.610-6.050, P=0.001), and need for intra-aortic balloon pump (IABP) treatment (HR 3.356, 95% CI 1.072-10.504, P=0.038). Conclusion: In TVR, impaired cardiac function before the operation and a need for CRRT or IABP treatment after the operation is independently associated with increased mid-term mortality.

Background: The axillary artery (AX) access for intra-aortic balloon pump (IABP) as a bridge to heart transplant (HT) allows mobility while awaiting a suitable donor. As end-stage heart failure patients often have an implantable cardioverter defibrillator (ICD) on the left side, the left AX approach may be avoided due to the perception of difficult access and proximity of two devices. We aimed to evaluate the outcomes of patients bridged to HT with a left-sided AX IABP with or without ipsilateral ICDs., Methods: We retrospectively reviewed HT candidates at our institution supported by left-sided axillary IABP from November 2019 to February 2024, dividing them into two groups based on the presence (Group ICD, n = 48) or absence (Group No-ICD, N = 19) of an ipsilateral left-sided ICD. The exposure time was defined as the time from skin incision to the beginning of anastomoses of a Dacron graft., Results: Technical success was achieved in 100% of the cohort, with median exposure times for AX access similar between groups (ICD, 12 [7.8, 18.2] vs. No ICD, 11 [7, 19] min; p = 0.75). The rate of procedural adverse events, such as significant access site bleeding and ipsilateral limb ischemia, did not significantly differ between both groups. Device malfunction rates were comparable (ICD, 29.2% vs. No ICD, 15.8%; p = 0.35). Posttransplant, in-hospital mortality, severe primary graft dysfunction, and stroke rates were comparable in both groups., Conclusion: The presence of an ipsilateral left-sided ICD does not adversely impact the procedural efficacy, complication rates, or posttransplant outcomes of left-sided AX IABP insertion in HT candidates., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Intro-aortic balloon pump (IABP) is widely used in cardiac surgery patients nowadays. This study aimed to analyze the predictor of short-term survival in cardiac valvular surgery patients with intra-aortic balloon pump implantation., Methods: This was a retrospective study and a total of 102 cardiac valvular surgery patients who received intra-aortic balloon pump implantation were consecutively included. We retrospectively collected the baseline characteristics and short-term outcomes. Baseline characteristics were compared between survivors with non-survivors, and logistic regression was performed to identify predictors for short-term mortality., Results: Among all the patients, there were 71 (69.6%) patients successfully weaned from IABP and survived to discharge, the other 31 (30.4%) patients failed to wean from IABP and died within the first 30 days after surgery. When compared with non-survivors, survivors had a higher proportion of males (62% vs 32.3%, p = 0.006), a lower rate of Atrial fibrillation (38% vs 62%, p < 0.03). After IABP implantation, vasoactive drug use was significantly lower in survivors compared with non-survivors, and survivors showed significant improvements in cardiac function and urine volume. Univariate and multivariate logistic regression analysis indicated that atrial fibrillation and combined use of continuous renal replacement therapy (CRRT) were significant independent predictors for short-term mortality., Conclusion: Timely implantation of IABP can improve patients' cardiac and renal function and reduce the dosage of vasoactive drugs. Atrial fibrillation and combined use of CRRT are independent predictors for short-term mortality in patients who underwent cardiac valvular surgery with IABP implantation., (© 2023. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

Machine learning algorithms are frequently used to clinical risk prediction. Our study was designed to predict risk factors of prolonged intra-aortic balloon pump (IABP) use in patients with coronary artery bypass grafting (CABG) through developing machine learning-based models. Patients who received perioperative IABP therapy were divided into two groups based on their length of IABP implantation longer than the 75th percentile for the whole cohort: normal (≤ 10 days) and prolonged (> 10 days) groups. Seven machine learning-based models were created and evaluated, and then the Shapley Additive exPlanations (SHAP) method was employed to further illustrate the influence of the features on model. In our study, a total of 143 patients were included, comprising 56 cases (38.16%) in the prolonged group. The logistic regression model was considered the final prediction model according to its most excellent performance. Furthermore, feature important analysis identified left ventricular end-systolic or diastolic diameter, preoperative IABP use, diabetes, and cardiac troponin T as the top five risk variables for prolonged IABP implantation in patients. The SHAP analysis further explained the features attributed to the model. Machine learning models were successfully developed and used to predict risk variables of prolonged IABP implantation in patients with CABG. This may help early identification for prolonged IABP use and initiate clinical interventions., (© 2024. The Author(s).)

Background: The aim of this study was to determine whether pre-operative intra-aortic balloon pump (IABP) insertion improves surgical outcomes in high-risk coronary artery bypass grafting (CABG) patients., Methods: Patients with a EuroSCORE II greater than 1.2% who underwent CABG from 2009 to 2016 were included in the study, while those who utilized intra-operative or post-operative IABP were excluded. The analysis included a total of 2907 patients, with 377 patients undergoing preoperative IABP insertion (EuroSCORE II > 5.018%) and 1198 patients in the non-IABP group before matching; after propensity score matching (PSM), both groups consisted of a matched cohort of 250 patients., Results: 30-day mortality events occurred in 9 (3.6%) non-IABP group and in 12 (4.8%) IABP patients (OR: 1.33 95%CI: 0.52-3.58). Kaplan-Meier survival curve analysis showed no significant differences between the two groups in mortality up to one year after the operation (p = 0.72). On multivariate analysis, IABP usage among the PSM patients was associated with lower 30-day mortality (OR: 0.28, 95%CI: 0.07-0.92, P-value = 0.043), 90-day mortality (OR: 0.26, 95%CI: 0.08-0.78, P-value = 0.022) and reduced risk of developing severe respiratory disorders (OR: 0.10, 95%CI:0.01-0.50, P-value = 0.011)., Conclusion: Pre-operative IABP use in high-risk patients reduces 30- and 90-day mortality rates, along with a notable decrease in rates of severe respiratory disorders., (© 2024. The Author(s).)

Background: Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage., Case Presentation: A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful., Conclusion: We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases., (© 2024. The Author(s).)

BackgroundWith conflicting evidence regarding the usefulness of intraaortic balloon pump (IABP), reports of IABP use in the United States have been inconsistent. Our objective was to examine trends in IABP usage in percutaneous coronary intervention (PCI) in the United States and to evaluate the association of IABP use with mortality.MethodsThis is a retrospective, observational study using patient data obtained from the Nationwide Inpatient Sample database from 1998 to 2008. Patients undergoing any PCI (1,552,602 procedures) for a primary diagnosis of symptomatic coronary artery disease and acute coronary syndrome, including non-ST-elevation myocardial infarction and ST-elevation myocardial infarction, were evaluated.ResultsThe overall use of IABP significantly decreased during the study period from 0.99% in 1998 to 0.36% in 2008 (univariate and multivariate P for trend < .0001). Patients who received IABP had substantially higher rates of shock compared with those who did not receive IABP (38.09% vs 0.70%; P < .0001), which was associated with markedly higher inhospital mortality rates (20.31% vs 0.72%; P < .0001). However, IABP use significantly decreased in patients with shock (36.5%-13.4%) and acute myocardial infarction (2.23%-0.84%) (univariate and multivariate P for trend for both < .0001). A temporal reduction in all-cause PCI-associated mortality from 1.1% in 1998 to 0.86% in 2008 (univariate and multivariate P for trend < .0001) was also observed.ConclusionsThe utilization of IABP associated with PCI significantly decreased between 1998 and 2008 in the United States, even among patients with acute myocardial infarction and shock.

BACKGROUND: Data on relative safety, efficacy, and role of different percutaneous left ventricular assist devices for hemodynamic support during the ventricular tachycardia (VT) ablation procedure are limited. METHODS AND RESULTS: We performed a multicenter, observational study from a prospective registry including all consecutive patients (N=66) undergoing VT ablation with a percutaneous left ventricular assist devices in 6 centers in the United States. Patients with intra-aortic balloon pump (IABP group; N=22) were compared with patients with either an Impella or a TandemHeart device (non-IABP group; N=44). There were no significant differences in the baseline characteristics between both the groups. In non-IABP group (1) more patients could undergo entrainment/activation mapping (82% versus 59%; P=0.046), (2) more number of unstable VTs could be mapped and ablated per patient (1.05±0.78 versus 0.32±0.48; P

BackgroundLimited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI).Methods and resultsWe queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)

Abstract Background The patient state index (PSI) is a parameter of a four-channel electroencephalography (EEG)-derived variable used to assess the depth of anesthesia. A PSI value of 25–50 indicates adequate state of hypnosis, and a value of 100 indicates a fully awake state. Due to reduced interference from electronic devices like electrocautery, falsely high intraoperative PSI values are rarely reported. However, this case report cautions about falsely high PSI during cardiopulmonary bypass (CPB) with intra-aortic balloon pumping (IABP). Case presentation A 68-year-old man was scheduled for coronary artery bypass graft surgery with IABP. General anesthesia was maintained using sevoflurane. Initial PSI was between 30 and 50 before CPB. Propofol was administered during CPB, and IABP provided pulsatile flow. IABP was stopped soon after the initiation of CPB, and the ascending aorta was partially clamped to anastomose the saphenous vein graft to the ascending aorta. The PSI value decreased drastically, but with resumption of IABP, the value increased to approximately 80, despite increasing the dose of anesthetics. Meanwhile, the EEG waveform was nearly flat. After discontinuing CPB, the PSI value returned to being extremely low. There was no evidence of intraoperative awareness or instrument trouble. After reviewing the anesthesia record, the high PSI value was almost consistent with ongoing IABP during CPB. We suspect that the oscillation noise created by IABP during CPB erroneously influences the PSI algorithm, resulting in a falsely high PSI. Conclusions Anesthesiologists should note that adherence to pEEG-derived values without discretion may cause errors when monitoring the depth of anesthesia.

Background: The new heart allocation policy places veno-arterial extracorporeal membrane oxygenation (VA-ECMO)-supported heart transplant (HT) candidates at the highest priority status. Despite increasing evidence supporting left ventricular (LV) unloading during VA-ECMO, the effect of LV unloading on transplant outcomes following bridging to HT with VA-ECMO remains unknown., Methods and Results: From October 18, 2018 to March 21, 2023, 624 patients on VA-ECMO at the time of HT were identified in the United Network for Organ Sharing database and were divided into 2 groups: VA-ECMO alone (N=384) versus VA-ECMO with LV unloading (N=240). Subanalysis was performed in the LV unloading group: Impella (N=106) versus intra-aortic balloon pump (N=134). Recipient age was younger in the VA-ECMO alone group (48 versus 53 years, P =0.018), as was donor age (VA-ECMO alone, 29 years versus LV unloading, 32 years, P =0.041). One-year survival was comparable between groups (VA-ECMO alone, 88.0±1.8% versus LV unloading, 90.4±2.1%; P =0.92). Multivariable Cox hazard model showed LV unloading was not associated with posttransplant mortality after HT (hazard ratio, 0.92; P =0.70). Different LV unloading methods had similar 1-year survival (intra-aortic balloon pump, 89.2±3.0% versus Impella, 92.4±2.8%; P =0.65). Posttransplant survival was comparable between different Impella versions (Impella 2.5, versus Impella CP, versus Impella 5.0, versus Impella 5.5)., Conclusions: Under the current allocation policy, LV unloading did not impact waitlist outcome and posttransplant survival in patients bridged to HT with VA-ECMO, nor did mode of LV unloading. This highlights the importance of a tailored approach in HT candidates on VA-ECMO, where routine LV unloading may not be universally necessary.

Background: This study aimed to describe the use of perioperative mechanical circulatory support (MCS) and its impact on outcomes in patients with ischemic cardiomyopathy who were undergoing surgical revascularization., Methods: Patients with an ejection fraction <35% who underwent isolated coronary artery bypass grafting (CABG) from 2015 to 2021 were identified (N = 378). Patients were divided into no MCS, preoperative MCS, and postoperative MCS groups on the basis of timing of MCS initiation, which included intraaortic balloon pump, extracorporeal membrane oxygenation, or Impella device (Abiomed) use. The primary outcome of interest was operative mortality., Results: The median Society of Thoracic Surgeons Predicted Risk of Mortality was 2.4%. Sixty-six percent (n = 246) of patients had a previous myocardial infarction, and 61.8% of these patients were within 21 days of CABG. Twenty-one patients (5.6%) presented in cardiogenic shock. The preoperative MCS cohort consisted of 31 patients (8.2%) who underwent CABG a median of 2 days after MCS initiation. Thirty (7.9%) patients required postoperative MCS. Independent risk factors for requiring postoperative MCS included the preoperative ejection fraction (odds ratio, 0.93; P = .01 and the presence of preoperative MCS (odds ratio, 3.06; P = .02). Overall, operative mortality was 3.4%, and 3-year survival was 87.0%. Operative mortality in patients who did and did not receive preoperative MCS was 7.7% and 2.9% (P = .12) with no difference in long-term survival (P = .80), whereas patients requiring postoperative MCS had significantly increased operative (16.7%) and late mortality (63%; P <.01)., Conclusions: CABG can be performed safely in patients with ischemic cardiomyopathy with selective use of perioperative MCS. Despite advanced disease severity, patients requiring preoperative MCS demonstrate acceptable short- and long-term survival. Patients requiring postoperative MCS have increased postoperative morbidity and mortality., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Cardiogenic shock is a lethal condition with significant morbidity, characterized by myocardial insults leading to low cardiac output and ensuing systemic hypoperfusion. While mortality rates remain high, we have improved upon our recognition and definition of cardiogenic shock, now with an emphasis on defining stages of shock to help guide effective treatment strategies with either pharmacologic or mechanical circulatory support. In this review, the authors summarize these stages as well as discuss indications, function, selection, and troubleshooting of the various temporary mechanical circulatory support devices., Competing Interests: Disclosure None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This single-center, observational study assessed the impact of age, gender, and body mass index (BMI) in patients with cardiogenic shock (CS) on temporary mechanical circulatory support. All adult patients admitted to the Cleveland Clinic main campus Cardiac Intensive Care Unit (CICU) between December 1, 2015, to December 31, 2019, CICU with CS necessitating mechanical circulatory support (MCS) with intra-aortic balloon pump, Impella, or venous arterial-extra corporeal membrane oxygenation were retrospectively analyzed for this study. Baseline characteristics and 30-day outcomes were collected through physician-directed chart review. The impact of age, gender, and BMI on 30-day mortality was assessed using multivariable logistic regression. Kaplan-Meier survival curves were used to analyze the survival difference in specific subsets. A total of 393 patients with CS on temporary MCS were admitted to our CICU during the study period. The median age of our cohort was 63 years (interquartile range 54 to 70 years), median BMI was 28.50 kg/m 2 (interquartile range 24.62 to 29.72) and 70% (n = 276) were men. In total, 22 patients >80 years had received MCS compared with 372 patients <80 years. Patients >80 years on MCS had significantly higher 30-day mortality compared with those <80 years (81.8% vs 49.3%, p = 0.006). Upon stratifying patients by BMI, 161 (41%) patients were found to have BMI ≥30 kg/m 2 whereas 232 (59%) patients had BMI <30 kg/m 2 . Comparison of 30-day mortality revealed that patients with BMI ≥30 did significantly worse than patients with BMI <30 (59.6% vs 45.3%, p = 0.007). There was no difference in 30-day mortality between men and women. On multivariable logistic regression, both age and BMI had a positive linear relation with adjusted 30-day mortality whereas gender did not have a major effect. Advanced age and higher BMI are independently associated with worse outcomes in patients with CS on MCS. Utilizing a strict selection criterion for patients in CS is pertinent to derive the maximum benefit from advanced mechanical support., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose of Review: This review will focus on the indications of mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI) and then analyze in detail all MCS devices available to the operator, evaluating their mechanisms of action, pros and cons, contraindications, and clinical data supporting their use., Recent Findings: Over the last decade, the interventional cardiology arena has witnessed an increase in the complexity profile of the patients and lesions treated in the catheterization laboratory. Patients with significant comorbidity burden, left ventricular dysfunction, impaired hemodynamics, and/or complex coronary anatomy often cannot tolerate extensive percutaneous revascularization. Therefore, a variety of MCS devices have been developed and adopted for high-risk PCI. Despite the variety of MCS available to date, a detailed characterization of the patient requiring MCS is still lacking. A precise selection of patients who can benefit from MCS support during high-risk PCI and the choice of the most appropriate MCS device in each case are imperative to provide extensive revascularization and improve patient outcomes. Several new devices are being tested in early feasibility studies and randomized clinical trials and the experience gained in this context will allow us to provide precise answers to these questions in the coming years., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: With the growing population of advanced heart failure, the use of Impella 5.5 has been increasing. Here, we report an effective strategy of removing the intra-aortic balloon pump (IABP) in the setting of escalation of support to Impella 5.5. Results: From January 1, 2022 to June 30, 2022, a total of 6 patients have undergone IABP removal during Impella 5.5 insertion. The IABP was subsequently removed over the long wire with manual compression on the femoral artery to control bleeding. An 8 or 9 Fr short sheath is inserted over the wire. Staged hemostasis was successfully performed in 4 patients, and the remaining two patients required escalation of support to veno-arterial membrane oxygenation as EC-PELLA utilizing the femoral arterial sheath. Conclusion: This does not only achieve secured hemostasis but also enables a smooth transition to further escalate support such as extracorporeal membrane oxygenation support, if necessary., 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.

We review the pharmacologic, interventional and device programming treatment options for patients with implantable cardioverter-defibrillators who present with acute heart failure and implantable cardioverter-defibrillator shocks.

Objective: This study aimed to investigate the clinical characteristics and impact of intra-aortic balloon pump (IABP) implantation on the prognosis of patients with anaphylactic shock (AS) during cardiac catheterization. Methods: We analyzed the medical records of 34 patients who had AS caused by iodine contrast media (ICM) between January 2009 and December 2019. Clinical features and treatments were analyzed, and patients were categorized into survival and dead groups. In addition, the patients were further divided into IABP and non-IABP (NIABP) groups to assess the impact on AS according to whether a IABP was used or not. Results: Of the 417,938 patients in whom ICM was used, 34 with AS were monitored. The prevalence of AS was 0.008%. Among the 34 patients, 6 (0.001%) died from fatal anaphylactic reactions accompanying shock, 26 (76.5%) had hypotension as the first presentation of AS in the survival and dead groups (78.6% and 66.7%, respectively), and 5 (14.7%) had unconsciousness at the initial onset of AS. The subgroup analysis revealed a higher mortality in the IABP group than in the NIABP (4/9, 44.4% vs. 2/25, 8%; P = 0.031). Conclusions: The present study suggests a low prevalence of ICM-related AS. Hypotension was more frequent in AS related to ICM, and unconsciousness at the initial onset of AS implied a poor prognosis. The use of an IABP did not improve the outcome of the patients with AS. IABP implantation should not be used as a routine treatment for patients with AS.

Copyright of Herz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Impella was approved for mechanical circulatory support (MCS) in 2008, but large-scale, real-world data on its use are lacking. Our objective was to describe trends and variations in Impella use, clinical outcomes, and costs across US hospitals in patients undergoing percutaneous coronary intervention (PCI) treated with MCS (Impella or intra-aortic balloon pump).Methods: From the Premier Healthcare Database, we analyzed 48 306 patients undergoing PCI with MCS at 432 hospitals between January 2004 and December 2016. Association analyses were performed at 3 levels: time period, hospital, and patient. Hierarchical models with propensity adjustment were used for association analyses. We examined trends and variations in the proportion of Impella use, and associated clinical outcomes (in-hospital mortality, bleeding requiring transfusion, acute kidney injury, stroke, length of stay, and hospital costs).Results: Among patients undergoing PCI treated with MCS, 4782 (9.9%) received Impella; its use increased over time, reaching 31.9% of MCS in 2016. There was wide variation in Impella use across hospitals (>5-fold variation). Specifically, among patients receiving Impella, there was a wide variation in outcomes of bleeding (>2.5-fold variation), and death, acute kidney injury, and stroke (all ≈1.5-fold variation). Adverse outcomes and costs were higher in the Impella era (years 2008-2016) versus the pre-Impella era (years 2004-2007). Hospitals with higher Impella use had higher rates of adverse outcomes and costs. After adjustment for the propensity score, and accounting for clustering of patients by hospitals, Impella use was associated with death: odds ratio, 1.24 (95% CI, 1.13-1.36); bleeding: odds ratio, 1.10 (95% CI, 1.00-1.21); and stroke: odds ratio, 1.34 (95% CI, 1.18-1.53), although a similar, nonsignificant result was observed for acute kidney injury: odds ratio, 1.08 (95% CI, 1.00-1.17).Conclusions: Impella use is rapidly increasing among patients undergoing PCI treated with MCS, with marked variability in its use and associated outcomes. Although unmeasured confounding cannot be ruled out, when analyzed by time periods, or at the hospital level or the patient level, Impella use was associated with higher rates of adverse events and costs. More data are needed to define the appropriate role of MCS in patients undergoing PCI. [ABSTRACT FROM AUTHOR]