Author + information
- Kevin Morine1,
- Michele Esposito1,
- Shiva Annamalai1,
- Robert Pedicini1,
- Lena Jorde1,
- Kyle Gobeil2,
- Jamie Hernandez-Montfort2 and
- Navin Kapur1
The impact of congestive profile on clinical outcome in patients with cardiogenic shock (CS) supported by acute mechanical circulatory support (AMCS) is not well understood.
We retrospectively analyzed all patients (n=140) between 2012-2016 receiving veno-arterial extra corporeal membrane oxygenation (VA-ECMO) (n=59) or Impella (n=81) for CS at two institutions. Hemodynamic data were available for 106 patients and were used to categorize CS as euvolemic right atrial pressure (RAP)<14 and pulmonary capillary wedge pressure (PCWP) <16], LV-dominant (PCWP>16 only), RV-dominant (RAP>14 only) or biventricular (BiV) congestion.
BiV congestion (56%) was more common than LV-dominant (15%), RV-dominant (14%) or euvolemic shock (14%) (Fig. A). Compared to LV- or RV-dominant congestion, BiV congestion correlated with higher serum creatinine (1.94±1.12, 1.45±0.59, 1.64±1.15 mg/dl, p<0.01 for all comparisons), aspartate aminotransferase (AST) (1178±3281, 588±1774, 299±257 IU/L), alanine aminotransferase (ALT) (541±1264, 358±1041, 161±196 IU/L), and lactate (5±4.1, 3.8±6.7, 4.3±2.6 mEq/L). Euvolemic shock was associated with similar serum creatinine, AST, ALT and lactate compared to LV- and RV-dominant congestion. Mortality was similar among patients with BiV congestion managed with left- or right-sided Impella (44%), BiPella (40%), VA-ECMO without (43%) and with an LV venting strategy (60%). Compared to VA-ECMO, in-hospital mortality was lower among patients with LV-dominant congestion receiving Impella (0 vs. 67%; p<0.01; Fig. B).
BiV congestion is common and associated with worse end organ function compared to univentricular dominant congestion among patients with CS supported by AMCS. Mortality was lower for patients with LV-dominant congestion supported by Impella. Improved understanding of hemodynamics in CS may allow for congestive profile-device matching and potentially improve outcomes.