Timing of mechanical circulatory support in patients with cardiogenic shock

J. Sundermeyer (Hamburg)¹, C. Kellner (Hamburg)¹, B. Beer (Hamburg)¹, A. Dettling (Hamburg)², L. C. Besch (Hamburg)¹, S. Blankenberg (Hamburg)¹, I. Eitel (Lübeck)³, D. Frank (Kiel)⁴, N. Frey (Heidelberg)⁵, T. Graf (Lübeck)³, P. Kirchhof (Hamburg)⁶, J. Krais (Regensburg)⁷, D. von Lewinski (Graz)⁸, N. Mangner (Dresden)⁹, S. Möbius-Winkler (Jena)¹⁰, P. Nordbeck (Würzburg)¹¹, M. Orban (München)¹², M. Pauschinger (Nürnberg)¹³, C. M. Sag (Regensburg)⁷, C. Scherer (München)¹², C. Skurk (Berlin)¹⁴, H. Thiele (Leipzig)¹⁵, D. Westermann (Freiburg im Breisgau)¹⁶, B. Schrage (Hamburg)^1
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ²Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland; ³Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ⁴Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; ⁵Universitätsklinikum Heidelberg Klinik für Innere Med. III, Kardiologie, Angiologie u. Pneumologie Heidelberg, Deutschland; ⁶Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Lübeck, Deutschland; ⁷Universitätsklinikum Regensburg Klinik und Poliklinik für Innere Med. II, Kardiologie Regensburg, Deutschland; ⁸Medizinische Universität Graz Graz, Österreich; ⁹Herzzentrum Dresden GmbH an der TU Dresden Klinik für Innere Medizin, Kardiologie und Intensivmedizin Dresden, Deutschland; ¹⁰Universitätsklinikum Jena Klinik für Innere Medizin I - Kardiologie Jena, Deutschland; ¹¹Universitätsklinikum Würzburg Medizinische Klinik und Poliklinik I Würzburg, Deutschland; ¹²LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ¹³Universitätsklinik der Paracelsus Medizinischen Privatuniversität Klinik für Innere Medizin 8, Schwerpunkt Kardiologie Nürnberg, Deutschland; ¹⁴Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; ¹⁵Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ¹⁶Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland

Background: Despite extensive research efforts in recent years, the mortality risk associated with cardiogenic shock (CS) remains high, and evidence on mechanical circulatory support (MCS) in this setting is so far neutral. However, the optimal timing of MCS use in patients with CS remains unclear, with some advocating for earlier/proactive use whereas others see its role as a bail-out strategy.

Purpose: This study aims to evaluate patient characteristics and outcome associated with the timing of MCS implementation in patients with CS.

Methods: In this study, patients with CS treated with MCS at 18 tertiary-care centres in 4 countries were enrolled. Patients treated with MCS were stratified into early vs. delayed MCS implantation by using the median time interval between CS onset and first MCS device implementation. To evaluate the association between timing of MCS implantation and 30-day mortality, Cox regression models were fitted, adjusted for age, sex, baseline lactate and cause of CS (acute myocardial infarction vs. non-ischemic CS).

Results: A total of 330 patients with CS treated with MCS were included in this study; mean age was 57 (interquartile range [IQR] 49-66) years, with 249 (75.5%) of them being male. The median lactate level upon admission was 7.6 mmol/l (IQR 4.1-11.7), and 202 (61.2%) had an acute myocardial infarction as the underlying etiology of CS. The median time from CS onset to initial MCS device was 4 hours (IQR 2-10.4). Of these, 186 (56.4%) patients were treated with early and 144 (43.6%) patients were treated with delayed MCS implementation. Although crude mortality was slightly higher in patients with delayed MCS implementation (65.9% with delayed MCS vs. 61.1% with early MCS), after adjustment for relevant confounders, there was no significant association between timing of MCS implantation and 30-day all-cause mortality (adjusted hazard ratio 1.28, 95% confidence interval 0.87-1.88, p=0.21, Figure 1).

Conclusion: In this exploratory study patients with CS treated with MCS, early vs. delayed device implantation was not associated with 30-day all-cause mortality. The point estimator suggests that a small effect could exist. This needs testing in larger and better characterized cohorts.

 

Figure 1: Association between timing of MCS implementation and 30-day mortality in patients with cardiogenic shock.

MCS: mechanical circulatory support.