Active Left Ventricular Unloading improves survival in DanGer-Shock-like Patients with Heart Failure-Related Cardiogenic Shock: Results of an international registry

Clin Res Cardiol (2025). DOI 10.1007/s00392-025-02625-4
A. Dettling (Hamburg)¹, J. Sundermeyer (Hamburg)², B. Beer (Hamburg)², L. C. Besch (Hamburg)², L. F. Bertoldi (Milan)³, S. Blankenberg (Hamburg)², J. Dauw (Aalst)⁴, D. Eckner (Nürnberg)⁵, I. Eitel (Lübeck)⁶, T. Graf (Lübeck)⁶, P. Horn (Mönchengladbach)⁷, P. Horn (Düsseldorf)⁸, J. Jozwiak-Nozdrzykowska (Leipzig)⁹, P. Kirchhof (Hamburg)², S. Kluge (Hamburg)¹⁰, A. Linke (Dresden)¹¹, U. Landmesser (Berlin)¹², E. Lüsebrink (München)¹³, N. Majunke (Leipzig)⁹, N. Mangner (Dresden)¹¹, S. Möbius-Winkler (Jena)¹⁴, P. Nordbeck (Würzburg)¹⁵, M. Orban (München)¹⁶, F. Pappalardo (Alessandria)¹⁷, M. Pauschinger (Nürnberg)⁵, M. Pazdernik (Prague)¹⁸, A. Proudfoot (London)¹⁹, M. Kelham (London)²⁰, T. Rassaf (Essen)²¹, H. Reichenspurner (Hamburg)²², C. Scherer (München)¹³, C. Schulze (Jena)¹⁴, R. H. G. Schwinger (Weiden i. d. Oberpfalz)²³, C. Skurk (Berlin)²⁴, M. Sramko (Prag)²⁵, G. Tavazzi (Bravia)²⁶, H. Thiele (Leipzig)⁹, E. B. Winzer (Dresden)¹¹, D. Westermann (Freiburg im Breisgau)²⁷, B. Schrage (Hamburg)^2
1Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland; ²Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ³Cardio Center, Humanitas Clinical and Research Center – IRCCS, Rozzano, Milan, Italy Milan, Italien; ⁴Cariovascular Center Aalst, OLV Hospital, Aalst, Belgium Aalst, Belgien; ⁵Universitätsklinik der Paracelsus Medizinischen Privatuniversität Klinik für Innere Medizin 8, Schwerpunkt Kardiologie Nürnberg, Deutschland; ⁶Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ⁷Städtische Kliniken Mönchengladbach GmbH Kardiologie & Angiologie Mönchengladbach, Deutschland; ⁸Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Duesseldorf, Duesseldorf, Germany Düsseldorf, Deutschland; ⁹Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ¹⁰University Medical Center Hamburg-Eppendorf, Department of Intensive Care Medicine, Hamburg, Germany Hamburg, Deutschland; ¹¹Herzzentrum Dresden GmbH an der TU Dresden Klinik für Innere Medizin, Kardiologie und Intensivmedizin Dresden, Deutschland; ¹²Deutsches Herzzentrum der Charite (DHZC) Klinik für Kardiologie, Angiologie und Intensivmedizin Berlin, Deutschland; ¹³LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ¹⁴Universitätsklinikum Jena Klinik für Innere Medizin I - Kardiologie Jena, Deutschland; ¹⁵Universitätsklinikum Würzburg Medizinische Klinik und Poliklinik I Würzburg, Deutschland; ¹⁶LMU Klinikum der Universität München Kardiologie München, Deutschland; ¹⁷Dept Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo Alessandria, Italien; ¹⁸Department of Cardiology, IKEM Prague, Tschechische Republik; ¹⁹Department of Perioperative Medicine, St. Bartholomew’s Hospital London, Großbritannien; ²⁰Department of Perioperative Medicine, St. Bartholomew's Hospital London, Großbritannien; ²¹Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland; ²²Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; ²³Kliniken Nordoberpfalz AG Medizinische Klinik II, Kardiologie Weiden i. d. Oberpfalz, Deutschland; ²⁴Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; ²⁵Department of Cardiology, IKEM Prag, Tschechische Republik; ²⁶Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia Italy; Anesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS Bravia, Italien; ²⁷Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland

Background: The DanGer-Shock trial recently demonstrated that active left ventricular (LV) unloading improves outcomes in patients with cardiogenic shock (CS) due to acute ST-elevation myocardial infarction (STEMI). This analysis evaluated the effects of active LV unloading in patients with CS due to heart failure (HF-CS).
 

Methods: Data of patients with HF-CS from 16 tertiary-care centers in five countries collected between 2010 and 2021 (NCT03313687) were analyzed. Patients without STEMI but fulfilling the other DanGer-Shock enrollment criteria (cardiogenic shock, left ventricular ejection fraction <45%, lactate ≥2.5 mmol/L, no prolonged cardiopulmonary resuscitation) were included. The primary outcome 30-day mortality and in-hospital complications were compared in patients receiving active LV unloading (Impella only or ECMELLA) and in patients without LV unloading using adjusted Cox and logistic regression models.

 

Results: Of 154 patients with HF-CS meeting DanGer-Shock-like enrollment criteria, 53 (34.4%) were treated with active LV unloading. The 30-day mortality was 31.6% vs. 41.5% in those with vs. without active LV unloading (adjusted hazard ratio 0.828, 95% CI 0.668–0.996, p=0.045, Figure1). However, patients with active LV unloading presented with a higher likelihood of in-hospital complications including moderate bleeding (adjusted odds ratio (OR) 2.43, 95% CI 1.88–3.14, p<0.01), severe bleeding (OR 2.84, 95% CI 1.89–4.26, p<0.01), and interventions due to bleeding (OR 4.70, 95% CI 3.22–6.85, p<0.01), as well as the need for renal replacement therapy (OR 2.90, 95% CI 2.30–3.65, p<0.01) and the occurrence of sepsis (OR 1.99, 95% CI 1.54–2.57, p<0.01). In contrast, active LV unloading was associated with a lower likelihood of ischemic stroke (OR 0.46, 95% CI 0.22–0.93, p=0.03, Figure 2).

 

Conclusions: These hypothesis-generating data suggest that active left ventricular unloading could improve outcomes in patients with CS due to heart failure without prolonged resuscitation. Randomized trials with sufficient follow-up are needed to further evaluate active left ventricular unloading in this population.

 Figure 1.

 

Kaplan-Meier estimates for 30-day all-cause mortality in patients with vs. without active left ventricular unloading.   Hazard ratio (HR) adjusted by age, sex, lactate, pH, prior cardiopulmonary resuscitation, and Society for Cardiovascular Angiography & Interventions (SCAI) class. CI, confidence interval.

 

Figure 2.

Association between active left ventricular (LV) unloading and safety endpoints. To evaluate the association between active LV unloading and secondary endpoints, logistic regression models were applied, adjusted for age, sex, lactate and pH at baseline, prior cardiopulmonary resuscitation (<10 min), and Society for Cardiovascular Angiography & Interventions (SCAI) class.