Cardiogenic shock and rapidly deteriorating heart failure requiring mechanical circulatory support: from pathophysiology to clinical outcome

Aim of the study: Aim of this study was to investigate the acute impact of mechanical circulatory support on patient haemodynamics and metabolism, in the setting of cardiogenic shock, with correlation to clinical outcomes. Methods and results: Four-hundreds and two patients admitted in two tertiary centres from 2015 to 2020 in cardiogenic shock requiring mechanical circulatory support (MCS) were studied retrospectively. To the purpose of this study, three different MCS devices were included: intra-aortic balloon pump (IABP), Impella (2.5, CP and 5.0) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Blood tests and haemodynamic data were studied at baseline, 24 and 72 hours from MCS initiation. Primary outcome was 30-day morality. Analysis of total population and sub-cohorts according to the device inserted was performed. In the total population, independent predictors of primary outcome at multivariate analysis resulted age (OR=1,01, 95%CI=1,00-1,02, p=0,009), previous admission for cardiogenic shock (OR=1,86, 95%CI=1,09-3,17, p=0,02), baseline lactate ≥2 mmol/L (OR=2,25, 95%CI=1,02-4,97, p=0,045) and MAP <60 mmHg at 24h (OR=2,07, 95%CI=1,18-3,61, p=0,011). ROC analysis identified 73 years as best cut off for survival in the total population, and 58 and 77 years in the sup-cohorts treated with ECMO or IABP, respectively. Presence of ICD was protective in terms of short-term mortality (OR=0,46, 95%CI=0,25-0,82, p=0,009). In the ECMO population, MAP <60 mmHg at 24h (OR=3,03, 95%CI=1,25-7,37, p=0,01) correlated with the primary outcome. In the IABP population, higher creatinine values at baseline and 24h (OR=2,16, 95%CI=1,13-4,14, p=0,02; OR=1,72, 95%CI=1,22-2,44, p=0,002), and lactate ≥2 mmol/L before IABP insertion (OR=4,80, 95%CI=1,51-15,2, p=0,008) predicted 30-day mortality. Conclusion: In conclusion, age, comorbidities, renal dysfunction and lactate ≥2 mmol/L are predictors of 30-day mortality in patients admitted for cardiogenic shock requiring MCS. In addition, persistence of renal dysfunction and MAP <60 mmHg after 24h of support correlate with worse outcome.