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The real impact of mechanical bridge strategy in patients with severe acute infarction
D Loisance1, P Deleuze, M L Hillion
1Department of Cardiology and Cardiac Surgery, C.H.U. Henri Mondor, Créteil, France.
Insights
Patients with acute myocardial infarction (AMI) and cardiogenic shock face high sudden death rates before heart transplantation. Early mechanical support is crucial to improve survival in these critically ill patients.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Transplantation Medicine
Background:
- Acute myocardial infarction (AMI) with cardiogenic shock presents a critical clinical challenge.
- Mechanical circulatory support is used as a bridge to urgent heart transplantation.
- Assessing the impact of current strategies is vital for clinical practice improvement.
Purpose of the Study:
- To evaluate the effectiveness of mechanical support as a bridge to transplantation in patients with AMI and cardiogenic shock.
- To analyze the outcomes and identify factors influencing survival in this patient cohort.
Main Methods:
- Retrospective analysis of ten patients with AMI and cardiogenic shock undergoing mechanical support.
- Maximal sympathomimetic support and intravenous enoximone were administered.
- Inclusion of total artificial heart (TAH) and left ventricular assist device (LVAD) implantation in select cases.
Main Results:
- Two patients received TAH, one received LVAD due to fibrillation.
- Two patients successfully underwent heart transplantation and are alive after 20 months.
- Seven patients listed for urgent transplant experienced a high mortality rate (3/7) due to sudden ventricular fibrillation before transplant.
Conclusions:
- Despite initial hemodynamic improvement with medical management, sudden death from ventricular fibrillation remains a significant risk before transplantation.
- Early consideration of less invasive mechanical support systems is recommended for patients with AMI and cardiogenic shock.
- Current strategies require re-evaluation to reduce pre-transplant mortality.
Abstract:
Results obtained in the past 3 years in patients referred with acute myocardial infarction (AMI) and cardiogenic shock for a mechanical bridge to urgent transplantation permit one to assess the real impact of the present strategy in clinical practice. Ten patients (mean age = 49) were admitted in serious condition (CI = 1.8 +/- 0.2 L/min/m2, PCWP = 28 +/- 6 mmHg, systolic aortic pressure = 88 +/- 20 mmHg, urine output 11 +/- 20 ml/hr) and were treated by maximal sympathomimetic support and i.v. enoximone. Two had to be implanted with a total artificial heart (TAH) and one with a left ventricular assist device (LVAD) for recurrent fibrillation despite hemodynamic improvement, within 8 hr. Two have received transplants and are living well after 20 months. Seven who initially improved markedly have been listed as urgent transplant candidates: two of these have been successfully transplanted, and three died suddenly after 6, 25, and 45 days, respectively. One has undergone successful coronary surgery. One patient (age 62, diabetic) was secondarily rejected for a transplant and died. This experience clearly shows that despite initial spectacular hemodynamic improvement, which was due to optimized medical management, death rate before transplant because of sudden ventricular fibrillation remains unacceptably high. This should prompt early mechanical support, with less invasive systems, in patients with AMI.