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Published on: August 16, 2021
[Ischemic cardiogenic shock and short-term mechanical circulatory support as bridge to transplantation]
María F Renedo1, Chen Chao2, Roberto R Favaloro1,3
1Servicio de Insuficiencia Cardíaca, Asistencia Circulatoria Mecánica y Trasplante Cardíaco, Departamento de Trasplante Intratorácico, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina.
Insights
Emergency heart transplantation (HT) can be a life-saving option for patients experiencing acute myocardial infarction (AMI) with cardiogenic shock (CS) refractory to standard treatments. This study highlights positive survival outcomes for selected patients bridging to HT with mechanical circulatory support (MCS).
Area of Science:
- Cardiology
- Cardiac Surgery
- Transplantation Medicine
Background:
- Cardiogenic shock (CS) carries a high mortality rate, frequently necessitating advanced interventions like mechanical circulatory support (MCS) and heart transplantation (HT).
- Patients with acute myocardial infarction (AMI) complicated by CS often require MCS as a bridge to HT, representing a critical subgroup with complex management needs.
Purpose of the Study:
- To retrospectively analyze the outcomes of patients with AMI and CS who received MCS as a bridge to HT.
- To evaluate the efficacy and survival rates of emergency HT in selected patients with refractory CS.
Main Methods:
- Retrospective analysis of 11 patients with AMI and CS requiring MCS as a bridge to HT between January 1997 and June 2020 at a single center.
- Patients received standard inotropic and vasopressor therapy, intra-aortic balloon pump (IABP), and in some cases, left univentricular assist devices or peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO).
- Assessment of demographics, interventions (primary angioplasty, revascularization surgery), time to HT, donor characteristics, extent of myocardial infarction, and histopathological findings.
Main Results:
- The median time from AMI to HT was 15 days. All patients had extensive AMI with signs of transmural necrosis and reperfusion injury.
- No in-hospital or 1-year mortality was observed post-transplantation.
- Survival rates at 5 and 10 years were 73% and 55%, respectively, with a median follow-up of 9 years.
Conclusions:
- Emergency heart transplantation can be a viable and effective option for carefully selected patients suffering from acute myocardial infarction and cardiogenic shock unresponsive to conventional therapies.
- The use of mechanical circulatory support as a bridge to transplantation in this high-risk group demonstrated favorable long-term survival outcomes.
Abstract:
Cardiogenic shock (CS) has a high mortality rate and often requires advanced therapies such as mechanical circulatory support (MCS) and heart transplantation (HT). Those patients who presented an acute myocardial infarction (AMI) with CS and required support through MCS as bridge to HT were retrospectively analyzed in a single Center. Between January 1997 and June 2020, 524 patients received HT, 203 for ischemic-cardiomyopathy, 103 were in emergency waiting list. Eleven patients met the inclusion criteria (mean age 53 ± 11 years old; men 73%). Five primary angioplasties and 2 emergency myocardial revascularization surgeries were performed. Four patients had coronary anatomy not subject to revascularization. All received inotropic and vasopressor treatment and required intra-aortic balloon pump (IABP). Subsequently, two required support with a left univentricular centrifugal pump (BioMedicus®, Medtronic) and two with peripheral veno-arterial extracorporeal membrane oxygenator (VA-ECMO) (Maquet®, Getinge Group). The median between AMI and HT was 15 days (range 7-21) and the mean age of the donors 28 ± 11 years. All had extensive AMI (necrotic amount 35 ± 5%) with histopathological signs of transmural necrosis and reperfusion injury. The median follow-up was 9 years (range 1-15). None died in hospitalization or during the first year after transplantation. Survival at 5 and 10 years was 73% and 55%. Emergency HT may be the best option for selected patients with acute myocardial infarction and cardiogenic shock refractory to conventional therapy.
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