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Prognostic Value of Hemodynamic Indices Prior to tMCS Explantation: An Analysis from the Cardiogenic Shock Working
Christian Said1, Jaime Hernandez-Montfort2, Jonas Sundermeyer3
1The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts; The Victor Chang Cardiac Research Centre, Darlinghurst, New South Wales, Australia; The University of New South Wales, Kensington, New South Wales, Australia; Cardiology Department, Gosford Hospital, Central Coast Local Health District, Gosford, Australia.
Background:
Standardized hemodynamic-guided weaning criteria are needed for patients with cardiogenic shock receiving temporary mechanical circulatory support (tMCS). We aimed to determine whether hemodynamic indices prior to tMCS explant predict mortality and native heart survival and whether performance varies across device platforms.
Methods:
We analyzed 385 cardiogenic shock patients from the multicenter Cardiogenic Shock Working Group registry who received tMCS. Four indices were evaluated: blood pressure response index (BPRI), organ perfusion pressure (OPP), aortic pulsatility index (API), and modified API (mAPI). The primary outcome was in-hospital mortality; the secondary outcome was native heart survival. Multivariable models were adjusted for age, sex, and device type. Receiver operating characteristic (ROC) curves assessed discrimination, restricted cubic splines examined nonlinear relationships, and device-stratified analyses evaluated platform-specific performance.
Results:
BPRI demonstrated the highest area under the curve (AUC) for mortality (AUC, 0.786) and native heart survival (AUC, 0.747) compared with OPP (0.711), mAPI (0.654), and API (0.600). Survivors demonstrated BPRI improvement (8.4-18.2), whereas nonsurvivors showed stagnation (4.7-5.2). Each 10-point BPRI increase was associated with a 46% mortality reduction (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.42-0.68; P < .001). BPRI remained strongly associated with lower mortality across device platforms, including Impella (OR, 0.24; 95% CI, 0.10-0.58; P = .001) and the intra-aortic balloon pump (OR, 0.65; 95% CI, 0.48-0.90; P = .008).
Conclusion:
Pre-explant BPRI demonstrated the highest prognostic accuracy for mortality and native heart survival across multiple tMCS platforms.
