Basir Mir B, Schreiber Theodore L, Grines Cindy L, Dixon Simon R, Moses Jeffrey W, Maini Brijeshwar S, Khandelwal Akshay K, Ohman E Magnus, O'Neill William W
Division of Cardiology, Henry Ford Hospital/Wayne State University, Detroit, Michigan.
Division of Cardiology, Detroit Medical Center/Wayne State University, Detroit, Michigan.
Am J Cardiol. 2017 Mar 15;119(6):845-851. doi: 10.1016/j.amjcard.2016.11.037. Epub 2016 Dec 18.
The role and timing of percutaneous mechanical circulatory support (MCS) devices in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS) are not well understood. We sought to evaluate patient characteristics and predictors of outcomes in patients presenting with AMICS supported with an axial flow percutaneous MCS device; 287 consecutive unselected patients enrolled in the catheter-based ventricular assist device registry presenting with AMICS who underwent percutaneous coronary intervention (PCI) were included in this analysis. All patients were supported with either the Impella 2.5 or Impella CP. Mean patient age was 66 ± 12.5 years, 76% were men, and mean left ventricular ejection fraction was 25 ± 12%. Before receiving MCS, 80% of patients required inotropes or vasopressors and 40% were supported with intra-aortic balloon pump; 9% of patients were under active cardiopulmonary resuscitation at the time of MCS implantation. Survival to discharge was 44%. In a multivariate analysis, early implantation of a MCS device before PCI (p = 0.04) and before requiring inotropes and vasopressors (p = 0.05) was associated with increased survival. Survival was 66% when MCS was initiated <1.25 hours from shock onset, 37% when initiated within 1.25 to 4.25 hours, and 26% when initiated after 4.25 hours (p = 0.017). Survival was 68%, 46%, 35%, 35%, and 26% for patients requiring 0, 1, 2, 3, and ≥4 inotropes before MCS support, respectively (p <0.001). In conclusion, MCS implantation early after shock onset, before initiation of inotropes or vasopressors and before PCI, is independently associated with improved survival in patients presenting with AMICS.
经皮机械循环支持（MCS）设备在治疗并发心源性休克的急性心肌梗死（AMICS）中的作用和时机尚未完全明确。我们试图评估接受轴流经皮MCS设备支持的AMICS患者的特征及预后预测因素；本分析纳入了287例连续入选的、未经过筛选的、登记在基于导管的心室辅助设备注册表中的、并发AMICS且接受了经皮冠状动脉介入治疗（PCI）的患者。所有患者均接受了Impella 2.5或Impella CP支持。患者平均年龄为66±12.5岁，76%为男性，平均左心室射血分数为25±12%。在接受MCS之前，80%的患者需要使用正性肌力药物或血管升压药，40%的患者接受主动脉内球囊泵支持；9%的患者在植入MCS时正在进行积极的心肺复苏。出院生存率为44%。在多变量分析中，在PCI之前（p = 0.04）以及在需要使用正性肌力药物和血管升压药之前（p = 0.05）早期植入MCS设备与生存率提高相关。当MCS在休克发作后<1.25小时启动时，生存率为66%；在1.25至4.25小时内启动时，生存率为37%；在4.25小时后启动时，生存率为26%（p = 0.017）。在接受MCS支持之前需要0、1、2、3和≥4种正性肌力药物的患者的生存率分别为68%、46%、35%、35%和26%（p<0.001）。总之，在休克发作后早期、在启动正性肌力药物或血管升压药之前以及在PCI之前植入MCS与AMICS患者生存率提高独立相关。
