Shock Stages in Cardiac Surgical Patients

Figures

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  Figure 1. CS-SCAI Stages Applied to Cardiac Surgical Patients The criteria for assigning CS-SCAI stages in this study are indicated on the pyramid diagram. Criteria are applied top down (from CS-SCAI E to A), stopping when the criteria are met. Patients with emergent/salvage status in the database or who are receiving extracorporeal life support (ECLS) are classified as CS-SCAI E. Patients not meeting that criteria are CS-SCAI D if they are receiving one or more inotropes as well as a form of temporary MCS (other than ECLS). Patients on a single inotrope or single MCS device are classified as CS-SCAI C. Patients with heart failure of NYHA class 3 or 4, or characterized as urgent surgery or having had a cardiac arrest during the index hospital stay are considered CS-SCAI B and the remainder of the patients undergoing cardiac surgery as CS-SCAI A (“at risk”). CS = cardiogenic shock; MCS = mechanical circulatory support; STS = Society of Thoracic Surgeons; tMCS = temporary mechanical circulatory support.

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  Figure 2. CONSORT Diagram of Flow of Patients Through the Study The diagram illustrates the breakdown of patients from the cohort into types of cardiac surgery performed, complexity (as assessed by procedural complexity composite score), and then also by preoperative CS-SCAI stage to provide a clear understanding of the procedures and degree of illness of patients prior to cardiac surgery. CABG = coronary artery bypass grafting; CONSORT = Consolidated Standards of Reporting Trials; PCC = procedural complexity composite; other abbreviation as in Figure 1.

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  Figure 3. Clinical Trajectory of Patients Undergoing Cardiac Surgery Assessed by CS-SCAI Stage, and Operative Outcomes The number of patients in each CS-SCAI stage preoperatively is compared to the postoperative status with arrows graphically illustrating the transition of CS-SCAI stage for those patients who did not remain at the preoperative CS-SCAI stage. In addition, the 30-day mortality is presented for those patients with the same stage, and different postoperative stages. Abbreviation as in Figure 1.

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  Figure 4. Transitions of CS-SCAI Stage Postoperatively and Use of tMCS This is a flowchart examining the use of temporary MCS and ECLS in patients who had a transition of CS-SCAI stage following operation. It is divided into those patients who were in CS-SCAI A/B vs CS-SCAI C/D/E preoperatively. It demonstrates the use of IABP, temporary MCS, and ECLS for patients. ECLS = extracorporeal life support; IABP = intra-aortic balloon pump; other abbreviations as in Figure 1.

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  Central Illustration. CS-SCAI Construct and 30-Day Mortality Including the Effect of Worsening Stage A simplified set of phrases to assess CS-SCAI stage (less words than Figure 1) and also shows the 30-day mortality by preop CS-SCAI stage, postop CS-SCAI stage, and for patients who experience a single stage worsening from preoperative to postoperative. It illustrates that even modest deterioration of CS-SCAI stage is associated with a high mortality at 30 days, regardless of initial preoperative stage. Abbreviations as in Figures 1 and 4.