What is the clinical evidence from this study?

Study design: Cohort. Population: Non-ischaemic cardiogenic shock (n=807). Intervention: Mechanical circulatory support (MCS) vs. No mechanical circulatory support. Primary outcome: 30-day mortality (MCS use in patients with LVEF ≤ 20%) (HR 0.72, 95% CI 0.51-1.02, p=0.017 for interaction).

November 20, 2023Open Access

Association between left ventricular ejection fraction, mortality and use of mechanical circulatory support in patients with non-ischaemic cardiogenic shock

Resultado clave

Mechanical circulatory support use in patients with non-ischaemic cardiogenic shock was associated with a lower 30-day mortality risk only in those with severely reduced LVEF ≤ 20% (HR 0.72).

Diseño del estudio

Tipo

Cohort (n=807)

Multicéntrico

Sí

PICO estructurado

Does mechanical circulatory support reduce 30-day mortality in patients with non-ischaemic cardiogenic shock?

Población

807 patients with non-ischaemic cardiogenic shock (CS) and available data on LVEF from 16 tertiary-care centres in five countries. Mean age 63, 74.5% male. Excluded: acute myocardial infarction, need for urgent coronary revascularization, right heart failure, ECMO-assisted resuscitation, post-cardiotomy CS, life expectancy <6 months.

Intervención

Mechanical circulatory support (MCS) including VA-ECMO, Impella, or both

Comparador

No mechanical circulatory support

Resultado

30-day mortalityhard clinical

In patients with non-ischaemic cardiogenic shock, mechanical circulatory support may be associated with a lower 30-day mortality risk specifically in those with severely reduced LVEF (≤20%).

Resultado numérico

Estimación del efecto: HR 0.72 (95% CI 0.51-1.02)

valor p: p=0.017 for interaction

Limitaciones

Non-randomised retrospective design precludes concluding causal relationships
LVEF assessment is susceptible to examiner- and centre-dependent subjectivity
Lack of relevant data on co-existing valvular diseases
Selection bias in MCS use, as patients with higher physiological reserve are more likely to be treated with MCS devices

Resumen

Abstract Background Currently, use of mechanical circulatory support (MCS) in non-ischaemic cardiogenic shock (CS) is predominantly guided by shock-specific markers, and not by markers of cardiac function. We hypothesise that left ventricular ejection fraction (LVEF) can identify patients with a higher likelihood to benefit from MCS and thus help to optimise their expected benefit. Methods Patients with non-ischaemic CS and available data on LVEF from 16 tertiary-care centres in five countries were analysed. Cox regression models were fitted to evaluate the association between LVEF and mortality, as well as the interaction between LVEF, MCS use and mortality. Results N = 807 patients were analysed: mean age 63 interquartile range (IQR) 51.5–72.0 years, 601 (74.5%) male, lactate 4.9 (IQR 2.6–8.5) mmol/l, LVEF 20 (IQR 15–30) %. Lower LVEF was more frequent amongst patients with more severe CS, and MCS was more likely used in patients with lower LVEF. There was no association between LVEF and 30-day mortality risk in the overall study cohort. However, there was a significant interaction between MCS use and LVEF, indicating a lower 30-day mortality risk with MCS use in patients with LVEF ≤ 20% (hazard ratio 0.72, 95% confidence interval 0.51–1.02 for LVEF ≤ 20% vs. hazard ratio 1.31, 95% confidence interval 0.85–2.01 for LVEF > 20%, interaction- p = 0.017). Conclusion This retrospective study may indicate a lower mortality risk with MCS use only in patients with severely reduced LVEF. This may propose the inclusion of LVEF as an adjunctive parameter for MCS decision-making in non-ischaemic CS, aiming to optimise the benefit–risk ratio. Graphical abstract Impact of left ventricular ejection fraction on mortality and use of mechanical circulatory support in non-ischaemic cardiogenic shock. Hazard ratio for 30-day mortality across the LVEF continuum, adjusted for age, sex, SCAI shock stage, worst value of lactate and pH within 6 h, prior resuscitation and mechanical ventilation during the index shock event. LVEF: Left ventricular ejection fraction; MCS: Mechanical circulatory support; HR: Hazard ratio; CI: Confidence interval.

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