LVAD Centers Linked to Less Mortality From Cardiogenic Shock

By Marilynn Larkin

December 10, 2020

NEW YORK (Reuters Health) - Patients in cardiogenic shock are more likely to survive when treated in an LVAD center, a large observational study suggests.

"A multidisciplinary approach to the management of cardiogenic shock, with collaboration among CT surgeons, interventionalists, advanced heart failure physicians and critical care has quickly become the new paradigm for care in the field. But the evidence for this shock team approach is limited to a few excellent, single-center studies," Dr. Udhay Krishnan of Weill Cornell Medicine/New York Presbyterian Hospital in New York City told Reuters Health by email. "We wanted to get a better understanding of this using a real-world case mix on a national level."

As reported in the Journal of the American Heart Association, Dr. Krishnan and colleagues studied cardiogenic shock patients in the 2012-2014 National Inpatient Sample.

Multivariable logistic regression models revealed that of 272,075 hospitalizations, 26% were in LVAD centers. Most cases of cardiogenic shock were attributable to causes other than acute myocardial infarction (AMI).

Patients at LVAD centers were younger, more likely to be Black, and more likely to have private insurance compared with non-LVAD centers. Cardiovascular risk factors were similar among the groups, but those who were younger derived the most survival benefit from LVAD centers compared to non-LVAD centers.

In-hospital mortality was lower in LVAD centers (38.9% vs. 43.3%); after multivariable adjustment, the odds of mortality remained significantly lower for LVAD center hospitalizations (OR, 0.89).

In patients with cardiogenic shock after AMI (129,330 cases), rates of PCI or CABG were similar in LVAD and non-LVAD centers (53.6% versus 52.6%), but CABG rates were higher in LVAD centers.

Use of an intra-aortic balloon pump (18.7% vs. 18.8%) and Impella/TandemHeart (2.6% vs.1.9%) was similar between hospital types, whereas extracorporeal membrane oxygenation was used more frequently in LVAD centers (4.3% vs. 0.2%).

Dr. Krishnan said, "This study adds to the body of evidence supporting a specialized approach to cardiogenic shock, and a need to identify centers of excellence. This doesn't mean that the center has to be an LVAD center per se, but it should have the processes and systems in place which can allow for a cohesive shock-team model with access to both temporary and durable support devices."

"Hospital systems are already structuring spoke and hub networks that prioritize the transfer of the sickest patients to specialized, tertiary centers, but ways to do this that emphasize efficiency, expediency and safety are key," he concluded.

Dr. Daniel Goldstein, Vice Chairman, Department of Cardiothoracic Surgery at Montefiore Health System in New York City told Reuters Health by email that he agreed with the findings, and with the caveats, as outlined in the paper, which "revolve around the lack of granularity of the cardiogenic shock cases - no data on hemodynamics, medications, LVEF, etc., all of which can impact outcomes."

"Cardiogenic shock is one of the most challenging clinical entities to treat due to its acuity necessitating rapid diagnosis and institution of care, terrible early prognosis, heterogeneous etiologies, and requirement of sophisticated technologies, skills and knowledge to effectuate good outcomes," he said. "Like in many other medical conditions, (centers with) a multidisciplinary team that is able to leverage system processes already in place - e.g., LVAD implantation, heart transplantation - and thus are able to rapidly diagnose, triage, and treat complex patients are likely to experience better outcomes."

SOURCE: https://bit.ly/2W0whdP Journal of the American Heart Association, online November 23, 2020.

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