Longitudinal changes in right atrial pressure are associated with outcomes in patients with cardiogenic shock receiving acute mechanical circulatory support devices.

Davila, Carlos

Background
Cardiogenic shock (CS) is associated with high mortality despite advances in revascularization and acute mechanical circulatory support (AMCS) devices. Here we sought to describe the association between longitudinal hemodynamic changes and clinical outcomes in patients with CS.

Methods
Retrospective analysis of patients from Tufts Medical Center enrolled in the Cardiogenic Shock Working Group Registry that received AMCS. Baseline characteristics and invasive hemodynamics were collected and analyzed. Hemodynamics were recorded at different time intervals during index admission. Pre specified time points included: pre-AMCS, 24 hours after AMCS (post AMCS), and last available set of hemodynamics (final-AMCS). The difference (Δ) between final-AMCS and pre-AMCS hemodynamics was calculated and correlated against outcomes by logistic regression.

Results
A total of 76 patients had longitudinal hemodynamics available. AMCS included: VA-ECMO (35.5%), Impella (63.1%), and Tandem heart (1%). Indications for AMCS were: post-MI (35.5%), acute on chronic HF (42.1%), Myocarditis (7.8%), and other (14.6%). Mean duration of AMCS was 3.5 days. In hospital mortality occurred in 46% of the cohort. Mean right atrial pressure (RAP) was significantly different in survivors when compared to non survivors at all time points (pre AMCS: 16.3 vs. 19.5 mmHg p=0.03 – 24 hrs. post AMCS: 11.2 vs. 15.7 mmHg p=<0.001 – final-AMCS: 10.4 vs. 15.8 mmHg p=<0.0001). Moreover, the ΔRAP was higher in survivors (-6.5±6.9 mmHg vs. -2.5±6.2 mmHg p=0.03) and it was significantly associated with in hospital all-cause mortality (OR 1.1 95% CI: 1.002–1.207 p=0.045).

Conclusions
In this analysis persistently elevated RAP over time despite AMCS therapy was associated with worse outcomes in patients with CS. To our knowledge this is the first study to evaluate the temporal changes in hemodynamics and its relationship with outcomes in patients receiving AMCS for CS.