Revascularization in Cardiogenic Shock and Advanced Heart Failure
Purpose of review
Ischemic heart disease is the most common cause of heart failure with systolic dysfunction. The progressive course of heart failure characterized by increasing levels of care and worsening quality of life often indicates an advanced stage. Similarly, cardiogenic shock remains a major clinical problem with prohibitively high mortality rates despite major advances in clinical care. Here, we review the current treatment options and available data for revascularization in patients with ischemic cardiomyopathy, advanced heart failure, and cardiogenic shock. We also explore the emerging role of Interventional Heart Failure specialist within the Heart Team.
Although guideline-directed medical therapy remains the cornerstone treatment strategy for patients with advanced heart failure, coronary revascularization is sometimes indicated. There is a relatively paucity of evidence regarding different revascularization strategies and the use of acute mechanical circulatory support in patients with advanced heart failure and in those presenting with cardiogenic shock. A deep understating of the physiologic and hemodynamic effects of different acute mechanical support platforms is of paramount importance in preparation for revascularization in these patients.
The decision regarding revascularization in patients with coronary artery disease in the setting of left ventricular dysfunction remains challenging. Clinical decision-making in these cases requires interdisciplinary discussion and assessment of the potential long-term survival derived from surgical revascularization against its higher perioperative risk.
KeywordsCoronary artery disease Cardiogenic shock Heart failure Interventional heart failure
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.Fonarow GC, Heywood JT, Heidenreich PA, Lopatin M, Yancy CW, Committee ASA, et al. Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004: findings from Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2007;153(6):1021–8.CrossRefGoogle Scholar
- 5.Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2016;68(13):1476–88.CrossRefGoogle Scholar
- 6.Metra M, Ponikowski P, Dickstein K, McMurray JJ, Gavazzi A, Bergh CH, et al. Advanced chronic heart failure: a position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2007;9(6–7):684–94.CrossRefGoogle Scholar
- 7.Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):1810–52.CrossRefGoogle Scholar
- 8.• Kirklin JK, Naftel DC, Stevenson LW, Kormos RL, Pagani FD, Miller MA, et al. INTERMACS database for durable devices for circulatory support: first annual report. J Heart Lung Transplant. 2008;27(10):1065–72 The INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles provide important prognostic information for patients with advanced heart failure (HF) receiving mechanical support. Although it has not been validated for patients with advanced heart failure undergoing revascularization, it remains an important tool to classify and prognosticate these patients prior to revascularization.CrossRefGoogle Scholar
- 9.Perera D, Clayton T, Petrie MC, Greenwood JP, O'Kane PD, Evans R, et al. Percutaneous revascularization for ischemic ventricular dysfunction: rationale and design of the REVIVED-BCIS2 trial: percutaneous coronary intervention for ischemic cardiomyopathy. JACC Heart Fail. 2018;6(6):517–26.CrossRefGoogle Scholar
- 11.Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891–975.CrossRefGoogle Scholar
- 12.•• Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med. 2011;364(17):1607–16 STICHES was an extended follow-up of patients from the STICH trial, which found no differences in mortality rates between the groups at 56 months. However, at 10 years, CABG plus medical therapy significantly reduced mortality rates in patients with ischemic cardiomyopathy when compared to medical therapy alone.CrossRefGoogle Scholar
- 13.•• Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, et al. Coronary-artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med. 2016;374(16):1511–20 STICHES was an extended follow-up of patients from the STICH trial, which found no differences in mortality rates between the groups at 56 months. However, at 10 years, CABG plus medical therapy significantly reduced mortality rates in patients with ischemic cardiomyopathy when compared to medical therapy alone.CrossRefGoogle Scholar
- 14.Bangalore S, Guo Y, Samadashvili Z, Blecker S, Hannan EL. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation. 2016;133(22):2132–40.CrossRefGoogle Scholar
- 15.Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med. 1999;341(9):625–34.CrossRefGoogle Scholar
- 16.Mehta RH, Grab JD, O'Brien SM, Glower DD, Haan CK, Gammie JS, et al. Clinical characteristics and in-hospital outcomes of patients with cardiogenic shock undergoing coronary artery bypass surgery: insights from the Society of Thoracic Surgeons National Cardiac Database. Circulation. 2008;117(7):876–85.CrossRefGoogle Scholar
- 17.•• Thiele H, Akin I, Sandri M, Fuernau G, de Waha S, Meyer-Saraei R, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med. 2017;377(25):2419–32 The CULPRIT-SCHOCK trial showed that culprit-lesion-only PCI is superior to multivessel PCI in patients with AMI complicated by cardiogenic shock and evidence of multivessel disease on the initial angiogram. This superiority remains true at 1-year follow-up.CrossRefGoogle Scholar
- 18.•• Thiele H, Akin I, Sandri M, de Waha-Thiele S, Meyer-Saraei R, Fuernau G, et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018;379(18):1699–710 The CULPRIT-SCHOCK trial showed that culprit-lesion-only PCI is superior to multivessel PCI in patients with AMI complicated by cardiogenic shock and evidence of multivessel disease on the initial angiogram. This superiority remains true at 1-year follow-up.CrossRefGoogle Scholar
- 23.Deppe AC, Weber C, Liakopoulos OJ, Zeriouh M, Slottosch I, Scherner M, et al. Preoperative intra-aortic balloon pump use in high-risk patients prior to coronary artery bypass graft surgery decreases the risk for morbidity and mortality-a meta-analysis of 9,212 patients. J Card Surg. 2017;32(3):177–85.CrossRefGoogle Scholar
- 24.O'Neill WW, Kleiman NS, Moses J, Henriques JP, Dixon S, Massaro J, et al. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study. Circulation. 2012;126(14):1717–27.CrossRefGoogle Scholar