Acta Cardiol Sin 2020;36:326-334 Original Article doi: 10.6515/ACS.202007_36(4).20191015A

Percutaneous Coronary Intervention Application and Comparison of Different Prognostic Scoring Systems in Patients Who Underwent Cardiologist-Managed Percutaneous Cardiopulmonary Support

Shih-Chieh Chien,1,2 Wei-Ren Lan,2 Shu-Hao Wu,2 Chen-Yen Chien,3 Yu-Shan Chien,1 Chi-In Lo,1,2 Cheng-Ting Tsai2 and Chun-Yen Chen4

Background: Temporary mechanical support, including percutaneous cardiopulmonary support (PCPS), is crucial for reversing patients’ compromised hemodynamic function. Knowledge about whether cardiologists can directly manage patients receiving PCPS and about the predictive values of different prognostic scores is insufficient. Methods: We examined the data and in-hospital mortality of 45 eligible patients receiving cardiologist-managed PCPS from July 2012 to January 2019 in our institute. We compared different prognostic scores [namely Survival After Veno-arterial ECMO (SAVE), modified SAVE, prEdictioN of Cardiogenic shock OUtcome foR acute myocardial infarction patients salvaGed by VA-ECMO (ENCOURAGE), and Sequential Organ Failure Assessment (SOFA) scores] through area under the receiver operating characteristic curve (AUC) analysis. Results: The patients’ mean age was 64.3 ± 11.3 years, and 71.1% were men. The overall in-hospital survival rate was 35.6%. Compared to survivors, nonsurvivors were more likely to have an ischemic etiology, cardiopulmonary resuscitation, and higher lactate levels. Survivors had higher SAVE (-5.9 vs. -11.4) and modified SAVE (4.2 vs. -7.1) scores than nonsurvivors (both p = 0.001), but SOFA (9.7 vs. 10.3) and ENCOURAGE (24.8 vs. 26.8) scores were similar (both p > 0.1). In multivariate models, only modified SAVE score remained statistically significant (hazard ratio: 0.96, 95% confidence interval: 0.93-1.00; p = 0.047). Modified SAVE score showed the best risk discrimination (AUC = 0.78). Conclusions: Establishing regular and continual training protocols can enable cardiologists to perform emergency PCPS (without on-site surgery) and daily care for patients with refractory cardiogenic shock. The modified SAVE score facilitates risk stratification and future decision-making processes.

Key Words: Cardiogenic shock · PCPS · Peripheral V-A ECMO · Prognostic score

INTRODUCTION

Received: August 3, 2019 Accepted: October 15, 2019 1 2 Cardiogenic shock (CS) is a state of systemic hypo- Department of Critical Care Medicine; Cardiovascular Division, Department of Internal Medicine; 3Division of Cardiovascular perfusion caused by a primary cardiac disorder. CS man- Surgery, Department of Surgery, MacKay Memorial Hospital, ; agement remains a clinical challenge owing to its di- 4 Cardiovascular Division, Department of Internal Medicine, MacKay verse etiologies, rapid progression, and high in-hospital Memorial Hospital, , New Taipei City, . 1 Corresponding author: Dr. Chun-Yen Chen, Cardiovascular Division, mortality rates. Incorporating medical, surgical, and Department of Internal Medicine, MacKay Memorial Hospital, No. mechanical circulatory support (MCS) is key to rescuing 45, Minsheng Rd., , New Taipei City 25160, Taiwan. a failing heart and reversing CS.2 Several MCS devices Tel: 886-2-2809-4661; Fax: 886-2-2809-4679; E-mail: mwplasma@ ms9.hinet.net have been introduced in clinical practice, such as intra-

Acta Cardiol Sin 2020;36:326-334 326 Prognostic Scoring Systems for PCPS Patients aortic balloon pump systems, extracorporeal membrane tional ECMO team, with cardiovascular surgeons and oxygenation (ECMO), and ventricular assistance devices.1 perfusionists constituting the team’s core members. We Peripheral veno-arterial ECMO, also called percutaneous subsequently realized the importance of the initial tim- cardiopulmonary support (PCPS), has the advantages of ing of ECMO use in patients with refractory CS and the miniaturization, percutaneous cannulation, and rapid increasing volume of patients undergoing high-risk PCI priming (autopriming) designs, and it can enable car- or other percutaneous interventions in our cardiac ca- diologists to initiate extracorporeal life support in eligi- theterization laboratory. Accordingly, since July 2012, ble patients without additional assistance from surgeons we have used an alternative MCS system — PCPS system or perfusionists, which is required in traditional ECMO — to shorten delays in MCS initiation in eligible patients systems.3-6 with refractory CS. The operating protocol of this system The volume of patients who are at risk when under- is briefly described as follows. The PCPS system involves going a high-risk percutaneous coronary intervention a team comprised of interventional cardiologists who (PCI) or new percutaneous cardiovascular intervention is are trained to perform percutaneous femoral cannula- increasing.6-12 Although current evidence and guidelines tion (with a 16.5-Fr. arterial cannula and 21-Fr. venous support performing PCI without on-site cardiac surgery, cannula) and initiate PCPS (Terumo Inc, Tokyo, Japan) in they recommend that interventional centers should have the cardiac catheterization laboratory for a clinically ir- access to MCS systems, such as PCPS, for emergency reversible patient. The entire cannulation process is per- management.8,13 formed under fluoroscopic guidance, with the tip of the The temporal trends of PCI and ECMO volumes have arterial cannula being placed at the iliac artery and the continually increased in Taiwan.9,14 Accordingly, devel- tip of the venous cannula being placed at the junction of oping a reliable prognostic scoring system for facilitating the inferior vena cava and the right atrium. Trained, patient selection and risk stratification is imperative. on-duty nurses stationed in the nearby intensive cardiac Several scoring systems have been proposed for predict- care unit (CCU) perform PCPS through the autopriming ing survival in patients treated with veno-arterial ECMO, method. Three trained cardiologists, designated as PCPS such as the Survival After Veno-arterial ECMO (SAVE) specialists, receive an emergency call simultaneously, score, prEdictioN of Cardiogenic shock OUtcome foR and one of them responds to provide support in post- acute myocardial infarction (AMI) patients salvaGed by PCPS care and troubleshooting. When a patient’s hemo- VA-ECMO (ENCOURAGE) score, and modified SAVE dynamic and cardiac function improve, a surgeon weans score.15-17 However, these scoring systems have been es- the patient from PCPS through the surgical repair of ves- tablished for traditional ECMO systems that involve sels. All involved cardiologists and nurses must undergo teams composed of cardiovascular surgeons and per- regular PCPS training courses and attend case-based dis- fusionists, and whether these scoring systems can be cussions for each patient treated with PCPS. applied to PCPS systems that involve teams composed of only cardiologists and nurses is unclear. Study population This study investigated the in-hospital mortality of In this study, we enrolled 45 consecutive patients patients who underwent cardiologist-managed PCPS aged > 20 years from an observational PCPS cohort from and explored the discrimination ability of the aforemen- July 2012 to January 2019. All enrolled patients under- tioned prognostic scoring systems in the study popula- went PCPS administered by cardiologists in the cardiac tion. catheterization laboratory and subsequently received daily care from cardiologists; cardiovascular surgeons were involved only for vascular repair during PCPS wean- METHODS ing. Patients were excluded if (1) PCPS was implemented by a cardiovascular surgeon with or without a perfu- PCPS versus ECMO teams sionist and not in the cardiac catheterization laboratory Our institute — a tertiary medical center in Taipei, (n = 4), (2) surgeons or perfusionists participated in sub- Taiwan — has established a well-organized and func- sequent post-PCPS care (n = 2), or (3) PCPS was used for

327 Acta Cardiol Sin 2020;36:326-334 Shih-Chieh Chien et al. pulmonary support in a veno-venous configuration (n = mortality. This study was conducted in accordance with 1). PCPS was initiated either under active cardiopul- the Declaration of Helsinki and approved by the In- monary resuscitation (CPR) or indication of profound stitutional Review Board of Mackay Memorial Hospital shock, defined as systolic blood pressure less than 75 (19MMHIS198e). mmHg — despite receiving an intravenous inotropic We explored the discrimination ability of four scor- agent — that was associated with altered mental status ing systems: SAVE, ENCOURAGE, modified SAVE, and se- and respiratory failure. The choice between the PCPS quential organ failure assessment (SOFA). We selected and ECMO was made by the cardiologist in charge along these scoring systems because they have been imple- with a PCPS specialist or cardiovascular surgeon who mented and applied to study patients with CS who un- was included in the process of evaluating screening cri- derwent veno-arterial ECMO, similar to our study popu- teria. lation.15-18 Records of prothrombin activity, an ENCOUR- AGE variable, were not available in our hospital data- Data collection and prognostic scoring systems base. Therefore, we derived prothrombin activity by cal- Clinical details were retrospectively extracted from culating the international normalized ratio (INR) accord- prospective records of the PCPS database. Baseline cha- ing to a previously proposed equation: prothrombin ac- racteristics included demographic characteristics, medi- tivity (%) = 1/(0.028 INR - 0.018).19 cal history, laboratory data, and reasons for CS. The rea- The primary endpoint was defined as in-hospital son for ischemic shock was identified for those who de- mortality, and this endpoint was analyzed on a time-to- veloped refractory CS due to disturbances in coronary event basis. If death did not occur, the date of censoring macro-flow and myocardial ischemia, including the fol- was considered the date of final follow-up. lowing conditions: (1) acute myocardial infarction, (2) complications related to myocardial ischemia/infarction, Statistics and (3) complications related to coronary angiographic Baseline characteristics and prognostic scores were procedures with a rise in cardiac biomarkers (creatine stratified into two groups according to in-hospital sur- kinase-MB or troponin) above the upper limit of normal. vival status, and the two groups were compared. Con- The others were categorized as being nonischemic rea- tinuous variables are expressed as mean ± standard sons, including acute myocarditis, pulmonary embolism, deviation, and categorical variables are presented as dilated cardiomyopathy, and valvular heart disease. We percentages. For group comparisons, we used the Stu- carefully recorded the details of patients who had a cir- dent’s t test for continuous variables and the chi-square culatory collapse that required CPR. Patients who re- test for categorical variables. Survival probability curves quired chest compression in the hospital were defined were plotted using the Kaplan-Meier method and com- as having an in-hospital cardiac arrest (IHCA), whereas pared using the log rank test. Cox proportional hazards patients who required chest compression before hospi- regression analysis was performed to evaluate the asso- tal arrival were defined as having out-of-hospital cardiac ciation of variables with in-hospital mortality. Independ- arrest (OHCA). PCPS under CPR was defined as active ent baseline variables with a p value of < 0.05 in uni- CPR during the initiation of PCPS. Intervals from the ear- variate analysis were included in multivariate analysis. liest recorded time of cardiac arrest and activating the The modified SAVE score was calculated as follows: SAVE PCPS system to initiating extracorporeal circulation were score+15(iflactatelevel<75mg/dL)orSAVEscore+0 recorded as arrest to PCPS time and activation to PCPS (if lactate level ³ 75 mg/dL). The rationale behind this time, respectively. The procedural time was estimated calculation is that in a previous study, the effects of a from the arrival time at the catheterization laboratory if lactate level of < 75 mg/dL appeared to outweigh the the patient underwent PCPS as the first procedure, or effects of the SAVE score in terms of survival prediction, from the request of PCPS preparation if the patient was with the corresponding odds ratios being 8.74 and 1.17, already on the table in the catheterization laboratory to respectively.17 Accordingly, because of the inevitably the complete establishment of extracorporeal circula- strong interaction between lactate levels and the modi- tion. The outcome recorded in this study was in-hospital fied SAVE score, we did not include data regarding lac-

Acta Cardiol Sin 2020;36:326-334 328 Prognostic Scoring Systems for PCPS Patients tate levels in multivariate adjustments for the modified Prognostic scores SAVE score. The accuracy of the various prognostic scor- Compared with the nonsurvivors, the survivors had ing systems in predicting in-hospital mortality was as- higher SAVE (-5.9 vs. -11.4, p = 0.001) and modified sessed using area under the receiver operating charac- SAVE (4.2 vs. -7.1, p = 0.001) scores. However, the two teristic (ROC) curve (AUC) analysis. We used SPSS (ver- groups did not exhibit statistical differences in SOFA (9.7 sion 22.0; SPSS, Chicago, IL, USA) and MedCalc (version vs. 10.3, p = 0.65) or ENCOURAGE (24.8 vs. 26.8, p = 0.4) 19.0.5; MedCalc Software, Mariakerke, Belgium) for all scores. As presented in Table 1, the HR (95% CI) for the statistical analyses. We considered a p value of < 0.05 to SAVE score was 0.92 (0.86-0.98; p = 0.01), and that for be statistically significant. the modified SAVE score was 0.95 (0.92-0.99; p = 0.005). In multivariate analysis, the predictive power of the SAVE score for mortality was lost (HR: 0.95, 95% CI: RESULTS 0.88-1.02; p = 0.15), as presented in Table 2 (model 1). By contrast, a relatively high modified SAVE score was inde- Baseline characteristics and survival pendently associated with hospital survival (HR: 0.96, The 45 patients enrolled in this study had a mean 95% CI: 0.93-1.00; p = 0.047), as shown in Table 2 (model (range) age of 64.3 (53-76) years. Among these patients, 2). We conducted assessments to determine the optimal 71.1% were men, all of whom underwent cardiologist- cutoff value of the modified SAVE score for creating a di- managed PCPS with a mean support time of 95.5 (±69.9) chotomous variable, and a mean value of the score (-3) hours. In addition, 16 (35.6%) patients survived to hos- appeared to be the optimal cutoff. Accordingly, we ap- pital discharge (the survivors group), and 29 (64.4%) pa- plied this cutoff (-3) to stratify the entire cohort into bi- tients died (the nonsurvivors group). The nonsurvivors nary groups: one comprised of patients with a modified were more likely to have had an ischemic etiology for SAVEscoreof>-3,andtheotherwithamodifiedSAVE CS, received CPR before PCPS implementation, and had score of £ -3.AsindicatedinTable2(model3),amodi- higher lactate levels (all p < 0.05) compared with the fied SAVE score of > -3 was more significantly associated survivors. No significant differences were observed be- with hospital survival compared to a score of £ -3 (HR: tween the two groups in terms of demographics, history 0.37, 95% CI: 0.15-0.94; p = 0.04). We also plotted a of comorbidities, refractory cardiac arrest resuscitated Kaplan-Meier survival curve (Figure 1), which showed by salvage PCPS, total CPR time, activation time, proce- that a modified SAVE score of £ -3 was associated with a dural time, hematocrit levels, or estimated glomerular lower survival probability than a modified SAVE score of > filtration rates. All of the patients with ischemic reasons -3 throughout the observation period (hospital survival received coronary revascularization, including PCI (n = rate: 9% vs. 29%; log rank p = 0.005). 32/35, 91.4%) and coronary bypass surgery (n = 3/35, We plotted ROC curves (Figure 2) to evaluate the ac- 8.6%). PCPS in those with non-ischemic reason was most curacy of the various scoring systems in predicting in- used as a bridge to cardiac recovery except in two cases, hospital mortality. According to the results, the SOFA one of whom underwent aortic valve replacement sur- and ENCOURAGE scores exhibited limited predictive ac- gery for etiology of severe aortic valve stenosis, and the curacy (AUC observed for SOFA score = 0.54; AUC ob- other received thrombolytic therapy for acute pulmo- served for ENCOURAGE score = 0.62). The SAVE score nary embolism. In univariate analysis, the hazard ratios exhibited a relatively high-risk discrimination ability [HRs; 95% confidence intervals (CIs)] for pre-PCPS car- (AUC = 0.74), but it remained inferior to that of lactate diac arrest, ischemic etiology, and lactate levels were level (AUC = 0.76). The modified SAVE score exhibited 4.05 (1.21-13.6; p = 0.02), 3.72 (0.88-15.7; p = 0.07), the best risk discrimination ability (AUC = 0.78). and 1.01 (1.01-1.02; p = 0.001), respectively. Notably, of all patients, 75.6% experienced at least one cardiac ar- rest (IHCA or OHCA) and 60% were resuscitated by sal- DISCUSSION vage PCPS (ECPR), indicating the clinical severity of our study population (Table 1). This study demonstrated the feasibility of establish-

329 Acta Cardiol Sin 2020;36:326-334 Shih-Chieh Chien et al.

Table 1. Baseline characteristics of patients who underwent PCPS according to in-hospital survival status All patients Survivors Non-survivors Univariate pvalue n=45 n=16 n=29 Hazard ratio (95% CI) pvalue Demographics Age, year 64.3 ± 11.3 63.6 ± 12.7 64.7 ± 10.6 0.75 Sex, male (%) 32 (71.1) 12 (75.0) 20 (69.0) 0.74 Body mass index, kg/m2 25.5 ± 3.90 26.4 ± 3.90 25.1 ± 3.90 0.29 Pre-PCPS SBP, mmHg 65.2 ± 22.0 71.7 ± 10.6 58.8 ± 28.5 0.16 Medicalhistory,n(%) Previous MI 08 (17.8) 02 (12.5) 06 (20.7) 0.69 Previous stroke 2 (4.4) 1 (6.3) 1 (3.4) 1.00 Pre-PCPS cardiac arrest, n (%) 34 (75.6) 08 (50.0) 26 (89.7) 00.009 4.05 (1.21-13.6) 0.02 IHCA 29 (64.4) 07 (43.8) 22 (75.9) 0.05 OHCA 05 (11.1) 1 (6.3) 04 (13.8) 0.64 PCPS under CPR, n (%) 27 (60.0) 08 (50.0) 19 (69.5) 0.35 CPR time, (min) 34.1 ± 23.0 32.6 ± 22.0 34.6 ± 23.7 0.84 Activation to PCPS time, (min) 38.0 ± 14.7 37.5 ± 13.6 38.3 ± 15.6 0.87 Arrest to PCPS time, (min) 36.6 ± 24.0 24.1 ± 14.7 40.7 ± 25.3 0.12 Procedural time, (min) 17.9 ± 4.80 16.1 ± 3.7 18.9 ± 5.20 0.07 Duration of PCPS support, (hr) 95.5 ± 69.9 115.8 ± 48.9 84.3 ± 77.6 0.15 Shock reasons, n (%) Ischemia 35 (77.8) 8 (50.0) 27 (93.1) 0.002 3.72 (0.88-15.70) 0.07 Laboratory Hematocrit, (%) 36.8 ± 9.3 38.9 ± 6.70 35.9 ± 10.5 0.40 eGFR, ml/min/1.73 m2 41.4 ± 24.6 53.9 ± 27.4 36.3 ± 21.9 0.08 Lactate, mg/dL 95.8 ± 57.5 70.8 ± 61.4 110.3 ± 50.8 0.04 1.01 (1.01-1.02) 0.001 Prognostic scores SOFA 10.1 ± 4.1 9.7 ± 4.8 10.3 ± 3.9 0.65 ENCOURAGE 26.1 ± 7.3 24.8 ± 8.2 26.8 ± 6.8 0.40 SAVE -9.5 ± 5.9 -5.9 ± 4.6 -11.4 ± 5.5- 0.001 0.92 (0.86-0.98) 0.01 Modified SAVE -3.1 ± 10.7 4.2 ± 9.8 -7.1 ± 9.1 0.001 0.95 (0.92-0.99) 0.005 PCPS, percutaneous cardiopulmonary support; 95% CI, 95% confidence interval; SBP, systolic blood pressure; MI, myocardial infarction; IHCA, in-hospital cardiac arrest; OHCA, out-of-hospital cardiac arrest; CPR, cardiopulmonary resuscitation; eGFR, estimated glomerular filtration rate; SOFA score, Sequential Organ Failure Assessment score; ENCOURAGE score, prEdictioN of Cardiogenic shock Outcome foR AMI patients salvaGed by VA-ECMO score; SAVE score, Survival After Veno-arterial ECMO score.

Table 2. Predictive values of SAVE score and modified SAVE score in multivariate analyses Hazard ratio (95 % confidence interval) p value Model 1 SAVE score 0.95 (0.88-1.02) 0.15 Pre-PCPS cardiac arrest (yes vs. no) 1.72 (0.66-4.45) 0.27 Ischemic reason (yes vs. no) 02.33 (0.52-10.50) 0.27 Model 2 Modified SAVE score 0.96 (0.93-1.00) 00.047 Pre-PCPS cardiac arrest (yes vs. no) 2.63 (0.62-7.98) 0.22 Ischemic reason (yes vs. no) 1.60 (0.35-7.62) 0.55 Model 3 Modified SAVE score (> -3 vs. £ -3) 0.37 (0.15-0.94) 0.04 Pre-PCPS cardiac arrest (yes vs. no) 2.47 (0.71-8.67) 0.16 Ischemic reason (yes vs. no) 1.50 (0.33-6.84) 0.60 PCPS, percutaneous cardiopulmonary support; 95% CI, 95% confidence interval; SAVE score, Survival After Veno-arterial ECMO score.

Acta Cardiol Sin 2020;36:326-334 330 Prognostic Scoring Systems for PCPS Patients

Figure 2. ROC curves for in-hospital mortality in patients who under- went emergency PCPS according to different variables. Various AUC Figure 1. Hospital survival percentage in enrolled cohort according to values were observed during the prediction of in-hospital mortality: modified SAVE score. Survival probability for patients with a modified SOFA = 0.54; lactate = 0.76; SAVE score = 0.74; modified SAVE score = SAVE score of -3 or less was lower than that of those with a modified 0.78; and ENCOURAGE score = 0.62. AUC, area under the ROC curve; SAVE score of more than -3 throughout the study period (hospital sur- ROC, receiver operating characteristic curve; SOFA score, Sequential vival rate: 9% vs. 29%; log rank p = 0.005). SAVE score, Survival After Organ Failure Assessment score; ENCOURAGE score, prEdictioN of Car- Veno-arterial ECMO score. diogenic shock Outcome foR AMI patients salvaGed by VA-ECMO score; SAVE score, Survival After Veno-arterial ECMO score. ing a PCPS team without on-site surgeons or perfu- sionists to respond to and treat hemodynamically irre- (eitherIHCAorOHCA).28,29 versible patients in a cardiac catheterization laboratory. Intraaortic balloon pumping only provides partial The overall rate of survival to hospital discharge in this hemodynamic support, and might have limited clinical study was 35.6%, which is similar to rates reported in benefits.30,31 Peripheral ventricular assist devices have previous studies and registries.14,17,20,21 Compared with also been developed for use in emergency situations, existing scoring systems for veno-arterial ECMO, the but they are still unavailable in Taiwan.32 Moreover, they modified SAVE score provided the best risk discrimina- have other limitations, including the requirement of ad- tion (AUC = 0.78). A modified SAVE score of £ -3 was in- ditional procedures and devices for biventricular sup- dependently associated with an increased risk of in-hos- port, lack of extra-oxygenation in some devices, and pital mortality. high cost. Therefore, peripheral ventricular assist de- vices should be only applied to selected patients in em- Mechanical support in CS ergency situations.33 TherateofmortalityfromCShasbeenreportedto be high, with the rate approaching 60%-80% in patients Role of PCPS in the interventional era without advanced therapies.22,23 A comprehensive heart- Implementing traditional ECMO systems is a time- lung support system such as ECMO is sometimes pivotal consuming process and requires backup by surgeons or to stabilizing patients’ hemodynamic status and affords perfusionists. PCPS has attracted attention because of sufficient time for recovery or to receive subsequent its simple and timely implementation, particularly in the therapeutic modalities regardless of the etiology.7,24-27 current interventional era.3,4,26,29 To the best of our Incorporating ECMO into conventional CPR (ECPR) can knowledge, the present study is the first to introduce be also effective in saving patients with cardiac arrest the implementation of a PCPS team composed of car-

331 Acta Cardiol Sin 2020;36:326-334 Shih-Chieh Chien et al. diologists and CCU nurses and to report the correspond- population enrolled in the study by Chen et al. and that ing in-hospital outcomes. Specifically, in our hospital, enrolled in our study comprised Taiwanese patients who the team responsible for percutaneous interventions or had acute presentations, high prevalence of pre-ECMO daily care can be transformed into a PCPS team without cardiac arrest (74.7% vs. 75.6%), and high lactate levels on-site surgeons upon encountering a patient with re- (97.4 vs. 95.8 mg/dL). Second, the patterns and quality fractory CS. This conceptis in line with current recom- of clinical care in Taiwan are similar. Czobor et al. initi- mendations, which state that interventional centers can ated PCPS in a cardiac catheterization laboratory and effectively perform emergency MCS procedures such as proposed the initial SOFA score to be a major prognostic percutaneous interventions without on-site surgery and factor (odds ratio = 0.577); nevertheless, their results should implement effective quality control policies. How- might not be generalizable to our patients because they ever, consolidated training programs and relevant case- enrolled a limited number of patients (n = 25) with a rel- based discussion should be particularly emphasized for atively low degree of clinical severity.20 The SAVE and all teammates, because most will be inexperienced ENCOURAGE scores have been validated in studies in- owing to the relatively low volume of PCPS. Insufficient volving relatively large samples of patients treated with training or unfamiliarity with procedural processes will veno-arterial ECMO.15,16 However, the application of prolong the implementation time and increase the risk these two scores to our population was primarily limited of operating errors. Our study also reflected the real- by differences in baseline characteristics between the world condition that there was still a time lag between patients. Patients enrolled in the previous study con- activation and procedural time because some cardiolo- ducted on the SAVE score had less severe conditions and gists still needed additional waiting time for the assis- fewer ischemic etiologies,15 and all of the patients en- tance of PCPS specialists to implement PCPS. In this rolled in the previous study using the ENCOURAGE score study, the rate of survival to hospital discharge was had acute myocardial infarction.16 35.6%, which is similar to the survival rate (41.4%) of pa- tients in the global registry of the Extracorporeal Life Study limitations Support Organization (ELSO).21 The slightly lower sur- This study has several limitations. First, this was a vivalrateinourcohortmightbebecausethepatientsin retrospective single-center study and some missing data our cohort exhibited a higher prevalence of cardiac ar- (such as neurologic function, initial rhythms of arrest) rest before or during PCPS and had a major etiology of and potential bias were inevitable. The generalizability myocardial ischemia/infarction (77.8%) compared with of our findings to other hospitals could be restricted. the patients in the ELSO registry. Previous studies on Because of this study’s single-center design and small ECMO have demonstrated that cardiac arrest and an cohort, some unknown confounding factors may have etiology of myocardial ischemia/infarction are poor affected the study results, despite the statistical adjust- prognostic factors.15,28,29,34 ments. Second, all patients were cannulated under fluo- roscopic guidance in our cardiac catheterization labora- Prognostic scores for cardiologist-managed PCPS tory to prevent complications or unsuccessful cannu- Precise risk prediction for patients undergoing PCPS lation. We could not determine whether this could have can help physicians to stratify the risk of candidate pa- resulted in potential patient selection bias. Third, the tients, help them evaluate the quality of care retrospec- small cohort may have introduced bias and limited the tively, and in particular facilitate their future decision- predictive value of any baseline factors, regardless of making processes.35 The findings of this study are con- factor adjustments. Therefore, we could not provide a sistent with those of Chen et al., who reported that the new scoring system. Fourth, eliminating the disease he- modified SAVE score had the best risk discrimination terogeneity in our study population was difficult. Finally, ability (AUC = 0.78), and that stratifying patients by us- a surgeon participated in our PCPS system in the final ing a cutoff value of -3 was independently associated step of surgical repair of femoral vessels. The effective- with in-hospital mortality.17 The possible reasons for ness and safety of the applied percutaneous closure de- these observations are provided as follows. First, the vice was not tested.

Acta Cardiol Sin 2020;36:326-334 332 Prognostic Scoring Systems for PCPS Patients

CONCLUSIONS SHOCK Investigators. Should We Emergently Revascularize Oc- cluded Coronaries for Cardiogenic Shock. N Engl J Med 1999; In conclusion, patients with refractory CS were ef- 341:625-34. 8. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS fectively treated by our PCPS team composed of inter- Guidelines on myocardial revascularization. Eur Heart J 2019;40: ventional and critical care personnel. However, all PCPS 87-165. team members should receive regular and continual 9. Liang FW, Lee JC, Lu TH, Yin WH. Trends in proportions of hospi- training to prevent operating errors. The modified SAVE tals and operators not meeting minimum percutaneous coro- score is useful for risk stratification in patients who have nary intervention volume standards in Taiwan, 2001-2013. Ca- received PCPS and can help in making future therapeu- theter Cardiovasc Interv 2018;92:247-50. tic decisions. 10. Chen YJ, Ho CT, Tsai FC, et al. Outcomes of pulmonary endar- terectomy for chronic thromboembolic pulmonary hypertension at a single center in Taiwan. Acta Cardiol Sin 2019;35:153-64. 11. Wayangankar SA, Bangalore S, McCoy LA, et al. Temporal trends ACKNOWLEDGMENTS andoutcomesofpatientsundergoingpercutaneouscoronary interventions for cardiogenic shock in the setting of acute myo- The authors thank the support from MacKay Memo- cardial infarction: a report from the CathPCI Registry. JACC Car- rial Hospital (107DMH0100326; 108DMH0100005). We diovasc Interv 2016;9:341-51. also appreciate Ms. Wen-Chen Lin for her excellent work 12. Guerrero-Miranda CY, Hall SA. Cardiac catheterization and per- cutaneous intervention procedures on extracorporeal membrane on data collection. oxygenation support. Ann Cardiothorac Surg 2019;8:123-8. 13. Goel K, Gupta T, Kolte D, et al. Outcomes and temporal trends of inpatient percutaneous coronary intervention at centers with CONFLICTS OF INTEREST and without on-site cardiac surgery in the United States. JAMA Cardiology 2017;2:25-33. All authors declare no conflicts of interest. 14. Hsu CP, Lee WC, Wei HM, et al. Extracorporeal membrane oxy- genation use, expenditure, and outcomes in Taiwan from 2000 to 2010. J Epidemiol 2015;25:321-31. 15. Schmidt M, Burrell A, Roberts L, et al. Predicting survival after REFERENCES ECMO for refractory cardiogenic shock: the survival after veno- arterial-ECMO (SAVE)-score. Eur Heart J 2015;36:2246-56. 1. van Diepen S, Katz JN, Albert NM, et al. Contemporary manage- 16. Muller G, Flecher E, Lebreton G, et al. The ENCOURAGE mortality ment of cardiogenic shock: a scientific statement from the Ame- risk score and analysis of long-term outcomes after VA-ECMO for rican Heart Association. Circulation 2017;136:e232-68. acute myocardial infarction with cardiogenic shock. Intensive 2. Tehrani BN, Truesdell AG, Sherwood MW, et al. Standardized Care Med 2016;42:370-8. team-based care for cardiogenic shock. J Am Coll Cardiol 2019; 17. Chen WC, Huang KY, Yao CW, et al. The modified SAVE score: pre- 73:1659-69. dicting survival using urgent veno-arterial extracorporeal mem- 3. Sung K, Lee YT, Park PW, et al. Improved survival after cardiac brane oxygenation within 24 hours of arrival at the emergency arrest using emergent autopriming percutaneous cardiopul- department. Crit Care 2016;20:336. monary support. Ann Thorac Surg 2006;82:651-6. 18. Ferreira FL, Bota DP, Bross A, et al. Serial evaluation of the SOFA 4. Shinn SH, Lee YT, Sung K, et al. Efficacy of emergent percu- score to predict outcome in critically ill patients. JAMA 2001; taneous cardiopulmonary support in cardiac or respiratory fail- 286:1754-8. ure: fight or flight? Interact Cardiovasc Thorac Surg 2009;9:269- 19. Lindahl TL, Egberg N, Hillarp A, et al. INR calibration of Owren- 73. type prothrombin time based on the relationship between PT% 5. Lan WR, Chien SC, Su CH, Tsai CT. The utilization of a new, mi- and INR utilizing normal plasma samples. Thromb Haemost 2004; niaturized veno-arterial bypass system for cardiogenic shock: a 91:1223-31. review article. J Intern Med Taiwan 2017;28:213-7. 20. Czobor P, Venturini JM, Parikh KS, et al. Sequential Organ Failure 6. Husser O, Holzamer A, Philipp A, et al. Emergency and prophylac- Assessment score at presentation predicts survival in patients tic use of miniaturized veno-arterial extracorporeal membrane teated with percutaneous veno-arterial extracorporeal mem- oxygenation in transcatheter aortic valve implantation. Catheter brane oxygenation. J Invasive Cardiol 2016;28:133-8. Cardiovasc Interv 2013;82:e542-51. 21. Lorusso R, Gelsomino S, Parise O, et al. Venoarterial extracor- 7. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in poreal membrane oxygenation for refractory cardiogenic shock acute myocardial infarction complicated by cardiogenic shock. in elderly patients: trends in application and outcome from the

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