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, Taipei; 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, MacKay Medical College, New Taipei City, Taiwan. 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., Tamsui District, 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