Physiologic Phenotype of Cardiogenic Shock Due to End-Stage Heart Failure and Acute Myocardial Infarction: Effect of ECLS

Purpose This study (i) models and compares the pathophysiology of cardiogenic shock (CS) due to end stage heart failure (ESHF) and acute myocardial infarction (AMI) using patient data and (ii) compares the effects extracorporeal life support (ECLS) in these 2 patient groups. Methods Data from consecutive patients with CS due to ESHF and AMI were used as the basis for simulating the hemodynamics with the computational model by Burkhoff et al. ESHF is defined as diagnosis of an ischemic or non-ischemic cardiomyopathy prior to CS. The effects of right atrial (RA) to femoral artery ECLS at 3.5L/min were simulated. Results Patient with ESHF had lower ejection fraction, more mitral regurgitation and higher right atrial pressure [TABLE]. Compared to AMI, CS due to ESHF is associated with (i) lower left (LV) and right ventricular (RV) diastolic pressure-volume relation (lower ‘stiffness’) [FIGURE]; (ii) lower LV and RV end-systolic elastance (Ees) and (iii) larger pressure-volume loop area (PVA) corresponding to high myocardial oxygen consumption (MVO2), (iv) lower RV efficiency (ratio of stroke work to MVO2). ECLS increased systemic blood pressure and pulmonary artery wedge pressure (PAWP) in both groups, but patients with AMI had higher relative increase in PAWP due to the steeper diastolic pressure-volume relation compared to ESHF. Conclusion The hemodynamic phenotype in CS due to ESHF differs from AMI with higher LV and RV capacitance (lower 'stiffness'), lower LV and RV Ees (contractility) and lower RV efficiency in the former. ECLS increased systemic and pulmonary artery wedge pressure, which is more marked in AMI.