Faculty Bibliography

We present a case of rapidly ascending left ventricular assist device driveline and tunnel infection in a patient with a long length of driveline buried beyond the distal velour coating. Device salvage with radical debridement, exit site relocation, and local tissue advancement is described. The findings in this case suggest that the interface between nonvelour covered driveline and subcutaneous tissue can become the nidus of a virulent ascending infection because of poor tissue ingrowth.

BACKGROUND: In the SHOCK trial an invasive strategy of early revascularization was associated with a significant mortality benefit at 6-months when compared with initial stabilization in patients with cardiogenic shock complicating acute myocardial infarction. Our objectives were to evaluate the data on real world practice and outcomes of invasive vs. conservative management in patients with cardiogenic shock. METHODS: We analyzed data from the Nationwide Inpatient Sample (NIS) between 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention or coronary artery bypass graft surgery) vs. conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality. RESULTS: We identified 60833 patients with cardiogenic shock of which 20644 patients (10322 in each group) with similar propensity scores, including 11,004 elderly patients (>/= 75 years), were in the final analysis. Patients who underwent invasive management had a 59% lower odds of in-hospital mortality (37.7% vs. 59.7%; OR=0.41; 95% CI 0.39-0.43; P<0.0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (>/= 75 years) (44.0% vs. 63.6%; OR=0.45; 95% CI 0.42-0.49; P<0.0001) and those younger than 75 years (30.6% vs. 55.1%; OR=0.36; 95% CI 0.33-0.39; P<0.0001) although the magnitude of risk reduction differed (Pinteraction <0.0001). CONCLUSIONS: In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup.