Mechanical circulatory support for Takotsubo syndrome with cardiogenic shock

Abstract Background Cardiogenic shock complicates clinical courses of a significant proportion of patients with takotsubo syndrome (TTS), with an incidence of up to 20%. While catecholaminergic inotropic agents are generally considered contraindicated, data on the use of mechanical support devices in TTS complicated by cardiogenic shock remain scarce. Purpose The present study aimed to compare the effectiveness use of mechanical support devices compared to medical therapy alone in TTS patients with cardiogenic shock and to evaluate associated safety outcomes. Methods Patients with TTS were enrolled from the International Takotsubo (InterTAK) Registry. Propensity score matching was performed based on age, sex, apical type, InterTAK Classification, acute comorbidities, left ventricular ejection fraction, and out-of-hospital cardiac arrest. The primary outcomes included in-hospital death and a composite safety endpoint including limb ischemia, compartment syndrome, retroperitoneal hematoma, arterial thrombosis, aneurysms, and bleeding events. Results Overall, 309 patients with TTS and complicating cardiogenic shock were included in this study (mean age 64.6±14.3, 69.8% female). Of these, 197 patients (63.8%) received medical therapy only (MTO), 69 (22.3%) patients received IABP only, 24 (7.8%) patients received Impella only, and 19 (9.6%) patients received other mechanical support or combinations of the above-mentioned devices. The median support time was 1.5 (IQR, 1.00 – 3.25) days in the IABP group and 2.0 (IQR, 1.00 – 2.00) days in the Impella group. In the matched cohort, the use of IABP was found to be associated with a lower in-hospital mortality rate than medical therapy only (N IABP: 69 vs N MTO: 138, 14.5% vs. 35.5%, P=0.002), while in-hospital mortality in the Impella and medical therapy were comparable (N Impella: 24 vs N MTO 24, 25.0% vs. 29.2%, P=0.47). Data on device-related complications were available for 82 patients. A total of 14 (17.1%) patients had MCS-related complications. MCS-related complications were more frequently observed in patients with the Impella or other MCS devices and were the lowest in patients with IABP (31.3% vs. 37.5% vs. 6.0%, P = 0.003). Conclusion In this observational multicenter study, MCS was increasingly used to manage cardiogenic shock complicating TTS. The Impella device was not associated with improved survival, while the IABP resulted in a lower mortality rate compared to propensity score matched controls with medical therapy only. The use of MCS was associated with a significant incidence of device-related, which were most frequent in large-diameter devices.