Short-term use of mechanical circulatory support has become more common in the United States, according to a serial cross-sectional study published in the October 7, 2014, issue of the Journal of the American College of Cardiology. The shift has been accompanied by concomitant declines in hospital costs and in-hospital mortality.

Historically used predominantly in response to circulatory collapse, support devices are now increasingly used “in an anticipatory or prophylactic fashion,” write Pramod Bonde, MD, of Yale University School of Medicine (New Haven, CT), and colleagues. 

Large Increase in Both Percutaneous, Nonpercutaneous Support

From 2007 to 2011, use of percutaneous devices for short-term circulatory support grew by more than 15 times, while that of nonpercutaneous devices increased by 101%.

Mortality among patients who received short-term mechanical circulatory support decreased from 2004 to 2011, both overall and in the subset of patients with cardiogenic shock, although there were only positive trends in those with acute MI or CAD. Length of hospital stay decreased for patients with congestive heart failure (CHF) but not for those with acute MI or CAD. Cost of hospitalization dropped for all diagnoses except heart valve disorders and “other miscellaneous diagnoses” (table 1).

Increasing patient age strongly corresponded with decreasing hospital costs, and IABP use and in-hospital mortality were associated with costs higher by 25.2% and 28.5%, respectively (P < .001 for both).

On multivariate adjustment, predictors of death included:

• Patient age of 65 to 79 years (OR 2.41; 95% CI 1.49-3.88)
• Baseline coagulopathy (OR 2.35; 95% CI 1.88-2.94)
• Cardiogenic shock (OR 1.42; 95% CI 1.14-1.77)
• Prior IABP use (OR 2.00; 95% CI 1.58-2.52)
• Prior cardiopulmonary resuscitation (OR 3.50; 95% CI 2.20-5.57)

During the period of 2008-2011 compared with earlier years, patients were more likely to be discharged home (P for trend = .001). Also, there was a decline over time in patient transfers to other facilities (P for trend = .019).

Percutaneous Devices Drove Change in Usage

Improved availability of percutaneous devices for short-term circulatory support and the evolution toward upfront use have “profoundly changed the field,” as evidenced by such devices being employed in patients with CAD or a diagnosis unrelated to shock, explain Dr. Bonde and investigators.

Furthermore, percutaneous delivery allows for the devices to be used in the cath lab without the need for surgical consultation, shortening the time it takes for implantation, they add.

The study authors note the difficulty in determining causality between mortality and increased use of short-term circulatory support due to other possible confounders such as decreased door-to-balloon times and length of inpatient stays.

That IABP use was associated with higher hospitalization cost is surprising, they note, suggesting it might be explained by delays in giving more aggressive forms of circulatory support to patients who need them, leading to worsened shock severity and higher costs of care.

To improve outcomes further, they recommend: “Guidelines need to be developed to help enable early identification of patients for whom IABP is likely to be insufficient.”

Source:
Stretch R, Sauer CM, Yuh DD, et al. National trends in the utilization of short-term mechanical circulatory support: incidence, outcomes, and cost analysis. J Am Coll Cardiol. 2014;64:1407-1415.

Disclosure:

• Dr. Bonde reports no relevant conflicts of interest.

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