Long-term outcomes and predictors of mortality in patients with cardiogenic shock and severe valvular heart disease
S Kawanami, Y Egami, K Nagai, R Muroya, H Matsubara, T Mukai, N Kobayashi, A Sugino, M Abe, H Nohara, N Okamoto, Y Matsunaga, M Yano, M NishinoAbstract
Background
Cardiogenic shock (CS) is a heterogeneous condition with high mortality, and valvular heart disease (VHD) represents an important underlying cause. Although valvular intervention has been proposed for patients with CS and severe VHD, its prognostic benefit remains uncertain, and long-term outcome data are scarce.
Purpose
This study aimed to evaluate the impact of severe VHD on long-term mortality in CS and to identify predictors of long-term mortality, including the effect of valvular intervention in patients with CS and severe VHD.
Methods
Consecutive patients admitted to our institute with acute myocardial infarction or acute decompensated heart failure between January 2015 and December 2024 were retrospectively identified. Patients requiring vasopressors and/or mechanical circulatory support during hospitalization were defined as having CS and included. Time-dependent covariate analysis was performed to address immortal time bias related to valvular intervention among patients with CS and severe VHD.
Results
A total of 530 patients with CS were included in the analysis, of whom 94 (17.7%) had severe VHD. The median age was 77 years (interquartile range [IQR], 68–83), and 36.6% were female. At CS onset, 64.9% of patients were classified as SCAI stage C, 24.7% as stage D, and 10.4% as stage E. During a median follow-up of 395.6 days (IQR, 32.4–1191) from CS onset, 202 deaths (38.1%) occurred. Multivariable Cox regression analysis showed that severe VHD was an independent predictor of long-term mortality (Figure 1). Among patients with CS and severe VHD, severe mitral regurgitation was observed in 48 patients (51.1%) and severe aortic stenosis in 24 patients (25.5%). Overall, 28 patients (29.8%) underwent valvular intervention, including 14 surgical procedures (50.0%), 10 transcatheter aortic valve replacements (35.7%), and 4 transcatheter edge-to-edge mitral valve repairs (14.3%). The median time from shock onset to valvular intervention was 17.4 days (IQR, 8.0–35.9). During a median follow-up period of 181.9 days (IQR, 21.28–2333) from the onset of CS, 51 deaths (54.3%) occurred. Multivariable Cox regression analysis identified older age, prior heart failure hospitalization, and higher serum creatinine as independent predictors of long-term mortality (Figure 2). In time-dependent Cox regression analyses, valvular intervention was not independently associated with long-term mortality after adjustment for hemodynamic severity or renal dysfunction (hazard ratio 0.46; 95% confidence interval 0.18–1.14; p=0.09).
Conclusions
Severe VHD independently predicted long-term mortality in patients with CS. Long-term outcomes were driven more by patient characteristics and organ dysfunction than by valvular intervention. Therefore, valvular intervention should be considered by a heart team based on individual patient characteristics.Figure 1Figure 2