Shifts in MCS utilization and early outcomes within a bridge-to-decision strategy for cardiogenic shock across the destination therapy Era
H Tomita, T Watanabe, F Matsuyama, N Kitahata, R Shiomura, H Mochizuki, T Sato, Y Tadokoro, T Kakuta, K Suzuki, K Yamashita, N Kawamoto, S Fukushima, C Izumi, Y TsukamotoAbstract
Background
Cardiogenic shock (CS) frequently requires temporary mechanical circulatory support (MCS) as part of a bridge-to-decision (BTD) strategy. With the availability of destination therapy (DT) using durable left ventricular assist devices (LVADs), treatment pathways have evolved. However, how the DT Era has reshaped practice patterns within BTD strategies and whether such shifts have translated into improved early outcomes remain uncertain.
Purpose
To describe changes in device utilization and patient outcomes within a BTD strategy before and after the introduction of the DT Era, and to identify consistently high-risk subgroups.
Methods
In this single-center retrospective cohort study, we analyzed patients with CS who received their first BTD device between January 2017 and December 2025. Temporary MCS devices included extracorporeal LVAD and high-flow percutaneous ventricular assist devices (PVADs). Patients were categorized into a pre-DT Era group (January 2017–April 2021) and a DT Era group (May 2021–December 2025). The primary outcome was 60-day mortality. Prespecified subgroup analyses focused on age ≥65 years and ischemic cardiomyopathy (ICM).
Results
Among 191 patients (pre-DT Era: n=104; DT Era: n=87), the use of high-flow PVAD increased markedly from 27.9% to 54.0% in the DT Era (p<0.01), indicating a substantial shift in device allocation. Overall 60-day mortality was 17.8%, with no significant difference between the Eras (17.3% vs. 18.4%, p=0.82). Age ≥65 years and ICM consistently conferred higher risk across both periods (≥65 years: pre-DT Era 50.0% vs. 13.0%, p=0.01; DT Era 45.5% vs. 14.5%, p<0.01; ICM: pre-DT Era 32.4% vs. 9.0%, p<0.01; DT Era 35.7% vs. 10.2%, p<0.01).
Conclusions
In the DT Era, clinical practice within the BTD strategy shifted toward greater adoption of high-flow PVADs, yet early outcomes remained comparable to those in the pre-DT Era. This discrepancy may reflect the expanded application of BTD strategies to higher-risk patients or persistent constraints in device–patient matching and timing. Across Eras, advanced age and ICM consistently identified high-risk subgroups, underscoring the need for refined risk stratification and optimization of BTD algorithms in the DT Era.