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Canadian Journal of Cardiology

Significant Valvular Dysfunction and Outcomes in Cardiogenic Shock: Insights From the Randomized DOREMI Trial

  • Author Footnotes
    ‡ These authors contributed equally to this article.
    Simon Parlow
    Footnotes
    ‡ These authors contributed equally to this article.
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
    Search for articles by this author
  • Author Footnotes
    ‡ These authors contributed equally to this article.
    Willy Weng
    Footnotes
    ‡ These authors contributed equally to this article.
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
    Search for articles by this author
  • Pietro Di Santo
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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  • Richard G. Jung
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada

    Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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  • Melissa Fay Lepage-Ratte
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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  • Pouya Motazedian
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Graeme Prosperi-Porta
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Omar Abdel-Razek
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Trevor Simard
    Affiliations
    Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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  • Vincent Chan
    Affiliations
    Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Marino Labinaz
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Michael Froeschl
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Rebecca Mathew
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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  • Benjamin Hibbert
    Correspondence
    Corresponding author: Dr Benjamin Hibbert, University of Ottawa Heart Institute, 40 Ruskin Street, H-4238, Ottawa, Ontario K1Y 4W7, Canada. Tel.: +1-613-696-7358; fax.: +1-613-696-7245.
    Affiliations
    CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
    Search for articles by this author
  • on behalf of theCAPITAL DOREMI Investigators
  • Author Footnotes
    ‡ These authors contributed equally to this article.
Published:April 13, 2022DOI:https://doi.org/10.1016/j.cjca.2022.04.004

      Abstract

      Background

      Patients with cardiogenic shock (CS) suffer high rates of in-hospital mortality, with little evidence guiding management. The impact of valvular heart disease in patients with CS remains unclear. We therefore conducted a post hoc analysis of the randomized Dobutamine Compared to Milrinone (DOREMI) trial to determine the impact of valvular disease on outcomes in patients with CS.

      Methods

      We defined significant valvular disease as moderate to severe or greater valvular stenosis or regurgitation and divided participants into a group of those with significant valvular disease and those without. Our primary outcome was all-cause in-hospital mortality. Secondary endpoints included resuscitated cardiac arrest; cardiac transplantation or mechanical circulatory support; nonfatal myocardial infarction; stroke; initiation of renal replacement therapy; as well as changes in renal function, perfusion, and hemodynamics over time.

      Results

      One hundred eighty-nine (98.4%) participants from the DOREMI trial were included in our analysis, and 74 (39.2%) had significant valvular dysfunction. Thirty-six (48.7%) patients with valvular disease died in hospital, compared with 37 (32.2%) in the comparator group (relative risk, 1.5; 95% confidence interval 1.06-2.15; P = 0.02). Patients with aortic stenosis (2.42, 1.56-3.75; P < 0.01) and patients with mitral regurgitation (1.63, 1.1-2.43; P = 0.02) also had increased incidence of in-hospital mortality. There was no significant difference in any secondary outcomes among groups, apart from variances in mean arterial pressure observed in patients with valvular disease (P < 0.01).

      Conclusions

      Significant valvular dysfunction is associated with increased in-hospital mortality in patients with CS. Randomized clinical trial data are needed to further elucidate the role of transcatheter valvular interventions as a therapeutic target in this population.

      Résumé

      Contexte

      Les patients atteints d'un choc cardiogénique (CC) présentent des taux élevés de mortalité à l'hôpital, avec peu de données probantes permettant de guider leur prise en charge. L'impact d'une valvulopathie chez les patients souffrant d'un CC n'est pas clair. Nous avons donc effectué une analyse post hoc de l'essai randomisé Dobutamine Compared to Milrinone (DOREMI) pour déterminer l'impact d'une valvulopathie sur le pronostic des patients atteints de CC.

      Méthodes

      Nous avons défini une valvulopathie significative comme une sténose ou une insuffisance valvulaire de grade modéré à sévère, voire plus grave, et nous avons réparti les participants entre un groupe de patients présentant une valvulopathie significative et ceux qui n'en présentaient pas. Notre principal critère d'évaluation était la mortalité hospitalière, toutes causes confondues. Les critères d'évaluation secondaires comprenaient un arrêt cardiaque réanimé, une transplantation cardiaque ou une assistance circulatoire mécanique, un infarctus du myocarde non fatal, un accident vasculaire cérébral, l'initiation d'une thérapie de remplacement rénal, ainsi que les modifications de la fonction rénale, de la perfusion et des paramètres hémodynamiques au fil du temps.

      Résultats

      Cent quatre-vingt-neuf (98,4 %) participants de l'essai DOREMI ont été inclus dans notre analyse et 74 (39,2 %) présentaient une dysfonction valvulaire significative. Trente-six (48,7 %) patients atteints de maladie valvulaire sont décédés à l'hôpital, contre 37 (32,2 %) dans le groupe servant de comparaison (risque relatif, 1,5; intervalle de confiance à 95 %, 1,06-2,15; P = 0,02). Les patients présentant une sténose aortique (2,42, 1,56-3,75; P < 0,01) et les patients avec insuffisance mitrale (1,63, 1,1-2,43; P = 0,02) présentaient également une incidence accrue concernant la mortalité à l'hôpital. Aucune différence significative n'a été constatée entre les groupes en ce qui a trait aux critères d'évaluation secondaires, à l'exception des variations de la pression artérielle moyenne observées chez les patients atteints de valvulopathie (P < 0,01).

      Conclusions

      Une dysfonction valvulaire significative est associée à une mortalité accrue à l'hôpital chez les patients atteints de CC. Des données issues d'essais cliniques randomisés sont désormais nécessaires pour mieux élucider le rôle des interventions valvulaires transcathéter comme solution thérapeutique dans cette population.

      Graphical abstract

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