AIMS:The impact of systemic inflammation in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) is still a matter of debate. The present ECLS-SHOCK sub-study investigates the association of C-reactive protein (CRP) levels with short-term outcomes in patients with AMI-CS. METHODS AND RESULTS:Patients with AMI-CS enrolled in the multicentre, randomized ECLS-SHOCK trial between 2019 and 2022 were included. The prognostic impact of CRP levels on admission, as well as the effect of extracorporeal life support (ECLS), stratified by CRP levels, was tested with regard to the primary endpoint of 30-day all-cause mortality. In 371 patients with AMI-CS and available CRP level on baseline, the median CRP level was 18.0 mg/L. Patients with CRP levels in the highest tertile were older and less often resuscitated from cardiac arrest. The highest tertile (i.e. CRP >61.0 mg/L) was associated with an increased risk of 30-day all-cause mortality compared with patients with lower CRP levels (lowest tertile: ≤5.0 mg/L) [adjusted odds ratio: 3.54; 95% confidence interval (CI) 1.88-6.68; P = 0.001]. The use of ECLS did not reduce 30-day all-cause mortality, irrespective of CRP levels on admission. The additional inclusion of CRP to the IABP-SHOCK II score was associated with a slight improvement of the prediction of 30-days all-cause mortality (area under the curve: 0.74; 95% CI 0.68-0.79). CONCLUSION:Higher CRP levels were independently associated with the risk of 30-day all-cause mortality in AMI-CS. The additional inclusion of CRP to a validated CS risk score may further improve the prediction of short-term prognosis.

AIMS:This study aimed to investigate incidence and predictors of weaning failure and in-hospital death after successful weaning from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock (CS). METHODS AND RESULTS:Overall, 685 patients with CS treated with VA-ECMO from 23 tertiary care centres in 7 countries were analysed (median age 57 [interquartile range 49-66] years, 542 [79.1%] male, median lactate 7.6 [interquartile range 4.1-12.7] mmol/L). The cause of CS was acute myocardial infarction in 438 (63.9%) patients, and 431 (62.9%) patients presented with cardiac arrest. A total of 410 patients (59.9%) were successfully weaned from VA-ECMO, whereas in 275 patients (40.1%) weaning failed (i.e. patients died on or within 48 h after VA-ECMO support). Of the successfully weaned patients, 150 (36.6%) died before hospital discharge. On multivariable logistic regression, predictors for both patient groups varied: age (per 10 years, odds ratio [OR] 1.49, 95% confidence interval [CI] 1.25-1.76; p < 0.001) and cardiac arrest before VA-ECMO implantation (OR 1.64, 95% CI 1.01-2.64; p = 0.04) were associated with weaning failure, whereas lactate clearance within 24 h after VA-ECMO initiation was associated with successful weaning (OR 0.21, 95% CI 0.1-0.44; p < 0.001). In-hospital death after successful weaning was more likely with higher age (per 10 years, OR 1.56, 95% CI 1.24-1.97; p < 0.001), renal replacement therapy (OR 2.56, 95% CI 1.4-4.68; p = 0.002) and bleeding events (OR 2.93, 95% CI 1.4-6.14; p = 0.004). CONCLUSION:Weaning from VA-ECMO fails in 40% of patients treated with VA-ECMO for CS. When successful, survival after VA-ECMO weaning mostly depends on age and the incidence of device- and shock-related complications.

Abstract Background/Introduction Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has not been shown to reduce short-term mortality in patients with acute myocardial infarction complicated by cardiogenic shock. However, whether some patients might benefit from VA-ECMO remains to be cleared. Purpose To identify the impact of VA-ECMO therapy on outcomes by leveraging the potential of machine learning. Methods The ECLS-SHOCK trial is a randomized controlled trial where patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early VA-ECMO plus usual medical treatment or usual medical treatment alone. The primary outcome was death from any cause at 30 days. Extreme gradient boosting (XGBoost) was used to develop a model for the prediction of 30-day all-cause mortality and to assess the influence of VA-ECMO on outcomes. Results Overall, 209 patients were randomized to the VA-ECMO and 208 to control. Baseline characteristics between groups were well balanced (median age 63 years, 81% male, 67% presenting with ST-segment elevation myocardial infarction). At 30-days 100 patients in the VA-ECMO and 102 in the control group were dead. The final XGBoost model contained 27 variables and the 10 most influential variables are shown in Fig. 1. On derivation the model predicted mortality with an AUC of 1.00 and on validation with an AUC of 0.80 (95% CI 0.71 to 0.89), with a sensitivity of 95% (95% CI 88% to 100%) and a specificity of 55% (40% to 69%), resulting in a positive predictive value of 65% and a negative predictive value of 92% at a Youden-derived cut-off. Importantly, neither the VA-ECMO therapy nor its complications were among the most influential factors of the model with a relative importance of 1.1% for VA-ECMO therapy and 0.25% for peripheral vascular complications and bleeding complications even being discarded by the model. Conclusion In patients with acute myocardial infarction complicated by cardiogenic shock the influence of VA-ECMO therapy on 30-day mortality, even when investigated with complex machine learning models, is negligibly low.

Abstract Background Aortic stenosis due to calcific aortic valve disease (CAVD) is the most common valvular heart disease. In symptomatic patients, without repair the prognosis is poor. Treatment to date is based on surgery or catheter-based interventions. Pharmacological therapy options to prevent the progression of valve calcification are not available. In vascular smooth muscle cells, cellular accumulation of sphingolipids is associated with a proinflammatory response in the sense of lipotoxicity. Chronic inflammatory processes are indeed also essential for aortic valve calcification. Purpose With the subsequent goal of developing innovative treatment approaches for CAVD, we therefore aim to elucidate the unclear role of sphingolipids in the development of CAVD. Methods Human aortic valve and plasma samples of CAVD patients and controls (n=26) were analysed by liquid chromatography–mass spectrometry for lipidomics and proteomics. Human aortic valve interstitial cells (hVICs) were stimulated with ceramides. Calcification was detected by alizarin red staining. mRNA expression of bone-related proteins was determined by qPCR. NF-kB pathway was assessed by proteome profiler. Myriocin and GW4869 were applied to inhibit ceramide biosynthesis. PDTC and MCC950 were used to inhibit NF-kB Pathway and NLRP3 activation. ApoE-/- mice received a gain-of-function PCSK9 adeno-associated virus vector and fed high cholesterol diet for 14 weeks. Myriocin was applied orally over the treatment period to inhibit ceramide de novo synthesis in vivo. Murine echocardiography was used to measure transvalvular velocity and left ventricular function. Calcification degree of murine aortic valve was determined by histological staining. Results A significantly altered sphingolipid profile was observed in aortic valve tissue of CAVD patients (Fig. 1). Ceramide species e.g. Cer (17:1;2O/16:0) were increased. Verifying the biological relevance of these findings in vitro, C2-Cer (d18:1/2:0) enhanced hVIC calcification (Fig. 2). Accordingly, ALP activity and mRNA expression of osteogenic genes RUNX2, ALPL and MSX2 were increased. Furthermore, C2-Cer (d18:1/2:0) enhanced NF-kB p65 phosphorylation and NLRP3 activation, while treatment with both PDTC and MCC950 protected against C2-Cer (d18:1/2:0) induced calcification. Supporting the role of sphingolipid biosynthesis in hVIC calcification, Myriocin and GW4869 both reduced ox-LDL-induced VIC calcification which was reversed by C2-Cer(d18:1/2:0). Finally, Myriocin reduced the degree of calcification and transvalvular jet velocity of aortic valve in the PCSK9-AAV ApoE-/- mice model. Conclusion CAVD is accompanied by an accumulation of ceramides causing lipotoxicity in human aortic valve tissue. Pharmacological modulation of sphingolipid metabolism is an effective approach to prevent the development and progression of aortic valve calcification in vivo and should be considered as a future therapeutic strategy in CAVD patients.Volcano Plot of CAVD tissue lipidomicsC2 Ceramide enhances hVIC calcification

Abstract Background Transradial access (TRA) is the recommended approach for coronary procedures considering safety benefits over femoral access with radial artery occlusion (RAO) being the most frequent complication. Although usually not clinically significant, the presence of RAO affects potential future procedures and medical treatments. Distal TRA (dTRA) has been suggested to reduce the risk of postprocedural RAO compared to conventional TRA (cTRA) with, however, inconsistent results in clinical trials. Purpose This study aimed to compare the efficacy and safety of dTRA versus cTRA in patients undergoing diagnostic coronary angiography. Methods The RAPID trial is a single-center, open-label, 2x2 factorial, randomized study of patients undergoing coronary angiography through a 6-F radial access. The trial was stopped early by the data and safety monitoring board after the second pre-planned interim analysis and inclusion of 600 participants. Patients were randomized to dTRA or cTRA with further stratification according to periprocedural heparin use and preexisting oral anticoagulation. The primary endpoints were the incidence of RAO assessed by vascular ultrasound and puncture-site related bleedings. Results The final study population consisted of 298 patients randomized to dTRA and 302 patients to cTRA. Periprocedural heparin was administered in 382 patients (63.7%) and percutaneous coronary intervention was performed in 161 cases (26.8%) without differences between the study groups (p=0.700 and p=0.465; respectively). Distal TRA was associated with a significantly increased number of puncture attempts (2.4 ± 2.0 versus 1.5 ± 1.2; p<0.001) and failed punctures leading to access site crossover (11.7% versus 5.0%; p=0.003). Consequently, the total procedure time was longer in the dTRA group (30 min versus 25 min; p=0.004) without increasing fluoroscopy time (p=0.320), dose area product (p=0.245), or contrast volume (p=0.884). Patent hemostasis was achieved in 91.7% of patients with cTRA. The rates of RAO (16.1% versus 15.6%, p=0.855) and puncture-site related bleedings (6.7% versus 8.3%; p=0.466) were similar in both groups. Conclusions According to this study, dTRA does not reduce the risk of RAO or bleeding events compared to cTRA.

Abstract Background Permanent pacemaker implantation (PPI) is frequently required following transcatheter aortic valve implantation (TAVI). However, the predisposing parameters increasing the likelihood of severe conduction abnormalities are still not fully understood. Purpose To analyze predictors of PPI 30 days after TAVI. Methods The SOLVE-TAVI trial randomized 447 patients to TAVI using either the balloon-expandable Edwards Sapien 3 valve or the self-expanding Medtronic Evolut R valve. Pacemaker rates at 30 days were relatively high, but comparable between both transcatheter heart valve (THV) types (19% vs. 23%). Computed tomography (CT) scans were analyzed semi-automatically to determine aortic annulus size and subannular calcification. The percentage of THV oversizing was calculated using the formula (nominal THV circumference/annular circumference – 1) x 100). Results From all patients treated with either the Sapien 3 or Evolut R valve, 47 patients were excluded because of prior pacemaker implantation. Rates of new PPI at 30 days were similar in patients with and without pre-existing left bundle branch block (7/36 patients vs. 53/342 patients, p=0.48) and right bundle branch block (11/51 patients vs. 48/327 patients, p=0.22), without significant differences according to valve type. Patients with new PPI showed a significantly higher degree of THV oversizing compared to patients without PPI (median 15%, interquartile range [IQR] 9-20% vs. median 12%, IQR 7-17%; p=0.03). Moderate/severe compared to no/mild subannular calcification did not result in higher PPI rates (17/121 patients vs. 40/245 patients; p=65). Conclusion THV oversizing but not pre-existing left and right bundle branch block and subannular calcification is associated with PPI after TAVI.

Background and aims Low-density lipoprotein cholesterol (LDL-C) is the main therapeutic target in the treatment of hypercholesterolemia. Small interfering RNA (siRNA) inclisiran is a new drug, which targets PCSK9 mRNA in the liver, reducing concentrations of circulating LDL-C. In randomized trials, inclisiran demonstrated a substantial reduction in LDL-C. The German Inclisiran Network (GIN) aims to evaluate LDL-C reductions in a real-world cohort of patients treated with inclisiran in Germany. Methods Patients who received inclisiran in 14 lipid clinics in Germany for elevated LDL-C levels between February 2021 and July 2022 were included in this analysis. We described baseline characteristics, individual LDL-C changes (%) and side effects in 153 patients 3 months (n = 153) and 9 months (n = 79) after inclisiran administration. Results Since all patients were referred to specialized lipid clinics, only one-third were on statin therapy due to statin intolerance. The median LDL-C reduction was 35.5% at 3 months and 26.5% at 9 months. In patients previously treated with PCSK9 antibody (PCSK9-mAb), LDL-C reductions were less effective than in PCSK9-mAb-naïve patients (23.6% vs. 41.1% at 3 months). Concomitant statin treatment was associated with more effective LDL-C lowering. There was a high interindividual variability in LDL-C changes from baseline. Altogether, inclisiran was well-tolerated, and side effects were rare (5.9%). Conclusion In this real-world patient population referred to German lipid clinics for elevated LDL-C levels, inclisiran demonstrated a high interindividual variability in LDL-C reductions. Further research is warranted to elucidate reasons for the interindividual variability in drug efficacy. Graphical abstract

Diese Stellungnahme der Deutschen Gesellschaft für Kardiologie fasst Informationen und Empfehlungen zum Umgang mit nicht-aktiven (auch genannt „passiven“) kardiovaskulären Implantaten (z. B. Koronarstents) bei der Magnetresonanztomographie (MRT) zusammen. Es wird empfohlen, bei jedem Patienten vor einer MRT-Untersuchung das Vorhandensein von nicht-aktiven kardiovaskulären Implantaten zu erfragen, gegebenenfalls detaillierte Implantat-Informationen einzuholen und schließlich unter individueller Nutzen-Risiko-Abwägung die Entscheidung für oder gegen die MRT-Untersuchung zu treffen. Bei der MRT-Untersuchung sind gegebenenfalls Anpassungen der technischen MRT-Parameter oder des Untersuchungsablaufs zu berücksichtigen. Diese Aufgaben obliegen dem die MRT-Untersuchung durchführenden Arzt. Er wird unterstützt, indem der Patient selbst sowie der überweisende Arzt die notwendigen Informationen rechtzeitig zur Verfügung stellen. Dabei ist die Verwendung von Implantatpässen und Implantatdatenbanken hilfreich. Werden diese Vorsichtsmaßnahmen berücksichtigt, sind nach derzeitigem Kenntnisstand MRT-Untersuchungen bei Patienten mit nicht-aktiven kardiovaskulären Implantaten im Allgemeinen ohne gravierende Sicherheitsbedenken durchführbar.

This statement of the German Cardiac Society summarizes information and recommendations how to deal with non-active (i.e. passive) cardiovascular implants (e.g. coronary stents) in magnetic resonance imaging (MRI). It is recommended to check for the presence of any non-active cardiovascular implant in every patient before MRI, to seek for detailed implant-specific information if appropriate and finally to decide in favour or against the MRI after careful risk-benefit analysis. When performing the MRI, modifications of the technical MRI parameters and of the course of the exam may be necessary. The physician who performs the MRI is responsible for these tasks and should be supported by the patient and by the referring physician by providing all relevant information in time. The use of implant passes and implant databases may help to keep the procedure efficient and safe. Under consideration of these precautionary measures, MRI exams can be generally performed without serious safety concerns in patients with non-active cardiovascular implants.

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac magnetic resonance myocardial feature tracking (CMR-FT) derived global strain assessments provide incremental prognostic information in patients following acute myocardial infarction (AMI). Functional analyses of the remote myocardium (RM) are scarce and whether they provide an additional prognostic value in these patients is unknown. Methods 1052 patients following acute myocardial infarction were included. CMR imaging and strain analyses as well as scar size quantification were performed after reperfusion by primary percutaneous coronary intervention. The occurrence of major adverse cardiac events (MACE) within 12 months after the index event was defined as primary clinical endpoint. Results Patients with MACE had significantly lower RM circumferential strain (CS) compared to those without MACE. A cut-off value for RM CS of -25.8% best identified high-risk patients (p < 0.001 on log-rank testing) and impaired RM CS was a strong predictor of MACE (HR 1.05, 95% CI 1.07-1.14, p = 0.003). RM CS provided further risk stratification amongst patients considered at risk according to established CMR parameters for 1.) patients with reduced left ventricular ejection fraction (LVEF) ≤ 35 % (p = 0.002 on log-rank testing), 2.) patients with reduced global circumferential strain (GCS) > -18,3 % (p = 0.015 on log-rank testing), and 3.) patients with large microvascular obstruction ≥ 1.46 % (p = 0.038 on log-rank testing). Conclusion CMR-FT derived RM CS is a useful parameter to characterize the response of RM and allows improved stratification following AMI beyond commonly used parameters, especially of high-risk patients.

Abstract Objective Type 2 diabetes mellitus (T2DM) associates with worse cardiovascular outcome following acute myocardial infarction (AMI) as compared to non-diabetic patients. Since the mechanisms behind these observations are not fully understood we aimed to quantify the underlying pathophysiology on ventricular and atrial levels and study their prognostic implications using cardiovascular magnetic resonance (CMR) quantitative feature-tracking (FT) and tissue characterization. Research Design and Methods: A total of 1147 consecutive patients with AMI (n = 265 with diabetes; n = 882 without diabetes) undergoing cardiac magnetic resonance (CMR) imaging in median 3 days after AMI were included in this multicenter study. Left ventricular (LV) function and volumetry included LV ejection fraction (LV-EF), global longitudinal (GLS), radial (GRS) and circumferential strain (GCS) as well as left atrial (LA) strain and strain rate parameters of LA reservoir, conduit and booster pump function. LV damage assessment included infarct size (IS), edema and microvascular obstruction (MO). The clinical study endpoint was the rate of major adverse cardiovascular events (MACE) at 12 months. Results T2DM patients had impaired LA reservoir (19.8 vs. 21.2%, p < 0.01) and conduit strains 7.6 vs. 9.0%, p < 0.01) but no differences in ventricular function or myocardial damage. They were at higher risk of MACE than non-diabetic patients (10.2% vs. 5.8%, p < 0.01) with the majority of MACE occurring in patients with LVEF ≥ 35%. Whilst LVEF was an independent predictor of adverse events in non-diabetic patients (p = 0.04 on multivariable analysis), LV GLS as well as LA strain emerged as independent predictors of poor prognosis in patients with diabetes (p < 0.02 on multivariable analysis). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with higher 12-month event rates. Conclusions In patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above LVEF.

Objectives: To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). Background: Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. Methods: This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. Results: Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®; n = 95 extracorporeal membrane oxygenation (ECMO); n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p < 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p < 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7–5.9; p < 0.001). Conclusions: In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

Objectives: Even though a bicuspid aortic valve (BAV) was excluded in landmark clinical trials of transcatheter aortic valve replacement (TAVI), several reports suggest that TAVI is also feasible for treatment of BAV patients with aortic stenosis. The aim of this study was to compare clinical outcomes of surgical aortic valve replacement (SAVR) and TAVI for treatment of BAV stenosis.

Abstract Background Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation and may be especially attractive in patients with high risk or a history of bleeding. However, data of clinical benefit and incidence of post-procedural bleeding in patients with both high risk of bleeding and ischemic cerebral stroke after LAAC are lacking. Objectives This study sought to identify predictors and the prognostic impact of post-LAAC bleeding in patients at high risk and/or history of bleeding in the direct oral anticoagulant therapy (DOAC) era. Methods and results We retrospectively enrolled a total of 195 patients (75 ± 8.7 years, 38% female, 47% with previous major bleeding, mean CHA2DS2-VASc score 4.3 ± 1.6 and mean HAS-BLED score 2.7 ± 1.1) undergoing endocardial (91%) or epicardial (9%) LAAC during a mean follow-up of 339 ± 319 days. Twenty-three (11.9%) patients developed procedure-unrelated bleeding events after a median of 147 (43, 362) days after LAAC, in 12/23 (52%) patients under single antiplatelet therapy (SAPT), 6/23 (26%) dual antiplatelet therapy (DAPT), 1/23 (4%) DOAC, 1/23 (4%) VKA, 2/23 (9%) dual therapy (SAPT and DOAC/VKA) and 1/23 (4%) triple therapy (DAPT and DOAC/VKA). (Figure) Diabetes mellitus and previous major bleeding were identified as the independent predictors of post-LAAC bleeding (Odds ratio 2.65 [95% CI:1.04-6.73], p = 0.041, and 5.50 [95% confidence interval:1.72-17.5], p = 0.004). Post-LAAC bleeding was associated with all-cause death (9/23 [39%] vs 18/171 [11%], p = 0.001), but not ischemic stroke/TIA (1/23 [4%] vs 6/171 [4%], p = 0.593) nor device thrombus (2/23 [9%] vs 3/171 [2%], p = 0.108). Kaplan-Meier curve estimated that patients with post-LAAC bleeding had a worse mortality than those without post-LAAC bleeding (3-year mortality; 35.6% [95%CI; 11.6-61.0%] vs 68.7% [45.0-83.8], p = 0.029) Conclusions In AF patients with high bleeding risk or history of bleeding undergoing LAAC, bleeding events are common and may occur even after long-term duration after LAAC. Previous major bleeding history strongly predicts subsequent bleeding events following LAAC and is associated with unfavorable mortality. Further investigations are required to identify optimal post-procedural antithrombotic strategies for patients undergoing LAAC with previous major bleeding. Abstract Figure. The association between time to bleeding

AIMSTo compare general anaesthesia (GA) and deep sedation (DS) with regard to safety and length of intensive care unit (ICU) stay in patients undergoing percutaneous edge-to-edge mitral valve repair (PMVR).METHODS AND RESULTSFour studies comparing GA and DS in patients undergoing PMVR were included in an individual patient data meta-analysis. Data were pooled after multiple imputation. The composite safety endpoint of all-cause death, stroke, pneumonia, or major to life-threatening bleeding occurred in 87 of 626 (13.9%) patients with no difference between patients treated with DS as compared to GA (56 and 31 events in 420 and 206 patients, respectively). In this regard, the odds ratio was 1.27 (95% confidence interval, 0.78 to 2.09; p = 0.338) and 1.26 (95% confidence interval, 0.49 to 3.22; p = 0.496) following the one-stage and two-stage approach, respectively. Length of ICU stay was longer after GA as compared to DS (ratio of days 3.08, 95% confidence interval, 2.18 to 4.36, p < 0.001 and 2.88, 95% confidence interval, 1.45 to 5.73, p = 0.016 following the one-stage and two-stage approach, respectively).CONCLUSIONSBoth, DS and GA might offer a similar safety profile. However, ICU stay seems to be shorter after DS.

Abstract Background Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) is increasingly used for treatment of severe cardiogenic shock, although it causes an increase in left ventricular (LV) afterload and might therefore hamper myocardial recovery. Recently, the addition of catheter-based left ventricular assist device (cLVAD) on top of VA-ECMO has been used to unload the LV and to improve outcome measures. However, there is limited data on predictors of outcome in this high-risk population. Aim The aim of this study was to evaluate predictors of 30-day survival in a multicentre cohort of severe cardiogenic shock patients treated with cLVADon top of VA-ECMO. Material and methods We report on consecutive patients from six tertiary care centers being treated with cLVAD in addition to VA-ECMO for treatment of cardiogenic shock. The primary endpoint is 30-day all-cause mortality. To identify predictors of the primary endpoint, multivariate analysis using an “elastic net” variable selection algorithm was done after imputation of missing variables. Results A total of 220 patients treated with cLVAD on top of VA-ECMO were included in the analysis. Of these, 79.1% were male with a median age of 55.5 (25thpercentile 48.0, 75thpercentile 65.6) years. In 60.5% of the patients, acute myocardial infarction was the underlying cause of cardiogenic shock and in 44.6% VA-ECMO was used for refractory cardiac arrest (eCPR). In the multivariable analysis, the following baseline parameters were significantly associated with the primary endpoint: Age (odds ratio of 1.68 per standard deviation), duration of cardiopulmonary resuscitation (OR 2.08 per SD), lactate (OR 1.04 per SD) and time from onset of shock to VA-ECMO (OR 1.30 per SD). Conclusion and outlook In this large-scale multicentre analysis of severe cardiogenic shock patients treated with VA-ECMO plus additional cLVAD unloading, age, duration of cardiopulmonary resuscitation, lactate and time from onset of shock to VA-ECMO were significantly associated with 30-day all-cause mortality. To further investigate this topic, we will evaluate predictors of outcome in distinct patient populations such as acute myocardial infarction vs. acute heart failure and patients without vs. patients with prior cardiopulmonary association.