Door-to-unload time and mortality in patients with ST-segment elevation myocardial infarction complicated by cardiogenic shock

Shin Nagai¹, MD; Toru Kondo¹, MD, PhD; Shingo Kazama¹, MD, PhD; Asuka Nozaki¹, MD; Takahiro Imaizumi²^,³, MD, PhD; Shotaro Komeyama¹, MD; Chiaki Mizuno¹, MD; Ryota Ito¹, MD, PhD; Hiroaki Hiraiwa¹, MD, PhD; Ryota Morimoto¹, MD, PhD; Yasunari Hayashi⁴, MD, PhD; Tomo Yoshizumi⁴, MD, PhD; Masato Mutsuga⁴, MD, PhD; Toyoaki Murohara¹, MD, PhD; on behalf of the J-PVAD investigators

Abstract

Background: Microaxial flow pumps (mAFPs) provide left ventricular unloading and haemodynamic stabilisation, with evidence suggesting a survival benefit in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). The prognostic impact of early mAFP placement after hospital arrival remains unclear.

Aims: We aimed to investigate the association between door-to-unload time and in-hospital mortality in patients with STEMI-CS.

Methods: We analysed data from the Japan Registry for Percutaneous Ventricular Assist Devices, including consecutive patients with STEMI-CS who underwent mAFP placement between February 2020 and December 2023. The primary outcome was in-hospital mortality.

Results: Among 1,783 patients, the median door-to-unload time was 99 min. The overall in-hospital mortality rate was 39.2%, and this increased with longer door-to-unload times: 32.9% (≤60 min), 33.0% (61-90 min), 40.1% (91-150 min), and 48.3% (>150 min). Using a 90 min cutoff, delayed placement (>90 min) was associated with higher mortality (adjusted odds ratio 1.56, 95% confidence interval: 1.26-1.95). A restricted cubic spline model showed that mortality remained stable when placement was within 90 min, followed by an increase. When stratified by no prior mechanical circulatory support and prior venoarterial extracorporeal membrane oxygenation (VA-ECMO) only, the patients with prior VA-ECMO only had more severe baseline characteristics and higher mortality; however, the association of longer door-to-unload time with higher mortality was consistent. Predictors of delayed mAFP placement included older age, lower institutional volume, higher heart rate, higher creatinine levels, prior use of an intra-aortic balloon pump or VA-ECMO, and percutaneous coronary intervention before mAFP placement.

Conclusions: A shorter door-to-unload time, particularly within 90 min, is associated with better survival in patients with STEMI-CS.

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Coronary interventions Interventions for valvular disease Interventions for heart failure Peripheral interventions Interventions for hypertension Interventions for stroke STEMI NSTEMI Stable CAD Stents and scaffolds Left main and multivessel disease Bifurcation lesions CTO TAVI Mitral valve replacement and repair Tricuspid / Pulmonary valve Acute heart failure Chronic heart failure Below the knee AAA Iliac / Femoral / Popliteal Renal artery angioplasty Renal denervation Carotid stenting LAA closure Ischaemic stroke

st-segment elevation myocardial infarction cardiogenic shock mechanical circulatory support Impella microaxial flow pump door-to-unload time

Volume 22 Number 12

Jun 15, 2026