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Complessità nell’infarto
evolvente complicato
da disfunzione ventricolare
sinistra
Angelo Sante Bongo
Aritmiche
Ischemiche
Meccaniche
Complicanze dell’IMA
Aritmiche
Ischemiche
Meccaniche
Complicanze dell’IMA
 Diagnosi
anatomo coronarica precoce
 Rivascolarizzazione , se indicata
 Supporto a ventricolo
Ruolo dell’emodinamista
“Defibrillation was attempted again but remained unsuccessful.
CPR continued. We suspected that the patient’s heart was too distended
to permit termination of ventricular fibrillation … a decision was made to
consult cardiac surgery about the initiation of extracorporeal membrane
oxygenation (ECMO) for full hemodynamic support and to decompress the
heart and facilitate termination of ventricular fibrillation.”
n engl j med 369;11 nejm.org september 12, 2013
Aritmiche
Ischemiche
Meccaniche
Complicanze dell’IMA
Shock cardiogeno
Trombosi coronarica
no reflow
Complicanze ischemiche
e
Shock cardiogeno
Trombosi coronarica
no reflow
Complicanze ischemiche
e
Shock cardiogeno
Trombosi coronarica
no reflow
Complicanze ischemiche
e
•L’attuale terapia di rivascolarizzazione ha
ridotto la mortalità per IMA a meno del 5%
•La più frequente causa di mortalità post-IMA, lo
shock cardiogeno, complica 8-12% nello STEMI
e 5% nel NSTEMI
•Mortalità attuale 40-50 %
Shock cardiogeno post IMA
Trends in the incidence
rates of cardiogenic
shock in patients with
acute myocardial infarcts.
Goldberg et al. Thirty-year
trends (1975 to 2005) in the
magnitude of,management of, and
hospital death rates associated
with cardiogenic shock in patients
with acute myocardial infarction
Circulation 2009;119:1211
1 in 20
Trends in hospital case
fatality rates in patients with
acute myocardial infarct
according to the presence of
cardiogenic shock.
40%
 Trattamento
del
Tronco comune
 Trattamento di
tutte le lesioni
coronariche
 Contropulsatore
aortico
 Assistenza
ventricolare
Disfunzione Ventricolare sinistra:
il ruolo dell’Emodinamista
01/03/17
25
SHORT TERM
Sostegno al flusso
SI gonfia durante la Diastole
Contropulsatore Aortico
Datascope/Arrow
CONTROPULSATORE
01/03/17
28
Si sgonfia durante Systole
IABP in MI without shock
Recent data for IABP
Intra-aortic balloon pump: indications, efficacy, guidelines and future directions. Curr.Opin Cardiol. 2014 Jul;29(4):285-92.
IABP in cardiogenic shock

IABP-SHOCK II :
the largest randomized control trial ever performed
in cardiogenic shock - randomised 600 patients enrolled
in 37 centres in Germany from June 2009 to March 2012
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:1287-1296.
IABP-SHOCK II STUDY
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:1287-1296.
IABP-SHOCK II STUDY

Primary Study Endpoint: 30-DAY Morality
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:1287-1296.
IABP-SHOCK II STUDY

Conclusions：
Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367:1287-1296.
.
Lancet.2013 Nov 16;382(9905):1638-45
IABP in cardiogenic shock
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction:Circulation 2013; 127:e362–e425.
2014 ESC/EACTS guidelines on myocardial revascularization:European Heart J (2014)35;2541-2619
Femoral cannulation for veno-arterial (VA) ECMO …
RA/IVC drainage from CFV access (23/25F)
…venous return limits flow
Arterial inflow (17F) … “downsize”
Distal arterial inflow (6F) … “downsize”
…“open” versus “percutaneous” access ?
*no complications
*exit strategy
VAda ECMO
VenoArterial (distal artery)
ECMO
Non physiologic and inherently
unstable
Efficacy proportional to LVEF
Retrograde arterial flow … LVEF and cerebral perfusion, LVEDP !
Distal malperfusion …
The patient … sedate and non-ambulatory
Blood path and directional flow …
Family of MACS
INTERMACS® – A North American registry established in 2005 for patients
who are receiving mechanical circulatory support device therapy to treat
advanced heart failure.
PediMACS – The pediatric portion of INTERMACS. While INTERMACS
has always included durable devices implanted in pediatric patients,
pediMACS has been developed to focus on capturing data elements unique
to pediatric patients.
MedaMACS – The Medical Arm of Mechanically Assisted Circulatory
Support (MedaMACS Registry), a prospective study of medically managed
advanced heart failure patients, will report the nature of optimal
contemporary medical therapy for heart failure and provide information on
medical outcomes in terms of timed endpoints of mechanical support,
transplant, or death through two years of follow-up.
IMACS – The International Society for Heart and Lung Transplantation
Registry for Mechanically Assisted Circulatory Support (IMACS) is an
international registry intended to enroll and follow patients who receive
durable mechanically assisted circulatory support devices (MCSD) in all
countries and hospitals that wish to participate.
50
la macchina (VAD)
•
La disfunzione ventricolare sinistra post IMA evolvente in SHOCK
cardiogeno è una complicanza gravata ancora oggi da elevata
mortalità.
•
La terapia medica massimale nei casi più gravi non consente un
adeguato recupero
•
Il contropulsatore aortico non garantisce alcun miglioramento di
sopravvivenza ma va considerato come “bridge” per una assistenza
ventricolare più avanzata
•
L’ECMO rappresenta un mezzo di supporto circolatorio più utile per
consentire un recupero finalizzato ad una terapia di supporto con VAD
ed eventuale successivo trapianto
•
L’impianto di VAD in fase acuta , nonostante la maggior gravità di
esordio offre nei pazienti con IMA, gli stessi vantaggi dell’impianto nei
pazienti senza IMA . Il suo impiego andrà validato con studi prospettici
Conclusioni
• Lo sviluppo di tecniche di assistenza avanzate in grado di
supportare il ventricolo sin nella fase acuta dello IMA impone
una riorganizzazione in rete che, analogamente a quanto si è
verificato per la riperfusione coronarica, consenta a tutti i
pazienti in shock cardiogeno post IMA (e non IMA) di
raggiungere i centri qualificati prima che si verifichi un
deterioramento irreversibile del danno miocardico
Conclusioni
Conclusions
 Transcatheter closure of PIVSRs can be performed with high technical
success and relatively low procedural complication rates;
 however, in the acute setting it is associated with very high in-hospital
mortality rates.
 Device closure appears well suited to treatment of patch leaks post
surgical repair in particular, thus a hybrid strategy of early surgical repair
with transcatheter closure of patch leaks as needed is preferable for
primary PIVSRs regardless of haemodynamic status. T
 Transcatheter closure can also be considered in patients who are not
surgical candidates, generally have haemodynamically tolerable defects,
and survive a period of watchful waiting.
 Long-term outcomes appear good in patients with or without prior
surgery who are treated subacutely and survive to hospital discharge.
Conclusioni
Il ruolo ell’emodinamista è cruciale nella
gestione dell complicanze IMA
 I casi più complessi debbono essere
affrontati in centri con heart team
 Il contropulsatore non è più indicato nello
shock cardiogeno ma si deve utilizzare
l’assistenza ventricolare
 La rottura del setto post IMA può essere
affrontato con chiusura percutanea in casi
selezionati in laboratori che praticano
trattamento delle cardiopatie strutturali
 Il trattamento con assistenza ventricolare
del post arresto ed il trattamento della
rottura del papillare necessitano di ulteriori
validazioni

Among 98 patients …
cardiogenic shock (34), ventricular fibrillation or pulseless ventricular
tachycardia (23), or asystole /pulseless electrical activity (41)
96% underwent emergency revascularization (2 received CABG)
with successful angioplasty achieved in 71% (TIMI 3 flow)
55% were weaned from ECLS …
ECLS-related complications occurred in 36%... cannulation site bleeding
All-cause in-hospital mortality rate was 67.3%,
and the survival rate to hospital discharge was 32.7%
Aritmiche
Ischemiche
Meccaniche
Complicanze dell’IMA
Complicanze meccaniche dell’
IMA
PRECOCI
ROTTURA SETTO
INTERVENTRICOLARE
ROTTURA DI
PARETE LIBERA
PAPILLARE
ISCHEMICO
(insuff. Mitralica)
TARDIVE
ANEURISMA DEL
VENTRICOLO SX
PSEUDOANEURISMA
ISCHEMIA
PAPILLARE
CRONICA