Download Management of post-infarction cardiogenic shock

INTERNATIONAL SCHOOL OF CARDIAC SURGERY
The management of postinfarction cardiogenic Shock
John Pepper
Royal Brompton Hospital
London
Erice, Friday 17th June 2011
Acute heart failure with cardiogenic
shock
► Low
output syndromes
► Acute decline of pre-existing heart failure
► Acute MI
► Mechanical complications of AMI
► Aortic valve disease: AS/AR
► Prosthetic valve failure
► Acute myocarditis
► Dissection
Early Revascularisation in AMI with
Cardiogenic Shock
[Hochman JS. N.Engl.J.Med. 1999; 341: 625]
<75yr
>75yr
Prior MI
No prior MI
Mortality: 46.7 vs. 56.0
Difference: -9.3%[95% CI= -20.5 – 1.9%]
SHOCK Registry
N=884
[ Webb JG. Am.Heart J. 2001; 141: 964]
In-hospital
mortality
Medical
PCI
CABG
P
N
499
276
109
Overall
78%
46.4%
23.9%
<0.001
1 VD
32.9
33.3
NS
2 VD
42.2
17.7
0.025
3 VD
59.4
29.6
<0.0001
Comparison of PCI and CBG after
AMI + Cardiogenic Shock
Kaplan-Meier survival estimates at:
96 hours
p=0.07
30 days
p=0.86
1 year
p=0.71
[White HD. Circulation 2005; 112: 1992]
Risk factors for CABG in CS
[Rastan A. Circulation 2008]
►  2000-2007
►  302
patients
►  Age 69; 76% male
►  42% STEMI
►  30
day M=37.1%
►  1 year survival=50.7%
►  Mean
survival time
3.2years
OR
P
MV
Preop
renal
2.3
0.004
*
STEMI
1.8
0.013
Lactate
>4
3.6
0.001
LVEF<30
%
1.7
0.032
Log
EURO
>20
19.2
0.004
*
*
AMI
+
CS
PCI of culprit artery
Multivessel PCI
Inotropes and fluids
IABP
No mech.complications
YES
Adequate support?
wean
NO
wean
YES
Percut.
Short-term
LVAD
Recovery?
Implantable LVAD NO
Tx.
Mech.complications
Adequate support?
NO
Percut.
Short-term
LVAD
Surgery
YES
Benefits of LV unloading
► 
► 
► 
LVEDP
Cardiac work
O2 demand
►  NB:
unload prior to
revascularisation
► 
Pl. adrenaline
Pl.
Pl.
Pl.
Pl.
Pl.
noradrenaline
angiotensin ll
arg.vasopressin
IL6 + IL8
TNFα
Haemodynamic criteria
LVAD
RVAD
Cardiac index
l.min-1.m2
< 1.8 - 2.0
Systolic AoP
mmHg
< 90
LAP
mmHg
> 20
< 15
RAP
mmHg
< 15
> 25
Short Term Mechanical
Circulatory Support
Ventricular Assist Devices are very effective in
the treatment of severe end-stage cardiac
failure
However it is particularly difficult to salvage:
•  Critically ill patients
•  Postcardiotomy cardiogenic shock
LVAD for CS complicating AMI
► 17
studies
► Mean
weaning rate = 58.5%
► Mean survival rate = 40%
Contraindications to LVAD
► Anticoagulation
► Severe
problems
AR
► Terminal disease
► CNS injury
► RV failure
► Sepsis
► Severe PVD.
Short Term Mechanical
Circulatory Support
► Use
as a rescue device
► for short term use
► to support one or both sides of the heart
► to treat patients in acute cardiogenic shock
► as a “bridge to decision” when it is unclear
whether the patient’s heart will recover or
whether the patient will need alternative,
longer-term therapies.
Short Term Mechanical
Circulatory Support
►  Reversal
of renal and hepatic failure
►  Treatment
of infection
►  Assesssment
of neurological function
►  Extubation
►  Improvement
of cardiac dysfunction if
possible
in moribund patients
Short Term Mechanical
Circulatory Support
►  Bridge
to recovery
§  Acute cardiogenic shock
Postcardiotomy
Acute myocarditis
Right Heart Failure following
transplantation
►  Bridge to transplant
►  Bridge to long term device in very moribund
patients
Randomised comparison of IABP and
LVAD
[Thiele H. Eur.Heart J. 2005; 26: 1276]
Revascularised AMI with cardiogenic shock
RCT in 41 patients
Haemodynamic benefit with Tandem
30 day
Mortality
IABP
Tandem
LVAD
P
45%
42%
0.86
Veno-arterial ECMO for cardiogenic
shock
[Bakhtiary F. JTCS 2008; 135: 382]
Jan 2003 – Nov 2006
N= 45 of 5750 patients undergoing open heart surgery
Mean age= 60
35 males
Duration of ECMO= 6.4 (+/- 4.5 days)
In-hospital
Mortality
71%
Discharge from
Hospital
29%
3 year follow-up
22%
Short Term Mechanical Circulatory
Support
CentriMag® Characteristics
► Magnetic levitation eliminates bearings and seals
► Large mechanical gaps in the pump allow low
shear forces reducing haemolysis
► Flow up to 9.9 liters per minute
► Effective at high and low speeds
► Priming volume of 31 ml
► Approved for support for up to 28 days
Levitronix: bearing and rotor
function
Pump
Housing
Bearingless Centrifugal Pump
pump housing
Inlet
impeller
outlet
rotor
winding
stator
Peripheral Cannulation
Technology Comparison
Medos approx. €15000
Thoratec approx € 25000
BVS5000 approx. €9000
IABP approx. €900
CentriMag approx. €5000
Anticoagulation
Protocol
• 
No anticoagulation for 6-12 hours
• 
Attempt to normalize coagulation profile
• 
Chest tube drainage < 50 cc/hr for 2 - 3 hrs.
• 
Start heparin infusion, without bolus
• 
Maintain ACT to 150 to 170 secs (PTT 50
secs)
Management of LVAD patients
Pre-op: LVAD Indications
•  Deteriorating NHYA Class IV heart failure
- with low CO despite appropriate medical Rx (incl
inotropes + IABP)
- with evidence of secondary organ dysfunction
•  Early application of LVAD essential
BRIDGE TO DECISION
F De Robertis et al 2008
Patient demographics N=31
Male Gender
32.4%
37.9%
Mean Age
y
30
37.6 ± 14.2
IABP
15
Inotropes
Ventilated
8
MOF
16
Infection
8
8
Uncertain CNS
3
29.7%
RV failure post LVAD implantation
OCTx primary failure
1st choice device as "bridge to decision"
100
90
18.9%
43.2%
10.8%
80
70
60
50
40
30
20
10
0
19%
Dead
Long-term VAD
Ongoing
survival, %
8.1%
total
OCTx primary failure
RV failure post LVAD
1st choice device as "bridge to decision"
TO
Transplanted
Recovered
T1
T2
T3
T4
T5
T6
T7
time, months
T8
T9 T10 T11 T12
TandemHeart pVAD
►  Removes
oxygenated
blood from LA via
transseptal cannula in
the femoral vein
►  Returns blood via
femoral artery
►  Reduces preload
►  Increases MAP
►  Continuous flow
MECHANICAL ASSIST DEVICES
DEVICE
FLOW l/min
REMARKS
Impella
(Abiomed)
Tandem
2.5
Exact positioning
4.0
CC. trans-septal
Centrifugal pumps
(Biomedicus)
9-10
Rapid insert
Centrifugal + ECMO
IABP + ECMO
9-10
9-10
Surgery
LevitronixCentrimag
Up to 9.0
Surgery
Acute mitral regurgitation
► Post-inferior
myocardial infarct
► Endocarditis
► Trauma
► Acute
on chronic
Myocardial
infarction
Local LV
remodelling
contractility
Ischemic
mitral regurgitation
LAp
Pulmonary hypertension
Pulmonary edema
Volume
overload
stroke
volume
Heart failure
Death
LVEDP
wall tension
O2 consumption
Subendocardial
ischemia
Mitral valve surgery for acute
papillary muscle rupture
Author
N
30 day
1 year
mortality survival
%
%
5 year
survival
%
Chen Q.
2002
33
21
75
65
Tavakoli
R. 2002
21
19
81
68
18.5
[67–8.7]
79
65
Russo A. 54
2008
Cancion System for Continuous
Aortic Flow Augmentation (CAFA)
Patient Prognosis in Heart Failure
Axial impellor LVAD: continuous
flow [Henein M.et al. Circulation 2002; 105:
2324]
HeartMate II
CentriMag® MagLev Ventricular Assist
System:
Pump
Console
Motor
Clinical Advantages with CentriMag VAS
Ø 
Versatile: LVAD, RVAD, BIVAD, ECMO
Ø 
Easy device insertion
- Can be inserted without cardiopulmonary bypass
Ø 
Minimal anticoagulation requirement, (less vulnerable to
thrombus & embolic complications)
Ø 
Gives adequate flow
Ø 
Maximizes potential for recovery
Ø 
Minimal blood trauma, minimal haemolysis
Ø 
Transportable
Ø 
Costs acceptable
Short Term Mechanical Circulatory
Conclusions
Support(1)
►  Easy
device insertion
§  Can be inserted without cardiopulmonary bypass
►  Only requires moderate levels of anticoagulation
►  Gives adequate flow
►  Costs acceptable
Allows
►  Reversal of renal and hepatic failure
►  Treatment of infection
►  Assesssment of neurological function
►  Extubation
►  Improvement of cardiac dysfunction if possible
In moribund patients to optimise them prior to
insertion of a longer term device
Short Term Mechanical Circulatory
Support
Conclusions
(2)
Useful for
►  “Bridge to decision”
§  Acute cardiogenic shock
►  Bridge to recovery
- Postcardiotomy
- Acute myocarditis
- Right Heart Failure following
transplantation
►  Bridge to transplant
What was this operation ?
PVE: what are likely organisms?
Thank you
Levitronix for End Stage Cardiac Failure
®
CentriMag ICU Support
Transport on LVAD