Download Shock

SCAI FALL FELLOWS COURSE
LAS VEGAS, NEVADA
DECEMBER 5-8,2012
CARDIOGENIC SHOCK
Howard A. Cohen, MD, FACC, FSCAI
Professor of Medicine
Director Temple Interventional Heart & Vascular Institute
Director Cardiac Cardiac Intervention and Catheterization Laboratories
Temple University Health System
DISCLOSURE
• Medical Director CardiacAssist Inc
• Stock Options
CARDIOGENIC SHOCK
Etiology
• AMI
• Ischemic cardiomyopathy
• Non-ischemic cardiomyopathy
• Myocarditis
• Acute valvular disease
• Chronic valvular disease
• Toxic
• Metabolic
Thirty-Year Trends in CGS in Patients with AMI
CGS Incidence in AMI
Trends in CFR in AMI
Goldberg et al. Circulation 2009;119:1211-1219
Clinical Presentation to Catheterization Lab
PCI
n=941,248
Diagnostic only
n=1,110,150
CAD presentation %
%
%
No sx and no AP
3.0
17.6
Sx unlikely to be ischemic
9.0
17.6
Stable AP
17.6
21.4
Unstable AP
36.7
33.0
NSTEMI
17.9
8.8
STEMI
15.8
1.7
1.9
0.7
CGS within 24 hours
Dehmer et al. JACC 60;2117-31, 2012
CGS AND ACUTE MI
SHOCK TRIAL
P=0.027
P=0.11
Hochman JS, et al. The New Engl J of Med:341; 1999:625-634
CONSEQUENCES OF DELAY
• Higher mortality
– Gibler et al., 2002; Newby et al. 1996, Maynard et al., 1989
• Reduced benefit of PCI
– Kent et al., 2001
• Larger infarct size
– Liem et al., 1998
• Higher incidence of shock
– Newby et al., 1996
• Worse left ventricular function or heart
failure with associated increased disability
– Liem et al., 1998; Newby et al., 1996
Moser, Jan 2007
Time is Outcome: Primary PCI
6 RCTs of Primary PCI by Zwolle Group 1994-2001
One-Year Mortality (%)
12
10
P=0.001
8
6
4
2
RR=1.08 for each 30 min delay (P=0.04)
0
0
60
120
180
240
300
360
Symptom-to-balloon inflation (mins)
DeLuca G et al. Circulation 109:1223, 2004
Reducing Myocardial Infarct Size
• “Time is muscle”
• Decreasing door to balloon time (D2B) has
become the mantra in primary PCI
• Resultant markedly improved survival
• How can we further improve outcomes,
particularly in CGS?
Importance of Other Factors
 Reperfusion injury
 Does reperfusion injury exist in man?
 If reperfusion injury exists in man, can it be
prevented?
Contribution of Lethal Reperfusion Injury to Final MI Size
Yellon D and Hausenloy D. N Engl J Med 2007;357:1121-1135
Major Mediators of Lethal Reperfusion Injury
Inflammation
cytokines
Rapid Δ in pH
Calcium Overload
Reactive O2 species
PTP pore
LRI
Yellon D and Hausenloy D. N Engl J Med 2007;357:1121-1135
Tandem Heart PVAD
TandemHeart Escort™
Controller
TandemHeart Enhanced
Flow Cannula
TandemHeart Pump
Percutaneous LVAD in
Severe Refractory Cardiogenic Shock
Ischemic and Non Ischemic 117 Patients
Mortality - 30 Day 40.2%, 6 Month 45.3%
Ischemic 80 Patients
30 Day 43.8%, 6 Month 50%
Non Ischemic 37 Patients
30 Day32%, 6 Month 35%
Kar et al. J Am Coll Cardiol 2010
Percutaneous LVAD in Severe Refractory Cardiogenic
Shock
Survival Function
Kar et al. J Am Coll Cardiol 2010
Percutaneous LVAD in Severe Refractory Cardiogenic
Shock
Bridge to Transplant
Bridge to LVAD
Bridge to Recovery
Kar et al. J Am Coll Cardiol 2010
Non-Ischemic
Ischemic
Percutaneous LVAD in Severe Refractory
Cardiogenic Shock
SAFETY
ADVERSE EVENT
FREQUENCY
%
GROIN HEMATOMA
6/117
5.12
LIMB ISCHEMIA
4/117
3.41
BLEEDING AROUND CANNULA
SITE
34/117
29.05
FEMORAL ARTERIAL
DISSECTION
1/117
0.85
ATRIAL PERFORATION
1/117
0.85
SEPSIS
35/117
29.9
COAGULOPATHY
13/117
11.0
STROKE
8/117
Kar et al. J Am Coll Cardiol 2010
BLOOD TRANSFUSION
70/117
6.83
59.8
Percutaneous LVAD in Severe Refractory Cardiogenic
Shock
FACTOR
HAZARD RATIO
95% CI
p VALUE
AGE
1.035
0.995-1.076
0.085
IABP
1.028
0.20-5.24
0.974
CPR
4.54
1.61-14.28
0.004
PRESSORS
1.14
0.76-1.71
0.513
MAP
1.00
0.97-1.02
0.985
CREATININE
1.35
0.86-2.12
0.192
Kar et al. J Am Coll Cardiol 2010
Percutaneous LVAD in SRCS
FACTOR
SHOCK TRIAL
THI SRCGS
SRCS
NO
YES
30 DAY MORTALITY
47%
40.2%
BASELINE EF
29.1±10.6%
23.4±11.5%
CI
1.8±0.7 L/min/M2
0.36±0.7L/min/M2
SBP
89±22.8 mmHg
70.9±10.9 mm±Hg
PCW
24±7.0 mmHg
29.8±10.3 mmHg
CPR during LVAD
insertion
0%
51.2%
PRIOR MI
40%
80%
PRIOR REVASC
17%
80%
CRI
11%
50%
Kar et al. J Am Coll Cardiol 2010
Hochman JS, et al. The New Engl J of Med:341; 1999:625-634
THI TandemHeart “Bridge to”
Kar BS et al; The J of Heart and Lung Transplantation 2009.28(2): S 256
Recovery
LVAD
Surgery
Transplant
N
74
32
34
5
Support
(DAYS)
5.6
6.4
3.0
6.4
Mortality
RATE
57%
12%
43%
0%
META-ANALYSIS of IABP vs LVAD in CGS
Cardiac Index
MAP
PCW
Cheng et al. Eur Heart J 2009;30:2102-2108
META-ANALYSIS of IABP vs LVAD in CGS
Leg ischemia
30 D Mortality
Bleeding
Fever/sepsis
Cheng et al. Eur Heart J 2009;30:2102-2108
Mechanical Circulatory Assist in CGS
Device
IABP
Ease of
Duration Flow
Insertion of use
L/min
MVF
Cost
Available
++++
Days to
weeks
±
±
$
++++
ECMO
+
Hours to
Days
5.0
NA
$$$$
++
Impella
2.5
+++
Hours to
days
2.5
+
$$$
+++
LA-FA
Bypass
++
Days to
weeks
5.0
+++
$$$
++
Intraaortic Balloon Support for Myocardial
Infarction with Cardiogenic Shock
• The use of intraaortic balloon counterpulsation did
not significantly reduce 30-day mortality in patients
with cardiogenic shock complicating acute
myocardial infarction for whom an early
revascularization strategy was planned.
• Problems with the Study
• Clinical diagnosis without hemodynamic
measurement
• End-point 30 day mortality
Thiele et al.N Engl J Med
Volume 367(14):1287-1296
October 4, 2012
BRIDGE TO DECISION
Acute refractory CGS
Medical therapy, IABP
Temporary VAD support
Revascularization
Recovery assessment
MSOF
Neurologic deficit
Palliative care
Bridge to Bridge
long –term MCS
Bridge to transplant
Destination therapy
Gregoric and Bermudez
MCS explant
Rehabilitation
Bridge to recovery
WHEN SHOULD WE USE MCS
Advantages
Risks
Unloading of the
ventricle
End-organ Perfusion
Bleeding
Embolism
Infection
Leg ischemia
Deconditioning
Timing
Patient Selection
THANK YOU
Potential Strategies for Myocardial Protection and
Preservation
Drugs
EPO
Atorvastatin
ANP
Glucagon-like
protein
Acadesine
ST Elevation
Myocardial Infarction

Mechanical Stimuli
Activation of RISK Pathways
Ischemic Pre/Post/Per
Conditioning

Reperfusion Therapy with
Adjunctive Antithrombotic Strategies

Inhibition of MPTP opening
Cyclosporine

Reduce Infarct Size
LV Unloading???
Cooling

Impella, LA-FA Bypass
SS02
Improve LV function, Lower Morbidity and Mortality