The Pathophysiology of Cardiogenic Shock Knowledge Gaps & Opportunities
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1 The Pathophysiology of Cardiogenic Shock Knowledge Gaps & Opportunities Navin K. Kapur, MD, FACC, FSCAI, FAHA Associate Professor, Department of Medicine Interventional Cardiology & Advanced Heart Failure Programs Executive Director, The Cardiovascular Center for Research & Innovation
2 Relevant Disclosures Research Funding & Speaker/Consulting Honoraria: Abiomed, Abbott, Boston Scientific, Maquet, Medtronic, MD Start, Cardiac Assist Herbert J. Levine Foundation Tufts Medical Center RO1HL139785, RO1H Charlton Award Tufts Medical Center
3 Which Cardiogenic Shock Are We Talking About? AMI-Shock Acute HF Syndromes 10/ / /2007 3/2008 HR-PCI 4/2009 Anterior MI LAD PCI and IABP LVEF 20% 7/2012 Readmitted Heart Failure LVEF 25% Ambulatory Shock 3/2015 Readmitted - HF ICD Implanted LVEF 25% 12/2017 Readmitted Recurrent HF LVEF 25% Advanced HF-Shock 12/2017 Readmitted HF/ACS Impella Supported LAD and LCx PCI LVEF 25% 4/2018 Readmitted Recurrent HF LVEF 20% Readmitted Recurrent HF LVEF 20% Cardiogenic Shock Impella + VA-ECMO LVEF 10% Cardiogenic Shock Biventricular Centrimags LVEF 10% Orthotopic Heart Transplant LVEF 65%
4 Which Cardiogenic Shock Are We Talking About? Acute MI Cardiogenic Shock Advanced HF Cardiogenic Shock Modified from Goodlin. JACC 2009;54:386
5 Our Current Understanding of CGS Physiology Founded in AMI-Shock AHA Shock Consensus Statement Circ 2017 Coronary Problem Ventricular Failure Vascular Response
6 Plumbing Principles: Pressure and Volume Normal Acute Load (AMI) Compensatory Hypertrophy Systolic Failure Dilated Cardiomyopathy Primary Target of Heart Failure Therapy: Reduce LV Wall Stress Pressure x Radius ESP x EDV 2 x Wall Thickness LV Mass Laplace s Law: Wall stress = = Wall Stress
7 Plumbing 101: Ventricular Loading Conditions Arterial Elastance (Ea) Ea = ESP SV End-Systolic Elastance (Ees) Contractility Afterload = Wall Stress = ESP x EDV Pressure Stroke Volume Stroke Work Potential Energy Volume
8 Plumbing 201: Ventriculo-Arterial Coupling Arterial Elastance (Ea) End-Systolic Elastance (Ees) Contractility Pressure Stroke Volume Ventriculo-Arterial Coupling = Stroke Work Ea Ees Potential Energy Volume
9 How Does Preload Impact the Failing Heart? Ees Stroke Volume Pressure 4 4 LVEDP or LVEDV (Preload) LV Volume Condition 1: Normal Condition 2: AMI Condition 3: Compensated HFrEF Condition 4: Cardiogenic Shock (AMI or HFrEF)
10 Inefficient VA-Coupling & Increased Wall Stress in Shock Ea Ees = 1 Ea Ees >> 1 Pressure Volume
11 Plumbing 301: RV-PA Coupling Afterload: 1. Resistance 2. Impedance 3. PA compliance 4. PA elastance Pulm. Arterial Hypertension Courtesy of HC Champion
12 Plumbing 401: RV-PA-LV Coupling Effect of elevated pulmonary capillary wedge pressure (PCWP) on pulmonary vascular resistance-compliance relationship (RPA-CPA). Pulm. Venous Congestion PCWP = PA Compliance PA Resistance Tedford R J et al. Circulation 2012;125:
13 Plumbing 401: RV-PA-LV Coupling LV Capacitance & Stroke Volume LV Capacitance & Stroke Volume
14 Message 1: CGS is a Biventricular Problem Fincke JACC 2004 Hemodynamic Indices of RV Failure A. CVP>16 B. RA:PCWP >0.6 or >0.8 C. RVSW < 450 D. PAPi (PAPP/CVP) < 1.0 RA:PCWP PAPi
15 Message 1: CGS is a Biventricular Problem Lala and Kapur et al. J Card Failure 2017
16 The Cardiogenic Shock Working Group Total: 1010 Cases Largest US registry of Acute MCS device use in Cardiogenic Shock Over 500 patients with PA Catheter Indices
17 Message 1: CGS is a Biventricular Problem Tufts Cardiogenic Shock Algorithm Hemodynamically driven decision making Message 1: CGS is a Biventricular Problem Biventricular Congestion in Cardiogenic Shock is Common and Associated with High In-Hospital Mortality Cardiogenic Shock Working Group
18 Message 2: Congestion is as Critical as Cardiac output Cardiac Preload, not Cardiac Index, is a Major Determinant of Clinical Outcomes J Card Fail 2016
19 Message 2: Congestion is as Critical as Cardiac output Central Venous Congestion Worsens Renal Function in HF Mullens and Tang JACC 2009
20 Message 2: Congestion is as Critical as Cardiac output Venous Congestion Drives Morbidity and Mortality in CS Right Atrial Pressure is a common denominator for poor outcomes Cardiogenic Shock Working Group
21 Right atrial pressure is independently associated with in-hospital mortality Odds ratio 1.12 per 1mmHg increase (p<0.001) Should we be utilizing better approaches to reduce biventricular filling pressures in HF?
22 Message 3: Hemodynamic vs Hemo-Metabolic Shock
23 Message 3: Hemodynamic vs Hemo-Metabolic Shock Pre-Shock Early Shock Mild Shock Hemodynamic Shock Late Shock Deep Shock Severe Shock Hemo-Metabolic Shock Morine & Kapur et al. Shock Working Group
24 Message 3: Hemodynamic vs Hemo-Metabolic Shock An Issue of Timing: Diagnosis, Stratification, Therapy Hemodynamic Problem Hemo-Metabolic Problem Recovery Time in Cardiogenic Shock Death Rx: Hemodynamic Support Circulatory and Ventricular Rx: Multi-organ Support Unloading, Ventilator, CVVHD Kapur and Esposito Curr Cardio Risk 2016 Kapur and Esposito F
25 Tufts Cardiogenic Shock Algorithm Hemodynamically driven decision making Message 4: Escalating Pharmacologic Therapy is Futile Escalating Inotrope/Vasopressor Use Morine & Kapur et al. Shock Working Group
26 Message 5: Hemodynamically Driven Decision Making CGS Management begins with a PA Catheter Kapur & Esposito. Curr Cardiol. 2016
27 Esposito, Zhang, Qiao & Kapur et al JACC 2018 Future Directions for the Science of Cardiogenic Shock Ventricular Load Impacts Myocardial Recovery C
28 Future Directions for the Science of Cardiogenic Shock Ventricular Load Impacts Myocardial Recovery
29 The Pathophysiology of Cardiogenic Shock Knowledge Gaps & Opportunities Thank you
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