Counterpulsation. John N. Nanas, MD, PhD. Professor and Head, 3 rd Cardiology Dept, University of Athens, Athens, Greece

Transcription

1 John N. Nanas, MD, PhD Professor and Head, 3 rd Cardiology Dept, University of Athens, Athens, Greece

2 History of counterpulsation 1952 Augmentation of CBF Adrian and Arthur Kantrowitz, Surgery 1952;14: Extracorporeal blood pump (arterial counterpulsation) 1962 Diastolic balloon pumping in the aorta (IABP) 1968 The first 2 clinical applications of the IABP 1980 Percutaneous IABP insertion Today Worldwide >200,000 IABPs annually Harken DV, JTCS 1961;41: Moulopoulos SD, AHJ 1962;63: Kantrowitz, JAMA 1968;203: Bregman D, AJC 1980;46:261-64

3 IABP Inflation IABP Deflation

4 Normal Heart Counterpulsation IABP on LV Mechanoenergetics IABP OFF 14% LV Stroke Work IABP ON 17% LV End-Systolic Pressure 10% LV End-Diastolic Pressure 14% LV Stroke Work 10% Coronary Blood Flow Diastolic AOP Bonios et al, Int J Cardiol, 2008

5 Failing Heart Counterpulsation IABP on LV Mechanoenergetics IABP OFF IABP ON Bonios et al, Int J Cardiol, % LV End-Systolic Pressure 18% LV End-Diastolic Pressure 7% LV Stroke Work 11% Coronary Blood Flow Diastolic AOP

6 IABP Complications ( ): Major limb ischemia %

7 IABP: Indications in Benchmark Registry (n=16909) Post-MI cardiogenic shock (CS or CS with mechanical complications*) : 25% Weaning from CPB : 16% Hemod. support for high risk cath and PCI : 21% Preoperatively in high-risk CABG : 13% UA refractory to medical therapy : 12% CPB=Cardiopulmonary bypass UA=Unstable angina, * MR, PMR, VSR Am J Cardiol 2006;97:1391-8

8 Post discharge long term survival of patients with AMI with and without CS Am J Cardiol 1999;84:18

9 IABP + Thrombolysis in Post-MI CS Ohman E, Nanas J et al, J Thrombosis Thrombolysis 2005;19:33-39 Kovack PJ et al, J Am Coll Cardiol 1997;29: Andreson RD et al, J Am Coll Cardiol 1997;30: Barron HV et al, Am Heart J 2001;141:

10 Survival of patients with post-mi CS and delayed (1-10d) revascularization 6-month survival Nanas et al. Coronary Artery Disease 2008;19:521-6

11 IABP utilization in patients with post-mi CS Eur Heart J 2010;31:1828

12 New PVAD(TandemHeart, Impella Recover LP2.5) vs IABP in post-mi CS randomized studies (meta-analysis) New PVAD -Impella Recover LP 2.5 -TandemHeart -Reitan catheter pump n (IABP)=47 n (LVAD)=53 IABP is the device of first choice for the post-mi CS Eur Heart J 2010; 31:1828

13 Potential new indications for the IABP 1. Adjunctive treatment for patients with extensive AMI without CS 2. Bridge to decision making 3. Bridge to transplantation

14 IABP adjunctive to PPTCA for patients with extensive AMI without CS IABP followed by reperfusion in AMI: a. experimental study (dogs) b. experimental study (pigs) Group 1 (NR) Group 2 (R) Group 3 (R+IABP) Nanas J et al, Ann Thorac Surg 1996;61:629 Pierrakos et al. Submitted for publication

15 IABP application before vs after PPTCA in patients with post MI CS Mohamed Abdel-Wahab et al, Am J Cardiol 2010;105:967

16 After PPTCA adjunctive IABP application in patients with extensive AMI without CS 30 days mortality Cardiol Clin 2010;28;169 A new randomized study is needed

17 IABP as a bridge to decision making No of patients Mean (range) days Survival Kantrowitz et al (20-71) 70.4% Simonsen et al (10-66) 95.8% Nanas J et al (10-180) 90% Overall (10-180) 84% Kantrowitz et al, Am J Cardiol 1988, Simonsen et al, Eur J Heart Failure 2009, Nanas et al, unpublished data The IABP seems a suitable device for more than a short period of MA

18 IABP as a bridge to transplantation 40/179 listed for Tx, needed mechanical assistance ( ) Patients (n) Survival to Tx Mean duration in days (range) No need for MA % (139/139) NR IABP only 33 97% (32/33) 21 (3-66) VAD/ ECMO 7 86% (6/7) 25 (1-49) Simonsen et al, Eur J Heart Failure 2009;11: MA = Mechanical assistance

19 New counterpulsation device suitable for long term mechanical assistance CPD (SV=30-40 ml) Implanted on the subclavian artery Experimental studies only ASAIO J 2008;54:

20 Sunshine Heart C-Pulse device Implanted around the ascending aorta Implanted in 1 patient Duration of support 7 months Ann Thor Surg 2008;85:2122

21 New counterpulsation device suitable for long term mechanical assistance Kantrowitz CardioVAD Device Implanted on the descending aorta Implanted in 5 patients 1 died perioperatively 3 survived up to 30 days 1 survived 7 months Circulation 2002;106:I-183-I-188

22 New counterpulsation device suitable for long term mechanical assistance KardiaPulse Device 60 ml maximum stroke volume Implanted in 4 patients with severely deteriorating HF resulting in infractable CS. Support up to 54 days Nanas et al, JACC 1996; 7:

23 Summary (1/2) 1. All patients with post MI CS without contraindication must undergo IABP assistance in conjunction with reperfusion even if delayed 2. The IABP seems to be a suitable device for more than a short period of support as a bridge to decision making or as a bridge to cardiac transplantation

24 Summary (2/2) 3. Experimental data support the use of the IABP before PPTCA in patients with a large AMI without CS. A randomized clinical study is needed. 4. The emerging new counterpulsation devices suitable for long term mechanical assistance are highly promising and their use might expand the indications to less severe HF for long term mechanical assistance.

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28 Backup

29 Suga-Sagawa law Hypothetical P-V curves without (1) and with (2) IABP assistance Nanas J et al, Cardiology 1994;84:156

30 Hemodynamic variables affected by the IABP Left-ventricular pressures Left-ventricular work Diastolic aortic pressure Ejection fraction Cardiac output Coronary blood flow Nanas JN et al, Cardiology 1994;84:

31 Reperfusion therapy and mortality in patients with Post MI CS assisted by the IABP Variable (n=69) (n=99) (n=132) p value Reperfusion therapy 66% 77% 89% < day Mortality 52% 41% 36% < 0.05 Am J Cardiol 2009; 104:327

32 Summary (1/2) The purposes of the diastolic pumping devices are: to increase the blood flow during diastole, especially through the coronary arteries to decrease the end-diastolic pressure, and therefore to decrease the work of the failing left ventricle The entire inflation had to be completed at least 20 msec before the next ventricular systole began, in order to assure lowering of the end-diastolic pressure in the aorta Moulopoulos SD et al, Am Heart J 1962;63:669

33 Summary (2/2) The diastolic arterial support to the circulation as described would probably be contraindicated in cases of aortic insufficiency Moulopoulos SD et al, Am Heart J 1962;63:669-75

34 Use of IABC in CS complicating acute myocardial infarction. Do we really need more evidence? We conclude that the benefit / risk ratio of intraaortic counterpulsation in AMI patients with preshock or CS is likely to be high, and the routine use of this device should be highly recommended in these patients as current guidelines state. In addition, the APACHE II score may be clinically useful as a simple bedside prognostic indicator in this patient group Cardiol Clinic 2010;28:169

35 Moulopoulos SD et al, Am Heart J 1962;63:669-75

36 Time course of the effect of the IABP on CBF during reperfusion: experimental study Submitted for publication

37 Time on Cardiopulmonary Bypass (min.) Pre-operative IABP Support in High-Risk* Coronary Patients 120 (p < 0.001) IABP Group Control Group (no IABP) * EF, LM, Redo, UA Eur J Cardiothorac Surg 1997; 11:1097

38 The effect of IABP on CBF during reperfusion in AMI: experimental study Normal Heart 60 ο min of reperfusion 120 ο min of reperfusion Submitted for publication

39 Brief history 78-year-old man with a history of MI and substernal chest pain accompanied by faintness starting 2 hrs before admission On admission, BP=70/50mmHg with weak regular pulses 100/min The ECG revealed alternate L and RBBB

40 Coronary angiography

41 After Primary PCI

42 Clinical course Before Primary PCA: Blood Pressure 70/50 mmhg After Primary PCA: Blood Pressure 110/60 mmhg

43 Percutaneous left ventricular support devices The use of IABP is a representative example of a treatment based on a concept that becomes clinical practice. The IABP has evolved into an amateur technology 4 decades after its introduction. Owing to the ease of percutaneous implantation, the low cost, and the beneficial hemodynamics at a low complication rate, it continues to be the most common mechanical cardiac assistance method in the catheterization laboratory Cardiol Clinic 2010;28:169

44 Eur Heart J 2009;30:2102 Thiele et al, Eur Heart J 2005;26: Burkoff et al, Am Heart J 2006;152:469e Seyfarth et al, J Am Coll Cardiol 2008;52:

45 Eur Heart J 2009;30:2102

46 Am J Cardiol 2009; 104:327

47 Optimal Timing of Preoperative IABP Support in High-Risk Coronary Patients The time period (2h, 12h, 24h) of preoperative IABP assistance did not show any differences in the time on Cardiopulmonary Bypass or the clinical outcome Annals Thorac Surg 1999; 68:

48 IABP adjunctive to PPTCA for patients with extended AMI without CS Reperfusion plus IABP in AMI: experimental study (pigs) Submitted for publication

49 IABP as a bridge to transplantation Post mortality in pre transplantation ambulatory (stable), needed IABP or LVAD / ECMO assistance No of patients 30 days 1 year Stable pts to Tx % 11.1% IABP assisted to Tx % 9.4% VAD/ECMO assisted to Tx 7 17% 33% Simonsen et al, Eur J Heart Failure 2009;11:

50 IABP as a bridge to recovery Recovery of the peripheral organs 10 patients Duration of support 56±48 days Range days Nanas J et al, unpublished data